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Chapter 5 EAST BOSTON NEIGHBORHOOD HEALTH CENTER East Boston Neighborhood Health Center* program is a large, fee-for-service, multispecialty group practice, organized as a not-for-prof it corporation and wholly owned by a community board of directors. Although located in one of the largest urban areas of the country, it serves the relatively isolated 32,000 residents of East Boston who are separated from the rest of the city by Boston Harbor. The East Boston program has a long term commitment to epidemiologic research in hypertension as one of the earliest collaborators in a national hypertension detection and follow-up study. Thus, East Boston represents the blending of community control and the concentration of skills in population-based research within a primary care program. This blend of unusual elements results in a program that incorporates the ma jor elements of COPC . me need for primary health care services became apparent in East Boston in the late 1960s when the number of local primary care prac- titioners dropped. The few remaining practitioners and a city operated relief station soon became inadequate for the provision of primary care to the residents. East Boston was started as one of seven health cen- ters affiliated with the Boston Department of Health and Hospitals in an overall effort to divide the city into primary care districts. Each district included a geographic area and was affiliated with a nearby hospital East Boston was aff iliated with Boston City Hospital. . ~ _ ~ . . . . , _ By 1969, there were two organizational elements to East Boston. One was the East Boston Health Committee, a group of local residents concerned about health issues but not yet incorporated, and the other -~-a_ _ em ~_~~ ILL OU~L ~ office, ~oca~ea an Castle square, staffed with community organizers who were there to help develop the health center. AS with several other health centers in the city, tension grew between the health committee and the central support office over control of leadership of the health center. More specifically, the health committee and the city off icials were at odds over hiring practices. After sane struggling and negotiations with the Co''~nissioner of uric . no ~~~ ~_- __~ _ ^ _cc: __ ~ ___~_ ~ ~ . *He reafter referred to as East Boston. 71

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72 Health in Boston, it was established that local control was necessary for East Boston and the support group provided by the city should be just that, a support group; they should not attempt to run the health center. Once that was established, in July 1970, James Taylor, a physician who had worked at East Boston while completing a fellowship in infectious disease at Boston City Hospital, was hired by the East Boston health committee as medical director of the health center. From the early days of the center, there has been an expressed interest on the part of both Dr. Taylor and the health committee in promoting primary care services to all the residents of East Boston. They both acknowledged the value of having information about the total population and its implications for prevention, intervention, and treatment. In 1970, a small grant was awarded to Channing Laborator- ies then associated with Boston City Hospital, to carry out a pilot study in East Boston. This study involved a door-to-door survey of a 3 172 percent sample of the East Boston community. This survey collected blood pressures, urine samples, and formed the basis for an eventually funded proposal to National Institutes of Health for participation in the Hypertension Detection and Follow-up Program (HDEP}, a 14-center cooperative study. In 1975, the East Boston Health Committee developed a proposal for a Hill-Burton grant for 2 million dollars in order to build a health center. At that time, the health center was operating out of an aging city-owned building, and consisted of a hodge-podge of programs funded with federal, state and, private foundation money. In organizing for the Hill Burton grant proposal, the committee became a nonprof it cor- poration, the East Boston Health Committee, Inc., and upon receiving the Hill-Burton grant were able to match it with S250,000 in community development block grant funds. An additional S700, 000 was obtained wi th a loan secured by a 10-year service contract f rom the Massachu- setts Port Authority to serve as a back-up medical f acility and to provide disaster response for nearby Logan Airport. With all of this, a 3 million dollar facility was built and opened in 1978. The compatibility of the medical director and the East Boston Health Committee has been a signif leant factor in East Boston' s ability to perform many of the COPC functions in a fairly rigorous way. From its inception, East Boston had been involved in population- based studies that have served to attract resources and to fulf ill the design of epidemiologic research. AS their community data base grew, they became increas ingly competitive for both service and research grants. For example, during the 1970s, grant proposals for maternal, infant, and children (TIC) funds increasingly emphasized denominator- based assessments of need. East Boston had a competitive edge in this regard that proved helpful in obtaining some of the MIC funds coming into the Boston area.

