Closing Gaps in Care to Improve Health

“When I got into administration, my main focus and passion was in quality and increasing access to care,” say Amit Pabla, Chief of Quality and Transformation at Axis Community Health. “Without community health centers, (our patients) would have no access to care…and when we are able to meet a challenge or overcome a barrier, it means so much more than it would anywhere else.”

As a quality transformer, Pabla tracks how Axis is delivering care to its patients and sets up ways for his colleagues to act from that knowledge.  “I think quality has evolved. Before, it was regulatory, how many charts did you audit, incident reports, etc., but now it’s so much more. It’s about ensuring that our access to care is spreading and getting to people who don’t know about us yet.”

The field of Quality Improvement, for Pabla, is for anyone who wants to learn about the healthcare delivery system and its impact. “Especially with payment reform it’s going to be on health outcomes and it’s going to be on HEDIS,” he says, referring to a type of data measuring managed care performance (Healthcare Effectiveness Data Information Set).  HEDIS measures track hypertension rates, diabetes, immunizations, cancer screenings, and number of visits, among other indicators.  Each measure has a target, and when health centers meet targets they receive an incentive payment from health plans.

To meet HEDIS targets means engaging the total Medi-Cal membership assigned to Axis. “We’ve always had this as our mission – we serve the Tri-Valley community. (But) those members that are linked to us (through Medi-Cal assignment) we may not normally engage because they don’t come here. HEDIS makes us accountable for them.” Among its total membership, up to 30 percent may not meet HEDIS targets by virtue of never having entered the health center.

CHCN HEDIS Gap In Care Project 

In order to support health centers, Community Health Center Network (CHCN) launched its HEDIS Gap in Care pilot with three health centers.  CHCN has set up a data tool (Tableau) that allows health centers to find gaps in their measures quickly, and convenes Tri-City Health Center, LifeLong Medical Care and Axis Community Health to share best practices for tracking and outreach.

“So now we’re entering this new realm where we go out into the community, find these patients and partner with the hospitals that may see them more frequently than we do, partner with the health plans and CHCN who may have their contact information and teach them about Axis and primary care, prevention, and why these screenings are so important.”

In addition to using Tableau to call in members for services and screenings, “If a care team wants to improve on a specific measure as their goal, they would go into the Tableau report, identify that population and do outreach.”

Using data to drive outreach and engagement represents the first steps in population health, for Pabla. “It’s about going out into the community, addressing that vulnerable population and supporting lifestyle changes around obesity, exercise, nutrition, so that they don’t end up sicker ten, fifteen years  down the line.”

Care Teams Drive Success

Linking the community to care tailored to each member’s health needs requires teamwork.    Pabla points to care team transformation, in partnership with CHCN, as the strong foundation for rolling out the HEDIS pilot. With members of the team working “at the top of their license,” teams share the quality improvement work.

“Now we’re trying to empower MAs to do motivational interview, calling the patient because they need the service but also exploring why they don’t want to come in, the barriers, collecting the social determinants … We want that interpersonal rapport with them.”

While Axis is on the path to targeted outreach using HEDIS data, it continues to face obstacles.  “Sometimes it’s really hard to track a patient down, let alone getting them on the phone and engaging that patient.” Barriers for care teams include constraints on time, money and staff, in addition to the social and economic barriers patients face in accessing their primary care home and managing their health on a daily basis. Continued funding that supports care management and care teams, for Pabla, would help advance the work.

Despite these limits Pabla believes progress is possible. “I like the culture here at Axis. It’s very forward thinking. It’s (quality improvement) what we have to do, at the same time, we are going to experiment and explore motivational interviewing calls, care coordination, care team management, group classes and group education. Because that is the future, and HEDIS supports that.”

The data shows that some of the support services that Axis has put in place, in addition to CHCN supports, are effective. “I’m proud that we as a consortium, as a clinic, as an organization, that we’re heading in the right direction. Data speaks volumes.  I can’t say, ‘that’s not true,’ you can’t ignore data. So we’re going to, as much as we can, stretch our resources to try to make an impact.”