Practice Facilitation Handbook
Module 2. Working With Safety Net Practices
Safety net practices are defined by the Institute of Medicine (IOM) as “those providers that organize and deliver a significant level of health care and other needed services to uninsured, Medicaid and other vulnerable patients” (Lewin & Altman, 2000).
The IOM identifies “core safety net providers” as providers that maintain an “open door” to patients regardless of ability to pay and whose case mix primarily includes uninsured, Medicaid, and other vulnerable patients. These core providers include:
- Public hospital systems,
- Federal, State, and locally supported community health centers and Federally Qualified Health Centers (FHQCs),
- Local health departments, and
- Special service providers such as:
- Family planning clinics.
- School-based health programs.
- Ryan White AIDS programs.
- Some communities’ teaching and community hospitals.
- Private physicians who care for predominantly uninsured or Medicaid patients.
- Other ambulatory care sites with demonstrated commitment to serving poor and uninsured patients (Lewin & Altman, 2000).
Because of their patient populations and mandate to serve poor and uninsured populations, safety net practices differ from traditional practices. They have unique needs and drivers that will affect your work with them, and that you, as a practice facilitator, will need to be prepared to meet.
Demand That Exceeds Supply
Safety net practices often have more patients needing care than they have the clinical capacity to serve. As provider of last resort, they do not turn patients away but they may also lack the resources to hire more staff to meet demand for services. In addition, many patients who are cared for in the safety net are dealing with more complex health issues, which need more clinical time to adequately address. Therefore, demand for service can often exceed supply, resulting in overcrowded waiting rooms, stressed clinicians and staff, and practices that view anything that takes time away from direct patient care, including quality improvement (QI), as a problem.
Reimbursement rules may create barriers to implementing new treatments and care models. Reimbursement structures and rules vary across States and regions but a common thread across all is that safety net practices are often underresourced. Many safety net practices receive capitated payments to care for publicly insured or uninsured patients. Often, the costs of delivering this care exceed payments received.
While providing flexibility, these payment structures can create disincentives for practices to provide indicated but expensive or time-consuming procedures or treatments. Practices may opt to refer patients out for services or care that are too costly for them to deliver. For example, safety net practices may refer patients out for pneumococcal vaccinations because of the difficulties they encounter receiving reimbursement for this service.
The practice’s ability to provide important services such as health education and self-management support training may also be affected by reimbursement structures. In some cases, practices are only reimbursed for physician services, not for ancillary service providers. This payment model requires physicians to deliver services that others could handle and creates barriers to implementing new models of patient care such as team-based care. In other cases, practices may only be reimbursed for a single visit in a day. Having the patient see multiple clinicians the same day may be the best approach to improving the care and health of the patient but can create real financial challenges for the practice.
As a practice facilitator, you will need to become familiar with the financial barriers that may affect your practices’ ability to implement new approaches to care and new treatments.
Improvement can create costs for practice. While improvement can be cost neutral, at least at the beginning improvement activity can result in increased costs for the practice. For example, estimates of the costs of implementing the Care Model (see Module 16) vary from $6.41 to $23.93 per patient (Huang, et al, 2007). Under fee-for-service reimbursement, savings associated with implementing the Care Model ($685-$950 per patient [Bodenheimer, et al., 2002]) mostly accrue to payers, such as health plans, rather than to practices (Huang, et al, 2007).
As a practice facilitator, you will need to familiarize yourself with the financial environment in which your practice operates. In the current climate, many organizations need their providers to see patients every 10 to 15 minutes to generate sufficient revenue for the organization to remain open. This can create barriers to implementing new models of care if these new models increase the amount of time a clinician must spend with a patient.
For example, engaging patients as partners in care can take more of the clinician’s time. Implementing care teams is one way to alleviate this problem. Nonphysician members of the care team can handle routine tasks through standing orders and other means. This frees the physician to spend more time with more complex patients and carry out important activities such as wellness planning and proactive care. But care team roles must sync with reimbursement mechanisms and requirements.
Reimbursement structures also affect the ability to implement guidelines. Guidelines may call for lab tests that the patient’s insurer may not cover or that the patient cannot afford. The tests also may be too expensive for practices to routinely obtain under capitated contracts. You will need to work with the practice to develop work-arounds to overcome this financial barrier to guideline implementation. For example, the practice might modify guidelines if appropriate. Another option is to expand your role to help practices reach out to health plans to modify terms so that the practices can deliver care not currently supported by existing payment structures.
