Special Meeting. January 23, :00 p.m. Agenda

Transcription

1 Maricopa Health Centers Governing Council Special Meeting January 23, :00 p.m. Agenda

2 Council Members Gary Tenney, Chair Christine Hammond, Member Gino Turrubiartes, Vice-Chair Melissa Kotrys, Member Simon Thomas, Treasurer Elizabeth McCarty, Member Abdirahiim Ahmed, Member Adriana Perez, Member Laurie Carnal, Member Anita Jordan, Member Mary Jo Whitfield, Member Susan Gerard, Ex-Officio Member AGENDA Maricopa Health Centers Governing Council Special Meeting Maricopa Medical Center Administration Building Auditorium 2 Julie Roberts, Member 2601 E. Roosevelt St. Phoenix, AZ Clerk s Office Fax Maricopa Medical Center Administration Building Auditorium E Roosevelt St Phoenix, AZ Clerk s Office Fax Friday, January 23, :00 p.m. If you wish to address the Council, please complete a speaker s slip and deliver it to the Clerk of the Council. If you have anything you wish distributed to the Council and included in the official record, please hand it to the Clerk who will distribute the information to the Council Members and Maricopa Integrated Health System Staff. Speakers are limited to (3) three minutes. (NOTE: One or more of the members of the Maricopa Health Centers Governing Council will attend either in person or by telephone conference call or video communications.) ITEMS MAY BE DISCUSSED IN A DIFFERENT SEQUENCE Call to Order Roll Call Call to the Public This is the time for the public to comment. The Council Members may not discuss items that are not specifically identified on the agenda. Therefore, pursuant to A.R.S (H), action taken as a result of public comment will be limited to directing staff to study the matter, responding to any criticism or scheduling a matter for further consideration and decision at a later date. Presentation, Discussion, and Action: 1. Discuss, Review and Approve the Health Resources and Services Administration Annual Certification, Reporting Period: 04/01/13 to 03/31/14: 60 min Gary Tenney, Chair Adjourn Agendas are available within 24 hours of each meeting in the Clerk of the Council s Office, Maricopa Medical Center, Comprehensive Health Center, 1 st Floor, 2525 E. Roosevelt, Phoenix, AZ 85008, Monday through Friday between the hours of 8:00 a.m. and 4:30 p.m. Accommodations for individuals with disabilities, alternative format materials, sign language interpretation, and assistive listening devices are available upon 72 hours advance notice through the Clerk of the Governing Council s Office, Maricopa Medical Center, Comprehensive Health Center, 1st Floor 2525 E. Roosevelt, Phoenix, Arizona 85008, (602) To the extent possible, additional reasonable accommodations will be made available within the time constraints of the request. 1/22/ :12 AM

3 Maricopa Health Centers Governing Council Meeting January 23, 2015 Item 1 HRSA Annual Certification, Reporting Period: 04/01/13 to 03/31/14

4 Project Abstract for 2014 Annual Certification Application Reporting Period: 04/01/13 03/31/14 HISTORY OF THE ORGANIZATION & COMMUNITY SERVED Maricopa Integrated Health System is a comprehensive health care delivery system consisting of Maricopa Medical Center, Maricopa County s only public teaching hospital; Desert Vista Behavioral Health Center; a network of primary care Family Health Clinics (FHC); a large multi-specialty clinic, and Medicaid-participating managed care health plans. Primary care is offered at twelve (12 sites through Maricopa County, including the McDowell Healthcare Center, a clinic for people living with HIV and eight (8) Whole Health Home Clinics (WHHC) serving the SMI population of Maricopa County. Established shortly after the County s formation in 1877, Maricopa Integrated Health System was created by the Maricopa County Board of Supervisors to provide health services to the residents of Maricopa County. Initially established to provide care for the poor and sick, the County s health system has continued to grow and evolve into a modern, integrated, academic health care center. Today MIHS is the foremost health care safety net for citizens of Maricopa County and includes Arizona s only nationally verified burn center, the Arizona Burn Center. In November 2003, Maricopa county voters approved the creation of a tax-levying healthcare district. The new Special Health Care District, with a newly elected Board of Directors, was created in The District s elected five-member Board of Directors oversees the Maricopa Integrated Health System (MIHS). MIHS is located in the central portion of Arizona and serves as the health care safety net. MIHS serves people of many races and nationalities who come from diverse cultures and speak several different languages. Many of the patients face major challenges, such as lack of health insurance, complex medical problems, and difficult socio-economic situations. Caring for the demands of these patients requires special knowledge and sensitivity. MIHS is committed to giving culturally appropriate, sensitive medical care and helping their patients to live healthier lives. The MIHS clinics are JCAHO accredited and utilize a number of quality improvement programs. MIHS provides health care services with an emphasis on providing care to the poor and medically underserved populations. MIHS consists of the Maricopa Medical Center (teaching hospital), Desert Vista (mental health facility), Arizona Children s Center, a Walk-in Clinic, and the Comprehensive Health Center (CHC). The CHC houses additional FQHC-LA clinics; Women s Care, Pediatric Primary Care and Internal Medicine. MIHS also includes the Maricopa Health Plan (MHP), a state sanctioned Medicaid health plan which has been providing complete health care services to adults and children in Maricopa County. In October, 2005, Maricopa Integrated Health System (MIHS) and the University of Arizona Health plan (UAHP) entered into an agreement for UAHP to manage MHP. The partnership has allowed UAHP to utilize their 18+ years of highly successful health plan management experience to ensure that MHP is the premier plan in Maricopa County. Page 1

5 LOCATIONS, SERVICES, & PROVIDERS All Professional medical staff at the FQHC-LA clinics is board certified. The Family Health Centers are designed to provide health care services in one location. Services may include primary care, OB/GYN, radiology, dental care and pharmacy services. Outpatient primary and specialty care are offered at the Comprehensive Healthcare Center (CHC), a multi-specialty care clinic located on the Maricopa Medical Center campus. The Center treats pediatric and adult populations, and provides primary care services including family and internal medicine, obstetrics/gynecology, and pediatric care. Additional services at the CHC include antepartum testing, a breast center, cardiology and cardiac rehab clinic, dental clinic, dialysis, ear-nose-throat clinic, various medical subspecialty clinics, oncology, orthopedics, ophthalmology, pharmacy, radiology, a surgical vascular clinic, internatal clinic, OB complications clinic, and a women s refugee clinic that provides services in eight languages. TOTAL PATIENT & VISITS The most recent patient demographics as reported in the 2013 UDS. Medical 04/01/ /31/2013 Total Patients 91,218 Children (< 18 years old) 30.80% Adult (18-64) 63.90% Older Adults (age 65 and over) 5.30% White 86.30% Racial and/or Ethnic Minority 74.30% Hispanic/Latino Ethnicity 60.80% Black/African American % Asian % American Indian/Alaska Native % Native Hawaiian/Other Pacific Islander % More than one race % Gender of patients by Age Women s Data Patients Under 15 Who are Female 21.80% Patients Who are Female 72.90% Patients 65 and Over Who are Female 5.30% Men s Data Patients Under 15 Who are Male 33.00% Patients Who are Male 61.80% Patients 65 and Over Who are Male 5.20% Services (# of patients) 2013 Medical 88,370 Dental 11,125 Mental Health 939 Enabling 729 Page 2

6 Project Narrative for 2014 Annual Certification Application Reporting Period 04/01/13 03/31/14 NEED Maricopa County Special Health Care District, commonly known as Maricopa Integrated Health System (MIHS), is the only public teaching hospital and health care system in Arizona. MIHS is committed to offering comprehensive and safe care to all of those who live in Maricopa County including the underserved and medically needy, through a seamless continuum of care that keeps our community healthy, self-sufficient and effectively treats illness. MIHS has provided the full spectrum of wellness oriented healthcare in an academic environment to thousands of low-income and at-risk members of the community for 140 years. Maricopa Integrated Health System (MIHS), implemented a vast paradigm shift to connect people to care in a different way. With the onset of health care reform, the Affordable Care Act (ACA), and the restoration and expansion of the Arizona Health Care Cost Containment System (AHCCCS), MIHS chose to transform how health care coverage information was delivered to our customers. Embracing the philosophy that our community needed health care coverage, the MIHS Culture of Coverage began with the beliefs that we have countless opportunities to make a difference in people s lives, that business had to be conducted differently, and that it was fundamental to our mission to help the community learn and understand the changes in health care law, offering resources to identify, inform and educate consumers, and assist with them with enrollment activities. Goal: Help 10,000 individuals submit applications to AHCCCS or the Marketplace from October 1, 2013 to March 31, Results: 10,347 individuals submitted applications, exceeding our goal. In-reach and outreach activities were implemented to identify vulnerable and hard-to-reach populations. Targeted efforts were launched to reach special populations such as: persons living with HIV/AIDS, Latinos, refugees and those on health plans due to sunset. Multi-cultural marketing promotions, mass mailings, calling campaigns and Secret Shopper programs were designed to be innovative and serve multiple purposes. 3. PRIMARY HEALTH CARE SERVICES Family Practice is the delivery of primary, comprehensive medical care to patients of all ages. Practitioners who specialize in Family Medicine include physicians, nurse practitioners and physician assistants. Their focus is on the whole patient rather than on one system or patient concern. According to the CDC, the major reasons for Family Practice visits include: New problem 46% Chronic problem 25% Preventive care -- 18% Chronic problem, flare-up 8% Pre- or Post-surgery injury follow up 1% Page 1

7 In an effort to meet the comprehensive needs of our patients, MIHS has made considerable effort to create a one stop comprehensive health care environment in each of the health centers. For example, at the majority of our family health centers geographically dispersed throughout Maricopa County, we have placed physicians and midlevel providers / nurse practitioners to meet the health care needs of all ages and developmental stages of our patients. Furthermore, ancillary services such as pharmacy support, radiological services and oral health are also offered at the health center in an effort to elevate the health of our patients. As difficulty with transportation is frequently identified as a social disparity which confronts our patient population, we have been exploring opportunities to bring additional services to the family health centers identified as a service gap by both our patients and providers. Examples include: Digital retinopathy screening and testing for our diabetic patients Increased diabetes education offerings for patients Cardiology and pulmonology services General behavioral health / substance abuse for the general non SMI population A new FHC service site to be located in the West Phoenix area. Some of the examples cited may result in a HRSA changes in scope to be submitted in 2014 and Family Practice represents the portal into the health care system. Since most family practitioners build an established population or panel, they see their patients over long periods of time. These practices become the medical home for the patients. This facilitates familiarity and awareness of the patient s health history and baseline medical condition. This awareness leads to earlier identification of the development of chronic conditions. If the patient develops a highly complex condition, the family practitioner will refer to the specialist who focuses on that specific organ system or condition. Once the management of the acute phase is complete, the family practitioner assumes the ongoing care of these complex, chronic patients. This serves as rationale for the continued investment of resources and refinement of our NCQA Level III Certified Patient Centered Medical Home (PCMH).Consistent with the CDC discussion surrounding chronic disease management, our PCMH team provides additional focus on the management of diabetes, congestive heart failure and hypertension. During this time period, a multi division initiative was instituted in coordination through our PCMH team to provide a mechanism whereby high risk hospital discharge patients and emergency department patients are outreached and scheduled for a primary care ambulatory visit within a few days following discharge. While chronic disease management is a key element of our program, another important role of our family practice is to treat acute conditions. These include minor injuries such as sprains, as well as medical issues such as cough, skin rash, upper respiratory infections and pharyngitis. These are considered episodic type visits which are symptom-focused and usually recover with only one visit intervention. It is not uncommon in the MIHS practices for our providers to address more than one problem per visit. This is in direct response to the complex medical and social / behavioral needs of the patients that we serve. A third and very important aspect of Family Practice is preventive care. This is an encompassing aspect of family medicine. To fulfill their responsibilities in maintaining the health and wellness of their panels of patients, Family Practices have organized processes to oversee patients wellness and preventive activities. Services include: Page 2

