System Strategies for Colorectal Cancer Screening at Federally Qualified Health Centers

Objectives. We assessed the protocols and system processes for colorectal cancer (CRC) screening at federally qualified health centers (FQHCs) in 4 midwestern states.Methods. We identified 49 FQHCs in 4 states. In January 2013, we mailed their medical directors a 49-item questionnaire about policies on CRC screening, use of electronic medical records, types of CRC screening recommended, clinic tracking systems, referrals for colonoscopy, and barriers to providing CRC.Results. Forty-four questionnaires (90%) were returned. Thirty-three of the respondents (75%) estimated the proportion of their patients up-to-date with CRC screening, with a mean of 35%. One major barrier to screening was inability to provide colonoscopy for patients with a positive fecal occult blood test (59%). The correlation of system strategies and estimated percentage of patients up-to-date with CRC screening was 0.43 (P = .01).Conclusions. CRC system strategies were associated with higher CRC screening rates. Implementing system strategies for CRC screening takes time and effort and is important to maintain, to help prevent, or to cure many cases of CRC, the second leading cause of cancer in the United States.Federally qualified health centers (FQHCs) attempt to provide comprehensive, quality primary health care services to medically underserved communities and vulnerable populations. Approximately 1198 centers receive operating grants from the Public Health Service Act and thus qualify for reimbursement from Medicare and Medicaid.1 FQHCs served 21 million patients in 2012, of whom 36% were uninsured and 92% were living below the 200% poverty level.1 One of the services provided by FQHCs is colorectal cancer (CRC) screening through stool testing for occult blood.2 This service is covered under the Medicare FQHC benefit for persons aged 65 years and older and for those who qualify for the Medicaid program.3CRC is the second leading cause of cancer deaths in the United States.4 Only 63% of US adults report being up-to-date with CRC screening.5 CRC is a disease that is largely preventable; colonoscopy, through detection of early tumors and removal of precancerous polyps, could prevent 65% of CRC cases.6,7 Several national organizations have guidelines for CRC screening.8,9 National guidelines promote any of several tests for CRC screening: tests that pick up occult bleeding and endoscopic tests that visualize all or part of the colon.8–10Clinical tests to directly visualize colorectal cancer and precancerous polyps are colonoscopy, flexible sigmoidoscopy, double-contrast barium enema, and computed tomographic colonography (virtual colonoscopy). Fecal occult blood tests (FOBTs), which detect blood in the stool that is not visible and that indicates possible cancer, are the guaiac-based test and the fecal immunochemical test (FIT). FOBTs are recommended annually, and colonoscopy is recommended every 10 years, if no polyps are found.8–10 FOBTs are much less expensive than colonoscopy and are often preferred by patients. In many safety net settings, FOBTs are the initial option for patients, because of the prohibitive cost and limited availability of colonoscopy.11,12Through an infrastructure grant to enhance community-based cancer control in Iowa, we visited 4 FQHCs in Iowa and learned that FOBTs were available for use, but were for the most part not given to patients to avoid having to arrange and pay for a follow-up colonoscopy if FOBT results were positive. One FQHC director explained that the annual budget included a fund for extra tests that might be needed for any medical reason, and once these funds were exhausted, no more funding was available in that year. Thus, CRC screening was not a top priority, because of many other competing health care needs.To enhance CRC screening, system strategies are appropriate. A system strategy is a group of interrelated items that are part of a plan of action to accomplish a specific goal, such as improving CRC screening. Many different system strategies have been identified for improving CRC screening, such as physician recommendation,13,14 mailed patient reminders,15–17 and electronic medical record (EMR) physician reminders.18,19Patients at greatest risk for not receiving CRC screening are racial and ethnic minorities, Asians and Hispanics, and individuals who lack a usual source of health care or health insurance.20 Underuse of CRC screening is frequently associated with socioeconomic disadvantage21 and is associated with higher late-stage CRC rates.22 Because many of our nation’s most disadvantaged individuals make use of FQHCs, we assessed the protocols and system processes in place for CRC screening at FQHCs in 4 midwestern states and estimated rates of CRC screening in these FQHCs.     

