Transforming Primary Care: It Takes All of Us

2. Transforming Primary Care:
It Takes All of Us

3. Disclosures
I have no disclosures to report.

4. Federally Qualified Health Centers (FQHCs)
• Nation’s largest safety net setting
• Located in designated high need communities
• Caring for 24 million patients annually
• 93% served are below 200% poverty and 35% uninsured
CHCI Profile
• Founding year: 1972
• Primary care hubs: 14; Sites: 204; Staff: 1,000
• Patients/year: 100,000
• Specialties: Onsite psychiatry, podiatry, chiropractic
• Specialty access by eConsult to 20+ specialties
Elements of Model
• Fully Integrated teams and data
• Integration of key populations into primary care
• Data driven performance
• “Wherever You Are” approach to care delivery
Weitzman Institute
• QI experts; national coaches
• Project ECHO®— special populations
• Formal research and R&D
• Clinical workforce development
CHCI Locations
in Connecticut
CHCI Foundational Pillars

5. • Ryan White/HIV
comprehensive services
• Hepatitis C
• Chronic pain
• Opioid addiction
• Healthcare for the Homeless
• LGBT care
• Maternal-infant/obstetrics
Center for Key Populations

6. “…stressed the importance of community engagement.
We want a consumer majority board… we are creating
advocates to make sure questions are answered…
accompany the patient to the hospital if need be.”
—Middletown Press, May 1972

8. Health Center Program: Impact and Growth
Over its 50 year history, the Health Center Program has grown from two health centers to nearly
1,400 health centers operating more than 11,000 sites in every U.S. state, the District of Columbia,
Puerto Rico, the Virgin Islands, and the Pacific Basin.
Impact
For millions of Americans, including some of the most vulnerable individuals and families, health
centers are the essential medical home where they find services that promote health and diagnose
and treat disease and disability. In 2015, health centers employed nearly 190,000 people and
served over 24 million patients. One in 13 people nationwide rely on a HRSA-funded health center
for their preventive and primary health care needs.
Despite serving a population that is often sicker and more at risk than the general population,
health center quality of care equals and often surpasses that provided by other primary care
providers.
• Over 93% of HRSA funded health centers met or exceeded at least one Healthy People 2020
goal for clinical performance in 2015.
• More than 68% of health centers are recognized by national accrediting organizations as
Patient Centered Medical Homes (PCMH)—an advanced model of patient centered primary
care that emphasizes quality and care coordination through a team‐based approach to care. Source: https://bphc.hrsa.gov/about/healthcenterprogram/

9. How to Find a Health Center

10. • Silos are giving way to systems
• Scope of practice is expanding across disciplines
• Education and training is transforming
• Technology is giving rise to virtual care
• Interprofessional practice and integrated teams
are increasingly the norm
• Fee for service is very slowly giving rise to
value-based payment
• Consumers are seeking care where, when,
how, and with whom they want it
We Have All Been Changing and Growing

11. • Veterans Affairs: 9m patients
 2001 PL 107-135 mandated that the VA provide
chiropractic care to veterans
• Kaiser Permanente: 11.8m members
 Chiropractic administered by American Specialty
Health Plans
• FQHCs/Community Health Centers: 25m patients
 178 FQHCs have “alternative and complementary”
services in scope
Large System Leaders in Primary Care

12. • “Integration of Chiropractic Services in Military and Veteran
HealthCare Facilities: A Systematic Review of the Literature”;
Green, Johnson, Daniels, et al (2015).
• “Complementary and Alternative Medicine in an Integrated
Health Care Delivery System: Users of Chiropractic, Acupuncture,
and Massage Services”; McCubbin, T.; Kempe, K.; Beck, A. (2017).
• “Comprehensive Assessment of Chronic Pain Management in
Primary Care: A First Phase of a Quality Improvement Initiative at
a Multisite Community Health Center”; Anderson, D.; Wang, S.;
Zlateva, I. (2012).
Integrated Systems
Contribute to Evidence Base

