Mark Masselli on Building A World Class Primary Health Care System

Mark Masselli, Community Health Center:
Building A World Class Primary Health Care System
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Mark Masselli, Community Health Center
Building A World Class Primary Health
Care System
Thank you for that warm introduction
Good to be in Pennsylvania – I spent lots of time here in the early 70’s as I had a friend
at Hershey Medical School – drove that route often from Middletown, Connecticut -- you
all have a big state – you could fit 9 Ct’s in Pennsylvania - and one of my good friends
who helped me start our Community Health Center in Connecticut was born and raised

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just outside of Philadelphia – he’s now the Governor of Colorado – John W.
Hickenlooper – ( he’s a big Community Health Center supporter) both as mayor of
Denver and now governor, he cites the lessons he learned growing up here as well as
working at a CHC as the core of his governing style…..
To the Health Centers gathered here today – Thank you and congratulations on the
work you do and the great people who work at your Health Centers – caring for our
friends, neighbors who have been marginalized by the rest of the health care system.
Through your work, you have created health care homes, ensuring the right of every
citizen in need to have access to a family doctor, dentist and BH professionals -and
you do this while honoring and respecting the dignity of the patients who you care for.
And Thanks To the Primary Care association since 1981 you’ve been working to
strengthen, promote and grow Health center programs throughout Penn /you support
Health Center’s that care for 700,000 residents and growing - from urban to rural
settings all across this great State.
You all in Penn are doing a great job.
And speaking of Thanks - I think we can all thank the lord that the election is over – and
speaking personally – praise the lord – for the outcome – In that last week you all in
Penn were the subject of a lot of national attention - I knew you wouldn’t let us down –
your pretty tough down here – I know this personally - As a New York Giants fan –
your Steelers - I mean they beat us even when we had the refs on our side – you all
never give up on your patients, your team or your candidate.
So while I’m here to tell you about the seed we planted at our health center 40 years
ago and how it flourished I need to just reflect for a moment on the soil we planted our
seed in and how it's influenced the work we have down - - WE have a saying at our
Health Center – we didn’t get here on our own and we can’t move forward alone – let’s
give praise to those who got us here.
The story starts with the battle for national health insurance- Over 100 years ago at the
beginning of the 20th
Century the flag is raised by President Teddy Roosevelt in 1900 –
it’s a battle picked up again by in the 1930’s by FDR and then in the 50’s by President
Harry Truman – President Johnson was able to bring some relief to people in need with

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the passage of Medicaid and Medicare in 1965 – President Nixon – and Clinton all
weighed in – but it wasn’t until this President - President Obama - that we begin to see
the light at the end of the tunnel – Hope is here.
But I’m not really here to talk about National Health Insurance – I would much rather talk
about Sex, drugs and Rock and Roll – I’m mean I’d rather talk about the 1960’s.
While that struggle for National Health Insurance was going on – another equally
important struggle was underway in our country ––it was a struggle to determine who
and how health care would be delivered to those populations living in the shadow of
poverty . Yes It is important to pay for care – but what was missing was the question
of who even had access to care in the first place.
It was then, in the late sixties, that two different movements emerge on the national
stage at the same time– the Community Health Center movement, and the Free Clinic
movement –– which is how our HC in Ct operated in our first few years.
You all know the story about the Community Health Center movement.
-it’s 1965 and two Harvard trained Physicians Jack Gieger and Count Gibson are
worried about the lack of access to health care for the poor - Geiger had been exposed
to the South African system of Community Oriented Primary care - and He sets out to
replicate that model here in America – with the help of a recently elected Senator from
Mass – Ted Kennedy. Geiger finds a funding source at the Office of Economic
Opportunity/ part of the War on Poverty - they were willing to support this community
centered model of health delivery - and two health Centers are started – one at a Public
Housing project Columbia point in Boston, the second located in a 500 mile rural area –
in the Mississippi Delta – – It was a start, but it wasn’t enough; Geiger and others
wanted to spread the model – But troubled loomed on the horizon - not only was there a
war on poverty – but there was a war on the war on poverty – President Nixon – during
his run for the presidency had one of those campaign pledges - and this might sound
familiar – he vowed as one of his first actions to dismantle the OEO - I think we heard
that refrain in this past election - – But Sen Kennedy works hard and fast and in 1972 –

