- The Uniform Data Set (UDS) requires CHCs to report performance capturing Social Determinants of Health, Sexual Orientation and Gender Identity and their performance closing gaps in care
- CHCs are evaluating approaches to improve performance and reach Healthy People 2030 goals
- Use of electronic patient engagement communication tools is showing promise to capture sensitive patient information and to better engage patients in preventive care.
AllianceChicago and IPHCA (Illinois Primary Health Care Association) hosted a conference in the suburbs of Chicago early October 2023. AllianceChicago is a health center-controlled network (HCCN) that supports community health centers across the United States. IPHCA is an Illinois-based organization focused on supporting community health centers, specifically in Illinois.
A little background on me. I worked for AllianceChicago for 12 years, working to best support community health centers. My role was to help them optimize their operations and workflows, to assist in their usage of their electronic health record (EHR) and any other components that tied to their EHR, and to support those that led the organization, from executive leaders to the EHR manager. After my move to QliqSOFT, I was thrilled to participate in this conference as a vendor sponsor, as I can share the value in our product based on my knowledge of community health centers and their workflows. The work community health centers do with patients is truly admirable. They serve the most underserved and those in need, including the homeless, the most chronically ill, and those that need substance use care to name a few.
This conference’s theme was “Better Together: Aligning Mission, Values, + Goals.” One of the opening speakers was Dr. Kye Rhee. Dr. Rhee is the new President and CEO of NACHC. NACHC serves as the main organization that supports community health centers, so they may best serve the underserved. Dr. Rhee kicked off the conference perfectly, focusing on his own mission and goals. One of his goals is to visit 1,400 community health centers across the country to best understand their own mission and goals, and then advocate for them. His speech was a great motivator to kick off the conference. His mission is one to not only advocate for change, but to bring those needs to Congress, to better support and fund community health centers.
Community Health Centers must collect standardized data into their EHR, to best report, learn and take action to support the patient. HRSA (Health Resources and Services Administration) requires FQHCs (Federally Qualified Health Centers) report UDS (Uniform Data Set) every February. FQHCs must meet certain thresholds in order to provide funding to them to keep their doors open. The data themes that were highlighted included SDoH, which are social determinants of health. Social determinants like transportation, food insecurity, and housing are a few examples that contribute to health disparities and inequity. If a patient has needs in these areas, their health comes second to these. For example, if a patient cannot get a ride to the clinic, they do not have access to care. Therefore, their health suffers.
Other data themes included collecting SOGI data, which is sexual orientation and gender identity, as well as collecting preferred pronouns and preferred name. These topics require the community health centers to ask them in a way that makes the patient feel comfortable and understand the importance (“the why”) this data is being collected. The research has shown this is best collected electronically versus a staff person asking the patient verbally these questions. Self-disclosure of this data has been proven to allow the patient a safe space to respond accurately and honestly, as this can be private and sensitive information.
This information is also crucial to be able to get patients access to care, but most importantly the right care. By getting accurate data in these areas, care teams at the community health centers can ensure a patient has housing options, has appropriate care based on their gender identity, is addressed by their correct name and pronoun. All these items make a patient feel cared for, understood, and builds trust between the patient and their care team.
Health centers are recognizing that this sensitive information requires an electronic way to capture it respect the dignity of the patient. For example, QliqSOFT partnered with AllianceChicago and Settlement Health to proactively send chatbots to patients with gaps in care provide education and to screen for SDoH needs. 58% of patients identified and requested help addressing SDoH needs. The way a patient responds to these questions drives the community health center to ensure they have access to care, but most importantly to understand them as a whole patient, so they keep coming back for quality care that focuses on them as an individual and acknowledges their unique needs.
Value-Based Care was another major theme of the conference. This approach focuses less on the quantity of visits, but more around the provider improving patient outcomes and closing gaps in care for the patient. Gaps in care range from administering immunizations to ensuring the patient receives their cancer screenings. It was so rewarding to be able to speak to how QliqSOFT supports the goals behind value-based care. Two of our community health centers leveraged chatbots to do outreach for preventive screening. “CHEC-UP” was one of the projects, reaching out to parents/guardians to provide anticipatory guidance and make it easy to schedule a well-child visit. Heartland Health Centers increased well-child visits and immunizations by 27%!
The other project called “REACH” reached out to a variety of patient populations simultaneously to increase engagement and close gaps in care including mammogram screening, enrolling hypertensive patients for remote blood pressure monitoring, colorectal cancer screening, and well-child visits and immunizations. 27% of patients responded, increasing mammography and colon cancer screening rates. Think of all the patients you could reach with chatbots! These chatbots now only provide information and assist with outreach, but they gather pertinent information from the patient to individualize their care and access to care.
All the areas discussed here also support the Healthy People 2030 objectives. Care is shifting towards a holistic patient-centric approach. From screening patients for SDoH identifying needs and acting, gathering patient details such as preferred name and pronouns to personalize their care, and SOGI data to guide the delivery of care and support needed.
In conclusion, the conference really highlighted the importance of community health centers leveraging electronic patient engagement and communication tools to reach more of their patients and move them closer to achieving Healthy People 2030 goals.
Ms.Bubb joined QliqSOFT in 2023. Jaimie previously worked at AllianceChicago, where she supported and guided health centers around any new products, implementations and optimization efforts. She also strategized with health center leadership to advise around activities surrounding HCCN, CIN and other healthcare related changes. Ms. Bubb is a Registered Nurse with experience in burn care, intensive care, general telemetry, and medical surgical nursing. In addition to clinical experience, she also has three years of experience in disability and disease management. Ms. Bubb received her master’s degree in Medical Informatics from Northwestern University and has a B.S.N. from University of Otterbein.
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