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OCR for page 71
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
OCR for page 72
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
OCR for page 74
74
Aim'
1 Low
ad
'
51
E'
8'
. I~
ba ~
-
-
Lam
l
1 ~m
_
~ Law
~ .
~ ~ ~ ~~ 5
l]
,02
1
~ .
~1
L
.
~ 1-~1 ~ 1'
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Bi
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04
-
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11
it.
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15 1
165 1
t
~ 1
al 1
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1~1 ~ 1 ~ 1 851 M!
i i
1~1 ~1 ~ 1
1~ law
FIGURE 1 Organization Chart of East Boston Neighborhood Health Center.
OCR for page 75
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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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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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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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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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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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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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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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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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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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 ~ .
Representative terms from entire chapter:
health center