13. • Like all good partnerships, based on mutual interests
• 2012 study published by CHCI confirmed low rates of referral
to chiropractic or any complementary/alternative providers
• Opportunity for University of Bridgeport College of
Chiropractic Medicine to extend its reach, provide training
opportunities and service
• Opportunity for CHCI to address a fundamental problem—
acute and chronic pain, and the increasing burden of
prescription medications
How One Health Center Embraced
Chiropractic Care

14. • Shift from fee for service to value-based care
• Consumer preference and demand
• Absolute need to move away from
medicating pain to addressing
and resolving pain
• Primary care provider shortage and
need to maximize team-based approach
for care, quality and access
Other Drivers

15. Year Visits Unique Patients
CY 2012 453 133
CY 2013 2,632 713
CY 2014 4,538 980
CY 2015 7,409 1,356
CY 2016 9,741 1,656
CY 2017 9,977 1,740
Chiropractic Visits and Patients
CY 2012–CY 2017

16. Preventive Medicine. Vol 54, Issue 1, June 2012
Chiropractic or osteopathic manipulation (8.4%)
and massage (8.1%) were most commonly used;
acupuncture was used by 1.4% and naturopathy
by 0.3% of respondents. Substantial proportions
of respondents reported using CAM for wellness
and disease prevention, and informed their
medical physician of use. Fifty-four percent were
overweight or obese, 22.0% physically inactive,
and 17.4% smokers; 18.0% reported
hypertension, 19.6% high cholesterol, and 9.1%
prediabetes or diabetes.

17. In Calendar Year 2017,
there were 2,868 referrals
for internal chiropractic care.
Referrals were by:
• The top diagnoses on the referrals included:
 28% Backache, unspecified
 25% Lumbago
 5% Unspecified musculoskeletal disorders
and symptoms ref. to neck
 4% Cervicalgia
 3% Chronic pain syndrome
• Patient insurance included:
 68% Medicaid
 12% Medicare
 12% Private
 8% Uninsured
Chiropractic Care at CHCI

18. In the last two quarters, CHCI’s Chiropractors were in the top quartile for
provider specific patient satisfaction measures
Survey Item Provider A Provider B Provider C Provider D
Provider Listening 100 92.5 97.5 90.6
Provider Explanation 100 92.5 97.5 96.9
Provider Advice and Treatment 97.5 92.5 95 90.6
Provider Knowledge of Health History 94.4 82.5 97.5 96.9
Overall Satisfaction 90 90 92.5 96.9
Patient Satisfaction with Chiropractor

20. Improved
clinical
outcomes
Better
patient
access and
experience
Improved
support for
highly
complex
patients
Reduced
burnout for
providers
and staff
Opportunity
to lower
cost,
increase
safety
Why Primary Care Teams?

21. Every Patient Has a Team

22. Patient’s Extended Team:
• Pharmacist
• Chiropractor
• Nutritionist
• Specialty eConsults
• Psychiatry
• Community Resources
• Family and Friends
Patient’s
Core
Team
Medical
Behavioral
Health
Nursing
Access
to Care
Medical
Assistant
Dental
Care That Is Comprehensive:
Integrated Team

23. Evaluation
Training
Workflow/Processes
Facilities/Systems
Leadership Structure
The Components of Integration

24. Pod Design Supports Integration

25. The Key Functions or Competencies
of Excellent Primary Care

26. Shared Communication Among the Team

27. • Chronic pain affects approximately 100 million Americans1
and costs more than $635 billion in medical treatment and
lost productivity2
• Majority of patients with pain seek care in a primary care setting3
• Primary care providers express low knowledge and confidence in
pain management and receive little pain management education3
• Opioids are heavily relied on for pain management in primary care
• Prescription opioid overdose is a major and growing public
health concern
Chronic Pain in the U.S.

