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OCR for page 25
Chapter 3
THE CM:CRERBOARD AREA HEALTH SYSTEM
.
The Checkerboard Area Health System* is a private, nonprofit, com-
prehensive health care program, located in the Checkerboard area of
northwest New Mexico. The area receives its name from the checkered
pattern of land ownership, by federal and state government, Nave jo
Indians, and the Spanish and Anglo populations. Serving a scattered
rural population, the program draws its support from a variety of pri-
vate and public grants, contracts with federal and state governments,
and fee-for-service. AS a case study, Checkerboard demonstrates the
extent to which COPC can be supported and practiced by a combination of
innovative approaches to financing the program, e.g., contractual
arrangements with local governments for population-based health
programs, and a rich data base that includes the entire community.
The initial design and planning of Checkerboard was carried out by
the Presbyterian Medical Services {PMS) of Sante Fe, New Mexico, an
autonomous, nonprofit, community-based organization, which originated
as a division of the Board of National Missions of the United Presby-
terian Church. PMS has been independent of church leadership since
1970, but continues to work closely with rural communities in estab-
lishing primary health care systems. The governing body of PMS has
always included a majority of consumers of the health care services
being provided.
The Checkerboard program became an entity within the PMS organiza-
tion in 1971, and was funded in 1972 as a demonstration project by the
Social and Rehabilitation Service of the Department of Health, Education
and Welfare to develop anew and innovative methods of providing health
care to an economically depressed area.. After 197S, it continued to
be supported in part by federal grants from U.S. Public Health Service
(specifically' the Health for Underserved Rural Area and Primary Care
Research and Demonstration Programs). From its inception, the program
was created around an integrated planning model that sought to provide
a f ull range of health prevention and pr imary care medical services
(Reid and Smith, 1982~.
*Hereafter referred to as Checkerboard.
25
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26
During the first four or five years (the implementation phase), the
program experienced some setbacks: personnel problems surfaced almost
immediately; nurses and physicians willing to make a long-term cam~it-
ment to the program had to be recruited and nurtured; and a pool of
support staff needed to be trained. In 1975, a break in the funding
resulted in a temporary crisis and medical services had to be curtailed
for some patient groups. However, in late 1975, a long-term government
grant and contract was awarded and financial security was improved, and
the program began to stabilize.
During the next year as the funding was becoming relatively stable,
PMS recruited Dr. Richard Rozoll. In his first years at Checkerboard,
Dr. Kozoll unraveled some of the difficult organizational and adminis-
trative problems that had been gnawing at the program and was appointed
director of Checkerboard in January of 1979. Dr. Rozoll came from a
metropolitan hospital rotating intership and general preventive
medicine residency program at Johns Hopkins University. He served as a
physician with the Indian Health Service and the National Health
& rvices Corps prior to his residency years. Bmmediately before coming
to Checkerboard he worked for the New Mexico State Health Agency as
district health officer for San Juan and McKinley counties. Dr. Rozoll
came with enthusiasm and eagerness to help set up a system of health
care based on the nonprofit model. According to Dr. Kozoll, many of
the notions and elements of COPC were nascent at Checkerboard when he
arrived' but the coordination of those elements--the recruitment of
staff with a long-term commitment, development of a data system,
definition and description of the population served, formation of local
advisory groups, the training of support personnel, and development of
reasonable hospital services--all required attention if the program was
going to become a smoothly operating system. It is toward these ends
that Dr. Kozoll and his staff have been working for the last nine years
A recent article describes the current status of the Checkerboard
Area Health System:
[Checkerboard ] has matured both f inancially and organ-
izationally. The public health, family planning,
school health, and INS contracts appear to have
excellent potential for continuation. BURA and WIC
funding appears relatively secure of the for seeable
future, so financial barriers to care access should
remain low. Personnel turnover rates have been
reduced and a critical mass of dedicated provider and
administrative personnel has been assembled. Appro-
priate dispersion of the system's resource. through
satellite facilities appears to minimize physical
barriers to obtaining care. Virtually all health
services within the catchment area have been
consolidated into a single integrated system for
comprehensive health care delivery (Reid et al.,
1982~.
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27
THE PRIMARY CARE PROGRAM
Organization of the Practice
The Checkerboard Area Health System is a primary care program
serving a culturally diverse population widely dispersed over 4,000
square miles of rural northwestern New Mexico. The program provides a
full range of primary care services including diagnostic and treatment
procedures for acute and chronic conditions, screening and health
assessments, dental programs, health education, transportation services,
and a variety of outreach programs. The program tries to ensure that
both preventive and curative services are provided in a continuous and
coordinated way. The scope and magnitude of the program's service
capabilities can be seen in Tables 3.1 and 3.2, which describe
available resources and the utilization of services by the community,
respectively (Reed et al., 1982~.
These services and programs are provided through a system of satel-
lite clinics supported by a central health center. The central facility
also houses a 9-bed, Medicare-certified hospital and emergency room,
available 24 hours per day, 7 days per week.