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13 THE PRIMARY CARE PRACTICE Organization of the Practice East Boston is a large health center providing comprehensive pri- mary care services to the population of East Boston. The relatively new three story building is open 24 hours a day, 7 days a week, for emergency care and provides an array of other services from 8:30 a.m. to 9 :00 p.m. The health center services include adult medicine, pedi- atrics, adolescent medicine, obstetrics and gynecology, home care, den- tal care, social services, nutrition services, public health nursing, optometry and opthalmologoy, and laboratory and X-ray services. These services have been expanded over the 14 years of operation in response to identif fed community needs. Anyone is welcome to register as a patient at East Boston and, except for walk-ins and emergencies, appointments are necessary. The number of visits to East Boston has almost doubled in six years, from 63,026 visits in FY 1977 to 121,747 in FY 1983, with the biggest increase being in adult medicine (8,690 to 29,112), home care (~2,427 to 8,062), and lab and radiology (1,332 to 6,481~. Both the East Boston staff and board of directors are concerned with providing high quality medical care efficiently. Patients are encouraged to contact anyone on the executive staff or on the board of directors if they feel their needs are not being met. Organizationally, the community board is In the top administrative position. Ironed lately under the board are the medical director and the administrative director. (See Figure 1. ~ They are coequal and split their work between programmatic medical issues/ medical affairs and f inancial and management, respectively. Immediate' y below the medical and administrative directors are the members of the executive committee, i.e., the chief financial officer, the general operations manager, and the operations manager for research. The medical staff relates to the medical director and the general operations manager supervises the nursing stat f and all other care givers. Staff and Facilities mere a re 17 departments at East Boston. The medical staf f is divided into teams. Internal medicine, for example, has 8 to 10 teams consisting of an internist, a mid-level nurse practitioner or physician assistant, and a medical assistant. The patient is either assigned to or chases a particular team and receives all of his/her primary health care from that team. The medical assistant is reported to be a key person in dealing with the community. The medical assistant makes appointments, takes calls, and is essentially the medi- cal staff liaison with the team's patients. When the health center moved into the new building there was a sense among the practitioners and among the community people that there was a breakdown of personal contact. In the old building, there were one or two people who sat at

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74 Aim' 1 Low ad ' 51 E' 8' . I~ ba ~ - - Lam l 1 ~m _ ~ Law ~ . ~ ~ ~ ~~ 5 l] ,02 1 ~ . ~1 L . ~ 1-~1 ~ 1' 5! Bi _ _ 04 - ~ 1 11 it. 1 1 - 1 15 1 165 1 t ~ 1 al 1 l 1~1 ~ 1 ~ 1 851 M! i i 1~1 ~1 ~ 1 1~ law FIGURE 1 Organization Chart of East Boston Neighborhood Health Center.

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75 the Front desks and and knew everyone who came and went. The new building was designed with many work stations and the capacity to wee more people and offer more services but direct personal contact with the same receptionist became more difficult. It was at this time the medical staff looked into another way of organizing the medical care and it was then they went to the team approach. Medical Records In general, the medical record system at East Boston is organized by family; each nuclear family is given a number that is assigned to the medical records for that family. However, beyond physically storing the records. together there doesn't seem to be much by way of linking family information to patient records. When a patient is seen, only the medical record for that patient is pulled. The medical data on the entire family is not automatically available at the time of con- tact with any given individual. The medical record itself contains a standard problem list for the individual. The problem list is displayed prominently at the top right side of the chart. However, the problems for the fenily group or other family members relevant to this individual are not displayed systematically. Similarly, data on the patient's environment, occupation, and the patient's family and economic condi- tion, although noted in an initial work-up or subsequent progress note, is not as readily available as the individual's problem list. And, except for cases in which tests, such as tympanograms, have been made, there is no mechanism for routinely linking patient information obtained as part of the epidemiologic studies being done in the community with patients' clinical records. Data Systems Currently, East Boston is working with two data systems. It has a time-sharing arrangement with a local company that is used for billing, accounts payable, and general ledger. This system contains little or no clinical information that could be useful for anything but billing. me other data system exists to support the volume of data collected and analyzed for epidemiolog to research. This research data system is part of Channing labs, which is linked to the Harvard Computer Systems. Although much of this patient data is collected on an individual basis {e.g., patient specific data collected in door-to-door surveys, clinical data collected on subsets of patients f itting criteria for certain studies, etc. ) , little of this information is routinely added to the patient's medical records or the financial management data system. At present it appears that there are very few ways to link patient specific data from the medical record, from the management data system, and from the various data bases involved in research. Recognizing the need for more than general accounting type data, East Boston has contracted, as of July 1, 1983, with a firm to develop an in-house data system and management information system. According

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76 to the financial officer, this development and implementation is expected to take about two to three years. Currently, personnel from the health center are working with the consulting f irm in a needs assessment for the new data system. The emphasis for this new management information system will be on billing and will not include or attempt the computerization of the medical records. The new manage- ment information system will, however, result in the development of a new encounter form. it is unclear whether or not this new management information system will have the capacity to engage in community research projects. East Boston does have several other sources of data. The medical director noted that in Massachusetts there is what is called The police list", which is a census done by the police annually for purposes of voter registration. It is not very accurate, but gives some measure of the entire population. There are also U.S. census data specific to and available for East Boston. Furthermore, the state of Massachusetts collects a good deal of information around certain vital statistics. Dr. Taylor mentioned that aggregate data from birth certificates, for example, since 1975 represents a very rich source of information about marital status, risk of the mother, etc., and because East Boston is a geographically identifiable area of the city with distinct zip codes, the information that the state feeds back to East Boston is very useful information. Relationship to an Academic Program East Boston has several academic ties. It is linked as a subcon- tractor to Channing Laboratories now of Brigham Women's Hospital (BWH). East Boston subcontracts with BWA to do commmunity research in East Boston. it was through this link that the center first became a site in the federal Hypertension Detection and Follow-up Program and the various other studies that were piggybacked on to that. Fast Boston also participates in several primary care residency programs and provides a placement for interns f roan the local schools of public health. Organization of Financing The financing for East Boston comes basically from two major sources. One is service related revenues and the other is community research (Table S.1~. Generally speaking, the service-related revenues represent approximately 90 percent of the total revenues, and the community research component represents the balance. The service- related revenues include income from patients directly and f ram third party payers as well as income from service contracts, usually with public sources (city, state, and local). In the last few years approximately 75 to 78 percent of total revenues was from patients directly and third party payers while about 14 to 17 percent was generated f ram service contracts and grants.

