Table A18c: Patients Screened for Clinical Depression .................................................................. A-23
Table A19: Hypertension/Stroke Related Measures ........................................................................ A-24
Table A19: Diabetes Patients A-26
Table A20: BMI Screenings A-27
Table A21: Asthma Patients A-28
Message from the PCA CEO
On behalf of the Primary Care Association, it is my privilege to share this HCCN Strategic Plan Report for the 2022–2025 grant period. This report reflects not only the collective accomplishments of our Health Center Controlled Network (HCCN), but also the strength of the partnership between PCA and HCCN staff and the member health centers we serve.
Over the past three years, we have renewed and strengthened our relationship with our health center partners. Together, we have demonstrated what is possible when collaboration, innovation, and shared purpose guide our work. This renewed commitment has allowed us to align resources, support clinical and operational excellence, and advance our mission to ensure accessible, quality care for communities across our state.
A highlight of this period was our successful HCCN site visit, which affirmed the impact of our work and validated the systems, processes, and partnerships we have built. This achievement is a testament to the dedication of our staff and member health centers, and it underscores our ability to work collectively toward common goals.
Most notably, we are proud to report 100% completion of all project work plan activities over the 2022–2025 grant cycle. This rare achievement reflects the perseverance, accountability, and excellence of our network. Each milestone accomplished represents better support for our health centers, stronger infrastructure for data-driven care, and ultimately, improved health outcomes for the patients and communities we serve.
A special thank you to Dr. Marico Bryant Howe, CHCA Chief Quality and Informatics Officer, for her perseverance in leading the HCCN activities. Her leadership, vision, and tireless dedication were instrumental in ensuring a successful site visit and in driving the completion of all activities we set out to achieve. On behalf of the PCA, I extend heartfelt congratulations to Dr. Howe for this outstanding accomplishment and her ongoing commitment to our member health centers.
As we look ahead, the PCA remains committed to deepening our partnership with health centers, building on the successes of this grant cycle, and continuing to strengthen the foundation for high-performing, sustainable primary care. Together, we will face future challenges with resilience and pursue opportunities with a shared vision for healthier communities.
With appreciation, Dr. Lanita S. White
Chief Executive Officer
Community Health Centers of Arkansas, Inc.
Message from the Arkansas HCCN Project Manager
Since assuming my role as Chief Quality and Informatics Officer at CHCA, we have renewed and strengthened our commitment to enhance the operational and clinical capabilities of health centers participating in the AHCCN. This commitment has been demonstrated in the programming that we offer through our specialized trainings and technical assistance (T/TA), which includes group purchasing power, shared trainings, and data analytics that support quality measures and improvement. AHCCN supports workgroups, the Quality and Informatics Network, and a digital platform, onBoard, which is a secure portal that allows real-time collaboration and the ability to share resources.
From 2022-2025, the AHCCN worked diligently to complete 100% of the project work plan activities as articulated on an annual basis. Health centers staff completed an annual needs assessment survey and we utilized feedback as input to future project work plan activities and T/TA. Annually, we meet with health center staff to setup each participating health center project work plan with activities that are specific, measurable, attainable, and relevant In doing so we help ensure that health center defined project work plan activities align with the HRSA HCCN goals. These activities could not have been accomplished without the hard work and dedication of the Clinical Quality Analyst, Laida Egbosimba, and the invaluable input and collaboration with the Chief Operating Officer, Mia Stark. Additionally, special thanks to the Data Analyst, Dr. Margaret Calhoun for the analyzing the HRSA UDS data in Appendix A.
Over the past three grant cycles (2022-25), the Arkansas Health Center Controlled Network (AHCCN) has worked diligently to support the participating health centers (PHCs) by leveraging health Information Technology (IT) and data to enhance the delivery of affordable, accessible, and high-quality primary care. The initiative focused on optimizing data management and analytics, improving system interoperability, and facilitating the submission of Uniform Data System Patient-Level (UDS+) data. Through these efforts, AHCCN successfully completed 100% of its Project Work Plan activities across all eight required HRSA objectives and two optional objectives.
The AHCCN has been instrumental in leading Arkansas in the adoption and use of health information technology (HIT) in the PHCs. The AHCCN has proven to be critical to continuing the progress among the PHCs in meeting the Quintuple Aim, which include: improving patient experience, improving population health, reducing healthcare costs, improving the well-being of care teams, and advancing health equity. Technology plays a critical role in today’s healthcare ecosystem, with the overall goal of improving patient outcomes. There have been extensive digital developments seen in primary care with the rapid and significant changes prompted by the COVID-19 crisis over the last few years. The AHCCN has worked to help the PHCs improve technology within their respective organizations to deliver affordable, accessible, and high-quality care.
Community Health Centers (CHCs) utilize secure online patient portals and related applications to provide patients with access to their health information and enable twoway communication with providers. The AHCCN has delivered specialized training and
technical assistance on patient portal implementation, configuration, system optimization, and best practices to bridge the digital divide for patients with limited technology skills. The adoption of remote, virtual, and/or telehealth visits between providers and patients became prevalent in 2020 because of the COVID-19 pandemic within most Arkansas PHCs. The opportunities are endless with growing technologies using artificial intelligence, wearable devices, remote patient monitoring equipment, and speech recognition technology - all of which can have tremendous impacts on improving patient outcomes, reducing provider burden, increasing access for patients, and reducing overall healthcare costs. The AHCCN has played a pivotal role in supporting PHCs through training and technical assistance, ensuring that they keep pace with rapid digital transformation in healthcare.
In summary, AHCCN has strategically leveraged health information technology (HIT) and data to strengthen PHCs’ ability to deliver high-quality, comprehensive primary care. These efforts have prioritized improvements in clinical quality, patient-centered care, and provider and staff well-being. To achieve these objectives, AHCCN implemented a multifaceted approach that includes developing shared resources, conducting advanced data analytics to drive quality improvement, and promoting health information exchange and interoperability. By fostering collaboration and standardization across PHCs, AHCCN ensures that PHCs can effectively utilize technology to enhance care delivery, streamline operations, and support sustainable improvements in patient outcomes.
