Information Exchange Online Toolkit (CHCS)

This toolkit provides resources to assist organizations in managing patient information exchanges between the various providers involved in a clinical care team. It also offers examples of state behavioral/physical health coordination consent forms.


Articles and Briefs

Patient Experience of Chronic Illness Care and Medical Home Transformation in Safety Net Clinics

The objective of this research study was to examine the relationship between medical home transformation and patient experience of chronic illness care. This study included 13 safety net clinics located in five states enrolled in the Safety Net Medical Home Initiative. They reported that, 5-year medical home transformation may be associated with modest improvement in patient experience of chronic illness care for vulnerable populations in safety net clinics.

Treating Opioid Dependence with Buprenorphine in the Safety Net: Critical Learning from Clinical Data

Research has examined the safety, efficacy, feasibility, and cost-effectiveness of buprenorphine for the treatment of opioid dependence, but few studies have examined patient and provider experiences, especially in community health centers. Using de-identified electronic health record system (EHRS) data from 70 OCHIN community health centers (n = 1825), this cross-sectional analysis compared the demographics, comorbidities, and service utilization of patients receiving buprenorphine to those not receiving medication-assisted treatment (MAT).  It is important for providers, clinic administrators, and patients to understand the clinical application of medications for opioid dependence to ensure safe and effective care within safety net clinics.

Accelerating and Aligning Primary Care Payment Models White Paper

This Primary Care Payment Model (PCPM) White Paper, published by the Health Care Payment learning & Action Network (HCP LAN) views primary care teams as uniquely positioned to serve as catalysts for innovative care as well as effective stewards of health care resources. The paper offers principles and recommendations for implementing PCPMs that can help overcome the barriers to effective primary care tied to traditional fee-for-service payments based on the volume of services provided rather than the quality and value of care.

"Salt in the Wound": Safety Net Clinician Perspectives on Performance Feedback Derived From EHR Data.

This research article published in The Journal of Ambulatory Care Management, discusses Safety Net clinician perspectives on performance feedback from HER data. Through qualitative analyses, we identified perspectives on barriers and facilitators to the perceived legitimacy of EHR-based performance feedback, in 11 community health centers (CHCs). Providers said such measures rarely accounted for CHC patients' complex lives or for providers' decisions as informed by this complexity, which diminished the measures' perceived validity. Suggestions for improving the perceived validity of performance feedback in CHCs are presented.

Integrating Health Care and Social Services: Moving from Concept to Practice

This brief, prepared by Bailit Health Purchasing and the Robert Wood Johnson Foundation, examines practical approaches that state agencies might employ to better integrate social services and health care delivery.

Organizational Factors Affect Safety-Net Hospitals’ Breast Cancer Treatment Rates

The primary objective of this study presented in AcademyHealth was to identify key organizational approaches associated with underuse of breast cancer care in nine New York City area safety-net hospitals. The study concluded that at safety-net hospitals, underuse of needed cancer therapies is associated with organizational approaches to track and follow-up treatment. Findings provide varying approaches to safety nets to improve cancer care delivery.

Strengthening the Oral Health Safety Net

Funded by the DentaQuest Foundation, this initiative is a partnership with the National Association of Community Health Centers and Massachusetts League of Community Health Centers. The partnership is working with 15 state Primary Care Associations and over 100 Community Health Centers to strengthen local and state oral health programs.

Community Care Teams: An Overview of State Approaches

The paper was produced by the Center for Health Care Strategies and the State Health Access Data Assistance Center (SHADAC) with support from the Center for Medicare & Medicaid Innovation (the Innovation Center). This resource paper provides information on Community Care Team programs in several states and includes: An overview of core program features, key elements of governance models, approaches to financing and reimbursement, considerations for workforce requirements, and examples of health informatics models to support CCT initiatives.

Developing Care Management Programs to Serve High-Need, High-Cost Populations: Insights from the health care transformation task force

The Health Care Transformation Taskforce published this white paper, which provides information on the building blocks of care management; reviews case studies of Task Force member care management programs, and lessons learned and important areas for improvement.

Interdisciplinary Care Teams for Medicare-Medicaid Enrollees: Considerations for States

This brief published by the Center for Health Care Strategies was developed through support from The Commonwealth Fund and The SCAN Foundation. The technical assistance brief describes key interdisciplinary care teams (ICTs) considerations and explores how eight states – Idaho, Massachusetts, Minnesota, New Jersey, New York, Rhode Island, Virginia, and Washington – addressed these issues.

Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

This Commonwealth Fund article describes a study of medical practices recognized as patient-centered medical homes found that a team approach to primary care was fostered by: delegating more of physicians’ nonclinical tasks to other staff; soliciting staff input on workflow modifications and feeding back data to the team; expanding the roles of medical assistants and nurses; and holding regular team “huddles.”

Safety Net Integration: A Shared Strategy for Becoming Providers of Choice

This scholarly article provides insight into strategies to promote care integration in the safety net. The researchers interviewed safety net hospital and health center leaders from five US cities to understand specific strategies implemented by their organizations.

Forging Community Partnerships to Improve Health Care: The Experience of Four Medicaid Managed Care Organizations

This issue brief from The Commonwealth Fund establishes the drivers, goals, and challenges of forging community partnerships from the perspective of four Medicaid managed care organizations.

Innovation in the Safety Net: Integrating Community Health Centers Through Accountable Care

This article from The Commonwealth Fund offers evidence to support the value in partnerships between accountable care organizations and community health centers.

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety- Net Patients: A Randomized Controlled Trial

This scholarly article documents the effects of implementing a patient navigator program in a safety net hospital on hospital readmission rates.

Improving the Care of Dual-Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists

This scholarly article investigates the impact of care coordinators and clinical pharmacists in rural FQHCs on care for patients covered by both Medicare and Medicaid. The study indicates that investments in care coordination and clinical pharmacy review can significantly reduce hospitalization and harmful polypharmacy in this patient population.

Impact of a Chronic Care Coordinator Intervention on Diabetes Quality of Care in a Community Health Center

This scholarly article evaluates the impact of chronic care coordinators on diabetes care quality within six community health centers. The chronic care coordinator intervention in this study yielded some improvement, but requires some modification.

Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment

This report from The Commonwealth Fund offers a financial argument to support the need for health care providers to address patient’s social needs. It also provides strategies for health care organizations to achieve this goal.

Disease Management of Early Childhood Caries

This report explores the effectiveness of a disease management (DM) program for early childhood caries. The DM clinical protocol included a caries risk assessment tool (CAT), in-office and at-home care management, and other tools. The results from this analysis indicate that a risk-based DM approach may improve health care quality and patient outcomes. Safety net oral health providers can use this report to improve care for early childhood caries.

Cost Effectiveness of a Disease Management Program for Early Childhood Caries

This report investigates the cost-effectiveness of a disease management (DM) program for early childhood caries. The study concludes that the DM program is cost-effective and may reduce overall health care costs. Safety net oral health providers may use this report to financially justify a DM intervention for early childhood caries.

DentaQuest Institute Safety Net Solutions

Safety Net Solutions is a DentaQuest Institute program that seeks to provide care management assistance to safety net dental programs. This report outlines the SNS model and its impact, as well as provides lessons and recommendations based on efforts from 2006- 2011. Safety net providers may use this report to improve their dental programs.