To address barriers to screening for and immunization against human papilloma virus (HPV), the primary cause of cervical cancer, HCN and member health centers have participated in multiple research projects to increasing access to these services.  The South Florida Center for Reducing Cancer Disparities SUCCESS project, conducted in partnership with faculty of the University of Miami, Miller School of Medicine and the Sylvester Comprehensive Cancer Center, examined strategies for participant recruitment and delivery of an HPV self-sampling intervention. The Health in Your Hands (HIYA) study tested the impact of the community health workers CHW role in SUCCESS by comparing delivery of self-sampling kits by CHWs or through U.S. mail. HCN also participates in the Oregon Community Health Information Network (OCHIN)-led EVERYWOMAN project – a mixed-methods study using electronic health records (EHR) and community vital signs data to assess women’s preventive, contraceptive, prenatal, and postpartum care before and after Affordable Care Act implementation.

The CMS Center for Clinical Standards and Quality’s Network of Quality Improvement and Innovation Contractors (NQIIC) initiative supports community-based primary and specialty ambulatory care clinicians in quality improvement projects. Projects focus on four priority areas that will maximize impact on the healthcare system and leverage innovation, quality improvement, and data-driven methodologies to achieve four broad aims: 1) Improve Behavioral Health Outcomes; 2) Increase Patient Safety; 3) Chronic Disease Self-Management (Cardiac and Vascular Health, Diabetes, Chronic Kidney Disease); and 4) Increase Quality of Care Transition. HCN participates in the CMS NQIIC initiative operated by Indiana Universitythe Agile Innovation Network (AIN). HCN is the Coordinating Partner for Florida.

Florida International University’s Center for Children and Families, HCN and the Nurse Family Partnership have joined forces to launch this small research study that integrates Háblame Bebé telephone app into the NFP Program for select families as a means to understand how new Hispanic mothers from low-income backgrounds can best provide their children with language and literacy development. The phone app is used to measure ways in which Hispanic mothers interact with their children in ways that support language development in both short and long-term processes. Particular attention is devoted to Continuous Quality Improvement (CQI) methods to improve language outcomes for such children. FIU researchers will analyze the intervention at various implementation stages; the results will be utilized to further support literacy and language development in these families and strengthen the impact of HCN’s NFP program. Another key goal of the research study is to strengthen the relationship between nurses and participating families. Funding for this research is provided by a HARC (Home Visiting Applied Research Collaborative) grant.

An outgrowth of the Target: BP™ program, the Home Blood Pressure Monitoring (HBPM) Project includes five member health centers in south Florida in collaboration with the American Heart Association (AHA) and grant support from the Health Foundation of South Florida. Patients participating in the HBPM program measure their blood pressure outside of the clinical setting, typically at home, with a validated device provided by the project. Demonstrated benefits of home monitoring of blood pressure include increased adherence to prescribed treatment, earlier indication of potential health complications, and more clinically accurate and predictive blood pressure values. HBPM training and resources provide health centers with knowledge and tools needed to implement HBPM effectively with patients.  HCN has provided clinical guidance to participating centers on patient eligibility and process flows, developed standardized electronic health record (EHR) data collection templates, and coordinated group purchasing of home blood pressure reading devices.

HCN’s Jessie Trice Cancer Prevention Project (JTCPP) is a cancer prevention, education and early detection program targeting low-income African-American and Hispanic women that aims to reduce health disparities through collaboration. JTCPP employs a multifaceted approach toward early detection and diagnosis of cancer, leveraging partnerships among faith- and community-based organizations. Named for and developed in honor of esteemed health center and community leader Jessie Trice, the program has been operational since 2001 and has focused on breast and cervical cancer since 2005.  By linking community health centers with other community organizations, including 100 faith-based organizations, cancer centers, health departments and tertiary services, JTCPP facilitates access to health care resources, provides communication to patients about breast and cervical cancer screening guidelines, addresses patients’ misconceptions regarding cancer and cancer screenings, and leverages community and social networks of women to strengthen screening efforts.

