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COPC in the Texas Valley
Stanley 1. Fitch
Su Clinica Familiar (SCF) is a federally funded community health center
located in a rural, medically underserved area on the Texas-Mexico border.
Now in its eleventh year of operation, SCF provides comprehensive primary
care services to its predominantly indigent patient population. Medical care
providers, including physicians, nurse midwives, nurse practitioners, and
physician assistants, are organized in health teams that relate to outreach,
social, and nutrition services. Taking special note of the demographic char-
acteristics of itS population and their health care needs, SCF has emphasized
and been innovative in developing maternal-child health services and out-
reach, counseling, and health services for adolescents.
The elements of SCF's program and organizational design that have con-
tributed to its success include:
1. The integration of primary medical services with social, nutrition, and
outreach services.
2. The fostering of a "coalition of commitment" among community groups,
providers, patients, and funding sources, all in fundamental agreement with
SCF's goal of providing acceptable, accessible, and high-quality primary
health services to the people of our two-county service area.
3. The development of a "cultural cognizance" in the program, making
it more sensitive to the needs, expectations, preferences, and concerns of
. , .
Our patient population.
4. Specific integration of SCF's physicians into the medical community
by establishing after-hours coverage and gaining hospital staff membership,
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COPC in the Texas Valley
215
thus significantly reducing our physicians' isolation from the larger medical
community and at the same time increasing SCF's credibility.
SCF's problems and struggles are not unique; many other community
oriented programs experience similar challenges, which include:
1. Rapid, uncontrolled growth in the number of patients to be served.
2. Increased expectations from funding sources and other support groups.
3. Sorting Out needs and wants of patients and deciding which to address
and then accounting for those decisions to the community.
4. Balancing providers' needs and patients' demands in a system that is
not provider-controlled or -dominated.
5. Delineating governance and management—defining, balancing, and
integrating into a collaborative whole the prerogatives, responsibilities, and
needs of board, administration, and providers.
6. Defining "community" when there are at least four communities to
which a health care organization variously orients itself: patients and their
families, providers outside the organization (the "medical community"), the
supporting institutions such as the Bureau of Community Health Services,
and the organization's own providers.
A number of general lessons can be derived from the SCF experience.
First, stability, competence, collective consciousness, and credibility of a
community oriented practice depend significantly upon its ability to retain
providers and key managers for long terms. Those community oriented
practices organized as community health centers have particular difficulties
in securing the full support and commitment of their own providers, whose
needs are often not readily accommodated in a system where providers are
not dominant, where they have little authority to shape the institutional
environment of patient care, and where they tend to be isolated from their
professional peers in the larger community outside the practice.
Secondly, a community oriented practice needs internal integrity. It must
be patient-oriented, meaning that, as a guiding principle, the patients' needs
come first. It must be soundly managed and should strive to function as
would a healthy community, with open communication and collaboration
among all levels of the organization. There must be appropriate delegation
of responsibility and authority to achieve optimal division of labor, per-
formance and productivity, and accountability within a supportive and ther-
. .
apeutlc environment.
A third lesson is that community oriented practice needs a research
component to bring it in touch with the "community" in all its ramifications
and forms. Depending upon the practice's information needs and the par-
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216
ticular community to be studied, such tools as demographic analysis, epi-
demiologic measures, and anthropological observations may all serve to
better position the practice in its social environment so that it may become
more responsive and effective in carrying out its mission.
Finally, providers and managers must be well prepared for community
oriented practice. During the formal training process, through didactic ex-
ercises, experiences with role models, and apprenticeships, providers and
managers must get solid clinical, organizational/managerial, interactive, and
survival skills. And, perhaps more importantly over the long term, a support
network and/or organization must develop to specifically and continuously
support the work of community oriented practices. Such a network must
husband the development of the discipline of community oriented primary
care by stimulating and publishing the results of community research and
. . .
practice Innovation.
PART II: PRACTICAL APPLICATIONS
Representative terms from entire chapter:
oriented practice
