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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, 214

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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 managementódefining, 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