I. Mission and Strategy
A. Expectation
In order to fulfill the health centers' mission of improving the health status of underserved populations, health centers must continue to survive and thrive through health care reforms, marketplace changes and advances in clinical care. Health centers must assess the needs of underserved populations and design programs and services which are culturally and linguistically appropriate to those populations. They must measure the effectiveness and quality of their services and continuously evolve their programs to achieve the greatest impact. They must operate as efficiently as possible. Health centers must collaborate with other organizations, at the same time maintaining their integrity as federally-funded health centers by continuing to fulfill their mission, and complying with applicable law, regulation and expectations.
B. Explanation
1. Underserved Populations
Federally funded health centers provide health services to underserved populations. This includes all people who face barriers in accessing services because they have difficulty paying for services, because they have language or cultural differences, or because there is an insufficient number of health professionals/resources available in their community.
Underserved populations also include people who have disparities in their health status. Some health centers may focus on specific special populations such as homeless people, migratory and seasonal farmworkers, residents of public housing, or at-risk school children, while most serve a cross-section of the population in their communities.
The specific population groups to be served by a health center are defined by that health center through a process of assessing the needs, resources and priorities in their community.
For many health centers, the need for services far exceeds available resources. Health centers are faced with extremely difficult choices regarding which underserved population groups to serve and/or which needed services to provide. An inclusive and informed planning process frames the decisions every health center must make.
2. Cultural Competency
Health centers serve culturally and linguistically diverse communities and many serve multiple cultures within one center. Although race and ethnicity are often thought to be dominant elements of culture, health centers should embrace a broader definition to include language, gender, socio-economic status, sexual orientation, physical and mental capacity, age, religion, housing status, and regional differences. Organizational behaviors, practices, attitudes, and policies across all health center functions must respect and respond to the cultural diversity of communities and clients served.
Health centers should develop systems that ensure participation of the diverse cultures in their community, including participation of persons with limited English-speaking ability, in programs offered by the health center. Health centers should also hire culturally and linguistically appropriate staff.
3. Strategic Positioning
Significant changes are occurring throughout the country in the way in which health care is being financed and delivered. Health centers need to understand their health care marketplace and be willing and able to adapt and reposition themselves to survive. Understanding the health care marketplace requires looking beyond the health center's service area to what is occurring with key players in the larger marketplace and identifying opportunities and challenges for health centers.
a. Planning
In order to succeed, health centers must engage in active, ongoing planning processes. Planning should include both long term strategic planning and annual operational planning. Strategic planning should establish long term strategic goals. Operational planning focuses on short-term objectives within the context of the strategic plan. Planning should be based on collecting and analyzing data, as well as on input from diverse stakeholders: health center governing board members, staff at all levels, community members, clients and organizations involved in providing or paying for health care in the marketplace. Recipients of funding to provide services to residents of public housing must consult with residents as part of their planning and grant application processes.
Planning should include ongoing evaluation, feedback and adjustment based on environmental, operational, or clinical change. While remaining flexible and allowing for response to new opportunities and pressures, plans should describe the health center's goals and priorities sufficiently to guide members of the organization in strategic and operational decision-making.
b. Collaboration and Affiliation
Health centers must collaborate appropriately with other health care and social service providers in their area. Such collaboration is critical to ensuring the effective use of limited health center resources, providing a comprehensive array of services for clients, and gaining access to critical assistance and support (e.g. housing, food, jobs).
In many instances, health centers may consider more formal affiliation opportunities such as contractual relationships, certain types of joint ventures or mergers. Affiliations are desirable when they lead to integrated systems of care which strengthen the safety net for underserved clients. Health centers may join other organizations such as other health centers, hospitals, specialty groups and social service providers to form integrated delivery systems. An integrated system may be formed through contractual relationships or memoranda of agreement. In these situations, each partner in the affiliation retains its organizational autonomy and integrity and the health center governing board continues to meet expectations. In other situations, a new organization may be formed.
While health centers are encouraged to collaborate with other entities, they must ensure that all the laws, regulations and expectations regarding the health center governing board member selection, composition, functions and responsibilities are protected if the health center wants to retain eligibility for federal funding. The resulting delivery system must contribute to the desired outcomes of availability, accessibility, quality, comprehensiveness, and coordination.
c. Cost-effectiveness/cost-competitiveness
Many decisions in the health care arena are being driven by economic considerations, and it is imperative that health centers strive to be cost-competitive. All health centers must be as efficient as possible, understand the costs of the services they provide, and bring costs in line with other providers in the marketplace providing comparable services.
