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CHAPTER 9 TARBORO-ED<;ECOMBE HEALTH sER\rIcEs SYSTEM Services a As the f inal case study, the Tarboro-Edgecombe Health System represents an innovative approach to the development of community~oriented primary care program based on the components of the health care system that exists naturally within the community. The Tarboro Program cons ists of an informal coalition of the major original , comEx~nents, which are the Tarboro Clinic, a private, fee-for-service, multispeciality group practice, and the Edgecombe County Health Depart- ment. Over t fine, other components have been added to form a system of care that has assumed responsibility for the health care of an enti re county in rural North Carolina. The Tarboro Clinic was founded in 1926 bar four general practitioners who formed a group practice in Tarboro, the county seat of Edgecombe County in Eastern North Carolina. From its inception until well into the l950s, the Tarboro C1 inic was closely allied to the community. In 19 36, Ed Roberson, M. D., joined the practice and for many years was very active as a community leader, serving for a long period of time as the mayor of Tarboro. In the 1930s, the Tarboro Clinic attempted a pre-paid capitated system of health care stimulated largely by the depressed economy of the community and the d if f iculty encountered in collecting fees. This venture was planned largely without the benef it of solid actuarial data and resulted in considerable abuses and depressed income for the physicians. However, it formed a solid bond between the community and the Tarboro 'clinic. There is also a strong history of cooperation with the Edgecombe County Health Department. For many years the Tarboro Clinic physicians had off ice space in the Edgecombe County Hospital until 1961 when the original portion of their present off ice building was constructed ad jacent to the new hospital building . In 1953, John Whaley, M.D., joined the Tarboro Clinic as the first board~certif fed specialist ~ internal medicine) . Or . Whaley instituted a number of solid medical practices including standardized histories and physicals on each patient and formed the foundation of the excel- lent medical record system which the Tarboro Clinic now enjoys. By the mid-1960s, the Tarboro Clinic had grown to 10 physicians whose income from the group practice was based on the amount of revenues that they generated. 163

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164 As the Tarboro Clinic was increasing its physician stat f in the late 19 60s, a net ive of Edgecombe County was f inishing h is res idency at the University of North Carolina at Chapel Hill. Lawrence H. Cutchin, M.D., had been developing notions of the delivery of the health care that had early set his apart from his fellow residents in internal med icine and pediatr ics. In a paper wr itten while at Chapel Hill, Dr . Cutchin descr ibed the shortcomings of the system of health services delivery and argued that certain needs of both the patients and physicians were going unmet. Dr. Cutchin decided to step beyond the academ ic world and to work toward the development of a model group practice that would be set up to integrate the existing health structure the community, maintain strong academic ties, and meet the individual . health needs of all members of the community. [1p to the 1960s Tarboro Clinic had focused largely on the residents of Tarboro itself . Howeve r, dur ing the 1960s there was a substantial loss of many of the solo practitioners in Edgecombe County. In 1969, Dr. Cutchin joined the Tarboro Clinic and introduced a number of inno- vative notions to the health care community of Edgecanbe County. It was from this time that the Tarboro Clinic turned its attention to long- term planning of health care, focusing on all residents of the county. During the 1970s the Tarboro Clinic increased their physician oaf f to its current level of 17 physicians, and in 1978 expanded the physical plant to the present modern facility. In 1972, the TarborO Clinic incorporated as a professional association with all physicians constituting the board of directors. Dr. Cutchin was elected as the president of the association and has continued as such until the present time. In 1980, an executive committee was formed in which physician members of the practice are elected to four years staggered time. At that time, the term of the president was established at four years. From the late 1960s, the Tarboro Clinic has served the community as a source of medical manpower, whose physicians have been active in serving the c= - unity in various health related ways. A number of the phys lo fans contracted with the county health department to stat f clinics and several physicians served as directors and members of the board of both public enc. private health care organizations. AS the several proprietary long-term care facilities have developed within the community in the last few years, a number of the physicians provide medical support and serve on the governing boards. Until very recently, the only in-patient facility in Edgecombe County was operated by the county health department. The original hos- pital was constructed in 1901 and the current facility was built in 19 59. In 19 70, the hospital expanded its bed capacity f ram 75 to 125. When federal (and later state) money became available for the development of the Area Health Education Centers (AHEC), the Department of Education the hospital applied for and was awarded the AHEC grant for a f ive-county area of northeastern North Carolina. The Area Health Education Center occupies a new wing of the Edgecombe Hospital and coordinates the activities of its component programs in the four adjoining counties. Dr. Cutchin has acted as the director of the AHEC