Health Care Expenditures for Urban and Rural Veterans in Veterans Health Administration Care

Objective. To compare Veterans Health Administration (VA) patients, non-VA-using veterans, and nonveterans, separated by urban/rural residence and age group, on their use of major categories of medical care and payment sources.
Data Source. Expenditures for health care–using men in Medical Expenditure Panel Surveys from 1996 through 2004.
Study Design. Retrospective, cross-sectional analysis.
Data Collection/Extraction Methods. Controlling for demographics, health status, and insurance, we compared groups on population-weighted expenditures for inpatient, hospital-based outpatient, office-based, pharmacy, and other care, by major payers (self/family, private insurance, Medicare, other sources, and VA).
Results. VA users received most of their health care outside of the VA system, paid through private insurance or Medicare; self-payments were substantial. VA users under 65 reported worse health if they were rural residents but also lower expenditures overall and less care through private insurance.
Conclusions. VA health care users get most of their medical care from non-VA providers. Working-age VA users have less insurance coverage and rely more on VA care if they live in rural areas.     

Prevalence of Traditional Asian Postpartum Practices at a Federally Qualified Health Center

To evaluate the knowledge of, participation in, attitudes towards, and experiences with “doing the month” (DTM), a traditional Chinese and Vietnamese postpartum practice, at a federally qualified health center that serves predominantly Asian immigrants. DTM practices revolve around the balance between yin and yang and include practices such as the mother remaining on bed rest for as long as possible, restricting diet to certain foods, and avoiding visitors and social activities. A cross-sectional survey in Chinese, Vietnamese, and English was developed to determine the prevalence of women who have heard of and participated in DTM. 154 respondents participated. The mean age of respondents was 40.1 years. Without prompting of what DTM was, 58 (37.7%) responded that they had heard of DTM. After an explanatory paragraph, this increased to 117 (76.6%) participants. Out of 107 patients who have children, 65 (60.7%) “did the month” after giving birth. Participation rates were highest for women who identified as Chinese or Vietnamese. Likert-type scale questions showed that respondents believed DTM was stressful but enjoyable and helpful for recovery from childbirth. In conclusion, DTM is a common practice that health providers should be aware of.

     

Frequency of Food Insecurity and Associated Health Outcomes in Pediatric Patients at a Federally Qualified Health Center

Food insecurity (FI) has been recognized as a public challenge not only for developing countries but also for the U.S. population. The present study was designed to identify the prevalence of FI and the association of household FI with the health status of pediatric patients seen at a Federally Qualified Health Center in New Jersey which provides health care mainly for Latino patients. Patients were included if they were screened for FI at their well visits during a 4-month period following implementation of the 2-item screening tool recommended by American Academy of Pediatrics. We compared demographic and morbidity data of children with FI to those living in food-secure households. The results are presented as the distribution of frequency (%) and odds ratios (OR) with 95% confidence interval (95% CI). FI was detected in 15.8% (95% CI 14.2–17.5%) of 486 studied children. We recorded higher rates of anemia (10.4 vs. 3.2%, p?<?0.005), hypercholesterolemia (10.4 vs. 3.4%, p?<?0.01), and any morbidity (24.7 vs. 9.3%, p?<?0.02) in children living in FI households. Multivariate logistic regression analysis revealed an association of household FI with at least one recorded morbidity independent of the patient’s age, gender, and body mass index (OR 1.79, 95% CI 1.31–2.43). No one was diagnosed with diabetes, and only a few with asthma and hypertension. We have concluded that living in households with FI increased the risk for unfavorable health outcomes in a predominantly economically disadvantage community of children within the U.S. population.     

Assessing Knowledge and Experience of Integrated Behavioral Health among Patients with Limited English Proficiency at a Diverse,Urban Federally Qualified Health Center

Journal of Immigrant and Minority Health - Integrated behavioral health (IBH) embeds behavioral health clinicians in primary care settings to improve access and quality of care. This study...     