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he gets the Health Center movement put over into the Health , Education and Welfare (
HEW ) where Congress can keep an eye on it and the rest is the history you know –
And then there was that other movement taking shape in the 1960’s – – It’s 1967 –
100,000 young people are converging on San Francisco –it’s the famed summer of
Love - and a young Doctor is concerned that the local Health system is not equipped
nor responsive to address the cultural, financial and health needs of this population –
his name is Dr David Smith – he’s set up a Free Clinic at the corner of Haight and
Ashbury Street in July 1967 - and launches the Free Clinic movement – across the
country similar Free Clinics are sprouting up in Cities – The Free Clinic movement has
some important allies one of them is rock promoter Bill Graham – who sets up a
system of financing these clinics through music concerts – they’re called the Dr
Sunday’s medicine show – performers like Jimi Hendrick, Grateful Dead, George
Harrison and Led Zepplin and other groups help out - – but the movement is growing
even bigger than that and Smith, like Geiger, is worried about how will these HC get
funding.

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By stu_spivack - Haight Ashbury Free Medical ClinicUploaded by LongLiveRock, CC
BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=9579306

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it’s now 1972 and Smith brings a group of over 900 Health activists to Washington to
see if we can’t organize the movement and get federal support – I’m one of the group/
hair was a little longer - and there we form the NFCC – similar to NACHC and federal
support comes to Health Center – – But unlike the Health Center movement – the
funding fades and Free Clinics revert to being of and by their communities.
What binds these two movements are their 4 guiding principles – and not surprisingly
they are very closely aligned and they go to the heart of why we are special today
1. Health care needed to be located in the neighborhoods of those in need
2. the services needed to be comprehensive
3. the cost of the services should reflect the ability of the patients and
4. the organization of these services needed to be owned and controlled by those
receiving the care-
Of the four principles, clearly, the notion of local control by patients was radical in the
context of a country that vehemently opposed a national health insurance plan and was
deep in the midst of a larger civil rights struggle fighting for equal rights
Those are the roots of our collective movement. And like many of you, as the sixties
turned to the seventies, we were inspired to build system of care for the people in our
community

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We started out in 1972 with a free clinic in Middletown, CT – it was a second floor
walk-up apartment that we’d converted into exam rooms with volunteer labor from
Wesleyan University up the hill ( you could have been in San Francisco ) We were a
group of community activists and college students, and we rallied under the banner
“Health Care is a Right, Not a Privilege”, - with the help of a volunteer dentist and
physicians , we began offering services and everything was going along until we got a
knock on the door – it was the State health department. Do you have a license It turns
out that the “local ” doctors in town had gotten together and complained that non-
doctors were setting up a medical practice – and so the inspectors went through our
operation with a fine tooth comb and they weren’t too happy to find that everything was
in order, just as it should be. Until they were on their way out, and someone pulled out
a tape measure – it seems that our hallways were one half-inch too small for regulation,
so they shut us down, and it looked like the end of the community health center . But
we didn’t give up. We took some time to assess what had happened, and in those
months the real culture of our health center was born. We wondered, if our community
deserved access to care, didn’t they deserve access to the best care? If we based our
model on using the leftovers of the “official” health care system – volunteer labor,

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donated supplies – how could we meet the need that we knew was there? Were we
building a place where people could do their best work?
Now I’m not suggesting that we had the answers to these questions – but when we had
rallied and re-opened our community health center at a new location, those fundamental
questions animated our work. Our new health center raised the bar and it also had very
wide hallways!! . When a second community about 30 miles away called us a few years
later– it was a group of seniors looking for dental care in their shoreline town as
Medicare didn’t cover that services – we were ready to expand. And over the years, we
added offices in towns across Connecticut that faced the same challenges – a
population in need that wasn’t served well by the existing health care system.
It would be 20 years after we started that we became a FQHC look-a-like and then
shortly after that we received 330 funding.
Today 40 years later we’re in 208 locations and care for 130,000 patients and will
provide over 450,000 visits this year.
Along the way, we developed a mantra that keeps us centered on our path, and here it
is:
We’re building a World Class Primary Health care system – committed to serving
Special Populations – focused in on improving patient outcomes and cultivating Healthy
Communities.
Let me break that down for you
Building a world class health care system - Now it might sound arrogant to say from
our neigborhoods that you could build such a system – but why wouldn’t we want to
create such an environment and in doing so realize, just like Jack Geiger - that when
you look around the world there is great inspiration to draw from – in our case – we
look to the Aravind Eye Center in South Indian – or the Joung shipping Health system in
Sweden – or the Group Health Cooperative in Washington State – or the many
high-performing CHC’s from Hawaii to Boston – if you’re thinking about building a World

