Project Grant U8645896

HEALTH CENTER CONTROLLED NETWORK - ADDRESS: 710 SPENCE LANE, NASHVILLE, TN 37217-1144 PROJECT DIRECTOR: ASHLEY PASQUARIELLO PHONE: (615) 425-5846 FAX: (615) 329-3823 EMAIL: ASHLEY.PASQUARIELLO@TNPCA.ORG WEBSITE: WWW.TNPCA.ORG PROGRAM: HEALTH CENTER CONTROLLED NETWORKS (HCCN) FUNDING REQUESTED: $750,000 AWARD RECIPIENT: HCCN GRANT NUMBER: H2QCS30285 NUMBER OF PARTICIPATING HEALTH CENTERS (PHCS): 22 HEALTH CENTER PROGRAM AWARD RECIPIENTS AND 0 LOOK-ALIKES (LALS) THE TENNESSEE PRIMARY CARE ASSOCIATION HAS RECEIVED THREE ROUNDS (2012, 2016, 2019) OF HCCN FUNDING, WHICH HAVE BEEN USED TO ESTABLISH AND OPERATE THE CENTER FOR QUALITY IN COMMUNITY HEALTH (CQCH). THE CQCH COORDINATES THE HEALTH IT AND QUALITY IMPROVEMENT EFFORTS OF TENNESSEE'S COMMUNITY HEALTH CENTERS. THROUGH CQCH, PARTICIPATING HEALTH CENTERS (PHCS) PURSUED A COMMON GOAL OF IMPROVING THE HEALTH OF THEIR COMMUNITIES THROUGH ENHANCING THE PATIENT AND PROVIDER EXPERIENCE, ADVANCING INTEROPERABILITY, AND USING DATA TO ENHANCE VALUE. NEEDS TO BE ADDRESSED: CQCH IDENTIFIED SEVERAL DATA AND HEALTH IT NEEDS RELATED TO CLINICAL QUALITY, PATIENT-CENTERED CARE, AND PROVIDER AND STAFF WELL-BEING THAT ARE SUMMARIZED AS: 1) PHCS NEED SUPPORT TO IDENTIFY AND EFFECTIVELY UTILIZE DIGITAL PATIENT ENGAGEMENT TOOLS THAT ARE EVIDENCE-BASED, ACCESSIBLE, AND INTEGRATED WITH THEIR EHR. 2) MOST PHCS ARE UNABLE TO SYSTEMATICALLY DOCUMENT THAT THEY HAVE DEVELOPED CARE PLANS INFORMED BY PATIENTS' SOCIAL RISK FACTORS AND ENSURED THAT PATIENTS RECEIVED SOCIAL SERVICES WHEN THEY ARE REFERRED. PHCS NEED TRAINING AND TECHNICAL ASSISTANCE (TA) TO COLLECT, SHARE, AND UTILIZE SOCIAL RISK FACTOR DATA FOR INTEGRATED CARE COORDINATION THAT ADDRESSES SOCIAL DETERMINANTS OF HEALTH. 3) GIVEN THE LACK OF A STATEWIDE, COMPREHENSIVE HEALTH INFORMATION EXCHANGE (HIE) IN TENNESSEE, PHCS NEED SUPPORT FOR SECURELY EXCHANGING AND INTEGRATING DATA FROM EXTERNAL PROVIDERS. 4) SOME PHCS HAVE LIMITED STAFF CAPACITY TO MAINTAIN CYBERSECURITY KNOWLEDGE, SKILL S, AND SYSTEMS AND NEED TRAINING AND TA FOR IMPLEMENTING POLICIES AND PRACTICES THAT PROTECT INDIVIDUALS AND ORGANIZATIONS FROM MISUSE, CYBER-ATTACKS, FRAUD, AND OTHER HARMS. 5) PHCS NEED HEALTH IT TRAINING, TA, AND TECHNICAL SUPPORT THAT FACILITATES CONTINUOUS DATA VALIDATION AND MAXIMIZES FUNCTIONALITY FOR POPULATION HEALTH MANAGEMENT. PHCS ALSO NEED ACCESS TO HEALTH IT THAT ENABLES ADVANCED ANALYTICS FOR BENCHMARKING, PERFORMANCE IMPROVEMENT, AND VALUE-BASED CARE. 6) ELECTRONIC HEALTH RECORD (EHR) VENDORS DO NOT CONSISTENTLY PROVIDE ADEQUATE TRAINING, CUSTOMER SERVICE, AND TECHNICAL SUPPORT. THEREFORE, PHCS NEED SUPPORT TO SECURELY SEND ELECTRONIC CLINICAL QUALITY MEASURES (ECQMS) FOR REQUIRED REPORTING AND TO OPTIMIZE THE FUNCTIONALITY OF THEIR EHRS FOR IMPROVED USABILITY AMONG THEIR PROVIDERS AND STAFF. PROPOSED SERVICES: CQCH IS SUPPORTED BY TPCA STAFF MEMBERS AND CONSULTANTS WHO PROVIDE TRAINING, TA AND OTHER FORMS OF SUPPORT TO PHCS. INDIVIDUAL PHC AND GROUP-LEVEL SERVICES WILL BE DELIVERED VIRTUALLY AND IN-PERSON, INCLUDING TA, TRAINING, MEETINGS, ON-SITE SUPPORT VISITS, AND COLLABORATION. CQCH WILL ALSO SUPPORT PHCS IN CONNECTING TO AND USING A NETWORK-LEVEL POPULATION HEALTH REPORTING AND ANALYTICS PLATFORM. PROPOSED CQCH SERVICES WILL SUPPORT PHCS IN IMPROVING CLINICAL QUALITY, PROVIDING PATIENT-CENTERED CARE, ENHANCING PROVIDER AND STAFF WELL-BEING, AND ULTIMATELY IMPROVING THE HEALTH STATUS OF MEDICALLY UNDERSERVED TENNESSEANS. TPCA WILL LEVERAGE PARTNERSHIPS WITH ENTITIES SUCH AS THE NATIONAL HEALTH CARE FOR THE HOMELESS COUNCIL AND I2I POPULATION HEALTH TO DELIVER PROJECT SERVICES. POPULATION GROUPS TO BE SERVED: THE CQCH WILL SERVE THE TWENTY-TWO (22) HRSA HEALTH CENTER PROGRAM (H80) AWARD RECIPIENTS THAT HAVE COMMITTED TO PARTICIPATE IN THE CQCH. THESE 22 PHCS OPERATE 150 SERVICE DELIVERY SITES, EMPLOY 2,288 PROVIDER AND STAFF FTES, AND SERVE APPROXIMATELY 296,745 PATIENTS (UDS, 2020).