Posttraumatic Stress Disorder Among Women Receiving Prenatal Care at Three Federally Qualified Health Care Centers

This study assessed the prevalence and interrelationships of posttraumatic stress disorder (PTSD), antecedent trauma, and psychosocial risk factors among pregnant women served at three urban Federally Qualified Health Care Centers. This analysis was part of a validation study of the prenatal risk overview, a structured psychosocial risk screening interview. The study sample included 745 prenatal patients at three clinics who also were administered the major depression, PTSD, alcohol, and drug use modules of the Structured Clinical Interview for DSM-IV (SCID). Most participants were women of color (89.1 %), under the age of 25 years (67.8 %), and unmarried (86.2 %). The rate for a current PTSD diagnosis was 6.6 % and for subthreshold PTSD 4.2 %. More than half (54 %) of participants reported a trauma that met PTSD criteria; 21 % reported being a victim of or witness to violence or abuse, including 78 % of women with PTSD. Compared to those without PTSD, those with PTSD were 4 times more likely to be at risk for housing instability (AOR 4.15; 95 %CI 1.76, 9.80) and depression (AOR3.91; 95 %CI 2.05, 7.47) and 2 times as likely to be at risk for a drug use disorder (AOR 1.96, 95 %CI 1.04, 3.71) and involvement with child protective services (AOR 2.27; 95 % CI 1.06, 4.89). Women age 25 or older were twice as likely to meet PTSD diagnostic criteria as younger women (AOR2.27; 95 %CI 1.21, 4.28). Trauma exposure and pervasive PTSD were common in this population. Systematic psychosocial risk screening may identify the population with PTSD even without questions specific to this disorder.     

FQHC (Federally Qualified Health Center): harnessing the incentives of cost reimbursement

Community health centers (CHCs) are federally supported primary care providers to the low-income and uninsured. The federally qualified health center (FQHC) legislation requires states to pay CHCs for Medicaid services on the basis of reasonable cost. The statute generated controversy, particularly in a time when, for most providers, cost-related reimbursement has given way to fixed payments and managed care. This article examines the impact of FQHC on revenue and utilization of CHCs, using data for 328 centers that were in continuous operation between 1989 (the year the legislation was enacted) and 1992, the first year of full implementation. During this period, the CHCs Medicaid revenue grew rapidly. FQHC is estimated to account for under one third of the total increase, while inflation and growth in utilization due to expanded Medicaid eligibility are estimated to account for the other two thirds. At the same time, the change to cost-related reimbursement had a significant increase in total service users and Medicaid recipients receiving care from CHCs. Although some expected that cost-reimbursement would lead to inflationary increase in utilization, this did not occur. There was no statistically significant relationship between the change in payment methodology and changes in encounters per user. The experience of FQHC indicates that, for safety net providers of primary care, cost-related reimbursement is not "inherently inflationary." Results of this study raise the question of whether payment within constraints, but bearing relationship to cost, is not an appropriate approach to developing primary care capitation rates for these providers--and assuring maintenance of the safety net for the uninsured.     

Use of Evidence-Based Interventions and Implementation Strategies to Increase Colorectal Cancer Screening in Federally Qualified Health Centers

While colorectal cancer (CRC) screening rates have been increasing in the general population, rates are considerably lower in Federally Qualified Health Centers (FQHCs), which serve a large proportion of uninsured and medically vulnerable patients. Efforts to screen eligible patients must be accelerated if we are to reach the national screening goal of 80% by 2018 and beyond. To inform this work, we conducted a survey of key informants at FQHCs in eight states to determine which evidence-based interventions (EBIs) to promote CRC screening are currently being used, and which implementation strategies are being employed to ensure that the interventions are executed as intended. One hundred and forty-eight FQHCs were invited to participate in the study, and 56 completed surveys were received for a response rate of 38%. Results demonstrated that provider reminder and recall systems were the most commonly used EBIs (44.6%) while the most commonly used implementation strategy was the identification of barriers (84.0%). The mean number of EBIs that were fully implemented at the centers was 2.4 (range 0–7) out of seven. Almost one-quarter of respondents indicated that their FQHCs were not using any EBIs to increase CRC screening. Full implementation of EBIs was correlated with higher CRC screening rates. These findings identify gaps as well as the preferences and needs of FQHCs in selecting and implementing EBIs for CRC screening.     

