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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
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~.
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
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
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
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.
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.
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
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
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.
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.
36 A National Health Service Corps agreement was negotiated to bring additional manpower to Checkerboard to initiate the comprehensive program. Dental screening in all schools each year was begun for the purpose of prioritizing children for treatment. The program offered full follow-up exam and treatment to children in need of attention. Transport and follow up wan coordinated with the schools, including reservation of large blocks of dental clinic time for specific classrooms. m e program instituted a fluoride rinse program in Cuba schools, because the water in Cuba has one of the lowest fluoride levels throughout the area served. The teachers have all children r' nse with fluoride once a week in school. The school screening program is accomplished through the school health program and BHCDA grant at an estimated cost of $2 per child screened. Although there has been no systematic effort to document the impact of the school-based program, it can be estimated from the practice impressions and subsequent screening results. In the fall of 1983, among the upper grades (6th to 8th), only 3 out of 100 children screened had priority 1. designation, indicating need for urgent care. In the past, among a comparable group of children, there had been about 25 "priority 1. results. Over the last five or six years, the number of young children losing their six-year molars to decay has dropped from about 50 per year to about 3 or 4. Also, the children who do need attention have less severe disease. High-Risk Prenatal Care A total of 177 delivery histories for births in the community were reviewed for calendar year 1978, and revealed a perinatal complication rate among the patient population that was higher than the statewide average. m e data suggested that there had been delayed identification of high-risk pregnancies, and 10 women (of the 177) who should have had planned referrals as part of their prenatal care. A1SO there was evidence of several deliveries with risk factors appearing during labor that were not promptly recognized . Finally, it was noted that by standard risk criteria approximately one-third of the patient population was at elevated risk for adverse perinatal outcome. Also several sources of subjective opinion, including the clini- cians and school nurses, suggested a particular problem with adolescent pregnancies. This was supported by data from the Health Department that demonstrated that Sandoval County had the highest rate of births of unwed mothers in the state. Also, data from the Indian Health Ser- vice suggested that the rate of teenage pregnancy among the Navajo was quite high.
37 In order to deal with these problems, changes were made both in the primary care and community health programs. These modifications included: . A nurse midwife was added to the staff; she began monitoring all pregnancies. A Navajo-speaking outreach worker was added to the staff. An aggressive program of education in the schools was initiated, in same cases enlisting teaching staff in the schools. The clinic began evening clinics for the adolescent female population, specifically to encourage prenatal care, family planning activities, and general gynecological care. The nurse midwife developed and implemented an education and clinical services program specifically to identify and track the high-risk pregnancies. This was done by completing a risk profile on all patients making a first visit for pregnancy. A specific risk assessment is made for each patient and each high-risk patient is entered into a manual tracking system, which leads to a periodic review of their chart in addition to an accelerated schedule of prenatal visits. Thus, patients who drop out of care are rapidly identified and encouraged to continue their care by the outreach worker. Checkerboard successfully developed a proposal for an Improved Pregnancy Outcome Contract with the State of New Mexico, in order to absorb some of the costs of this; ef fort. When this contract expired in 1982, the program was able to absorb the personnel costs of the nurse midwife and the outreach worker, and thus keep the ef fort going . Within the first six months of the program, there was suggestive evidence of program success, particularly in terms of program partici- pation and completion of adequate prenatal care for the subset of the pregnancies identified at risk. Using data from the EMS system, the Impact of the program continues to be monitored each quarter and has suggested several important trends: · an increase in breast feeding rates among all ages · an increase in birth weight in infants of mothers of all ages · a decrease in rate of both premature and small for gestational age births. According to information from the data system, the teenage pregnancy rate in the community remained stable at the 1981 rate through 1982 and the first half of 1983, while the reported rate based on state vital statistics for Sandoval County continued to climb.
