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Chapte r 7 ~ONTEFlORE FAMILY HEALTH CENTER The Montef lore Family Health Center* in a federally-funded com~uu- nity health center entering its fourth year of operation. As a case study, the Family Health Center illustrates the potential for COPC practice in a densely populated urban area with strong academic ties to a ma jar postgraduate medical education program. As an of f iliate of the Montef lore Hospital and Medical Center, the Family Health Center shares a long her itage. for over a century, the Montef lore Hospital has demons strafed a consistent social concern for the people of the Bronx, and has been a major innovator in cononunity-based health programs. The Family Health Center developed the f irst home health program in 1939 and later in the 1940s began the f irst Department of Social Medicine. In the early 1960s, the Martin Luther Ring Health Center was established in the South Bronx as one of the original neighborhood health center demonstration sites of the Office of Economic Opportunity. By 1980, there were 10 community health centers in the Bronx, yet a large area with an underserved population of approximately 200, 000 people was located south of the Montef lore Hospital in the Fordham University area. At that time, the most active local community organi- zation was the Northwest Bronx Community and Clergy Coalition that had been focusing on a variety of issues in housing. Working with this group, the Department of Family Medic ine at the Family Health Center was able to obta in a federal 9 ~ ant and open a cotton ity health center . The Family Health Center provides comprehensive medical services to a catchment area including approximately 105, 000 individuals. During it. three years of operation, the utilization has grown steadily, and in the past year, a number of additional grants have been obtained for special emphasis programs. The health center serve. as the priory practice s ite for the 18 to 24 residents in the family practice track of the Residency Program in Social Medicine at Mantef tore Hospital, which also includes tracks in pediatr ins and internal medicine. Under the leadership of Dr. Robert Massad, Chairman of the Depart- ment of Family Medicine of Montefiore Medical Center, the Family Health *Hereafter referred to as Family Health Center llS

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116 Center has worked to become a model of con~unity~oriented primary care. mis effort was considerably strengthened when, in 1982, Dr. Sidney Kark, on sabbatical from the Hebrew-Hadassah Medical Center in Jerusalem, was able to spend one day a week with the faculty and stat f . He contr ibuted to a thorough grounding in the conceptual base and practical applications and techniques in cononunity-or tented primary care. It was during thin time that the staff began a major shift in its activities toward the practice of co~unity~oriented primary care. Although this may have been reflected most in the content of the Residency Program in Social Medicine, Or . Rark ' ~ influence also was clearly felt on the organization and delivery of services at the Family Health Center. TEE PRIMARY CARE PROGP~I Organization of the Practice The Family Health Center is open for both scheduled and ~walk-in. patients fran 9 a.m. to 5 p.m., Monday through Friday, with extended hours until 7 p.m. on Monday and Wednenday and 9 a.m. to 1 p.m. on Saturday. Af ter regular hours, a staff physician in on call and is available through the phone system that rings the Montef lore Hospital operator. The workload of the Health Center ha. grown steadily from lS,000 patient-visitn in its first full year of operation (1981) to over 38,000 patient-visit in 1983. The active patients of the health center are not necessarily representative of the community at large and include a higher proportion of women and children. The health center serves fewer than the expected number of individuals over the age of 65 years. Staf f and Facilities one practice group consists of six physicians, four family nurse practitioners, and the full-time equivalent of f ive family practice res idents. Additional clinical stat f include a f till-time social worker, a nutritionist working half the, and a health educator working one-third t=e at the Family Health Center. Medical consultants include a radiologist (10 percent), a dermatologist {10 percent), and an ob/gynecologist (10 percent) available to Family Realth Center. Me clinical support staff consists of two full-time ambulatory care super- visors and 12 ambulatory care assistants. 'the provider group is organized in health care teams and each team has its own panel of f amities registered for care. Originally, there was an attempt to divide the geographic catchment ares of the Faintly Health Center into four districts with a patient advisory group f rom each distr ict meeting regularly with its respective health care team. However, several factors have served to discourage active pursuit of this program. First, the active users of the health center are not equally d istr ibuted among geographic areas, two of the health care

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117 districts accounted for a small percent of the facility' 8 active patients. Second, the patient advisory groups were relatively inactive in meeting with the health care teams. Finally, it was felt that the geographic areas were designated arbitrarily and did not describe any meaningful social or cultural entity toward which a single health care team could d irect i ts attent ion. Med ice 1 Reco rds The medical records of the Family Health Center are organized by family and filed within a family folder. In each family folder is a complete list of all members of that family; the entire family folder is made available to the provider at the time of service for any family member. At the tune of the site visit, the records of f ive family folders were reviewed. A total of 22 individuals were listed in the family constellation of these f ive families, and a total of 18 health records were in the family folders. With the exception of one patient (who had newly registered that day and whose family had no previous contact with the health center ), all family folders listed the entire f Wily constellation. Of the 2 2 patients, 16 had a problem list in the chart and 13 appeared to have the problem list actively maintained. A total of 8 of the 22 patients had a recent complete history, physical, and patient prof ile in the health record. In general, the health records appear to be well organized and legible, with most basic health care information easily access ible to the primary care provider . Data System At the time the Family Health Center was conceived, plans were underway for the development of a data system that would support both the administration and the process of patient care for the health center. A contract wan let to a consultant group to assist in the development of the requirements for the data system, and to review systems in operation in other health centers across the country. The resulting report concluded that although there were excellent systems to support f inancial operations and excellent systems to support clini- cal car e there were very ~ ew system that ef f ect ively combined the two operations. Therefore, the dec is ion was made to develop a patient care information system for the Family Health Center . The Clinical and Management Information System (C - IS} was developed by a local contractor and i ~ based on two data entry documents. me f trot is an encounter form that requires the provider of service to abstract selected informal ion f ram that visit onto a ~elf~carboning, three-part encounter form. Over 50 fields of data are completed on each encounter and entered in the system, including date, the specific provider of service, laboratory and X-ray tests ordered (no results are entered), all diagnoses made (coded to ICEPPC), all procedures performed (coded with CPT-4), all referrals, consultations, and hospitalization. resulting franc the encounter, and prescriptions categorized into 23

