Achieving NCQA-PCMH Recognition: Challenges for Federally Qualified Health Centers Mobile, Alabama September 15, 2013 Jerry P Abraham, MPH, MD Candidate 2014 GE-NMF Primary Care Leadership Program Scholar University of Texas School of Medicine, San Antonio Judy Phifer Mitchell GE-NMF Primary Care Leadership Program Site Mentor Director of Healthcare Quality Franklin Primary Health Center, Inc. Rena D McAuthor Health Information Manager Franklin Primary Health Center, Inc. Prince C Uzoije, MD GE-NMF Primary Care Leadership Program Clinical Mentor Medical Director Franklin Primary Health Center, Inc. Franklin Trimm, MD GE-NMF Primary Care Leadership Program Faculty Mentor Pediatrics Residency Program Director University of South Alabama School of Medicine
Transcript
Achieving NCQA-PCMH Recognition: Challenges for Federally Qualified Health Centers
Mobile, Alabama
September 15, 2013
Jerry P Abraham, MPH, MD Candidate 2014 GE-NMF Primary Care Leadership Program Scholar
University of Texas School of Medicine, San Antonio
Judy Phifer Mitchell GE-NMF Primary Care Leadership Program Site Mentor
Director of Healthcare Quality Franklin Primary Health Center, Inc.
Rena D McAuthor Health Information Manager
Franklin Primary Health Center, Inc.
Prince C Uzoije, MD GE-NMF Primary Care Leadership Program Clinical Mentor
Medical Director Franklin Primary Health Center, Inc.
Franklin Trimm, MD GE-NMF Primary Care Leadership Program Faculty Mentor
Pediatrics Residency Program Director University of South Alabama School of Medicine
BACKGROUND The Franklin Primary Health Center (FPHC) is a private, not-for-profit Community Health Center (CHC) and Federally Qualified Health Center (FQHC), which was founded in Mobile, Alabama in 1975 to serve the health needs of underserved patients in the community. Currently, the FPHC is working to achieve recognition and designation as a National Committee of Quality Assurance (NCQA)—Patient Centered Medical Home (PCMH). In order to achieve the NCQA-PCMH designation, clinics must organize care around patients, promote team-based care, measure quality and effectiveness, and coordinate and track patient care over time. The current PCMH model originated from the chronic disease management model employed by pediatricians to care for children. The chronic disease management model requires accessible, coordinated, patient-centered care that utilizes Health-Information-Technology (HIT), coordinates office systems and protocols, and reforms reimbursement structures. The chronic disease management model has proven to be effective at improving clinical outcomes and improving the quality of care patients experience. The earliest mention of the PCMH was in 1967 by pediatricians caring for children with special needs (Ullrich 2013). Furthermore, adoption of the chronic disease management model as the template for the current PCMH model demonstrates an “epic whole practice re-imagination and redesign” by providers and clinic administrators (Nutting 2009). PCMHs have most recently been defined as “accessible, continuous, comprehensive, family-centered, coordinated, and compassionate” (Sia 2004). In 2007, the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) presented “Joint Principles of the Patient-Centered Medical Home (Table 1). Medical homes are designed to deliver patient-centered, multi-faceted personal primary health care. The success of the medical home is built on the foundation of a strong patient-physician relationship. Consequently, this central commitment to the patient results in the physician responsibly and appropriately navigating the patient through the vast continuum of care that includes referrals to specialty services, diagnostic tests and treatments (Rosenthal 2008). The PCMH model has been proven to be effective in improving health outcomes, the quality of care delivered and has resulted in higher patient satisfaction. Furthermore, evidence suggests that the PCMH model results in reduced medical errors and improved patient safety. “The better the primary care, the greater the cost savings, the better the health outcomes, and the greater the reduction in health and health care disparities” (Epstein 2001). NCQA-PCMH Recognition is voluntary and the evaluation process is designed to be transparent. The NCQA provides a license to a web-based tool that guides practices through the evaluation process. Practices then complete a self-evaluation and provide supporting documentation to validate and verify their self-assessment. A practice is defined as “One or more physicians working at a single geographic location and practice together.” The providers must spend more than half of their clinical time at the geographic site, share medical records, employ a single system of procedures to support clinical and administrative functions of practice management. Non-physician staff must follow the same procedures and protocols for all physicians within the practice. In January 2008, the NCQA’s Physician Practice Connections (PPC) developed evaluation criteria for PCMH standardization. CHCs must meet these NCQA-PPC measures in order to achieve one of three PCMH Recognition Levels: I, II, or III (Table 2). The NCQA-PPC has designated 10 “Must Pass” elements (Table 3). In order to obtain, Level I recognition, CHCs must achieve 5 of the 10 “Must Pass” criteria and additionally must score at least 25 of the available 100 points in the NCQA-PPC scoring rubric. Level II recognition requires CHCs
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to demonstrate 10/10 “Must Pass” criteria as well as achieve a minimum of 50 points. Level III recognition requires all of the criteria of Level II and a minimum of 75 points. The NCQA-PPC PCMH standards cover 9 diverse areas of practice management including: Access and Communication, Use of Registry Data, Care Management, Patient Self-Management, Test Tracking, Referral Tracking, e-Prescribing, Performance Reporting and Improvement, and Advanced Electronic Information (Table 4). An estimated 75% of FQHCs have achieved NCQA-PCMH Level III Recognition. For CHCs to continue to competitively compete for scarce resources, it is imperative for CHCs to actively work toward achieving HCQA-PCMH Level III Recognition. These newly identified standards are rapidly becoming adopted as essential measures for evaluating the performance of ambulatory healthcare delivery in the United States. The 9 standards are further sub-divided into a total of 30 elements, of which 10 are “Must Pass” elements, for a total 100 points available (Table 5). Some requirements are easier to achieve than others. Elements that are easier to achieve include: written standards for patient access/communication, data to identify important diagnoses and conditions and measured performance by physician (Table 6). While other requirements are far more challenging to achieve: using data to show that the practice meets standards for access/communication, supporting patient self-management, systematically tracking test results, and tracking referrals (Table 7). These elements may be more difficult to achieve as a result of requiring larger data infrastructure and a greater meaningful use of data, such as accurately tracking patient wait times. Furthermore, these elements may be more challenging to acquire because they require additional staff competencies (Scholle 2011). In 2011, a study conducted by the NCQA reviewed the practices that achieved NCQA-PCMH Recognition and resulted in several trends among applicants. Practices with more physicians were more likely to obtain higher levels of recognition (ie II or III). Only 52% of solo physician practices were able to achieve Level 3 Recognition compared to 78% of practices with more than 20 providers. Furthermore, multi-site practices were also found to be more likely to achieve Recognition (Scholle 2011). Three-quarters of FQHCs achieved Level III Recognition and 74% of NCQA-PCMH Pediatric Primary Care Practices achieved Level III Recognition compared to only 54% of NCQA-PCMH Adult Primary Care Practices that achieved Level III Recognition. Practices achieving Level III Recognition tend to employ greater HIT infrastructure including advanced electronic clinical data systems, e-prescribing capabilities with safety checks, electronic test tracking systems, clinical decision-making support tools, advanced care management tools, and quality improvement tools. Regardless of practice size, population management, e-prescribing, external reporting of quality measures and advanced electronic patient communication tools present challenges for all primary care practices (Scholle 2011). By October 2011, only 1500 of over 280,000 primary care practices had achieved some level of NCQA-PCMH Recognition. Furthermore, it is estimated that 13.5% of primary care practices are PCMH “ready” and 45% would meet some of the NCQA-PCMH criteria; however a staggering 41% of small and nonmetropolitan practices would not meet any NCQA-PCMH criteria. Practice size was found to be the most significant factor in predicting whether or not a practice would meet NCQA-PCMH standards, irrespective of whether they were urban or rural practices (Ullrich 2012).