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Class Primary Care System you have to have a frame of reference that looks at people
who are doing great work in health care delivery. You have to study the best practices
of health systems and other industries around the world.
Committed to serving special populations –
We’re in primary care, but we’re specialists – our specialty is the people we serve. The
challenges they face inform the way we deliver care. But it’s not just need that defines
special populations – our movement is about their capacity to lead – its where our
Board membership comes from, and on a national level, those health center board
members have over the past 40 plus years built a movement that cares for 20 million
people – that’s the largest primary care system in America.
We’re focused in on improving patient outcomes – you’ll see in our organizational
design a fundamental concept that if you are going to engage in the delivery of primary
care you have an obligation to improve primary care – at our HC we do this through the
research that we undertake at the Weitzman Center for innovation – As much as we’re
a health care organization, we’re a data and research company. The challenges that
our population faces in chronic disease: cardiovascular, diabetes, hypertension, oral
health and depression require us to put more focus on outcomes, and we can no longer
rely on anecdote – we need the data to know if we’re making real progress.
Finally cultivating Healthy communities – We all know too well that the diabetic
patient we sees only comes to us 4 times a year but has diabetes 365 days a year –
the communities that we are located in need our active engagement – farmers markets,
ways to be healthy and active, and social justice issues are all on the table if we are to
really address the social determinants of health.
So let’s me take you on an overview of our organization -moving from our mantra to
how we translate that into our organizational design - touching on some of the
transformations we have undertaken.
•Clinical Excellence

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•Research & Innovation
•The Next Generation
The Health Center identified three pillars on our path to building a world class system.
-We are always striving for clinical excellence in the delivery of primary care.
-We are constantly innovating and researching seeking new ways to improve outcomes
for our patients and redesigning the primary care space
-We are committed to training the next generation of providers in our model of care –
but training to our model of care
When we think about clinical excellence in the delivery of primary care, there are two
drivers. First we think about how to organize care around patients’ needs. Then we set
up systems that monitor our quality and lead to improvement.
CARE ORGANIZED AROUND PATIENT NEEDS
•Advanced Access
• Expanded Hours/24-hour Coverage
•Care Where You Are
•Patient Portals
• Language Line
•Integrated Behavioral Health
Let me be very clear that many of our ideas and innovations are begged borrowed and
stolen from other groups – our great skill set at CHC is to crosswalk their ideas over to
our platform and execute according to our own standards – I also want you to know that

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each innovation brought moments of great doubt amongst team members – but we all
persevered –
First, let’s look at our patient- centered practices.
Patients need access to health care around their schedules, so we use advanced
access methodologies to have slots for patients to come in the next day, not two weeks
from now. Advanced Access was developed by some folks at Kaiser and they took the
idea from Toyota who was trying to figure out how to get car parts delivered the moment
they were needed and not a minute later – it’s transformed our no- show rates from
double digits to single digits – but like every innovation it takes time, data and patience
to get it right – Likewise, Patients need to access health care after work or on the
weekends, which is why expanded coverage is so important.
We work to meet the patients not only at times that are best for them, but also at
locations that are best for them. Through mobile dental and school based health
centers, we meet our patients where they are. This is even more important for patients
in shelters that we serve with our Wherever You Are program. Think about this model
in the context of the American Hospital outpatient health system – many of those
facilities had been located in poor neighborhoods – then new populations of need
emerged in other parts of the community and they simple weren’t able to serve them –
This will repeat itself with Health Centers and we need to be more organizationally
nimble and find ways to deliver services with more ease and elegance.
Besides working to make our schedules fit our patients’ schedules, there are other
important needs to meet. For example, our providers need to be culturally aware. They
need to be able to communicate with patients in the languages that patients know best.
Using our language line we can communicate with patients in 170 different languages.
While we have staff that speak many languages we’ve come to the decision that we
have to have trained medical translators and this technology is the right solution – as an
aside – I think this is a real business opportunity for a network of Health Centers or
within our communities – language translation services are only going to increase in
need and we collectively we have great strength in these areas.
We even provide a patient portal, available to all 130k patients, to make it easier for our
patients to get critical information. The patient portals are connected to our fully

