Development of PRAPARE Social Determinants of Health Clusters and Correlation with Diabetes and Hypertension Outcomes.

INTRODUCTION: PRAPARE is a leading social risk screening tool. No studies yet have simplified the 22 PRAPARE social determinants of health (SDoH) into clusters to analyze associations with chronic disease outcomes. METHODS: A federally qualified health center conducted cross-sectional PRAPARE screening on its general adult population. Exploratory and confirmatory factor analyses were used to identify SDoH clusters and construct cluster scores and SDoH total risk scores. Logistic regression assessed relationships between cluster scores and uncontrolled diabetes and/or hypertension. RESULTS: Of the 11,773 adults who answered the survey, 716 had diabetes only, 2,388 had hypertension only, 1,477 had both, and 7,192 had neither. We found 3 composite SDoH clusters (social background, social insecurities, insurance/employment) and 3 standalone clusters (housing status, social isolation, poverty). Among patients with diabetes, those at risk in social background, social insecurities, and insurance/employment were more likely to have uncontrolled diabetes. Among patients with hypertension, those at more risk in social insecurities were more likely to have uncontrolled hypertension. CONCLUSIONS: We simplified the 22 PRAPARE SDoH into 3 composite clusters and 3 individual clusters and demonstrated the reliability and validity of PRAPARE. The 3 composite clusters were positively associated with uncontrolled diabetes and/or hypertension.

Comparing Rates of Multiple Chronic Conditions at Primary Care and Mental Health Visits to Community Health Centers Versus Private Practice Providers.

This study identifies differences in rates of multiple chronic conditions at primary care and mental health visits to Community Health Centers and private practice providers using 2013 National Ambulatory Medical Care Survey data. Community health center visits had higher rates of 1 or more, 2 or more, and 3 or more chronic conditions for working-age patient visits (ages 18-64). There were no differences in other age groups. After controlling for age and other covariates using logistic regression, community health center visits had 35% higher odds of having any chronic condition and 31% higher odds of having 2 or more chronic conditions.

Collecting Social Determinants of Health Data in the Clinical Setting: Findings from National PRAPARE Implementation.

BACKGROUND: The Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) is a nationally recognized standardized protocol that goes beyond medical acuity to account for patients' social determinants of health (SDH). AIMS: We described the magnitude of patient SDH barriers at health centers. METHODS: Health centers across three PRAPARE implementation cohorts collected and submitted PRAPARE data using a standardized data reporting template. We analyzed the scope and intensity of SDH barriers across the cohorts. RESULTS: Nationally, patients faced an average of 7.2 out of 22 social risks. The most common SDH risks among all three cohorts were limited English proficiency, less than high school education, lack of insurance, experiencing high to medium-high stress, and unemployment. CONCLUSIONS: Findings demonstrated a high prevalence of SDH risks among health center patients that can be critical for informing social interventions and upstream transformation to improve health equity for underserved populations.

How 6 Organizations Developed Tools and Processes for Social Determinants of Health Screening in Primary Care: An Overview.

Little is known about how health care organizations are developing tools for identifying/addressing patients' social determinants of health (SDH). We describe the processes recently used by 6 organizations to develop SDH screening tools for ambulatory care and the barriers they faced during those efforts. Common processes included reviewing literature and consulting primary care staff. The organizations prioritized avoiding redundant data collection, integrating SDH screening into existing workflows, and addressing diverse clinic needs. This article provides suggestions for others hoping to develop similar tools/strategies for identifying patients' SDH needs in ambulatory care settings, with recommendations for further research.

Community health centers at the crossroads: growth and staffing needs.

In response to increased demand for primary care services under the Affordable Care Act, the national network of community health centers (CHCs) will play an increasingly prominent role. CHCs have a broad staffing model that includes extensive use of physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs). Between 2007 and 2012, the number of PAs, NPs, and CNMs at CHCs increased by 61%, compared with 31% for physicians. However, several policy and payment issues jeopardize CHCs' ability to expand their workforce and meet the current and rising demand for care.

Identifying key patient demographics and organizational factors that contribute to health center participation in research.

