Managing diverse populations of patients, especially those who are non-English speakers, is more challenging than ever before. Now, intelligent, multilingual “chatbots” embedded in the electronic medical record are a new solution for efficiency, cost-effectiveness, and patient management. Using these innovations for conversational two-way patient communications, community health clinics can achieve new levels of compliance and better health outcomes., while lowering the burden on staff.

This session will discuss how Open Door Health Services embraced Lean methodologies to drive efficiencies within their organization. By using a variety of tools, Open Door Health Services tackled projects including patient scheduling/access, medical assistant workflows, and implementation of a chronic care management (CCM) program. These initiatives have led to significantly increased access, decreased patient cycle time, and improved patient engagement related to chronic diseases.

Enabling services, defined as non-clinical services that aim to increase access to health care and improve health outcomes, are a hallmark of community health centers, connecting vulnerable patients to supports that enhance their ability to become active partners in their own health care. Patients with chronic conditions may require enabling services such as care coordination, language assistance services, transportation, and/or other supports to help them fully adhere to their clinical treatment plans. Community health centers effectively address patients’ social determinants of health (SDH) barriers and can benefit from a standardized protocol to systematically document those interventions. The ability to track and evaluate these services is essential in order for health centers to demonstrate their value in meeting and addressing patient social risks. The Association of Asian Pacific Community Health Organizations (AAPCHO) offers an enabling services data collection (ESDC) tool and best practices for community health centers.

Health centers care for a medically and socially complex patient population. While there are many examples of this complexity, as centers go into value-based pay, they are being asked to prove/measure this complexity. This session will evaluate risk adjustment in value-based pay. The session will review current risk adjustments system in place, such as the Ohio CPC program, that rely on diagnosis and service information. We will discuss the importance of risk-adjustment in total cost of care or risk contracts. We will also evaluate what other risk adjustment data is currently available, including the NACHC PRAPARE tool.

The National Consortium of Telehealth Resource Centers work to support providers in starting or growing telemedicine programs. Our regional center in California (CTRC) developed a concrete and accessible Telehealth Implementation Roadmap. It was designed to help individuals identify the critical steps and their logical order of completion towards successful program implementation. This panel will identify and discuss in detail the critical steps every program should consider when planning for a telehealth program. A successful telehealth program integrates leadership and ensures adequate capacity across all four sectors: 1) Telehealth Operations 2) Technology 3) Clinical Services 4) Business and Sustainability. The panelists will also address some often-overlooked challenges, including structured relationships, contracting models, and policy and reimbursement. Panelists will share their unique perspective as it relates to each portion of the Roadmap.