28. Oxycodene Consumption (mg/capita)
1980–2013

29. Setting Type % Distribution
Emergency department 39%
Primary care office 31%
Medical specialty office 13%
Surgical specialty office 10%
Hospital outpatient department 7%
Source: National Center for Health Statistics. Medication Therapy in Ambulatory Medical Care: United States, 2003-04
Sources of Opioid Analgesics

30. • We prescribe when there is no indication and when there are contraindications.
• We prescribe to patients with active addiction.
• We prescribe to patients whose problem is non-opioid responsive and places them at high risk
for adverse events.
• We ignore recurring non-reassuring behaviors.
• We don’t consider the household or community environment into which we place these drugs.
• We devalue effective alternatives.
• We treat “pain” but not addiction.
• We use dangerous combinations of meds.
• We don’t like what we’re doing.
The Harm

31. • Full range of medical interventions
are employed but in a context that
emphasizes the far greater importance
of the efforts the patient makes in his
or her own long term rehabilitation
• Not an effort to convince patient
that their pain is “caused” by
psychosocial factors
• Not a grim alternative to failed
medical treatments
Collaborative Self-Management

32. Caring for Patients with Pain
Must Be Team-Based

33. • Co-location of behavioral health and primary care
• Warm handoffs
• Group therapy
• Behavioral health participation in Project ECHO
• Provide access to Cognitive Behavioral
Therapy (CBT)
Integration of Behavioral Health
for Pain Management

34. • Coverage is variable, both absolute and relatively.
• Commercial plans—90% include chiropractic, but deductibles,
co-pays, and limits have huge impact.
• Medicaid is worthy of your focus—and not straightforward.
Coverage by age groups, and by site of care may vary greatly.
• FQHCs have to get specific federal approval to add a new
service or specialty to its “scope.”
Policy Considerations

35. CT Husky Chiropractic Coverage

36. Medicaid Benefits:
Chiropractor Services
CN =
Clinically
Necessary
MN=Medically
Needy
The Henry J. Kaiser Family Foundation: 2012 data
American Chiropractic Association: 2018
data
Data Location Benefit Covered
Coverage
Code
Copayment
Required?
Prior
Approval
Required
Limit on
services
days
Reimbursement
Methodology Footnotes
State Medicaid
URL
2012:
United
States
2
0
1
2Yes - 27 No - 29
Yes - 17 No
- 10
2018:
United
States
2
0
1
8
Yes = 35 No = 17
Under 21 only = 4
Changes in Medicaid Policy

37. On May 19, 2016, the HERC approved several additional
changes, including changing the requirements for
patients already on opioid therapy who would need to
work with their provider to establish a plan to transition
to other pain management strategies, including
nonpharmacologic treatments, by January 1, 2018.
Each plan covers up to $2,000 per plan year for
alternative care services such as chiropractic,
naturopathic, and acupuncture, including labs and x-rays.
Evidence of Response to Current Crisis:
Oregon

38. Treat Pain by Moving Knowledge, Not Patients

39. Weekly, distance, case-based learning
with a team of experts in the care and
management of patients in chronic Pain,
HIV, Hepatitis C, pediatric behavioral
health and opioid addiction treatment.
Training Providers to a New Model of Care

40. Pain Management eConsult

41. • “Chiropractic Identity, Role and Future: A Survey of
North American Chiropractic Students.” J. Gliedt, C.
Hawk and M. Anderson et al. (2015). Chiropractic and
Manual Therapies 23:4
 Survey of 1,237 chiropractic students in North America: 69%
agreed or strongly agreed
that clinical chiropractic training internships and postgraduate
residency training should occur in integrative settings
• Careers in Chiropractic Health Care: Exploring a
Growing Field (2017). Edited by Cheryl Hawk DC, PhD,
CHES
 Focused on chiropractors in VA and integrated care settings
 Document that chiropractors report higher satisfaction than other
physician groups
 Opportunities growing more quickly
 VA—2001 PL 107-135: VA to provide chiropractic care as a benefit
to veterans
Forward Focus

42. • Health centers are
teaching institutions.
• They are ideal sites
for interprofessional
training and practice.
• Please consider reaching
out to your local health
center!
Training the Next Generation

43. • CHCI’s postgraduate NP Residency Program
for new family NPs and Psychiatric/Mental
Health NPs
• CHCI’s postdoctoral clinical psychology
residency program
• National Institute for Medical Assistant
Advancement (NIMAA)
• Administrative Leadership Fellowship
• Center for Key Populations Fellowship
• 300 students of all the health professions
Training the Next Generation

44. Thank you from CHCI and its Patient-Majority
Board of Directors