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integrated electronic health records, which I’ll talk more about a little later. There is a lot
of talk about the digital divide in our neighborhoods – that’s dated talk – the new
platform for all Health Care technology and one that we spend lots of time and money
on is the mobile phone - look around the world in Africa and India - the transformations
that are underway – in our own communities the % of people with Cell phone is huge
and the increase in smart phones is growing exponentially.
Often when we meet with our patients we find that their physical health is tied to
behavioral health concerns. To address this concern, our providers work in teams, set
up to facilitate a ‘warm hand-off’, where a medical provider walks a patient over to meet
a behavioral health provider, and doesn’t simply write a referral which may never get
followed up on. Working in teams addresses one of the fundamental realities of
medicine – over 40% of all presenting problems have a BH component and our medical
providers need help.
SYSTEMS FOR IMPROVEMENT AND QUALITY
•Pods and Huddles
•Electronic Health Records
•Health Information Exchange
•Clinical Dashboards
• NCQA Level 3 + Joint Commission PCMH accreditation
Now we look at the systems we have in place to support improvement and quality
Let me continue to pull the thread on the Warm hand-offs - To make these warm
handoffs effective, we’ve spent considerable time with our architect informing them of
our model of care and how it needs to capture our work flow –
All of our fixed sites and many of our SBHC all have the same design for our clinical
team - they operate in PODS – usually 8 seats – 2 providers, 2 MA’s 1 RN – 1 BH (

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Psychiatrist, psychologist LCSW) rotating seats for podiatry, Diabetic educator –
residents share these seats.
As I noted earlier, we’re a data company as much as a health care company, and we
were the first statewide primary care system to have fully interoperable electronic health
care records.
All of us are waiting for our States to role out Health Information Exchanges – this is
coming – but the progress is slow – in the interim we have taken some steps on a
couple of fronts that I will discuss – one of those is our own system allows us to create a
limited exchange - our HC has put links onto the ER computers – ( we have over 15
hospitals that we deal with) which provide access to our own HIE exchange and to the
patients Continuity of Care Document – this give hospitals a view of the patients
medication list, problem list, allergies , history and referrals, lab information , diagnostic
imaging - it’s also designed to allow Hospital to schedule appoints live into our system
– for active patient – they must be a CHC patient – I’d like to say this is successful - but
the culture in ER is not always conducive to coordinating care.
Our integrated, electronic health records, including connections to other health care
organizations also allows us to lead the way in telemedicine which has been a key area
of our research.
All of this data, now with 8 years of experience, has been brought together into a clinical
cube that has data on 250,000 patients. Our BI staff tell me that the cube can provide
81 billion answers – most of them are meaningless – just like a good consult – you need
to have the right question - to elicit the correct answer – All of this data is available live
time – and we put this up on our intranet – it feeds our dashboards and further fuels our
quality improvement efforts.
These are examples of some of the ways we’ve embraced the standards set by national
organizations – achieving both NCQA Level 3 and JC PCMH accreditation – early

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rewards are both clinical and financial - CT’s Medicaid Department is paying any level
3 accreditated organization or practice an extra 9 per visit.
SLIDE: Clinical Dashboards
Our Clinical Dashboards allow us to track how the health center, as a whole is
performing and where some of our greatest opportunities for improvement are. They
illustrate where we’ve been achieving improvements and where we still need to work.
Key areas in our dashboards include hypertension and diabetes control, as well as how
well we are doing with screening for various forms of cancer, and helping our patients
manage chronic pain.
Evidence that electronic health records improve the quality of clinical care has been
slow to emerge. One principal reason for this is that existing EHR’s have not been
designed to support QI work. In order to leverage the power of an EHR to improve
quality, data needs to be made “Actionable”. In practice, this means not simply giving a
provider a monthly “scorecard” showing them their rate of hypertension control or
cancer screening, but rather giving them actionable data such as a tool that identifies
which patients have poor control or are due for a mammogram.
CHC has invested considerable resources in this area, creating a data warehouse that
is accessible and flexible. One of the first products from this work has been a series of
clinical dashboards that give primary care teams data on specific patient populations.
Our opioid dashboard gives them data on all the patients using opioids chronically,
whether or not they have had or are due for a urine toxicology screen, whether they
have been re-assessed within the past 3 months, or whether they have an active opioid
agreement completed in the chart.
Our diabetes dashboard allows each PCP to sort through their diabetic panel, looking at
which patients have HbA1C’s about 9, or which have not been seen in a certain
timeframe.