Working with Million Hearts® to help health centers to optimize care for community members with or at risk for cardiovascular disease, the National Association of Community Health Centers (NACHC) has enlisted HCN to facilitate the implementation of this prevention and quality improvement program. This project uses a multi-pronged approach to achieve progress toward optimizing care that prevents heart attacks and strokes and improving cardiovascular health outcomes for priority populations. HCN is working with NACHC to explore and implement effective strategies health centers can use to improve performance in increasing appropriate statin use by high-risk groups, improve blood pressure control for African Americans, and identify and diagnose patients. HCN has worked closely with Centers to explore provider behavior and patient engagement strategies, analyze workflows and information flows to prioritize evidence-based intervention strategies, and to implement quality improvement activities to optimize care processes.

To support low-income, first-time mothers in Miami Dade County, HCN implements the evidence-based Nurse Family Partnership Program (NFP), which supports home  visits from nurses to these families. The NFP fosters long-term success for these families by introducing vulnerable, first-time parents to caring, professional nurses. Nurse  provide the support families need to have a healthy pregnancy, become knowledgeable and responsible parents, and provide their babies with the best possible start in life. In addition to leveraging its extensive network of community health centers (Center for Family and Child Enrichment,  Jessie Trice Community Health System, The Elijah Network, and Community Health of South Florida), HCN implements the NFP in collaboration with other community partners to comprise the Nurse-Family Partnership Alliance of Miami Dade County. In 2018 alone, HCN exceeded key target outcomes by serving more than 160 home families, screening over 90% for Intimate Partner Violence and Developmental concerns, and helping more than 98% of participating mothers initiate breastfeeding. More than 60% of participating mothers are unemployed, and roughly 30% did not receive their high school diploma.

Project ECHO (Extension for Community Healthcare Outcomes) is an innovative outreach model operating in more than 30 states, with more than 190 partners in the U.S. and more than 100 global partners, to address more than 100 complex conditions. Project ECHO builds primary care capacity and promotes use of best practices at community health centers and other practices targeting the underserved through intensive training for primary care physicians (PCPs) in managing common chronic illnesses. HCN is partnering with the University of Florida Diabetes Institute’s (UFDI) Project ECHO Diabetes program to connect community health center providers to a UFDI’s multidisciplinary specialty diabetes care team. Health center providers receive training on best practices as well as new diabetes treatment and technology and receive real-time support from UFDI from Type 1 and 2 Diabetes specialists.

With funding from the Health Resources and Services Administration (HRSA), HCN is initiating Phase III of the Quality Transformation Empowering Community Health (Q-TECH III) program. Q-TECH III will ensure that participating health centers are well-equipped to leverage health information technology (HIT) to improve operational and clinical practices. In Phases I and II, HCN led member health centers in advancing goals related to HIT implementation and meaningful use, enhanced data quality and reporting, population health management, and enhanced operational excellence. Q-TECH III builds upon these accomplishments by supporting enhanced patient engagement and experience, patient population management, reduced provider burden, advanced interoperability, and data analytics to facilitate quality improvement and value. Q-TECH III provides services to 30 Federally Qualified Health Center (FQHC) Health Center Program award recipients, located across Florida and in seven additional states (CA, MO, RI, MD, KS, NC and HI).

Target: BP™ is a national initiative spearheaded by the American Heart Association (AHA) and the American Medical Association (AMA) to help health care providers and patients achieve better blood pressure control.  Target: BP™ includes both clinical guidelines and system-wide programmatic elements. HCN and 17-member community health centers, including 13 Florida-based centers, formed a partnership with the AHA and AMA to implement the care delivery algorithm developed as part of Target: BP™. Community health centers implemented the Target: BP™ model by using Target: BP™ tools, resources and evidence-based approaches, and by capitalizing on their strengths as long-standing providers of comprehensive primary and preventive health care in their communities. HCN provided centralized support, tools and infrastructure, including coordination of provider training, health information technology-enabled algorithm integration, use of Population Management tools, and identification and dissemination of best practices and lessons learned.