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77 TABLE 5.1 [total Annual Revenues for East Boston Neighborhood Health Cente r by Source and by Year 1983 1982 1981 . TC)TAL REVENUES S6~437,S67 S5~506,.876 34~696~679 (100%) (100% ) (100%) Patient Services/ Direct & 3rd Party S4.836. 582 S4,271,137 S3,645,238 (75%) (781) (78%) Direct 243, 727 133, 676 Hedicare N/A 1,302,508 1,024,208 Private Ins. 1,990,435 1,568,825 Other 40, 621 161, 370 Patient Service/ Contracts & Grants S 877, 949 S 901, 642 3 814 ,139 (14%) (16%) {17%) Federal 30,126 5, 950 State 2S4, 075 231,188 local N/A 617, 441 577, 001 Pr ivate - ~~~ ~~~ Community Research S 645, 539 $ 274, 224 S 143, 017 (1096) (5%) (31) Other S 77, 497 $ 59, 873 $ 94, 285 (11) - (11) (296) N/A ~ not available. Revenues from community research, which in FY 1983 were approxi- mately S650,000, include a portion for direct cost (S9 percent) and another portion for indirect cost (41 percent). What seems noteworthy in East Boston's financing is the large percentage of revenues (approx- imately 60 percent in 1982) that came as fees for services from private insurance and Medicare. It should also be noted here that East Boston because of its ties to Boston City Hospital {BCH) is treated, for reimbursement purposes as an outpatient clinic of BCH. This level of reimbur sement is somewhat higher than if East Boston were a f ree- standing clinic or group practice.

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78 Over the years, there have been some changes in the organization of f inancing at East Boston that have inf luenced the practice of COPC. Generally, the changes had to do with the movement f rom a health center that had no billing (1972 to 1975) to a health center today that generates almost S5 million f ram patient revenues as result of billing third-party payerse The administrative director reported that there was no billing at the health center prior to 1975. From 1975 to 1978, there was an inefficient and ineffective system of billing third-party payers. In 1978, the Health Center earned S365,000 in third-party reimbursement. One year later , in 1979, the center earned S750,000 in third-party revenues--almost double the previous year . This revenue increase was as a result, in large part, of more efficient billing. The revised billing system combined with eventual increases in the number of visits and the actual utilization of the health center has generated the bigger total revenues. This kind of financing allows same flexibility and probably contributes to some cross-subsidization of the nonreimbursable community-oriented services. Another change in the financing that inf luenced the East Boston's financial status was negotiation of indirect cost rate for their com- munity research project. Acting as a subcontractor for Peter Bent Brigham Hospital, East Boston was able to secure an indirect cost rate of 41 percent. mis has helped absorb some of the administrative costs of running East Boston as a COPC. East Boston seems to have been relatively unaffected by the various fluctuations in public funding over the last 10 years. ILS financial situation seems to be marked by steady and rapid growth due primarily to the innovation of some sound f inancial management techniques in 1978 that marked a signif icant increase in revenues for the health center. When asked, the f inancial off leer noted that the current emphasis on fiscal management at East Elos ton (i.e., hiring a full-time f inancial manager ~ is more a function of organizational development and increased size than it is of concern over recent cut-backs. THE COMMUltI,rY Demog r aphy East Boston def ines its community as all of the residents in the geographic area, which, according to the 1980 census, numbered 32,000. This figure is about the same as that determined by the house-to-house survey done by the health center for its community research project. East Boston is predominantly an Italian-American working class community located on the east side of Boston, isolated from the rest of the city by the Boston Harbor, and sharing their geography with Logan Al rport. The 1980 U. S. . Census reported that the median income for East Boston was 314, 496, whereas for the city of Boston it was $16, 253 and it was S21, 258 for the Commonwealth of Massachusetts .