TABLE 3.1 Major Personnel and Facility Resources Available at
Checkerboard Area Health System
Type of Resource
Personnel
Medical/Dental
Nursing
Ancillary and support
Administrative
Visiting medical consultants
Facilities
Limited hospital
Satellite clinics
Emergency room
Ambulances
Outpatient examination rooms
Dental chairs
Pharmaceutical dispensaries
Diagnostic laboratory
Radiologic facility
Radio communications system
Quantity
17
16
42
19
8
10 beds
6
24 hours~day
2
20
10
7
1
1
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28
TABLE 3.2 Selected Measures of Checkerboard Area Health System utiliza-
tion in 1977
Type of Utilization
Inpatient
Admissions
Births
Hospital days
Average length of stay
Occupancy rate
.
Outpatient encounters
Curative services
Satell ite cl inics
Cuba health center
Emergency room
Dental care
Medical specialist clinics
Preventive services
WIC nutritional
Public Health
Medical screening
Family planning
School health
Quantity
804
118
2305
2.9 days
63%
45110
26778
9852
3198
3257
2025
8460
2711
2073
2556
649
471
Staff and Facilities
The central health center is located in the town of Cuba. Five
satellite clinics are located in the surrounding communities of
Torreon, Ojo Encino, Nageezi, Counselor, and Jemez Springs. The
satellites clinics are open on a schedule ranging from two to five days
per week, and two have full-time dental clinic services. In all cases
the responsible practitioner is a physician assistant or dentist. The
main facility in Cuba serves as base for the four family practitioners,
four dentists, and eight mid-level practitioners (including a midwife}.
A director of nursing services located at the Cuba facility super-
vises a nurs ing stat f of 10. One of the services, school health
nursing, is financed through contracts with the three public school
districts in the Checkerboard area. Another, public health nursing,
fulfills the role of a county heath office. It is financed through a
contract with the New Mexico Department of Health and Environment.
Several special projects include a Woman, Infant, and Children MICE
project, funded through the State of New Mexico; a dietary and nutri-
tion service; a women's health service, assisted in part by a state
family planning contract; a health promotion and disease prevention
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29
project, with an alcoholism component, funded through a supplemental
grant froen the Bureau of Health Care Delivery and Assistance (BHCDA);
and a Robert Wood Johnson Foundation supported upswing Bed. project for
the hospital.
Dr. Richard Rozoll is the director of the Checkerboard program and
is directly assisted in his management responsibility by a business
manager and an administrative assistant jointly supervising an adminis-
trati~re support staff of 11. The total staff consists of 89.35 full-
tune equivalent positions and is organized as shown in Table 3.1.
It should be pointed out that Checkerboard has one of the smallest
Medicare certified inpatient services in the country. me nine-bed
hospital (not including two labor bed and two newborn bassinets) has
been in operation since 197S, certified for acute care since 1981, and
certified as a Swing bed. facility since 1983. Average census runs
between six and seven.
Checkerboard is in the process of renovating the four satellite
facilities and renovating and adding to its main facility. In the
health center in Cuba, a new outpatient medical and dental clinic,
emergency room, and three extra hospital beds will be added in phase I
with a 12-bed addition to the hospital slated for phase II.
Medical Records
The medical records have traditionally been filed alphabetically.
However, Checkerboard is in the process of converting to numerical
filing system utilizing a seven-digit number to identify community of
residence, families in the community, and individuals within the family.
m e new filing system is felt to have the advantage of placing the medi-
cal record of entire families in proximity to each other.
The medical record employs a one-page encounter form that is
self -carboning so that copies of all encounters may be f fled both at
satellite facilities and health center. me chart contains a number of
locally designed forms to assist in the special emphasis programs. For
example, on the left side of the medical records can be found in order
a problem list, health maintenance flow sheet (tailored for both adults
and children) , and a three-page data base. These are all special forms
developed locally to be consistent with local program priorities.
Date' System
Since 1972, Presbyterian Medical Services initiated a manual data
system to capture encounter-specific patient care data. Computer ized
in 1980, the data have been enriched substantially with the inclusion
of diagnostic data (coded to ICD-9), procedure data (coded to CPT-4),
all services provided, lab procedures done {but without results) , and
specific drugs prescribed. Since its inception the system has captured
age, sex, residence, and source of thi rd-party coverage, along with the
date, time, and provider of service. This data system routinely
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30
provides a monthly operating summary that updates and profiles the list
of registered patients, the utilization of services, and
provider-specific behavior. The hardware is located in the PMS central
offices in Santa Fe and programmers are available to respond to special
data requests. mid allows Checkerboard to search its data base for
patients with certain characteristics, either for an epidemiologic
study of health needs or for identifying selected patients to be
targeted for specific services. The data system also supports payroll,
billing, and preparation of financial statements.
Recently, Checkerboard reinstituted a series of computer-generated
chronic disease registries (they were previously inconsistently kept
manually), which include CVA, hypertension, diabetes mellitus,
syphillis, arthritis, Parkinson disease, alcoholism, blindness, child
abuse, prenatal care, and mental retardation. These registries are
maintained within the PMS data system, that provides a printout each
month on those persons who have failed to contact the health care
system within a specified period of time. The printout will provide
the delinquent patient's name, the phone number {if available), and a
mailing label if a letter is to be sent out to the patient.
m e data system contains records of over 15,000 patients, all of
whom have made contact with some component of the health care system
over the past two years. Since the 1980 census counted the population
of the Checkerboard area at less than 10,000 people, it is assumed that
the data system contains all members of the community and for practical
purposes is a population-based data base.
