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COPC in a Hospit~- Affiliatec! Health Center Harvey A. HoZzberg The catchment area of the Sunset Park Family Health Center (SPFHC) of Lutheran Medical Center (LMC) includes a neighborhood of approximately 100,000 people, predominantly Puerto Rican, medically underserved, living in deteriorated housing and receiving inferior environmental services when compared to more affluent neighborhoods within and outside New York . _lty- Prior to 1967 and the beginning of the SPFHC, LMC was a 300-bed community hospital in a deteriorated physical plant suffering from a poor financial position, with little hope for the future. LMC was a teaching hospital, however, and had an excellent, if traditional, attending medical staff and ran a small Emergency Room (ER) and Out Patient Department (OPD). It was the tenuous fiscal position of LMC that allowed for an atmosphere of risk-taking that might not have been as available in a more stable institution. Efforts toward community oriented primary care (COPC) really began in 1966, with an acceptance of the ER's role as the primary care provider for the residents of Sunset Park, who had little access to more traditional delivery systems because of economic restraints and scarcity of providers. In 1966, the ER operated as both an Emergency Service Department and an "unscheduled general practice unit." It was staffed with salaried attending physicians, and the leading general practitioner in the area was employed as director. This individual ultimately developed the first family practice residency training program in New York City. The SPFHC began in 1977 as an Office of Economic Opportunity- 227
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228 PART II: PRACTICAL APPLICATIONS funded neighborhood health center with a Community Board setting policy and atmosphere. The history of the Community Board's development and the relationship between the board and the medical center and health center administration are not the particular subject of this case study. Generally it followed the ups and downs typical of most such programs until the more recent past. For about the past 5 years there has been a sharing of goals and strengthening of credibility, trust, and friendship among board and staff leadership. The Community Board today is a model of stability and is quite knowledgeable in the complexities of health care delivery. Another example of the COPC approach is the operating philosophy of both LMC and the SPFHC. The medical center has, since 1967, defined health to include problems of environment, housing sanitation, street lights, education, zoning, etc. LMC considers itself part of the neighborhood it serves and continues to offer all its resources (grant writers, engineers, access to foundation and political offices, etc.) to all legitimate community groups. The goals of the SPFHC remain consistent since 1967, even in the face of fluctuating resources: 1. To provide family centered ambulatory care to the registered popu- lation and to ensure that the care is comprehensive, continuous, and of high quality. 2. To provide specialty and support services that are coordinated with and augment the primary care component. 3. To fuse preventive and therapeutic services in an atmosphere of dig- nity. 4. To create an interest in, and an opportunity for, employment of community residents in health-related careers. 5. To implement the concept of maximum feasible community partici- pation. Both LMC and the SPFHC have flourished in this atmosphere in spite of cost containment, waning resources, increasing regulation, and the general atmosphere of "shrinkage" that has permeated the health industry for the past several years. LMC moved into a new physical plant in 1977, and true to its philosophy it is now located in the most deteriorated part of Sunset Park in a building that was totally renovated within an abandoned 500,000-square-foot factory. It is now a 532-bed, primary care hospital with a 30,000-square-foot com- munity health center located in its core. The development of this unique plant and the combined efforts of staff and community tO bring it tO fruition are obviously quite interesting and have been the subject of a number of articles, but the limits of time restrict further discussion in this case study.
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COPC in cz Hospital-Affiliated Health Center 229 The SPFHC currently has almost 40,000 registered patients, 185,000 physician and dentist visits, more than 300 employees, and a budget ap- proaching $12 million. Support for the funding of this program now comes from third-party reimbursement, patient fees, a large Health and Human Services Section 330 grant, and an integrated network of some 20 smaller federal, state, local, and private foundation grants. These grants have been integrated in a manner that establishes one coordinated health delivery system where neither the patient nor employee has any knowledge of which grant is paying for the specific care being received or rendered at any point in the system. The LMC teaching programs have been vastly improved in the SPFHC setting. The SPFHC evaluates residents and exposes them to an organized primary care setting. Recruitment of SPFHC physicians is almost exclusively from graduating residents, and this has strengthened the medical staff of the medical and health centers. Cross membership has developed between the LMC and SPFHC boards of directors, and this, too, has broadened and strengthened both groups. The COPC principle that has probably received the least attention thus far is the use of epidemiologic data for planning purposes. The two most often used tools are the BCRR and New York City Health Department statistics. The BCRR data too often, however, are used by Health and Human Services for program evaluation and too often become an end in themselves. The goal becomes one of meeting the standards set. The New York City Health Department data are used after the fact as a tool to measure success against rather than as a planning tool around which to develop future programs of concentration. It is interesting to note, however, that in spite of the obvious inner-city problems in Sunset Park, recent Health Department statistics indicate a lower infant mortality in Sunset Park when compared with New York City (14.8 per 1,000 live births, and 16.9 per 1,000 live births, respectively, in 1977~. Other mortality and morbidity data also strongly indicate the positive impact of the SPFHC. The fact is, though, that if the staff of the program concentrate only a little on epidemiologic data, the Community Board concentrates on it not at all. They review the BCRR to be certain the program meets the standards and are simply not presented with other health status indicators. A more epidemiologic approach could be taken using medical students, public health students, and others. Although the emphasis may be somewhat askew, the forcing of data gathering by the Bureau of Community Health Services is at least a beginning and in some respects a . . . pioneering approach. It seems apparent that while the program at SPFHC had most of the COPC facets, the epidemiologic approach could be cost-effective and cost- efficient.