Many Steps Toward Look-Alike Status
Many Steps Toward Look-Alike Status
Nineteen requirements. That’s the number of items you have to have in place, prior to even applying to becoming a HRSA Health Center. Getting compliance-ready is occupying much of 2014 for Catawba Care, a Ryan White grantee pursuing Health Center status with “look-alike” designation.
This blog is the latest in a series tracking the health care reform adjustments underway at South Carolina’s Catawba Care which has set their sites securing Health Center designation as they broaden their HIV mission to encompass primary medical care for lower income individuals.
Catawba is following a compliance checklist from HRSA’s Bureau of Primary Health Care. The list was first scanned to determine where the agency was broadly compliant and noncompliant, so to speak, giving Catawba a sense of what priorities they needed to set in getting compliance-ready in 2014. Below are their top activities currently underway, leading up to their application for look-alike status in early 2015.
Types of Health Centers (from HRSA/BPHC)
- FQHCs: Grant-Supported Federally Qualified Health Centers
- Look-Alikes: Non-grant-supported Health Centers
- Outpatient health programs/facilities operated by tribal organizations
Money is a necessity to meet these compliance requirements. Catawba recently received a foundation grant to help them get started—an early payoff from their strategy to write grant proposals and reach out to funders, who “like one time funding” with demonstrable outcomes, according to Anita Case, Catawba’s Executive Director. The United Way, local foundations, and appeals to the local community are part of Catawba’s strategy to raise funds to support some of the below activities. “You have to be compliant with all Health Center requirements prior to applying for look-alike status, said Case, adding “we’ve written several grants to [help us] comply with those” requirements.
New Sliding Fee Scale
Both Ryan White and Health Centers have sliding fee scales. Both say that clients with incomes under 100% of the federal poverty level should provide care, free of charge. However, they differ in other details, which Catawba is working to resolve in its billing system.
- Ryan White’s is very flexible, according to Case, in that it lets agencies determine their own sliding fee scale, with Part-specific variations around caps on charges and client incomes.
- The Health Center sliding fee scale, however, is much more specific in that the statute says that client incomes of 100-200% of poverty are to pay a discounted fee for services while those with incomes over 200% of poverty must be full pay.
Staffing Primary Care
Catawba is an HIV clinic but needs a 6-month track record of delivering primary medical care, prior to applying for look-alike status. Much of the fundraising underway is to fund these positions, which will continue both HIV care but also devote a set proportion to primary care. Catawba started recruitment of a physician in April 2014, after having been approved as a National Health Service Corp (NHSC) site at the beginning of the year. That designation makes Catawba a more attractive location as new medical school graduates can have their loans forgiven if they commit two-years to working at an NHSC location.
Catawba is hoping to secure private funding for the clinician position as well as for a medical assistant and case manager—both to devote 75% to HIV and 25% to primary care—along with funds to cover some dental and mental health services.
Health Center’s must demonstrate meaningful consumer involvement, like a board of directors with 51% consumer representation. Several current Catawba board members are ready to become patients, which will help Catawba ramp up their consumer representation in advance of expansion of their patient population toward overall primary care. Board members don’t have to be talked into becoming Catawba patients, said Case, as they “recognize the quality of our care and believe they will be improving their care quality by making the switch.”
As Catawba’s patient population grows, more patient board members will be recruited. For additional recruitment from the current patient population: “we ask staff members to make recommendations for patients who might be good Board candidates. We contact these patients to find out their interest and to learn more about how they could be an asset and provide education to [these] patients about what it means to be Board members before bringing them on.”
Securing Discounted Services for Patients
Catawba is reaching out to secure an agreement with a local hospital to provide discounted services to look-alike patients. The discounts would be available to referred patients who were at or below 200% of the federal poverty level. Charges to those at or below 100% of poverty would be free or nominal. The hospital network extends well beyond inpatient services and includes various clinical practices, reflecting the increasingly common practice of hospital systems across the nation to broaden their networks as they buy up physician networks and practices to extend their competitive position and market share.