Relationship to Academic Programs
Early in his tenure at Checkerboard, Dr. Rozoll began to forge a
strong relationship with the University of New Mexico Medical School,
where all four of the Checkerboard physicians have clinical faculty
appointments in the department of Family, Community, and Emergency
Medicine. His results in periodically providing a learning environ-
ment for medical students, predominantly in the second and fourth year
of their training. It also provides a site for one-month electives for
pediatric and family practice residents. Checkerboard has maintained a
strong but less fonnal relationship with the Colleges of Nursing,
Pharmacy, and Laboratory Technology at the University of New Mexico,
with students f roan these disciplines occasionally spending time with
the program.
Organization of Financing
The funding sources for Checkerboard are varied. Over the last few
years, the vast majority (98 percent) of the total revenues has come
from or has been linked in some contractual way to the actual delivery
of patient services. Only about two percent has come from
miscellaneous income such as donations, interest, rental space, etc.
There has been no research funding.
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31
Within the broad category of revenues from patient services there
are two principal sources of revenue--.direct/third-party payment. and
Recontracts and grants. '~ -I-- I- --'' ~ ~
As Known In ladle ., tne latter represents
ene largest source of revenue. In 1983, 75 percent of total revenues
is projected to come in the form of contracts or grants for services
provided to designated populations and the distribution of these funds
is shown in Table 3.4. Of the 75 percent, 88 percent come n from federal
sources, specifically the Indian Health Service and the Bureau of Health
Care Delivery and Assistance.
The Indian Health Service contracts with Checkerboard for out-
patient, inpatient. and emergency servicer far the n-=rl v 7 nnn ~;^Q
living in the Checkerboard area, and the BHCDA grant (or P.L. 330
money) reimburses Checkerboard for care to the non-Indian, medically
indigent. Together, these two sources constitute an amount of
~ ~ —- - — ~ ~ ) ~ ~ _ _ ~ ·~ ~ ~ ~ _ _
TABLE 3.3 Total Annual Revenues in 1983 and 1981 for Checkerboard Area
Health System by Source
1983
Patient Services1
Direct/3rd Party2
Contract & Grants
Federal
State
Local
Pr ivate
Othe r
TOTAL
$1,901,500
(98%)
S 440, 000
(23% )
$1,461,500
(75%)
S1,273,000
79, 100
66,300
43, 100
S 44, 000
2.
$19945,500
100%
1981
S1J663, 153
(98%)
S 260, 014
(15%)
S1J4039139
(83%)
$1, 210 ~ 806
139, 653
529680
S 30~960
$1, 694, 113
Patient Services does not include dental services but does include
hospital care.
2Includes Medicare, Medicaid, private insurance, ocher third party
payers and out of pocket payment.
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32
TABLE 3.4 Checkerboard Area Health System Revenues f rom Contracts and
Grants for 1983 by Source and by 11 pe of Service
Tape of Se rvice
Outpatient Inpatient Total
Federal - Indian Health Service 3665, 000 S220, 000 8885, 000
~ 60%
Federal - Bureau of Health Care
Delivery and Assistance
(include Alcoholism Program)
State - Health Department
WIC, Family Planning
Focal School Distr lots
Pr ivate FOundation
Total Revenues from Contracts
and Grants in 19 83
363, 000
79, 100
66,300
25,000 388,000
(26~)
79,100
(S%}
66,300
{5%)
43,100
43,100
~ 3%)
$1,461,500
S1,273,000, approximately 64 percent of the program's total revenues
for 1983. The other contractual funds came from a few categorical
state grants, contracts with local school districts to provide the
school health program, and a grant from the Robert Wood Johnson
Foundation for a swing bed demonstration project.
Direct payment and third-party reimbursement represent a smaller,
but nonetheless substantial proportion of the revenues from patient
services. It should be noted that over time this revenue source has
been increasing as a percent of total revenues; in 1981, it was IS
percent of total revenues and by 1983 it jumped to 23 percent
(Table 3.3).
Checkerboard has been creative in the way it has integrated and
coordinated its revenues. For example, in 1975, in an effort to reduce
the inefficiencies resulting from overlapping responsibilities and
duplication of services between Checkerboard and the public health
personnel, discussion'; were inititated with the New Mexico State Health
Agency concerning a potential contract with Checkerboard for delivery
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33
of all public health services in its area, integrating such services
into the existing primary care system, consolidating medical records,
and thereby improving continuity and accessibility of care. In June
1976, after careful consideration, the State Health Agency made a
precedent setting decision to award the public health contract to
Checkerboard. In addition to securing another source of revenue, this
arrangement resulted in an immediate doubling of public health
encounters for the same expenditure.
Similarly, Checkerboard has negotiated contracts with three of the
local school systems to coordinate and administer a school health pro-
gram. These contracts afford the opportunity to find out more about
the health status of the community through data gathering, screening,
and feedback from health education efforts in the school-age
population. It is this kind of Creative financing. that seems to
enable Checkerboard to assume responsibility for their community and
practice COPC.
