Journal of General Internal Medicine

, Volume 29, Issue 11, pp 1484–1490 | Cite as

Innovation in the Safety Net: Integrating Community Health Centers Through Accountable Care

  • Valerie A. Lewis
  • Carrie H. Colla
  • Karen E. Schoenherr
  • Stephen M. Shortell
  • Elliott S. Fisher
Original Research

ABSTRACT

BACKGROUND

Safety net primary care providers, including as community health centers, have long been isolated from mainstream health care providers. Current delivery system reforms such as Accountable Care Organizations (ACOs) may either reinforce the isolation of these providers or may spur new integration of safety net providers.

OBJECTIVE

This study examines the extent of community health center involvement in ACOs, as well as how and why ACOs are partnering with these safety net primary care providers.

DESIGN

Mixed methods study pairing the cross-sectional National Survey of ACOs (conducted 2012 to 2013), followed by in-depth, qualitative interviews with a subset of ACOs that include community health centers (conducted 2013).

PARTICIPANTS

One hundred and seventy-three ACOs completed the National Survey of ACOs. Executives from 18 ACOs that include health centers participated in in-depth interviews, along with leadership at eight community health centers participating in ACOs.

MAIN MEASURES

Key survey measures include ACO organizational characteristics, care management and quality improvement capabilities. Qualitative interviews used a semi-structured interview guide. Interviews were recorded and transcribed, then coded for thematic content using NVivo software.

KEY RESULTS

Overall, 28% of ACOs include a community health center (CHC). ACOs with CHCs are similar to those without CHCs in organizational structure, care management and quality improvement capabilities. Qualitative results showed two major themes. First, ACOs with CHCs typically represent new relationships or formal partnerships between CHCs and other local health care providers. Second, CHCs are considered valued partners brought into ACOs to expand primary care capacity and expertise.

CONCLUSIONS

A substantial number of ACOs include CHCs. These results suggest that rather than reinforcing segmentation of safety net providers from the broader delivery system, the ACO model may lead to the integration of safety net primary care providers.

KEY WORDS

health care reform health care costs health care delivery underserved populations safety net accountable care integrated care community health centers 