8 Annual health evaluations with referral as recommended for specialty screenings such as colonoscopy Obstetrics, including prenatal, postpartum care Newborn follow-up Pediatric EPSDT s Vaccines and flu shots Well woman exams Procedures including placement of IUD s, excision of skin tags, toenail removal Screening and identification of possible behavioral health needs with referral for early intervention Working closely with the various payer plans, MIHS Family Practices reach out to our patients to encourage them and through the Patient Centered Medical Home to manage all aspects of wellness. These visits are tracked with follow up as needed to encourage their visits. The outcomes of these activities are tracked through quality review data. The importance of Family Practice in maintaining the health of the community cannot be overstated. With the Affordable Care Act providing coverage for preventive care, now more than ever before patients have the resources to help them stay healthy and reduce risk of chronic disease. The impact of a better quality, longer life is now a reality for many who in the past could not afford this care. One of the greatest challenges facing our family health centers is the prevalence (The uninsured exceed 50% in some of our clinics) of patients which are not eligible for state or federal medical and dental insurance coverage. Other considerable socioeconomic challenges experienced by our patients include, language barriers, behavioral health needs, and long term unmanaged health conditions. These challenges are realized daily in each of our family health centers and while managed well by our clinical teams, contribute to the financial strain experienced by our organization. A concerted focus of our Dental Services program has been designed to Increase the number of preventive dental visits for children under the age of 20 and to create a Pediatric Medical Dental Home at MIHS. To support this effort we have undertaken many initiatives. First and foremost, through an innovative collaborative partnership, we initiated a pedodontic residency training program to treat all age groups under the age of 20. Additional attention has been placed on the 0-5 age group with whom our general dental practitioners are less experienced. The pedodontic residents are present in the Pediatric Primary Medical Care Clinic at MIHS to offer education to parents and to perform oral exams on children who are appointed in the medical pediatric clinic for a well-child checkup or physical exams. Fluoride varnish capability is offered upon parental consent. Finally, discussion surrounding a new family health center to be located in west Phoenix includes a pediatric dental practice located on a school campus. Students would be able to obtain preventive and restorative dental care at a convenient location in the community. This dental clinic would be staffed by a pedodontic resident, an attending dentist from the Lutheran Health Care Network, and an MIHS dental assistant who is skilled in coronal polishing. Family Health Centers serve our nation by caring for patients as their medical home, striving to maintain the patients at their highest level of wellness and preventing visits to the Emergency Room. By reducing the financial burden to the patients and the hospital medical systems, Family Practice is critical to our nation s health. MIHS is committed to this effort and is continuously looking for ways to elevate clinical quality and to reduce avoidable costs. Page 3

9 4. HEALTH CARE ENVIORNMENT MIHS is committed to providing health care to all those who live in Maricopa County. As a proactive effort and with Health Care Reform, we began an outgoing call campaign to screen uninsured patients for Medicaid or the Marketplace. Every Medicaid screened eligible patient was offered an appointment to complete a Medicaid application with our Eligibility Specialists at one of our Family Health Centers or Comprehensive Health Center. Since July 2014 we have assisted over 5,000 patients in applying for Medicaid at our Family Health Centers and Comprehensive Health Center. For patients that are overincome for Medicaid benefits, we have referred over 1300 to Certified Applications Counselors to assist with Marketplace enrollments. Changes to Health Care Environment: o Family Health Centers have added more same day appointments to accommodate urgent/same day appointment requests o Increase patient access to medical care by expanding hours (including Saturdays at some health centers) RESPONSE Response To Change Maricopa Integrated Health System (MIHS) is the health care safety net for citizens of Maricopa County. The health system serves people of many races and nationalities who come from diverse cultures and speak several different languages. MIHS is committed to providing culturally appropriate, sensitive medical care and helping our patients live healthier lives. MIHS provides comprehensive and coordinated health services regardless of a patient s ability to pay. MIHS has refined expertise in providing health care services to the residents of Maricopa County, particularly those patients that are safety net patients and are un- or under insured through the use of our Family Health Centers (FHC), Comprehensive Health Center (CHC), Whole Health Home Clinics (WWHC) and Dental Services, collectively referred to as MIHS FQHC-LAs. Comprehensive integrated services include primary care, behavioral health services, dental, referral to specialty services, case management and health education and promotion. These services are listed on form 5A Services Provided. The MIHS-FQHC-LA services are available and accessible to patients in all stages of life, regardless of ability to pay. All FQHC-LA services are offered on a sliding fee scale for patients below 200 percent FPL. (Attachment 8: Schedule of Discounts/Sliding Fee Scale) Page 4

10 Patient Demographics: Age and Race/Ethnicity 2013 Total Patients 91,218 Age (% of total Patients) Children (< 18 years old) 30.80% Adult (18-64) 63.90% Older Adults (age 65 and over) 5.30% Patients By Race & Ethnicity White 86.30% Racial and/or Ethnic Minority 74.30% Hispanic/Latino Ethnicity 60.80% Black/African American 10.60% Asian 1.70% American Indian/Alaska Native 0.80% Native Hawaiian/Other Pacific Islander 0.10% More than one race 0.40% Best Served in another language 18.70% Patient Characteristics 2013 Patients at or below 200% of poverty 67.10% Patients at or below 100% of poverty 67.10% Uninsured 40.50% Children Uninsured (age 0-17 years) 16.30% Medicaid/CHIP 41.60% Medicare 7.30% Other Third Party 10.60% Homeless 111 Patients Under 15 Who are Female 21.80% Patients Who are Female 72.90% Patients 65 and Over Who are Female 5.30% Patients Under 15 Who are Male 33.00% Patients Who are Male 61.80% Patients 65 and Over Who are Male 5.20% Page 5

11 Change in Scope Change in Scope initiatives were submitted for the following: Name Change for Integrated Health Home clinics (IHH) to Whole Health Home Clinic (May 2014) no approval was required. Name change impacted the following clinics: Former Clinic Name Name Change Sunnyslope FHC IHH PIR Metro Whole Health Home Clinic PIR Metro 7 th Ave FHC IHH POCN Comunidad Whole Health Home Clinic POCN Comunidad South Central FHC IHH Choices Whole Health Home Clinic Choices South Central Chandler FHC IHH SWN San Tan Whole Health Home Clinic SWN San Tan 7 th Avenue FHC IHH POCN Capitol Whole Health Home Clinic POCN Capitol Mesa FHC IHH PIR East Valley Whole Health Home Clinic PIR East Valley Sunnyslope FHC IHH Choices Midtown Whole Health Home Clinic Choices Midtown Sunnyslope FHC IHH SWN Highland Whole Health Home Clinic SWN Highland Change in Scope Cardiology was submitted February 10, 2014 adding a new service to scope. The Change in Scope approval received was December 1, Locations for the new Cardiology Service will be at the Mesa FHC, Avondale FHC, El Mirage FHC and Chandler FHC. Hours of operation will be: Avondale Monday El Mirage pm Monday Glendale am Wednesday Mesa am Friday Chandler 1230p-4pm Friday Our goal is provide continuity of care for at risk cardiac patients. This would give our MIHS patients convenient access to a cardiologist as the cardiologist would be providing the visit at the patients medical home / primary care clinic. It would also allow the primary care physicians regular access for follow up and referrals with a cardiologist. Change in Scope Relocation McDowell Health Care Center. Change in Scope was submitted July 17, 2013 and approved June The McDowell Health Care Center was relocated to a new location to accommodate the growth of the HIV clinic. The new site has 12 exam rooms and 2 procedure rooms. A triage room is also available in the new and expanded space. The McDowell Health Care Center captures 30% of the market share in Maricopa County for HIV/AIDS. Hours of operation for the McDowell Health Center are Monday Friday 7AM 5:30PM. Page 6

12 2a/b. Locations Hours of operations The following table lists each site and hours of operation. The Maricopa Health Centers Governing Council (MHCGC) reviews recommendations and approves changes in hours of operation to meet the site and community needs. MIHS NETWORK Family Health Centers (FHCs) Avondale Family Health Center Chandler Family Health Center Clinic Hours: Monday Friday 7:00am 5:00pm El Mirage Family Health Center Clinic Hours: Monday Friday 7:00am 5:00pm Saturday 7:30am 11:30am Glendale Family Health Center Clinic Hours: Monday-Friday 7:00am 5:00pm Saturday 7:00am 11:00am Clinic Hours: Monday - Friday 7:00AM 5:00pm Guadalupe Family Health Center Clinic Hours: Monday - Friday 8am 4:30pm McDowell Family Health Center Clinic Hours: Monday Friday 7:00am 5:30pm (HIV CLINIC) Maryvale Family Health Center Clinic Hours: Monday-Friday 7:00am 4:30pm Mesa Family Health Center Clinic Hours: Monday Friday 7:00am 5:00pm South Central Family Health Center 7th Avenue Family Health Center Clinic Hours: Clinic Hours: Monday Friday 7:00am 5:00pm Monday Friday 7:00am 4:30pm Sunnyslope Family Health Center 7th Avenue Walk- In - Clinic Clinic Hours: Clinic Hours: Monday Friday 7:00am 5:00pm Daily 7:00am 10:00pm Comprehensive Healthcare Center (CHC) Clinic Hours Women s Care 8:00am 5:00pm Monday Thursday Friday 8:30am 12:00pm Clinic Hours Internal Medicine Monday Friday 8:00am 5:00pm Clinic Hours Same Day Monday Friday 8:00am 5:00pm Clinic Hours Pediatrics Monday & Wednesday 8:00am 7:00pm Tuesday Thursday Friday 8:00am 5:00pm Clinic Hours Dental Monday Friday 7:30am 4:30pm Maricopa Integrated Health System collaborates with four provider network organizations (PNOs) to develop a Whole Health Home Clinic model designed to improve the health status of seriously mentally ill (SMI) patients. These service sites are located within the behavioral health provider delivery sites. MIHS offers Page 7

13 primary medical care within the PNO behavioral health delivery sites. The literature suggests that SMI patients in Arizona have a life expectancy that is 30 years less than the non-smi patient. One of the contributing variables is that the SMI patients are not engaging in physical medical services. Through colocated medical delivery within the behavioral health agency s delivery site, patients have improved access to physical medical care. Through improved coordination of care with the behavioral health providers, we address medical conditions that are contributing to the health disparities of the SMI patients. Co-located sites (primary medical care and behavioral health) include Whole Health Home Clinic PIR Metro, Whole Health Home Clinic POCN Comunidad, Whole Health Home Clinic Choices South Central, Whole Health Home Clinic SWN San Tan, Whole health Home Clinic POCN Capitol, Whole Health Home Clinic PIR East Valley, Whole Health Home Clinic Choices Midtown, and Whole Health Home Clinic SWN Highland. MIHS Network Integrated Health Home (IHH) Whole Health Home Clinic PIR Metro Whole Health Home Clinic POCN Comunidad Clinic Hours: Monday, Wednesday & Friday 8:00am 4:00pm Whole Health Home Clinic Choices South Central Clinic Hours: Monday, Tuesday & Thursday 8:00am 4:30pm Whole Health Home Clinic POCN Capitol Clinic Hours: Wednesday and Friday 8:00am 4:30pm Whole Health Home Clinic Choices Midtown Clinic Hours Tuesday and Thursday 8:00am 4:30pm Clinic Hours: Monday, Tuesday & Thursday 8:00am 4:30pm Whole Health Home Clinic SWN San Tan Clinic Hours: Monday, Wednesday and Thursday 9:00am 5:00pm Whole Health Home Clinic PIR East Valley Clinic Hours: Monday Friday 9:00am 5:00pm Whole Health Home Clinic SWN Highland Clinic Hours Wednesday and Friday 8:00am 4:30pm 3. Accessibility and Service Delivery FQHC Look-Alike Scope of Care Service: The MIHS FQHC-LA Clinics offer a full range of medical services provided by board certified providers, including; family medicine, obstetrics, pediatrics, internal medicine and care of the geriatric patient population. The range of services offered includes preventive care and the diagnosis and treatment of medical conditions. Many of our facilities also provide ancillary support in the form of radiology, pharmacy and laboratory services. Ambulatory clinic staff is competency validated on an annual basis to ensure the highest quality care is delivered. Many of our employees are bilingual, some multilingual, and all have access to interpreters or phone interpretation services during all hours of operation. Our goal is to help patients and their families live healthier lives by providing comprehensive, coordinated, patient centric care. By following the Patient Centered Medical Home model, we encourage patients to become active participants and informed decision makers regarding their health care needs. Staff is well versed with both internal and external resources for specialty medical care, psychosocial support services, Page 8