Access to Oral Health Care: The Role of Federally Qualified Health Centers in Addressing Disparities and Expanding Access

Objectives. We examined utilization, unmet need, and satisfaction with oral health services among Federally Qualified Health Center patients. We examined correlates of unmet need to guide efforts to increase access to oral health services among underserved populations.Methods. Using the 2009 Health Center Patient Survey, we performed multivariate logistic regressions to examine factors associated with access to dental care at health centers, unmet need, and patient experience.Results. We found no racial or ethnic disparities in access to timely oral health care among health center patients; however, uninsured patients and those whose insurance does not provide dental coverage experienced restricted access and greater unmet need. Slightly more than half of health center patients had a dental visit in the past year, but 1 in 7 reported that their most recent visit was at least 5 years ago. Among health center patients who accessed dental care at their health center, satisfaction was high.Conclusions. These results underscore the critical role that health centers play in national efforts to improve oral health status and eliminate disparities in access to timely and appropriate dental services.The “silent epidemic” of poor oral health in America was highlighted by the US Surgeon General’s 2000 report, Oral Health in America, which also called attention to the disparities that persist in oral health status, access to care, and unmet need for dental care.1A Government Accountability Office report from the same year echoed the need to address oral health disparities, noting that oral health problems are the most prevalent chronic disease suffered by children despite being largely preventable.2 As with medical care, numerous studies also have found that both disease burden and access to oral health care are associated with income,3 race and ethnicity,4 language,5 and insurance status and type.6 These factors are associated with barriers to access in underserved communities such as affordability, lack of provider availability, inadequate transportation, and low health literacy around the need for oral health care. Whereas nationally almost 60% of individuals with high incomes had a dental visit in the past year, less than 30% of low-income patients (those with incomes below 200% of the federal poverty level) had a dental visit in the past year.7In the 2011 brief Advancing Oral Health in America, the Institute of Medicine (IOM) offered recommendations for improving access to oral health prevention and treatment services through a variety of mechanisms, including expanding the focus on oral health in primary care settings. Components of the strategy included training primary care providers to screen patients for emergent oral health issues, to assess patient risk for oral health problems, and to refer patients to dental professionals when appropriate. The IOM also called for improving oral health literacy through education efforts aimed at individuals, communities, and health care professionals. For example, community-wide public education campaigns were recommended to enhance awareness and knowledge about the causes and implications of oral disease and the importance of preventive oral health services. Building the health literacy of patients and promoting healthy behaviors may increase patient activation around these issues, especially when coupled with guidance on how to access oral health services in the community.8A subsequent IOM report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations, suggested ways to narrow or eliminate disparities and improve the oral health status of vulnerable populations, guided by the principles that (1) oral health is essential to overall health and, thus, is an important part of comprehensive health care, and (2) any broad strategy to increase access to care should include components aimed at oral health promotion and disease prevention.9 Building on the existing literature, recommendations for improving access to oral health services for underserved individuals included expanding oral health care capacity by encouraging the integration of oral health services into overall health care.10 Improving dental education and training for nondental primary care providers may facilitate such integration.11 Financial and administrative barriers such as the lack of coverage for dental care need to be addressed, while supporting policies that encourage all professionals to practice to the full extent of their training and licensure.12Federally Qualified Health Centers (health centers) play a key role in these strategies as they are uniquely positioned to increase access to oral health services in the communities experiencing the most acute access problems. Health centers provided comprehensive primary care to 19.5 million patients in 2010, while also serving as an affordable and convenient access point to oral health services for underserved communities and populations. More than 3.8 million patients received dental services at health centers in 2010, and there were more than 9.2 million visits to dental providers employed in health centers.13All health centers are required to provide preventive dental services either on site or by referral, and 4 out of 5 health center grantee organizations provided dental services in at least 1 of their sites in 2010, and 62.0% provided emergency dental services on site.14 By enhancing affordability for needy patients and providing other services such as transportation, translation, and case management, health centers address barriers to access for the most vulnerable and underserved patients in the nation. In the report on underserved populations,9 the IOM specifically calls for health centers to utilize a variety of oral health care professionals in addition to dentists, to educate health center providers about best practices in oral health care, and to provide oral health services as part of outreach efforts beyond the walls of the health center.The oral health objectives in Healthy People 2020 are the guideposts for evaluating efforts to improve access to timely dental care and, ultimately, oral health status.15 The oral health goals in Healthy People 2020 seek to reduce the incidence and prevalence of dental problems by reducing delays and barriers to timely prevention and treatment, and 2 of the 17 oral health objectives specifically call for health centers to expand their role as a source of access to dental services. The first objective seeks to increase the proportion of health centers with on-site oral health care programs from 75% in 2007 to 83% by 2020. The second objective seeks to increase the proportion of health center patients that receive oral health services at their health center from 17.5% in 2007 to 33.3% by 2020.16 By 2010, 80% of grantees offered on-site oral health services in at least 1 site14 and 19.5% of health center patients received oral health services at their health center,13 demonstrating progress toward these goals.We examined data from the 2009 Health Center Patient Survey regarding access to oral health services among health center patients. We examined utilization and unmet need for oral health care, along with satisfaction with oral health care among health center patients.     