REFERENCES

  1. 1.
    Shin P, Sharac J, Alvarez C, Rosenbaum S, Paradise J. Community Health Centers in an Era of Health Reform. Kaiser Family Foundation: Washington, DC; 2013.Google Scholar
  2. 2.
    Goldman LE, Chu PW, Tran H, Romano MJ, Stafford RS. Federally qualified health centers and private practice performance on ambulatory care measures. Am J Prev Med. 2012;43(2):142–9. doi:10.1016/j.amepre.2012.02.033.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Shi L, Lebrun LA, Zhu J, et al. Clinical Quality Performance in U.S. Health Centers. Health Serv Res. 2012;47(6):2225–49.PubMedCrossRefGoogle Scholar
  4. 4.
    Epstein AJ. The role of public clinics in preventable hospitalizations among vulnerable populations. Health Serv Res. 2001;36(2):405–20.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Falik M, Needleman J, Wells BL, Korb J. Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers. Med Care. 2001;39(6):551–61.PubMedCrossRefGoogle Scholar
  6. 6.
    Hadley J, Cunningham P. Availability of Safety Net Providers and Access to Care of Uninsured Persons. Health Serv Res. 2004;39(5):1527–46. doi:10.1111/j.1475-6773.2004.00302.x.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Shi L, Stevens GD. The role of community health centers in delivering primary care to the underserved: experiences of the uninsured and Medicaid insured. J Ambulatory Care Manage. 2007;30(2):159–70. doi:10.1097/01.JAC.0000264606.50123.6d.PubMedCrossRefGoogle Scholar
  8. 8.
    Gusmano MK, Fairbrother G, Park H. Exploring The Limits Of The Safety Net: Community Health Centers And Care For The Uninsured. Health Aff (Millwood). 2002;21(6):188–94. doi:10.1377/hlthaff.21.6.188.CrossRefGoogle Scholar
  9. 9.
    Zuckerman KE, Cai X, Perrin JM, Donelan K. Incomplete Specialty Referral among Children in Community Health Centers. J Pediatr. 2011;158(1):24–30. doi:10.1016/j.jpeds.2010.07.012.PubMedCrossRefGoogle Scholar
  10. 10.
    Cook NL, Hicks LS, O’Malley AJ, Keegan T, Guadagnoli E, Landon BE. Access To Specialty Care And Medical Services In Community Health Centers. Health Aff (Millwood). 2007;26(5):1459–68. doi:10.1377/hlthaff.26.5.1459.CrossRefGoogle Scholar
  11. 11.
    Doty MM, Abrams MK, Hernandez SE, Stremikis K, Beal AC. Enhancing the Capacity of Community Health Centers to Achieve High Performance. The Commonwealth Fund; 2010.Google Scholar
  12. 12.
    McClellan MB, McKethan AN, Lewis JL, Roski J, Fisher ES. A National Strategy to put Accountable Care into Practice. Health Aff (Millwood). 2010;29(5):982–90. doi:10.1377/hlthaff.2010.0194.CrossRefGoogle Scholar
  13. 13.
    Lewis VA, Colla CH, Carluzzo KL, Kler SE, Fisher ES. Accountable Care Organizations in the United States: Market and Demographic Factors Associated with Formation. Health Serv Res. 2013;48(6):1840–58. doi:10.1111/1475-6773.12102.PubMedCrossRefGoogle Scholar
  14. 14.
    Fisher ES, Berwick DM, Davis K. Achieving health care reform—how physicians can help. N Engl J Med. 2009;360(24):2495–7. doi:10.1056/NEJMp0903923.PubMedCrossRefGoogle Scholar
  15. 15.
    Berwick DM. Making Good on ACOs’ Promise—The Final Rule for the Medicare Shared Savings Program. N Engl J Med. 2011;365(19):1753–6. doi:10.1056/NEJMp1111671.PubMedCrossRefGoogle Scholar
  16. 16.
    Fisher ES, McClellan MB, Safran DG. Building the path to accountable care. N Engl J Med. 2011;365(26):2445–7. doi:10.1056/NEJMp1112442.PubMedCrossRefGoogle Scholar
  17. 17.
    Pollack CE, Armstrong K. Accountable care organizations and health care disparities. JAMA. 2011;305(16):1706–7. doi:10.1001/jama.2011.533.PubMedCrossRefGoogle Scholar
  18. 18.
    Lewis VA, Larson BK, McClurg AB, Boswell RG, Fisher ES. The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles. Health Aff Proj Hope. 2012;31(8):1777–85. doi:10.1377/hlthaff.2012.0490.CrossRefGoogle Scholar
  19. 19.
    McWilliams JM. Accountable Care Organizations: A Challenging Opportunity for Primary Care to Demonstrate its Value. J Gen Intern Med. 2013:1-2. doi:10.1007/s11606-013-2713-9.
  20. 20.
    Neuhausen K, Grumbach K, Bazemore A, Phillips RL. Integrating Community Health Centers Into Organized Delivery Systems Can Improve Access To Subspecialty Care. Health Aff (Millwood). 2012;31(8):1708–16. doi:10.1377/hlthaff.2011.1261.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Valerie A. Lewis
    • 1
  • Carrie H. Colla
    • 1
  • Karen E. Schoenherr
    • 1
  • Stephen M. Shortell
    • 2
  • Elliott S. Fisher
    • 1
  1. 1.The Dartmouth Institute for Health Policy and Clinical PracticeGeisel School of Medicine at DartmouthLebanonUSA
  2. 2.School of Public Health and Haas School of BusinessUniversity of California, BerkeleyBerkeleyUSA

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