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Successfully achieving NCQA-PCMH Recognition depends heavily on the number of providers and affiliations with larger organizations including academic medical centers and hospital systems. Furthermore, the most successful NCQA-PCMHs excelled at a number of best practices including: advanced care management activities, setting and monitoring patient-specific goals for chronic disease management and providing support to patients for patient self-management of chronic disease (Scholle 2011). Despite the challenges practices face, PCMHs continue to be increasingly attractive to federal agencies, state governments and third-party private payers because of the potential cost-containment measures achieved by the PCMH model. In North Carolina, the Community Care Public Program pays providers an additional $2.50 to $3.50 per patient per month depending on the NCQA-PCMH Recognition Level obtained. United Healthcare provides complimentary Health Information Techonology (HIT) support and enhanced payments for NCQA-PCMH practices. The national Bridges to Excellance program provides physicians additional payments for caring for more complex patients with complicated chronic disease conditions (Ullrich 2013). Additionally, there is no available data on how many primary care practices may have unsuccessfully attempted to achieve NCQA-PCMH Recognition. Because of the NCQA self-assessment web-based tools, many who attempt to achieve Recognition may never submit their application for Recognition. In 2010, there were 447 NCQA-PCMH Level I, II or III Recognized practices, representing 2,274 physicians, which is a small fraction of the 280,000 primary care physicians in the healthcare workforce (Scholle 2011). While three-quarters of all ambulatory care delivered in the United States is delivered by small, independently physician-owned practices with 5 or fewer providers, these very practices are least likely to achieve NCQA-PCMH Recognition. These practices are shut-out of the process and may find an environment where there is no support for their existence. The immediate and imminent threat is that many of these practices may resort to retiring early, closing their practices or selling their practices to larger medical groups or for-profit healthcare corporations. There are challenges for the NCQA in developing PCMH standards as well. They must balance providing standards that are obtainable for small and newly forming PCMH practices, while at the same time providing further direction and Recognition Levels for practices that are far exceeding Level III requirements. There are several NCQA-PCMH Elements that continue to be of importance to applicants seeking Recognition. These items include implementing and assessing patient management goals, improving EHR utilization and meaningful use of data, addressing and documenting patient health literacy. Additionally, monitoring and evaluating high impact metrics are important for improving clinic outcomes including: improving patient satisfaction, reducing patient wait times, reducing patient no-show rates, creating a more effective scheduling protocol, increasing provider productivity, and improving work flow patterns. Reducing patient no-show rates continues to prove challenging for practices seeking NCQA-PCMH Recognition. No-show appointments is defined as intended appointments that were not cancelled or rescheduled at least 2 hours before the scheduled appointment time (Izard 2005). The Medical Group Management Association (MGMA) estimates that no-show rates in clinics in the United States vary from 10% to 60% (Woodcock 2003). No show rates may even be more challenging for urban and underserved practices. In 2000, the MGMA estimated that 63% of clinics tracked missed appointments, however only 46% had policies or strategies to address missed appointments (Woodcock 2003). First, it is essential for practices to establish the meaningful-use of clinical data to determine no-show rates. A minimum of 3 months data should be analyzed. Furthermore, it is important to identify which dates have the
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highest no-show rates and factors that may affect these trends (ie holidays, weather, etc). It is also important to identify which patients miss the most appointments (Reese 2012). Common causes of no-show appointments include: no appointment reminders provided, booking appointments too far in advance, long office wait times, or difficult rescheduling or canceling processes (Table 8). Accurate scheduling is an important element in reducing no-show rates. Reducing no-show rates are directly related to the effectiveness of scheduling protocol, reducing patient wait times and patient satisfaction. For example, appointments should be scheduled appropriately and given the appropriate amount of time with the provider according to the needs of the patient (Cascardo 2005). Additionally, various strategies have been proven effective at reducing no-show rates including personal telephone reminder within 24 hours of the appointment. A prospective, randomized study of 13,505 patient appointments at the Robert Wood Johnson University Medical Group between March and July 2007 demonstrated that patients who receive a “live”, personal telephone call from clinic staff are less likely to miss appointments, 13.6% compared to 17.3% that did not receive a personal telephone reminder (Parikh 2010). Furthermore, the same study found that the overall no-show rates dropped when the personal phone calls were utilized, from 8% to 5% during one period and from 9% to 5% during another. Additionally, the study found that 85% of patients who were given a personal reminder telephone call found it helpful, compared to only 48% who received an automated call service message. Overall, 90% of all patients believed that a personal telephone call would be useful. However, personal calls to patients can often cost the clinic valuable staff time. Automated call services are a useful alternative although may not be as effective as personal phone calls. Another study demonstrated that patients were more likely to cancel their appointments in a timely manner when the clinic employed personal telephone calls (Hashim 2001). Finally, a pediatric practice increased patient attendance when telephone calls were provided 24-48 hours prior to the scheduled appointment (O’Brien 1998). An academic primary care practice in Wisconsin analyzed their no-show data in order to devise a strategy (Izard 2005). The no-show rate was found to be 30% on average. Further investigation identified that a small number of patients accounted for a large proportion of missed appointments. In 2002, the clinic has 12,100 patients who presented for their appointments and 4,438 no-shows. The 4,438 no-shows accounted for 1,300 unproductive clinic hours. Of the 2,138 patients who did not show for 4,438, 12% were responsible for 35% of the 4,438 missed appointments. Habitual no-show patients were defined as patients that did not show for (4) or more appointments. The clinic found that the majority of these 254 habitual no-show patients were patients who had complex chronic conditions requiring close monitoring. In fact, habitual patients were also found to have high show rates because these patients were most likely to need the services of the clinic regularly. The clinic employed a strategy that would not add these habitually absent patients to the schedule, rather they would be seen whenever they presented to the clinic unannounced. Additionally, these habitually absent patients are only seen by their one primary provider so as to provide the maximum continuity of care for their complex management. As a result of this strategy, the clinic reduced it’s no-show rate by over 20% (Izard 2005). A FQHC in Woodland, California, The Peterson Clinic, was found to have a no-show rate of 30%. Further investigation showed that patients at the clinic had limited access and flexibility when scheduling appointments. Furthermore, the scheduling protocol did not take into consideration patient needs or requests. The clinic was scheduling follow-up appointments 3-6 months in advance. The clinic also determined that farming season in the rural community resulted in more missed appointments, requiring the