As a facilitator, you will need to remain aware of the pressure clinicians and staff are under and modify your methods and approaches appropriately. Optimal models of care may be intellectually interesting to clinicians in these contexts but may be met with skepticism by those who are struggling to deliver even basic care to patients in short periods of time.
You will need to work with your program and the practice to evaluate how the improvements you are supporting can improve or at least not negatively affect the practice’s financial standing (e.g., streamline care, increase efficiency, secure payments for performance or QI). Resources such as the AHRQ toolkit Integrating Chronic Care and Business Strategies in the Safety Net can help you analyze the financial drivers of a safety net practice and can help you and your program identify strategies for improving practices’ bottom line. You may also want to look to financial “exemplars” in your area—practices that have found creative ways to solve some of these problems—and set up site visits or learning sessions for your practices with them to exchange ideas.
For example, group visits can be a way to increase access in cases where demand exceeds supply. They can also improve patient experience and outcomes by connecting patients to peers and strengthening their social networks. However, while group visits can be a clear improvement to patient care, depending on the State and area, a practice may have difficulty implementing them because of reimbursement rules for patient visits. Practices that have been early adopters of group visits have often found ways to overcome barriers to reimbursement. These practices can be tapped as a resource for practices that are interested in adopting but have not yet done so.
Complex and layered administrative structures. Safety net organizations, particularly FQHCs, often operate more than one practice site. Many have 3 or more sites and some as many as 40 or 50. In these cases, practice-level and organizational-level leadership structures exist. Organizations may have chief executive officers, chief financial officers, and chief operating officers in addition to site medical directors and practice managers. Sometimes what central leadership wants to change in the organization may be at odds with the needs of staff and clinicians at individual practice sites.
You will need to know the leadership and reporting structure of the organization and the priorities of both central leadership and the individual practice sites you will support. One important role for you will be to optimize communication between administration and frontline practitioners and staff. You may serve as an advocate for clinicians and staff at the practice level, helping to communicate their challenges and needs to the organization’s leadership. Similarly, you can help central leadership adapt and modify their interventions so they are the most effective at each practice site.
Complex staffing patterns. Many staff and clinicians who work in the safety net are mission driven and derive great satisfaction from caring for poor and underserved patients. In addition, care provided through FQHCs and similarly organized practices can be some of the best available anywhere. However, working in the safety net also has downsides.
Clinicians in safety net settings are typically paid less than those working in non-safety net settings. To attract and maintain clinicians in these practices, clinic leadership often offer flexible schedules and job-sharing types of arrangements. These present challenges to scheduling, empanelment, and team-based approaches to care. For example, an organization with the full-time equivalent (FTE) of 15 clinicians may actually employ 40 individuals for varying percentages of time to make up the 15 FTEs.
Turnover can also be a problem for the safety net. Intense workloads, pressure to see a patient every 15 minutes, and lower pay can create stress, job dissatisfaction, and early burnout. Thus, practices may rely heavily on temporary staff to fill workforce gaps. Furthermore, some safety net practices use volunteers who, in addition to having unpredictable schedules, may not be as responsive to directives of the practice leadership.
You will need to consider the impact of these complex staffing issues on your work with your practices as it has implications for everything from forming lasting relationships with staff and clinicians to how you schedule and structure your support sessions with a practice. These issues also have implications for core changes such as empaneling patients, implementing care teams, and ensuring that improvements are sustained over the long term. You will need to work closely with practice leadership to understand staffing issues at each practice and to determine the best way to address these challenges.
Limited management experience of practice leadership. Physicians and others practitioners who occupy leadership roles in safety net practices are often excellent clinicians but may lack essential administrative, leadership, and change management skills. You will need to be aware of this and not assume that an individual’s title implies skills in management or leadership. In some cases, you may need to provide executive coaching support to practice leadership to build their skills in these areas.
Insufficient staff and human resources. It will come as no surprise that safety net practices may lack the financial resources to hire staff to provide self-management support for patients, manage patient panels, or ensure health information systems at the practice are optimized. Some organizations solve this problem by obtaining grant funds to cover a health educator or to support a promotora program. However, these are often not sustainable solutions.
Thin staffing will have implications for any improvement work you engage in with a practice and the ability of staff to take on additional activities or roles related to the targeted improvements. You will need to remain aware of this issue and work with the QI team and leadership at the practice to design or modify improvements so that they are feasible to implement, do not cause staff burnout, and can be sustained long term.