Sincerely,
Dr. Marico Bryant Howe Chief Quality and Informatics Officer Community Health Centers of Arkansas, Inc.
INTRODUCTION
Community Health Centers of Arkansas (CHCA) is a non-profit organization established in 1985 to expand access to affordable quality care in Arkansas, and to create a unified voice for Community Health Centers (CHCs) and the patients they serve. For forty years, CHCA has received funding to provide training/technical assistance to CHCs for improving care delivery.
CHCA is the Primary Care Association (PCA) for Arkansas. PCAs are designated by the federal Health Resources Services Administration (HRSA) to assist CHCs in each state.
CHCA bylaws reflect that it is governed by a Board of Directors, comprised of the Chief Executive Officer from each member CHC. CHCA’s mission is to advocate for and facilitate the success of CHCs and promote access to healthcare in Arkansas. Our vision is to be the trusted partner for our member organizations and a respected leader and advocate for healthcare access in Arkansas. CHCA serves 12 CHC organizations and their 200+ service locations across Arkansas.
The services offered by CHCA help Arkansas CHCs provide effective and efficient care to their patients, furthering their goals of improving access to care and health outcomes. CHCA has over the years successfully served as a conduit for new programs, projects and funding that supports greater access to comprehensive services for underserved populations throughout Arkansas.
CHCA collaborates with local, state and federal partners, organizations and policy makers to positively influence changes to policies, regulations, and legislation aimed at strengthening CHCs' ability to provide affordable, accessible, comprehensive, quality healthcare services to all regardless of ability to pay.
BACKGROUND
Since 2009, CHCA has served as the conduit to support HCs in improving HIT infrastructure through a Health Center Controlled Network (HCCN) grant. In 2012, CHCA established the Arkansas Health Center Controlled Network (AHCCN), operating as a dba of CHCA. Since that time, the HCCN has collaborated with various federal, state, and National Training and Technical Assistance Program (NTTAPs) to support the work of participating health centers in HIT, data security, data analytics, and healthcare delivery transformation. The HCCN has been instrumental in leading Arkansas in the adoption and use of health information technology (HIT) in the state’s HCs. HCs are one of the largest healthcare providers in the state of Arkansas and provide patientcentered, high-quality care through integrating HIT tools to empower their work and contribute to their overall success. HCs are using HIT to enhance the patient and provider experience, advance interoperability, and support value-based care transformation. The HCCN is critical to continuing the progress among the Arkansas HCs in meeting the quintuple aim.
In response to a transition in leadership at CHCA in October 2021, the HCCN held a 2day strategic planning workshop on September 30, 2021, and October 1, 2021. Participating Health Centers (PHCs) developed a unified and well-aligned strategic plan to guide the HCCN in executing its updated mission. The new mission is to align and support member health center organizations in the strategic use and optimization of HIT, systems, and data to provide a patient-centered, evidence-based environment of care focused on improving clinical, operational, and financial outcomes. The mission was adopted at the December 2021 Boad Meeting.
The AHCCN offers specialized training and technical assistance (T/TA) to take advantage of economies of scale, including group purchasing power; shared training; and data analytics to support quality measurement and improvement.
The AHCCN fully embraces new strategies for managing information to improve patient care. The AHCCN Strategic Plan for January 2022 – January 2025 written by Jennifer Calohan, former Principal at CURIS Consulting served the organization and its stakeholders well.
HRSA Focus Areas
The Fiscal Year (FY) 2022 Health Resources and Services Administration (HRSA) Health Center Controlled Network (HCCN) goals to support Participating Health Centers (PHCs) in leveraging health information technology (IT) and data to deliver high-quality, culturally competent, equitable, and comprehensive primary health care, with a specific focus on improvements in:
• Clinical quality
• Patient-centered care
• Provider and staff well-being
As noted in the HRSA-22-009 funding opportunity, HIT had become essential in enabling the delivery of high-quality, culturally competent, equitable, and comprehensive primary health care. This increased the need for health centers to expand their use of digital health tools. HCCNs are charged with helping health centers access and efficiently use digital health tools such as Electronic Health Records (EHRs), telehealth, patient portals, and electronic registries, along with virtual care platforms that support their integration. HCCNs also support health centers with translating robust clinical and population data into quality improvement and culturally competent, patient-centered care using, in part, data collected through digital health tools. This data can be used to help health centers’ improve clinical quality, while more effectively advancing health equity.
Overarching Goals:
• Leverage Health IT and Data:
Support health centers in using health information technology and data to deliver high-quality, culturally competent, equitable, and comprehensive primary care.
• Improve Key Areas:
Focus on clinical quality improvement, patient -centered care, and provider/staff well-being within participating health centers.
Table 1, shown below lists the eight required and two optional HCCN objective and provides the description of each.
Patient Engagement
Increase the percentage of PHCs that support patients and families’ participation in their health care through expanded use of integrated digital health tools (e.g., electronic messages sent through patient portals to providers, telehealth visits, remote monitoring devices).
Patient Privacy and Cybersecurity
Increase the percentage of PHCs with formally defined health information and technology policies and practices that advance security to protect individual privacy and organizational access.
Social Risk Factor Intervention
Increase the percentage of PHCs that use patient level data on social risk factors to support patient care plans for coordinated, effective interventions.
Disaggregated, patient-level data
Increase the percentage of PHCs with systems and staff aligned with submitting disaggregated, patient-level data via UDS+.
Interoperable Data Exchange and Integration
Increase the percentage of PHCs with the capacity to integrate clinical information with data from clinical and nonclinical sources across the health care continuum (e.g., hospitals, specialty providers, departments of health, health information exchanges (HIE), care coordinators, social service/housing organizations) to optimize care coordination and workflows.