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clinic to think about scheduling and appointment time alternatives including early morning and/or late evening appointments. The clinic also employed a strategy where when clinic staff called patients for the appointment reminder they would ask specific questions about the care the patients was seeking or services the patient needed to see if needs had changed since the last office visit. One clinic found that up to 25% of missed appointments were not necessary appointments and should have been cancelled by the clinic (Weisse 2006). The clinic also calls patients on the same-day minutes before the appointment to check-in on them and determine whether the patient will be tardy or a no-show, allowing the clinic to better manage that lost patient-encounter time. As a result of employing the various strategies and interventions, The Peterson Clinic reduced no show rates from 30% to less than 8% (Reece 2012). Additional new strategies are emerging as well. Open-access scheduling and the increased utilization of technologies and computer programs are helping. Rather than scheduling 3-6 month follow-up appoints in advance, patients are asked to call the clinic to schedule an appointment time at their convenience closer to the follow-up period. If a patient fails to schedule an appointment within 1 month of the follow-up period, the Health Information Technology (HIT) can automatically generate a reminder for the scheduling staff to contact the patient and schedule an appointment. Open-access scheduling is eliminating no-show rates altogether. With open-access scheduling, patients are seen the same day they call for an appointment, regardless of reason for visit including: urgent, acute, or routine. Under open-access scheduling, no appointments are scheduled far in advance (ie 3 months, 6months). Patients contact the clinic and are provided same-day appointments or appointments that accommodate the patients schedule, rather than a rigid clinic schedule. Furthermore, clinic staff can reach out to patients needing more attention and care and get them into the clinic more regularly and efficiently. In order to best implement open-access scheduling, practices must overhaul their scheduling infrastructure, reducing the varieties of appointments, simplying processes, using past patient behaviours to predict patient demand and needs (Cascardo 2005). However, open-access scheduling may not meet the needs of all patients, particularly patients that have more complex medical problems or require more time to arrange transportation and care. Some clinics have also found the implementation and enforcement of a “No-Show Policy” useful. Policies could include a number of occurrences (ie 3 strike rule) of no-show appointments that would then result in termination of that patient-physician relationship from the clinic. Furthermore, in 2005 the American Medical Association (AMA) adopted a policy allowing clinics to charge patients a fee for missed appointments (AMA 2005). Both of these strategies penalize patients, and while they may improve the efficiency and productivity of the clinic, they have not proven to improve health outcomes in patients. Additionally, some have found no-show penalty fees to adversely harm the clinics reputation and affecting the patient-physician relationship. Overbooking appointments, especially for clinics with chronically high no-show rates, has also proven to be somewhat immediately beneficial. However, overbooking appointments have resulted in backlog, increased patient wait times and increased staff overtime (Zeng 2009). These are all important considerations to consider when deciding to employ these strategies (Table 9). Finally, new emerging techniques are addressing no-show rates as well. The use of text messaging and email are beginning to show demonstrated utility in improving clinic attendance. While one study found that the effectiveness of these tools depends on the familiarity of these technologies by the patient, patients perceived that these tools are more beneficial than more conventional automated telephone reminders (Finklestein 2012). Most importantly, no-show rates will become less critical to clinic productivity as primary care payment reform, particularly bundled and global payment alternatives emerge, freeing up clinic staff to provide care to patients in new ways including over the phone, telemedicine, email, web portals, etc.
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METHODS In order to achieve the esteemed designation, the FPHC has already conducted preliminary assessments to identify components that require additional improvement to ensure successful accreditation. These items include: implementing and assessing patient management goals, improving EHR utilization and meaningful use of data, addressing and documenting patient health literacy. Additionally, monitoring and evaluating high impact metrics are important for improving clinical outcomes including: improving patient satisfaction, reducing patient wait times, reducing patient no-show rates, creating a more effective scheduling protocol, increasing provider productivity, and improving work flow patterns. To further investigate the following variables: patient satisfaction, wait times, no-show rates, and provider productivity data was obtained from the Management Information System (MIS) team at the FPHC Clinic. De-identified patient appointment and encounter data was compiled for the 23 various FPHC clinical sites for the 2012-2013 period (Table 10). The data was then analyzed by site for total number of patient encounters, appointments kept, appointments cancelled, and appointment no-shows. Additionally, one site was selected for further investigation. More detailed information was provided for patient encounters at the Springhill Health Center. Patients were then randomly selected and contacted to further inquire about why the patient was unable to keep their appointment. Patients were given various options to select from including: forgot, no longer needed appointment, transportation issues, currently admitted in a facility, other. In order to test the impact of personal reminder telephone calls, patients would not be contacted or provided any reminders for their appointment by clinic staff between August 26 to September 9 for all patient visits at the Springhill Health Center. Then, from September 10 to September 24, the FPHC staff will provide personal telephone reminders for all scheduled patient appointments 24-48 hours prior to their appointment. The data was compiled and then analyzed to identify the effect personal telephone calls have on patient absenteeism rates at the Springhill Health Center. Patient satisfaction survey results from 2012 were also collected and aggregated from the various FPHC clinical sites. The data was compiled and system-wide satisfaction results were produced. The patient satisfaction survey instrument utilizes a 5-level Likert scale: Great, Good, OK, Fair and Poor. The instrument is divided into 7 distinct domains: Ease of Getting Care, Wait Times, Clinical Staff (Provider, Nurse, Medical Assistant), Receptionist & Administrative Staff, Payment, Facility, Confidentiality and Other. Finally, a Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis was performed of the FPHC NCQA-PCMH application. The SWOT analysis incorporates interview data from various FPHC administrators including the: Chief Executive Officer, Chief Operating Officer, Chief Quality Officer, Chief Privacy Officer, Chief Information Officer, Chief Medical Officer, Chief Nursing Officer among others. RESULTS Between August 1, 2012 and July 31, 2013, there were 155,631 appointments scheduled at the FPHC system-wide. Of those, 94,112 (60.4%) were appointments with patient attendance, 14,976 (9.6%) resulted in cancellations and 46,451 (29.8%) resulted in patient absenteeism.