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165 since its inception, and more recently David M. Webb, Ed.D., has assigned the major administrative responsibilities acting as the deputy director of the AHEC. The education department, established the Edgecombe Hospi tal in 1969, became in 1972 the community medicine department, and began to consider ways in which the Tarboro Clinic, the hospital, and the resources of the county health department might be better coord inated to serve the health needs of all residents of Edgecombe County. By the 1960s, many of the solo practitioners in Edgecombe County had either ret ired or lef t the area. Thus, although there was ready access to health care for the residents of Tarboro, but steadily decreasing access to health care in the periphery of Edgecombe County. In 197S, the hasp i ta 1 ' s cosm~un ity med ic ine department opened a satell i te cl inic in a donated store in the small town of Whitakers in northwestern Edgecombe County. With funds provided by the Kate B. Reynolds Foundation, this facility began operating with a staff consisting of a nurse practitioner and an office nurse in 1976. In 197S, the community medicine department was awarded a grant from HEW for Health for Underserved Rural Areas (HURA) . The community medic ine department then preceded to open additional satellite facilities in the towns of Pinetops, Rocky Aunt, and Oak City around the edge. of Edgecombe County. These three clinics initially operated as did the Whitakers facility, with a nurse practitioner providing primary care. In 1982, a Board cert if fed f amily practitioner was recruited to join the Tarboro Clinic and to live in Whitakers and work in the satellite facility there. Similarly, physicians have been recruited for the other three facilities and will arrive within the next year. In 1979, the community medicine department moved out of the Edge- combe Hospital and was established as a nonprof it corporation called The Commun ity Medicine Foundation, Inc . (CHF) . When the HULA grant expired, The Community Medicine Foundation was able to obtain funding through the Rural Health Initiative to continue operation of all four satellite facilities. The Community Medicine Foundation Board of Directors includes consumers frae the community who in turn are drawn f ram the advisory cononittee. from each of the satellite facilities. The Community Medicine Foundation has recently spun off two for- profit corporations. Medical Services, Tnc., it beginning to market an off ice-based patient care data system a seven-state area. More recently, CMF ha. spun off Independent Pharmacist, Inc., with the purpose of establishing pharmacies in the towns served by the satellite facilities, recruiting pharmacists who may either work for the torpor at ion 0 r buy into a pharmacy . In addition to operating the Hospital, the county health department began in the 1970s to strengthen its health care program. Utilizing physicians from the Tarboro Clinic work ing on contract, the County Health Department developed primary care programs in maternal and child health. In 19 70, a mental health center was built as part of a two~county mental health district and contracted for the part-time services of the psychiatrist and clinical psychologist from the Tarboro Clinic.

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166 In reponse to a growing awareness in the late 1970s of the health needs of the increasingly elderly population, the health care program began to consider several alternatives for developing both residential and home health services for the elderly. Af ter some effort, state legislation was passed that enabled the county health department to become involved in long-term care. In the meantime three proprietary and one not-for-prof it organizations opened long-term care facilities in Tarboro. The PRIVY ~ P=CTI~ Organization of the $arboro System Tarboro-Edgecombe consists of an informal coalition of a number of individual components of county, state, and federal government and several components of the pr ivate sector. me system is centered largely around the Tarboro Clinic that in organized in the traditional priorate, fee-for-service, multi-special~cy group practice model. With the exception of an elderly solo practitioner in $arboro and a solo practioner in Pinetops, all the medical manpower in Edgecombe County organized in the Tarboro Clinic. The medical staff of the Tarboro Clinic currently consists of 18 physicians. They have offices in a modern facility built in 1961, with an addition built in 1978 that has an estimated capacity for 23 physi- cians. Specialty representation among the clinical staff includes one pediatrician, three physicians trained in both pediatrics and internal medicine, two internists, three obstetric-gynecologists, five family practitioners, two surgeons, an ophthalmologist, and a psychiatrist. Included on the clinical staff are a clinical psychologist and an Opt0~etr ist. Three family practitioners are scheduled to join the stat f within the next year and will work in the satellite facilities. Support of the clinic includes fourteen nurses in addition to f ive laborator and two X-ray technic tans. The administrative stat f of 30 is headed by William G. Gainey, MPA. The county health department runs an extensive program employing a total of 55 people and includes a nursing program divided into three individual teams. The Child Health Team deals with issues in pediatrics and school leapt and constets of six public health nurses. The Adult Health Team deals with issues in materns1 and child health, VD, To, family planning and chronic disease and consists of a staff of six public health nurses, two nurse practitioners, and two laboratory technic sane. The How Health Care Program consists of f ive nurses and four full time visiting health aids. Additional personnel in the health department include three sanitar ions, two health educators, a nutri~iontst, two has e economists, a social worker and a respiratory therapist, physical therapist, occupational therapist and speech therapist. For many years, the Health Department was directed by a physician on contract, who divided his time among various duties including those of health director of another county. In 1980, a full-time director with a public health backgound and training was recruited.

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167 The Area Health Education Center operates with a budget provided by the State of North Carolina and provides medical education, continuing education, and recruitment of health manpower for Edgecombe County, as well as for four adjacent counties. The Area Health Education Center has a full-time staff of 14, including a medical director. There are several additional persons working on a part-time basis at the main facility in Tarboro and in peripheral locations in the four surrounding counties that constitute its service area. The 125-bed Tarboro-Edgecombe Hospital was operated, until recently, by the county health department. In 1982, the county board of super- visors sold the hospital to the Hospital Corporation of America. The physicians of the Tarboro Clinic continue to provide the medical staff for the hospital with one of the physicians acting as the Chief of Staff . The Community Medicine Foundation (CMF) is a non-prof it corporation with the Board of Directors drawn both from physicians of the Tarboro Clinic and members of the community. IF receives grant money from several sources in order to maintain its program of service and research. Since 197S, it has generated grant monies to operate four satellite facilities in the towns of Whitakers, Pinetops, Oak City, and Rocky Mount. Each of these facilities is staffed to provide primary care to residents of these communities with referral capability to either specialty physician services at the Tarboro Clinic, or inpatient care at the Tarboro-Edgecombe Hospital. Within the next year all four satellite facilities will be staffed by physicians, who will be members of the Tarboro Clinic, but will be living in ache community in which the satellite facilities are located. CHF has a full-time staff of 29. This includes a physician, four nurse practitioners, and four nurses who currently staff the satellite facilities. It occupies off ice space within the facility of the Tarboro Clinic. CMF also obtains grants for research in a variety of health care issues that are relevant to the health needs of Edgecombe County. The major current project involves a study examining the determinants of patient compliance with therapeutic reg imens for hype rtens ion . In 1975, CMF was awarded a primary care development grant to set up a low-cost data system to support the primary care services delivered in the satellite facilities. The foundation, in turn, cc.,tracted with the SysteMetrics Corporation of Santa Barbara, California, for the development of the data system . or ig inally called the Med ical Of f ice Management System (MOMS}, this system was developed and implemented at the four satellite facilities and three other practices in North Carolina. In the recent purchase of SysteMetrics by McGraw Hill, CMF has retained the exclusive distributorship for marketing the data system in a seven-state area. Consequently, it has recently created a totally owned, for-profit subsidiary called Medical Systems, Inc. In 1977, the CMF purchased a pharmacy located near the satellite facility in Whitakers. This proved to be so successful that a totally owned, for-profit subsidiary called Independent Pharmacist, Inc. was created. mid organization is considering the purchase of pharmacies operating near the satellites, in order to attract pharmacists to the