THE COMMUNITY
Demography
Checkerboard accepts primary responsibility for a culturally diverse
population residing in a 4,000 square mile area of northestern New
Mexico. According to the 1980 census, the Checkerboard area contains
less than 10,000 people, but there are more than 14,000 people
registered with the them as active patients. Navajo Indians represent
about 63 percent of the population served and non-Indians 37 percent.
For the population as a whole, there are approximately 7 percent over
age 6S, 56 percent between 15 and 6S, 23 percent between 5 and 14, and
14 percent under 4 years of age.
According to one published report (Reid et al., 1982), the Checker-
board area resembles an underdeveloped rural area. The only significant
local sources of income, other than cattle ranching and sheepherding,
are natural resource extraction, small service businesses and trading
posts, and governmental service systems such as schools, Checkerboard,
and the highway department. In some communities, more than one half of
the work force is unemployed. me majority of area residents depend on
subsistence agriculture and stock raising, along with governmental
financial assistance, for survival. Approximately 85 percent of the
area families live on incomes below the federal poverty level.
Geographic isolation and the absence of communication facilities
characterize the area. Communicable disease and poor nutrition
expressed in the high prevalence of disease such as shigella, enter-
itis, trachoma, impetigo, pneumonia, and otitis media reflect the
relatively hostile physical environment.
Other Health Programs
Checkerboard is the only provider of health services in the immedi-
ate area. One has to go a considerable to find other primary care
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34
systems. The Navajo families could obtain care by traveling west to
the Indian Health Service facilities at either Gallup, Crownpoint, or
Shiprock. To the south and east, there are several metropolitan areas,
notably Santa Fe, Espanola, Los Alamos, and Alburquerque, all of which
have a number of available primary care service systems including
private practices, Indian Health Service facilities, community health
centers, and health maintenance organizations.
Community Involvement
The Board of Directors of Presbyterian Medical Services consists of
19 members with strong representation by consumers of health services.
Of the consumer representatives, four are from the Checkerboard Area
Health System, four are from a Farmington-based program, three from a
Questa program, and four represent the newly opened nursing home. Of
the four consumers representing Checkerboard, two are Navajo, one is
from the Cuba area, and one is from the Jemez Valley.
The PMS Board of Directors own and govern the Checkerboard program,
as well as the three other programs mentioned above. The PMS board
select their own officers, which include the president {chief executive
officer) and administrative staff who, in turn, hire the director of
Checkerboard and the other three programs. Beyond selecting the top
management positions in the PMS system, the board of directors have no
direct responsibility for hiring, supervising, or firing employees.
Personnel actions are the responsibility of the supervisor within each
program. The board, however, are very active in all matters of policy
for PMS.
Within the Checkerboard program, there are three guidance councils,
one for each of the constituent ies served including Navajo, Jemez
Valley, and Cuba area. Each of the guidance councils exists specifi-
cally to provide consumer input into the day-to-day operation of the
health care program. The guidance councils do not have direct voice in
setting policy; however, they do nominate individuals for election by
the board of directors to f ill board vacancies when they occur. The
guidance councils are particularly active as a bilateral communication
link between the cow unities and the health care programs. Guidance
councils occasionally play other roles, such as fund raising and some
aspects of heal tb education.
AS an example, the Jemez Community Guidance Council consists of 11
individuals with staggered terms of one to three years. When vacancies
occur in the guidance council, volunteer users from the community are
solicited by a mass mailing and individuals are selected to fill vacan-
cies. Although there is an attempt to balance the representation
geographically, individual positions on the guidance council are not
specific to villages. There are, however, two slots on the guidance
council reserved for the mayors of the two municipalities of the Jemez
Valley. Although the guidance council plays no direct role in hiring
personnel, the informal policy has allowed the guidance council the
opportunity to interview and react to people applying for positions at
the Jemez Valley Medical Clinic.
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35
Consumer/community input into the daily operations of the health
care program comes primarily from the guidance councils. Each guidance
council represents a relatively small population subset and thus is in
a good position to express concern over health program operations.
Occasionally, all three guidance councils meet jointly with the board
of directors specifically to provide grass roots input into ma jor
policy issues confronting EMS. The guidance councils individually meet
bimonthly with the director of Checkerboard and other key staff. The
agenda of these meetings usually consists of bilateral communication
and discussion of both problems and successes in the operation of the
program.
The practitioners of the Checkerboard program promote community
involvement by actively reaching out to support community efforts in
health issues. For example, the alcoholism counselor has been recently
involved with the public schools in teaching a 12-session course in the
3rd and 4th grades on alcohol use and value clarification. me health
educator has been active in working with the social groups among Navajo
women as an entre to introducing a variety of topics in nutrition
and child care. The nutritionist offered a six-week course in basic
nutrition to the people in Jemez Springs, and several physicians and
EMTs on the stat f organized an operating satellite rescue service in
the village of the Lybrook and trained EMT s for first response in
Torreon, Jemez Springs, and Gallina. Very recently, one of the physic-
ian assistants provided special educational sessions to forest service
personnel on the relationship of sun exposure and skin cancer. In the
development of a ~swing-bed" proposal for the inpatient service, a
number of the staff spent time with local church groups explaining the
process to the ministers and other leaders who in turn explained the
program to their congregations. Church groups are one of the few regu-
larly meeting and active social networks existing in the non-Navajo
components of the Checkerboard area.
