CMJ3 - Care Model Transformation: Positioning a Federally Qualified Health Center to Achieve the Quintuple Aim

Session Description: Access Community Health Network (ACCESS) is a federally qualified health center providing primary and behavioral health care to nearly 165,000 low-income residents of the Chicago metropolitan region across 34 sites. Operating in a primarily fee-for-service environment has limited the full implementation of the PCMH model due to challenges with financial sustainability. With the growth of value-based care, ACCESS identified the opportunity to create its own PCMH model that is focused on improving health equity, clinical outcomes, and patient satisfaction while reducing cost and ensuring our staff experience joy in their work—the quintuple aim. This session will focus on the care model transformation work that ACCESS has undertaken over the past 18 months. Specifically, 1) The learnings from an in-depth assessment using the literature, NACHC Elevate resources, and patient and staff feedback were used to develop a customized ACCESS care model with the following pillars: Direct Care, Coordination of Care, Patient Self-Management, Patient Access, Care Team Approach, Whole Person Approach, and Performance Improvement; 2) The layers of maturity assessment that the ACCESS Model of Care team conducted to identify priority transformation initiatives to be implemented in 2024 and 2025; 3) Implementation planning for initial priority areas, including establishing a performance framework, refining foundational factors including empanelment, risk stratification and non-clinical factors of health screening, and re-configuring the care team; 4) The implications of care model transformation on organizational governance and operational structures; and 5) The new shared language that is needed to support organizational change management for care model transformation.