Data Utilization
Increase the percentage of PHCs that use data strategies, such as use of predictive analytics with data visualization, to support performance improvement and valuebased care activities.
Leveraging Digital Health Tools
Increase the percentage of PHCs that support providers and staff in achieving and maintaining proficiency in the use of digital health tools (e.g., telehealth and remote patient monitoring tools).
Health IT Usability and Adoption
Increase the percentage of PHCs that improve health IT usability and adoption by providers, staff, and patients (e.g., align EHRs with clinical workflows, improve structured data capture in and/or outside of EHRs, use of metadata to improve EHR user experience).
Health Equity (Applicant Choice)
Develop one objective and associated outcome measure that will focus on utilizing a health IT innovation (e.g., digital patient engagement tools, remote patient monitoring, emergency preparedness, artificial intelligence) to improve the health status of their PHCs’ communities by reducing health disparities and/or addressing social determinants of health.
Improving Digital Health Tools (Applicant Choice)
Develop one objective and associated outcome measure that will enhance the quality and coordination of health services by focusing on improving the functionality of digital health tools (e.g., EHRs, virtual care platforms, patient portals, analytic systems) in one or more of the following areas: (1) support relationships between providers and staff with patients, their families, and the community; (2) support highfunctioning care teams; (3) integrate care delivery across systems and communities; (4) reduce workload; and (5) make care more equitable.
Table 1: HRSA HCCN 2022-2025 Objective and Descriptions
Arkansas HCCN Workgroups
The Arkansas Health Center Controlled Network (HCCN) workgroups are designed to strengthen health centers by addressing critical areas of patient care, provider support, and data management. Collectively, these groups ensure that health centers are equipped with the tools, strategies, and guidance needed to deliver high-quality, efficient, and secure care. By focusing on patient engagement, provider workflow, and information security, the workgroups provide a comprehensive framework for improving both clinical outcomes and organizational performance.
The Patient Data & Engagement Workgroup plays a critical role in supporting health centers by enhancing their capacity to collect, analyze, and utilize patient information. This workgroup emphasizes the use of innovative tools and strategies to foster stronger patient engagement, improve communication, and ensure that care delivery is responsive to the needs of diverse patient populations. By focusing on both data collection and patient interaction, the group directly contributes to more patient-centered care and improved health outcomes.
The Provider Burden & Workflow Workgroup is dedicated to addressing challenges associated with provider workload and operational efficiency. This workgroup promotes the integration of care teams and the implementation of streamlined workflows to alleviate provider fatigue and maximize staff effectiveness. Through its initiatives, the workgroup enables health centers to achieve greater efficiency, reduce administrative and clinical burdens, and strengthen the quality and continuity of care.
The Data & Information / Data Security & Integration Workgroup ensures that health centers are well positioned to meet increasing data and reporting requirements while maintaining the highest standards of information security. This workgroup provides technical guidance and shared strategies for reporting across multiple programs, including UDS, PCMH, MIPS, BCBS, and Aledade. In addition, the group focuses on safeguarding health information by promoting the use of secure systems and tools that meet and exceed regulatory standards.
Over the past year, the workgroups have addressed a wide range of critical topics, including necessary workflow enhancements, the expanding digital health and telehealth landscape, formal assessments of patient safety culture, health promotion campaign strategies, and the application of Arkansas State Health Alliance for Records Exchange (SHARE) Health Information Exchange (HIE) to improve access to patient records. Furthermore, the groups have facilitated discussions on communication best practices, such as the use of presumptive versus participatory language in immunization recommendations, ensuring that health centers are equipped with both technical and practical resources to advance care delivery. Together, these workgroups provide Arkansas PHCs with the knowledge, tools, and collaborative support necessary to address evolving challenges in patient care, provider efficiency, and data security. By fostering shared learning and coordinated action, the workgroups not only enhance
individual health center performance but also contribute to the overall advancement of health outcomes across the state.
DEFINING OUR CULTURE: MISSION, VISION, AND VALUES
The culture of CHCA reflects the shared values, beliefs, and behavioral norms that define who we are as an organization. At its core, our culture is centered on a deep commitment to community, collaboration, and accountability. These principles are not only written statements but are evident in the way our team works with one another, with our member health centers, and with the communities we serve. By fostering an environment built on respect and trust, we create space for innovation, meaningful partnerships, and lasting impact.
In September 2023, CHCA reintroduced its mission, vision, core values, and brand promise to ensure they more accurately reflect the evolving needs of our organization and the health centers and communities we support. This intentional work has strengthened alignment across staff, partners, and stakeholders, bringing clarity and purpose to our shared efforts. The redefined elements have reinforced a sense of belonging, encouraged excellence in service, and fostered a more inclusive and collaborative environment. These updates have also strengthened the way we interact externally, ensuring that our partners and communities see us as reliable, missiondriven, and forward-looking.
Together, CHCA’s mission, vision, and values serve as the foundation for our strategies and guide the behaviors that shape our culture. They provide direction as we pursue initiatives that improve access to care, support health center sustainability, and drive quality outcomes. Just as importantly, they remind us that our work is rooted in serviceto patients, families, and communities across Arkansas. By holding true to these guiding principles, CHCA is well-positioned to embrace future challenges with resilience and to cultivate positive outcomes that advance health for all and strengthen primary care in Arkansas for years to come.
CHCA Mission, Vision, Core Values & Brand Promise
• Mission
To equip, unify, and advocate for an innovative network that provides exceptional healthcare to all
• Vision
To be the trusted partner for our member organizations and a respected leader and advocate for healthcare in Arkansas.
• Core Values
o Act with Integrity
o Demonstrate Leadership
o Commit to Excellence
o Be Accountable for Results
o Drive Innovation
o Execute with Focus
• Brand Promise
Access. Action. Advocacy.
WHAT INTERNAL AND EXTERNAL FACTORS IMPACT OUR WORK?