Predictors of Colorectal Cancer Screening Prior to Implementation of a Large Pragmatic Trial in Federally Qualified Health Centers

Colorectal cancer screening can prevent cancer deaths. Federally qualified health centers serve a unique patient population that often is not screened. Knowing who in this environment is getting screened via fecal testing and via colonoscopy can assist in tailoring intervention to raise rates of colorectal cancer screening. We examined patient-level and neighborhood-level characteristics associated with being up to date with colorectal cancer screening guidelines. We also examined associations between these factors and being screened with a fecal test. We observed an increase in colorectal cancer screening rates from 2010 to 2015. Adjusted analyses revealed that the following factors were significantly associated with colorectal cancer screening: aged 65 or older, having any type of insurance, previous outpatient visits, and current or other preventive screenings. Among adults aged 50–75 who were up to date with colorectal cancer screening, factors associated with use of fecal testing, as opposed to colonoscopy, were: being younger, speaking a non-English language, being uninsured, having prior office visits, and having had a flu shot in past year. Our findings may inform clinic-based effort to raise rates of colorectal cancer screening, especially in the community clinic setting. Trial Registration: ClinicalTrials.gov, NCT01742065.     

The Cost-Effectiveness of Improving Diabetes Care in U.S. Federally Qualified Community Health Centers

Objective. To estimate the incremental cost-effectiveness of improving diabetes care with the Health Disparities Collaborative (HDC), a national collaborative quality improvement (QI) program conducted in community health centers (HCs).
Data Sources/Study Setting. Data regarding the impact of the Diabetes HDC program came from a serial cross-sectional follow-up study (1998, 2000, 2002) of the program in 17 Midwestern HCs. Data inputs for the simulation model of diabetes came from the latest clinical trials and epidemiological studies.
Study Design. We conducted a societal cost-effectiveness analysis, incorporating data from QI program evaluation into a Monte Carlo simulation model of diabetes.
Data Collection/Extraction Methods. Data on diabetes care processes and risk factor levels were extracted from medical charts of randomly selected patients.
Principal Findings. From 1998 to 2002, multiple processes of care (e.g., glycosylated hemoglobin testing [HbA_1C] [71→92 percent] and ACE inhibitor prescribing [33→55 percent]) and risk factor levels (e.g., 1998 mean HbA_1C 8.53 percent, mean difference 0.45 percent [95 percent confidence intervals −0.72, −0.17]) improved significantly. With these improvements, the HDC was estimated to reduce the lifetime incidence of blindness (17→15 percent), end-stage renal disease (18→15 percent), and coronary artery disease (28→24 percent). The average improvement in quality-adjusted life year (QALY) was 0.35 and the incremental cost-effectiveness ratio was $33,386/QALY.
Conclusions. During the first 4 years of the HDC, multiple improvements in diabetes care were observed. If these improvements are maintained or enhanced over the lifetime of patients, the HDC program will be cost-effective for society based on traditionally accepted thresholds.     

Changes in Self-management During the COVID-19 Pandemic Among Adults with Type 2 Diabetes at a Federally Qualified Health Center

The COVID-19 pandemic affected how adults with diabetes perform self-management, and impacts may be greater among vulnerable populations. We assessed the impact of the pandemic on diabetes self-management among adults with type 2 diabetes at a Federally Qualified Health Center. Participants were surveyed by phone in Spanish and English from July to October of 2020. Most respondents (74%) were Latino and preferred to speak Spanish, with mean age of 54 years and mean HbA1c of 9.2%. Fifty-three percent reported less physical activity during the pandemic. While 43% had more difficulty obtaining healthy food, 38% reported eating more healthfully. Sixty-one percent had increased difficulty accessing medical care. Many felt more socially isolated (49%) and stressed (51%). Changes in diabetes self-management were both positive and negative for majority Latino patients in this low-resource community, which may require tailored approaches to mitigate negative impacts of the pandemic on physical and mental health.