COPC ACTIVITIES OF ACRE - Of ~ MATH SYSTEM
Dental Caries
In the mid 1970s, one of the dentists screened the school children
in the Cuba and Gallina areas and documented the need for more aggres
sive school child dental services in the community. This quick survey
revealed a large number of children needing ~urgent. attention as well
as other less urgent problems.
Several steps were taken to set up a systematic school-age dental
program:
· Fluoride surveys were performed by Checkerboard in cooperation
with the state and the Indian Health Service. These revealed
wide variation in amounts of fluoride in local water supplies.
Children from low fluoride communities had a clearly higher
incidence of smooth surface decay.
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Alcoholism
Data obtained from the PMS data system, listing alcohol related
injuries and alcohol related clinic visits, suggested that the problem
of alcohol abuse was very prevalent in all subsets of the community,
but particularly prevalent among the Navajos. The severity and extent
of the problem is also confirmed by the practice impression of the
clinicians and by all of the Community Guidance Councils. Finally,
vital statistical data from the state suggested that Sandoval County
has one of the highest cirrhosis mortality rate in the state.
An Hispanic alcoholism counselor was added to the Checkerboard
staff to work closely with the medical staff in direct counseling of
referred patients . He has begun four AA g roups and has developed and
implemented an alcoholism prevention curriculum in the public schools.
The school program is targeted at third and fourth grade students and
focuses on substance abuse and value clarification in a series of in
sessions.
Because of the difficulty in evaluating the impact of such a
program, the long-term nature of any impact, and the generally
technically difficult nature of evaluating any program dealing with
alcoholism, there is no specific plan to gauge the effect of this
effort. However, interim process data suggested that there is a
heightened awareness among the clinical staff of alcoholism in
patients.
Well Child Care
In 1981, the state cut back on the WIC program, which has furnished
a strong incentive for parents to bring children in for well child
care. The cutback essentially eliminated all children over the age of
one year from the WIC program. Practice impressions of the clinical
staff were that the number of children appearing for routine well child
care dropped precipitously beginning in early 1981. Data were obtained
from the PMS Data system listing all children in the community under
the age of five years. A printout was also generated listing all
children who had not had a well child contact with the health program
In the last six months.
When the state cut back the WIC program, the case load among the
Checkerboard child community dropped from 1,050 to 450. The data con-
firmed the problem -- of the nearly 1,400 children in the co''~'unity,
nearly 300 were delinquent in well child care.
Start ing with the printout that listed all children under the age
of five within the community, all newborns were added to the list, thus
maintaining the printout as a master list. Since June 1981, all chil-
dren have been manually tracked for compliance with well child visits
against the list. Postcards are sent out for each delinquent child in
the community reminding their parents of the need for well child care.
At the time of the s ite visit, it was the impression of the clinical
staff that the rates of well child supervis ion had begun to return to
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their original high levels. Within a few months, another updated print-
out from the PMS data system was to be obtained. Visit and immunization
data will be cross-referenced from the original master list, enabling
the program not only to compute well child care and immunization rates,
but also to identify the cohort of children who have not responded to
the postcard reminders.
Screening in School Children
Between 1973-1976, the community and the Checkerboard program parti-
cipated in an EPSDT demonstration project. This resulted in an enriched
body of data on the prevalence of many childhood health problems and
also on the yield and sensitivity of selected screening procedures.
Between 1973-1976 the following screening procedures were shown to be
of low yield:
PPD positive rate was only 0. 8 percent. Of those positives,
two thirds were already known to the system. m us the yield of
new "cases. was only 0.3 percent.
No cases of lead poisoning were discovered.
Using criteria from the National Heart, Lung and Blood
Institute, only three referrals for hypertension were made.
It was noted that the screening nurse was referring very large
numbers of children for cardiac murmurs, approximately 8 percent
of all children were being referred each year. Of 130 children
referred one year, only 18 were even suspected by a
cardiologist to have pathology.
Consequently, several changes were made in the routine screening
procedures. In 1978, Checkerboard stopped screening with PPD alto-
gether. However, in 1982, an effort was instituted by which all stu-
dents in the junior year of high school and all new school entrants
were screened by the school nurse. All children found to be PPD con-
verters could then have INH treatment monitored by the school nurse for
the subsequent year. Checkerboard stopped lead screening in 1978,
which was largely justified by the absence of cases found during the
EPSDT demonstration project and by the lack of lead-ba';ed paint and
Mexican pottery within the community. In 1978, it began a school pro-
gram of BP screening only on selected grades. In 1976, an algorithm
was developed to guide the school nurses in referral of children with a
murmur.
m ese changes have resulted in greatly reduced screening workload
and false positive referrals in the school age population`;. However,
the school nurses continue to monitor their screening results carefully
to detect any signif icant departure from expected patterns.
For PPD screening, they continue to observe a low prevalence of
positive school children in the high school. Elevated blood pressure
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42
continues to be detected only rarely, and usually reverts to normal in
retesting. Finally, referral rates for heart murmurs have dropped
dramatically. There is a plan to begin to track all children referred
for murmur=, in order to document outcomes.
