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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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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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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.
Representative terms from entire chapter:
family health