A comprehensive Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was conducted to identify actionable strategies. The SWOT analysis provided an opportunity for the PHCs provided value added input for the AHCCN during annual strategic planning session. During these sessions, a diverse team from the PHCs gathered to prioritize a list that would help inform decision making for the AHCCN’s ongoing achievement of goals.
Strengths
• Innovative Approaches: Embracing new methodologies, such as AI tools and digital health technologies, which enhance clinical and operational efficiencies.
• Collaborative Group Effort: Strong culture of collaboration across health centers, committees, and partner organizations, enabling the sharing of best practices.
• Strong Leadership: Effective, visionary leadership both within the HCCN and across member health centers ensures strategic alignment and operational success.
• Desire to Provide Meaningful Resources: Commitment to delivering tools and services that genuinely impact health center operations and patient outcomes.
• Commitment to Health Center Data: A dedicated focus on improving data accuracy, integrity, and utility to support value-based care (VBC) and performance improvement.
• PCA Collaboration: Productive partnerships with Primary Care Associations enhance outreach, advocacy, and statewide support.
• Learning and Knowledge in VBC: Ongoing education and experience in VBC models create a foundation for successful adoption and performance.
• Varied Experiences and Perspectives: A wide range of expertise across centers, enhancing creativity and problem-solving.
• Resourceful and Resilient: Ability to adapt to changing landscapes and overcome challenges with innovative solutions.
• Connecting People to Social Resources: Effective identification and linkage of patients to social services, addressing social determinants of health (SDOH).
• Strategic Planning Skills: Proven ability to set goals and execute on strategy in a rapidly evolving healthcare environment.
• Statewide Representation: Inclusive and diverse voices across geographic and demographic lines improve equity and policy relevance.
• Supportive CHCA & HCCN Staff: Strong infrastructure of support ensures centers have access to timely guidance and technical assistance.
• Revitalization and Optimization of HCCN: Continuous improvement efforts ensure network efficiency and relevance.
• Training and Education: Regular workforce development initiatives improve technical capabilities and job satisfaction.
• Strong Network Security: Early adoption of cybersecurity practices protects data and builds trust.
• Commitment to Data Sharing: Strong ethos around interoperability and information transparency to improve patient care.
• Technology Utilization: Use of advanced tools (AI, web bi-directionality, digital health) to optimize care delivery and reporting.
• Validated Reporting: Emphasis on ensuring UDS+ and other reports are accurate and standardized.
• Board and Staff Commitment: High level of buy-in from governance and operational leadership supports strategic continuity.
Weaknesses
• Funding Constraints: Limited or inconsistent funding affects the ability to plan long-term or scale innovation.
• Competing Priorities: Health centers may face difficulty aligning HCCN initiatives with day-to-day operational needs.
• Data Validation Challenges: Issues around inconsistent, incomplete, or inaccurate data limit the effectiveness of analytics.
• Staff Turnover: High turnover impacts institutional memory and continuity of HCCN initiatives.
• Lack of Centralized Resources: Decentralized support systems lead to duplication and inefficiencies.
• Variability in EHR Platforms: Differences in systems hinder interoperability and data standardization.
• Lack of Buy-In and Trust: Some health centers remain hesitant to fully engage with HCCN efforts due to concerns about value, data sharing, or clarity of goals.
• Unclear Definitions and Mapping: Undefined terms and inconsistent mappings complicate analysis and benchmarking.
• Technology Challenges: Difficulty integrating digital tools with current workflows and infrastructure.
• Staffing for Data Roles: A shortage of skilled analysts and specialists limits progress on complex data initiatives.
• Cybersecurity Posture: Reactive rather than proactive stance in some cases, exposing centers to evolving threats.
• AI Concerns: Questions around accuracy, bias, and transparency in AI tools like Sunoh impede trust and adoption.
• VBC Participation Gaps: Lack of standardization across payors complicates participation and limits shared outcomes.
• Data Silos: Persistent issues with data fragmentation and lack of access reduce the ability to deliver coordinated care.
• Time and Capacity Limitations: Staff are stretched thin, affecting implementation of HCCN initiatives.
Opportunities
• Enhanced Communication Across Committees: More streamlined knowledge sharing can accelerate innovation and avoid duplication.
• AI Implementation and Education: Embracing AI across functions clinical, administrative, financial—offers efficiency gains if implemented thoughtfully.
• Broader Health Center Engagement: Involving frontline staff improves adoption, innovation, and relevance of tools.
• Digital Health Literacy: Focused education initiatives can empower both staff and patients to effectively use technology.
• VBC Optimization: Collaborating to negotiate better contracts, align workflows, and track performance will improve outcomes and revenue.
• Data Sharing and Transparency: Increasing openness across organizations allows for benchmarking, collective improvement, and advocacy.
• External Partnerships: Strategic collaboration with academic institutions, tech vendors, and government entities can drive growth and innovation.
• Group Purchasing: Leveraging collective bargaining power to lower the cost of digital tools, services, and training.
• Innovation in Patient Engagement: Tools that promote shared decisionmaking, remote monitoring, and patient self-management can improve care and outcomes.
• Grant Funding: Opportunities to pursue funding for pilots, capacity-building, and infrastructure.
• Data Cleanup with UDS+: More accurate and actionable information through enhanced data processing.
• Unified Voice for Advocacy: Creating one clear message at the state and national level improves influence and resource access.
• Workforce Development: Continued investment in training will build a futureready workforce.
• Revitalization of HCCN Network: Opportunity to refresh brand, strategy, and tools in alignment with 21st-century healthcare needs.
Threats
• Political and Regulatory Pressure: Changing policies or funding models can undermine HCCN sustainability.
• Staffing Shortages: National and regional shortages in healthcare and IT talent threaten capacity to deliver services.
• Cost Pressures: Rising costs for technology, training, and compliance burden already strained budgets.
• AI Reliability and Security: Concerns around bias, accuracy, legal implications, and patient safety slow adoption.
• Cybersecurity Risks: Persistent and evolving threats require constant investment and vigilance.