14 and community self-management resources. In addition to the above services, our clinics offer RN care coordination services to assist patients with obtaining coordinated care, provide appropriate support for transitions of care, address barriers to care, and promote self-management education and support services. The Family Learning Centers (FLC): are designed to meet the growing needs of families that encounter barriers to obtaining health information, referrals and education in the health care system. The Family Learning Centers are designed to be user-friendly and easily accessible for Maricopa Integrated Health System (MIHS) patients, consumers, community, and staff. The Family Learning Centers will assist in the gathering of health information, referrals to community agencies, both medical and non-medical, as a means of contributing to informed choice in health care decision-making. The Family Learning Centers will conduct literacy and community education events to meet the changing needs of the consumers. Assistance to public benefit programs is provided. Programs, services, and materials are provided in a culturally sensitive and language appropriate manner. Family Learning Center Access: Our four Family Learning Centers (FLCs) are libraries to benefit our patients, their families and the entire community with health education and literacy programs. More than 47,000 residents visited our Family Learning Centers in 2013 and another 9,900 attended FLC classes and events. Multiple-language reading materials are also available to meet the needs of our diverse community, along with wide-ranging multilingual healthy living resources brochures and DVSs. Each FLC also features a children s reading area, computers, and internet access. Classes including parenting and child development, basic nutrition, car seat safety, bike helmet safety, CPR, and support groups. 1. Comprehensive Healthcare Center (CHC), 2nd Floor 2. South Central Family Health Center 3. Maryvale Family Health Center 4. Chandler Family Health Center Open Access Scheduling Open Access Scheduling is a method of scheduling the patients on the same day of the call. It is also referred to as Same Day Scheduling. The U.S. Department of Health & Human Services survey of patient populations access to care shows the following results: When consumers needed care right away in a clinic, emergency room or doctor s office, how often they got care as soon as they needed it: Adult Medicaid: 20% Child Medicaid: 15% Not counting times consumers needed care right away, how often they got an appointment for health care as soon as they needed it: Adult Medicaid: 23% Child Medicaid: 20% Maricopa Integrated Health System constantly seeks opportunities to improve access to care while improving efficiency and outcomes. As the ambulatory leadership considered piloting this model of scheduling, they reviewed the following outcomes and challenges: High No Show rates of up to 35% Patient dissatisfaction with not being able to get an appointment on the day they needed it. Care fragmentation due to patients seeking acute care from external providers. Provider dissatisfaction from high overbooking to provide their patients access to same day care. Page 9

15 High workload demands placed on the FHC Manager and staff as they attempt to work in patients requesting to be seen same day. MIHS initially piloted Open Access scheduling at the El Mirage Family Health Center in December At the pilot site, a 50% Open Access model was initiated. After three months a patient survey demonstrated highly satisfied patient response to the new system. The model assured patients who needed care on the day of their call were seen. Usually the patient was seen by their own provider. If their provider was not available, they were offered an appointment with another provider. Key outcomes of the El Mirage Open Access Pilot included: Highly satisfied patients. Decreased No Show rates. One provider even experienced a 7 % rate, the lowest ever experienced at MIHS. Increased session volume. The average at El Mirage is 9+ patients per session. This is the most productive site in the system. Increased Manager and staff satisfaction due to decreased time spent on managing patient work in appointments. With the pilot s success, ambulatory leadership expanded Open Access Scheduling throughout the FHC s. At every site there are open appointments available for patient same day access. Each FHC has a combination of Open Access and pre-scheduled appointments. At two of the FHC s, the open access appointments are so popular, two of the nurse practitioners are now 100% Open Access. As we look to the future, it is ambulatory leadership s goal to expand to 100% Open Access throughout the FHC system. With the evidence-based outcomes and demonstrated successes, Open Access Scheduling is a winning initiative for both the patient and MIHS. Page 10

16 Clinic Locations: FHC Whole Health Home Clinic POCN Capitol 1540 W Van Buren St, Phoenix AZ Whole Health Home Clinic POCN Comunidad 1035 E Jefferson St, Phoenix AZ th Avenue FHC 1205 South 7 th Avenue Phoenix AZ th Ave Walk-in Clinic 1201 South 7 th Avenue, Phoenix AZ Avondale FHC 950 E Van Buren, Avondale AZ Chandler FHC 811 South Hamilton, Chandler AZ Whole Health Home Clinic SWN San Tan 1465 W Chandler Blvd, Chandler AZ El Mirage FHC W Thunderbird Road, El Mirage AZ Glendale FHC 5141 W. La Mar Rd, Glendale AZ Guadalupe FHC 5825 E Calle Guadalupe, Guadalupe, AZ Maryvale FHC 4011 N 51 st Ave, Phoenix AZ McDowell Health Care Center 1101 N. Central Avenue, Suite 201, Phoenix AZ Mesa FHC 59 S Hibbert, Mesa AZ Description of Service Adult Family Practice (ages ), Lab-Waived Testing and Draw Station, Care Coordination and Financial Eligibility. Adult Family Practice (ages ), Lab-Waived Testing & Draw Station, Care Coordination and Financial Eligibility. Women s Health, Family Practice, Pharmacy, Lab-Waived Testing & Draw Station, Radiology, Care Coordination and Financial Eligibility. Family Practice, Lab-Waived Testing, and Financial Eligibility. Allergic Reactions Bronchitis, Ear pain, Simple Facial or Periorbital bruises, febrile child (over 2 months of age) with a temperature of 103 degrees or less, Children less than 2 months are transferred to a higher level of care, Foreign body in eyes, minor eye problems, simple headache, Mild/Minor (asthma, Burn under 5% Body Surface Area involvement, foreign body removal from skin, Musculoskeletal back pain, uncomplicated puncture wounds and Financial Eligibility. Family Practice, Care Coordination, Pharmacy, Lab-Waived Testing & Draw Station, Dental Care, Radiology Services, Radiographs, Ophthalmology, Ultrasound, Mammograms, Acupuncture, and Financial Eligibility. Family Practice, Care Coordination, Women s Health, Internal Medicine, Pediatrics, Dental, Pharmacy, Lab-Waived Testing and Draw Station, Ultrasound, Radiology and Financial Eligibility. Adult Family Practice (ages ) Lab-Waived Testing and Draw Station and Financial Eligibility. Family Practice, Care Coordination, Services, Lab Waived Testing and Draw Station. Center provides Immunizations, Patient Education, Nutritional/Diabetic Counseling, Laboratory, and Financial Eligibility. Family practice Adolescent Medicine Pharmacy Dental Care Coordination Lab-Waived Testing- nutrition and diabetic education and classes -Draw Station and Financial Eligibility. Family Practice, Women s Health, Care Coordination, Lab-waived Testing and Draw Station, and Financial Eligibility. Women s Health, Pediatrics, Adolescent Medicine, Laboratory Waived Testing and Draw Stations, Ultrasound, Ortho Sports Medicine, Refugee Women s Health Clinic, Teen Pregnancy Clinic, Care Coordination, and Financial Eligibility. Family Learning Center. Primary outpatient medical care provided on-site including prevention, early intervention, and outpatient treatment to those at risk of or infected with HIV/AIDS. Outpatient behavioral health assessments and referral to neuro-psych testing, counseling, psychotherapy, and medication prescribing services for HIV/AIDS patients. Routine oral healthcare, prophylaxis and dental health education, HIV counseling and testing, HIV risk assessment and counseling. Financial Eligibility. Family Practice, Women s Health, Internal Medicine, Pediatrics, Dental, Ortho Sports Medicine, Neurology, Lab-Waived Testing and Draw Stations, Pharmacy, Care Coordination and Financial Eligibility. Page 11

17 FHC Whole Health Home Clinic PIR East Valley E University Drive, Mesa AZ South Central FHC 33 West Tamarisk Street, Phoenix, AZ Whole Health Home Clinic Choices South Central E Roeser St. Phoenix, AZ Sunnyslope FHC W. Hatcher Road, Phoenix Whole Health Home Clinic PIR Metro N 31 st Avenue Phoenix AZ Whole Health Home Clinic Choices Midtown 3333 N. 7 th Avenue, Phoenix AZ Whole Health Home Clinic SWN Highland, 4707 N 12 th Street, Phoenix AZ Description of Service Adult Family Practice (Ages ), Lab-Waived Testing and Draw Station, Care Coordination and Financial Eligibility. Internal Medicine, Pediatrics, Dental, Pharmacy, Family Practice, Women s Health including prenatal and postpartum care, Family Learning Center, Lab-Waived Testing and Draw Stations, Care Coordination and Financial Eligibility. Adult Family Practice (Ages ), Lab-Waived Testing and Draw Station, Care Coordination and Financial Eligibility. Family Practice, Internal Medicine, Women s Health, Pharmacy, Lab- Waived Testing and Draw Station, Care Coordination and Financial Eligibility. Adult Family Practice (Ages ), Lab-Waived Testing and Draw Station, Care Coordination and Financial Eligibility. Adult Family Practice (Ages ), Lab-Waived Testing and Draw Station, Care Coordination and Financial Eligibility. Adult Family Practice (Ages ), Lab-Waived Testing and Draw Station, Care Coordination and Financial Eligibility. Professional After-Hours Coverage: Policy: There will be a District Medical Group provider assigned to take after hour calls from the patients receiving primary care at the Family Health Centers, Whole Health Home Clinics, CHC Internal Medicine Clinics and CHC Pediatrics Clinics. During after-hours when the clinics are not open to patients all incoming phone calls will be routed to a message that directs patients with an immediate emergency to hang up and dial 911. Patients that wish to speak with a provider will be prompted to stay on the line. If the patient needs to speak to the office staff regarding billing, scheduling or other non-clinical issues patients are instructed to call back during normal business hours. Clinical Staffing 4. (a) MIHS FQHC-LA provider staffing is described in Form 1A, and includes appropriate medical and support staff to provide high quality, patient centered care to the current and projected patient populations. The care team consists of providers, registered nurses, medical assistants, RN care coordinators, and additional support staff. To enhance patient care services, MIHS has 12 sites that are NCQA recognized as Patient Centered Medical Homes, Level III and includes an ambulatory care management team. The team consists of 10 RN care coordinators that are imbedded in the individual clinics, 2 RN discharge management coordinators to support transitions of care, and 2 outreach/preventive services staff. The ambulatory care management team provides population level management to ensure the highest risk patients are identified and provided necessary services in a coordinated manner. 4. (b) MIHS provides culturally and linguistically appropriate services to our patients. The organization requires both initial and ongoing staff and provider cultural competency training, provides translation services or translation lines depending on locations, and preferentially hires bilingual or multilingual staff when possible. Page 12

18 4. (c) MIHS has maintained its NCQA Patient Centered Medical Home, Level 3, recognition for 12 of the FQHC-LA clinics. As part of this program, MIHS proactively addresses the needs of patients to obtain preventive and enabling health services. This effort includes the use of provider decision support tools in the electronic health record such as health maintenance and best practice alerts, to assist providers in identifying needed services at the time of the visit. The ambulatory care management team also supports this effort by providing population management services to identify high risk populations and patients non-compliant or overdue for required preventive health services. The care management team collaborates with the provider and clinic care team to facilitate patients obtaining required care provided both internally at MIHS and external to the system. 5. Contracts and Formal Referral Arrangements The Contracts Management Department is responsible for managing the procurement and contracting activities for the Maricopa County Special Health Care District dba Maricopa Integrated Health System ( District ). Primary accountabilities include the issuance/management of public procurements; contract negotiations; contract database management and monitoring associated with goods and services utilized by the District as well as Vendor set-up and maintenance in STAR. A List of the MIHS Active Contracts is summarized in Attachment 3. Page 13

