As with other site visits conducted for this project, preparation for the visit began approximately one month prior to the in-person meetings with initial telephone conversations with CHCN leadership. These initial conversations were conducted to share the aims of the site visit, obtain agreement from network leadership to participate in the site visit, discuss potential discussants for the in-person meetings and set a date for the in-person meetings. Following these initial telephone conversations, we revised background materials, developed detailed agendas for each meeting and set appointments with clinical, administrative and IT leadership from across CHCN member health centers in and nearby Alameda County.
The site visits themselves took place on the week of March 9, 2009. We deployed one two-person team to conduct meetings with three health centers as well as CHCN’s executive staff. For each meeting, we prepared materials that outlined our preliminary knowledge of the discussant organization and highlighted outstanding questions to address during the in-person discussion. Having two team members at each meeting allowed us to have one individual dedicated to taking notes and documenting the content from the meeting while the other focused on assuring that the goals of each meeting were being addressed through engagement with the participants. Finally, after concluding the site visit, we conducted an additional telephone meeting with CHCN’s CEO, Ralph Silber, to follow-up on some of the findings from the health center discussions and explore priorities and future direction for the network.
CHCN Network Profile. The Community Health Center Network of Alameda County, CA was formed in 1996, largely response to rapid expansion of managed care in California. CHCN was established out of the Alameda Health Consortium (AHC), an entity that serves as a primary care association for Alameda County. The network’s seven member clinics came together and formed CHCN in order to facilitate their member clinics’ participation in California’s safety net managed care system.
To serve its primary purpose, CHCN began operations as a managed care management services organization or MSO establishing “at risk” contracts on behalf of member health centers with three MediCal health maintenance organizations (HMOs). The network still maintains these contracts and offers managed care services including all claims adjudication, capitation distribution, membership reports, quality improvement, utilization management, financial and encounter data reporting and HMO contracting for its member health centers. To facilitate reporting, CHCN maintains a data warehouse that holds claims, labs, pharmacy, and hospital visit data for all of CHCN’s managed care patients as well as outpatient claims and clinical laboratory data for all patients seen by CHCN’s member clinics.
After building capacity to operate functions associated with a typical MSO, CHCN began offering practice management, business operations, quality improvement and information systems in response to the needs of network members. For example, CHCN employs a network-wide medical director who coordinates chronic disease management programs focusing on diabetes, asthma, and cardiovascular health. In the QI role, CHCN led its member health centers in an effort to apply for a Tides Foundation grant and to implement i2i Tracks. CHCN is also implementing for its managed care patients, an advanced case management system using an application called Altruista. Increasingly, CHCN plans to create and support options for health center adoption of electronic health records (EHRs).
CHCN member health centers include: Asian Health Services, Axis Community Health, La Clinica de La Raza, LifeLong Medical Care, Native American Health Center, Tiburcio Vasquez Health Center, and Tri-City Health Center. As of July 2009, West Oakland Health Council has joined CHCN. These health centers provide services in more than 29 locations throughout the East Bay. CHCN centers are located in a range of settings from urban (Oakland, Berkley) to suburban (Fremont) and “small city” locations (Pleasanton). The NORC team visited three CHCN health centers, LifeLong Medical Care, Axis Community Health and Tri-City Health Center, located in Berkley, Pleasanton and Fremont respectively.
CHCN’s health centers provide medical care to a diverse population and use over 25 different languages in delivering health care and outreach services. Combined, CHCN’s health centers serve 164,717 patients with 647,055 annual encounters. These visits include over 400,000 general medical visits, over 36,000 prenatal visits and just fewer than 55,000 dental visits each year. The vast majority of their patients are uninsured or on Medicare, Medicaid or CHIP. Approximately 40 percent of patients seen in CHCN centers report to be of Hispanic ethnicity, 20 percent each report to be African American and Asian Pacific Islander and 4 percent Native American7.
Tri-City Health Center Profile. In the early 1970’s Tri-City Health Center (TCHC) first opened as a women's health clinic, offering family planning health services and pregnancy counseling. They have had section 330 funding for nearly (if they opened in the 70’s) 40 years and over the last couple of years have almost tripled in size. TCHC serves a 150 square mile radius in Southern Alameda County. In 2007 TCHC’s clinics provided services for over 19,000 patients with more than 70,000 yearly visits. Seventy-seven percent of their patients are below the poverty level, and 67% of patients who visit the clinic are uninsured. Overall they serve a relatively young population with only 3 to 5 percent seeking geriatric care.
In addition to primary care, TCHC offers some specialty care programs including dental services for all ages. They also maintain an HIV treatment facility that is the second largest in the area and provide a range of social support and wellness services to complement their healthcare program. Their management structure includes a board of directors, an executive director, quality director, chief financial officer, development director, medical director, chief operating officer, human resources director and chief information officer.
LifeLong Medical Profile. LifeLong Medical Care was formed in 1996 as a merger between two clinics with deep community roots in Berkeley. One clinic had focused on care for older Americans and another focused on pre-natal care for low income women. Since the merger, they have grown to include five medical clinics, a dental clinic, an adult day health center for elders with complex care needs and a supportive housing program for formerly homeless adults.
Their mission is to provide health and social service programs to improve access to care for the underserved and improve population health. LifeLong provides primary care, mental health and case management programs. LifeLong is known as the primary safety net provider of medical services to the uninsured and those with complex health needs and due to its origins cares for a greater elderly population than its counterparts. Lifelong concentrates its activities in Berkley where 5 of its sites are located. Outside of Berkley Lifelong has sites in Oakland, Albany and Emeryville. In 2007, LifeLong provided approximately 115,000 primary care visits to over 18,000 people.
Typical of many health centers, LifeLong is managed by a Board of Directors and directly led by an executive director, chief financial officer and chief medical officer. They also have a QI director and IT director. LifeLong employs 100 full time equivalents (FTEs) providing care as licensed medical providers. Their IT department employs six FTEs. Overall they employ about 430 staff members at about 340 FTEs. Their QI department includes a clinical measures committee, a chronic care management committee and a clinical planning committee. These committees are comprised of the medical director other clinicians and the QI director and are staffed by three FTE AmeriCorps volunteers.
Axis Health Services Profile. Axis Community Health began in 1972 in Pleasanton, CA as a health center for low income children in far eastern Alameda County who had no other access to health care. Over the past thirty years Axis has grown to include medical care for all ages. They have added mental health counseling services, addiction recovery programs, court-ordered courses, a WIC nutrition program, and school and community-based health education services. A week prior to NORC’s visit to the Bay Area Axis received word that they will become a federally funded health center beginning immediately as part of ARRA infrastructure funding.
Axis’ patients come from a large geographical area. Because they are the only safety net provider in their region, they receive all of the uninsured patients and Medicaid patients in their service area of about 108 square miles. They have four sites, one exclusively for nutrition services, one focused only on behavioral health and two others that provide medical and mental health services. To meet new requirements for being funded by HRSA, Axis reported needing to increase their business by approximately 40 percent.
Axis employs a staff of 60 FTEs that include physicians, nurses, mental health professionals, drug and alcohol counselors, registered dieticians, health educators and a variety of support personnel. Axis also has an intern program for post-master's level mental health professionals. Their staff provides services in a variety of languages. At the executive level they employ a chief executive officer, medical director, chief financial officer, development director and IT director.