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168 small towns of rural North Carolina. Independent Pharmacists would be in a position to either hire a pharmacist or allow a pharmacist to buy into the pharmacy. Finally, there are four organizations within the town of Tarboro operating home health services and extensive care facilities. The Albemarle Retirement Center is a non-prof it organization supported by the Presbytar fan Church. It has recently opened a facility with 150 apartments and a 40-bed long-term care facility. The Beverly Health Care Center operates 159 acute and intermediate care beds, the Westgate Center operates a 58-bed intermediate care facility, and the Breadhaven Health Center has recently announced plans to expand its [SO-bed inter- mediate care facility to a total of 250 beds. All four of these prom grams operate in close conjunction with the medical staff of the Tarboro C1 into . The professional staff of the Tarboro Clinic provide the medical manpower to stat f the other components of the health services system. Through a contract, the Tarboro Clinic provides X-ray and ultrasound services to the mate real and child health program of the county. The mental health center, operated with state funds independent of the county health department, provides direct services using the psychia- tr ist and the clinical psychologist of the Tarboro Clinic on a part- tine salary basis. Similarly, four other physicians of the Tarboro Clinic provide clinical services for the maternal and child health services offered by the county. The physician staff is directly involved in the care provided by the long-term care and home health services. In addition to making referrals and patient evaluations, the physicians are also involved routinely in making rounds on their patients and deeply involved in the utilization review process of the nursing homes. Similarly, the physician staff of the Tarboro Clinic is also the medical stat f for the Tarboro-Edgecombe Hospital. One of the physicians acts as the ch ief of stat f and all phys icians are involved ~ not only in direct patient care, but also on the various committees of the hospital. Individual physicians have become involved in providing services for the light industry operating in Edgecombe County. The Tarboro C1 inic has recently developed a multiphasic screening capabil- ity and frequently contracts with individual companies for physical examination and screening services for their employees. The physicians of the Tarboro Clinic have traditionally provided emergency room cover- age at the hospital. However, with the acquisition of the hospital by Hospital Corporation of Amer ice within the last year, the Tarboro Clinic physicians no longer carry this responsibility an HCA has contracted with an emergency room physician group in Raleigh, North Carolina. Tarboro Clinic phys tic ions, however, maintain one physician in each specialty on call at all times.

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169 Primary Care Services The Tarboro Clinic has regular office hours from 8:30 a.m. to 5:30 p.m., Monday through Friday, with Saturday hours of 9 a.m. to 1 p.m. With a solo practitioner in three of the satellite clinics, regular hours are restricted to 8:30 a.m. to 5:30 p.m. Monday through Friday. However, with both a nurse practitioner and a physician at the Fast Rocky Mount facility, regular hours been extended to 10 p.m. On weekdays and from 9 a.m. to S p.m. on Saturday. The Tarboro Clinic and the four satellite facilities accounted for over 100,000 patient visits in 1983. Medical Records There are several medical record systems for documenting patient care in Edgecon~be County, including the medical record at the Tarboro Clinic, the hospital, each of the four satellite clinics, and the direct services programs of the county health departments. Although there is believed to be a relatively small overlap, it is possible that any given patient could have an active medical record in each of these service programs. At the present time, there is no mechanism of easy linkage, although there are informal mechanisms by which information is shared across d if ferent medical record systems . The Tarboro Clinic maintains a problem~oriented medical record on each individual f fled by terminal digit with no mechanism for linking individuals within family constellation. The physicians' notes are dictated and typed in the medical record, which also includes discharge summaries and emergency room visits from the hospital, as well as referral documents from the satellite facilities. The medical records in each of the satellite facilities are problem- oriented and are f fled using a six-digit number denoting family unit. A two digit suffix uniquely identifier the specific individual within the f amity. The individual' s medical record, while f fled in proximity to the records of other member. of the family, are not included in a of amily j rickets nor are records of other family members made available to the provider when seeing a patient. The medical records at the hospital are filed by terminal digit with no mechanism for linking individuals within family unit. For the most part the hospital record contains only the inpatient record and notes made on emergency room visits. There is no active outpatient department and outpatient notes are maintained in the patient' s record at the Tarboro Clinic or in one of the satellite facilities. Data System Me Tarboro Clinic has a data system designed and operated primarily to support administration and billing. Although it captures diagnoses coded to CD-9 and procedures coded to CET-4, it is neither structured nor used to support patient care management.

