We help organizations achieve their goals for clinical care, team development, and community impact.

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Solution Spotlight:

The Community Health Center Value Model

In today’s environment, clinical organizations are expected to deliver excellent care, engage with their communities, and demonstrate value to patients, payers, funders, and policy makers.  We help clinical organizations meet these challenges through effective strategy and practice. We can deliver support to a single organization, or to groups of organizations through collaborative initiatives of associations, foundations, and federal grant initiatives.  Learn more below.

Quality has always been important in health care, but QI takes on new meaning in an environment of population health management.   Today’s payers are highly focused on quality, outcomes, and cost measures as they relate to their sponsored populations.  Evidence of this trend can be seen in the expanding array of pay-for-performance models and reporting requirements for patient-centered medical home recognition and other types of credentialing programs.   The challenge for health care organizations is to develop a quality management program that has authentic clinical value to the organization while also meeting the requirements of external funders and oversight agencies.  We can help you:

  • Define strategic objectives for clinical quality.
  • Design an efficient portfolio of quality measures.
  • Develop organizational capacity for quality improvement and quality measurement.
  • Optimize quality management including data development, analytics, reporting, review, and action.
Chronic care management is designed to optimize the care of patients who have or are at significant risk for chronic conditions.  The prevalence of chronic conditions has been increasing due to the aging of the population and rising levels of lifestyle-related risk factors.   Projecting these trends forward, the growing burden of disease and costs could be crippling.  Consequently, chronic care improvement is a high priority for population health management.  Community Health Solutions can help you:

  • Define objectives for chronic care improvement based on assessment of current capabilities;
  • Design strategies for building chronic care capabilities;
  • Build organizational capacity for implementing chronic care improvement; and
  • Execute for improved quality and outcomes.
The patient-centered medical home (PCMH) is a model of care that is intended to optimize the patient experience within and beyond the primary care setting.  Community Health Solutions has substantial experience and an extensive toolkit for helping primary care practices build capacity for  PCMH.  For practices seeking to achieve or sustain NCQA Patient-Centered Medical Home (PCMH) Recognition, we have specially trained staff and a detailed toolkit designed to streamline the capacity building process.   We also support practices that aim to develop specific aspects of the PCMH model without necessarily seeking formal recognition.  We are especially adept at helping safety net providers navigate their way through PCMH development.  We help primary care practices:

  • Define objectives for PCMH development based on assessment of current capabilities;
  • Design strategies for building PCMH capabilities;
  • Build organizational capacity for implementing the PCMH model; and
  • Execute through the process of applying for PCMH recognition.
Integrated primary care models provide systematic coordination of primary care and other services such as behavioral health care and oral health care.  A growing body of research shows that integrating primary care with other services can produce positive outcomes for people with multiple healthcare needs.  Integrated care models can be designed in a variety of ways depending on population health needs and the capacity of local health care organizations.  Community Health Solutions can help you:

  • Define objectives for integrated care;
  • Design an integrated care model that meets defined needs;
  • Build organizational capacity for integrated care; and
  • Execute for improved quality and outcomes.
Care transitions occur when a patient moves from one health care provider or setting to another, or from a health care provider to home.  Effective care transitions are important for optimizing patient health and for avoiding unnecessary utilization of hospital services and related services.  Community Health Solutions works at the community level to support the development of community-based care transition models. We can help you:

  • Define objectives for optimizing care transition for specific groups of at-risk patients;
  • Design care transition models that meet defined needs utilizing evidence-based practices and community partnerships;
  • Build organizational capacity for implementing care transitions; and
  • Execute for improved quality and outcomes.
Population health management requires new capabilities for improving health and health care for defined populations.  Community Health Solutions has identified seven core capabilities that are essential for organizations across the spectrum of clinical care, public health, and community services.  By building these capabilities now, you can help assure that your organization or community is positioned to engage in population health management.  We can help you:

  • Identify patient populations for health management
  • Assess patient health risks
  • Define care needs
  • Optimize care models
  • Collaborate for impact
  • Assure quality
  • Demonstrate value.

For clinical programs and organizations, the key to sustainability is to define and communicate value in ways that matter to key stakeholders. By applying a systematic Community Value Analysis, a program or organization can define its value for key partners and funders, and use the results to drive improvement and make the case for funding.  CHS offers training and technical assistance to help organizations conduct Community Value Analysis using a five-step process:

  • Define Your Audience
  • Understand Audience Expectations
  • Define Your Value Story
  • Define and Produce Your Key Value Indicators
  • Produce and Deliver Your Value Reporting Products

CHS has been a pioneer in the application of collaborative strategies to support clinical improvement for health organizations.  Much of this work has been sponsored by associations and foundations.  As a ‘backbone’ support organization, we can:

  1. Assist with overall strategic design of the collaborative project
  2. Design and facilitate collaborative meetings
  3. Design program-specific learning objectives, content, and instructional plans
  4. Design and manage online support resources for collaborative members
  5. Provide or facilitate a wide range of training and technical assistance supports for collaborative members
  6. Help foster peer learning and problem solving among collaborative members
  7. Help design and facilitate program evaluation activities.
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