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118 major categories. An encounter record is also completed each time a primary provider from the Family Health Center visits a patient at another location, including a hone visit, or a visit to a hospitalized patient at the Family Health Center. The second input document is used when new patients are registered for care. This document includes over 50 separate data elements such as medical record/hou~ehold number, the household constellation, basic demographic data on the patient, basic social/economic data, third party coverage, and census track of patients' primary residence. Both input forms were developed and used to capture encounter data when the f i rst pat lent was seen in the new Family Health Center in November of 1980. However, it was not until February 1982 that the hardware/software conf iguration was developed and tested, and data entry was started. Although registration data is entered into the data base almost immediately, there is approximately a Sunday turn-around between a patient encounte r and the completion of data entry into the data base. At the present time, there are approximately 20, 000 indi- viduals included in the data base, accounting for approximately 60, 000 total visits to the Family Health Center. The output of the data system consists of a relatively large number of prefor~tted reports including a number of reports to satisfy feder- ally mandated reporting requirements, reports describing the number and characteristic. of reg istered patients and active users of the Family Health Center, reports of payment source for registered and active patients, f inancial reports describing the collection status of all accounts, and miscellaneous clinical reports that describe most colon diagnoses made, utilization of ancillary services, provider prescription patterns, etc. Most reports can be broken down to the level of health care team or even to the individual provider. Academic Environment - One of the campelling reasons for selecting the Family Health Center as a study site was to include a practice having a major priority of tr wining health prof ess ionals in COPC . The Family Health Center is the practice site for the family practice residents in the Department of Family Medicine. me training program was begun in 1974 as a track in the Residency Program in Social Medicine, and predates the department which was founded in 1978. me family practice residency shares a~ini- strative offices and faculty with primary care residencies in pediatrics and internal medicine. The three programs share the following stated goals: I) to encourage and prepare primary care physicians for practice in underserved areas of the inner city 2} to train physicians who will work toward change in the health care system 3) to produce research in areas of health care delivery, clinical primary care, and pr imary care education.

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1 19 Residents are recruiter] and selected according to these general goals with special attention to recruiting minority medical school graduates. In addition to a solid grounding in clinical care, all residents are expected to acquire core skills and knowledge in social medicine, includ ing understanding health teams and the health systems, community assessment, epidemiology, and clinical Spanish. All residents complete a community or ientation and a social/community medicine research or action project during their residency and participate in ongoing confer- ences and seminars designed to provide the core sk ills and knowledge . A partnership system is employed to facilitate the continuity of the ambulatory care practice and provide time for social medicine projects and courses, while meeting hospital responsibilities. mus, two residents share a single resident's hospital duties, their joint ambulatory practice, and ongoing camunity health pro jects, as well as actively participate in the management of the residency program. The partnership and program ~self~nanagement. prepare physicians for teem and group practice and encourage the mutual support necessary for ef fec- tive change efforts and the heavy demand- of inner city patient care. Since the beginning of the Residency Program in Social Medicine (RPSM) over 14 years ago, all graduates have been surveyed annually to deuce ibe their professional activities. Of the 166 graduates of RASH, over 70 percent were practicing in an underser~red area at the time of the last survey. In its short history, the program has also produced an impressive array of leaders in community health and social medicine. The Depa rtment of Family Med ic ine also conducts a sure r elective for medical students that introduces them to the principles of COPC as practiced in an inner city area (Boufford and Shonubi, in press). handing for the program comes from the Robert Wood Johnson Foundation, the American Medical Student Association Preceptorship Program, and the National Health Service Corps. The goals of the program are to attract students with a demonstrated interest in social medicine and to assign them to a primary care physician preceptor in one of the affiliated community health centers. Each student is also encouraged to undertake a special project that either identifies and characterizes a community health problem or attempts to improve some aspect of health of the community. The department also provides occasional senior medical student electives at the health center, but has no general responsi- bil ity f or underg raduate medical education. Through the Department of Family Medicine there is also active participation with and collaboration in a variety of academic pursuits both with the Department of Social Medicine at Albert Einstein College of Medicine as well as with the Sophie Davis School of Biomedical Education at the City College of New York. Organization of Financing A. a result of the multiple relationships between the health cen- ter, the Department of Family Medicine, and the Residency Program in Social Medicine, the actual budget of the health center is difficult to state precisely. the funding base for the direct care program can be