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170 In the 1970~3, CALF was the recipient of a Primary Care Research and Development grant. Working with SysteMetrics, a data system for practice management was developed. Org inally called Med teal Of f ice Management System (MOMS), the system is now known as Computerized Medical Management System, and is encounter-based with selected data abstracted f ram the providers ' progress notes. The system captures time, place, and provider of contact along with demographic data on the patient. Diagnoses are coded to ICD~9 and procedures performed are coded to CPT-4. The system captures additional clinical information including such things as blood pressure (systolic and diastolic), immunization, and lab tests ordered. Mowe~rer, neither lab results nor medication information is included . To date, the ma jor uses of the system have been in practice manage- ment, including billing, developing the BCRR reports, and the need demand assessment required by one of the funding agencies (the Bureau of Health Care Delivery and Assistance). The system is also used to provide f eedback to the pr imary provider, including such items as number of encounters by age, race, sex, and location of service provided, and status reports f ram the several tickler f iles that are kept within the system. Feedback in also provided with regard to the provider performance for clinical issues for cents in health problem". Ear example, providers routinely receive feedback on their management of patient with hypertension, including such indices an the number of patients seen with an elevated blood pressure who have not been diagnosed as hypertensive, the number of hypertensive patients that have no future scheduled appointments, etc. One of the ma jar tickler f iles developed and used actively at the satellite facilities monitors the immunization status of all children in the practice. With the passage several years ago of a state law requiring that all f ive-year~old~ be fully immunized in order to attend school, the individual practices have developed a population-based count of the children in the community along with their immunization status. For example, it is estimated that in the Whitakers community virtually all children have an immunization record, but the data system indicates only 35-40 percent immunized at the Oak City facility. There is no formal linkage between the data system maintained in the Tarboro Clinic and that developed and maintained by the Community Medicine Foundation for the four satellite facilities. Similarly, neither of these systems are linked directly to the hospital data system. Re lationship to Academic Programs The Tarboro-Edgecc~mbe Health Services System maintains active links with both the University of North Carolina in Chapel Hill and the University of Eastern Carolina in Greenville. The Tarboro Clinic serves as a preceptor site for both f irst- and fourth-year medical students f Axe the University of North Carolina and accommodates the pharmacy students on a three~month preceptorship. Also, thi rd-year family practice residents from the School of Medicine at East Carolina

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171 University participate in the Tarboro program. Dr. Cutchin holds joint clinical appointments in the Department of Family Practice and in the School of Public Health at UNC and Carry Lewis, OFF administrator, has an adjunct appointment in the School of Allied Health at the East Carolina University. Several of the physicians in the Tarboro Clinic also have clinical appointments in the department of their speciality at UNC. The Area Health Education Center has provided a close alliance between the Tarboro program and the University of North Carolina for nearly a decade. In the mid-1910s, the AHEC operated an approved training program for nurse practitioners. After graduating two classes, this program was turned over to the new medical school at East Carolina UniversitY. Org an i zat ion of Financ ing The individual components of the Tarboro-Edgecombe Health Services System generate revenues in distinctly different ways. The Tarboro Clinic operates on a fee-for-service basis and thus generates most of its revenue from direct patient care services, although in recent years contracts for screening and health promotion servicer have been negoti- ated with local industrial employers. Projecting for calendar year 1983 the amount of revenue generated in each of several categories can be approx unated as shown in Table 9 .1 . In contrast, the satellite facilities, operating under the auspices of the Community Medicine Foundation, receive revenues from a .330 grant. as well as from fees for direct service, as shown in Table 9. 2. The AHEC operates solely on a grant from the State of North Carolina, which .. 1983 totaled S650,000. The county health department receives general revenues from the county, state, and federal governments, and some third-party reimbursement for home health care. The budget for the Edgecombe County Health Department for 1983 was just over S1.2 million and is shown in Table 9. 3. Us ing the pro jections for calendar year 1983, the proportion of revenues f ram the component sources can be compared and egg regaled for the Tarboro Clinic and the Community Medicine Foundation. as shown in Table 9. 4. On the assumption that revenues generated from patient services are largely consumed by direct costs, the proportion of total revenues generated from sources other than patient services may be a rough indi- cator of the ability of the System of care. to respond to specific health needs of the community beyond those ref lected in patient- presented demand. The f igures in Table 9.5 show the total health care revenue generated by the system in 1983; it can be seen that 33 percent are derived from sources other than payment/reimbursement for direct patient services .

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172 TABLE 9.1 Source of Revenue Generated by the Tarboro Clinic for 1983 Self -pay Workmen ' ~ Comp . Other Insurance Med icaid Medicare Contracts roTAL $1, 630, 047 48, 939 1, 167, 000 410, 33S 331,279 176, 933 S3,764,533 TABLE 9 . 2 Sources of Funding for the Community Medicine Foundation CY 1981 CY1982 l CY 1983 Hypertension Study S 68, 637 S 86, 000 S 87, 900 (Contract with UNC} RHI Grant 319,000 341,000 296,000 State Primary Care S4, 793 54, 000 54, 000 Grant Coon unity fund Raising 6, 500 TOTAI. GRANTS $448, 930 S481.000 S437, 900 Medicaid S207. 095 S254. 123 $18S, S79 Medicare 18,096 24,467 27,557 Other Insurance 11,074 3,469 21,685 Self-pay 151, 882 210, 968 266 ~ 265 TOTAL SERVICE REVENUE $388, 147 $493, 027 SS01, 0 86 TOT" PROGRAM REVENUE S837,077 S974, 027 S938,986

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173 TABLE 9.3 Source of Revenue for the Edgecombe County Bealth Department for 1983 Carry~over f r~ 1982 County Tax Appropr fat ion S tate Aid to County Othe r State Aid to Ind igent TOTAI COUNTY E1JNDS Th i rd-Party Payment f or Home Heslth Care State/Federal Grants Family Planning MCH Aging WIC Chronic Di sease Pr imary Care Cr ippled Ch ildren TOTAl, S 65, 000 311, 000 78, 000 3, 000 15,000 472, 000 ~ 221,000 8 176, 000 146, 000 37, 000 62,000 12,000 21, 000 54, 000 29,537 S S37, 300 S1, 230, 300 TABLE 9.4 Comparison of Projected Sourcen of Revenue for the Tarboro Clinic and the Co~unity Hedicine Foundation, CY 1983 Tarboro C1 inic Co~nunity Hedicine Foundation Total Medicaid S 410, 335 (11%) gl85, 579 {37~) ~ 595,914 (151) Medicare 331,279 (101} 27,557 {6~) 358,836 (91) Other Insur. 1,21S,93S {34~) 21, 68S (41} 1,237,620 (30~) Self-pay 1,630,047 (45%) 266,265 {53~) 1,896,312 (468) TOTAL 33,S87,596 (1001) S501, 086 (1001) S4.088.682 {1001)