     

Increasing Human Papillomavirus Vaccination in a Federally Qualified Health Center Organization Using a Systems-Based Intervention Integrating EHR and Statewide Immunization Information System

Public acceptance of the HPV vaccine has not matched that of other common adolescent vaccines, and HPV vaccination rates remain below the Healthy People 2020 target of 80% compliance. The purpose of this study was to evaluate the capacity of nine pediatric clinics in a Federally Qualified Health Center organization to implement a systems-based intervention targeting office staff and providers using EHRs and a statewide immunization information system to increase HPV vaccination rates in girls and boys, ages 11 to 16 over a 16-month period. System changes included automated HPV prompts to staff, postcard reminders to parents when youths turned 11 or 12 years old, and monthly assessment of provider vaccination rates.

During the intervention, 8960 patients (11–16 yo) were followed, with 48.8% girls (n?=?4370) and 51.2% boys (n?=?4590). For this study period, 80.5% of total patients received the first dose of the HPV vaccine and 47% received the second dose. For the first dose, 55.5% of 11 year old girls and 54.3% of 11 year old boys were vaccinated. For ages 12 to 16, first dose vaccination rates ranged from the lowest rate of 84.5% for 14 yo girls up to the highest rate of 90.5% for 13 yo boys. Logistic regression showed age was highly significantly associated with first dose completion (OR?1.565, 95% CI?1.501, 1.631) while males did not have a significant association with first dose completion compared to females. The intervention increased overall counts of first and second HPV vaccination rates.

     

Primary Care Practice Management in Rural and Urban Veterans Health Administration Settings

Limited access to specialty care in rural settings may result in more expectations of primary care providers and a higher demand for primary care. The authors used survey and administrative data from 1999 from the Veterans Health Administration (VHA) to compare primary care practice management and performance in 19 rural to 103 urban VHA hospitals nationally. Rural VHA hospitals were smaller, less likely to be academically affiliated, and had fewer integrated specialty care services. Primary care providers in rural settings were more likely to manage specialty care services, provide continuity across patient care settings, and have complete responsibility for a broader range of services. However, rural hospitals had more staff per patient allocated to primary care than did urban hospitals. Patients in rural settings received comparable quality care to those in urban settings, and they appeared to be more satisfied with the care they received. Within the VHA system, primary care providers in rural settings provided a broader range of services than those in urban ones. This increased breadth may be attributable to the lack of availability of integrated specialty care services in rural settings. Because of this broader range of responsibilities, the provision of primary care in rural settings may require higher staffing patterns and may be inherently more costly than in urban settings; therefore, researchers should be cautious when comparing primary care expenditures across rural and urban settings.     

Early Access to Health Care Services Through a Rural School-Based Health Center

ABSTRACT: School-based health centers (SBHCs) and school-linked health centers (SLHCs) represent relatively new models for health care service delivery. This article examines the question: Are SBHCs accessible as defined by four criteria of accessibility: available, community-based, affordable, and culturally acceptable? A literature review and an examination of a rural SBHC providing care to young children are presented in this paper. Both support the hypothesis that SBHCs are accessible to children and families in the school community. In particular, this SBHC's enrollment rate of 98% and its usage rate of 99% provide strong evidence that SBHCs are culturally acceptable. Ten strategies for a successful SBHC are presented to assist in planning and implementation of other SBHCs.     

Feasibility of Using a Community-Supported Agriculture Program to Increase Access to and Intake of Vegetables among Federally Qualified Health Center Patients

Objective

This study explored the feasibility of using a 23-week subsidized community-supported agriculture program to increase access to and intake of vegetables among Federally Qualified Health Center patients.

Feasibility study of family planning services screening as clinical decision support at an urban Federally Qualified Health Center network

Objective

The objective was to assess the feasibility of an intervention introducing family planning services screening clinical decision support to improve provision of contraception and/or preconception services for women of reproductive age in our primary care Federally Qualified Health Center (FQHC) network.