The EPSDT demonstration project also resulted in information
suggesting that two health problems in the school-age child should be
the subject of accelerated efforts at case funding and treatment. In
particular, conductive hearing loss was a problem of considerable scope,
having the highest prevalence also among the Navajo school children and
affecting 10 to 12 percent of those screened. Therefore, school
screening procedure was continued after the demonstration project with
school nurses or assistants performing impedance audiometry on every
child in each school year. Between 1973-1978, the Indian Health Service
was able to coordinate tympanoplasty and during this period 35 to 40
Navajo children were referred for this procedure.
As a preventive measure, the medical staff has incorporated discussions
of supine feeding and bottle propping in their well child routines.
The school health staff continues to monitor the rate at which children
fail audiometric screening, which appears to continue at the same
rates.
Results of the 1973-1976 EPSDT demonstration project also suggested
that the majority of significant orthopedic problems discovered were
scolios is. Approximately 10 to 15 cases were documented per year in
the three school districts and nearly all cases involved pre-adolescent
females.
Consequently, the school health program was modified to include a
careful scoliosis exam on each fifth grade female and all new school
entrants. School nurses received special training in the detection of
scoliosis, and all referrals coordinated through one of the physicians.
m e program continues to identify a few new cases of appreciable scolio-
sis each year (Kozoll, 19791.
ANALYZ ING CHECKERBOARD AS A COPC PRACTICE
The Functions of COPC
Defining and Characterizing the Community
The PMS data system provides a monthly listing of all individuals
who are reg intend with Checkerboard. This list also includes the
active patients -- those who have visited one of the program's faci-
lities within the last two years. There also is a mechanism for speci-
fying persons known to be transient patients at the time of the
contact. This enumeration of the community can be organized by any
combination of age, sex, residence, utilization pattern, family
grouping, or outpatient clinic of most common usage. The monthly
operating summaries that are routinely received sort the total regis-
tered population into several categories that is useful for character-
izing social/economic status of the community (Presbyterian Medical
Services, 19833. The evidence of routine use of this capability of the
data system by the Checkerboard program places them at stage IV in the
development of this function.
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Checkerboard also utilizes data provided f ram other agencies, most
notably the Indian Health Service, and the State of New Mexico. State
data is usually examined focusing on data for Rio Arriba or Sandoval
counties that is assumed to best reflect health indices of the non-
Indian subset of the community. Data f ram the Indian Health Service is
assumed to reflect health status of the Navajo subset of the community.
Additional data has been obtained on special request from the Office of
the Medical Investigator of the State of New Mexico, usually limited to
studies of the cause of death for subsets of the community sorted by
age .
Finally, a limited number of surveys have been conducted, the first
being a sample survey done as part of the SRS grant of the early 1970~.
However, several other surveys examining issues of patient satisfaction
and acceptability of services have been conducted intermitently over
the last 10 years.
Identifying the Community Health Needs
Rather than routinely engaging in new data collection activities,
in general, the Checkerboard program makes maximal use of existing
data, particularly data that is available from the Indian Health Ser-
vice and from the State Health Department. Checkerboard has not made
any specific study of the total community for the purpose of
identifying health problems since the early 1970s; however, it appears
that the program has excellent documentation of the extent and sever ity
of its major health problems. Checkerboard has conducted major data
collection efforts on subsets of its population, most notably among the
younger age groups. Weir contract with the school systems permits
them to do population-based screening on the school aged child.
Similarly, the demonstration project for EPSDT between 1973 and 1976
provided a rich data base on which to make some important program
decisions. During this time, data were collected on nearly 2, 000
children, which has served as a source of information on the health
status of this important subset of the population.
Of the eight COPC activities described for the Checkerboard
program, four of them would be located at stage III of the development
of this function (see Table 3. 5) . Stage III is characterized by the
identif ication of of a health problem through the use of data that is
specif ic for the community. Checkerboard utilized the data system to
identify a].1 deliveries in the community as the basis of a review of
medical records for examining prenatal care, and similarly used the
data base to examine the apparent extent of the alcoholism problem
within the community. The problems of infant gastroenteritis and
inf ant death due to motor vehicular accident were identif fed and
characterized by review of all death certificates for the infants in
the comaun ity .
One of the COPC activities would qualify for stage IV for this
function. Beginning with the data from the EPSTD demonstration project
in the early 1970s, Checkerboard has maintained a consistent effort to
routinely screen school children, monitor the trends, and modify the
program emphases as a function of the results.
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TABLE 3.5 Comparison of the Laurel of Development of the Major Func-
tional Elements of CORC in the Checkerboard Area Health
System
Identify Modify
Def ine and Community the Monitor
Character ize Health Health Impact of
the Cononunitv Problems Program Modif ications
STAGE O
STAGE I
STAGE I I
STAGE I ~ I
STAGE IV X
DENTAL
WELL CH I LO
FLU
.
GAS TRO
CAR SEAT
ALCOHOL
PREGNANCY
SCREEN
ALCO
DENTAL
WELL CHILD
CASTRO
CAR SEAT
ALCOHOI,
SCREEN
DENTAL
FLU
PREGNANCY
WELL CHILD
CASTRO
CAR SEAT
PREGNANCY
SCREEN
FLU
DENTAL refers to the emphasis program that address dental caries in
school children.