Negotiating and putting these memoranda of agreement in place is tough given the unknowns that concern nonprofits and for-profits alike.
- How many patients may need discounted services?
- What services might they need?
- What about the potential costs?
The amount of the actual discount to provide is typically not specified in the agreement. It could be substantial but also might well be minor.
These negotiations benefit from the pre-established relationships Catawba has with the hospital in its planning. The hospital understands how Catawba services can help them. “Hospitals want health centers who they can refer to for primary care so uninsured community members are not seeking primary care in the Emergency Department,” says Case.
Identifying Partners/Service Sites
Collaboration. Sounds good. What does it mean for seeking Health Center status? For one, expanding into primary medical care is an expensive undertaking. Partnering with existing service sites can make this more feasible, which Catawba is pursuing by reaching out to potential partners with access to their communities and existing facilities and staff. If successful in getting Look-Alike status, Catawba is hoping to bring four satellite sites into their orbit, which would provide Catawba with free facility space and access to their volunteer doctors.. Staff would be put on Catawba’s payroll.
The sites also serve children, which is yet another Health Center compliance requirement. Catawba’s hopes to have two of these sites add adult services to broaden access to care in their transportation-challenged rural service areas. These two sites are both located in a newly designated Medically Underserved Area.
Opportunities to collaborate don’t just happen. They are created. Case advises others to “always be listening to what is happening in the community and have collaboration on your mind at all times,” adding that their collaborative opportunity to partner with these satellite sites “started at a training for nonprofits on collaboration when two Executive Directors shared their current challenges.” Case also suggests this: “identify people in the community who can help you with identifying potential partners—people who pay attention to community needs and understand community dynamics.”
Designation as an Underserved Area
Another part of being Health Center-ready is to be located in, and serve, a Medically Underserved Area (MUA)—a special HRSA designation based upon various health indicators and the ratio of physicians to the area’s population. http://www.hrsa.gov/shortage/mua/
Catawba faced an early hurdle in planning for expansion in a region lacking the all-important MUA designation. The area is also home to the above two satellite sites that Catawba hopes to acquire. Catch 22: Acquiring the sites depends on securing Look-Alike status that, in turn, is dependent on MUA designation. Undaunted by feedback that MUA designation can be tough to secure, Catawba reached out to the state Office of Primary Care and got their help to apply to HRSA for MUA designation, which was granted.
Revising the Mission and Vision
In 2013, Catawba started strategic planning to set their sights on expanding into primary care beyond people living with HIV to also serve the broader community. That work is ongoing. Staff are working with a vision team of staff and board members to further revise Catawba’s mission and vision to guide future agency efforts.
Catawba’s current work in the visioning process entails, according to Case, “talking about the experience we want patients to have in our clinic and how to put this into words. Some of the words that express what we want to convey include: inspiring healthier living, empowering healthcare, patient-centered, accessible for all, welcoming to all, warm & friendly environment, high quality care with compassion and dignity, etc.”
Staff are also meeting with a few marketing firms to discuss a rebranding strategy. Catawba wants to maintain its focus on HIV but expand into primary care as a necessary step to surviving into the future. It’s a process that Case characterizes as simultaneously “keeping the compassion and staying alive. Our expansion is in who we will serve as opposed to what we will provide.”
Catawba also envisions focusing on many other tasks as 2014 wears on. Here’s a sampling:
- Changing bylaws to be consistent with community health center requirements.
- Attending trainings and participating in technical assistance opportunities to help with compliance.
- Adding staff and making changes to expand capacity in existing facilities in order to begin seeing new patients in Summer 2014.
- Begin efforts to become certified as a Patient Centered Medical Home.
- Adapting policies and practices to accommodate a new patient population and new requirements. Continually evaluating processes and capacity to ensure continued excellence in their service provision and patient-focused care.
Finally, Catawba hopes to be writing a New Access Point grant for Section 330 funding.