Organizations launch Kresge-funded project to assess and address patient risk

November 20, 2013
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[Archive] Stacy Lavilla
Director of Communications
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OAKLAND, November 20, 2013 – The National Association of Community Health Centers (NACHC), the Association of Asian Pacific Community Health Organizations (AAPCHO), the Oregon Primary Care Association (OPCA), and the Institute for Alternative Futures (IAF) have launched a Kresge Foundation-funded project to measure and capture health centers’ patient risks in terms of both clinical and non-clinical factors, such as the social determinants of health–the social, environmental, and economic factors that influence an individual’s health.

An $800,000 grant from The Kresge Foundation will support the three-year project to create, implement, and promote a standardized health risk assessment protocol that goes beyond medical acuity to account for the social determinants of health.

“At The Kresge Foundation, we’re focused on reducing health disparities by addressing conditions that lead to poor health outcomes,” says Kresge’s David Fukuzawa, who directs the foundation’s Health Program. “Creating a standard patient risk-assessment protocol will certainly be helpful to the community health center sector. The ultimate goal is to transition community health centers toward a more population-health focused approach.”

“We are delighted to be working on an issue that is a key health center concern and is so crucial to their mission of providing high quality care to America’s underserved populations,” said Dan Hawkins, Senior Vice President for Public Policy and Research at NACHC. “It is vital for health centers to collect data on patient risk to better know their patients and determine how best to meet their needs in a sustainable way.”

This project comes at a critical time, as payments become increasingly based on measures of health quality rather than the volume of services provided.  However, current quality measures do not account for the fact that much of the differences in health are related to the social determinants of health – poverty, jobs, education, housing, availability of healthy food, neighborhood safety, geographic isolation, and social exclusion.

As a result, quality measures and payment systems do not reflect the extra time and resources needed to help these patients become and stay healthy, putting health centers at a significant disadvantage.  Collecting data on patient risk, especially the social determinants of health that health center patients often confront in their environment and living situations, will be crucial to level the playing field for health centers when payment is based on performance rather than volume.

“Community health centers have been helping patients tackle access issues related to the social determinants of health for decades,” says Rosy Chang Weir, director of research at AAPCHO. “A standardized tool that measures patient risk and complexity is desperately needed so health centers can be recognized and fairly compensated for this work.”

“Oregon is breaking new ground in payment reform,” says OPCA Executive Director Craig Hostetler.  “Our health centers are piloting care and payment models designed to keep patients healthy, communities engaged and overall costs as low as possible.  We’re excited to further our learning with our project partners as we develop systems to better account for the social determinants of health.”

The protocol developed from this project will be critical to helping health centers better understand and manage their patient populations with needed services and community partnerships, identify which factors are driving higher health care costs and poorer health outcomes, and create more appropriate risk adjustments when operating under value- or performance-based payment systems.

“This protocol will be a major advance in integrating knowledge of social determinant-related risks with health centers’ practices as health centers become more systematic in understanding the root causes of their patients’ illnesses and more strategic in their role in shaping them,” says IAF Chairman and Senior Futurist Clem Bezold.

In the first year, the partners will review and assess the nature and use of existing patient risk assessment tools and protocols to inform the development a national standardized health risk assessment protocol.  If your health center or health organization currently uses a patient risk assessment tool and you would be willing to share it with us, please contact Michelle Jester at or 202-331-4609.  If you would like to be kept informed about the progression of this project, please contact Michelle Jester.

About the National Association of Community Health Centers
Founded in 1970, the National Association of Community Health Centers (NACHC) is a non-profit organization whose mission is to enhance and expand access to quality, community-responsive health care for America’s medically underserved and uninsured.  NACHC represents the nation’s network of over 1,200 Federally Qualified Health Centers (FQHCs) which serve over 22 million people through over 9,000 sites located in all of the 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam.

About the Oregon Primary Care Association
The Oregon Primary Care Association (OPCA) is a non-profit state-based membership organization for health centers in Oregon and their supporters.  OPCA is an innovative organization that has developed new and creative models related to the medical home, alternative payment methodologies, and Health Information Technology, and has a close relationship with OCHIN, a health center controlled network.   OPCA brings critical experience piloting the use of EHRs to capture data on both the social and behavioral barriers that health center patients face and the enabling services they receive, as well as on-the-ground experience providing health centers training and technical assistance.  OPCA is also a national leader in payment reform discussions involving appropriate risk adjustment.  The organization’s award-winning six-minute video, A Complex Case: Quality Care for Those in Need, makes a strong case for measurement and payment systems that account for the social determinants of health.

About the Association of Asian Pacific Community Health Organizations
The Association of Asian Pacific Community Health Organizations (AAPCHO) is the national leader and critical voice for Asian American, Native Hawaiian, and other Pacific Islander (AA&NHOPI) community health centers and consumers, representing 33 community health centers & organizations serving over 450,000 primarily AA&NHOPI patients.  They advocate for the unique and diverse health needs of AA&NHOPI communities and the community health providers that serve those needs, including the provision of health care services that are community driven, financially affordable, linguistically accessible, and culturally appropriate.  AAPCHO has been collecting and analyzing data regarding enabling services that encompass SDH through their Enabling Services Accountability Project (ESAP) for almost ten years and provide ongoing training to health centers and networks.  They have extensive experience in developing data collection protocols, encounter forms, and EHR templates to capture enabling services that will be instrumental to this project, as well as in conducting readiness assessments  and working within existing practice patterns.

About the Institute for Alternative Futures
The Institute for Alternative Futures is a nonprofit research and educational organization that helps communities and organizations more wisely understand and create the futures they prefer. Since 1977, IAF has been a pioneer in the use of futures methods, such as forecasts, scenarios, and vision, in health and health care, energy, transportation, education, and business. For more information, visit  IAF also developed and leads the Disparity Reducing Advances Project—a multi-year, multi-stakeholder project—to identify and accelerate advances that would achieve health equity. Learn more at  IAF led the first report on “Community Health Centers Leveraging the Social Determinants of Health”, funded by The Kresge Foundation, and will provide expert guidance and vision on this project.

About The Kresge Foundation
The Kresge Foundation is a $3 billion private, national foundation that works to expand opportunities in America’s cities through grantmaking and investing in arts and culture, education, environment, health, human services and community development efforts in Detroit. In 2012, the Board of Trustees approved 410 awards totaling $130.5 million; $150.3 million was paid out to grantees over the course of the year. For more information, visit


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