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79 According to the last census, the percent of people falling below the poverty level is 16.7 percent compared with 20.2 percent for the city of Boston and 9.6 percent for the Commonwealth. In East Boston, the percent of adults over 25 with a college degree is 11.6 (the lowest in all Boston neighborhoods). For the city, the figure is 33.4 percent and it is 3S.8 for the Commonwealth. The percent of the work force categorized as managers and professionals is 12. 3, the lowest in Boston, while 33.1 percent of East Boston's work force are categorized as blue collar. This represents the highest percent of blue collar workers in Boston. East Boston then appears to be compr ised of work ing poor . The infant death rate for children under one year in East Boston is considerably lower than for the city as a whole. According to informa- tion from'the Maternal and Infant Program of the Massachusetts Department of Family Health Services, in 1980 there were 644 -3 infant deaths per 100, 000 live births in East Boston as compared to 1,601.8/100 ,000 for the city of Boston. Other ethnic groups are in evidence in East Boston. Af ter Ital fan lamer ican, the second largest group is made up of a mix of Spanish- speaking people f ran Central and South America. Another group that arrived fairly recently in East Boston is Southeast Asians, mostly refugees and poor. There were no ratios, however, or actual figures given for the proportion of people in each ethnic group. From discussions with the director of social services, it appears that East Boston has good relations with a number of other community agencies in the area. She reported that East Boston has community- wide respect and visibility and is often called upon by other~social agencies to intervene or to counsel and/or to assume some responsi- bility for the social welfare of people living in Fast Boston. She also suggested that this might occur in part because people seem more willing to go to a health center for counseling or assistance than to another soc ial agency. The practice generally relates to community groups and other comanun ity health resources through the stat f . The board has attempted to maintain an arm's-length distance from the many organizations with both overt and covert political aims within the community. There are several projects or programs where East Boston is working closely with other local agencies. Specifically, there is something called the Parent Advocacy Consortium, 10 to 12 agent ies all concerned with problems of children and of rearing them. This group meets monthly and is coordinated by the social service department at East Boston. Another example of cooperation is something called the Elderly Services Network, wherein the social service department at the health center works closely with the community mental health center to coordinate services for the elderly. There has also been considerable contact between the medical director and various community groups in relation to the community surveys and epidemiologic research that has been part of East Boston activities.

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80 Community Involvement East Boston is a community governed and community run program. The East Boston Health Commitee, Inc., owns the building, is respon- sible for hiring staff, and is the grantee and/or contracting agent in awards of this kind. Health committee meetings are held monthly. Any resident of East Boston is allowed to attend. In general, the atten- dance at the health committee meetings is on the order of 30 to 40 individuals per meeting. me board of directors of East Boston is elected from members of the health committee and serve staggered terms of two years. Elections to the board occur in September at the monthly meeting of the health committee. An individual is eligible for election to the board if he/she has attended four out of six of the previous meetings (or can present a written excuse for not attending). Elec- tion to the board is then based on a majority vote of those members of the health committee present for the vote. Since its inception, the board has guarded against the possibility of a board member profiting in any way from being on the board. For example' the board made a decision that no relative of a board member is eligible for employment at the health center. The board members are not paid for their activities nor do they receive per diem or travel for attending board meetings. The board clearly governs the practice, and sets all relevant policy . Hey are responsible for the stat f ing of all positions within East Boston. Although they rely heavily on the medical d irector and the administrative director, the board members have the f inal say on all policy matters related to the program. Instances were cited in which apparently competent physicians were not hired as a result of poor performance at their interview with the community board. me members of the community board of directors bring a great deal of insight about the com`'unity's desires for medical care into the policy arena of the program. Although the board is primarily concerned with issues such as acceptability and accessibility of East Boston's services, they nonetheless are involved in identifying subsets of the community whose health needs are not being met. There are fewer examples in which the board was able to specifically identify a health need to which health center services should be directed. During the interviews, it was repeatedly stressed by the staff that the board has direct involvement in the identif ication of the survey research activities as well as the specific proceedures to be followed. How- ever, because of the close interaction between the board, the medical director and administrative director, it is difficult, for example, to determine the extent to which the board was involved in identifying the elderly population within the community as the focus for the recent senior health project. Theoretically, the community board can and does address all aspects of the operation of the practice. However, there appears to be little board concern for f inancial matters. They apparently rely a great deal on the stat f executive committee for dealing with f inancial matters. Often the board will approve pro jects such as start ing a cable

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81 television program, developing ~ congregate housing project, imple- menting a new management information system, etc., without a great deal of concern over the cost implications of these decisions. Hey trust that the staff will explore the f inancial implications of proposed projects. mere are a number of advantages in having the community involved in administration of a health center like East Boston, not the leant of which is the continual reminder of the patient perspective. However, community involvement does not occur without some costs. There are direct costs that include the personnel time for preparing for the meetings as well as attending the meetings. Preparations for the East Boston board meeting in fairly extensive in that this board reviews all personnel to be hired and requires that in most of the cases, at least two candidates be presented for their consideration. His occupies a great deal of administrative staff time. There is also the actual meeting time. The community board meets weekly for 10 months of the year for approximately three hours per meeting. The entire executive committee need to be available for each of those meetings. This represents considerable administrative personnel costs. There are also indirect costs associated with having a community board. Indirect costs in this case are the costs incur red by dealing with issues raised by the board, the costs related to spurting out the fires. it discovers. Given that the board tends not to concern itself with the f inancial ramif ications or implications of their decisions some of their decisions about dealing with community matters can be very expensive for the center. COPC ACTIVITIES AT EAST BOSTON Health Care for the Elderly Care and treatment of the elderly of East Boston has been a con- cern of the center s ince its establishmen~c. Community leaders have recognized for some time the need for appropriate services for the increas ing number of elderly in the community . More recently, East Boston is involved in a systematic ef fort to identify and document the health needs of the elderly. They are collaborating with the Univer- sity of Iowa and Yale in a study of health status of the elderly, funded by National Institute on Aging. This is intended to be a f ive-year study, with annual surveys of the senior citizens in the camnun ity. In 19 82, the f irst Senior Health Survey was done of all individuals within the community over the age of 65 years. This door-to-door sur- vey examined the individual's functional status, cognitive functioning, blood pressure , and functioning in activities of daily living, and measured the peak expiratory flow rates in all individuals. me sur- vey was nearing completion at the time of the site visit, and it was believed to have captured 80 percent of the community over 65. In addition, in 1983, a random 10 percent of the subset of the community