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Lastly, we created weekly “missed opportunities” reports, showing provider teams how
often in the past week they missed a chance to screen for cancer or order a needed
test.
These dashboards are also a crucial tool in our research. As I said earlier, it’s part of
our Fundamental philosophy that if you’re going to be engaged in primary care, you
have an obligation to improve it.
About 8 years ago we set up the Weitzman Center for innovation , one of the first
community – based research centers established by an FQHC – The center test
promising innovations in primary care delivery – we are engaged in implementation and
improvement research , we host an annual Weitzman symposium at Wesleyan
University bringing together leaders who share their work in innovation in community
health and primary care - we have great partnerships with organization near and far
and look to other industries and organizations for best practices. One of the driving
forces behind our thinking is that we ( CHC’s ) need to bring this research work into the
primary care settings –we have ceded to much to the academic centers with little return
to our populations and organizations – We don’t want to be adversarial but rather be
very clear about the value we can bring in this area. In fact, our research has led to
partnerships with GE, Dartmouth Institute and numerous others in which CHC plays a
lead role.
Let me highlight a few of our current research projects , such as our work in improving
health outcomes in pregnancy, early detection of autism in toddlers, improving cancer
screening among culturally diverse women and sharing best practices in pain
management with the VA Health System. We have standards for publishing for all of our
team members -
Other research is more focused on innovations at CHC, such as our use of telemedicine
to address diabetic retinopathy and to improve access to specialty care.
Additional research is focusing on evaluating the role of the nurse in the
Patient-Centered Medical Home. This research helps us as we look forward to the

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impact of the Affordable Care Act on access to primary care, particularly at Federally
Qualified Health Centers.
One of the key ideas underlying all our research is asking the people who do the work
what changes will really make a difference. This is core to the idea of clinical
Microsystems and is another way in which we empower and encourage our staff.
CHC uses the evidence based “Clinical Microsystems” methodology, developed
specifically for the healthcare setting, as its principal quality improvement tool to foster
innovation, empower team members, enhance adoption of the PCMH model, and
achieve Performance Improvement goals. This model enables us to harvest the best
practices within the agency and spread the best practices across our organization. Key
elements of the model include the use of a trained Microsystems coach and facilitator,
active participation by front line CHC employees, and use of data-driven rapid tests of
change.
A Clinical Microsystem is a front line team of people who work together on a regular
basis providing clinical care or other services. Microsystems exist in all CHC
departments. An empowered microsystem is one that has been provided with
appropriate time, training, support, and coaching to work together to improve
performance. These empowered Microsystems serve as generators of new ideas as
well as early adopters of ideas from other sources. In addition Microsystems provide
front line staff opportunities to take ownership of process changes and new ideas.
Microsystems provide a level playing field and an opportunity for staff at all levels of the
organization to take part in process improvement. CHC’s quality department identifies
key Microsystem teams and provides them with structure and support.
Some of the most exciting research we’re undertaking right now is around telemedicine.
For example, we’ve established a methodology for sending information off to specialists
for eConsults. Again , this is work done by others – Mitch Katz in San Francisco looked
at the issues that safety net providers find themselves in - very few specialist take our