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The disaggregated data by clinic site reports the total number of scheduled appoints for each clinic site, the show rate, the cancellation rate and the no-show rate. The clinics with the highest volume of scheduled appointments include: Franklin Medical Mall Adult Medicine (28,316), Dentistry (16,828), Optometry (11,634), and OB/GYN (10,216). These were followed by Loxley Family Medical Center (10,381), Baldwin Family Health Center (8,548) and the Maysville Medical Center Adult Medicine (8,211). The clinics with the highest attendance included: Franklin Express Dental (98%), the Savage Center (76%), and Gilbertown Medical (75%). The most cancellations were found at the Springhill Health Center (24%), Central Plaza (16%), Franklin Mall Adult Medicine (15%) and the Loxley Family Dental (15%). The overall no-show rate for the Franklin Primary Health Center was 29.8%. The clinic sites with the highest no-show rates include the Franklin Medical Express (48%), Franklin Medical Mall Optometry (46%) and the Hadley Vision Center (46%). The majority of the clinic sites fell between 20% to 40% no-show rates, explaining the system-wide no-show average just below 30%. The patient satisfaction survey showed that 45% of survey respondents were “Greatly” satisfied with their experience at the FPHC. Additionally, 25% had a “Good” overall patient satisfaction, resulting in over 75% of patients have a more than positive experience. Only 4% of respondents had an overall “Poor” response. The highest patient satisfaction is ease of scheduling an appointment (65%) and all responses related to patient satisfaction of their provider (57% - 73%). The lowest satisfaction was observed with patient wait times in the waiting roomwith 15% reporting that wait times in the waiting room are “Poor” and an additional 15% reporting “Fair”.
DISCUSSION, LIMITATIONS AND RECOMMENDATIONS After completing the analysis of the patient attendance data it is clear that further investigation is required. Future analysis should further disaggregate the data to include age, sex and date of missed appointments. Additionally, future analysis would benefit from identifying habitual no-show patients and high-utilizers of clinic resources. Furthermore, due to the timing of this report, data from the patient reminder telephone call intervention is still not available as data is still being collected until September 24. This data will help elucidate the impact personal telephone call reminders have on patient absenteeism. Also, due to resource and logistical constraints, only one site was selected for the intervention study. However, it is clear from the preliminary analysis that there is significant variation between the various FPHC clinic sites. There were also unique differences between the various types of specialties, with Dental clinics and substance abuse clinics having higher than average attendance. The dental clinics and the substance abuse clinics offer services that patients are committed to receiving. This is in stark contrast to adult medicine and pediatrics where there are sufficiently high numbers of no-shows. For the pediatric population no-shows may be explained by challenges from child care, parent’s work obligations and school attendance. Adult barriers resulting in patient absenteeism may include: transportation, mobility challenges, or high acuity of illness at the time of scheduled appointment. Cancellations may also be interesting further investigation as cancellations variedly widely from 0.1% to 24%. This may point to differences in scheduling protocol or variations in personnel and the ways follow-up appointments are ordered by the provider at the end of an office visit. While reducing patient no-shows remain an important measure of clinic effectiveness and critical for NCQA-PCMH Recognition, payment reform will ultimately augment the way clinics deliver care. Clinics will
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eventually find new and innovative ways to communicate and care for patients that may not include the traditional office visit. Additionally, much caution is needed as facilities work hard to minimize no-shows. As previously reported, no-shows, specifically among habitual no-show patients, may be a symptom of a greater problem with the management and care of high-utilizers of health care. Caution must be taken to avoid penalizing the sickest patients. The motivations of for-profit healthcare organizations stem directly from the inherent desire to increase productivity and subsequently profits. The literature points to a wide range of recommendations to improve patient absenteeism rates including using new technologies such as email and SMS texting to mobile cellular telephones. Future investigation should focus on the effectiveness of these new strategies and encourage clinics to become early adopters of best practices. However, it is also important to recognize the challenges new mediums of communication present for compliance and patient privacy concerns. Establishing expensive web-based patient portals will only add additional financial burdens to practices. The patient satisfaction surveys were helpful in understanding the patient experience. It is clear from the results that patients value access to the doctor’s office and a strong patient-physician relationship. Additionally, wait times continue to adversely affect patient satisfaction and may affect other variables including no-show rates as patients may weigh not showing up for an appointment when considering how inefficient office visits may be for patients. The patient satisfaction survey analysis can be greatly improved by disaggregating by clinic site to tease out specific issues patients feel most frustrated with. Additionally, biases exist as the survey is voluntarily completed by patients as they leave the doctor’s office. Patients with exceptionally positive or negative experience may be more inclined to share their experience, skewing the survey results. A cross-sectional study should be conducted to assess patients attitudes toward the clinic and its various aspects. The SWOT analysis of the NCQA-PCMH application prepared by FPHC helps to improve its application. The NCQA-PCMH maintains a strong commitment to guiding small and resource poor practices through the Recognition process. However, the NCQA-PCMH should introduce 5-tiers for Recognition so that practices that far exceed Level III Recognition can work to obtain higher levels of Recognition. In the long run, new, more challenging levels of recognition will help to identify new and emerging best-practices and provide new goals for NCQA-PCMH practices to strive for as they improve the care for their patients. Nonetheless, many challenges face CHCs attempting to fulfill the requirements necessary to achieve the NCQA-PCMH Recognition Status. For example, to better track wait times, more data must be collected and must be more easily accessible and useable. Furthermore, some of these tasks may require additional staff competencies that are difficult for smaller practices to provide. One example of the challenges facing smaller practices hoping to achieve NCQA-PCMH recognition, is the need for CHCs to employ robust Electronic Health Record (EHR) systems. Despite the essential utility and ubiquity of these systems, EHR systems pose significant financial challenges for smaller CHCs and require significant training and time investment of physicians, nurse practitioners, nurses and other members of the health care delivery team. While there may exist a plethora of EHR solutions, many are exorbitantly cost prohibitive. Furthermore, complex levels of regulations, requirements and privacy measures result in CHCs needing to purchase and utilize expensive products from a small number of large for-profit EHR products, who certainly have a monopoly over EHR. If there is a realistic, desire for CHCs to obtain NCQA-PCMH Recognition,
