By Nicole Kapinos, DNP, RN
Director of Population Health/Quality Improvement
The Federally Qualified Health Center Urban Health Network (FUHN) was established from the existing Neighborhood Health Care Network (NHCN) in 2012 and functions as a virtual Accountable Care Organization (ACO) which participates in Minnesota as an Integrated Health Partnership (IHP) and nationally as a Health Center Controlled Network (HCCN). FUHN was the first FQHC-only safety net Medicaid ACO in the nation. FUHN is comprised of ten member organizations which are Federally Qualified Health Centers (FQHC) or FQHC look-alikes:
· People’s Center Clinics & Services
· Indian Health Board of Minneapolis
· Native American Community Clinic
· Neighborhood HealthSource
· Open Cities Health Center
· Southside Community Health Services
· United Family Medicine
· AXIS Medical Center
· Community University Health Care Center (CUHCC)
· Minnesota Community Care
FUHN’s clinics have a long and proven commitment to serving their communities. The newest clinics participating in FUHN are AXIS Medical Center, which was founded in 2008 to serve the Somali and East African community with culturally and linguistically competent health care, and the Native American Community Clinic (NACC), which was founded in 2003 by three female physicians with many years of combined experience working in an FQHC setting and serving Native Americans. The oldest is United Family Medicine, which traces its history of serving needy community residents to the 1920s and its original predecessor organization, the Wilder Dispensary. The seven other organizations fall in between, having actively served their communities for decades.
Many of the network health centers were founded by neighborhood residents seeking to improve access to low-cost, quality health care. All FUHN clinics provide primary care and enabling services, are health care home certified, and work closely with many community partners such as county agencies, community mental health centers, racial and ethnic community organizations, and schools. This foundation of community members – both as planners and consumers of the services offered – is a continuing hallmark of the FQHCs. FUHN’s clinics are committed to advancing health equity, which means they believe people who experience the greatest disparities deserve not just the same level of access to mainstream health care services, but additional services and support so they can overcome the additional barriers and complexities they must face in order to be healthy and obtain the health care services they need.
Collectively, FUHN’s clinics serve over 111,000 patients, of those 91% represent diverse populations, 95% have incomes below 200% of the federal poverty level, and 41% are best served in language other than English. There are approximately 55,000 Medicaid/MN Care patients that are served at the FUHN clinics with 31,000+ of those patients attributed to the FUHN IHP/ACO. Communities of color, immigrants and refugees served by FQHCs experience a myriad of socio-economic, cultural, language, and other barriers to care; consequently, they bear a disproportionate burden of disease with higher rates of negative health outcomes. These realities result in a high burden upon the clinics to impact health disparities with positive outcomes.
In 2010, the Minnesota Legislature mandated the Minnesota Department of Human Services to develop a demonstration project for alternate healthcare delivery systems. The IHP program was born out of this legislation. FUHN clinic CEOs came together to join the IHP demonstration project because they recognized the opportunity to leverage their resources, foster collaboration with like-minded healthcare providers, improve the quality of care they offered their patients, and learn the new value-based payment landscape together. They also recognized that the healthcare environment was quickly changing around them, and they wanted to be active participants in payment reform. The CEOs realized that this was their opportunity to provide a voice for the underserved and shape the changes that were taking place around them rather than be shaped by those changes.
During the first IHP contract period (2013 – 2015), FUHN engaged a strategic partner to provide operational and data analytic support. FUHN also established monthly meetings with various stakeholders including clinical quality improvement, medical directors, and administration/leadership. Population health management and care management strategies were developed based on the data analysis provided by the strategic partner. FUHN deployed these strategies in various ways including patient education, outreach to patients, and other care coordination activities. Because FUHN is comprised of 10 disparate clinics, strategies had to be tailored to meet the needs of different patient populations, different provider/staff resource availability, and different organizational priorities. This was challenging work that resulted in a significant payoff in terms of decreased total cost of care and increased quality of care for the patients served by FUHN clinics. For example, from 2013 to 2016 Emergency Department visits were reduced by 23% and inpatient visits were reduced by 14%. These and other improvements in care resulted in a sixteen-million-dollar reduction in costs for the Medicaid attributed population (2013 – 2015). Due to FUHN being the nation’s first FQHC-led virtual ACO, the Commonwealth Fund and researchers from Dartmouth University studied FUHN and highlighted the following attributes as keys to its success: committed leadership team focused around a singular purpose, partnership with its strategic partner, and the diversity of programs, services, and experiences among the ten FQHCs.
FUHN continued to innovate through its second and into its third IHP contract. FUHN recognized early on that integrating clinical data from the electronic health record with the IHP claims data would allow the clinics to better target their efforts around population health management and care coordination. To that end, FUHN received a grant to support a health information technology initiative around interoperability and health information exchange. FUHN is also the recipient of the Health Center Controlled Network grant through HRSA which allows FUHN to employ staff to provide strategic support, run the health information technology initiative and infrastructure, provide data analysis, population health management and quality initiatives.
FUHN utilizes its clinical quality improvement group and chronic disease specific subgroups to develop programs and best practices to improve quality of care. For example, quality metrics indicated that the percentage of patients with hemoglobin A1c readings greater than 9 was increasing. Therefore, a diabetes subgroup was established to develop a care protocol for diabetes management that touched every area of care delivery. The group was comprised of quality staff, a medical director, certified diabetes educators, and nurses from many of the clinics. Evidence based protocols and existing clinic resources were combined to create a FUHN level Diabetes protocol. The protocol was validated by the medical directors from all clinics. The diabetes subgroup then tracked a sample of patients at each clinic to see if the protocol resulted in the desired reduction in hemoglobin A1c values. It was successful and the clinics were polled about which resources they were lacking to fully implement the protocol. Most clinics cited a lack of clinical pharmacy resources. FUHN was able to provide a clinical pharmacy resource to two clinics through the University of Minnesota Pharmacy Leadership Residency program which was funded by a grant from UCare. This grant allowed FUHN and the resident to design and implement a pilot program in which a clinical pharmacist and community health worker partnered to deliver comprehensive medication management services which also addressed the social determinants of health that may be preventing the patient from achieving optimal control of their hemoglobin A1c. Over 2018, FUHN clinics were able to reduce the number of patients with an A1c of greater than 9 by 7.0%.
FUHN clinics remain committed to advancing heath equity by continuous refinement and evolution its processes and methods by utilizing its data analytics, clinical quality metrics and organizational priorities to target areas of improvement.