In partnership with the American Medical Association (AMA), HCN will support member centers in launching Phase II of the Target: BP™ initiative. This project aims to improve blood pressure for patients with hypertension and will help to illuminate how health centers can most successfully implement the AMA’s M.A.P. Blood Pressure Improvement Program. The M.A.P. Framework - Measure Accurately; Act Rapidly; and Partner with Patients, Families, and Communities helps practice teams investigate best practices for providing coordinated, evidence‐based care to patients. Building on lessons learned from Phase I, seven practice sites have volunteered to implement a Customized Improvement Program adapted from AMA’s M.A.P.  HCN will assess the experience of participating health centers, share observations and insights regarding participating practice sites’ implementation progress, and assist in evaluating the potential for expansion of the initiative throughout the HCN network as well as in other practice sites across the nation.

Summary: Some states implemented Affordable Care Act (ACA) Medicaid expansions while other states did not, thus creating a natural experiment to study the impact of increased access to health insurance on cancer screening, cancer preventive services, and cancer survivor care. This innovative, timely study will use electronic health record (EHR) data from the ADVANCE clinical data research network (CDRN) of PCORnet, which has EHR data from 718 community health centers (CHCs), including 476 CHCs in 13 states that expanded Medicaid (n=576,711 patients), and 242 CHCs in eight states that did not expand Medicaid (n=361,421 patients). The ADVANCE CDRN dataset uniquely positions us to assess cancer screening, prevention, and survivor care among vulnerable populations immediately after the ACA Medicaid expansions, and to follow these patients for several years after this landmark health policy natural experiment.
Potential Impact: This study is significant, as it will assess the natural experiment resulting from some US states implementing ACA Medicaid expansion, while others have not. It addresses scientific knowledge gaps (how Medicaid expansion impacts receipt of cancer prevention and survivor care) and technology gaps (prior lack of novel data sources for studying populations not found reliably in claims or self-reported data). Findings from this study will have national relevance and will contribute to NCI’s priorities regarding improving cancer prevention knowledge.

Summary: The objective of this project is to determine the extent and impact of multimorbidity among CHC patients and to identify specific multimorbidity combinations associated with chronic disease complications, frequent healthcare utilizations, and death.
Potential Impact: This project examines the number and type of chronic conditions vulnerable adults are living with and identifies adults most at risk for worsened symptoms, escalation of chronic disease-related problems, and additional diagnoses that are accumulated over time. The proposed work will inform intervention programs for adults in the safety-net. By identifying disease combinations that are most predictive of complications, intensive use of health care services, and death, future work can test best practices and delivery models that are more attuned to the needs of individuals with the most challenging combinations of chronic disease. Our proposed research leverages clinical electronic health record (EHR) data from large networks of CHCs and non-CHCs. We anticipate important insights from findings that will inform clinical processes (workflow, clinical care decision-making) and policies that serve safety-net populations by identifying multimorbidity patterns predictive of rapid health downturns.

Summary: Latino children have poorer asthma-related outcomes than non-Hispanic white children. This disease-specific morbidity and mortality comes in spite of longstanding, well-known, evidence-based approaches shown to improve asthma outcomes and symptoms. In the setting of these significant gaps in the literature and limitations in prior data sources, we will use a robust, comprehensive electronic health record (EHR) data set, linked to geographically coded social determinants of health (SDOH) data, serving thousands of Latino children over a 10-year span, to longitudinally and objectively study the multi-level factors affecting the asthma care of low-income Latinos across a nationwide network of community health centers (CHCs). We will use EHR data from the OCHIN network and the ADVANCE clinical data research network (CDRN).
Potential Impact: Our analyses of children being seen in CHCs with EHR data linked to individual- and community-level social determinants of health will constitute a robust, rigorous, longitudinal, and multi-level study of healthcare disparities in this disease. Clearer links between care utilization and the built environment can better inform legislators and other policy makers as they weigh policies that will affect these environments. It will also aid health care providers caring for this population; better population-based data will help tailor clinic workflows and programs to improve asthma care quality in vulnerable children. Children could be better “risk stratified” according to important community and individual features, allowing clinics and providers to either intensify or adjust their approach to chronic disease management in these children and better their chance of successful asthma management.

