1. Welcome
The National Cooperative Agreement on
Clinical Workforce Development
WEBINAR 8: Dissolving the Walls: Clinic Community Connections
June 2nd, 2016
Presented by the
the Community Health Center, Inc.
& the MacColl Center for Health Care Innovation

2. Speakers
From MacColl Center for Health Care Innovation, Group Health Research Institute:
Ed Wagner, MD, MPH, Director Emeritus
Brian Austin, Deputy Director
Katie Coleman, MSPH, Research Associate
From Access Community Health Network:
Donna Thompson, RN, MS
From Community Health Center, Inc.:
Mark Masselli, CEO/President
Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director
Kerry Bamrick, MBA, Senior Program Manager

3. LEARNING COLLABORATIVE APPLICATIONS NOW
OPEN!
o Participation in the Learning Collaborative is FREE for health
centers.
o 9-month intensive learning collaborative provided by CHCI,
it’s Weitzman Institute and partners
o Team Based Care or Post-Graduate Residency Program
How to apply?
-Visit www.chc1.com/nca
-PDF of the application is available on our website
-Applications due June 10th

4. Learning Objectives:
1. Describe the relationship between understanding individual patients and
understanding their community and culture.
2. Identify 3 ways they can better connect with their community to provide the
services their patients need.

5. Get the Most Out of Your Zoom Experience
• Send your questions using Q&A function in Zoom
• Look for our polling questions
• Live tweet us at @CHCworkforceNCA and #primarycareteams and #HRSAnca
• Recording and slides are available after the presentation on our website within one week
• CME approved activity; requires survey completion
• Upcoming webinars: Register at www.chc1.com/nca

6. Dissolving the Walls: Clinic
Community Connections
Learning from Effective Ambulatory Practices
MacColl Center for Health Care Innovation
Group Health Research Institute
June 2nd, 2016
Ed Wagner, Director Emeritus
Katie Coleman, Research Associate | Brian Austin, Deputy Director

7. The Origins of Community Medicine
• In mid-1940s, Sidney and Emily Kark
establish a PC practice among the Zulu
in Pholela, SA. Provided primary care
but also surveyed the health needs of
the population, and responded
accordingly.
• In 1957, a med student, Jack Geiger,
spends 4 months in Pholela with the
Karks.
• In 1965, Geiger starts first U.S.
community health centers in Mound
Bayou, Mississippi, and Boston.

8. Delta Community Health Center Services
• In addition to providing PC
services, the Delta HC: developed
the CHW role, established a farm
coop to make healthy food more
available, dug wells for clean
water, provided education to
adults that hadn’t completed high
school, etc.
• The first health centers:
 Hired staff from the
community
 addressed the social
determinants of health in their
communities.

9. The three goals of clinic-community
connections
1. Hire staff from important communities to increase
cultural competence and reduce language barriers.
2. Connect patients with community resources that meet
important needs.
3. Help address social determinants of health.

10. Why hiring staff from the communities served is viewed
as critical by LEAP practice leaders
• People are more likely to seek medical care staffed by folks like
them.
• Patients often are more willing to confide personal information
with a peer.
• Staff from the cultures and communities served provide valuable
intelligence on community strengths and resources, as well as
factors threatening population health and well-being.
• Evidence suggests that patients receiving or reviewing information
from culturally indigenous staff become better self-managers.
• It helps the local economy.

11. Connect patients with community
resources that meet important needs.
• Most U.S. communities have a
confusing array of potentially helpful
resources and services.
• Providers are often not aware of
community agencies and resources
that can benefit patients, or how to
help patients access them.
• LEAP practices often employ staff (lay
workers, MAs, CHWs, etc.) who
develop relationships with services or
resources in the community and help
patients connect with them.

12. Help address social determinants of
health.
What can busy, financially strapped community health
centers do to improve the health and well-being of the
communities they serve?

13. Action Steps
1. Hire staff representative of communities served.
2. Designate staff to coordinate community linkages.
3. Learn community strengths and weaknesses.
4. Develop relationships with key community organizations.
a. Those providing key patient services.
b. Potential partners in addressing social determinants.
5. Use the practice’s influence and resources to better the
community.

14. www.improvingprimarycare.org

15. Resource Spotlight #1

16. Resource Spotlight #2: Program and Services
Brochure from 11th Street Family Health Services
www.improvingprimarycare.org

17. Presented by: Donna Thompson
CEO Access Community Health Network
June 2, 2016
‘Looking Beyond Our Walls’
Access Community Health Network

18. Key Objectives
• Share ACCESS’ experience as a Federally Qualified
Health Center (FQHC) serving the Chicago area
• Discuss the role of the community in caring for
our patients
• Explore how we learn from patients about their
needs ‘beyond our walls’
• Describe how ACCESS connects with existing
resources and advocates for those resources that
don’t exist

19. About ACCESS
• ACCESS is one of the largest FQHC organizations in the
country.
• Accredited by The Joint Commission, ACCESS operates 36
health centers across Chicago and Cook and DuPage
counties.
• This year, ACCESS will serve more than 180,000 low-income
individuals and families, including more than 30,000
uninsured patients with over 608,000 visits.
• ACCESS is proud to be named a Level 3 Patient-Centered
Medical Home (PCMH) Recognized Practice by NCQA.