• Technology Disparities: Larger health systems with more resources may outpace HCCNs in innovation and infrastructure.
• Data Interoperability Issues: Lack of standards across platforms hinders data integration and reporting.
• ROI Concerns: Without clear value, centers may withdraw participation, reducing collective impact.
• Health Center Readiness: Varying levels of readiness to adopt digital health tools can delay or derail implementation.
• Legal and Ethical Barriers with AI: Legal frameworks lag behind technological innovation, posing liability risks.
• HRSA Reporting Burden: Administrative burden from complex requirements can divert focus from clinical care.
• Patient Engagement Barriers: Digital divide and literacy issues can prevent full utilization of digital health tools.
• Data Integrity and Misinterpretation: Risks associated with inaccurate or inconsistent reporting damage trust and decision-making capacity.
SWOT Analysis Findings
AHCCN performed a new SWOT analysis on an annual basis, which allowed us to adapt strategic planning to internal and external modifications. Regular re-evaluation helped the AHCCN to adjust to newly identified challenges and proactively monitor for changes. The SWOT analysis helped AHCCN to make decisions based on current data rather than assumption to have a positive impact on the AHCCN’s strategy. Below are the top themes from the assessment. Additionally, Table 2 shows details from the SWOT analysis comparison over the past 3 years.
Strengths
✅ Strong Network Collaboration: Growth in partnerships and teamwork.
✅ Improved Healthcare Access: Affordable care expansion through GQHCs.
✅ Increased Patient Satisfaction: Providers are delivering high-quality care.
Weaknesses
❌ Workforce Shortages: Need to address recruitment and retention strategies.
❌ Interoperability Challenges: Need for better integration between platforms.
❌ Data Management Gaps: Improving the transition from i2i to Azara.
Opportunities
⭐ Leveraging New Partnerships: Expanding connections with vendors, UAMS, and GPOs.
⭐ Enhancing Data-Driven Decision Making: Expanding analytics to drive strategy.
⚠ Funding Uncertainty: HRSA funding at risk; need to explore new sources.
⚠ Security Vulnerabilities: Cybersecurity risks with increased data sharing.
SWOT Analysis Comparison
SWOT Analysis Finding
Innovative Approaches: Embracing new methodologies, such as AI tools and digital health technologies, which enhance clinical and operational eCiciencies.
Collaborative Group ECort: Strong culture of collaboration across health centers, committees, and partner organizations, enabling the sharing of best practices.
Strong Leadership: ECective, visionary leadership both within the HCCN and across member health centers ensures strategic alignment and operational success.
Desire to Provide Meaningful Resources: Commitment to delivering tools and services that genuinely impact health center operations and patient outcomes.
Commitment to Health Center
Data: A dedicated focus on improving data accuracy, integrity, and utility to support value-based care (VBC) and performance improvement.
PCA Collaboration: Productive partnerships with Primary Care Associations enhance outreach, advocacy, and statewide support.
Learning and Knowledge in VBC: Ongoing education and experience in VBC models create a foundation for successful adoption and performance.
Varied Experiences and Perspectives: A wide range of expertise across centers, enhancing creativity and problem-solving.
Resourceful and Resilient: Ability to adapt to changing landscapes and overcome challenges with innovative solutions.
Connecting People to Social Resources: ECective identification and linkage of patients to social services, addressing social determinants of health (SDOH).
Strategic Planning Skills: Proven ability to set goals and execute on strategy in a rapidly evolving healthcare environment.
Statewide Representation: Inclusive and diverse voices across geographic and demographic lines improve equity and policy relevance.
Supportive CHCA & HCCN StaC: Strong infrastructure of support ensures centers have access to timely guidance and technical assistance.
Revitalization and Optimization of HCCN: Continuous improvement eCorts ensure network eCiciency and relevance.
Training and Education: Regular workforce development initiatives improve technical capabilities and job satisfaction.
Strong Network Security: Early adoption of cybersecurity practices protects data and builds trust.
Commitment to Data Sharing: Strong ethos around interoperability and information transparency to improve patient care.
Technology Utilization: Use of advanced tools (AI, web bidirectionality, digital health) to optimize care delivery and reporting.
Validated Reporting: Emphasis on ensuring UDS+ and other reports are accurate and standardized.
Board and StaC Commitment:
High level of buy-in from governance and operational leadership supports strategic continuity.
Funding Constraints: Limited or inconsistent funding aCects the ability to plan long-term or scale innovation.
Competing Priorities: Health centers may face diCiculty aligning HCCN initiatives with day-to - day operational needs.
Data Validation Challenges: Issues around inconsistent, incomplete, or inaccurate data limit the eCectiveness of analytics.
StaC Turnover: High turnover impacts institutional memory and continuity of HCCN initiatives.
Lack of Centralized Resources: Decentralized support systems lead to duplication and ineCiciencies.
Variability in EHR Platforms: DiCerences in systems hinder interoperability and data standardization.
Lack of Buy-In and Trust: Some health centers remain hesitant to fully engage with HCCN eCorts due to concerns about value, data sharing, or clarity of goals.
Unclear Definitions and Mapping: Undefined terms and inconsistent mappings complicate analysis and benchmarking.
Technology Challenges: DiCiculty integrating digital tools with current workflows and infrastructure.
explicitly listed
StaCing for Data Roles: A shortage of skilled analysts and specialists limits progress on complex data initiatives.
Cybersecurity Posture: Reactive rather than proactive stance in some cases, exposing centers to evolving threats. Not explicitly listed
AI Concerns: Questions around accuracy, bias, and transparency in AI tools like Sunoh impede trust and adoption. Not explicitly listed
VBC Participation Gaps: Lack of standardization across payors complicates participation and limits shared outcomes.
Data Silos: Persistent issues with data fragmentation and lack of access reduce the ability to deliver coordinated care.
Time and Capacity Limitations: StaC are stretched thin, aCecting implementation of HCCN initiatives.