19 7. Sliding Fee Discount Scale Maricopa Integrated Health System s (MIHS) Financial Assistance Discount Policy exists to establish consistent policy and procedures to assist MIHS patient who are uninsured, underinsured, ineligible for any state or federal healthcare programs, and who lack the financial resources necessary to meet their financial responsibility for services offered or provided to them by MIHS. The financial assistance policy is a policy whereby MIHS determines a patient s financial responsibility for services offered or provide to them according to a self-pay discounted payment rate based upon federal poverty guideline and current AHCCCS rates and meeting the requirements of all federal and state requirements including Human Resources and Services Administration (HRSA). The financial assistance policy is not an insurance policy, not a charity program nor a health benefit program, but is a policy whereby MIHS patients are able to pay for services at a discounted rate. Any patient who meets the criteria under this policy will be required to provide the minimum information necessary for MIHS to determine if their income qualifies for benefits under this policy. When the financial assessment of an MIHS patient confirms that they are uninsured, underinsured, or unable to pay for MIHS services offered or provided. MIHS will evaluate each patient s financial responsibility for MIHS services according to an established Sliding Fee Schedule. Payment by the patient of the discounted amount, as measured by the Sliding Fee Schedule, is requested at the time of service; if the patient is unable to pay, services will be rendered in the FQHC-LA clinics and may be provided in all other areas of the health system based on medical need. MIHS will balance bill the patient for the nominal payment or balance outstanding. All self-pay patient receiving primary care services will receive an automatic discount reducing the outstanding balance to be equal to Medicare rates of reimbursement. The guarantor/patient may request an additional discount based on proof of income compared to the FPL, and other documents confirming eligibility for additional discounts under the MIHS Financial Assistance Policy (Policy # G) for primary care services. A copy of the MIHS-Low Income Discount Sliding Fee Scale is available for review as Attachment Quality Improvement/Quality Assurance MIHS includes Maricopa Medical Center, The Arizona Burn Center, Two psychiatric facilities and Integrated Health Homes, ten community-based family health centers, the McDowell Health Care Center, 7 th Avenue Walk-In Clinic, The Comprehensive Health Center, and Complete Comfort Care an attendant care program. MIHS is a premier training center for the nation s physicians. To fulfill our vision, mission, and values, we foster an environment that encourages innovation, embraces diversity, respects life, and values human dignity. MIHS s goal is to provide the highest standard of quality health care for our community and all patients who see services. Therefore, every effort will be made to ensure patients receive care that meets community and professional standards while exceeding the patients expectations Ambulatory services are a key component of the care provided by MIHS. As such, the need for a quality improvement program that is unique to Ambulatory and Physician Services requires integration into the overall quality improvement program of the health system and approval from the Maricopa Health Centers Governing Council (Council). The Ambulatory and Physician Services Quality Improvement Plan (here after referred to as the QI Plan) is not designed to supplant that of MIHS, but will serve as an interface with the overall quality improvement process. The plan is designed to improve the system processes of the programs within the primary care ambulatory arena at MIHS: the ten Family Health Centers (FHC), the McDowell Health Care Center, Eight Whole Health Home Clinics (WHHC), 7th Avenue Walk-In Clinic, and the primary care services provided at the Comprehensive Health Center. Page 14

20 Summary: The Executive Director of Nursing; Ambulatory and Physician Services co-chairs with the Ambulatory Medical Director the Ambulatory Services Medical Quality Improvement Committee. The information and recommendations are sent to both the Governing Council for the FQHC-LA and to the Performance Improvement Committee where the Executive Director of Nursing; Ambulatory and Physician Services actively serves on. The Vice President, Ambulatory and Physician Services/ Executive Director, Maricopa Health Centers Governing Council serves on the system wide Quality Management Council which reports to the MIHS Board. Page 15

21 9. Board-Approved Policies a. Clinical Standards of care Nursing Department Standard of Care: Revised August 2014 Purpose: 1. To provide written guidelines/standards of care for the patients. 2. To provide direction for staff on the operating procedures for specific departments 3. To ensure the safety and quality of care to all patients and families 4. To ensure staff comply with local, state, and federal laws, Arizona Nurse Practice Act and regulatory agency requirements. Care Management Scope of Service 2015 The Care Management Department provides a broad spectrum of services to assist with utilization review and discharge planning for the organization. The department s personnel function as a resource to collaborate with physicians to ensure patients are at the right level of care and assist patients through the continuum of care. b. Provider credentials and privileges Medical Staff Bylaws, Policies, and Rules and regulations of Maricopa Integrated Health System Credentials Policy Approved c. Risk management procedures: Risk Management Department Scope of Care Services MAJOR PURPOSE: The Risk Management Department is responsible to identify, mitigate and resolve exposures, risks, claims and losses that arise from employee work-related injury, third-party liability, property damage, regulatory compliance and other loss exposures arising from operations. The Risk Management Department provides loss prevention and control, and prompt and appropriate identification of potential problematic or compensable claims or events. Risk Management endeavors to improve patient, employee, and/or visitor safety and relations, and mitigate the potential of reputational risk, worker injury and third-party claims against MIHS. A multidisciplinary approach is utilized to identify, review, evaluate, and control risks that interfere with quality patient care, safety and services rendered by MIHS, and to implement appropriate corrective and preventive action as necessary. SERVICE(s) DEFINED Identify claims, events or occurrences that expose MIHS to reputational risk, losses/or claims against MIHS. Work in collaboration with leadership to monitor the performance of staff and volunteers providing care or services to patients, and to identify and correct practices which may present unnecessary risks to patients or deviate from acceptable practices. Continuous review of MIHS policies and procedures to update, amend, edit, and revise to reflect appropriate care, legislative requirements, and minimize or prevent reputational risk, liability, worker injury or claims. Investigate adverse occurrences to assess and determine how similar occurrences might be averted and to control exposures and losses related to adverse occurrences. Work in collaboration with departments to identify and correct potentially hazardous conditions which may present unnecessary risks to employees, patients, and others. Manage casualty claims against MIHS in accordance with the Maricopa Integrated Health System Risk Management Insurance and Self-Insurance Plan. Organize educational programs concerning Risk Management topics to promote awareness of Risk Management exposures, issues and practices. Page 16

22 Control automobile liability and property damage exposure through the Vehicle Use Permit Program using motor vehicle record reviews and monitoring. Perform annual reviews of the MIHS insurance policies and Self-Insurance Plan to maximize coverage against serious perils that threaten MIHS assets at the lowest possible cost. d. Patient grievance procedures Quality Management / Patient Complaints and Grievances Policy # S Revised 09/2014 Purpose: To establish a process whereby patients or their authorized representative may have their complaints and grievances resolved in a prompt, reasonable and consistent manner. MIHS, as part of its commitment to excellence, believes through the evaluation of patient complaints and grievances there is enhanced quality patient care and improvement to the services we provide. The Special Health Care District Board of Directors (SHCDBD) has delegated the responsibility of this grievance process to the MIHS leadership. Feedback is provided through complaint and grievance data aggregation and shall be reported to the Quality Management Council. MIHS Leadership will review complaints and trends occurring in their areas of responsibility and work to assure processes are developed to reduce or prevent complaints from occurring in the future. e. Incident management Physical Environment (PE) PE.6 Emergency Management System MIHS has a comprehensive Emergency Operations Plan (EOP) that is based upon a Hazard Vulnerability Analysis (HVA), both of which are updated annually with input from the Emergency Management Committee, Maricopa County Department of Emergency Management, various local hospitals, law enforcement, and fire and EMS representatives. A copy of the EOP is available in the Hospital Command Center, 7 th Floor Nurse Staffing Office, as well as, on the Copanet. A condensed, working version is available in each unit, referred to as the Red Book, f. Confidentiality of patient records Compliance/HIPAA Confidentiality/Workforce Member Confidentiality Agreement Policy # S Confidential Patient Information Workforce members will keep all information concerning MIHS patients confidential. They will access, use, and disclose a patient s protected health information ( PHI ) only for payment, treatment, and health care operation purposes unless permitted by MIHS HIPAA policies. MIHS respects patients, employees, and physicians rights to privacy and confidentiality. Workforce members will be sensitive to the privacy needs of MIHS patients, and will conduct communications involving patient care and PHI in compliance with the procedures set forth in this policy. Advances in technology are making it easier to use and disclose patient information. Workforce members must ensure that any transmission of patient information, including photographs or images of patients, patients families, or patient documents, comply with existing policies concerning the appropriate use and disclosure of protected health information, including the MIHS Policy S: Network Usage. Page 17

23 Confidential MIHS Information Workforce members will keep all confidential information concerning MIHS business operations, confidential. They will access, use and disclose this information only as expressly allowed by MIHS policy or by the MIHS Administrative Team. Workforce Confidentiality Agreement All workforce members will sign, and MIHS will maintain the signed MIHS Acknowledgement of Confidentiality Form. 10. Strategic Plan The voters of Maricopa County founded MIHS in 1871, and reaffirmed its community-critical mission in 2003, when County citizens voted to create the Maricopa County Special Health Care District and support MIHS with public funding. An elected five-member Board of Directors leads the Special Health Care District and has responsibility for ensuring the long-term viability of MIHS and its voter-mandated mission. In 2013, the Board of Directors (BOD) completed a strategic planning process and in August of that year, approved the Strategic Plan. The BOD developed the strategic plan by considering emerging community need, healthcare industry trends, the accomplishments achieved from the prior five-year strategic plan, an assessment of current operating assets, and the charter of the organization as approved by voters in The MIHS Strategic Plan contains the following key elements: 1. Enhancing Mission Relevancy and Community Leadership 2. Creating a System of Care to Improve Community Health 3. Addressing a Community Crisis in Behavioral Health 4. Offering Unmatched Community Value 5. Designing Health Facilities for the Future 6. Ensuring Financial Sustainability Each of these strategic elements is described below in greater detail. 1. Enhancing Mission Relevancy and Community Leadership: MIHS is the public teaching hospital and safety net health system of care serving the fourth largest populated county in the United States. During the strategic planning process, the BOD reaffirmed a set of core purposes for MIHS including: Teaching and training a next generation of physicians, nurses and allied health professionals in response to an ongoing shortage of clinicians in Maricopa County and statewide; Serving as a safety net provider to fill critical gaps in care for underserved populations and the under and uninsured individuals and their families.; Organizing primary care access points in communities across Maricopa County where access is insufficient to meet current demand; and Offering a critical point of leadership as the only medical system in the community directly accountable to the taxpayers to address broad public health issues and emerging and unmet community needs. MIHS has always adapted and responded to community needs. That is a common thread that runs through the organization s 140+ year legacy. It is a legacy of leaders who have carried the public teaching hospital and health system mission forward and it is a mission that is relevant as much today as it was in the beginning. As the public teaching hospital and health system grew over the hundred plus years, MIHS leaders viewed community wellness from a big picture perspective. Hence, the system today offers the full continuum of services to care for its community and is exactly the system of care model required for the future. From prevention and education programs, primary and specialty care clinics, behavioral health Page 18