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120 supported development of the categorized an grants and the several categories of payment for direct services, as shown in Table 7.1. The .330 grant. of 1980 included 31.1 million for alteration of the health center, and the grant for 1983 includes a S19, 000 grant for Health Promotion and Disease Prevention and a 350, 000 supplemental for services for the Cambodian refugees. The Robert Wood Johnson grant - CAMIS data system and an educational program for medical students and residents interested in inner city pr imary care practice. Finally, the Bother granted include a state grant (S50, 000 ~ to support a hypertension screening program and three grants frae the Montefiore Wa~en's Auxilliary to support the adolescent pregnancy pro; ect ~ S18, 000 I, the Hispanic Women ' ~ Pro Sect {S5, 000 I, and the purchase of equipment for glaucoma screening ($6, 200) . Our ing its relet ively br ief history, several trends are suggested in the revenue data. First, the .330 grant moneys from the Public Health Service in clearly declining both in absolute numbers and as a percentage of the health center'. total revenues. As the BHCDA grant continues to decrease, reimbursements for patient services continue to grow and represent an increasingly larger proportion of total program revenues as shown in Table 7. 2. TABLE 7.1 Sources of Revenue for Family Health Center by Year 19801 1981 1982 1983 % Medicaid 28,006 197,125 893,232 1,213,056 Medicare 680 17,150 9, 760 29, 960 Other Insurance 320 21,425 11,100 22,460 Self-pay 760 19,686 52,700 117,936 TOTAL 29,766 255,386 966,792 1,383,412 65% Grants: BHCDA Grants 1,745,000 1,3tO,000 1,251,500 Sea, 000 27% Robe rt Wood Johnson Foundation2 12,500 lS7,652 143,185 93,243 27% Other ----- ----- ----- 79,200 4% TOTAL 1, 787, 268 1, 783, 038 2, 361,477 2,138, 8S5 100% 1 Incomplete year . 2The total grant f ram the Robert Wood Johnson Foundation exceeded 3600, 000, and was used for educational programs.

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TABLE 7.2 Patient Service Revenue as a Percent of Total Program Revenue Percent of Total Progr am Revenues 21 1980 1981 1982 1983 14\ 411 62% Of the resources generated from patient service, the me jority come fray Medicaid reimbursement, accounting for 77 percent to 94 percent of total patient service resources since 1980. However, the ma jority of patient visits (and hence costs incurred by the program) are for non- Medicaid-eligible patients. As shown for 1982 in Table 7.3, self-pay or non-insured patients accounted for 53 percent of total visits, but contr ibuted only 5 pe rcent of the patient service revenue. THE CO.MUNITY Demography The community for which the Family Health Center accepts responsi- bility is def ined geographically to include nine health areas in the Bronx. me component area is broken into two parts with two health areas lying immediately to the east of the Bronx Park. The rest of the catchment area is roughly bisected by Fordham Road in its east/west diameter and by the Grand Concourse in the north/south dimension. This total area has a population of approximately 200, 000 people. However, the two health areas lying to the east of the Bronx Park have little access to and little reason to use the Family Health Center. mese areas were added to the catchment area originally with the ides that another health center would be built, but funding was subsequently cut. Therefore, the effective catchment area and the population the Family Health Center directs its major attention numbers about lOS,OOO. Of this population, there are approximately 20,000 patients who have registered with the F - ily Health Center during its three years of operation. Although this number is steadily growing, it represents only about a f if th of the estimated catchment area. She catchment ares consists of a large number of ethnic group. of which the predaminent minorities are Hispanics (mostly Puerto Rican) and blacks. Very recently, ~ small population of Cambodian refugees had been relocated into neighborhoods in the catchment area of the Family Health Center . The ma jar ity of the population in the catchment ares are at or below the poverty level. In general, the different subsets of the community of this catchment area are fairly active and well organized through housing organizations and block groups.

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122 TABLE 7.3 Number of Visits and Revenue Collected by Source of Payment for MPEC in 1982 No. of Amount visits ~ Collected Revenue Generated Per Visit Medicaid 12,466 44t S893,232 92% S71.65 Medicare 306 1% 9, 760 1% 31.90 Other Insurance 350 11 11,100 IS 31.71 Self-Pay 14,995 53% 52,700 5% 3.51 TOTAI. 28,117 99%1 S966, 792 1001 Does not add to 10 0% due to round ing . Other Health Programs an. The Bronx contains more than l. 2 million people and is one of the more densely populated areas of the Greater New York City Area. There are other sources of primary care in the Bronx although only a few of them are geographically, culturally, and f financially accessible to the community of the Fanily Health Center. In all, there are 11 community health centers in the en~cire Bronx and 11 hospitals. But neither of the two hospitals in the catchment area of the Family Health Center has an outpat tent department . Many health-related agencies in the Bronx are pursuing similar goals. Early in 1983, an organization called ache Bronx Adolescent Pregnancy Network was formed representing individuals f r on. nearly 70 active agencies within the community that were concerned with some aspect of problems of adolescents. In a similar manner the Bronx Committee for the Community Health obtained funding through the Community Service Society of New York City to develop a network con- sisting of the directors of the 11 federally funded health centers in the Bronx. The network is staffed by a group called the Primary Care Development Unit (Pa:,U) that meets regularly to consider problems in the delivery of primary care that affect the residents of the Bronx. Recently the PCDU has collaborated to produce a common statistical representation of the health status, utilization, and health needs for residents of the Bronx, as well as shared service contracts and a colla- borative school health program {Montef lore Family Health Center, 1983; The Community Service Society'. Primary Care Development Unit, 1983~.