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then it is of utmost importance that open-source or publicly developed and available EHR systems are employed. These systems should be developed so as to comply with all of the current requirements, but then made widely available for adoption by CHCs. Practices should not have to choose between joining larger practices or forging new affiliations in order to achieve NCQA-PCMH Recognition. There should not exist a “Go it alone” versus strive for NCQA-PCMH Recognition ultimatum. Without proceeding cautiously, NCQA-PCMH may inadvertently be driving the primary care landscape towards highly corporatized, for-profit environments that are extremely difficult for primary care practices to compete in. Additionally, these practices, while working to contain health care costs, result in large overhead and infrastructure including multiple health care administrators that are far removed from patient-centered healthcare delivery. Overtime, efforts to reduce costs using the PCMH model may even result in less necessary care delivered and the optimization of profits. There also exist many inherent biases within the NCQA-PCMH standards. The standards are far easier for larger practices to achieve. Many of these larger practices are for-profit or affiliated with large academic institutions or well-funded public organizations. The financial resources necessary to transform practices into PCMHs are often insurmountable for small and solo practices, and underserved communities without large public infrastructure or academic medical centers. Furthermore, these smaller, community-based not-for-profit or public systems may find it more difficult to compete in an ever highly corporatizing health care market place, especially when standards such as the NCQA-PCMH designation gain popularity, importance and become necessary for survival. CHCs are met with many challenges in light of increasing pressure to achieve NCQA-PCMH recognition. Purchasing expensive Electronic Health Record (EHR) platforms is one example. The Health Information Technology for Economic and Clinical Health Act (HITECH) of the American Recovery and Reinvention Act (ARRA) and the Patient Protection and Affordable Care Act (PPACA), both provide some resources, financial investment and incentives for the migration of paper-based health records to EHR. However, due to complex regulations and requirements, there only exist a handful of EHR products available to primary care practices and these for-profit EHR monopolies of the health data infrastructure put many of these products out of reach for smaller or resource poor practices. A national network of EHR inter-operability may be the only way to achieve the ideal patient data management system. It would be best if this system is publicly available to all healthcare delivery systems and publicly financed. Furthermore, these increased pressures force CHCs to coordinate and form partnerships with for-profit in-patient facilities, academic medical centers, and other organizations which may have both benefits and liabilities associated with such agreements and alliances. The complex healthcare delivery landscape is far more challenging for smaller organizations to exist and navigate in. This new landscape often forces the hand of the clinics to join the further monopolization of healthcare delivery by a small number of entities in any given environment. The bottom-line is that large financial incentives and infusion of new capital is necessary for increasing the number of primary care practices that could achieve NCQA-PCMH Recognition. Without a large infusion of capital, only the largest practices with robust resources and affiliations will continue to be recognized by the NCQA. Further investigation should also investigate the tax status of the NCQA-PCMHs. It is important to understand whether the NCQA-PCMH model has diversified or narrowed the primary care health care landscape. Are more organizations for-profit, public, not-for-profit? Has the standards encouraged the formation of much
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larger primary care organizations that may have conflicting interests? Furthermore, further investigation is needed to fully understand and quantify the infusion of capital that is needed to achieve Recognition and any affiliations, if any, that are forged as a result of the practices proceeding through the Recognition process. Identifying and transparently reporting any perverse or inherent incentives will continue to be critical for the future success of the NCQA-PCMH Recognition program. CONCLUSION There continues to exist a critical need for incentives and assistance for the vast majority of primary care practices that desire to transition to the PCMH model and those that continue to fail to gain NCQA-PCMH Recognition. An estimated, 75% of Federally Qualified Health Centers (FQHC) have achieved NCQA-PCMH Level III recognition. Therefore, it is imperative that the Franklin Primary Health Center continue to work diligently to obtain the same status in order to better compete for the various financial incentives available for CHCs. CHCs will continue to be challenged and taxed as new and emerging requirements for ambulatory healthcare delivery continue to be developed.
LITERATURE REVIEW
1. Berg, B. Estimating the cost of no-shows and evaluating the effects of mitigation strategies. Journal of Medical Decision Making. 20 March 2013.
2. Calman NS, Hauser D, Weiss L, Waltermaurer E, Molina-Ortiz E, Chantarat T, Bozack A. Becoming a patient-centered medical home: a 9-year transition for a network of Federally Qualified Health Centers. Ann Fam Med. 2013 May-Jun;11 Suppl 1:S68-73. Cascardo, D. Reducing the rate of “no-show” appointments isn’t easy, but it can be done. Medscape. March 8, 2005.
3. Chang A, Bowen JL, Buranosky RA, Frankel RM, Ghosh N, Rosenblum MJ, Thompson S, Green ML. Transforming primary care training--patient-centered medical homeentrustable professional activities for internal medicine residents. J Gen Intern Med. 2013 Jun;28(6):801-9.
4. Egger MJ, Day J, Scammon DL, Li Y, Wilson A, Magill MK. Correlation of the Care by Design primary care practice redesign model and the principles of the patient-centered medical home. J Am Board Fam Med. 2012 Mar-Apr;25(2):216-23. d
5. Fifield J, Forrest DD, Martin-Peele M, Burleson JA, Goyzueta J, Fujimoto M, Gillespie W. A randomized, controlled trial of implementing the patient-centered medical home model in solo and small practices. J Gen Intern Med. 2013 Jun;28(6):770-7.
6. Fifield J, Forrest DD, Burleson JA, Martin-Peele M, Gillespie W. Quality and efficiency in small practices transitioning to patient centeredmedical homes: a randomized trial. J Gen Intern Med. 2013 Jun;28(6):778-86.
7. Gabbay RA, Bailit MH, Mauger DT, Wagner EH, Siminerio L. Multipayer patient-centered medical home implementation guided by the chronic care model. Jt Comm J Qual Patient Saf. 2011 Jun;37(6):265-73.