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8z over the age of 65 years was brought into the health center for a detailed necrologic evaluation as part of a study examining the pre- valence of Alzheimer's disease in a noninstitutional population. Questions designed specifically for feedback into the service mix of the practice were also included in this senior survey. For example, one of the questions asked was, What services would you like to have added to East Boston?. East Boston has used the results of the Senior Health Survey to identify several specif ic health needs of East Boston's elderly and measures have been taken to address these needs. According to the survey results, a substantial number of elderly people perceived difficulty in obtaining foot, eye, and dental care. Although East Boston was already providing these services, the staffing and the number of clinic sessions held per week was increased to meet the expressed needs of the community. Foot care clinics were increased from two to nine sessions per week, in the morning, afternoon, and evening . Dental stat f were increased by 1 dentist and two additional dental chairs were added. And, eye clinics went from 10 to 12 sessions per week and evening hours were added. The increase in personnel and number of clinic sessions was decided by the board in conjunction with the executive committee of East Boston. Announcements of the expanded services were placed in the two local newspapers in order to inform the entire community. The impact of the modifications made on the perceived accessibility to these services will be assessed by repeating the same questions on the next Senior Health Survey in July 1985 and from preliminary evidence from telephone interviews scheduled for 19&A. Since the foot and eye clinics services have been expanded the sessions have been booked. The eye clinic experienced a dramatic increase in visits from 239 in July to 407 in August of 1983. Result s of the 1982-1983 Senior Health Survey also revealed that many of the elderly people in the community have dif f iculty in traveling from their home to the clinic. East Boston is currently seeking f unding for a local transport system for the elderly seeking care at the center. In addition, the survey confirmed that there are a large number of dependent elderly in East Boston, a community that has strong extended family ties and that resists institutionalization of elderly. In response to the identif fed needs of these dependent elderly and sens itive to the cultural res istance to institutionalization, ache com- munity board tried to obtain funding to convert an old school near the health center to congregate housing for the dependent elderly in the community. An application was submitted to the Department of Housing and Urban Development to f inance the renovation. Monies were awarded in September, 1983. Plans are now being made for a 44 unit structure tentatively scheduled to beg in in 1986. Some stat f f ram East Boston will be on the board of directors, as will be the Steering Committee and will help set criteria for admission but will not manage the building. East Boston will provide the medical care for the residents. Determining the impact of this change will be a longer range endeavor, however, results of the annual Senior Heal th Surveys over the next four years may provide some indication of the impact of this congre- gate housing arrangement in the health of East Boston's elderly.

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83 Violence East Boston has a death rate due to homic ide that exceeds the national urban rate. In 1981, one of the pediatricians at East Boston reviewed death cert if icates and tabulated causes of death for East Boston residents under the age of 40 yearn. The results suggested a higher proportion of deaths due to homicide and violence in East Boston than in other urban areas of the United States. The protocol for counseling parents in child rearing and discipline practices was mc~dif fed to reflect a de-emphasis on practices that condone or may predispose to violence. Programs are also being developed for the community health block of cable television that will highlight and discuss selected dilemmas in child rearing. At the time of the site visit, there were no plans for monitoring the effect of these changes on the homicide rate. The effects were considered to be so lonq-range that they would be difficult to link to program modifications. Prenatal Care Concern over the adequacy of prenatal care of pregnant women in East Boston can be traced to. several sources. We clinicians noted that they were seeing many children in Well Child Clinic whose mothers had either received little/no prenatal care or, more commonly, received prenatal care from a source outside the community. The staff at East Boston then reviewed birth certificate data from the State Department of Public Health, Division of Family Health Services. mese -~data revealed that many East Boston mothers were not receiving prenatal care or , i f they were receiving care, it was not at East Boston. In talking to women with positive pregnancy tests done at East Boston, practitioners discovered that they didn' t want to deliver at Boston City Hospital, the hospital for which East Boston physicians had admitting privileges. Since they wanted the same physician for both prenatal care and delivery they chose of ten to go elsewhere for their prenatal care. In response to this identif fed need , the community board lobbied the Health Commissioner (City of Boston) to open Beth Israel Hospital for deliveries by Fast Boston physicians. The case load of prenatal patients at the East Boston doubled in the year following the change in admitting privileges. The birth certificate data were reviewed following the change to Beth Israel and they con- firmed that more East Boston women were getting prenatal care at the health center. It is not known, however, how many of the women now using East Boston for prenatal care were among the portion of the popu- lation receiving inadequate prenatal care and how many were receiving adequate care, but from sources other than the health center. Health Care for Adolescents In the mid-1970s, the staff at East Boston became concerned about the small number of adolescents seen at the center. They compared

