VALUE BASED CARE DELIVERY & PAYMENT TRANSFORMATION

CARE DELIVERY TRANSFORMATION

Care delivery transformation is about redesigning how care is delivered so it is proactive, coordinated, and centered around the whole person. It shifts health centers from reactive, visit-based care to team-based, data-informed approaches that improve outcomes, patient experience, and long-term sustainability under value-based care.

Care Delivery Transformation

→Chronic Disease Management

→Patient Engagement & Digital Health Tools

→Behavioral Health

→Age Friendly Health Systems

Chronic Disease management & Prevention

HPCA supports health centers in strengthening chronic disease prevention and management to improve outcomes under value-based care models.

This work focuses on building standardized workflows, leveraging data to identify high-risk patients, and strengthening team-based approaches to long-term condition management.

Key areas of focus include:

• Evidence-based care pathways

• Risk stratification to prioritize high-need patients

• Team-based care models and care management workflows

• Monitoring quality metrics

PATIENT ENGAGEMENT & Digital Health Tools

Meaningful patient engagement goes beyond scheduling appointments. It is about building ongoing relationships that support patients in managing their health, navigating their care, and staying connected to their health center. Technology plays a growing role in making that possible, expanding the ways health centers can reach and support patients between visits and across the continuum of care.

We provide training and technical assistance to strengthen active patient engagement through patient portals, secure messaging, texting platforms, remote patient monitoring (RPM), and other digital tools. Our focus is on helping health centers improve access, communication, and ongoing connection with patients beyond the clinic walls

Key areas of focus include:

  • Patient portal adoption, activation, and workflow integration

  • Secure messaging and texting platforms for ongoing communication

  • Remote patient monitoring (RPM) implementation and workflows

  • Outreach strategies for preventive and chronic care

  • Addressing barriers to technology access

Behavioral Health

Behavioral health integration is the coordinated delivery of mental health, substance use, and primary care services within the same care setting. Rather than treating physical and behavioral health separately, integrated models bring providers together to address the whole person. This approach improves early identification of concerns such as depression, anxiety, trauma, and substance use disorders, reduces stigma, strengthens care coordination, and leads to better overall health outcomes across the lifespan.

HPCA supports health centers in advancing sustainable, team-based behavioral health integration models across clinic and school-based settings. Through our work with School-Based Health Centers (SBHCs) and the Pediatric Mental Health Care Access (PMHCA) initiative, we strengthen screening, referral pathways, care coordination, and provider capacity to support children, adolescents, and families. We also support integration efforts within adult primary care to ensure behavioral health is embedded into routine care delivery and aligned with value-based care expectations.

Key areas of focus include:

• Standardized behavioral health screening in primary care and SBHC settings

• Strengthening referral pathways and care coordination for pediatric and adult populations

• Provider training and consultation through PMHCA

• Shared care planning and documentation between primary care and behavioral health providers

• Tracking and improving behavioral health quality measures

AGE-FRIENDLY HEALTH SYSTEMS

Hawaiʻi's older adult population is growing, and health centers play a critical role in ensuring that older patients receive care that is safe, effective, and aligned with what matters most to them. Age-friendly care moves beyond managing conditions to understanding the whole person, including their goals, their mobility, their medications, and their social context.

We have been working in partnership with the Department of Geriatric Medicine at the John A. Burns School of Medicine, University of Hawaiʻi at Mānoa, to support health centers in becoming Age-Friendly Health Systems. This collaboration reflects our shared commitment to providing care that is safe, effective, and aligned with the needs of kūpuna in our communities.

This work is part of the Geriatrics Workforce Enhancement Program (GWEP), a federal initiative supported by HRSA that aims to improve health outcomes for older adults by strengthening the workforce that serves them. Grounded in the evidence-based 4Ms Framework, What Matters, Medication, Mentation, and Mobility, our training and technical assistance helps health centers build the workflows, team skills, and culture needed to deliver truly age-friendly care.

Key areas of focus include:

  • Implementation of the 4Ms Framework (What Matters, Medication, Mentation, Mobility)

  • Fall prevention and mobility assessment workflows

  • Care coordination for older adults