Federally Qualified Health Centers are well positioned for translational research given their diverse patient population, unique characteristics, and community knowledge. This was the first national survey that assessed their research activities. Those with research experience were more likely to be urban and Health Care for the Homeless grantees and had more patients, minority patients, and physicians relative to nonphysician providers, enabling services providers, Medicaid revenues per Medicaid patient, and total revenues per patient than health centers with no experience and no future interest in research. Only enabling services providers to patient ratios and total patients remained significant after controlling for other factors.

Engaging Community Health Centers (CHCs) in research partnerships: the role of prior research experience on perceived needs and challenges.

Despite community health centers' substantial role in local communities and in the broader safety-net healthcare system, very limited research has been conducted on community health center research experience, infrastructure, or needs from a national perspective. A national survey of 386 community health centers was conducted in 2011 and 2012 to assess research engagement among community health centers and their perceived needs, barriers, challenges, and facilitators with respect to their involvement in public health and health services research. This paper analyzes the differences between health centers that currently conduct or participate in research and health centers that have no prior research experience to determine whether prior research experience is indicative of different perceived challenges and research needs in community health center settings.

A needs-based method for estimating the behavioral health staff needs of community health centers.

BACKGROUND: Federally Qualified Health Centers are expanding to increase access for millions of more Americans with a goal of doubling capacity to serve 40 million people. Health centers provide a lot of behavioral health services but many have difficulty accessing mental health and substance use professionals for their patients. To meet the needs of the underserved and newly insured it is important to better estimate how many behavioral health professionals are needed. METHODS: Using health center staffing data and behavioral health service patterns from the 2010 Uniform Data System and the 2010 National Survey on Drug Use and Health, we estimated the number of patients likely to need behavioral health care by insurance type, the number of visits likely needed by health center patients annually, and the number of full time equivalent providers needed to serve them. RESULTS: More than 2.5 million patients, 12 or older, with mild or moderate mental illness, and more than 357,000 with substance abuse disorders, may have gone without needed behavioral health services in 2010. This level of need would have required more than 11,600 full time providers. This translates to approximately 0.9 licensed mental health provider FTE, 0.1 FTE psychiatrist, 0.4 FTE other mental health staff, and 0.3 FTE substance abuse provider per 2,500 patients. These estimates suggest that 90% of current centers could not access mental health services or provide substance abuse services to fully meet patients' needs in 2010. If needs are similar after health center expansion, more than 27,000 full time behavioral health providers will be needed to serve 40 million medical patients, and grantees will need to increase behavioral health staff more than four-fold. CONCLUSIONS: More behavioral health is seen in primary care than in any other setting, and health center clients have greater behavioral health needs than typical primary care patients. Most health centers needed additional behavioral health services in 2010, and this need will be magnified to serve 40 million patients. Further testing of these workforce models are needed, but the degree of current underservice suggests that we cannot wait to move on closing the gap.

Commentary on Gurewich et Al, "comparative performance of community health centers and other usual sources of primary care": community health centers: valuable partners for state medicaid programs.

Community health centers are well positioned to bring needed primary care to populations experiencing the most acute health disparities. Health centers already care for 1 in 7 Medicaid beneficiaries and 1 in 5 low-income, uninsured individuals. And they generate $24 billion in annual savings to the entire health care system, including $6 billion for Medicaid programs. Health center patients are distinctly different from patients of other providers, and successfully meet the challenges associated with serving those who have special needs that require more time and resources to address. For this reason, health centers provide a much more comprehensive array of services, both health care and services that facilitate access to care, compared to private practice physicians. With more beneficiaries joining the Medicaid rolls under health reform, and the limited number of providers available to serve the most complex, hard-to-reach, and underserved patients, health centers will play an increasingly important partnership role with state Medicaid programs. Continued investments are necessary to effectively serve at-risk patients.

Innovation networks for improving access and quality across the healthcare ecosystem.

Partnerships between patient communities, healthcare providers, and academic researchers are key to stepping up the pace and public health impact of clinical and translational research supported by the National Institutes of Health. With emphasis shifting toward community engagement and faster translation of research advances into clinical practice, academic researchers have a vital stake in widening the use of health information technology systems and telehealth networks to support collaboration and innovation. However, limited interaction between academic institutions and healthcare providers hinders the ability to form and sustain the integrated networks that are needed to conduct meaningful community-engaged research that improves public health outcomes. Healthcare providers, especially those affiliated with smaller practices, will need sustainable infrastructure and real incentives to utilize such networks, as well as training and additional resources for ongoing technical assistance.