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123 Community Invo' vement The mayor formal avenue of community participation in the Family Health Center is through the Board of Directors, who inf luence the operation of the health center both through setting genere1 policy and in assisting in the identification of priority health problems of the c~nunityO During the development and planning of the center, the Northwest Bronx Community and Clergy Coalition was the most active and strongest community organization. As a result, the early membership of the 80erd of Directors strongly reflected the active membership of this predominantly white, Catholic organization. Consequently, the board has made a concerted ef fort to involve the black and Hispanic communities within the catchment area. me board cons ists of 12 members who have met once a month in the two years since the board we- officially chartered. Many of the current board members are individuals who are active in the Northwest Bronx Community and Clergy Coalition or who joined the effort to establish the community center early in its planning phase. Selection of new members has largely been a recruitment rather than a selection effort. The board attempts to identify people with interests and skills and to encourage them to become members of the board. Where more than one interested person is available for a slot, the prospective board member is selected by a vote of the current members. Me three members of the board who were interviewed characterized the board itself as acting in an advisory capacity to the project d irector, and felt that the board has had Substantial inf luence on the policy of the health center. Examples cited included the efforts to open a pharmacy in the center, the decision to incorporate National Bealtl, Service Corps physicians into the program, and the recent deci- sion to charge a door fees for all patients with unpaid accounts. Dr . Massed, the pro ject director, sees the board ' ~ role as being one of setting general policy and identifying need. in the community that should be addressed by the health center. However, he thinks it i ~ appropr late that the board is not involved in the day-today running of the health center, including activities such as the selection of professional staff and the allocation of funds within the total budget. Although the interviewed board members downplayed their role in identi- fication of community health problems, Dr. Massad points out that it was in part after continual interest on the part of the board that the current efforts with adolescent pregnancy were implemented. Tbe Family Bealth Center also invokes community participation in a ember of less formal ways. For example, a pro ject has been initiated recently for the development of an Hispanic Women' ~ Network. mis is an effort to connect Hispanic women patients to ashore life experiences, to exchange resources {advice, referral, support, etc.), to provide emotional support and to learn about their strengths and possibilities as caregivers. (Rorin, n.d.) The group consists of 12 to IS when who meet weekly to discuss their experiences with emphasis on being Hispanic, women, and patients. The effort also provides training in group skills and health related topics necessary to eventually function as community health leader s. The pro ject is supported by a small grant from the Montefiore W~en's Auxiliary.

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124 One of the strong impressions frao the rite visit was the extent to which all professional members of the staff were deeply involved in one or more ca.ununity-based activities, frequently working directly with a community health action group . CO PC ACTIVITIES AT MONTEFIORE FAMI LY HEALTE CENTER Cambod fan Re f ugees As a routine part of the household survey conducted on a random sample of approximately 100 households during the surer of 1981, one of the outreach workers discovered a large family, living in the building across from the health center, who spoke no English and appeared to be of Southeast Asian or igin. The outreach worker reported this f inding to the pro ject. In searching out the origin of this f Emily i t was d iscovered that approximately 1, 000 Cambodian refugees had been relocated into the Bronx (many in the catchment ares of the health center ~ . me refugees had a tremendous backlog of special health and sac ial needs, and although it had been assumed that they would be eligible for public health and social services, no contact had been made wi th the local agenc ies . In order to respond to the special needs of this subset of the community, several changes were made in the basic primary care program of the health center. Two ambulatory clinical assistants of Cambodian origin who speak Khmer were added to the staff. They act both as inter- preters for the Cambrian patients coming to the clinic. and as outreach workers attempting to assess the health needs and cultural barriers to pr imary care services. Health maintenance and screening protocols were developed that were spec if ic to the health problem prof iles of thia special community. mese changes were largely supported through a supplemental grant of 50, 000 from the Bureau of Health Care Delivery and Assistance (BHa)A) of the Public Health Service {Supplemental Grant for Care of Canadian Refugees, n.d. ~ . In addition, a number of special efforts that required modif ications in the health program that went beyond the reason of the pr imary care services were necessary to meet the needs of the Cambodian population. For example, through the efforts of the Kh~er-speaking staff it was discovered that the Cambodian women were resistant to actively prac- ticing family planning, in large part due to some unfortunate exper- iences in the refugee camps in Thailand. It also became apparent that the Cambodian population had developed a general lack of trust in health professionals who encouraged family planning. In order to develop a better relationship with the Cambodian community, and particularly those individuals in need of family planning services, the clinical staff began meeting with Cambodian couples in the apartment building where they were living to discuss a number of health issues, in which family planning was included. As a direct result of this outreach effort increasing numbers of Cambodian couples began to request and accept family planning methods.