38 Influenza m is problem was identified, not as a result of specific studies of the community, but rather from national and well as Indian Health Ser- vice statistics that suggested there were substantial winter peaks of influenza. A program involving both community action and an accel- erated primary care effort is mounted each year in order to increase the rate at which the at-risk population is protected by flu vaccine. The key elements of this effort include: The availability and advisibility of receiving flu vaccine for the at-risk population is widely publicized within the commu- nity. This is accomplished by articles in the local newpaper, attendance and presentation at community meeting sites, such as senior citizens' centers and Navajo chapter houses. A printout is obtained from the data system that lists all individuals in the data base who are: -- over age 65 years -- diagnosed with one of a specified set of conditions that placed them in a high-risk category (e.g., emphysema, chronic bronchitis, diabetes, congestive heart failure, rheumatic heart disease) m e public health nurses all receive a list of the high-risk patients, sorted by area of residence, and an appropriate portion of the listing was provided to each satellite clinic. All clinics begin immunizing all high-risk patients who are seen. The public health nurses made home visits to immunize many patients not seen at one of the clinics by the late fall. · Community immunization clinics are also held (e.g., at the general store and Navajo chapter houses). In the first year of the effort, the data system produced mailing labels, and postcards were sent to all high-risk individuals urging them to come to the clinic and request flu vaccine. This however, did not appear to increase the yield and was abandoned in the second year. The first year of the effort saw a number of technical problems worked through, but the real succes of the effort came in the second and subsequent yearn, when the effort became quite systematic. The program in the fall seasons of 1981 and 1982 resulted in 60 to 70 percent of the subset of the population identified as ~at-risk. receiving the flu vaccine. Infant Gastroenteritis Data was requested and received from the Office of the Medical Investigator {State of New Mexico) on all infant deaths from 1975 to
39 1980. The medical record of each child on the list was reviewed and data were abstracted suggestive of either the cause or antecedents of death. Analysis of the record reviews indicate that 20 percent of all infant deaths during 197S-1980 were related to gastroenteritis. As part of a larger health promotion and disease prevention initi- ative, June 1983 was declared Diarrhea Month. It also involved heigh- tened sensitivity on the part of the clinical staff, several spots on the local radio, and an article in the local newspaper. This included an intensive patient education program to teach parents early detection and response to diarrhea. Checkerboard intends to repeat the effort each spring. ffl is effort had been mounted only months before the site visit and thus only preliminary data were available on program impact. The past experience at the Cuba facility is an estimated average of 1 to 2 deaths per year due to diarrhea and 10 to 12 hospitalizations due to dehydra- tion. During the summer of 1983, there were only 3 infants hospitalized and no deaths due to gastroenteritis or its sequelae. The evaluation plan calls for a review of all infant deaths in the community for the period 1980-1985, to be conducted in early 1986. Use of Infant Seat Restraints In 1981, data were obtained from the Office of the Medical Investi- gator {State of New Mexico) listing all child deaths from 197S to 1980. me medical record of each child on the list was reviewed and data were abstracted suggestive of either the cause or antecedents of death. In 1983, data were also received from the State Highway Department of morbidity and mortality rates for each of the main highways in the state. The results of the combined data suggested that 30 percent of all child deaths were caused by motor vehicle accidents. This was the leading cause of death for children in the community. It was also noted that Highway 44, the main thoroughfare through the Checkerboard area, had the second highest rate of automobile accidents in the entire state. A proposal was developed by Checkerboard asking the state to provide 40 infant seat restraints for loan to parents of low income in the community. This effort is being accompanied by an intensive community education campaign involving newspaper articles, flyers noting the new law in New Mexico requiring child restraints, and selected films shown to and loaned to community groups. Radio spots will also be used including the Navajo language radio station in Farmington, New Mexico. The impact of this program is expected to require several years to document. An evaluation is planned for 1986 that will involve reexa~in- ation of al' medical records of child deaths in the community, based on a listing from the Office of the Medical Investigator. In the meantime, it is planned to continue monitoring the road-specific statistics from the Highway Department.
40 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
41 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
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.
43 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.
44 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.
45 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
46 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
47 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
48 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.
49 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
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.