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84 census data information on the numbers of teenager S living in East Boston to the numbers of teens seen at the health center. (The latter data were generated from East Boston' s in-house management data system. ~ A very large discrepancy was noted. The board and ache eves cutive committee identif fed this discrepancy as a problem area. From d iscussions with staff f ran other community agencies they knew that adolescents in East Boston were facing problems such as substance abuse, family violence, and teenage pregnancy. They concluded that there were probably many adolescents in their community whose health needs were going unchecked. East Boston has responded to this need for an adolescent program in two ways, one that involves a modif ication of the service mix at the health center, i.e., the addition of a teen clinic , and the other that brings primary care out into the community at large , i . e., a teen clinic in the high school. In 1977, the Comprehensive Health Services for Adolescents (Teen Clinic ~ was begun with the assistance of a grant fran the Medical Foundation, Inc. It was later expanded with funds f rom the Title V Program awarded by the Commonwealth of Massachusetts Department of Public Health, and is now supported entirely by other health center funds. For several years, it operated two evenings a week with a staff of physicians, nurses, and counselors. Recently, the service was expanded to include an af ternoon clinic in the high school. The service provides medical care, and both individual and group counseling to teenagers on a conf idential basis. Pregnancies are handled within this department calling upon the broad range of support services provided by other departments. Although East Boston does not maintain a duplicate medical record system at the high school, notes from encounters with teens there are copied and incorporated into their medical record at the center; if they have no record at the, one is created. In addition to the Teen Clinic, the staff has been involved in a health education program in the East Boston Junior High School since 1977. A nurse educator from East Boston has worked with teachers in planning and developing a health education curriculum including growth and development, reproduction, alcohol and substance abuse. The nurse educator and other staff members have also taught classes at the school and coord inated introductory programs and tours at the health center . Most recently, in September 1981, East Boston began working under a contractual arrangement with school health of f icials in the East Boston schools to increase use of preventive services and establish continuity of services in physical and mental health, and to provide comprehensive high quality health services in East Boston schools. file Teen Clinic was put into place within the administrative structure of East Boston and the j unior high health education program was implemented as an integral part of the program' s outreach to high risk groups. The school health services program, however, involved East Boston making a proposal to the school committee of the City of Boston to provide complete school health services for all students in District 8, estimated to have an enrollment of 3, 060. me se programs increase the visibility of-East Boston and allow for directed outreach to a large child and youth population, many of whom are not as yet

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85 enrolled at the health center. According to the medical director of East Boston, the effects of these modifications in the program are being measured by the increased number of teenagers using the clinics. It is expected that the school health services program will promote more comprehensive screening for children and youth with special needs, and early identification of adjustment and other adolescent health and medical problems. ANAI,YS IS OF EAST BOSTON AS A COPC PRACTICE The Functions of COPC Def ining and Character izing the Community There are several lists of the individuals in the community that are available for use by the health program. First, the re is the Boston Redevelopment Authority (BRA) population estimate (also known as the police list. ), which is an annual door-to~door census to all people of East Boston over the age of 18 years. Although this list is believed to slightly overestimate ache population, it is done annually . Because East Boston has natural bounder ies that def ine its census tracts, the U. S . Census data are also available, although not on an annual teas is. However, the primary source of data to define and characterize the consul ity comes f rom the epidemiolog ic stud ies done by East Boston . me most complete count and descr iption of all individuals in the com- munity was the census done in 1973, facilitated by participation in the national Hypertension Detection and ~ol1ow-up Program, and repeated again in 198 3. This produced a count believed to be 90 percent com- plete, which included for each individual of Post Boston, date of birth, sex, occupation, and relationship within the household. Since these data were organized by housing unit, they also provided house- hold linkages. These data are maintained by a computer and listings of specific subsets of the community can be generated when needed for particular studies as described below. Among the study sites, East Boston shares with the Kaiser/Oregon program the distinction of main- taining the most comprehensive mechanism for def ining and character- i zing the community. Certainly the health center operates at stage IV for thi s f unction. Identifying Community Health Needs The health needs of the population of East Boston have been identif fed in a var iety of ways--through the community board, outside data sou roes, and surveys conducted by East Boston. The East Boston. Health Committee is active in the identif ication of the health needs of the community. The type of health needs generated through th is mechanism generally are related more to satisfaction, acceptability, and accessibility of services and somewhat less likely to identify unusually high prevalence of specif ic health conditions.