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125 As a second example, in the course of routine screening of Cambodian inf ants, elevated level. of f ree erythrocyte protoporphyr in (Fop) were noted. Initially these were attributed to iron~def iciency anemia (a problem relatively prevalent among the newly-arrived refugee popula- tion) . However, the elevated FEPs persisted and when several infants with per slstent elevations were noted to be in the came building, the Health Department was asked to investigate for environmental lead. L~ead-based paint we. subsequently detected in the building, and pressure was brought to bear on the landlord. The efforts eventually resulted in removal of the paint. The impact of the ef forts to address the health problems of the Cambodian population is based largely on the subjective impression of the health center stat f, rather than on solid data. However , it is known that t2S Canadian individuals were registered in the practice as of September, 1983, representing nearly 7S percent of the Cambodians believed to be li~rinq in the Bronx. In addition, educational and screening services have been provided to a larger number of Comedian individuals within the community (usually in the form of a home visit). Adverse Pregnancy Outcomes Data both from the health center data system (CAMIS) and the Depart- ment of Health {NYC} suggest that ce Stain adverse outcomes of pregnancy in the community of the health center exceed the norm for the city (e.g., preterm deliveries, low birthweight neonates} . me se cats also suggest that a large number of women from the community are delivering with a history of late or no prenatal care. Using the data system, a list was compiled of all pregnant women receiving services f ran the health center during 1982. The medical records of all women were reviewed to examine the pattern of prenatal care received and the presence of prenatal and delivery complications. Additional analysis of data provided by the Department of }lealth sug- gested that pockets of excess morbidity (low birth weights and preteen delivery) could be identif led. Several of these could be narrowed down to Specific addresses (large multifamily dwellings) within the community served by the health center. Thus, specific high risk groups within the cc~unity could be pinpointed for active outreach and casefinding. The intervention strategy planned is based on aggressive outreach and prospective identification of high risk pregnancies. Using outreach workers the effort hopes to target specif ic small geographic areas in the cc~unity of known high morbidity. The outreach effort will be based on a community health participation project initiated several years ago by the Department of Social Medicine {Albert Einstein College of Medicine}, in which individuals from specif ic large muleif~ily housing units were offered training and a small stipend to be health ombudsmen. In this effort, such individuals will be selected from and will target their efforts on the neighborhoods of known high morbidity. In these housing units, the health center will target specif to educa- tional campaigns to encourage early prenatal care, stress reduction and relaxation, and intensive nutrition education. Supplemental social

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126 support services will also be targeted on specif ic individuals identi- f fed at r isk. All pregnant patients seen at the health center will be ~ iven a thorough risk assessment, using a protocol and specific criteria developed by the Ob/Gyn Department at Einstein. Each patient will be placed in a r isk category and will be followed closely dur ing pregnancy with services appropriate to the category. A manual follow-up system is currently in place and will be used to quickly track any high risk patients who drop out of care. It is expected that the C1\MIS will be able to accommodate the follow-up system within its data base in the near future, thus making the tracking process less labor intensive. Cone staf f of the health center responded to a grant initiative of New York State for programs geared at improving pregnancy outcomes. The proposal was currently under review at the time of the site visit. AS a second line of intervention, several planning discussions had taken place between oaf f of the health center and the Sophie Davis School of Biomedical Education of CONY, directed toward a joint training/research/service effort to deal with the high rate of poor pregnancy outcomes in the community served by the health center. Tne ef festiveness of this ef fort will be assessed by noting the increase in the number of women registered for prenatal care dur ing the first year of the effort. It is expected that by targeting outreach efforts on specific neighborhoods of known excessive morbidity, an additional 200 women can be induced to seek prenatal care, of whom a large proportion can be expected to be at high risk. If this number of high r isk pregnant ies can be successfully provided wi th h igh qual ity prenatal care, i t is assumed that success of the intervention will be reflected by a change in the morbidity statistics of ache city health department for the community (Hassad, 1983) . Adolescent Pregnancy Th is problem has been identif fed through multiple mechanisms . The Household Surveys in the surer of 1980 and 1981 identif fed a community concern with the number of teenage pregnancies and the pattern of inade- quate prenatal care. The community board of directors had been pushing for an intervention for this problem for several years, and the clini- clans had become aware of the problem as a practice impression. The annual needs assessment done by the Pr imary Care Development Unit had suggested a problem with teenage pregnancies for several years, and national trends suggesting an increase in adolescent pregnant ies have been well publicized in the medical literature. In 19 80, 18 percent of all pregnancies in the 13 health areas served by the health center were teenagers, a rate higher than the 11.4 percent national average. Thirty six percent of the pregnant teens in ache EHC con munity received either late or no prenatal care. In response to this problem, the health center initiated an effort directed at three goals:

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127 1) prevention of unwanted teenage pregnancy 2) improvement of pregnancy outcomes for teenage mothers 3) improvement of adolescent parenting skillet The effort will attempt to prevent unwanted adolescent pregnancies by developing an educational program dealing with human sexuality. family planning, human relationships, and value clarification: by providing contraceptive services to adolescents, and by pro~ridir~ information regarding alternatives to pregnancy. Attempts to improve the pregnancy outcomes will include aggressive outreach to bring adolescents into prenatal care early and sensitization of the health center stat f to the special needs of pregnant teens. In order to enhance the abilities of adolescents to be parents, a basic one-hour per week, 4-week class will be developed. This course will address such skills as feeding, bathing, clothing, and temperature-taking. Also, a more detailed effort will combine new-parent classes with a group support network as a source of mutual support and resource shar ing . me program has already been initiated in 5 to 6 group hisses for adolescents and one of the project principals has become involved in newly fanned network of agencies in the Bronx that are concerned with problems of adolescents. Me program was started in 1983 with a grant f rom the Montef iore Women's Auxiliary. Since the project is quite young and there has been little opportunity to observe an ~pact. However, the grant propose' describes the planned evaluation of program impact in terms of moni- toring at 6-month intervals, the increase in the number of adolescents registered as patients at the health center, and the proportion of those sexually active who a re practicing contraception. As adolescents become pregnant and seek care at the health center, program impact will be monitored to observe a change in the proportion who receive prenatal care early {prior to the 16th gestational week) and the proportion who have attended one or more prenatal classes (Poole and P - dgers, 1983) . ANAI YSIS OF TOE FAMILY REALM CENTER AS A COPC ORGANIZATION The Functions of COPC Defining and Characterizing the Community There is no reliable list that enumerates all of the individuals living within the geographic catchment area of the Family Health Center. Even the data deriving from the 1980 census is believed by most who have tried to use it for the Bronx to be incomplete. Although the community can not be enumerated, there are several important sources of large area data from which one can extrapolate the character- istice of the population of the catchment area. The Realth Department of the City of New York is active in developing descriptive data of health issues in all boroughs of the city. me Department of Social Medicine of Albert Einstein Medical College has developed a rather