GAS TRo and CAR SEAT refer to the activities that addressed infant
gastroenteritis and pushed auto infant seat restraints e
SCREEN refers to the efforts to address the appropriate level of
screening for a var iety of problems in the school population.
WEIL CHILD refers to the effort to improve the well child care after
_ .
termination of the WIC program.
FIN refers to the emphasis program to provide inf luenza vaccine to the
higher isk subset of the population.
PREGNANCY refers to the effort to provide improved prenatal care to
-
the high-risk pregnancies in the community.
ALCOHOL refers to the emphasis program for alcoholism.
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Modifying The Health Care Program
Checkerboard appears to exe rc ise a balance between mod if ications of
both primary care programs and community health programs in addressing
pr for ity health problems. It was noteworthy that most of the program
modifications, in fact, had elements involving the primary care program
as well as the community program. It was interesting to note that most
of the clinical personnel interviewed were quite involved in a particu-
lar health issue well beyond their primary care health service delivery
responsibilities.
In general, the Checkerboard program operates at stage III in the
development of the function of modifying the health program to address
pr iority community health problems. Two important exceptions are the
ef fort to address the subset of the population at high r isk to inf luenza
and the program to improve the health care to the higher isk pregnancy.
Both of these ef forts qualify at stage IV, since they include program
components to identify the specific individuals at risk and monitor the
provision of required services to that group.
Monitoring Impact of Program Modif ications
In general, Checkerboard is quite active in establishing mechanisms
for monitoring the impact of program modifications. In many cases, the
monitoring is done through the use of the same outside data that were
used to characterize the magnitude of the development in the f i rst
place, which again reflects use of all the available data. In general,
Checkerboard also operates at stage III in the development of its
activities for this function, as shown in Table 3. 5. The exceptions
include the alcoholism ef fort that had been evaluated on the basis of
clients seen, since documenting an impact on alcoholism is a compli-
cated and long-term proposition. The effort to address dental caries
in the school-age population, has been evaluated largely on the practice
impress ions of the dentists , although some data apparently available.
The efforts to monitor the impacts of the influenza vaccination and the
high-risk pregnancy efforts just miss being classified at stage IV.
Although the efforts were designed to specifically focus on the high-
risk patient, the activities to evaluate their impact do not apparently
examine the differential impact on the high-risk subset, nor are parti-
cularly rigorous methods used to characterize the outcomes of the
prog rams .
Envi ror~mental Inf luences
Organization of the Program
The ability to mount an intervention strategy that employs modifi-
cation of both the primary care services as well as community health
efforts may be enhanced by Checkerboard's direct operation of many of
the community health programs. Since they have contracted with the
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school district for the provision of school health services and with
the state for the provision of public health services {most notably,
public health nursing services), Checkerboard has direct control over a
number of health efforts based in the community. In interviewing the
principal members of the program, one does not get any sense that it is
functionally divided into a primary care program and a community out-
reach program. As noted above, most health profess ionals seem to be
comfortable in their mix of daily activities that, while focusing on
either clinical or outreach activities, nonetheless have def inite
elements of the other.
An important feature of the current program is the continuity of
the staff ~ both administrative and professional. This is in sharp
contrast to a number of other programs operating in isolated and under-
served rural areas. Similarly, it is important that Checkerboard has
had continuity in its leadership. It is clear that much of the success
of the program has been the result of bold, long-range planning activi-
ties. Successful programs of the complexity of the Checkerboard system
cannot be planned, initiated, and nurtured to maturation in one or two
years. Consequently, it is fortunate that the program has had a leader
with vision who has remained for a number of years.
Or . Kozoll stresses the importance of ef festive group dynamics that
enable the medical stat f to develop its own medical record system, the
nursing staff developing nursing plans and standards, etc. He feels
that the sense of team work and pride of accomplishment felt by the
professional and management staff has bolstered the program through the
ups and downs experienced by any health care program. Dr. Kozoll also
points out that the existence of the inpatient service may be more
important to the overall program success than might be thought, and
cites four main hospital contributions as vitally important. First, he
feels the inpatient service provides the medical staff with the
opportunity to practice the full range of medicine for which they were
trained. He argues that if the staff physicians could only have
practiced outpatient medicine, he would have had difficulty recruiting
and maintaining the caliber of physic fans that he now has on his
staff . Second, he feels the inpatient service provides the mid-level
practitioners with a number of exciting professional activities that
maintain their enthusiam and sense of belonging to a health care team.
Third, he points out that the entire professional group is proud that
they can make a nine-bed hospital work when all conventional wisdom
says that it can' t. It has become a cause or rallying point for
professional staff . Finally, he feels that the small inpatient service
brings to the total program a certain economy of scale. While not
necessarily showing a positive cost-benefit ratio if examined in
isolation, the inpatient service does provide the additional revenues
to maintain a higher quality of several of the ancillary services,
including laboratory, radiology, nursing, and emergency room services.
The inpatient service provides the momentum to attract, hire, and
retain adequate numbers and quality of staff in these critical areas,
which, in turn, improve the quality of the ambulatory care program as
well.
