The introduction of the Affordable Care Act and the expansion of Medicaid in Pennsylvania catalyzed many changes in healthcare and created a new landscape that increased access to healthcare for over 30 million people nationwide. Community health centers serve as the primary source of care for many uninsured and underinsured individuals, and are often the only healthcare provider option available to these patients. Without these centers, individuals are forced to rely on expensive emergency room visits as their primary source of medical care, increasing the cost of healthcare for everyone.
For the Independence Blue Cross Foundation, implementation of ACA and Medicaid expansion created new opportunities to address the triple aim of improving healthcare cost, access and quality across the healthcare safety net through its Blue Safety Net grant program. Local health centers remain an essential factor in the success of the ACA as the safety net providers of affordable, quality healthcare in underserved communities.
Strengthening the Blue Safety Net
The Independence Blue Cross Foundation has a long-standing commitment of investing in private, nonprofit health centers. Since the first grant was awarded in 2004 through the Independence Blue Cross Charitable Medical Care grant program, the Independence Blue Cross Foundation Blue Safety Net program has helped ease the cost of services by providing over $24 million in unrestricted funding to fifty health centers. Nearly $13 million has been awarded to a variety of health center models including Federally Qualified Health Centers (FQHC), FQHC-lookalikes, free clinics and hospital system affiliates through the Independence Blue Cross Foundation Blue Safety Net program. General operating funding has given health centers the stability to serve their primary purpose: providing health services in medically underserved areas. In addition, the Blue Safety Net program strengthens the entire healthcare system by supporting health centers that:
- increase access to care in medically underserved communities
- improve patient coordination and communication among community health centers
- develop innovative approaches that achieve sustainability
- promote projects that address specific healthcare gaps and obstacles to care
Leveraging Resources and Data-driven Decisions
The ACA presented additional challenges for health centers such as maintaining staffing and resources while managing an increase in patient volume, often coupled with serious health conditions that have gone untreated for years. Operationally, new demands made of health centers by the ACA require significant initial investments in technology and monitoring. Among the requirements of a Patient- Centered Medical Home was the implementation of an electronic medical record system. Results from an informal assessment of Blue Safety Net supported-health centers, indicated that EMR was not a practical solution that would address cost, access or quality.
Blue Safety Net program impact analysis has been conducted through surveys and applied research on regional indicators and outcomes that affect the healthcare safety net. U.S. Census data, Community Health Rankings data and the Community Health Database are sources for a variety of necessary data points including uninsured status, prevalence of chronic conditions, poverty and HRSA UDS measures, to compare the outcomes of Blue Safety Net supported health centers to County and Regional data. This community health-driven data exploration led to the realization that despite the extraordinary concentration of health centers across the five-county region of Southeastern Pennsylvania, the forty-four health centers in the Blue Safety Network served only a fraction (13%) of the uninsured, impoverished population of the region, and less than 4% of the region’s total population.
After seeking proposals from academic public health programs, Drexel University’s Dornsife School of Public Health and Center for Public Health Initiatives (CPHI) was selected to conduct an extensive needs assessment of the Blue Safety Net grantees. CPHI reviewed grantee reports, conducted focus groups, gathered critical service, financing and meaningful use information, as well as grantee experience as a Blue Safety Net funded health center. The Blue Safety Net Needs Assessment conveyed information about funding, policy impact and healthcare information technology.
The assessment provided deeper insight into the current state of the healthcare safety net in our region, as well as offering recommendations to best shape Blue Safety Net programming to address unmet needs of its grantees. The needs assessment confirmed the diversity of our region, which is not revealed in national trends. While the Blue Safety Net-funded health centers relied on unrestricted funding to pay for general operating expenses, the health center directors also recognized this funding was not the solution to growth or sustainability. Additional resources would be needed to accomplish this goal. CPHI’s recommendation was to allocate a new stream of funding designated specifically for capacity building projects within these health centers. Their second recommendation was to host workshops for the health centers that would equip staff with additional, new skills.
Innovation to Practical Application
After thorough review of the needs assessment results and recommendations, additional, new targeted grant awards were designed to increase access to care and support new models of care. In 2015 the Independence Blue Cross Foundation introduced its Blue Safety Net capacity building initiative, in addition to its general operating grants, to support approaches to address the remaining issues of access and quality for local and regional safety net providers. Grants totaling $3 million were awarded to 44 nonprofit, private community health centers that provide health services to over 200,000 patients in medically-underserved areas in southeastern Pennsylvania.
The Foundation’s grantmaking approach led to innovation as well. In the first year of its Blue Safety Net capacity building initiative, the Independence Blue Cross Foundation invested in nine capacity building grants, including four pilot projects. One example is an Emergency Department teletriage diversion pilot project with Public Health Management Corporation, in partnership with Temple University Hospital and Hahnemann University Hospital to redirect patients that over-utilize the emergency room for primary care. Before discharge, the targeted patients receive a virtual visit from a nurse manager at one of PHMC’s nearby health centers. The nurse manager can arrange same day transportation and follow-up visits, as well as connect the patient to the services offered at a patient-centered medical home.
Other innovative projects include telemedicine diabetic retinopathy screenings between a health center and Wills Eye Ophthalmology Clinic, mobilization of dental services by a health center to under- resourced populations in Chester County, and the expansion and advancement of trauma-informed care in our region. Capacity building activities for professional development have also been successful; Blue Safety Net grantees have attended two expert-led workshops that were tailor made to health center grant writing and marketing.
Determining a Sustainable Approach
The Independence Blue Cross Foundation applied data-driven decisions to innovate and create sustainable solutions to improve the health and well-being of our neighborhoods. The Blue Safety Net Needs Assessment was a critical step to enhance the Blue Safety Net grantmaking strategy, and a data tool to capture the gaps in capacity across the diverse Blue Safety Network. Operationally, the innovative redesign allowed for the greatest flexibility of future Blue Safety Net programming and simplicity of program administration. Distinct grant funding for core support and new initiatives was awarded to innovative projects that help achieve sustainability and further build capacity of the health centers that receive Blue Safety Net grant funding.