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128 extensive data base on health and social indicators for the Bronx (Sidel, 1983~. me Primary Care DeveloE - ent Unit (consisting of the directors of the 11 community health centers in the Bronx ~ has been actively pursuing the development of data describing health needs for the undereerved population of the Bronx. The unit uses existing data to compile an annual needs assessment for the Bronx, with indicators broken down for each of the community health centers (Montef tore Family Health Center, 19 83) . mts permits more specif ic characterization of the comn~unity of the health center than is possible by extrapolation frao large area data. For example, it is known that as a whole the Bronx has a relatively large elderly population. However, based on data compiled by the PCDU, only about 12 percent of the community served by the health center is over the age of 65 years. Many of these are Jewish and Italian long-time residents of the immediate area who are hesitant to interrupt their long-term relationship with the outpatient departments of Montef lore Hospital. Based on the lack of the ability to enumerate the community and the use of secondary data that corresponds closely to its community, the Family Health Center is at Stage II in the development of this function. Identifying the Unity Health Problems In general, the Family Health Center identif ies co' - unity health problems through a var iety of mechanisms, most of which tend to center around stages I] and III for this function. Stage I] describes the identif ication of problems through the use of large area statistical data. This i- a process by which the health center identified both adolescent pregnancy (using needs anses~ent data co~nplled by the PCDU) and adverse pregnancy outcomes {using data from the city health department) . Stage I :: deuce ibex the use of focused quantitative n~echanisme to identify problems, as illustrated by the household surveys that originally discovered the Cambrian population within the community. me educational programs with which the health center is associated provide ounpower that has been productively focused on the identi f ica- tion of community health problems. The summer program for medical students, operated in the Residency Program in Social Medicine, has resulted in several projects that have yielded important data to help both in characteriz ing the community and in identifying priority health problems. for example, the household survey, conducted in the seers of 1980, 1981, and 1982, and several focal screening studies were done (e.g., for anemia and hypertension}, both of which yielded Awe pre~ra- lence estimates as well as discovering new cases. It was an application of the household survey that uncovered the existence of the Cambodian refugees within the community. Also, the Residency Program in Social Medicine and the Department of Family Medicine at Monte flare Mospita1 requires all residents to do a project in social medicine during their residency. Over the last several years this has resulted in several important data sets that have identified health problems within the camunity.

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129 Although it is still in its infancy, the cats system at the Family Health Center will become an increasingly important source of health and health care data descr thing the population of the catchment area. Based currently on active patients of the health center, the data system in not representative of the total community. However, as the cats base becomes snore extensive it will become increasingly useful an a descriptor of the general health needs and health care utilization patterns of the community. Finally, the Hispanic Wa~en's Network currently provides subjective information to identify problems in the Pue rto Rican subset of the com- munity. As the network develops and expands, it is hoped that it will serve as an important source of more systematic information for iden- tifying health problems. Thus far, subjective information has pin- pointed several important problems, including adolescent pregnancy, lack of self-esteem among male Hispanics in the Bronx (an en~rirorment in which women often f ind work more easily than men), and the need for better explanations of the health care system and diagnostic and therapeutic procedures to Hispanic patients. Edifying the Health Care Program We modifications made to address important community health pro- ble~ fall generally into stages III and IV for this function. At stage III, program modifications are tailored to the unique character- istice of the problem in that community and involve both the primary care progr am and camunity health and/or public health programs as well. Certainly the program modifications that were formulated to address the varied needs of the Cambodian population and the problem of adolescent pregnancy meet these criteria. This is demonstrated in the modif ications of the program in response to the r.-mbodian subset of the community. In general, the health center has carefully monitored the results of the various screening efforts that have been mounted within this community and have Vilified their 'screening, treatment, and patient education protocols accordingly. In response to the severe English language difficulty of this subset of the community, two ~er-speaking ~ la tory care assistants were added to the staf f to serve as inter- preters and sociocultural liaison with the C~lan patients and cannily and a special computerized health maintenance monitoring protocol was established. Community health efforts were mounted to address health education needs, problems with housing, and the processes required to enable the Cambrian population to utilize other health and son ial services available in the community. Stage IV for this function describes program modifications that employ both primary care and community health program strategies, and also actively target those services on the identified high risk subset of the community. We Family Health Center has incorporated into its strategy to address adverse pregnancy outcomes, a process to identify and actively provide services to a discrete pocket of high risk ind ividuals .