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174 TA.81~E 9 .5 Total Health Care Revenue of the TarborO-Edgecombe Heal th Services System, 19 83 STAT GRANTS AHEC Comm. Hed. Found. Co. Health Dept. TOTAL PATIE=-SERVICE REVENUES Tarboro Clinic Con=. Med. Found. Co. Health Dept. GRAND TOTAL 32, 097, 200 (33%) ~ 6SO,ooo $ 431, 900 S1,oo9,300 S3, 587, 596 S 501,086 ~ 221, 000 THE COMMUNITY Demography 34, 309, 682 (671) $6,406~882 tlOO\) The Tarboro-Edgecambe Health Services System identif fed as its co~uni~cy all resident. of E:dgecombe County. Edgecombe county lies in ' -- - an area that is Credos the coastal plains of Eastern Norton ~arol~nzz in minantly based on an agricultural economy with tobacco as the major cash crop. Were is also light industry in the county and by some accounts this represents an increas ing trend. Edgecon~be County has approximately SS, 000 residents of which 48 percent are black and 52 Percent are white, according to the 1980 census. _ , Tarboro, with a population of approximately 12, 000, is located near the geographic center of Bdgecombe County and serves as the county seat. There are four other population centers around the edges of the county, including Oak City, Whitakers, Pinetops, and East Rocky Mount. East Pocky Mount is located near the county line and is part of the town of Pocky Mount with ~ total population of approximately 40,000 people. However, the county line passes through Pocky Mount leaving approximately 17 ,000 people within E:dgecombe County. The health care cysts for Edgecombe County consists almost entirely of the Tstboro-13dgecombe Realth Service System. The exceptions to this include one elderly physician, in part-time practice in Tarboro, and a younger physician in active practice in Pinetops. It is estimated that 40 percent of all hospitalization of Edgecasbe County residents occurs at the 13dgecombe Genere1 Hospital, with the bulk of the remainder accounted for by the residents of East Rocky Mount who may seek hospi- talization at the Nash County Hospital.

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175 Community Involvement Community participation in the the Tarboro-Edgecombe Health Services system is accomplished in several ways. For each of the satellite facilities, an advisory came ittee consisting of between 12 and 25 members of the community meet on a quarterly basis. They assist in the recruitment of medical staff, in fund raising, and in a general set of activities forming a liaison with the larger community. Members of the individual advisory committees are also members of the Board of Directors of the Community Medicine Foundation. The CMF Board includes physicians from the Tarboro Clinic, the administrator of the Edgecombe General Hospital, members of the satellite facility advisory committees, and other members of the community interested in health affairs in the county. The Board of Directors consists of twelve members and also meets the requirements for the Community Board for .330 funding. from the Bureau of Health Care Delivery and Assistance. The physician core of the Tarboro Clinic also forms an important link with the community at large. Several of the physicians in Tarboro Clinic grew up in or have been long time residents of Edgecombe County. Until recently, one of the physicians of the Tarboro Clinic, following in the tradition of Dr. Robe r son from the 19408, was elected to several terms as mayor of Tarboro. Also,, many of the phyatcians are active in community affairs and serve on the board of directors of many of the central and peripheral community agencies involved with health. In an effort to support the local economy and draw into the health care arena an important potential source of funding for health care, CMF has been actively recruiting the participation of local industry in the health care program. In addition to individual contracts with industry for physician examinations and screening services for its employees, there has been a substantial effort to market programs in health promotion and disease prevention to the industrial sector of the community. For example, Carolina Telephone and Telegraph has its home office in Tarboro employing approximately 15,000 local residents. CMF has recently begun negotiating with CTT for an assessment of health needs among its employees. Dr. Cutchin views the involvement of major local employers in the health care program as Closing the loop. and as a way of interesting large financers of health services in the planning and monitoring of the health care sytem. CO PC ACTIVITIES OF TARBORO-EDGECOMBE HEALTH SERVICES SYSTEM Access to Primary Care During the 1970s, many of the primary care practitioners in Edgecombe County either retired from active practice or left the area. As a result the Tarboro Clinic emerged as the primary source of care for the entire County. In the mid-1970s a patient origin study concluded that virtually 100 percent of the residents of Tarboro,