8. Green EP, Wendland J, Carver MC, Hughes Rinker C, Mun SK. Lessons learned from implementing the patient-centered medical home. Int J Telemed Appl. 2012;2012:103685.
9. Hashim, M., Franks, P., & Fiscella, K. (2001). Effectiveness of telephone reminders in improving rate of appointments kept at an outpatient clinic: A randomized controlled trial. Journal of the American Board of Family Practice, 14(3), 193-196.
10. Izard, T. Managing habitual no-show patients. Family Practice Management. 2005 Feb: 12(2):65-66.
11. O’Brien, G., & Lazebnik, R. (1998). Telephone call reminders and attendance in an adolescent clinic. Pediatrics, 101(6), e6- e13.
12. Parikh A, Gupta K, Wilson AC, Fields K, Cosgrove NM, Kostis JB. The effectiveness of outpatient appointment reminder systems in reducing no-show rates. Am J Med. 2010;123:542-548
13. Reece, S. How to stop no-shows. Medscape. November 20, 2012.
14. Rittenhouse, D. R., Schmidt, L. A., Wu, K. J. and Wiley, J. (2013), Incentivizing Primary Care Providers to Innovate: Building Medical Homes in the Post-Katrina New Orleans Safety Net. Health Services Research. doi: 10.1111/1475-6773.12080
15. Rosenthal, T. The medical home: growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008 Oct; 21(5): 427–440.
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16. Scholle SH, Asche SE, Morton S, Solberg LI, Tirodkar MA, Jaén CR Support and strategies for change among small patient-centered medical home practices. Ann Fam Med. 2013 May-Jun;11 Suppl 1:S6-13. doi: 10.1370/afm.1487.
17. Scholle SH, Saunders RC, Tirodkar MA, Torda P, Pawlson LG. Patient-centered medical homes in the United States. J Ambul Care Manage. 2011 Jan-Mar;34(1):20-32. doi: 10.1097/JAC.0b013e3181ff7080.
18. Ullrich FA, MacKinney AC, Mueller KJ. Are primary care practices ready to become patient-centered medical homes? J Rural Health. 2013 Spring;29(2):180-7.
19. Weisse, P. No show reduction playbook. Patient Redesign Group. 2006.
20. Woods R. The effectiveness of reminder phone calls on reducing no-show rates inambulatory care. Nurs Econ. 2011 Sep-Oct;29(5):278-82.
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APPENDIX: TABLES & GRAPHS
TABLE 1. JOINT PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME
1. Patients should have a personal relationship with their Primary Care Physician.
2. The Patient-Centered Medical Home (PCMH) should be led by the Primary Care Physician (PCP), leading a team who collectively care for the patients.
3. Holistic Approach where the physician provides for all of the patient’s healthcare needs and taking responsibility for appropriately arranging care with other professionals. Care should include: acute, chronic, preventive and address end-of-life.
4. Care is coordinated and integrated (specialists, hospitals, home health, nursing home) and includes the community (family members, the public and private community-based services). Coordination and integration is facilitated by registries, information technology, health information exchange, etc. Care should also be culturally and linguistically appropriate.
5. Quality and patient safety continue to be hallmark values of the care provided.
6. Enhanced access to care includes: open scheduling, expanded hours, new communication mediums between patients, their personal physician, and practice staff.
7. Payment appropriately compensates for the additional value added using the PCMH.
7. PPC 6A Tracks tests and identifies abnormal results systematically
STANDARD VII: REFERRAL TRACKING
8. PPC 7A Tracks referrals using paper-based or electronic system
STANDARD VIII: PERFORMANCE REPORTING AND IMPROVEMENT
9. PPC 8A Measures clinical and/or service performance by physician or across the practice
10. PPC 8C Reports performance across the practice or by physician
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Table 4. NCQA-PCMH AREAS OF PRACTICE MANAGEMENT
1. Standard I: Access and Communication
2. Standard II: Patient Tracking and Registry Functions
3. Standard III: Care Management
4. Standard IV: Patient Self-Management Support
5. Standard V: Electronic Prescribing
6. Standard VI: Test Tracking
7. Standard VII: Referral Tracking
8. Standard VIII: Performance Reporting and
Improvement
9. Standard IX: Advanced Electronic Communications
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TABLE 5. NCQA-PCMH ELEMENTS
STANDARD I: ACCESS AND COMMUNICATION (9) POINTS
PPC 1A Has written standards for patient access and patient communication
MUST PASS 4
PPC 1B Uses data to show it meets its standards doe patient access and communication
MUST PASS 5
STANDARD II: PATIENT TRACKING AND REGISTRY FUNCTIONS (21) POINTS
PPC 2A Use data system for basic patient information (mostly non-clinical data)
2
PPC 2B Has clinical data system with clinical data in searchable data fields
3
PPC 2C Uses the clinical data system 3
PPC 2D Uses paper or electronic-based charting tools to organize clinical information
MUST PASS 6
PPC 2E Uses data to identify important diagnoses and conditions in practice
MUST PASS 4
PPC 2F Generates lists of patients and reminds patients and clinicians of services needed (population management)
3
STANDARD III: CARE MANAGEMENT (20) POINTS
PPC 3A Adopts and implements evidence-based guidelines for three conditions
MUST PASS 3
PPC 3B Generates reminders about preventive services for clinicians
4
PPC 3C Uses non-physician staff to manage patient care 3
PPC 3D Conducts care management, including care plans, assessing progress, addressing barriers
5
PPC 3E Coordinates care/follow-up for patients who receive care in inpatient and outpatient facilities
5
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STANDARD IV: PATIENT SELF-MANAGEMENT SUPPORT (6) POINTS
PPC 4A Assesses the language preference and other communication barriers
2
PPC 4B Actively supports patient self-management MUST PASS 4
STANDARD V: ELECTRONIC PRESCRIBING (8) POINTS
PPC 5A Uses electronic system to write prescriptions
3
PPC 5B Has electronic prescription writer with safety checks 3
PPC 5C Has electronic prescription writer with cost checks 2
STANDARD VI: TEST TRACKING (13) POINTS
PPC 6A Tracks tests and identifies abnormal results systematically
MUST PASS 7
PPC 6B Uses electronic systems to order and retrieve tests and flag duplicate tests
6
STANDARD VII: REFERRAL TRACKING (4) POINTS
PPC 7A Tracks referrals using paper-based or electronic system
MUST PASS 4
STANDARD VIII: PERFORMANCE REPORTING AND IMPROVEMENT (15) POINTS
PPC 8A Measures clinical and/or service performance by physician or across the practice
MUST PASS 3
PPC 8B Survey of patients’ care experience 3
PPC 8C Reports performance across the practice or by physician
MUST PASS 3
PPC 8D Sets goals and takes action to improve performance 3
PPC 8E Produces reports using standardized measures 2
PPC 8F Transmits reports with standardized measures electronically to external entities
1
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STANDARD IX: ADVANCED ELECTRONIC COMMUNICATIONS (4) POINTS
PPC 9A Availability of interactive website 1
PPC 9B Electronic patient identification 2
PPC 9C Electronic care management support 1
TABLE 6. EASIER TO ACHIEVE ELEMENTS
PPC 1A Has written standards for patient access and patient communication
PPC 2E Uses data to identify important diagnoses and conditions in practice
PPC 8A Measures clinical and/or service performance by physician or across the practice
TABLE 7. DIFFICULT TO ACHIEVE ELEMENTS
PPC 1B Uses data to show it meets its standards doe patient access and communication
PPC 4B Actively supports patient self-management
PPC 6A Tracks tests and identifies abnormal results systematically
PPC 7A Tracks referrals using paper-based or electronic system
TABLE 8. COMMON CAUSES OF NO-SHOW APPOINTMENTS
1. Patients lack a strong connection to the clinic and patient-physician relationship (including new patients and patients that are bounced around between various providers in the same practice)