24 hospitals, regional burn and trauma center, emergency and hospital services, a managed care insurance company, and an integrated medical group, MIHS occupies an important public mission and is complementary to the private healthcare sector. The legacy of leadership is similarly represented in the multi-specialty physician group practice that is the primary partner and medical staff provider for MIHS, District Medical Group, Inc. (DMG). DMG is also the County s largest integrated medical group practice. The MIHS partnership with DMG is foundational to the Strategic Plan, and hence, the plan includes the contributions and passionate ideas of the medical group. DMG shares the MIHS mission of teaching and training future healthcare professionals and serving as the community safety net for the most vulnerable, and the MIHS vision of designing a public teaching hospital and health system model for the 21 st century. 2. Creating a System of Care to Improve Community Health: The demands on a public teaching hospital and safety net system of care are changing in light of the Affordable Care Act (ACA) and Maricopa County s growing and increasingly diverse and geographically dispersed population. As a safety net health system of last resort for people who lack the means to pay for care, and for high risk populations with complex co-morbid conditions and illnesses, MIHS must provide leadership in the design and deployment of new models of patient care and new methods of clinical training that align accountability for care outcomes and reduced costs. This is a shift of risk for performance to healthcare organizations and healthcare professionals, and MIHS must invest in the people, processes, and technology to manage that risk. To respond to those changes MIHS will pursue strategies to deliver more care outside the walls of the hospital and in the community, and teach and train clinicians to work in inter-professional teams to deliver efficient and effective care. Specifically: The MIHS strategic plan allocates a greater share of system resources to grow access to primary care and specialty services in underserved parts of the County and to deliver that care in a more efficient, integrated model that can improve outcomes and experience and reduce costs. This enhanced capacity and service is essential to address emerging and unmet needs that often translate into longer-wait times for primary and preventive care services, access to specialists, and overuse of the hospital emergency department for non-emergent needs. Moreover, community need is growing due to an aging population and an increase in co-morbid conditions (i.e., congestive heart failure, diabetes, pulmonary disease). This demand is occurring independent of the passage of the ACA and represents a shift of care from the hospital to the physician-office or ambulatory care setting. The ACA encourages development of medical homes that can manage the total care of patients and be accountable for outcomes and costs of populations. MIHS has a strong track record in delivering care in this model. MIHS care management support services such as diabetes education, family learning centers and prenatal programs focus on health and wellness, outcomes and value, preventing unnecessary and expensive hospitalization costs. The strategic plan specifically aligns to the medical home model and defines a scope of services in the ambulatory sites consistent with the required competencies of a medical home care site. The strategy recognizes the imperative to replace the functionally obsolete Maricopa Medical Center (MMC). That investment is essential so that the District might continue to serve both MIHS teaching mission and safety net role. Absent a new MMC it will be increasingly difficult if Page 19

25 not impossible for MIHS to teach, train, and continue its role as the region s only public safety net teaching hospital and health system of care. The system of care strategy commits MIHS to continue supporting through advocacy, education, and service delivery those programs that improve care outcomes, access, and costs at the population level. It represents an affirmation of the leadership role MIHS intends to play as a partner with payors, employers, municipalities, school districts and hospitals and physicians to make Maricopa County a healthier place to live and work. In effect, the strategy refines the role of a 21 st century public teaching hospital and system of care in a post-aca market. 3. Addressing a Community Crisis in Behavioral Health: The MIHS strategic plan recognizes the gaps in access to behavioral health services in Maricopa County and the reality that lack of access to needed mental health and substance abuse services drives up emergency room utilization and costs for the region s schools, law enforcement, other health systems and hospitals, and employers. To address those needs the plan specifically: Proposes increased inpatient bed capacity for behavioral health services as a response by MIHS to meet the glaring need in the community for more mental health and substance abuse services; Considers consolidation of MIHS inpatient behavioral health capacity on a single campus to enable better care for patients and enhanced service to families; Envisions the opportunity to generate operational efficiencies and savings via the construction of one new facility rather than maintaining three separate hospitals and then reinvest savings in new programs and expanded behavioral health services to meet emerging needs; and Supports the integration of behavioral health services into community-based primary care medical homes so that needed access to care can be provided closer to population centers across the County. 4. Offering Unmatched Community Value: The MIHS planning process considered the cost of transferring the case mix and mission of a public teaching hospital and safety-net system of care to private sector hospitals. Critical findings were: The need for taxpayer subsidy of care for the underserved and medically indigent would not go away; rather, funding would most likely need to be transferred to private hospitals to offset the adverse financial impact of a sudden influx of the medically indigent and under-insured at a time when all hospitals are already facing increased financial uncertainty from the ACA; in this scenario, challenges with respect to public accountability for use of those funds and the transparency that comes with a public governing board would be significant. A failure to re-invest in MIHS would have an adverse impact on employers at a time when they are already struggling with the rising costs of care from an aging, chronically ill and fast growing population that needs access to the primary and preventive care services that MIHS offers. MIHS, today, partners with numerous clinical training institutions and offers eight fully-accredited residency programs that are an essential training ground to address an already acute and unfortunately growing shortage of clinicians (physicians, nurses and allied health professionals) in Maricopa County. The investment of resources required and the complexity involved to replicate those programs in another system will only further strain the region s already stressed health care. Page 20

26 MIHS has a culture of caring, an integrated medical staff and faculty, a complex patient population, and the special expertise to support inter-professional training and clinical rotations unlike any other health system in the Valley. The emerging model for effective and efficient healthcare delivery will require organizations to teach and train physicians, nurses, pharmacists and allied health professionals to work together in teams organized around the needs of patients. The MIHS strategy is to build an integrative hospital campus that accommodates this team-based approach to training. The team-based approach is essential to implementing new models of care that hold out promise to improve care outcomes, patient experience, and to better manage costs of care. MIHS has a long-standing and deep history of collaborations. Its success is rooted in successful community collaborations and building of broad community coalitions. The Strategic Plan envisions the creation of many more such alliances. The plan specifically calls out opportunities to partner with other federally qualified health systems, private practice physicians, healthcare organizations, and educational institutions who share the same vision for improving community health. Lastly, the mission and work of MIHS as the County s vital public teaching hospital and health system is consistent with broader goals envisioned for the community. For example, the Center for the Future of Arizona in its The Arizona We Want 2.0 report suggests that education is the key driver of Arizona s economy; that we need to recruit and retain more talented young people who are committed to Arizona s future; and that the strength of the state rests in local communities. The MIHS strategic plan relates and contributes to each of these important goals. Specifically, MIHS provides more medical education and clinical training than anyone else in the County; has trained more physicians currently practicing in the County than anyone else; and has more community-based family health centers than any other healthcare organization. As MIHS continues its strategic transformation as the premier teaching provider of essential health services with a focus on wellness, population health, and chronic disease management, MIHS is indeed contributing to making Maricopa County a healthy and vibrant community. 5. Designing Health Facilities for the Future: An objective assessment of MIHS current facilities in the context of emerging community need and the organization s strategies to serve that need reveal a critical gap that can only be addressed through a reinvestment in MIHS community and physician-office based services, behavioral health facilities, and an acute care teaching hospital. Specifically: 6. The network of Family Health Centers (FHC) that are so critical to extending access to primary and preventive care services to at-risk and underserved populations are a collection of buildings inherited by the District from the County. Most are undersized, outdated relative to changing care models, and not in locations that correspond to emerging community needs. The Comprehensive Health Center (CHC) represents a good model for delivering quality, efficient care outside the hospital. The current CHC on the Roosevelt campus requires updating and expansion, and additional CHC sites are needed across the County to accommodate emerging community need for geographically dispersed specialty services. The two MIHS behavioral health hospitals are operating at capacity and cannot meet current and growing community need. Neither of these facilities is functionally effective nor do they have the ability to expand capacity and moreover, operating two facilities on separate campuses prohibits operating efficiencies that could be achieved by consolidation. Maricopa Medical Center (MMC) is more than 40 years old; changing community needs and care models has rendered it functionally obsolete and exceedingly costly to operate for purposes of providing safe, quality care. Page 21

27 7. Ensuring Financial Sustainability: The MIHS strategic plan has been designed to improve the District s financial performance so that it can stabilize its operating margin and prepare for anticipated funding challenges facing public teaching hospitals in the future. Specifically the plan calls for the following strategies: Converting Uninsured to Covered Lives: The strategic plan presumes that MIHS will be able to retain patients currently served by MIHS that are today uninsured, however, going forward, they will be covered through AHCCCS or the health exchanges. Retaining these reinsured and newly insured patients through an updated and renovated network of clinical sites and services will improve MIHS financial performance. Growing Ambulatory Capacity to Serve More People in Need: The plan expands outpatient capacity to enable MIHS to serve more unmet need and underserved patients outside the walls of MMC and in a community setting, producing an additional fiscal improvement for MIHS once fully implemented. Continuing to Manage Costs: The strategic plan acknowledges the continuing need to improve operations to reduce expenses consistent with the industry-wide pressure to deliver better care at lower cost as envisioned in the ACA. Assuming a reduction in cost aided in part by more efficient facilities will enable MIHS to improve operating performance on a go forward basis. Collectively, fully implementing the strategic plan, including funding new facility projects, could generate an improvement in margin to offset the costs of serving unmet community need as a public teaching hospital and safety net health system of care. 11. Anticipated Changes: Service Goal: The Goal is to provide a complimentary extension of specialty services to primary care patients in their medical home by decreasing travel, improving coordination of care and improving patient satisfaction. Our national health care trend is built on a model that supports quality, customer service, and the patient experience. Under the new care models payment incentives benefit from coordinated care. For MIHS to excel to that level of service we must be partners in a coordinated care effort which will provide the best available care to our patients. The following Specialty Services are anticipated in the upcoming certification period: Proposed Specialty Service Service description Proposed FHC outreach sites (1 session/4 hours per week) 10 patients per FHC per Week (5 locations proposed) 4 New patient appointment slots 6 Established patient appointment slots Cardiology Avondale 8am 12pm Monday El Mirage 1pm 4pm Monday Glendale 8am 12pm Wednesday Mesa 8am 12pm Friday Chandler 1pm 4pm Friday Page 22

28 Pulmonology Orthopedic Sports Proposed FHC outreach sites (1 session/4 hours per week) 10 Patients per FHC per week 2 location proposed 4 New patient appointment slots per session 6 Established patient appointment slots per session Avondale 1pm 4pm Wednesday Chandler 8am 12pm Tuesday Maryvale Monthly 1 st & 3 Tuesday 1pm 3pm Mesa Monthly 4 th Tuesday 8am 4pm Neurology Mesa Monthly 3 rd Wednesday 8:30am 1:30pm Podiatry Proposed FHC outreach sites (4 sessions/16 hours per week) 20 patients per FHC per day, 2 locations proposed 8 New patient appointment slots per day 12 Established patient appointment slots per day Avondale 8:00am 4:30pm Tuesday McDowell 8:00am 4:30pm Friday 12. Maximizing FQHC Benefits FHC Medicare/Medicaid/CHIP reimbursement, 340B Drug Pricing Program The Maricopa Integrated Health System (MIHS) provides comprehensive primary, specialty, and tertiary care for the residents of Maricopa County regardless of their ability to pay. The MIHS provides comprehensive primary health care services for the County s most high risk, vulnerable populations through a network of 11 Family Health Centers (FHCs) (FQHC Look-Alikes) spread across the Valley of the Sun. The high risk, vulnerable populations served by the FHC providers and staff are mostly low income, uninsured, underinsured, Medicaid, SCHIP, and Medicare enrollees. One of the most significant benefits of the FHCs being part of the MIHS delivery system is the resources that are made available to the providers, clinic, and patients from the Maricopa Medical Center (hospital) pharmacy team. Through this collaboration, outpatient pharmacy sites have been developed and are operated at the majority of the FHC sites. As a result of the FHCs and Hospital s 340B Program eligibility, the health center patients have access to affordable onsite administered and prescription drugs as well as pharmacy clinical support for consultation and chronic disease management. Significant benefits have and continue to be achieved through these efforts including: Improved prescription drug adherence; Reduced emergency room visits; Reduced complications from chronic disease (e.g., diabetes, asthma); Reduced unnecessary hospitalizations and/or length of stay; and Significant cost savings for the patient, third party payers (e.g., Medicaid managed care plans), and MIHS. Vaccines for Children Program Page 23