Suboptimal Health Information Technology
Health information technology (IT) resources present yet another challenge. Improving quality of care requires robust, well-organized, and intuitive health IT systems that enable providers to manage panels of patients, easily plan and track all care, and identify and track patients with special needs. These systems should also provide decision supports at point of care that can be easily updated as new evidence is produced and treatment guidelines are changed.
Electronic health records (EHRs) have been implemented with great speed in FQHCs and other safety net settings due to financial incentives and technical support made available by the U.S. Government. However, few, if any, of the systems are designed to easily support team-based or population-based approaches to care, both of which are central to the Care Model and the Patient-Centered Medical Home. Indeed, most EHRs need substantial modification after implementation to support even the most basic population management functions.
Many times, practices opt to maintain parallel standalone registries because of the inadequacies of EHRs. This is an additional cost to the practice and can require dual data entry or purchase of expensive software to enable EHRs and the registry product to exchange data. As a facilitator, you will need to become familiar with the different EHR and registry systems your practices use. You will also need to be aware of the technical support available to them through their IT product vendors and develop a working relationship with the staff at the organization or practice charged with overseeing their EHR or registry.
Much of the work you will do as a facilitator, especially at the start of an improvement project, will involve collecting data and setting up performance reporting systems. Depending on the focus of the improvement intervention, your work may also include helping practices structure their EHRs to support panel management and cross-team communication.
Obtaining the training you need to accomplish these tasks can be difficult. Product vendors are motivated to protect information about modifying their product because technical assistance is a revenue stream. Similarly, except in large organizations that can afford dedicated IT staff, practice staff charged with maintaining health IT systems are often inexperienced working with health IT products and limited in their knowledge and skills with the product.
As you continue your training as a facilitator, you will need to look for opportunities to increase your knowledge and skills working with the EHR and registry products most commonly used in your area. You can acquire this training by:
- Sitting in with your practices when they receive vendor-led training,
- Finding and connecting with practice staff who have become “exemplars” in the use of a particular product and learning from them, and
- Seeking assistance from the Regional Extension Center (REC) in your area. The Federal Government established RECs as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act to support implementation of EHRs nationwide. RECs can provide technical support to practices related to EHRs. More information on the RECs can be found at: http://www.healthit.gov/providers-professionals/regional-extension-centers-recs. Also see Module 17.
Many of the patients who receive care through the safety net have low income, come from cultures with different health beliefs and practices, may lack fluency in English or prefer to speak a different language, and have limited health literacy. Interventions that work with more affluent, health literate, or cultural majority populations may not work with patients from a safety net practice. For example, a depression management program involving nurse followup calls with patients that was effective with middle class patients was difficult to implement in a safety net practice. When nurses would call to follow up with patients, the patients did not understand the purpose of the call and ended up coming into the practice to “see what was wrong,” creating anxiety for the patient and additional work for practice staff.
In addition, many patients receiving care in the safety net have more complex and serious illness. These conditions often result from environmental stressors, delayed access to health care and treatment, limited access to healthy food and spaces for exercise, and exposure to stressful life situations and environments.
As a practice facilitator, you will need to develop a deep understanding of the patients coming to the practice, their daily lives, and the factors affecting their health and ability to participate as partners in their care. This is particularly important as care moves to becoming more “patient centered” and activating and engaging patients as partners in care becomes the gold standard. You will need to work closely with your practices to assess the degree to which they are addressing the cultural and health literacy needs of their patients and effectively engaging patients as partners in their care.
You may also want to work with your practices to include patients on their QI teams. This can take the work of a QI team to an entirely different level of effectiveness and ensures that the work that takes place results in more patient-centered improvements. An introduction to methods for engaging patients and families as members of QI teams can be accessed at: http://www.safetynetmedicalhome.org/sites/default/files/Webinar-Patient-Family-Advisory-Councils.pdf.
Various resources are available to help practices improve their ability to address the health literacy needs of their patients. The Agency for Healthcare Research and Quality (AHRQ) has an excellent toolkit for assisting practices to improve in this area, available at http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/. The Health Resources and Services Administration (HRSA) supports the National Center for Cultural Competence, which offers a free online training on health literacy and cultural and linguistic competence, available at http://www.hrsa.gov/publichealth/healthliteracy/index.html (HRSA, undated). The Institute of Medicine’s discussion paper provides a roadmap for becoming a health-literate organization (Brach, et al., 2012). Finally, you will need to learn about the National Standards for Culturally and Linguistically Appropriate Services, available at http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15 (HHS, 2013) and build them into your work.
