Partnerships with federally-qualified health centers help Michigan’s prevention efforts reach underserved young adult populations.
About the Collaboration
When Michigan’s Department of Community Health received a Partnerships for Success (PFS) II grant in 2012 to address health disparities among the state’s most at-risk populations, it understood immediately that this was not something it could accomplish alone.
The goal of Michigan’s PFS grant was to foster change in underserved communities by addressing underage drinking and prescription drug misuse among young adults. To be successful, prevention practitioners would need to involve partners who were already working with, and providing services to, these young people; partners who could help them connect with the populations they most needed to reach.
So the Department turned to the state’s network of federally qualified health centers (FQHCs). For an entity to be certified as an FQHC, it has to document that it provides services to an underserved area or population (among other requirements). According to Larry Scott, Manager of the Department’s Substance Abuse Prevention and Treatment Section, collaboration with the network was a common sense decision. “Since FQHCs serve communities with significant health disparities, their goals are in sync with the needs of the PFS II grant,” Scott says.
To facilitate collaboration, Michigan built into its funding model a requirement that sub-recipients partner with primary care providers, including FQHCs. Specifically, counties and tribes applying for PFS funding were expected to develop formal relationships with providers in order to better integrate substance use screening and education into FQHC primary care services. As part of the collaboration, the partnering providers were expected to identify high-risk individuals using an approved screening tool, and then refer these individuals and families to selected evidence-based education and prevention programs. By the end of 2012, twelve communities, including 10 counties, one tribe, and the City of Detroit, received PFS II funding to engage in these collaborations.
Elements of Success
Never Underestimate the Importance of Relationship-Building
Funded communities spent much of the first grant year creating or expanding their prevention coalitions to lead the work of the PFS II grants. Making sure that primary care was represented on those coalitions was a key activity. “For all the communities, one of the first steps was building those relationships [with their local providers] and establishing that trust,” says Brenda Stoneburner, Michigan’s PFS II Project Coordinator. She credits much of the coalitions’ networking success to individual-level relationship building. Instead of coalition leaders “cold calling” potential primary care partners, they focused on using personal connections to make the initial outreach. She recommends, “If you [as a group or an organization] don’t have that personal relationship to start with, find someone who does.”
Get to Know Your Partners’ Culture
Because healthcare professionals operate in a unique environment, coalition members spent considerable time early in their grants learning about the culture of healthcare and the needs of primary care providers—particularly those operating in FQHCs—and developing prevention approaches that were appropriate for this unique setting.
For example, clinicians across the board said that they cared about preventing substance use, but that they lacked the time to address the issue during clinical appointments. Acknowledging these time constraints, coalitions explored a variety of creative solutions. Some involved ancillary practitioners, such as nurses, to implement selected prevention approaches. Others trained volunteers to administer the substance use screening tools. Still others had patients complete electronic screening questionnaires, via computer tablets, while they waited for their appointments. These strategies reduced the time burden on physicians, and ultimately contributed to program adoption.
Coalitions also worked hard to develop billing protocols that would allow FQHC providers to be appropriately reimbursed for the time they spent delivering substance use screening and referral services. In the short-term, communities solved this problem by utilizing Substance Abuse Prevention Block Grant funds to support reimbursement. To identify a more sustainable, long-term solution, the state is working with its new healthcare partners. “We are building a relationship with the Michigan Academy of Pediatrics, which is bringing the coding/billing issue to the forefront," Scott says. "This is helping to aid our conversations with our Medicaid office and allowing dialogue [about higher reimbursement] to progress.”