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130 The stat f of the health center provides a strong inf luence in the modif ication of other health and social programs operating within their community . Many of the prof ess tonal stat f are deeply involved in a number of ca~unity-based programs, of ten functioning as volunteers . Special projects have been initiated over the past three years by students in the New York City Stammer Progress for Medical Students and Res idents, and through the community med. ic ine proj ects that are a requirement of the Residency Program in Social Medicine. Finally, as the Hispanic Women' ~ Network develops, it is expected that it will became a viable and functional entity within the Hispanic community. It is then intended to for a foundation upon which program modifications can be built. One of the goals of the network is to develop a corps of Hispanic women who will become knowledgeable about health i-sues in the community, who will become leaders in health issues, and will act to change existing patterns of health, health care, and health behavior within the Puerto Rican population. Monitor ing Frog ran Impact Of the four functional components of community-oriented primary care, the health center is weakest in its activities to monitor the impact of the program modifications that have been made. This is in large part a function of it. relatively short history. However, the plans that exist to monitor the Impact of program modifications as they mature tend to range from stage 0 to stage lI for this function. The various potentis1 effects of the program modifications that address health needs of the Cambodian population are currently monitored, based on the subjective impressions of the health center staff (stage I). me effect of program solidifications to address the problem of adverse pregnancy outcomes will be monitored through the use of data fran the NYC Bealth Department, comparing the rates of perinatal morbidity and mortality before and after the program modification, thus falling into stage II. However, the plan to monitor the impact of the adolescent pregnancy program will utilize practice-based rather than c~unity- based data and would thus fall into stage 0. The plan calls for moni- tor ing the number of adolescents registered with the practice, and of those the number who receive appropriate services {Poole and Pledgers, 1983) . Envi ronmental Tnf luences Organization of the Providers Among the enviroronental variables influencing the ability of health center to practice co~unity~oriented primary care, perhaps the most positive relates to the organization of the practice. Embedded f irmly within the Montef lore Hospital complex, the Family Bealth Center has a f irm philosophical continent to co~unity~oriented pr imary care. Th is is reinforced by the strong community~or tented emphasis of the Residency

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131 Program in Social Medicine. This is manifested in part by the thorough saturation of the professional stat f with a co~nunity~or tented philo- sophy. Another noteworthy organizational factor is the attempt made by the stat f to link the four health care teams to four geographic areas. Lois has been nearly abandoned due to several factors discussed above, but retains some of it. basic elements on a more informal basin. For example, all of the Cambrian community are cared for by health care teams 3 and 4. It is interesting that within the organizational structure of the health center that there are no personnel designated specif ically as outreach workers. This has not always been the case and in its f irst years, the health center employed family health workers, who carried out door-to-door surveys, marketed the health center, and conducted patient education. However, as the number of outpatient visits grew, these positions were pulled back into the health center, due largely to the cuts in the .330 grants and to the constraints imposed by the Bureau Common Reporting Requirements (BCRR) productivity indicators (discussed below}. However, on a less formal, but effective level a number of members of the clinic staff are involved in outreach ef forts that they see as an important part of their clinical routine. There is also a great deal of Institutional outreach,. involving the health center with other health agencies in the community. Currently the staff works closely with several Methadone Treatment Centers, a community mental health center, and several senior citizen groups and day care centers. The Community Among the obstacles to full expression of a COPC program, the Family Health Center encounters many that are related to the complexity of the co~nuni~cy for which it has assumed responsibility. While it is rela- tively easy to identify the community on a geographic basis, it is exceedingly dif f icult to enumerate the component individuals. Fortun- ately, the geographic catchment area corresponds relatively well to 55 census tracts but there is not a great deal of faith in the 1980 census cat`. for the Bronx (Massed, 1983~. Consequently, it is difficult for the health center to generate a listing of the individuals in its community and therefore to either def ine specif ic patterns of health problem and/or to target interventions at specific individuals. The problem is severely confounded by the lack of homogeneity of the populace in the catchment area. mere are at least three important subsets of the community, each with their own intact and functioning social and cultural support system. Finally, the community board has not been very aggressive either in sDecif ically representing the several subsets of the community, in organizing the communities to be receptive to health care interventions, or in actively assisting with the identification of priority health problems. On the other hand, the community board has been very supportive of the health care program and has supported many of the pr tor ity programs that have been proposed and subsequently initiated by the Oaf f .

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132 Organization of Financing The f inancial environment of the health center also presents several impediments to the full expression of community~or tented pr imary care . We health center serves a community that is economically depressed and where over half of the families live at or below the federally def ined poverty level. Although the program is publicly financed, its revenues are increasingly linked to specific patient services. In 1983, 62 percent of the total revenue coming into the health center was reimbursement for specific patient services, despite the existence of a .330 grant., two additional SHCDA grants, a state grant, three small grants f rom the Montef lore Women ' ~ Auxilliary, and the f inal grant year on a project funded by the Robert Wood Johnson Foundation. As a recipient of .330 money. the health center is required to report productivity indicators to the Public Health Service as a component of the Bureau Colon Reporting Requi regents (BCRR) . Of particular importance to the health center is the standard requiring each full-time equivalent practitioner to see patients at the rate of 4,200 ambulatory encounters per year within the facility (an equivalent of approximately three per hour). Beyond ruling out the ability to make home visits, the practitioners find compliance to this standard difficult in the light of the large number of social and psychological problems of patients within their community. This is most evident in the case of the Cambodian patients, many of whom have severe English language cliff iculty and have a myriad of ad just:ment problems in dealing effectively with the health and social support system within the Bronx. AS a recipient of a W330 grant., the Family Health Center must also con ply with a maximum cost per visit standard that is set at 326.00. This is a national standard that doesn't allow for local variation, and has only gone up $2.00 in the last six years. Also the health center is required to place a cap on its administrative costs at 16 percent. mis is difficult for the health center since an initial 12 percent is taken off the top for administrative costs by Montefiore Hospital and Medical Center. The relatively favorable side of the financial environment, however, is that New York has set ~ comprehensive rate for Medicaid reimburee- ment for diagnostic and treatment centers in the Bronx of S72.00 per visit. mis rate covers outpatient clinic visits, but does not include visits made by the health center staff to hospitalized patients nor does it apply to outreach visits at either the work site, the school. Or the patient's home. The resources available to the health center for COPC activities include not only the financial base, but also the manpower available to identify community health needs, mount intervention programs, and monitor their effect. In this respect, the health center has ~ rich resource pool within its educational activities. Although of less value for long term staffing of an intervention program, students can be of tremendous value in the conduct of studies to identify need and evaluate impact of programs within the COPC context.