2. Patients have not been adequately educated by clinic staff regarding the care they require.
3. Patients wait long periods of time before being able to schedule appointments.
4. Patients experience long wait times in the waiting room.
5. Patients do not receive high quality customer service from clinic staff.
6. Additionally, a variety of patient-related issues affect no-show rates including: lack of transportation, scheduling conflicts, or too ill at the time of the scheduled appointment.
7. Patient no longer requires appointment or clinic services scheduled.
8. Inaccurate appointments scheduled or clinic scheduling protocols fail.
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TABLE 9. CURRENT STRATEGIES FOR REDUCING NO-SHOW RATES
1. A strong patient-physician-clinic staff relationship. Patients are less likely to miss appointments when they feel that the clinic staff care about them and are providing them with a necessary, invaluable service.
2. Effective and accurate scheduling protocol including providing patients with the appropriate amount of time with provider based on the needs of the patient.
3. Cancel appointments that are no longer necessary. (For example, if results return or patient’s condition changes and no longer requires the follow-up visit.
3. Personal telephone reminders within 24-48 hours of the appointment (automated call services could be utilized but may not be as effective).
4. Providing appointment options to meet the needs of the patient and community. For example, later hours during the planting season for rural, farming communities.
5. Do not schedule appoints more than 3 months in advance.
6. Instruct patients to call and schedule an appointment closer to the follow-up period. If the patient falls to schedule an appointment, the clinic scheduling protocol should remind scheduling staff to contact the patient.
7. Use an Open Access scheduling system, where patients are provided same-day appointments and no appointments are made in advance.
8. Implement and enforce a “No Show Policy”. Patients have a set number of unexcused missed appointments before they are terminated from the clinic.
9. Charging patients penalties and fees for missed appointments.
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TABLE 10. FRANKLIN PRIMARY HEALTH CENTER Clinical Sites 1. Aiello Buskey Medical Center Adult Medicine
2. Aiello Buskey Medical Center Pediatrics
3. Baldwin Family Health Center
4. Central Plaza Towers Medical Center
5. Franklin Medical and Dental Express Adult Medicine
6. Franklin Medical and Dental Express Dentistry
7. Franklin Medical Mall Adult Medicine
8. Franklin Medical Mall Dentistry
9. Franklin Medical Mall OB/GYN
10. Franklin Medical Mall Optometry
11. Franklin Medical Mall Pediatrics
12. Gilbertown Dental
13. Gilbertown Medical
14. Savage Center
15. Hadley Vision Center
16. Loxley Family Dental
17. Loxley Family Medical
18. Maysville Medical Center Adult Medicine
19. Maysville Medical Center Pediatrics
20. North Baldwin Family Health Center
21. Springhill Health Center
22. West Mobile Family Medicine
23. West Mobile Pediatrics
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TABLE 11. PATIENT SATISFACTION SURVEY
EASE OF GETTING CARE Ease of scheduling an appointment Clinic hours Convenience of location Prompt return of phone calls
WAIT TIMES Time in waiting room Time in exam room Waiting for tests to be performed Waiting for test results
PROVIDERS (Physician, Dentist, Physician Assistant, Nurse Practitioner) Listens to you Takes enough time with you Explains what you want to know Gives you good advice and treatment
NURSES AND MEDICAL ASSISTANTS Friendly and helpful to you Answers your questions
RECEPTIONISTS & ADMINISTRATIVE STAFF Friendly and helpful to you Answers your questions
PAYMENT: What you pay Explanation of charges Collection of payment/money
FACILITY Neat and clean building Ease of finding where to go Comfort and safety while waiting Privacy
CONFIDENTIALITY Keeping my personal information private
OTHER The likelihood of referring your friends and relatives to us Do you consider this center your regular source of care
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TABLE 12. FRANKLIN PRIMARY HEALTH CENTER PATIENT APPOINTMENT ATTENDANCE, CANCELLATION AND ABSENTEEISM BETWEEN AUGUST 2012 AND JULY 2013
TOTAL APPOINTMENTS SCHEDULED 155,631 (100%)
TOTAL APPOINTMENTS KEPT 94,112 (60.4%)
TOTAL APPOINTMENTS CANCELLED 14,976 (9.6%)
TOTAL APPOINTMENTS NO SHOW 46,451 (29.8%)
FIGURE 1. FRANKLIN PRIMARY HEALTH CENTER PATIENT APPOINTMENTS KEPT, CANCELLED AND NO-SHOW
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Table 12. Appointments, Attendance Rates, Cancellations and Absenteeism Rates by site
Scheduled Show Show Cancelled Cancelled No
Show
No
Show
FRANKLIN PRIMARY HEALTH CENTER 155631 94112 60.5% 14976 9.6% 46451 29.8%
Aiello Buskey Medical Center Adult Medicine 6048 3972 65.7% 365 6.0% 1711 28.3%
Aiello Buskey Medical Center Pediatrics 3703 2599 70.2% 118 3.2% 986 26.6%
Baldwin Family Health Center 8548 5525 64.6% 844 9.9% 2179 25.5%
Central Plaza Towers Medical Center 2987 1689 56.5% 478 16.0% 820 27.5%
Franklin Medical and Dental Express Adult
Medicine
1093 557 51.0% 17 1.6% 519 47.5%
Franklin Medical and Dental Express Dentistry 1095 1076 98.3% 1 0.1% 18 1.6%