Don’t Assume You’re All Speaking the Same Language
Consistent with learning about culture, partners also began thinking carefully about the language they used with one another. Words and phrases common to prevention practitioners were sometimes foreign to healthcare providers—and vice versa. Other words and phrases were open to various interpretations. For example, practitioners and providers initially assigned very different meanings to the term “screening”—a core element of the collaboration. For the prevention community, screening is a fairly benign procedure that involves asking a few questions. For the medical community, it’s often a more invasive procedure—such as collecting bloodwork to screen for a disease. After discovering this misunderstanding, one coalition acknowledged the importance of not making assumptions about language, and began checking in regularly about word choices and clarifying their meanings. This thoughtful approach to language helped to reduce misunderstandings among partners, patients, and their families.
Involve Partners in Decision Making
Coalitions worked diligently to involve their respective healthcare partners in the design and development of the interventions each would be implementing. For example, provider input informed the development of five criteria used to select appropriate screening tools; the tools needed to be brief, evidence-based, credible with experts (e.g., the American Academy of Pediatrics), warrant provider reimbursement, and be appropriate for screening adolescents (or readily tailored to be so). Based on these criteria, the state recommended that providers use the CRAFFT screening interview and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) three-question screen.
Healthcare providers also contributed extensive feedback on the format of these tools. Preferences varied considerably: some clinicians preferred pocket reference cards; others preferred to have the screening questions pre-loaded into electronic visit notes, so the questions would pop up during patient visits. By presenting formats that were familiar and acceptable, coalitions were able to increase buy-in, promote ease of use, and reduce the clinicians’ anxiety about delivery (especially among those for whom substance use prevention was a new area of practice).
Keep Agreements Simple
Under their PFS II grants, funded communities were required to develop formal agreements with their partner FQHCs. For some coalitions, creating this agreement was a challenge—either because multiple entities within the health center needed to be involved in the agreement, or because the “formal” agreement was replacing what used to be a simple handshake of understanding between community members.
Coalitions quickly learned that “the simpler the agreements, the better,” says Stoneburner. Ultimately, the most successful agreements tended to be the most straightforward, limited to describing what each party expects to transpire. For example, “As a primary care organization, you will screen everyone coming in and use one of these two tools. And as a coalition, we will support your efforts and encourage communities to receive the services that you are providing.” The state currently provides a basic template and list of planning considerations that coalitions and FQHCs can modify to meet local needs.
Think Outside the Box
Not every funded community reported smooth outreach efforts to the primary care providers in their regions. Stoneburner encouraged communities to think creatively about such challenges. “If you keep running into road blocks, what are some other avenues you can go down? How can we still get to the same outcome?”
Thinking “outside of the box” led one community to invite pharmacy professionals to join their coalition. The pharmacists welcomed the opportunity to participate. Soon after joining, one local pharmacy school introduced training on the delivery of brief substance use screenings and interventions into its curriculum. Several other pharmacies spearheaded “take back” programs (i.e., collection sites for unused medications).
The community’s work came full circle when pharmacy professionals used their personal connections to bring primary care providers onto the local coalition.
Understanding what is and is not working in this collaborative effort is a priority at both the state and community levels. To this end, the state is engaged in a comprehensive evaluation, looking at both simple outputs such as numbers of screenings and referrals, as well as complex issues such as how effectively primary care providers are integrated into the prevention efforts. To achieve this, each coalition tracks the number of healthcare representatives on its team and evaluates their level of involvement (regular, sporadic, or “in name” only).
“Lessons learned” are also collected in narrative form during county-level site visits from state and evaluation staff, then shared more broadly across the state. For example, one county worked with its partner FQHC to integrate selected screening tools into its electronic medical records (EMRs), then modified the EMR to identify and flag patient risk based on responses to screening questions. In August 2015, the state convened a meeting for all of its funded communities to share experiences like these, and facilitate cross-site support and mentoring.
With several counties reporting positive outcomes, including expanded screening sites and lasting partnerships with primary care providers, Michigan’s Department of Health and Human Services’ Office of Recovery Oriented Systems of Care was recently awarded a PFS 2015-2020 grant that will build on the state’s foundational collaborative work. The expanded PFS project funds eight high need and underserved communities and incorporates key success elements identified during the first funding cycle.