Project Abstract: Intelligent Care Network (existing HRSA HCCN Grantee) Applicant Name: Alabama Primary Health Care Association, Grant Number H2QCS25654 8244 Old Federal Road, Montgomery AL 36116 www.alphca.com Total Participating Health Centers (PHC): 20 PHCs consisting of 17 Health Center Grantees, 3 Look-Alike Organizations Project Contact: Mary Hayes Finch, JD, MBA, 334.271.7068 (o); 334.271.7069 (fax) mfinch@alphca.com Amount of Funding Requested: $2,250,000 Project Need: Over the last several years, the COVID-19 pandemic revealed the underlying fragility of Alabama's health care system. Barriers to care within Alabama's medically underserved populations are even more significant, considering challenges to accessing care, decreased patient engagement, heightened challenges to provider and staff well-being, and ongoing fragmentation across health care systems. Additionally, the lack of standardized collection of and use of social risks impacting underserved patients creates missed opportunities to meet the needs of patients at the direct point of care. Variations in the type of electronic health records systems, reporting platforms, and lack of standardization in data collection, workflow, and procedures continue to present challenges to patient and provider access to health information. While there are advancements in providers' use of health IT, system challenges prevent effective integration across industries to improve quality and health outcomes. Alabama does not have a platform most providers use for health information exchange. Gaps in care are created, resulting in poorer clinical outcomes. Despite having multiple high performers within each category, significant performance variances exist across PHCs within each core quality measure. Because of the lack of standardization in data collection, workflow, and care systems, expediting best practices across the Network remains challenging. Proposed Services: APHCA will l
everage its Intelligent Care Network and population health management and information exchange platform to optimize the effectiveness and value of primary care delivered by PHCs. APHCA will focus on expanding the use of advanced health information technology to improve clinical quality, patient-centered care, and provider and staff well-being. APHCA's HCCN strategy expands upon its current data, reporting, and visualization (DRVS) platform to increase 1) patient engagement through integrated digital health tools, 2) patient privacy and cybersecurity, 3) use of patient-level social risk data to support more effective care plans and interventions, 4) system and staff alignment with new data Uniform Data System reporting requirements, 5) PHCs integrating clinical information from external clinical and non-clinical sources, 6) use of data strategies to support performance improvement and value-based care, 7) provider and staff efficiency in using digital health tools, 8) health IT usability and adoption by providers, staff, and patients, 9) use of health IT to improve population health, and 10) quality and coordination through digital health tools. Population Served: APHCA's proposal will serve 20 PHCs, over 400 providers providing care to 320,000 medically underserved patients; 92% of these patients are at or below 200% of the federal poverty level. Over the three-year project period, care provided to these patients will be improved through advanced health IT, system and process standardization, and coordination.