Back to Brainstorming PCCP
Link to refined objectives PCCP

Original "Brainstorming" Session including Ideas to Close the From-To GAP for: Enhance FQHC Effectiveness in the Gulf Region

FROM (Current State)

TO (Desired State)

1. Many communities don't know FQHCs exist or how to best work with them in their community.
1. FQHCs and Communities work together effectively as a team to address community health issues.
Ideas to close this From-To Gap:
  • one
  • two
2. FQHCs don't have established relationships with other healthcare and social services providers
2. FQHCs have written, formal agreements and partnerships with with health care system and social service providers
Ideas to close this From-To Gap:
  • Establish referral relationships, understand who is being referred to and why, and coordinate Health Information.
  • This can be a key part of an ER Diversion program (and this is further along in the Florida ER diversion program)
  • Idea
  • Idea
3. Many FQHCs are not PCMH recognized (Patient-Centered Medical Home)
3. All FQHCs are PCMH recognized
Ideas to close this From-To Gap:
  • Do a deeper dive of PCMH status of all the FQHCs.
  • Idea
  • Idea
  • Idea
4. Most FQHCs do not have integrated Primary Care Behavioral Health PCBH
4. All FQHCs have PCBH
Ideas to close this From-To Gap:
  • Link in with the other GRHOP program
  • Link to NOCHF, SAMHSA, etc.
  • Work to understand best practices and emerging standards for integrating PC & BH
  • Idea
5. Most FQHCs do not have bi-directional Specialty Referral and Consultation
5. All FQHCs have bi-directional Specialty Referral and Consultation
Ideas to close this From-To Gap:
  • Idea
  • Idea
  • Idea
  • Idea
6. FQHCs work independently and miss major opportunities to learn from each other and coordinate their efforts
6. Efficient mechanisms exist for FQHCs to learn from each others, team up to improve, and coordinate their efforts.
Ideas to close this From-To Gap:
  • PCCP Regional Care Collaborative
  • Leverage the HRSA-funded Health Care Coordination Network (HCCN)
  • Leverage the NOCHF Regional Care Collaborative
  • Leverage work from others and share what we develop to maximize value. Divide and conquer, share to get further faster.
7. FQHCs focus almost exclusively on clincial issues
7. FQHCs work as part of a team to help individuals and families address both the clinical and non-clinical issues including prevention.
Ideas to close this From-To Gap:
  • Use community health workers to link FQHC patients with non-clinical services
  • Integrate with healthy community coalitions
  • Community Outreach
  • Community Care Coordination tools for diverse types of social services, etc. Resource database, 211, etc.
  • Asset Mapping
8. Adoption of EHR technology by FQHC is inconsistent and uneven.
8. All FQHCs have high-functioning EHR systems
Ideas to close this From-To Gap:
  • Help Clinics to achieve Level 2 Meaningful Use to get incentive funding.
  • Do deeper dives and assesments of every clinics EHRs and technology
  • Idea
9. Telemedicine is non-existent or underutilized by FQHCs and Communities for Specialty Care and Behavioural Health and Occupational Health.
9. Telemedicine is effectively leveraged to efficiently meet specialty care and behavioral health and Occupational Health issues wherever practical
Ideas to close this From-To Gap:
  • Do an assessment of existing capacity of provider networks, technical/space capacity of clinics, states, etc.
  • We're developing a Quad State tele-health workgroup of experts in each state.
  • Learn what people already know about the state of Telehealth and what is going on, plans, etc.
  • Idea
10. No links to HIEs
10. Links to HIEs are as good as is practical
Ideas to close this From-To Gap:

  • There are 2 HIEs in LA (Greater New Orleans is further along than the State HIE)
  • Do an assessment of the state of HIE deployment in each state to clarify plans.
  • Idea
  • Idea