Enhanced Communication Across Committees: More streamlined knowledge sharing can accelerate innovation and avoid duplication.
AI Implementation and Education: Embracing AI across functions— clinical, administrative, financial oCers eCiciency gains if implemented thoughtfully.
Broader Health Center Engagement: Involving frontline staC improves adoption, innovation, and relevance of tools.
Digital Health Literacy: Focused education initiatives can empower both staC and patients to eCectively use technology.
VBC Optimization: Collaborating to negotiate better contracts, align
workflows, and track performance will improve outcomes and revenue.
Data Sharing and Transparency: Increasing openness across organizations allows for benchmarking, collective improvement, and advocacy.
External Partnerships: Strategic collaboration with academic institutions, tech vendors, and government entities can drive growth and innovation.
Group Purchasing: Leveraging collective bargaining power to lower the cost of digital tools, services, and training.
Innovation in Patient Engagement: Tools that promote shared decisionmaking, remote monitoring, and patient self-management can improve care and outcomes.
Grant Funding: Opportunities to pursue funding for pilots, capacitybuilding, and infrastructure.
Data Cleanup with UDS+: More accurate and actionable information through enhanced data processing.
Unified Voice for Advocacy: Creating one clear message at the state and national level improves influence and resource access.
Workforce Development: Continued investment in training will build a future-ready workforce.
Revitalization of HCCN Network: Opportunity to refresh brand, strategy, and tools in alignment with 21st- century healthcare needs.
Political and Regulatory Pressure: Changing policies or funding models can undermine HCCN sustainability.
StaCing Shortages: National and regional shortages in healthcare and IT talent threaten capacity to deliver services.
Cost Pressures: Rising costs for technology, training, and compliance burden already strained budgets.
AI Reliability and Security: Concerns around bias, accuracy, legal implications, and patient safety slow adoption.
Cybersecurity Risks: Persistent and evolving threats require constant investment and vigilance.
Technology Disparities: Larger health systems with more resources may outpace HCCNs in innovation and infrastructure.
Data Interoperability Issues: Lack of standards across platforms hinders data integration and reporting.
ROI Concerns: Without clear value, centers may withdraw participation, reducing collective impact.
Health Center Readiness: Varying levels of readiness to adopt digital health tools can delay or derail implementation.
Legal and Ethical Barriers with AI: Legal frameworks lag behind technological innovation, posing liability risks.
HRSA Reporting Burden: Administrative burden from complex requirements can divert focus from clinical care.
Patient Engagement Barriers: Digital divide and literacy issues can
prevent full utilization of digital health tools.
Data Integrity and Misinterpretation: Risks associated with inaccurate or inconsistent reporting damage trust and decision-making capacity.
Opportunity
Threat Worsen
Table 2: SWOT Analysis Comparison from 2022-2025
Appendix A
Below is data visualizing Arkansas FQHC aggregate UDS reporting requirements and metrics. Data used for these charts and graphs can be found here. The clarification regarding the measure or metric is based upon the 2024 UDS manual found here
Demographics
Total Patients
Total Patients
Table A1: Patient Demographic Data
Above is a graph of total patients seen at FQHCs in the state of Arkansas during the years of 2020 through 2024. There appears to be a slight jump in patients in the 2024 year, after a period of steady growth. This could be due to a targeted effort by health centers to increase patient population or the acquisition of new clinic sites.
Age of Patient Population Over Time
% Children (< 18 years)
% Adults (18 – 64 years)
% Older Adults (Ages 65 and over)
Table A2: Age Demographics
The above graph is a breakdown of age demographic populations (children, adults, and older adults) over time. There appears to be a slight decrease in the adult population and a corresponding slight increase in the older adult population with corresponds with the aging US population in combination with older adults living longer. (Citation:https://www.census.gov/library/stories/2023/05/2020-census-united-statesolder-population-grew.html)
Patients by Race & Ethnicity (% Known)
% Racial and/or Ethnic
Minority Patients
% Hispanic, Latino/a, or Spanish Origin Patients
% Non-Hispanic, Latino/a, or Spanish Origin White Patients
% Total Asian Patients
% Native Hawaiian/Other
Pacific Islander Patients
% Black or African American Patients
% American Indian/Alaska
Native Patients
% More than one race Patients
Table A3: Demographic Breakdown by Race and Ethnicity
The above graph is a demographic breakdown of known/disclosed patient race and ethnicity. The CHCA Data Analyst would like to note that certain demographics of people are missing in this data. For example, the percent Hispanic, Latino/a, or Spanish Origin Ethnicity Patients and percent Non-Hispanic, Latino/a, or Spanish Origin White Patients are represented, however the percent patients that identify as non-white but not of Hispanic, Latino/a, or Spanish Origin is not explicitly listed in this data even though it is reported by health centers. There seems to be a mixing of race and ethnicity data in this reporting even though they are separate categories in UDS.
%
Best Served in a Language other than English
Percent of Patient Population
Table
A4:
Patient Served by Language Other than English
The above graph shows the percentage of patients at health centers that are best served in a language other than English. The 2024 UDS definition of patients served in English are patients who are best served in language other than English, including sign language and includes patients who are best served in language other than English even in areas where language other than English is dominant language (Puerto Rico or Pacific Islands) There has been an approximate 2% increase in this patient population over the last 5 years.
Patient Poverty
% Patients at or Below 200% of Federal Poverty Guideline
% Patients at or Below 100% of Federal Poverty Guideline (included in above)
Table A5: Patient Poverty
The graph above is based upon the US Federal Government HHS Poverty Guidelines found here The reading of the metric and these guidelines leads to the percentages found in the chart above. In the guidelines for the 48 Contiguous States, higher incomes are reported the higher the percentage reads. This means that the metric “Patients at or below 200% of the Federal Poverty Guideline” would encapsulate half of the reported incomes available in the guidelines chart, thus leading to such a high number of patients being captured in the chart. The metric “Patient at or below 100% of the Federal Poverty Guideline” only account for 3 of the 24 available income bins in the guidelines, thus explaining the lesser number of patients captured in this metric.