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176 extending out to a 10-mile radius, were users of the health care system. However, it was noted that beyond the 10-mile red ius the pro- portion of people who were active users of the Tarboro Clinic fell off considerably. Because the Tarboro Clinic was rapidity becoming the only active medical practice in the county it was assumed that a substantial proportion of the community did not have reasonable access to pr ima ry health care . Beginning in 197S, the Community Medicine Foundation began to locate facilities and stat f for satellite clinics in the periphery of the county. me f irst satellite was opened in the town of Whitakers through funding support from the Kate El. Reynolds Foundation. Subse- quently, grant support was obtained through the Rural Health Initiative for the development and operation of a total of four satellitea and .330 money. from the Public Health Service provides continuing support. In 1978, it was estimated (based on the national utilization statistic) that the (then) 51,000 residents of Edgecanbe County would generate approximately 200,000 outpatient contacts per year. Utiliza- tion data in 1978 counted 72, 000 outpatient visits at the Tarboro Clinic, 3 ,000 visits each at the satellite facility at Whitakers and Pinetops, and 3, 000 outpatient visits at the facility at the East Rocky punt, which along with 10,000 outpatient contacts for the hospital emergency roam totalled 9G, 000 outpatient visits. Thus, it was esti- mated that 45 percent of the total need for outpatient services in Edgecombe County was being met by the Tarboro-Edgecombe Health Services System. Subsequently, a satellite facility has been opened in Oak City and by the end of the current year, each of the satellite facilities will have a full-time resident physician. These changes are expected to boost to well over 60 percent the proportion of demand for outpatient services met by the Tarboro system. The majority of the remainder is believed to represent individuals living in the city of Rocky Mount, which lies on the border of Edgecombe and the adjoining county, and who have access to other sources of primary care. As the Satellite facilities were opened it became apparent that patients still had to travel substantial distances to fill prescriptions. Since patients gained no advantage from visiting the satellite if they then had to travel to Tarboro or Rocky Mount to fill a prescription, the lack of access to pharmacy services continued to represent a relative barrier to care. In response, CMF has recently formed a wholly owned, for-profit, subsidiary called Independent Pharmacists, Inc. miS organization has purchased a building in the town of Whitakers, opened it as a pharmacy, and recruited a pharmacist to operate it. It is planned that the organization will open a pharmacy in the towns served by its other three satellite facilities arid in other locations where there is a need and a market. The general plan is for the organization to begin the pharmacy and recruit a pharmacist, who may work on a salary or buy into the pharmacy. Utilization of the pharmacy has been growing steadily since its opening nearly a year ago. Although not fully substantiated by hard data, it is generally believed that the opening of the pharmacy has increased the utilization of the Whitakers satellite facility.

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177 In 1980, the annual needs~demands assessment ~ required for the ~ 330 grants) suggested that the residents of East Rocky Mount included a substantial number of families with two worldling adults. Due to a con- cern that the regular hours of operation of the clinical facility in East Rocky Mount may present a relative barrier to such families, a questionnaire was developed and used to structure a telephone interview of 200 households, randomly selected from the community. Information was gathered about the reasons for using or not using the clinical facility and the perception of its accessibility. Me results suggested that there was a need in the community for expanded hours, and the hours of regular clinic operation were extended fran B:30 a.m. to 5:30 p.m. to 8:30 a.m. to 10 p.m. during the week, and 9 a.m. to 5 pa.. on Saturday. Usage patterns are being monitored to determine if the increased utilization of the facility dur ing the expanded are by individuals who would have dif f iculty in keeping an appointment during the day. An increasing number of individuals are using the facility during its expanded hours, and it is believed (although data are only pre, iminary) that the total utilization of the facility is increasing. Hype r tens ion A systematic health su rvey of 1, 0 0 0 randomly selected households in Edgecombe County was conducted in 1979 and repeated in 1983. These studies were conducted by CMF, supported by fund. from the University of North Carolina as a part of a collaborative study on compliance patterns in the management of hypertension. The individual surveys were directed pr imarily to the adult members of the household and obtained a substantial amount of data on health perceptions, sources of health care, and patterns of health behavior. Although emphasizing issues related to the hypertension research, the surveys also took the opportunity to gather additional information on the health status of the residents of Edgecombe County. Nearly half of the population of the county is black, with the expected higher prevalence of hypertension, particularly in the young black male subset of the population. A large number of individuals with positive screening blood pressures were apparently not aware of their condition, not under treatment, or had been under treatment but subsequently dropped out. In order to improve the performance of the health care system in recogniz ing and adequately treating the individuals with hypertension. a three-pronged effort was mounted involving interventions at the levels of the clinical care of patients, at the community level, and an intervention directed at the workplace. At the level of clinical care, an experimental effort was mounted to assess the impact of providing performance feedback to a subset of the clinicians at the Tarboro C1 inic. Feedback included such items an the number of patients seen w ith an elevated diastolic blood pressure who did not have a diagnosis of hypertension, the number of known

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178 hypertensive patients seen whose diastolic blood pressure was not under control, the number of known hypertext Ives seen who did not have a subsequent appointment made, etc. An intervention ef fort was mounted through some of the churches in the community by which volunteers were solicited, provided with educa- tion in the nature and treatment of hypertension, and trained to obtain blood pressure recordings. The volunteers were then used in a concerted effort to screen, encourage those screened positive to seek care, moni- tor control of those under treatment, and encourage all hypertensives to comply with their therapeutic regimen. Finally, an effort was mounted in the workplace {working with several of the major industrial employers in the county) to provide screening, monitoring of those under treatment, and encouraging com- pliance with therapy. This effort is supported in part by a research contract between CMF and the School of Public Health at the University of North Carolina, as part of a four-e ite study {funded by the National Heart, Lung, and Blood Institute of the Public Health Service}. the full impact of the total program is not yet known. Feedback is provided to the participating clinicians on a monthly basis, which allows the investigators to monitor trends in their performance. Preliminary evidence suggests that the feedback has yielded an appre- ciable improvement in the clinical performance of the participating phys ic fans . During the course of the hypertension program, it was noted that there is a subset of the hypertension patient population, resistant to usual methods of weight reduction, for whom severe obesity is a serious impediment to blood pressure control. With supplemental funding f ram an Rural Health Initiative grant, two health educators were added to the CMF stat f to develop and operate a we ight reduction program. The intervention consists of a stepped 10-week behavior modification pro-~ gram, for patients specifically referred by one of the primary care providers. Adolescent Pregnancy For Bode tome there had been a general concern among the community of the high rate of unwanted pregnancies among adolescents. This was of particular concern among the black adolescents. Based on vital statistics from the state health department, it was known that 50 percent of the births among the black population of the community are to unwed mothers under the age of 19 years. In order to gain a greater understanding of the determinants of the problem, a survey was done of the adolescent schoo 1 ch i Id ren in s ix of the schools of the county. The results suggested a generally low awareness of issues of sexuality and family planning. An intervention plan has been developed that includes a health team, organized from among the staff of the county health department, the schools, and the Community Medicine Foundation. Each team would