Community approaches to women's health: delivering preconception care in a Community Health Center model.

Preconception care has been recognized as an important set of interventions necessary to improve pregnancy outcomes and the overall health of women of childbearing age. Traditionally underserved populations such as the low income, uninsured, racial and ethnic minorities, homeless, and migrant farmworkers have less access to a usual source of primary care and therefore are more at risk for adverse health outcomes. The national network of Community Health Centers was created to break down compounding barriers to care that leads to poor health. Health centers are a vital source of care for low-income women. Almost 60% of health center patients are women, about half of whom are women of childbearing age. In addition, health centers provide care for > 17% of low-income births in the United States. Most health centers offer their patients preconception services, such as HIV/AIDS screening and treatment, weight management, nutrition counseling, and smoking cessation programs, in addition to comprehensive primary care services. Three quarters of health centers provide mental health services and half provide substance abuse treatment services onsite; the rest provide these services in partnership with other providers. Health centers also participate in a number of community-based programs focused on improving women's health and providing preconception care services. As policymakers and public health planners consider options for enhancing the utilization of preconception care, they must also consider options for expanding access to health centers nationwide.

The role of community health centers in responding to disparities in visual health.

BACKGROUND: Community health centers (CHCs) are nonprofit community-based providers of primary and preventive health care for medically underserved populations. At the same time, nationally, racial/ethnic minorities and low-income populations are disproportionately affected by poor access to comprehensive eye and vision care and are more likely to experience adverse outcomes. OVERVIEW: This report describes the fundamentals of CHCs, including mission, their patients, the types of health care and enabling services that they provide, the quality and cost-effectiveness of their care, and how they are funded. This report also reviews the demographics of vision disparities among at-risk populations, the economic impact of undiagnosed and untreated vision problems, and the similarities between those at risk for vision problems and the patients targeted by CHCs. CONCLUSIONS: Aimed at responding to disparities in access to health care services and health status outcomes, CHCs are optimally positioned to contribute to improved access to comprehensive eye and vision care as well as to the reduction of disparities in visual health status. There is need for extensive research in further defining and addressing disparities in access to optometric care in medically underserved populations and the potential role that CHCs can play in meeting those needs.

Adoption of health information technology in community health centers: results of a national survey.

To the extent that health information technology (IT) improves health care quality, differential adoption among providers that serve vulnerable populations may exacerbate health disparities. This first national survey of federally funded community health centers (CHCs) shows that although 26 percent reported some electronic health record (EHR) capacity and 13 percent have the minimal set of EHR functionalities, CHCs serving the most poor and uninsured patients were less likely to have a functional EHR. CHCs cited lack of capital as the top barrier to adoption. Ensuring comparable health IT capacity among providers that disproportionately serve disadvantaged patients will have increasing relevance for disparities; thus, monitoring adoption among such providers should be a priority.

Building a research agenda for community health centers and the medically underserved: meeting proceedings.

THE PROBLEM: Community, migrant, and homeless health centers (CHCs) are an integral component of the nation's safety net with a proven record of success in access, quality, and cost effectiveness. Still, as CHCs face rising numbers of vulnerable patients and shrinking resources, they must continue to improve quality of care to further narrow health disparities, as well as demonstrate their cost effectiveness and value to policymakers. PURPOSE: CHCs, researchers, national partners, and others met in December 2005 to produce a consensus-driven research agenda that lays out research priorities for CHCs and the medically underserved. This article details the meeting process and resulting research agenda. KEY POINTS: The meeting focused on three domains that touch on community need: health information technology (HIT), quality improvement, and cost effectiveness and value. Community representatives helped to drive research priorities. CONCLUSIONS: CHCs must continually demonstrate their efficiency and effectiveness. Accordingly, the research agenda must be continually revisited through a collaborative process.

Deserving the spotlight: health centers provide high-quality and cost-effective care.

Community health centers were designed to overcome barriers to healthcare and narrow health disparities faced by underserved communities. Given the increased attention health centers are now receiving over expansion efforts, questions over their quality of care and cost-effectiveness must be addressed. This article reviews the relevant literature and documents that health centers improve access for hard-to-reach and underserved populations, provide continuous and high-quality primary care, and reduce the use of costlier providers of care, such as emergency departments and hospitals. The health center model produces substantial benefits for patients, communities, insurers, and governments.