Patient Insurance
Percent of Patient Population
% None/Uninsured Patients
% None/Uninsured Children (<18 years)
% Medicaid/CHIP Patients
% Medicare Patients
% Dually Eligible (Medicare and Medicaid)
% Other Third-Party Patients
Table A6: Patient Insurance Type
The above graph is a breakout of insurance type amongst the patient population over time. The number of uninsured patients has gone down over time however we expect that number to rise after the federal changes to Medicaid/Medicare.
Percent of Patient Population
Patient Housing Status
% Homeless Patients
% Total Migratory and Seasonal Agricultural Workers or Their Family Members
% Public Housing Patients
Table A7: Patient Housing
The above graph shows the trend of certain types of patient populations over time. Homeless and Migratory worker populations have been stable over time. The public housing population has steadily decreased with possible reasons for this decrease being these patients no longer being in public housing either shifting to non-public housing or homelessness. Given the steady state of the homeless patient population this indicates that either the population is moving to non-public housing or that the patient population is not seeking care.
% Veteran Patients
Percent of Patient Population
Table A8: Veteran Population
The above graph shows the percent of veterans that have been served by health centers over time. While the veteran population has decreased slightly, it is only a 0.25% decrease over a 5-year period.
Female Patient Population
Percent Female
A9: Female Patients
% Patients Under 15 Who are Female
% Patients 15-64 Who are Female
% Patients 65 and Over Who are Female
The above graph shows that a vast majority of health center female patients are of reproductive age, and this population has maintained stability over time.
Table
Services
% Medical Patients
% Dental Patients
% Mental Health Patients
% Substance Use Disorder Patients
% Vision Patients
% Enabling Services Patients
Table A10: Services Rendered
The above graph shows the distribution of services provided by Arkansas health centers from 2020 through 2024. Patients can receive multiple services. Medical services make up the majority of services provided by health centers.
$600,000,000
$550,000,000
$500,000,000
$450,000,000
$400,000,000
$350,000,000
$300,000,000
$250,000,000
$200,000,000
Table A11: Total Accrued Costs
The "Total Cost" line in the graph above represents the total accrued costs before donations for the year (Table 8A, Line 17). For more information on what goes into this line, please refer to the 2024 UDS Manual section on Table 8A, which begins on page 145.
Cost Per Patient in US Dollars
$1,600.00
$1,500.00
$1,400.00
$1,300.00
$1,200.00
$1,100.00
$1,000.00
$900.00
$800.00
Total Accrued Cost per Patient
Table A12: Total Accrued Cost Per Patient
The above graph shows total accrued cost per patient, which is defined in the 2024 UDS Manual as “Total accrued cost per patient line total medical, other clinical services (dental, mental health, etc.), enabling, other program-related, and quality improvement services, and total facility and non-clinical support services per patient population”. Cost has increased by almost $500 per patient in the last 5 years.
School-Based Service Site Patients
Percent of Patient Population
The above graph shows the percent of the patient population that is seen at SchoolBased Service sites. While the number of patients seen at these sites is still a small percentage of the overall patient population (less than 10%) there has been a steady increase in this patient population since 2020. 0.00% 1.00% 2.00% 3.00% 4.00%
Table A13: School-Based Service Sites
Clinical Data Measures
Cancer Screenings
Percent Screened
Cervical Cancer Screening
Breast Cancer Screening
Colorectal Cancer Screening
Table A14: Cancer Screenings
The above graph shows three types of cancer screenings at Arkansas health centers: cervical cancer screenings, breast cancer screenings and colorectal cancer screenings. All three screenings increased during 2020 through 2022 but fell during 2024 and 2024 (colorectal screening did recover slightly in 2024). The UDS definitions for these measures are as follows: “Colorectal Cancer Screening: percentage pf patients 45 through 75 years of age who had appropriate screening for colorectal cancer; Cervical Cancer Screening: Percentage of women 24-64 years of age who were screened for cervical cancer; Breast Cancer Screening: Percentage of women 52-74 years of age who had a mammogram to screen for breast cancer ”
Number of Patients
Maternal Health Measures - Numbers
Number of Prenatal Care Patients
Number of Prenatal Care Patients who Delivered
Number of Access to Prenatal Care (First Prenatal Visit in 1st Trimester)
Number of Newborns with Low Birth Weight
Table A15a: Maternal Health Patients by Number
Percentage of Patients or Newborns
Maternal Health Measures - Percentages
Early Entry into Prenatal Care (first visit in first trimester)
% Low and Very Low Birth Weight
Table A15b: Maternal Health Patients by Percentage
The above graphs are maternal health related measures, with their UDS 2024 definitions:
- Number of prenatal patients: Patients who received some portion of prenatal care at health center
- Prenatal patients who delivered: prenatal care patients who delivered during the year
- access to prenatal care (prenatal visit in 1st trimester): prenatal patients with visit in the 1st trimester
- low birth weight: percentage of babies of health center prenatal care patients born whose birth weight was below normal (less than 2500 grams)
Not all measures were reported by UDS with percentages and those measures were reported as patient numbers on a separate graph. Newborns with low birth weights remain consistent, while the number of prenatal care patients are increasing at health centers.
Percent Screened or Children Vaccinated
Childhood Related Metrics
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Childhood Immunization Status
A16: Childhood Metrics
Above are the two childhood related measures, Weight Assessment Counseling for Nutrition and Physical Activity for Children and Adolescents (UDS 2024 Definition: Percentage of patients 3-17 years of age with a BMI percentile AND counseling on nutrition AND physical activity documented) and Childhood Immunization Status (UDS 2024 Definition: Percentage of children 2 years of age who received age-appropriate vaccines by their 2nd birthday). While childhood BMI screening has increased amongst health centers, the number of children who received age-appropriate vaccines by 2 years of age has dropped dramatically in the last few years. This could possibly be attributed to the cultural shift around vaccines.