29 The Pediatric Clinic starts by determining who qualifies for the VFC (Vaccines for Children Program). All of the patients are evaluated. Children that meet the qualification to receive the VFC sponsored immunizations are given them. They must be younger than 19 years of age, and is either Medicaid-eligible, uninsured, underinsured or American Indian or Alaskan Native. Children whose health insurance covers the cost of vaccinations are not eligible for VFC vaccines. For families that cannot afford shot fees, the shot fee is excused. No child is ever refused a vaccination due to the parent s inability to pay for shot administration. All charting is documented in the patient record. Medicare/Medicaid/CHIP Reimbursement MIHS works alongside DMG to recruit providers to meet the needs of the community and that may be eligible for the NHS Corps tuition reimbursement programs. In an effort to maximize FQHC benefits, MIHS is screening uninsured patients for Medicaid or Marketplace eligibility. Medicaid screened eligible patients are referred to the Eligibility Specialists for Medicaid application assistance. Registration Staff are responsible for: Screening uninsured patients for other coverage opportunities Collecting and entering correct demographic and insurance information to reduce delays in claims processing Pre-register patients prior to their visit ensuring insurance eligibility is verified Working denial claims Collect old balances Verifying patient s PCP Obtaining Prior authorizations for services that require authorization Ongoing Registration Training Providers and Clinical Staff are responsible for: Making sure visits are coded according to the services rendered Identifying any errors and correcting them promptly to reduce delays in claims processing Working denial claims promptly Identification of at-risk groups and provision of additional support through the Patient Centered- Medical Home Utilizing Vaccine for Children program for eligible participants Use of 340B Drug Pricing program 13. Budget Budget Narrative Attachment #9 Federally Qualified Health Center, Look Alike Budget The structure of the Family Health Centers (FHCs), Primary Care Clinics of the Comprehensive Health Center (CHC), 7th Avenue Walk-in Clinic and Dental offices operated by Maricopa Integrated Health System is that of a Federally Qualified Health Center Look-Alike (FQHC-LA). This status is available to those health centers that do not receive funding under section 330 of the Public Health Service Act, but operate and provide services similar to grant-funded programs. As such, FQHC-LA entities are expected to serve all populations residing in their medically underserved communities and to satisfy the administrative, management, governance and service-related requirements unique to section 330 funded health centers. The Federally Qualified Health Center Look - Alike Budget for FY 2013 assumes the following: Page 24

30 Volumes: Volumes are budgeted to increase 9.1% in the FHCs, 2.2% in the Primary Care Clinics of the CHC, 0.2%% in the 7th Avenue Walk-In Clinic and 3.5% in the Dental Clinics over the projected FY 2012 numbers. Total visits for all FQHC-LA entities are budgeted to increase from 298,068 to 320,596, an increase of 7.6%. Budgeted volumes are based on provider and clinic capacity and include a Strategic Initiative targeted to add four additional Integrated Health Home sites with our Behavioral Health partners. Revenue and Expenses: Net patient revenue is budgeted to increase 15.6% as a result of the projected increase in visits, improvements in the Copa Care mix. Total operating revenues are budgeted to increase 18.5%, largely due to an increase of the FQHC Revenue per visit from $252 per visit to $256 per visit, the addition of the Safety Net Care Pool and Patient Centered Medical Home dollars. Operating margin (before the allocation of administrative overhead expenses) is budgeted to increase by $3.9 million. Total FTEs are budgeted to increase from 380 to 420, an increase of 10.6%. The net increase includes the filling of some positions currently vacant, the addition of the Integrated Health Home sites added in FY 2012, Care Coordinator and Social Worker positions, the Dental locations that remained open in FY 2012 and the addition of 3.5 new positions that are related to the Strategic Initiatives. Page 25

31 COLLABORATION 1. Formal and Informal Collaboration Ryan White Program: McDowell Healthcare Center Scope of Service The McDowell Executive Staff Committee (ESC) provides oversight of the administration and operations of any and all federally supported and funded activities (Ryan White CARE Act grants) and the patient care services provided by such grants at the McDowell Health Care Center. Membership of the committee consists of the center s medical director, one or more of the providers, the HIV program manager, the center manager, a representative from the grants management department, the director of operations and/or director of nursing for the center, representatives from the center s behavioral health services. The McDowell ESC is held a minimum of four times yearly, with monthly meetings occurring on the third Friday of every month from 1:00PM to 3:00 PM. The committee is chaired by the McDowell medical director. McDowell Health Care Center provides services to HIV/AIDS positive youth (between the ages of years) and HIV/AIDS positive adults (ages 25 years and older). Services contracted by the department include direct patient care contracts, District Medical Group, Inc., and Phoenix Children s Hospital. Indirect patient care contracts include Dunbar, Care Directions, Ebony House, Chicanos por la Causa, and Johnson Control. In 2013, there were 11,959 visits to the McDowell Healthcare Center. 2. Community Partners In 2013, MIHS planned and developed 79 public fairs and presentations, bringing health information and education to 28,567 people across Maricopa County. Our community outreach teams provide complimentary health screenings for adults and children. Arizona Health Care Cost Containment System (AHCCCS) AHCCCS is Arizona s Medicaid program, designed to deliver quality health care under cutting-edge concepts of managed care. American Red Cross The American Red Cross touches millions of lives each year. American Red Cross employees and volunteers help keep the public prepared to respond to disasters and personal emergencies. The Red Cross provides training in lifesaving skills such as CPR and first aid, collects and distributes half the nation's blood supply, and helps victims of more than 67,000 disasters annually. Arizona Physicians IPA (APIPA) AmeriChoice offers health care coverage for beneficiaries of Medicaid and other state health care programs in 21 states and the District of Columbia. Area Agency on Aging As a private non-profit organization, the Area Agency on Aging, Region One, advocates, plans, coordinates, develops and delivers services for adults aged 60 years and older, persons of any age with HIV/AIDS, adults aged 18 years and older with disabilities and long-term care needs, and family caregivers. Association for Supportive Child Care ASCC s mission is to enhance the quality of child care for children in Arizona. We remain focused on the needs of children and families. We believe that every child should be provided the best possible care and nurturing. Barnes and Noble Community Economic Development Alliance (CEDA) The goal of CEDA is to enhance and improve the lives of disabled individuals, disadvantaged youth and adults, women and elderly victims of domestic violence, homeless individuals, and adults with children. Children's Museum of Phoenix Acting on the principle that learning is a joy, the Children s Museum of Phoenix s mission is to engage the minds, muscles and imaginations of children and the grown-ups who care about them. With hands-on, interactive exhibits designed for children ages birth to 10, the Museum focuses on learning through play, with emphasis on early childhood education and school-readiness. Page 26

32 Crisis Pregnancy Center Crisis Pregnancy Centers of Greater Phoenix is one of the largest & most comprehensive pregnancy resource services in the nation, with four clinics in the Phoenix area. We also offer prevention, abstinence, and sexual issue curriculum through our online resource website. Family Resource Center (Child Crisis Center) Our Mission: Strong Families, Safe Kids The Child Crisis Center is committed to preventing child abuse and neglect. We accomplish this by supporting and strengthening families through education and intervention, by providing a safe environment for children to heal, and by recruiting, training and supporting foster and adoptive families. First Way Pregnancy Support Center First Way Pregnancy Center provides free resources which support life affirming choices. This is accomplished through a loving and non-judgmental approach with peer counseling, education and practical services. Food Plus Fresh Start Women s Resource Center Fresh Start is a nonprofit organization dedicated to helping women help themselves. We do that through the work of the Jewell McFarland Lewis-Fresh Start Women s Resource Center. The women who come to us for help are not savvy about the system but rather are women just like you who are facing challenges that seem insurmountable. Help us help them. We welcome you to our website. Golden Gate Community Center Golden Gate Community Center, a member of Arizona s Children Association Family of Agencies, has been a beacon of hope for south and west central Phoenix neighborhoods for over 70 years. Healthy Families Healthy Families Arizona (HFAz) is a state system of home visiting support for prenatal families and families with newborns. Services include child development information and screening, activities that offer opportunities for parents and children to play together, and linkages to the community. Our primary goal is to support parents in becoming the best parents they can be. La Leche League of Arizona LLL is an international, nonprofit, nonsectarian organization dedicated to providing education, information, support, and encouragement to women who want to breastfeed. All women, especially pregnant and nursing mothers, are welcome to attend our meetings Life Choices Women s Clinic Life Choices Women s Clinic (LCWC) is dedicated to improving the lives of women and their families, by providing medical care, counseling and education. Our medical clinics offer a wide variety of medical services related to pregnancy and other areas of women s health. Our services are delivered in an atmosphere of care and respect, and are available to all women, regardless of their ability to pay. Maricopa Skills Center The Maricopa Skill Center has served over 86,000 students since opening its doors more than forty years ago. Since 1962 both full- and part-time students have benefited from MSC's dedication to excellence in teaching, apprenticeship, and service. Within this unique educational institution, you will find students practicing their trades under the watchful attention of their instructors. Mesa United Way The Mesa United Way mission is to increase the ability of the people of our community to care for one another, and to ensure that core services for children, the disabled, the elderly, and the needy are available in our community. MIHS Car Seat Program Maricopa Integrated Health System provides toddler car safety seats for children over 14 lbs. and booster seats for children 40 to 100 lbs. or 5 to 8 years of age. Children admitted to Maricopa Medical Center, the Arizona Burn Center, or seen in the outpatient burn clinic or one of our Family Health Centers may receive car safety seats. Page 27

33 MIHS Child Obesity Class Is your child overweight for their age? Does he or she suffer from high blood pressure or high bad cholesterol levels? This class may be a good fit for you and your child. Talk with us and your doctor about attending our class! MIHS Childbirth Classes Childbirth Classes The following services are available to ALL obstetrical patients inside or outside our health care system as well as MIHS employees. Classes are available at no cost. Childbirth Education Classes Childbirth Education Classes (English & Spanish). MIHS Domestic Violence Program The mission of the Center for Healthcare Against Family Violence is to provide educational resources, expertise and research support to the healthcare community and to ensure that support and services are provided to those affected by family violence. MIHS Financial Assistance Program (Copa Care Maricopa Integrated Health System knows seeking medical care can be overwhelming. That's why they have developed a program to help you deal with the financial stress of paying for the health care you deserve. MIHS' Financial Assistance Program is designed give you realistic payment options. Applicants must apply for, and be denied, AHCCCS to qualify for our Financial Assistance Program. National Safety Council - AZ Chapter The National Safety Council AZ Chapter s purpose is to educate and motivate people to live safer and healthier lives by reducing injuries, deaths, human suffering and losses caused by preventable accidents. As a chapter of the National Safety Council located in Phoenix, Arizona, our mission is to protect life and promote health through accident prevention. Parenting Arizona The mission of Parenting Arizona is: to assure a positive and safe environment for all children; to provide accessible and comprehensive services to families at-risk for violence toward children and support of the continuing goals of Arizona s Child Welfare System; and to promote healthy parenting among individuals and in communities raising children. Phoenix Fire Department The Phoenix Fire Department offers a number of services to Valley residents. Phoenix Public Library The Phoenix Public Library offers access to books, movies, music CDs and more. Public Health Smoking Cessation Program The goal of Tobacco Free Arizona is to use local and statewide resources, groundbreaking methods, and model national best practices to create a tobacco free future for Arizonans! Raising Special Kids Raising Special Kids is a non-profit organization of families helping families of children with disabilities and special health needs in Arizona. All programs and services are provided to families free of charge. At all ages and stages of a child's development, Raising Special Kids supports parents through a variety of methods. Salvation Army SARRC Established in 1997, the Southwest Autism Research & Resource Center s (SARRC) mission is to advance research and provide a lifetime of support for individuals with autism and their families. SIRRI AZ SIRRI, a Sensory Integration Learning Center, is dedicated to help build a stronger neurological and developmental foundation for children and adults by providing the most innovative and advanced multisensory programs and therapies available. South Phoenix Healthy Start The South Phoenix Healthy Start project provides perinatal case management services, health education events and learning opportunities and community referrals to women and their families in the South Phoenix area. Additionally, they work with the Maryvale community in West Phoenix as an outreach project of our program. SouthWest Center for HIV/AIDS The Southwest Center for HIV/AIDS is a research and resource center based in Phoenix, Arizona, USA. The Southwest Center for HIV/AIDS is the largest clinical trial, education, Page 28