Challenges Accessing Specialty Care
Safety net patients can experience great difficulty accessing specialty care depending on their insurer. Similarly, clinicians working in the safety net can have problems getting specialists to respond to requests for case consultation. In the words of one safety net provider, “They are not interested in working with us because we don’t send them patients that pay.” This can create real barriers to implementing targeted improvements in your practices and can have a significant impact on patient outcomes and experience.
You can play a role in helping a practice develop productive relationships with specialty providers by conducting outreach and building communication protocols between the practices and specialists. Specialists may have misconceptions about the practices’ patients, which you can dispel, or you can enlist the help of an opinion leader in the community to gain specialists’ cooperation.
You can also help practices improve their referral processes and followup by evaluating the effectiveness of the current processes and helping the practice redesign workflow in this area. Collecting data on wait times and unmet requests for specialty care services can provide valuable information to your practices that they can use to advocate for increased support from area health plans and health departments. In addition, you can help your practices explore programs designed to improve specialty care access, such as ProjectECHO, available at http://echo.unm.edu, or to participate in telehealth initiatives in your area.
At the same time you grapple with these challenges, you will benefit from the many assets safety net organizations offer. Most staff and clinicians in FQHCs, look-alikes, and other community health centers are mission driven and work in these settings because they have a commitment to improving the lives of underserved individuals and their families. Therefore, these practices can bring the best and brightest clinicians into their field.
Similarly, many of these organizations and practices have benefited from the range of resources provided through HRSA, the Centers for Medicare & Medicaid Services, and others. These have included opportunities to participate in learning collaboratives and early access to patient registries as a way to support population management. Most practices are also required to report quality metrics to HRSA, health plans, and county, State, and local officials, so they have some data systems already in place to use for QI and practice transformation work.
FQHCs and larger community health centers often provide a wider range and more comprehensive care than many traditional, non-safety net practices. For example, FQHCs often have full dispensaries and some may even have licensed pharmacies onsite. Many have health education programs and social services to help link patients to outside resources. Still others have implemented telemedicine and e-consultation programs to facilitate specialty care access for their patients. They may also serve as training sites for residents from local medical schools and residency programs, which can help keep them abreast of the latest developments in medicine and care. It is important that you view your practices through an assets-based lens.
While these things may be less true for for-profit practices in the safety net, clinicians and staff in these private practices may welcome the support and connections you offer as a facilitator, as well as the opportunity to participate in a learning community of other practices. While quality and motives can be a concern in some of these practices, some may look very similar to community health centers and FQHCs in their area and offer comprehensive and high-quality care to their patients. For example, a private safety net practice in Los Angeles provides a full range of health education programming for its patients and access 7 days a week. The practice also opens its doors in the evening for parenting and youth groups and is active in a number of QI projects that are also taking place in the area FQHCs.
As a practice facilitator, it is important for you to be aware of the challenges your practices face in delivering care to vulnerable populations. But you also need to pay attention to the many strengths these organizations have that can be leveraged to support continuous QI and implementation of new models of patient care (Kretzmann and McKnight, 1993). This is important not only in providing resources, but also in building your practices’ confidence and hope in their ability to improve.
In later modules, you will learn about asset-based approaches to assessment and development. It is important to keep this in mind at all times, or you may not see and engage important resources available in your practices.
Brach C, Keller D, Hernandez LM, et al. Ten attributes of health literate health care organizations. Washington, DC: National Academy of Sciences; June 2012. Available at: http://www.iom.edu/Global/Perspectives/2012/HealthLitAttributes.aspx. Accessed March 22, 2013.
Huang ES, Zhang Q, Brown SES, et al. The cost-effectiveness of improving diabetes care in U.S. federally qualified community health centers. Health Serv Res 2007 Dec;42(6 Pt 1):2174-93; discussion 2294-2323.
Kretzmann J, McKnight, J. Building communities from the inside out: a path toward finding and mobilizing a community’s assets. Evanston, IL: Asset-Based Community Development Institute, Northwestern University; 1993.
Lewin ME, Altman S, eds. America’s health care safety net: intact but endangered. Washington, DC: National Academy Press; 2000. Available at: http://books.nap.edu/catalog/9612.html.
U.S. Department of Health and Human Services, Health Resources and Services Administration. Effective communication tools for healthcare professionals. Available at: http://www.hrsa.gov/publichealth/healthliteracy/index.html. Accessed March 22, 2013.
U.S. Department of Health and Human Services Office of the Secretary. National standards on culturally and linguistically appropriate services (CLAS) in health care. 2013. Available at: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15. Accessed April 25, 2013.