Table
Percent of Visits by diagnosis regardless of primacy
% Symptomatic/Asymptomatic Human Immunodeficiency Virus (HIV)
Table A17a: HIV Patients
Above shows the percent of HIV-related visits regardless of time since diagnosis (the 2024 UDS definition of this metric is “percent visits by diagnosis regardless of primacy”). This data shows a steady number of visits related to HIV at Arkansas FQHCs.
Percent Patients Connected to Care
% of Patients seen for follow-up within 30 days of first ever HIV diagnosis
Table A17b: HIV Connection-to-Care
The above graph shows the UDS measure “HIV Connection-to-Care” which is defined in the 2024 UDS as “the percentage of patients whose first-ever HIV diagnosis was made by health center personnel between Dec 1 of the prior year and Nov 30 of the measurement year period and who were seen for follow-up treatment within 30 days of that first ever diagnosis”. While half of patients are receiving care within a month of their HIV diagnosis, the overall percentage of patients being connected to care has declined by almost 30% in the last 5 years.
Number of Patients Screened
Number of Patients 15 through 65 years of age who were tested for HIV when within age range (HIV Screening)
Table A17c: HIV Screening
The above graph shows the number of patients between 15 through 65 years of age who were tested for HIV when within age range (UDS 2024 HIV Screening Definition). This is the HIV Screening measure, however it was not listed as a percentage in the data and so the number of patients is shown. There has been a steady increase in screening from 2020 through 2024.
Percent Screened
Screening for Depression and Follow-Up Plan
Table 18a: Depression Screening
The above graph shows the Depression Screening measure which is defined by the 2024 UDS as “the percentage of patients 12 years of age older who were (1) screened for depression with a standardized tool AND (2) if screening was positive (2) had a follow-up plan documented”. Arkansas FQHCs have consistently screened patients over the last 5 years, increasing their overall screens by 10%.
Number of Patients 12 years of age and older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event
Number of Patients
Table A18b: Depression Remission
Above shows the Depression Remission Measure, which is defined by the 2024 UDS as “the number of patients 12 years of age and older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.” This measure did not have a percentage, so the number is graphed. In comparison to number of people screened (the graph of patient number screened is shown below), there is a two order of magnitude difference between the number of people screened and the number of people who reached depression remission. This could be attributed to due to patients not reaching remission within the timeframe of the measure (12 months +/- 60 days) or health centers not capturing index event information. It is also possible this is a representative sample of the number of health center patients with depression as the Depression Screening measure does not identify the number of patients who test positive for depression.
Number of Patients
Number of Patients Screened for Clinical Depression and if Positive had a Follow-Up Plan Documented
Table A18c: Patients Screened for Clinical Depression
Percent Patients or Visits
Hypertension/Stroke Related Measures
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Controlling High Blood Pressure
% Hypertension Patients
Percent Adults Screened for Tobacco Use and Receiving Cessation Intervention
Table A19: Hypertension/Stroke Related Measures
The above graphs are hypertension and stroke related measures, with their 2024 UDS
Definitions:
- % hypertension patients: number of visits by diagnosis regardless of primacy
- Controlling High Blood Pressure: percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into or starting during the first six months of the measurement period and whose most recent blood pressure (BP) was adequately controlled (less than 140/90 mmHg) during the measurement period
- Adults Screened for Tobacco Use and Receiving Cessation Intervention: percentage of patients aged 12 years of age and older who (1) were screened for tobacco use one or more times during the measurement period AND (2) if identified to be a tobacco user received cessation counseling intervention
- Statin Therapy for the Prevention and Therapy of Cardiovascular Disease: percentage of patients at high risk of cardiovascular events who were prescribed or were on statin therapy
- Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet: percentage of patients 18 years of age and older with a diagnosis of IVD or AMI, CABG or PCI procedure with aspirin or another antiplatelet
Hypertension patients and statin therapy use has been consistent over the 5-year period. The IVD measure and Tobacco Screening/Cessation Intervention had a drop in
2023 and subsequent rise in 2024. Blood pressure control increased over the last five years.
Percent of Patient Population
Diabetes Related Measures
% Diabetes: Hemoglobin
A1c Poor Control
% Diabetes Patients
Table A19: Diabetes Patients
The above graph shows diabetes related measures. Diabetes patients are defined by the 2024 UDS as “the percentage of patients 18-75 years of age with diabetes”. The percentage of diabetes patients has remained steady over the last 5 years. The percentage of diabetes patients with poor control is defined as “the percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c (HbA1c) greater than 9.0 percent during the measurement period”. This measure was steadily declining until it jumped in 2024.
Percent Patients Screened
Body Mass Index (BMI) Screening and Follow-Up Plan
Above shows the measure of BMI screening and documented follow up in adults from 2020 through 2024. The 2024 UDS defines this measure as “the percentage of patients 18 years of age and older with (1) BMI documented and (2) follow-up plan documented if BMI is outside normal parameters”. There has been an approximate 10% drop in the percentage of patients screened in the last two years, however the percentage of the patient population screened is still above 70%
Table A20: BMI Screenings
Percentage of Visits by Diagnosis Regardless of Primacy
Table A21: Asthma Patients
The above graph shows the percent of asthma visits regardless of time since diagnosis (the 2024 UDS definition of this metric is “percent visits by diagnosis regardless of primacy”). This data shows a 0.5% increase in the number of visits at Arkansas FQHCs.
Recommendations of the Data Analyst:
It is recommended that the committee standardize the evaluation of UDS reporting values and metrics.
Half a percent increase in the patient population or visit numbers of Asthma- or HIVrelated visits would be considered a substantial increase, however this increase in the hypertension or diabetes related visits would not.
These types of standards would allow for ease of interpretation of data by any staff member regardless of data analysis background and consistency amongst data interpretation during the next 3-year grant cycle.