34 behavioral health and nutrition support center dedicated to fighting HIV and AIDS in the Southwestern United States. Teen Outreach Pregnancy Services (TOPS) TOPS provides teen specific pregnancy, childbirth and parenting educational support so the teen and her family can experience a positive outcome. Valley Christian Center WIC Breastfeeding Support The Department operates programs in behavioral health, disease prevention and control, health promotion, community public health, environmental health, maternal and child health, emergency preparedness and regulation of childcare and assisted living centers, nursing homes, hospitals, other health care providers and emergency services. Letters of support The following letters of support have been uploaded for your review as Attachment 10 Other Information. Arizona for Community Health Centers John C. McDonald Rn, MS, CPHQ, Chief Executive Officer Adelante Health Care Avein Saaty-Tafoya Chief Executive Officer Page 29

35 EVALUATIVE MEASURES Clinical Performance Measures Diabetes: The proportion of diabetic patients with an HbA1c less than 7% increased by 5% (from 40% to 45%) since the previous clinical performance evaluation (4/2012-3/2013). Whereas, the proportion of diabetic patients with an HbA1c greater than 9% increased by 1.6% (from 22.86% to 24.52%) for the same time frame. Expanded diabetes education is now available at all Family Health Clinics and is available to patients at no charge, under the Patient Care Medical Home Program. Additionally, the organization has implemented DM decision support tools in the provider workflow to support the delivery of needed services. This process also includes RN care coordinators to conduct pre-visit planning, monitor gaps in care, and perform outreach for high risk patients. At one clinic a pharmacist has been included in the diabetic care team and has been very instrumental in lowering the HGA1Cs under her care. Also another issue that has impacted the score is the fact that the State of Arizona expanded the Medicaid program to include childless low income adults in January Many of the new patients had not had any preventative care or treatment for several years prior. Cardiovascular Disease: The clinics improved this measure by 2.2% since the previous clinical performance evaluation (4/2012-3/2013). The organization continues to utilize the best practice alerts in the electronic medical record for blood pressures greater than 140/90. Another issue that has impacted the score is the fact that the State of Arizona expanded the Medicaid program to include childless low income adults in January Many of the new patients had not had any preventative care or treatment for several years prior. Cancer-PAP Test: Compliance has slightly increased (from 65.7% to 67.14%). An issue that has impacted the score is the fact that the State of Arizona expanded the Medicaid program to include childless low income adults in January Many of the new patients had not had any preventative care or treatment for several years prior. The organization will continue to optimize enhancements and update the existing Epic report to appropriately capture data related to tracking the volume of Pap test completed. Clinics successfully implemented processes utilizing the American Congress of Obstetricians and Gynecologist guidelines as to when a PAP test is indicated. Prenatal Health-Prenatal Care in 1 st trimester: There was a decrease in the percentage of women that started prenatal care in the first trimester by 8.59% (54.29% to 45.7%) since the last annual evaluation. Although designed to meet the needs of the local refugee community the Refugee Clinic has also attracted women from out of the country. The low cost prenatal package plan was promoted by an outside company to women living in many of the African countries. Many of these women who have been living out of the United States wait until the last trimester to travel to our program for prenatal care. In this time period we had 709 refugee women, many did not bring medical records from their country of origin to validate start of prenatal care. Discussions are being held regarding the low cost prenatal package and its cost to non-maricopa County residents. One measure that we have taken is to improve the data collection. In the past, the date of the first prenatal visit was not in an unique field. In the Spring of 2014 we updated our electronic medical record to provide the practitioners with an unique field to easily capture this information. This will assist with reporting the data. In addition the information from the chart audit will be shared with the practitioners and staff. Perinatal Health- Underweight: There was a 2.7% improvement in the percentage of births under 2500 grams from 9.66% last year s clinical performance evaluation- to 6.9% for the present evaluation. Several specialty clinics have been added to target specific populations (an example is the Internatal Clinic that works with patients at high risk for obstetrical issues to space their pregnancies and improve their overall health prior Page 30

36 to conception. Additionally case management has been added to several of the clinics with high obstetrical populations. Child Health: The performance with this measure improved by 27.14% from the previous evaluative period 4/2012-3/2013. The Pediatric Care Coordination Team successfully deployed telephone follow-ups for children with immunization delays utilizing the EHR data. Additionally, clinic staff promoted the concept of updating vaccines during patient visits. Behavioral Health: In an effort to improve the overall care of the seriously mentally ill (SMI), MIHS committed to putting a total of eight (8) primary care clinics within existing behavioral health agencies. Historically in the state of Arizona the SMI population died 25 years earlier than the general population. This plan was to promote whole health in an environment that the SMI patients were already receiving care (behavioral health). We succeeded in opening 2 in the evaluative period (4/2012 2/2013) that brought it to a total of 6. Two other clinics had a delay in opening (July 2014) until providers and staff could be hired. There are now 8 primary medical care clinics sharing space with the behavioral health community organizations serving the seriously mentally ill (SMI) population. Oral Health: In this evaluation period there was a significant increase from 71.41% to % (an increase of 27.75%). This was due in part to increase focus on pediatrics, with a task force that implemented increase referrals from the medical providers to the dental clinics. Medical providers and staff were encouraged to walk patients to dental clinic with a warm handoff to encourage care. Weight Assessment and Counseling for Children and Adolescents: Clinics showed a 52.86% increase in compliance from the last evaluative period. We have also implemented a childhood obesity program that provides additional education on Monday evenings to parents and children and have adopted standardized templates to document EPSDT visits. Plan to review the audit findings and assist providers with utilizing templates whenever possible. Additionally the clinics attempt to convert an acute visit to an EPSDT visit whenever possible which includes not only weight assessment but also counseling on diet, exercise and other preventative education. Adult weight screening and Follow-up: The clinics increased compliance with this measure by 42.4% since the previous evaluative period (4/2012-3/2013). The organization is reviewing the workflow for this clinical measure, and based on the findings will provide education to providers and staff. Tobacco Use Assessment: As a result of the electronic health record -this query is part of every patient assessment. For this reasons we have sustained compliance above 95% for the past two annual clinical performance evaluations (4/2011-3/2013). Feedback will be provided to staff and providers on this measure and importance of capturing the information from 100% of the patients being provided care. Tobacco Use Cessation: We have increased compliance with this measure by 30% from the previous annual audit. Credit is due to the providers continuing referrals to the ASHLINE (Arizona Smokers Help Line) and their provision of tobacco cessation modalities. Also, MIHS and the clinics are now tobacco free campuses. Asthma-Pharmacological Therapy: A multidisciplinary task force of clinicians worked with Patient Centered Medical Home directors to expand the registry and provide targeted outreach. This was a contributing factor that allowed us to improve compliance from 82.86% to 100% for this clinical performance measure. Providers will continue to follow national guidelines and monitor clinically important conditions to sustain the process improvement gains in this area. Page 31

37 Coronary Artery Disease-Lipid Therapy: Compliance has improved 2.8% (from 91.43% to 94.29%) since the last evaluative period (4/2012-3/2013). Providers will continue to follow national guidelines with use of EHR and decision support tools to sustain the process improvement gains in this area. Ischemic Vascular Disease (IVD) Aspirin Therapy: Compliance declined by 14.28% since the last evaluative period(4/2012-3/2013). An issue that has impacted the score is the fact that the State of Arizona expanded the Medicaid program to include childless low income adults in January Many of the new patients had not had any preventative care or treatment for several years prior. Moving forward- the organization will implement Epic Decision Support and provider education to improve compliance for this clinical measure. Colorectal Cancer Screening: We decreased our compliance on this measure by 5.71% since the previous clinical performance evaluation (4/2012-3/2013. An issue that has impacted the score is the fact that the State of Arizona expanded the Medicaid program to include childless low income adults in January Many of the new patients had not had any preventative care or treatment for several years prior. Health maintenance alerts will be added to the workflow; in addition to provider education to improve compliance for this measure. Evaluative Measures Financial Performance Measures Costs (Total Cost per Patient): The total cost per visit has increased 1% compared to prior year and is 2% under the established target. Costs (Medical Cost per Patient): The medical cost per visit has increased by 0.43% from prior year and is 1% under the established target. Financial Viability (Change in Net Assets to Expense Ratio): The change in net assets to expense ratio has decreased from 2.3% to 2.2% compared to prior year, the established target being 2.4%. Financial Viability (Working Capital to Monthly Expense Ratio): The change in working capital to monthly expense ratio decreased by 31% compared to prior year and is 33% under the established target. Financial Viability (Long Term Debt to Equity Ratio): The long term debt to equity ratio has decreased from 8% to 6%, the established target being 7%. Page 32

38 RESOURCES / CAPABILITIES 1. Organizational Structure Attachment 4 Organizational chart Attachment 3 Referral Arrangements Description of Management Structure: The Council on Accreditation (COA) allows the MIHS FQHC-LAs to be operated in accordance with the terms and conditions of FQHC-LAs provisions under the Health Center Program requirements. Through the COA, the MHCGC shall act as a governing board for the MIHS FQHC LAs that have received FCHC Look-Alike status. Through the MHCGC bylaws, the Governing Council approves the selection and dismissal of the Executive Director and has direct administrative responsibility for the operation of the MIHS FQHC-LAs. The administrative responsibility for the FQHC-LA Clinics is assigned to a Director of Operations West; Avondale FHC, El Mirage FHC, Glendale FHC, Maryvale FHC, 7 th Avenue WIC, 7 th Avenue FHC and Sunnyslope FHC. The Director of Operations East is responsible for the management oversight for the Chandler FHC, Guadalupe FHC, Mesa FHC, South Central FHC and is responsible for the management oversight for the eight Whole Health Home Clinics. The Director of Operations CHC is responsible for the management oversight for the FQHC clinics within the CHC (Internal Medicine, Women s Care Clinic, Same Day Clinic, Med Subspecialty, and the FQHC Dental Clinics. The Executive Director of the Governing Council also serves as the Vice President of Ambulatory Services and the, Executive Director of Nursing is responsible for implementation of clinical operation plans into efficient, quality services at various ambulatory and physician service sites. 2. Management Team Attachment 5 Position Descriptions for Key Management Staff Attachment 6 Resumes for Key Management Staff as needed The COA allows the MIHS-LAs to be operated in accordance with the terms and conditions of FQHC Lookalike provisions under the Health Center Program requirements. Through the COA, the MHCGC shall act as governing board for the MIHS FQHC-LAs that have received FQHC Look-alike status. Through MHCGC bylaws, the Governing Council approves the selection and dismissal of the Executive Director having direct administrative responsibility for the operation of the MIHS FQHC-LAs. The MIHS FQHC-LA administrative team includes an Administrative Director of Primary Care Services (FHCs), Administrative Director of Specialty Services (CHC), Executive Director of Nursing, Director of Registration and Eligibility Services, and Director of Dentistry. Clinic Managers are directly responsible to one of these Directors. Key Management Title CEO Chief Executive Officer Position Description Attachment 5 In close collaboration with the Maricopa County Special Health Care District Board of Directors, the President and Chief Executive Officer provides overall executive leadership for all aspects of Maricopa Integrated Health System (MIHS); participates with the board in setting strategic direction and represents MIHS in the community. The President and CEO has ultimate responsibility for the operations of the Health System and works closely with MIHS and Medical Staff to enable the provision of high quality care in a compassionate, fiscally responsible manner and in compliance with regulatory agencies and accrediting bodies. The President and CEO continuously monitors service delivery systems, ensuring fulfillment of the System s mission, vision and values. Page 33