Franklin Medical Mall Adult Medicine 28316 15961 56.4% 4198 14.8% 8156 28.8%
Franklin Medical Mall Dentistry 16828 8881 52.8% 1625 9.7% 6322 37.6%
Franklin Medical Mall OB/GYN 10216 5541 54.2% 602 5.9% 3982 39.0%
Franklin Medical Mall Optometry 11634 5570 47.9% 695 6.0% 5369 46.1%
Franklin Medical Mall Pediatrics 7201 4791 66.5% 414 5.7% 1996 27.7%
Gilbertown Medical 3061 2291 74.8% 139 4.5% 631 20.6%
Savage Center 4694 3553 75.7% 611 13.0% 530 11.3%
Hadley Vision Center 1070 553 51.7% 26 2.4% 491 45.9%
Loxley Family Dental 6981 4526 64.8% 1019 14.6% 1436 20.6%
Loxley Family Medical 10381 6660 64.2% 635 6.1% 3086 29.7%
Maysville Medical Center Adult Medicine 8211 5300 64.5% 773 9.4% 2138 26.0%
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Maysville Medical Center Pediatrics 4007 2590 64.6% 207 5.2% 1210 30.2%
North Baldwin Family Health Center 1465 1093 74.6% 127 8.7% 245 16.7%
Springhill Health Center 5733 3256 56.8% 1380 24.1% 1097 19.1%
West Mobile Family Medicine 6826 4232 62.0% 343 5.0% 2251 33.0%
West Mobile Pediatrics 1833 1291 70.4% 46 2.5% 496 27.1%
FIGURE 2. NO SHOW RATES FOR THE FRANKLIN PRIMARY HEALTH CENTER
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FIGURE 3. NO SHOW RATES FOR THE FRANKLIN PRIMARY HEALTH CENTER BY SITE
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GREAT GOOD OK FAIR POOR
EASE OF RECEIVING CARE 46% 30% 11% 2% 1%
Ability to schedule an appointment
Clinic hours 65% 27% 4% 4% 0%
Convenience of clinic location 45% 38% 16% 1% 0%
WAITING 42% 31% 16% 11% 0%
Time in waiting room
Time in exam room 37% 28% 15% 15% 15%
Waiting for tests to be performed 36% 33% 22% 9% 0%
Waiting for test results 35% 33% 21% 11% 0%
PROVIDERS 35% 33% 16% 10% 6%
Listen to you
Takes enough time with you 60% 14% 14% 12% 0%
Explains what you want to know 59% 14% 13% 11% 3%
Gives you good advice and treatment 73% 16% 3% 8% 0%
NURSES & MEDICAL ASSISTANTS 57% 25% 13% 5% 0%
Friendly and helpful to you
Answers your questions 51% 22% 13% 11% 3%
RECEPTIONISTS 49% 12% 13% 11% 5%
Friendly and helpful to you
Answers your questions 50% 14% 13% 11% 12%
ADMINISTRATIVE STAFF 49% 15% 13% 11% 12%
Friendly and helpful to you
Answers your questions 47% 22% 13% 11% 7%
PAYMENT 46% 25% 13% 11% 5%
What you pay
Explanation of charges 29% 26% 15% 22% 8%
Collection of payment 30% 27% 14% 27% 2%
FACILITY 29% 27% 14% 25% 5%
Neat and clean building
Ease of finding where to go 42% 32% 24% 2% 0%
Comfort and safety while waiting 49% 33% 13% 5% 0%
Privacy 41% 29% 13% 3% 2%
CONFIDENTIALITY 39% 21% 24% 12% 4%
Keeping personal information private
OTHER 41% 12% 39% 7% 1%
The likelihood of referring friends and relatives 37% 24% 21% 10% 8%
Is this clinic your primary source of healthcare? 49%
OVERALL 45% 25% 15% 10% 4%
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FIGURE 4. OVERALL PATIENT SATISFACTION
45%
25%
15%
10%
4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
GREAT GOOD OK FAIR POOR
FRANKLIN PRIMARY HEALTH CENTER
OVERALL PATIENT SATISFACTION
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TABLE 15. SWOT ANALYSIS OF FRANKLIN PRIMARY HEALTH CENTER NCQA-PCMH APPLICATION
STRENGTHS WEAKNESSES Federally Qualified Health Center (FQHC)
Large, multi-provider organization
Multi-specialty, multi-center practice
Robust EHR system
Uses e-prescribing technology
Tracks diagnostic tests electronically
Well-respected, well-established in the community
Highly talented, dedicated staff to the success of the clinic
No formal affiliations with Academic Medical Center or Hospital System
EHR inoperability makes data sharing between in-patient and out-patient facilities difficult
NCQA-PCMH Level III Recognition may be more difficult to achieve without a large infusion of capital
Improving health literacy of patient population remains challenging
OPPORTUNITIES THREATS Integrating more technologies into clinic and
administrative functions
Potential partnership opportunities with specialty clinics and hospitals
Potential to be an ACGME Teaching Health Center
Increased meaningful use of health data presents many opportunities for targeted patient outreach and health programs
Potential for NHSC Scholars to serve at FPHC clinic sites
Continued partnerships such as the GE-NMF PCLP program presents unique research and community service learning opportunities
The Affordable Care Act provides new coverage options for patients, including possibly subsidies for products from the Federal Health Insurance Marketplace, which will result in greater access to care for patients. Additionally, some unfunded patients may become funded patients, helping to alleviate the financial burden imposed on the FPHC by caring for underserved and often uninsured patients.
Funding for underserved, uninsured patients continues to pose challenges
Other FQHCs and CHCs competing in the same geographic healthcare market
Not-for-profit healthcare organizations continue to face stiff pressures in an ever corporatizing healthcare delivery marketplace. Future challenges competing with large public and for-profit organizations loom.
Gulf Coast continue to face unique economic, catastrophic and natural challenges including the current Recession, the BP Oil Spill, Hurricanes, Tornados. These disasters pose risks and liabilities for the capital assets of the clinic, especially the physical clinic structures and mobile units