20. Our Mission
The mission of ACCESS is to provide
outstanding preventive and primary health
care, accessible to all in their own
communities.

21. Our Strategic Plan

22. Challenges We Face
• Newly insured population due to expansion of Affordable
Care Act (ACA): many decades behind in maintaining their
health
• Many patients are experiencing first face-to-face with a
provider since their last pediatric visit
• New competitors are now emerging in what was once
considered an undesirable market
• More patient choice
• Provider retention and recruitment
• Volume to Value-base reimbursement (aggressive
movement to risk contracts)
• Addressing social determinants of health

23. The Quality Factor
• The backbone of the ACA is prevention.
• Huge paradigm change: from volume to value
model
• Must be at the core of every organization’s
business and care model

24. Our Approach to Quality Improvement
• Emphasis on quality outcomes (measureable)
• Patient Centered Medical Home (PCMH)
model (Level 3)
• Strong technology investment
• Ability to be nimble and rapidly adapt to this
new health care environment

25. How We Impact Health Beyond Our Walls
• Engage patients between visits through technology, including 24/7
patient access via a secure online patient portal
• Screen patients for key social determinants that impact health (i.e.
food insecurity, housing) and link patients to the resources they
need to support their care and positively affect their health
outcomes
• Develop a team-based care model that is rooted in evidence-based
practices
• Engage our patients in their care plan through shared decision-
making and meet them where they are
• Invest in the right technology to give our providers access to real-
time data that can impact patient care and outcomes

26. How We Impact Health Beyond Our Walls
Role of the Community
• Imbedded in our strategic focus
• Stakeholders are within and outside our walls
• Long history of cultivating collaborative relationships
• Strategic community partnerships aren’t built with only those
organizations that think like you
• Intentional with creating a workforce reflective of the community at
all levels of the organization
• 51% of ACCESS’ Board of Directors are community representatives
• Community has to feel they have power and ownership
• Can influence change

27. How We Impact Health Beyond Our Walls
How we learn from our patients about their needs
• Build trust and non-judgmental relationships
• Shared decision-making
• Use of data from various sources to confirm/validate
and bring clarity when discussing community issues
• Advisory groups
• Change the milieu of the health center
– Comfort rooms
– Design of the exam rooms
– Group visits that create supportive environment
• Centering programs

28. How We Impact Health Beyond Our Walls
Connecting to existing resources
• Things to consider:
• Success is all about the detail
• Understanding the assets in the community and staying current
• Ideas that appear simple are usually more complex to execute
• What’s it really going to take to make a resource valuable for
the community
• Community perception of resources can make or break an idea
• Resources need to be aligned with how people navigate their
daily lives

29. How We Impact Health Beyond Our Walls
Advocating for resources that don’t exist
• Things to consider:
• Build a business case using data that supports the need and
desired impact
• Ideas that appear simple are usually more complex to
execute
• It’s better to seek resources with a group that has the same
shared interests. Strong by numbers and influence
• Explore non-traditional sources for advocacy or to build
coalition
• Patience and Focus - to build momentum and commitment
may take years before outcome is realized

30. Questions? Learn More About ACCESS
Donna Thompson, Chief Executive Officer
Donna.Thompson@accesscommunityhealth.net
• www.achn.net
• ACCESS on social media:
• http://Twitter.com/ACCESSHealth
• http://Facebook.com/ACCESSCommunityHealth
• https://www.LinkedIn.com/company/access-
community-health-network

31. Community Health Center, Inc.
Foundational Pillars
1. Clinical Excellence- fully Integrated teams, fully
integrated EMR, PCMH Level 3
2. Research & Development- CHC’s Weitzman Institute is
the home of formal research, quality improvement, and R&D
3. Training the Next Generation: Postgraduate training
programs for nurse practitioners and postdoctoral clinical
psychologists as well as training for all health professions
students
CHC Profile:
•Founding Year - 1972
•203 delivery sites
•145k patients

32. Community Health Center, Inc.
 Income Equality Starts with Us
 Solutions Need to be Scalable
 Build it, and They Will Come. Maybe..
 Who Wants to be on the Bus?
 The Visit Starts with a Phone Call

33. Q & A, Discussion