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Case Study 1
Federally Qualified Health Center (FQHC) health centers aimed at providing care for undeserved
areas such as - clinical care, transportation, translation and education
Qualified Health Center challenges
Economic slowdown
shifting demographic trends
shifting disease burden
increasing complexity of delivery of healthcare system
health and healthcare disparities
healthcare workforce shortage
rapid rate of technological growth
Health center impact
as of 2020 nearly 1400 FQHC's provide care at 13000 sites across all 50 states and every US
teritory
My Health GPS
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A coordinated care benefit program form medicaid beneficiaries with three or more chronic
conditions enrolled in either FFS or managed care plans
- seeks to improve outcomes and reduce unnecessary hospitalizations and emergency dept visits
by integrating interdisciplinary team led by primary care
Reach of My Health GPS
Targets about 25000 beneficiaries with 3 or more chronic conditions
Visits of GPS groups
Group 1 - two 25 minute contacts per month w/ care team
Group 2 - (higher acuity) - six 40 minute contacts per month w/ care team
Staffing of My Health GPS
Health home manager
Nurse care manager
Care coordinator
Social Worker
Licensed clinical pharmacist
Community health worker or peer navigator
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GPS provider payments
providers paid on per-member per-month(PMPM) basis
providers must:
1). inform beneficiary of this health home benefit
2). receive consent from beneficiary
3). develop care plan for beneficiary
Provider must deliver at least one home health visit w/n a given month to receive (PMPM)
Group acuity determines payment size for providers
Why Study Vulnerable Populations?
- Vulnerable populations have significantly greater health needs
- prevalence of vulnerability in US increasing
- Vulnerability is influenced by social forces and therefore should be remedied by them
- Vulnerability is fundamentally linked with national resources
- Vulnerability and equity cannot coexist
Minnesota's measuring adolescent depression screening and treatment in medicaid
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Minnesota uses several tools to screen for and treat adolescent depression
- MN still struggles with high rates of depression (43.4%) but 90% of adolescents who had well-
child visits also had some sort of mental health or depression screening
- Reporting and measurement systems continue to show positive influence on preventive care
quality measures of importance in public health
Injury Prevention and Control
Growing recognition of costs of injuries to a person and to society and of their predictability and
preventability helped promote the development of programs for injury prevention and control in
local and international health orgs
- JC helped aim to reduce # of fall related injuries in HC facilities
- Sentinel event alert more recently aim to reduce # of dosing errors from rushed IV injection -
encourages smart infusion pumps w/ drug libraries
CDC and Chronic Disease Program
CDC leads national efforts to prevent and control chronic diseases and their risk factors by
following four domains
- Surveilling chronic diseases and their risk factors through surveys and research
- improving environmental strategies to make health options easier for people to choose
- Strengthening HC systems to deliver prevention services that keep people well and diagnose
diseases early
- Connecting clinical services to community programs that help people prevent and manage their
chronic diseases