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86 The first major study of the health needs of the community was started in 1970 in which a 3 1/2 percent sample of the total of the East Boston Community was visited at home to obta in a blood pressure, a urine sample, and estimate of utilization of health services. It was largely through this study that, the East Boston was in a competi- tive position to bid successfully for participation in the more exten- sive Hypertention Detection and Follow-up Program (HDEP). As an outgrowth of the community census done by East Boston staff in 197 3, add itional data were collected on several other population groups including all women over the age of 16 years, all adults between the ages of 30 and 69 years, and all children between the ages of 2 to 6 years. Ebr these subsets of the community, additional data related to smoking, current symptoms, utilization of services, the screening of blood pressure was obtained. For the women over the age of 16 years, ur ine sables were also obtained. In 1975, a complete sample of all women between the ages of IS and 50 within the community was done using the 1973 census data as a base. This was part of a study of the use of oral contraceptives. In general, the health center identif ies and characterizes health problmes of the community with problem-specific epidemiologic studies. These are well designed and place East Boston at stage III in the development of this function, for the majority of their COPC efforts. Stage IV differs from TII in that at this level of development, problem identif ication is a process that involves formal mechanisms to identify and set priorities among a broad range of potential health problems in the community, identify their correlates and determinants, and character ize the existing patterns of health care related to the problem. Isis is essentially the process East Boston is using to address problems of the elderly population. In 1982, the first of five annual senior health surveys was conducted to determine the health status of the elderly {over 65) population in East Boston and identify their health needs. The door-to-door survey captured approximately 80 percent of the over-65 population in East Boston. In addition to the collection of physiologic data, such as blood pressure, cognitive functioning, and peak expiratory flow rate, inquiries were made about the adequacy and util ization of services at the health center. The data were reviewed by the health board and priorities were set among the many competing issues suggested by the study. AS a direct result, clinic hours for certain services and staffing at East Boston have been expanded, a transport system is also be ing planned, and a ma jor ef fort was mounted to develop a pro ject for congregate hous ing for the elderly. Modifying the Health Care Program At East Boston, the way data describing community needs are translated into changes in the primary care program rests primarily with the community board and The executive off leers working together. It is at this level that planning of modif ications in the health prom gram takes place to address the priority problems of the community.

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87 In general, the program modifications for all of the COPC activities descr ibed meet the or iter is for stage ~ II. All appear to be formulated based on extensive knowledge of the particular problem in the East Boston camunity, all employ an appropriate mix of primary' care and community health program strateg ies, and all appear to address the health issue at a point of reasonable intervention. Monitoring Impact of Program Modif ication~ Among the four functions of COPC, the health center has been rela- tively less systematic in monitor ing the impact of program nK'dif ica- tion made. Due to the long-range nature of any observed effects in the attest to deal with violence through modif ication~ in child rearing practices, there is, appropriately, no immediate plan to assess the impact of this effort. The plan to assess the effect of efforts to address a wide range of issues in adolescent health is based on an anticipated increase in the number of adolescents using the health center, and thus is at stage O of development. In contrast, the ef feet of improving the prenatal care for the community was based on a repeat review of the marital statistics for East Boston and clearly demonstrates stage III development. The most thorough assessment of program impact in illustrated in the efforts to address health problems of the elderly, and rigorous ef forts are under- way to monitor the impact of the program modif ications undertaken. Me senior health survey is part of a collaborative effort with the University of Iowa and Yale University, funded by the National Insti- tute on Ag ing, and there are plans to do senior health surveys annually for five years. Repetiton of the surveys over a five-year period will allow East Boston to not only ref ine what they know about the health needs of the elderly, but the sequential data will also allow for measurement of the ef feats of program changes. This ef fort as well demonstrates stage III activity for this function. Environmental Of luences mere are a number of historical and environmental factors that have facilitated the development and maintenance of a co~unity- oriented primary care atmosphere at East Boston: it is a large, con~unity~owned and operated health center: it has a distinctive community with a geography that set. it apart and thus attracts epidemiologic researchers: and has the ability to generate revenues fran a variety of sources. Organization of the Practice In the late 1960s, several coincidental factors led to the estab~ lishment of East Boston as a co~nunity~or tented practice. The decision on the part of the Boston Commiss ion on Health and Hospitals to support

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88 a health center in East Boston provided the core of a program to a com- munity that had relied on a city run relief station and an emergency room for same 50 years. This program became very much tied to the community when the struggle for control of the health center between the city's central service support and the community board ended with the board being recognized as the controlling entity. A third factor was the addition of Dr . James Taylor as medical di rector. Or . Taylor brought to East Boston a strong interest in co~nuni~cy-based epidemio- logic research. East Boston was particularly suited to this kind of research because of its relative isolation from the rest of the city of Boston and its relative homogeneity. East Boston has participated and continues to participate in national studies that generate data specif ic to the geographic area of East Boston and increase its capacity to per- form COPC functions. one interplay of theme three- factors over the last 13 years have resulted in a blend of elements that have supported an innovative program of COPC. Coccus ity The Board of Di rectors of the East Boston Health Committee, Inc. clearly govern the practice and set all relevant policy, a fact that is not challenged by the profess tonal stat f . The community board br ings a great deal of insight about the co~nunity's desires for medical care into the policy arena of the program. Although they are primarily con- cerned with issues of acceptability and accessibility of the East Boston's services, they, nonetheless, are involved in identifying and characterizing health needs thereby making East Boston community- oriented. Over the years, there has been a good deal of continuity among the board and the management structure contr ibuting to a success- ful working relationship. An important feature of East Boston that helps to keep the program running smoothly is the mutual respect and trust shared by the medical director, the administrative director, and the community board. The community involvement at rest Boston has played a key role in it. evolution as a COPC. Organization of Financ ing Ability to generate revenue f ram a variety of sources has been important to East Boston's ability not only to grow as a health center but also to support many of the COK: activities it has engaged in over the last ten year a. In its early years, East Boston struggled under the f inancial umbrella of the Boston City Hospital. In 1978, some sound f inancial management techniques were applied to the billing sys tem and withi n one year revenues f ram third-party re imbursement for personal health se rvices grew dramatically. This growth occurred with little or no increase In services. This boost in third-party reim- bursement made East Boston less dependent on the city budget for revenues and introduced more flexibility in the types of services offered and the stat f hired. With the opening of the new building,