Health centers should be able to document the value, i.e., cost and quality, of the services they provide and demonstrate the impact of their services on the health and well-being of the communities they serve. As part of becoming cost effective, health centers are expected to evaluate their management and delivery systems in order to be able to increase efficiency and to maintain operations in the competitive, cost conscious marketplace. Health centers will need to manage the care of their patients in accordance with their managed care risk arrangements and be able to monitor their financial risk related to managed care contracting requirements.
4. Needs Assessment
a. Understanding Community Needs and Resources
Crafting strategy demands a thorough knowledge of the community and population groups a health center intends to serve. In order to use limited resources effectively, this requires both an understanding of the health care needs of the target community, as well as resources available to meet those needs. Needs and available resources should be monitored on an ongoing basis and comprehensively assessed on a periodic basis, or when environmental changes dictate reassessment.
Although there is no prescribed way to conduct a needs assessment, each program should be able to describe:
- the geographic area and/or population groups which constitute their principal target population;
- the characteristics of this population in terms of age, sex, socioeconomic status, health insurance status, ethnicity/culture, language, health status, housing status and health care utilization patterns;
- perceptions of the target population about their own health care needs and barriers to accessing needed services;
- other providers of health and social services accessible to the population; and
- gaps in services that the health center proposes to address.
b. Description of Current and Potential Users of Services
All needs assessments should examine both people currently using services and those in the target population who are not using needed services. In order for health centers to be able to document their achievement of health care outcome goals, health centers should be able to describe their current clients in terms of demographics, utilization patterns and health care status. Health centers should not lose sight of people in their target population who are not using needed services. Sometimes, they have the greatest health needs and require extra effort to bring into care.
c. Special Populations
All health centers serve diverse populations and must understand the differing needs of these populations. Some health centers receive federal funding designated to serve special medically underserved populations including homeless people, migratory and seasonal farmworkers and their families, at-risk school children, or residents of public housing.
For those health centers receiving federal funding to serve homeless people, these funds may be used to provide services to formerly homeless people for up to twelve months after housing has been obtained. Programs receiving federal funding to serve special populations must specifically assess needs and resources for these populations.
Federal grant funds may not be used to supplant other funds or in-kind contributions from state and local sources for centers serving homeless people or residents of public housing. Health centers also serve populations with specific health needs such as those related to HIV, pregnancy, mental health or substance abuse.
All health centers must be able to provide or arrange for a full spectrum of primary care services. Health centers serving large numbers of individuals with a particular health care need should specifically assess service needs, develop outcome and services goals, and provide or arrange for access to needed services.
5. Continuous Quality Improvement and Performance Measurement
Performance measurement and quality improvement are critical elements for excellence in the health care industry. The environment is driving the use of data to increase accountability, support quality improvement, facilitate and support clinical decisions, monitor the population's health status, empower patients and families to make informed health care decisions, and provide evidence to eliminate wasteful practices. Similarly, both federal and state governments are requiring programs to document performance and improvement as a condition of continued support.
All health centers must have a quality improvement system that includes both clinical services and management.
Quality depends upon the health center's commitment to its community and its dedication to quality improvement. Quality of health center services also requires effective clinical and administrative leadership and functioning clinical and administrative systems.
The organization should support and establish a locus of responsibility, such as an interdisciplinary quality improvement committee, for the quality improvement program. Quality improvement activities and results should be reported to the clinical and management staff as well as the governing board.
Health center quality improvement systems should have the capacity to examine topics such as:
- patient satisfaction and access;
- quality of clinical care;
- quality of the work force and work environment;
- cost and productivity; and
- health status outcomes.
In addition, quality improvement systems should have the capacity to measure performance using standard performance measures and accepted scientific approaches. Centers are encouraged to establish performance standards in concert with other health centers serving similar populations.
In analyzing performance data, health centers should compare their results with other comparable providers at the state and national level, and set realistic goals for improvement. Periodic reassessment enables health centers to measure progress toward these improvement goals and respond to advances or changes in clinical care.
Since successful utilization management is an effective means of delivering appropriate services and maximizing value, quality improvement studies addressing utilization management of appropriate specialty, pharmacy, hospital and other services is key.
Issued and Last Revised: August 17, 1998
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