A central feature of the COPC activities of the Checkerboard program
is the PMS data system. The data base and the ability to extract f ram
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it information that is relevant and easy for the program to use, has
been cr itical to all four of the COPC functions across a variety of
activitiese Dr. Kozoll notes that if he were to attempt to start a
CO PC practice again, the development of a data system would be the
f irst item on his agenda. He notes that the current data system
supports both the quantitative activities of COPC as well as providing.
direct support to the emphasis program through its ability to produce
listings of specif ic individuals in need of service.
As a second priority in the development of a COPC practice,
Dr. Kozoll would establish an ongoing relationship with medical and
health care training programs. Such a relationship provides students
to participate in the program and assist in the many nonpatient care
activities required of a COPC practice. At Checkerboard, he has
developed a relationship with the medical school at the University of
New Mexico. This relationship is helpful in maintaining professional
cur rency of his stat f and attracting students and residents both as
additional sources of manpower and as potential recruits for profes-
sional positions in the program.
Organization of the Financing
The organization of the financial base of the Checkerboard program
also has a positive influence on its ability to conduct a variety of
COPC efforts. Although largely funded from the public sector, it has
managed to maintain a highly diversified financial foundation. This
diversity of funding gives the program a great deal of flexibility and
although it has been severely shaken when major funding sources have
been cut back, it nonetheless has managed to fill in the gaps in its
overall program.
For many of the program modifications, Checkerboard aggressively
developed innovative proposals for seek ing add itional funds. Over the
last seven years, they have been unusually successful in attracting
grant and contract money to mount special efforts. This may be due in
large part to the combination of their well documented knowledge of the
community 's health problems, their health program incorporating both
primary care and community health services, and their growing
reputation as a health care program capable of initiating, sustaining,
and car ry ing out to successf ul conclus ions innovative prog rams in
health services delivery.
Organization of the Community
me relative isolation of the community that the practice serves
has offered several "captive. populations upon which to focus. The
absence of an organized pr ivate sector of medical care in the community
has lef t Checkerboard with that portion of the community that has the
personal resources to support the fee-for-service portion of the
program. Dr. Kozoll regards as important the balance among the
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spec ia 1 inte red t g roups in the component coypu:, i t ie s . He f ee Is i t i
helpful that no s ingle group has become dominant and although many
different groups exist within the community (e.g., Navajo Indians,
Hispanics, Catholics, ranchers), the health care program is not seen as
belong ing to any ~ ing le ~ roup .
Dr. Kozoll also emphasizer the desirability of the primary care
services being adaptable to the felt needs of the people served.
Although it is important to respond to health needs determined
objectively, he feels that a health care system must not fails also to
meet the f elt needs of the individual consumers.
Sir
In general, the Checkerboard Area Health System is actively engaged
in the practice of community-oriented primary care, and demonstrates a
high level of development across all the COPC functions as shown in
Table 3. 5. It has achieved this level of development through a combi-
nation of consistency of purpose, reflected in both the leadership and
the professional stat f of the program, and an aggressive and innovative
approach to obtaining grant and contract funds to support the activities
that are not reimburseable through a fee-for-service approach. It is
part icularly interesting to note that the program has done this without
the use of research grants.
In its efforts to be responsive and responsible to the health needs
of the community, the Checkerboard program developed contracts with two
agenc ies that normally serve a population-based health care role. In
developing a source of funds and a commitment to serve as the school
health program and as the local health department, Checkerboard further
solidif fed its foundation as an active COPC program.
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INTERVIEWS
Richa rd Kozoll , M. D., M. P. H., Di rector
Randy L:ovato, H.P.A., J.D., Administrative Assistant
Jean Littlejohns, R.P.A., Business Manager
William Lawless, M.D., Staff Physician, Director of Medical Records,
Quality Assurance, and Utilization Review.
Bonner Dates, DDS, Staff Dentist for Cuba and Torreon
William Morningstar, DDS, Dental Director
Phillip Frey, DDS, Staff Dentist for Nazeezi
Elsie Otero, Nurse Aide at Torreon
Millie Antonio, Secretary at Torreon
Eleanor Begay, P.A., Physician' s Assistant at Torreon
Anna Marie Tomlinson, R.N., Coordinator of School Health Programs
Martha Barbe, M.S.N., F.N.C., Director of Nursing
Elizabeth Burleigh, M.P.H., Health Educator
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so
REFERENCES
Kozoll, R. 1979. A standard approach to school orthopedic screening in
rural New Mexico. Paper presented at 37th Annual Meeting of the
United States-Mexico Border Health Association, San Diego,
California, April 10, 1979.
Presbyterian Medical Services. 1983. Checkerboard Area Health System:
Monthly Operating Summary--July, 1983. Santa Fe, New Mexico :
Presbyterian Medical Services.
Reid, R.A., Bartlett, E.E., and Kozoll, R. 1982. The Checkerboard Area
Health System: Delivering comprehensive care in a remote region of
New Mexico. Human Organization 41 :147-155.
Reid, R.A., and Smith, H.L. 1982. Experience of the Checkerboard Area
Health System in planning for rural health care. Public Health
Reports 97 :156-164.
Representative terms from entire chapter:
checkerboard program