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89 paid for by a two million dollar Hill-Burton grant, there was an ir~crease in utilization and overall growth in the center that has contributed to its f inancial stability. Revenues frail conounity-based research have made performance of some of the COPC functions easier for East Boston. For example, as a participant in the national Hypertension Detection and Follow-up Program, the center was able to conduct the first door-to~door survey of the East Boston community in 1973. This census not only enumerated and characterized about 90 percent of the population, but also helped the staff identify she community health needs. These data are ma~n- tained on convoluter f iles and listings of specif ic subsets of the community can be generated when needed (e . g ., for other studies) . Having this base of information about the East Boston community has also served to make. East Boston an attractive site for more comounity- based research. Additional research has meant not only additional revenues, but also more information about the health status of the East Boston cononuni ty . SUMMARY S. ince its inception, East Boston has had a clear miss ion to serve all res idents of the community, and the pr inciples of CO PC form the foundation on which marry of the activities of East Boston are based. The brochure that descr ibes the health center state. that, Tour purpose is to provide personalized high quality health services easily access- ible to all residents of East Boston. ~ It also points out that for health care to be effective it Must be concerned with the factors that affect the spectrum of health and disease in the total community and not just the symptoms that bring patients to doctors. ~ lane concern for the spectrum of health and disease in the community has led the health cente r to conduct a number of door-to~door screening and prevention programs focusing on hypertension, respiratory condit- ions, otitis media in children, urinary tract infections in women, and needs of the elderly. The Senior Health Pro ject, which began in 1982, is one of the better examples of a COPC activity among any Of the study sites, particularly in che way in which it has systematically approached the range of poten- tial health issue. and set priorities in this age group. As part of a larger epidemiologic research project, the COPC effort began with a surrey to collect information describing the health and social status of all persons 6 5 years and older to assess the needs of this popula- t ion. The survey included questions about health and sac lal issues, but also included several physiologic measures. The primary objective of the survey was to better understand the range of medical and social problems of this age group in order that the health center might select an appropriate set of issues to address. In sum, East Boston is an active practice of co~nunity-oriented primary care. The health center has not only assumed responsibility for the health of all East Boston residents, but also systematically goes about identifying the individuals and families who make up the

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90 population, and calls on a variety of resources to address ache health needs of the community. Once identif led, every ef fort is made to modify the program in response to those needs and then measure the effectiveness of the change. An summarized in Table 5. 2, the health center is operating at a high level of development for all of the CO PC functions. With a strong commi~nent to the entire community, the East place a system that forms the foundation for Boston program has put In many f uture COPC activi ties. TABLE 5. 2 Comparison of the Level of Development of the Ma jor Func- tional Elements of COPC in the East Boston Ne ighborhood Health Center Identify Modify De f ine and Commun i ty the Mon i to r Characterize Health Health Impact of the Cononunitv Problems Program Modif ications . . STAGE 0 STAGE I STAGE I ~ STAGE ~ I I STAG1: IV TEENS PRENATAL VIOLENCE TEEMS X ELDERLY PRENATAL VIOL=CE TEENS ELDERI`Y PRENATAL ELDERLY ELDERLY refers to the activity that addressed the problems of the - elderly population of the East 80ston community. PRENATAL refers to the effort to improve the utilization of prenatal service among the community . VIOLENCE refers to the efforts to influence child rearing practices away f rom violence-pron~oting behavior . TEENS refer to the attempts to increase the utilization of the health center by the adolescent population of the community.

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91 INTERVI ENS James Taylor, M.~., Medical Director John Cradock, Executive Director Mary Abate, Director, Medical Records Mary Louise Cooney, Physician Assistant, Adult Medicine Mary Ellen Keough, Operations Manager for Research Helen M. P. McCormack, Pres., Board of Directors, East Boston Health Cocci ttee, Inc . Jean Nesbitt, Director, Home Health Care Linda Riesenberg, Director of Social Services Howard Rivenson, Chief Financial Of f icer Pete r Str ingham, M. D., clinician

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92 REFERENCES Boston Redevelopment Author ity, Neighborhood Planning Program. 1979. East Boston: District Prof ile and Proposed 1979-1981 Neighborhood Improvement Program. Boston: The Program. East Boston Neighborhood Health Center (n.d. ~ Good Medicine {brochure) . East Boston. 1975. Application for Hill-Burton Outpatient Facility Grant . East Boston Neighborhood Health Center. 1979. Establishment of Populations for Epidemiologic Studies. Technical Proposal to the National Insti totes of Health. East Boston Ne ighborhood Health Center . 19 82a. Annual Report to the East Boston Community Health Committee, Inc. East Boston Neighborhood Health Center. 1982b. Maternal and Infant Care Section of Proposal to the Massachusetts Department of Health for a Maternal Ch ild Health Program. East Boston Senior Health Pro ject . Good Health--Community Outreach and Preventive Program of East Boston Ne ighborhood Health Center ~ b rochure ~ .