39 Key Management Title CMO Chief Medical Officer CFO Chief Financial Officer CIO Chief Information Officer COO Chief Operation Officer Position Description Attachment 5 Reporting to the Chief Executive Officer, this position is accountable for the general management of a diverse group of departments providing support services that contribute to the quality of cost effective patient care. The incumbent works closely with the Chief Operating Officer of MIHS, in order to facilitate the achievement of the Mission, Vision and Values of MIHS. The Chief Medical Officer is the key liaison between Administration and the Medical Staff. The incumbent provides medical expertise and perspective to the development and implementation of system objectives. The Chief Financial Officer reports to the Chief Executive Officer of the Maricopa Integrated Health System with dotted line responsibilities to the Vice President of Health Plans. The purpose of this position is to direct the integrated health system's financial resources. Reporting to the Chief Financial Officer, the Chief Information Officer will provide executive level strategic and tactical direction to the Maricopa Integrated Health System in the area of infrastructure and systems architecture, development and deployment of clinical and business applications, and the conceptualization, planning, evaluation and deployment of technology platforms. The Chief Information Officer (CIO) provides technology vision and leadership for developing and implementing technology initiatives that improve cost effectiveness, health care service quality, and business development in a constantly changing, competitive marketplace. Under the direction of the CEO and Hospital Board of Directors, this position develops, directs and assures the effective operation of Maricopa Integrated Health System including its primary, specialty, behavioral, and acute inpatient components. Page 34

40 3. Recruitment Plan SCOPE OF SERVICE The Human Resources Department is responsible for the recruitment of adequate numbers of personnel to ensure the delivery of quality care to the patients of Maricopa Medical Center, CHC and FHC s. Additional responsibilities involve maintenance of accurate and complete Human Resource records to meet accreditation standards, and state and federal laws. IDENTIFY IMPORTANT SERVICE/CARE DELIVERY PROCESS Important processes include but are not limited to: PRIORITIZE SERVICE/CARE DELIVERY PROCESSES Recruitment: Timeframe for Filling Vacant Positions High Risk HR File Maintenance and Accountability HR File Maintenance Competency Measurement High Voluntary Turnover Competitive Salaries: Aligned to Local Market Salaries Not Aligned to Market Performance Appraisal Tracking and Reporting Recruitment for Market Sensitive Hard To Fill Jobs Voluntary Employee Turnover Problem Prone HR File Maintenance and Accountability IDENTIFY OVERALL IMPROVEMENT OBJECTIVES FOR Timely Performance Appraisals and Competencies THE YEAR HR File Maintenance and Accountability Voluntary Turnover Timely Performance Appraisals and Competencies High Volume Salary Alignment HR File Maintenance and Accountability Competitive Salaries District Medical Group (DMG) Provider Recruitment and Retention: DMG is a large multi-specialty group who partner with Maricopa Integrated Health Systems (MIHS) to ensure quality health care services are available for the underserved population. DMG Providers work within MIHS owned facilities which are located in geographic areas which qualify for federal designation as Health Professional Shortage Areas. As with most underserved facilities a large percentage of patients are uninsured and/or in a sliding fee scale program which limits reimbursement. This in turn, leads to lower compensation for the providers, increasing the difficulty of recruitment. MIHS outpatient facilities have been approved for eligibility for NHSC Loan Repayment Programs. DMG/MIHS has encouraged our providers to apply for and participate in the Loan Repayment Program and a number of them have been approved. This designation and financial assistance has proven to be a key component in the recruitment and retention of DMG providers within the Primary Care Specialties. 4. Electronic Health Records (EHR) Technology: Clinics have expanded patient/provider communication capabilities through the use of technology. , text and the MyChart patient portal allow patients to access a portion of their patient information via the web to request appointments at some of the clinics, seek medication refills, and to communicate with health care team. Additional clinical, financial and decision support systems are utilized and include: EPIC, STAR, and Trendstar. All patient care and patient accounts are within the system-wide Electronic Medical Record (EMR). EPIC is a certified EHR technology for meaningful use. EPIC interfaces with the financial system, McKesson STAR, and the cost accounting system, Trendstar, to provide accounts payable, general ledger, payroll/human resources, and Materials Management. These four functional modules plus the EPIC Patient Accounting revenues, claims, cash account and collections interface with Trendstar, and Dentrix for dental records make up the Decision Support application utilized by MIHS. Page 35

41 5. Financial Management Capabilities 5(a) The MIHS Finance Department provides reporting and analysis support for MIHS financial systems and processes account payments chargeable to MIHS. The department also prepares monthly and annual financial reports to assist the MIHS District Board, FQHC-LA Governing Council, FQHC-LA Finance Committee, and MIHS mangers to make effective service delivery and fiscally sound operating decisions. The Chief Financial Officer (CFO) directs and oversees the MIHS Finance Department. 5(b) Clinical, Financial and Decision Support systems (Epic,STAR and Trendstar) MIHS implemented Epic Systems, Inc., Version 2010 with a completed roll-out in March All patient care and patient accounts are within the system-wide Electronic Medical Record (EMR). Epic is a certified Executive Health Resource (EHR) technology. Epic contains the clinical and revenue pieces to the patient s medical chart and associated patient account for claims, payments and collections. This provides physicians and management insight towards the clinical and revenue reporting within their service lines, patient populations and quality indicators. Epic interfaces with the financial system, McKesson STAR and the cost accounting system, TRENDSTAR to provide complete financial decision support. General Account modules consist of Accounts Payable, General Ledger, Payroll/Human Resources, and Materials Management 6. Collections and Reimbursement: Finance team members and clinical managers meet regularly to monitor and review budgets and financial statements. MIHS prepares the annual budgets utilizing Business Objects Planning. TRENDSTAR calculates the scenarios for cost, volume and expected reimbursement scenarios to executives to assist in the development of meaningful budgets to budget appropriately. Budgets are prepared annually and approved by the MHCGC and MIHS district board for both operating expenses and capital acquisitions. MIHS performs monthly operations reports to review clinic performance to the current month, year to date, prepared budget, and prior year. MIHS monitors capital acquisition and implementation on a monthly basis through a designated capital committee. This provides vertical visibility of the organizations performance and adherence to the annual plans. MIHS Administrative Policy & Procedure: Finance/Revenue Cycle/Business Office: Copa Care Self Pay Discount Policy for Uninsured/Underinsured Purpose: Copa Care exists to establish consistent policy and procedures to assist Maricopa Integrated Health System patients who are uninsured, underinsured, ineligible for any state or federal healthcare program, and who lack the financial resources necessary to meet their financial responsibility for services offered or provided by MIHS. Copa Care is a sliding fee schedule program whereby MIHS determines a patient s financial responsibility for services offered or provided to them according to a self- pay discounted payment rate based upon federal poverty guidelines and current Arizona Health Care Cost Containment System (AHCCCS) rates. Copa Care is not an insurance policy, not a charity program, nor a health benefit program, but it is a program whereby eligible MIHS patients are able to pay for services at a discounted rate based upon income guidelines. Page 36

42 7. Corrective Actions: Policy G Board Policy Finance: An internal auditor will be employed or contracted to perform various audits of internal controls throughout the year. The internal auditor will report through the Chief Compliance Officer to the President & Chief Executive Officer. If the internal auditor has a question which relates directly to the Chief Compliance Officer, he/she is authorized to report directly to the President & Chief Executive Officer. If the internal auditor has a question which relates directly to the President & Chief Executive Officer, he/she is authorized to report directly to the Chief Compliance Officer, who will report to the Board. If the internal auditor has a question which relates to both the President & Chief Executive Officer and the Chief Compliance Officer, he/she is authorized to report directly to the Board of Directors through the Chairman of the Board. A formal audit plan shall be prepared annually and presented to the Board for approval. The audit plan shall identify high risk areas that need to be addressed first and then work down to areas of lesser risk. Formal reporting on internal audit activities shall be made to the Board no less than quarterly. The audit plan shall include input from the Chief Financial Officer and President & Chief Executive Officer on areas of concern. Any member of Management may request internal audit to review activities or areas that may be of concern. Also, the internal auditor shall work with the compliance officer to identify areas that need to be reviewed that may impact the organization on compliance issues. Policy G Board Policy Finance Annual Audit: The Board of Directors will engage external auditors to conduct an annual audit of the District s financial statements in accordance with auditing standards generally accepted in the United States and the standards applicable to financial audits contained in Government Auditing Standards, used by the Comptroller General of the United States. Such audit will be planned and performed to obtain reasonable assurance that the financial statements are free of material misstatement. The external auditors should review at a minimum, existing internal controls and compliance with legal and regulatory requirements in order to issue an opinion on whether the financial statements present fairly, in all material respects, the financial position of the District and its changes in financial position and cash flows in conformity with accounting principles generally accepted in the United States. Also, the external auditors will present the Board with a management letter identifying any material weaknesses discovered during the audit process. This letter will be deemed to be proprietary and such that its disclosure may cause demonstrable and material harm to the District and would place the District at a competitive disadvantage in the marketplace. This letter, therefore, is deemed not subject to public disclosure pursuant to A.R.S (M). The independent external auditors will report to the Board. It is the Board s responsibility to hold management accountable for taking corrective action related to issues identified in the management letter and to address other issues noted by the external auditors. The Board shall require a written response from management identifying what steps will be taken to correct the issues noted, and timely follow-up should be done by management to ensure that all items have been addressed appropriately. 8. Emergency Preparedness: Emergency Preparedness and management plan Participation in State and Local Emergency Planners: In 2014, the FHCs and several of the clinics within the CHC continued to participate in the Hospital Preparedness Program Grant. Grant Year 2014 ended 6/30/14 and all deliverables were met. Employees from the FHCs continued to participate in FEMA Training (Standardized Authorized Page 37

43 Awareness Training and Hospital Emergency Response Training [HERT]), along with Incident Command Systems training. This staff contributed 10 new HERT members in the grant year and had many of the existing team members take the expanded HERT 200 and HERT 300 classes. One of the members has qualified to become a FEMA Indirect Instructor for the HERT program and will attend the training in November The FHCs participated in the MIHS Mass Casualty Reception full-scale exercise in May 2014 and provided representation at the Regional Healthcare Coalition (AzCHER-Central) meetings to share plans and identified hazards/risks. Moving into Fiscal Year 2015 (7/1/14 to 6/30/15), grant funding has not been awarded directly to support preparedness activities. MIHS FHCs have access to some preparedness support from the AZ Alliance for Community Health Centers by means of education. MIHS continues to support training and exercises through the operational budget to ensure system-wide preparedness. Focus for preparedness has shifted to Pro Bowl/Super Bowl Event planning for January 2015, Ebola Virus Disease planning, training, and exercising, and IT Systems Failure planning, training, and exercises. The Ambulatory Services Disaster Subcommittee has been formed within the MIHS Emergency Management Committee and continues to tailor the Emergency Operation Plan Incident Response Annexes to meet individual FHC needs. Representatives from each FHC will have input in revision of these plans and further identification of training and exercise needs. MIHS continues to represent the FHCs at the Regional Coalition Meetings and share the plans with County Public Health, County Emergency Management, and State Public Health as changes occur. GOVERNANCE 1. Board Authority: A Copy of the Health Center s signed and dated Bylaws are provided in Attachment 2 for your review. Page 38

44 2. Board Composition: 3 Board Operations: The Maricopa Health Centers Governing Council is the independent governing board for the Maricopa Integrated Health System FQHC clinics and is responsible for oversight of those centers. (a) Meeting monthly. The Governing Council meets monthly on the first Wednesday of each month. These meetings are attended either in person or telephonically by a majority of Council Members. In addition to the regular council meeting, there is an Executive Committee and Finance Committee that meets monthly as well. (b) Maintaining a 51 percent consumer/patient majority, as applicable. The Governing Council makes a concerted effort to recruit user/members from the community served by its FQHC clinics. Currently the Council is made up of twelve voting members of which seven (58.33%) either personally use FQHC facilities or have dependent family members who use those services. All current user/members or dependent family have been treated by an FQHC provider within the last two years (c) Exercising required oversight responsibilities and authorities (e.g., selecting, evaluating, and dismissing the CEO/Executive Director; establishing hours of operation; approving annual budget; conducting board self-assessment). The Governing Council approves any changes in hours, services or capital investments in the FQHC clinics, sets budgets and provides further oversight for the clinic operations This year, the Maricopa Integrated Health System will be adding a new FQHC clinic which was approved after a rigorous examination of financial, service, location and other factors. The Governing Council takes its role as a good steward of public funds Page 39