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population and when they do coordinating visits is problematic – Katz decided that what
needed to happen first was to bring the information about the patient to the specialist
and determine a couple of thing s – let me use an example from our own work –in
Cardiology. A cardiologist is able to gets our data off of our Health exchange and has
three classic responses. Either they need more information, they can provide guidance
to the primary care provider, or a face to face visit is really needed. The data is
amazing in the reduction of referrals – but just like any good research organization we
have a 2 year study underway
Our Project ECHO initiative comes from New Mexico - Sanjeev Arroro – is its founder –
we’ve worked with him over the past year – and now we’re our running our own CT
based Project ECHO. It’s very simple and elegant - a team of specialists conduct video
conferences with primary care providers. In addition to providing specific
recommendations, there are didactic elements which help the primary care providers
learn more about how best to provide care in these complicated cases. Our focus has
been on HEP C and HIV – we launch a national ECHO project with the pain Center at
the University of Arizona very soon and have Health Centers from around the country
who will be joining us
As we constantly research the innovations in health care, we have a responsibility to
also train the next generation of health care workers. This is one of the core pillars of
who we are and it permeates everything we do. Yet there are some special programs
worth noting.
We have the first Family Nurse Practitioner Program Residency Program in the Nation.
It is important that Family Nurse Practitioners interested in community health centers
have the opportunity to learn about how best to care for our populations, and the
residency program as a key way that can gain and learn from this experience.
We take our responsibility to train the next generation very seriously. It is a larger task
that we can do ourselves and we’ve worked closely with organizations across the
country to replicate our Nurse Practitioner Residency Program, including Puentes de
Salud in Philadelphia.

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The IOM and RWFJ foundation are also looking at our program to establish funding and
meet the needs of new nurse practitioners.
We also have a Psychology Post Doctoral program and other opportunities for graduate
students, undergraduates, and even high school students to learn how best to provide
care in a community health center setting.
CHC Infrastructure
Just like the clinical team does a daily huddle – on the business side we do our own
daily huddle – we call it our 99 won’t do group -
That takes care of the three pillars of our organizational model, but underlying that
structure is a business model that helps us understand our productivity and our costs –
Four years ago, we asked ourselves what it would take to really understand the
connection between our actions and our financial standing. We decided to have an
meeting every afternoon – with the senior leadership but open to anyone in the
organization – to drill down on how we performed yesterday and today. We call it 99
won’t do –- we use a dashboard of information from week, month, ytd, productivity
numbers, how did we manage our phone calls – process improvement – how any one of
our clinical microsystem teams is doing – from the transactional to the transformational
– If our business was easy, anybody could do it – the discipline of asking ourselves
these questions every day helped us make an exponential leap - it’s about having the
resources and the focus to keep us true to our values – and meet our mission
With the implementation of the Affordable Care Act underway, explorations into models
like the Patient Centered Medical Home, and growing demands for primary care
providers, this is an exciting time to be involved in primary care, and especially at
Federally Qualified Health Centers. The demands for primary care is about to explode
as more people have coverage and as improvements in mobile communications and
mobile apps put more information in the hands of patients. We are working on Apps to
help our patient population.
Likewise, when we look at the larger picture of wellness, we see the way lifestyles affect
health. Health Centers need to address ways that diet, exercise, pollution and

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economic opportunity relate to our patients health. This includes little things, like
making it easier for our patients to get to farmers markets, up through national
programs, like our Recess Rocks program to combat childhood obesity.
All of this goes back to the four principles that founded our movement – that the
services should be where the people are, that they should be comprehensive,
affordable and under the control of the user – you could be describing the digital
revolution – fit right with these times. So CHC’s don’t have to change their philosophy,
but they do have to perform to the best of their abilities, because our patients deserve it.
These are the roots of our collective movement – and the struggle is no less important
today than it was at the start of our movement – Today we are at the crossroads in
Health care – Between Access and Access to what –
Instead of being just tossed along in the tumultuous changes, CHC is taking a proactive
role, seeking to employ best practices and to research their effectiveness and we
encourage you to join with us.
We are always looking for new ideas to explore and new partners to explore them with.
Hopefully, some of the ideas that I’ve shared today will stimulate new ideas and
opportunities for us to collaborate with innovators in Pennsylvania.
Yet, in many ways, I’m just preaching to the choir here. The people we really need to
inspire build healthy communities are our youth. So, we made an animated fairytale
which believe really captures what community health centers are all about. Enjoy, and
stay in touch.
So, do we have time for some questions? …. If you have other ideas you’d like to
explore, here is some of our contact information. Also, be sure to follow us on Twitter at
CHCConnecticut and on Facebook at Community Health Center, Inc.

Mark Masselli on Building A World Class Primary Health Care System

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