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133 SUM4ARY As a primary care program, the Family Health Center is relatively young, having been in operation for only three years. During this time is has made considerable progress in developing a COPC program. Table 7.4 compares the relative level of development of the different COPC activities. It is difficult to define the community for which the health center ha. assumed responsibility. Consequently, the health center has put the majority of its COPC efforts into defining and characterizing the community and attempting to identify its major health problems. Early in this effort a relatively small subset of the population of Cambodian refugee origin wan found to have a substantial number of Pressing health problems. While continuing ma jar efforts to def ine the total community, the health cente r has begun to address the vat fed needs of the ~all, but growing Cambodian elements. The relatively weakest functional component of the COPC program involves monitor ing the impact of the program modifications. The principal staff of the health center believe that systematic monitoring of effectiveness is necessary, but acknowledge that it is a process that is often neglected despite the presence of students who can be used for evaluation activities. One of the strik ing features of the Family Health Center is the extent to which the co~unity~oriented primary care philosophy is apparent in the actions of nearly all of the professional staff. This is due in large part to the s~crong coqnmunity~oriented educations] program associated with the Family Health Center. me emphasis on community orientation extends well beyond the family practice residents at the Family Bealth Center and in apparent in the many and varied community-oriented primary care activities undertaken by the profes- sional staff, often well beyond the requirements of their clinical responsibilities.

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134 TABLE 7.d Comparison of the Level of Developtent of the Major Func- tiona1 Elements of COPC in the Montef lore Family Health Center Identify Mod if y Def ine and Community the Monitor Character ice Health Health Impact of the Community Problems Program Mod if ications STAGE O STAGE ~ STAGE I I STAGE I S STAGE IV X PRENATAL PREEN PREG CAMBODIANS . TEEN PREG CAMBODIANS PRENATAL 1~:EN PREG CAMBODIANS PRENATAL ttOTE: me function of def ining and characterizing the community is not specif ic to a particular health issue. CAMBODIANS refer to the efforts to address the needs of the Cambodian refugees. T"N PREG refers to the adolescent pregnancy ef forts . PRENATAL refers to the efforts to reduce adverse pregnancy outcomes.

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135 INTERVIEWS c Robert J. Massad, M.D., Director, Residency Program in Social Medicine, and Chairman, Department of Family Medicine, Montef lore Bospita1 and Med ical Center Richard Younge, M.D., Medical Director, Montefiore F - wily Health Center Alvin H. Streloick, M.D., Residency Program in Social Medicine and Department of Family Medicine, Montef lore Hospital and Medical Center Patricia Shonubi, R.N., Residency Program in Social Medicine and Department of Fancily Medicine, Montef lore Hospital and Medical Center Jack Essex, Executive Off icer, Montef lore Family Health Center Lang Leang, Clinical Assistant, Montef tore Family Health Center Denise Rodgers, M.D., Montefiore Family Health Center Lauren E. Poole, R.N., F.N. P., Montef lore Family Health Center Denn is Chang, member, Lizard of Directors, Montef lore Family Health Cente r Megan Charlop, member, Board of Directors, Montef lore Family Health Center Arthur Marsh, member, Board of Directors, Hontefiore F - oily Health Center E1 iana Korin, Residency Program in Social Medicine and Department of Family Medicine, Montef lore Hospital and Medical Center Barry Bateman, M.D., Residency Program in Social Medicine, Montefiore Hospital and Medical Center

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136 REFERENCES Boufford, J. I. and Shonubi, P. (in press) . Community-Oriented Primary Care: Training for Practice in Urban/Rural Areas. Philadelphia: Praeger . Rorin, E. (n.d. ~ An Hispanic When' s Network: A Resource for Community Health. Department of Family Medicine, Montef lore Medical Center, Bronx, N.Y. Massed, R.J. Personal interview with the Project Director, Montefiore Family Health Center, in the Bronx, Sept. 29, 1983. Montef tore Hospital and Medical Center (n.d . ~ Your Family Health Center . Montef lore Family Realth Center . 1983. 1982 Health Needs Index Data Book . Pr Weary Care Development Unit, Bronx, N.Y. Poole I,.E., and pledgers. D.V. 1983. Proposal for Development of an Adolescent Pregnancy Prevention, Prenatal and Parenting Sk ills Program. ~ntefiore Emily Health Center, Bronx, N.Y. Sidel, V. 1983. Introduction to the Bronx. Presentation to f irSt-year residents in family medicine, Department of Family Medicine, Mon~afiore Bospital and Medical Center, Bronx, N.Y. Supplemental Grant for Care of Sian Refugees (n.d. ~ . Montef tore Family Bealth Center, Bronx, N.Y. The Community Service Society' ~ Primary Care Development Unit. 1983. Interim Progress Report, submitted to John A. Hartford Foundation.