Summary: The Affordable Care Act (ACA) called for every state to significantly expand Medicaid coverage by 2014; a Supreme Court decision made it optional for states to expand Medicaid to all adults with household incomes up to 138% of the federal poverty level. We will use this unprecedented natural experiment to study the effect of state-level Medicaid expansion on rates of hypertension incidence, screening, treatment, and management. In addition, access to care may be insufficient to reduce barriers to hypertension care. Thus, other social determinants of health ([SDOH]; e.g., individual- and community-level factors) may differentially affect the relationship between gaining insurance and receiving hypertension care. We will use electronic health record (EHR) data from the ADVANCE clinical data research network, linked to community-level SDOH. From this dataset, we will collect detailed information on changes in hypertension incidence, screening, treatment, and management comparing states that expanded Medicaid, and those that did not.
Potential Impact: Hypertension is the most common chronic condition among adults in the United States. Uninsured adults are more likely to have undiagnosed hypertension, less likely to receive regular screening, and less likely to have their hypertension under control than insured adults. The Affordable Care Act (ACA) called for every state to significantly expand Medicaid coverage by 2014; it is hypothesized that the ACA’s Medicaid expansion could substantially (i) improve access to essential preventive services for previously uninsured patients, and (ii) facilitate better access to routine healthcare for those who gain new health insurance. Little is yet known about how ACA Medicaid expansions are impacting hypertension care. The 2012 US Supreme Court ruling that made ACA Medicaid expansion optional for states created a natural experiment to answer this important question. As of April 2016, 32 states and the District of Columbia had expanded Medicaid.

Summary: EVERYWOMAN will examine the impact of the Affordable Care Act (ACA) and state level reproductive health policies on the full spectrum of women’shealth care provision and health experiences in safety-net populations. EVERYWOMAN applies a mixed-methods approach comprising patient-level electronic health record (EHR) data for large scale quantitative analyses, qualitative observations, and semi-structured interviews with patients and providers to understand perceptions and patterns of care delivery and utilization, and review of state-level reproductive health policies in inform our analyses.
Potential Impact: Findings from this study will identify practice and policy efforts to strengthen the provision of timely, effective, evidence-based reproductive health care. Study findings will impact patients and providers through relevant practice and policy changes to improve health outcomes and reduce disparities among low-income vulnerable populations of women.

Summary: Recommended preventive health care is underutilized in the United States, especially in older populations, despite evidence-based recommendations for providing these services. Cardiovascular disease prevention, cancer screening, adult immunizations, and fracture risk reduction are underutilized among older persons overall and are disparately utilized in racial / ethnic minority populations. Latino (the largest ethnic minority in the United States) seniors are significantly less likely, in general, to receive appropriate prevention measures, compared to non-Hispanic whites. Our goal is to better understand how the use of preventive services by older adults differs between Latino seniors and non-Hispanic whites over time, and the relative contribution of various social determinants of health among low-income Latino seniors.
Potential Impact: Results of this study will shed light on how individual and community-level SDH impact receipt of preventive health care services, providing important contextual information for public health professionals developing targeted interventions and health care providers serving elder Latinos populations.

Summary: Little is known about the impact of Affordable Care Act (ACA) Medicaid expansion on health care access and services for patients at risk for diabetes mellitus (DM) or diagnosed with DM. As many persons affected by both DM and the ACA Medicaid expansions receive primary care in safety net community health centers (CHCs), this study will compare pre-post access to and receipt of health care services and Medicaid expenditures within CHCs in states that did and did not expand Medicaid; compare pre-post receipt of primary and secondary DM preventive services in expansion versus non-expansion states; compare pre-post changes in DM-related biomarkers among the newly insured compared to already insured and uninsured patients in expansion states; and measure pre-post changes in Medicaid expenditures among newly insured compared to those already insured in Oregon.
Potential Impact: Because the ACA legislation was designed, in part, to improve health and mitigate healthcare disparities, results of this work will formally evaluate the extent to which the ACA’s eff orts to expand insurance coverage to vulnerable populations actually reduces disparities among patients with DM risk or DM. Furthermore, knowing more about the impact of ACA Medicaid expansions on DM screening and primary prevention among patients at risk for DM will be useful for informing future national and state health policies.