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179 cover one or more schools and provide a range of screening and counseling services, with particular emphasis on family planning. Although there is a solid body of support from both the school system and the c~,,unity, there has been difficulty in obtaining the funding for this effort. The project proposal called for a pilot test of the intervention in the schools of the Tarboro School Distr lot with an evaluation of the program impact. This was based on pre- and post-test Scores using measures, similar to those used in the or ig inal purvey, of the student ' s understanding of the reproductive process and the available methods of family planning. Also program impact would be based on review of the vital data of the county looking for an anticipated reduction of birth rate among adolescents within the community. ANALYS IS OF TARBORO~EDGECOMBE HEAI TE SERVICES SYSTEM AS A COPC PROGRAM The Eunctions of COPC Def ining and Characterizing the Community There is no reliable mechanism for listing all individusIs within Edgecombe County, the community for which the program has accepted responsibility. However' considerable effort has gone into character- izing the community and its health problems. In 1978, the Community Medicine Foundation began working with the county planning agency in an effort to define the community more precisely. Using aerial maps, each building in the 14 townships of Edgecombe County was located, and those that were occupied were numbered. In 1980, an attempt was made to cor relate census data with the maps, although it is not felt that this process has produced an accurate enumeration of all individuals in the community. In 1980 a sample of 1000 households was randomly selected and a questionnaire was administered to every adult member of each household. The questionnaire for each individual required approxi- mately 30 minutes and captured demographic data physiologic measures including weight, height, and blood pressure; family medical history; occupation and leered of education of the parental health perceptions; sources of health care; and patterns of health behavior. The refusal rate was less than 5 percent. Thus, the use of a survey to characterize the community, but without the ability to enumerate the community places Tarboro at stage II in the development of this function. Identifying the Community Health Problems At stage II] for this function, the practice identifies community health problems through the use of data that is specific to the co~nmu- nity, but uses methods that tend to isolate single health issues. This generally describes the manner by which Tarboro identified and examined

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180 the problems of hypertension and adolescent pregnancy. The problem of access to pr unary care services, on the other hand, was infe r red f ran census data and the fact of declining numbers of practicing physicians in Edgec~be County. However, one of the issues in the access of care had to do with the need for extended hours at the East Rocky Mount Clinic. his led to a survey of the community to estimate need, plac ing this activity at stage III . It is interesting to note that in many settings, determining the need for extended hours in of ten accomplished through a survey of pat tents' perceptions as part of the quality assurance ef fort of many primary care practices. There is a subtle, but important difference between examining the need for extended hours by surveying the active patients and by surveying a random sample of the total community. The former is a good primary care quality assurance practice, while the latter is indicative of this function of COEC. The Tarboro system also utilizes other subsets of the community, which, although not totally population-based, nonetheless provide information that is not biased by focusing on the active users of the system. For example, the Tarboro Clinic's physicians have been active for a number of years in screening programs in the schools. It was, in fact, through involvement with the schools that the clinicians began to sense the magnitude of the problem with adolescent pregnancy that ~ ed to the subsequent focused study. Modifying the Health Care Program The ma jor modif ication of the health care program has been the development and coordination of the various components of the health services system that enable the Tarboro program to operate as a con~nunity~oriented priory care organization. Once the system began to function, the first major problem addressed was the lack of access to primary care services by a substant ial proportion of the community . This was addressed through the development and subsequent operation of four satellite facilities, which provide access on the periphery of the county to primary care services with established linkages into Tarboro for specialty care and hospitalization. Subsequent issues addressed more recently include hypertension and adolescent pregnancy, both of which are addressed with a strategy that involves a mix of primary care and community health efforts. Thus as reflected in all three issues, Tarboro appears to be at stage III in its development for this function. Monitoring the Ef festiveness of Program Modif ications Only in the past several years ha. the Tarboro program been fully f unctioning and able to turn its attention to discrete health problems of the community. As a result of the hypertension comp].iance study begun in 1979, there is a current activity in which a sample of physicians in the Tarboro Clinic are being provided with feedback on

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181 their performance in managing patients with hypertension. While the results of this study are still preliminary, there is the suggestion that the form of feedback is substantially improving identif fed def i- ciencies in the management of hypertension. his activity is showing promise to improve the quality of care for hypertension, but is nonetheless practice-based and not designed to measure the impact of the Total ef fort on the community. In general, the plan to evaluate the impact of the hypertension program centers around an anticipated drop In hypertension-related morbidity as reflected in county-wide vital statistics. Similar approaches are in the plan to assess the ef fective- ne~s of the program to address adolescent pregnancy, placing these two efforts at stage lI] for this function. Finally, the magnitude of the increase in access to health care wan estimated by extrapolation f ran the large area data used to compute the needs/de~nands assessment and is more characteristic of stage II. Environmental Inf luences A noteworthy feature of the Tarboro-Edgecombe Health Services System is the extent to which it has taken an environment very typical of main- stream rural primary health care and structured the environment to be conducive to ca`~unity~oriented primary care. This was accomplished originally in large part by the dedication and efforts of a single physician. However, the results achieved have created a number of converts within the system and have attracted new health professionals into the program with a cos~..itment to continuing a system of health care for all residents of Edgecombe County. Org an ization of Providers In the mid-1960s, the health care system of Edgecombe County con- sisted of the Tarboro Clinic, the county health department, and a general hospital operated by the county. In addition, a number of other solo physicians were in practice in the county, although their advancing age was accompanied by a rapid decline in their numbers. Howe vet, by building in a step~wise manner and operating on a principle of planned opportuni - . the current coalition of health care programs has evolved. Each of the component programs is not organized in an unusual way, but the informal arrangements that link each together with the whole represents the innovation that has formed the organizational Structure that supports COPC. It is particularly noteworthy that this has been accomplished without affecting the basic organizational archi- tecture of any of the components. In particular, the Tarboro Clinic continues to operate very much in the mode of traditional fee-for- service group practice. Its organizational commitment to system collaboration within an existing coaltion is noteworthy.

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182 The Community The community itself presents neither a strongly posit ive nor nega- tive influence on the practice of cononunity~oriented primary care. Defining the community as all residents within the county, however, does create a community for which there is a functioning political structure, i.e., the county government, and for which some health services are organized through the county health department. One important feature of the community is the absence of any health care manpower pool other than the Tarboro Clinic. Although the virtual monopoly on physician services enjoyed by the Tarboro Clinic might be viewed by some as deleterious to the health care of the county, it nonetheless has provided an organization of health care manpower which, when directed constructively toward comprehensive health care of all residents o "he c~..unity, has resulted in a unified and consistent performance that would not have been possible if one were forced to Coordinate the activities of a large number of providers and small provide r organizations . Org an ization of Financ ing There is nothing in particular in the characteristics of the organ- ization of f inancing that distinguished Edgecombe County in the early 19 60s. AS a rural county in North Carolina, there was a substantial number of individuals for whom the affordability of health care was marginal at best. This has been one of The factors cited in the decline of the number of practicing physicians in the 1960s. However, with the advent of increased public spending in health care in the late 1960s and 1970s, financial accessibility to care was gained by a large segment of the community. What is notable is the extent to which the Tarboro- Edgecombe Health Service System has structured a f inancial base drawn fran several of the mainstream mechanisms of f inancing health care, e .g., fee-for-service, Medicare and Medicaid reimbursement, and .330 money. fran the Public Health Service. Perhaps the lesson to be learned from the Tarboro experience is the extent to which the various mecha- nisms of f inancing health services available in all communities can be coordinated and structured to complement each other within a total system of care. Dr. Cutchin notes that this process in incomplete, and current efforts are focused on by involving the major employers of Edgecombe County to buy into the program in vat ious ways as an investment in the health of the ir work force. SUMMARY In order to gain the proper perspective on the COPC program of Edgecombe County, i t is necessary to focus on the integration of the several programs that exists within the county. The major components of thin system consist of the Tarboro Clinic, the Edgecombe County Health Department, the Community Medicine Foundation, the Area Health

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183 Education Center, and the Tarboro-Edgeco~nbe Hospital. No single com- ponent of this system alone is practicing community~oriented primary care; rather the capability for COPC exists because of the system that has been assembled by an integration of the unique capabilities of each individual component. Each is typical of similar health care programs that may be found in many communities not able to practice COPC. one Tarboro Clinic is a fee-for-service, private, multi-.pecialty group practice that offers to the system a qualified medical staff and thus supply ing the med ical manpower for the county. The county health depar~cment provides public health services and also of fere pr imary care services for maternal and child health. The Area Health Education Center contributes to the health care system, with the development, recruitment, and maintenance of the medical manpower pool. Through its medical education efforts, it fosters and maintains a high quality of medical expertise within Edgecombe County. The ~arboro-Edgec~be Bos- pital, recently purchased by Hospital Corporation of America, operates 125 medical and surgical beds. Care of the elderly represents a niche that has been recently f illed by a combination of private, for-profit and not-for-profit organizations. Finally, and very crucial, is the Community Medicine Foundation that provides both the research and development capability for the health care system as well as identi- fying and f illing gaps in the performance of the total system. The majority of the COPC activities within the last decade have gone toward developing the system of health care capable of coord i- nating the health care resources in Edgecombe County for practicinq ca~nunity~oriented primary care. As the system began to function, initial attention was directed toward the major health problem in Edge- combe County--that of poor access to primary care services for many residents in the periphery of the county. Subsequently, the Community Medicine Foundation has developed four satellite facilities in towns in the periphery of the county. Staffed originally by nurse practitioners. all facilities within the year will be staffed by full-time physicians living in the local community. These physicians will also be on the staff of the Tarboro C1 inic . Subsequently the program turned its attention to discrete health programs, addressing the problems of hype rtension and adolescent pregnancy. In general, tube Tarboro-Edgeca~be Health Services System operates at a fairly high level of development of each of the functions of COPC, as summarized in Table 9. 6. The energy and enthusiasm that pervades the program assures continued progress in the development of a COPC program. The existence of this unique program in the virtual main- stream of health care in the United States makes it an important experiment in community~oriented primary care.

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184 TABLE 9 .6 Co - ar ison of the Level of Development of the ~ jor Func ~ tonal Elenents of COPC in the Tarboro-Edgeca~be Health Services System ; Identify Modify Def ine and Community the ~nitor Characterize Health Health Impact of the Conenunitsr Problems Program Modif ications STAGE O STAGE: ~ STAGE ~ I X ACCESS STA" II ~ ACCENTS ACCESS HIGH BP HIGH BP HIGH BE ~ P=G TEEN PIG DIN PI STA" IV - ACCESS refers to the acti~rity that addressed the problem of decreased access to primary in the periphery of the county. HIGE BP refers to the activity that addressed the problem of hyper- tension. TIN PIG refers to the activity that addressed the problem of adoles- cent pregnancy.