Community Oriented Primary Care A Practical Assessment, Vol. 1: Report of a Study (1984) / Chapter Skim
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Analysis of Current Practices
Analysis of Current Practices
Pages 47-96
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From page 47... ...
As a result, there were 147 sites suggested as places engaged in COPC-type ac~ci~rities. The suggestions ranged from solo practices in rural West Virginia to community health centers in San Franci~co to 47
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From page 48... ...
There were several different types of practices and program Mung the 58 suggested sites. There were 17 community health center program (5 rural and 12 urban}, 15 median Health Service units, 3 health maintenance organizations, 12 nonprofit private practices, 7 for-profit private practices, 2 hospital-based programs, ~ consortium of neighborhood heals cen~cers, and a union health program.
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From page 49... ...
With the exception of Raiser/Oregon, which generates revenues from member dues, the four sites (Checkerboard, East Boston, Montefiore, and Tarboro} that exist all or in part as not-for-profit operations have public grants and contracts as one cuff the ma jor sources of revenue . In was noted, however, that for several of these sites, third-E,arty payment is becoming an increasingly more significant source of revenue.
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so cn oD v o c)
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The Checkerboard Area Besith System is a primary care program composed of ~ health center and four satellite clinics serving culturally diverse population in northwestern New Mexico. The approximately 14,000 residents are widely dispersed over 4,000 square miles in small villages or family camps.
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Crow Bl11 Family Medicine Center. The Crow Bill Family Medicine Center, a priorate family practice begun in 1977, is located on a major highway in Bailey, Colorado, 60 miles west of Denver.
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East Boston Neighborhood Bealth Center is a large community owned and operated health center that provides comprehensive primary care services to the residents of East Boston, - ~sachusette. The health center has been operating since the late 1960 s under the direction of a community board that decides on major policy questions, owns the building , is responsible for hiring and firing staff, and is the grantee and/or contracting agent in awards of this kind.
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(For other examples of COPC activities at =st Boston, see Table 5.4.} However, there has been no systematic documentation or monitoring of the effects of these changes. Kaiser-Permanente Medical Care Program of Oregon.
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Be 2 o TIC ~ o ad o ~ TIC a .8 .!
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Montef tore Family Bealth Center* The Montefiore Family Health Center is an urban community health center established in 1980 and affiliated as a primary practice with the Department of Family Medicine at Mantefiore Bospitel and Medical Center.
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From page 62... ...
The tribal health program at Sells include ~ nutrition program, ~ disease control program, psychologica1 services, an alcoholism program, ~ program for the elderly, a community health representative program {outreach workers}, a program for traffic and highway safety, and the Papago Children ' ~ Ilome. Life on the Papago reservation is a combination of treditiona1 lifestyle with an ever increasing presence of modern influences.
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From page 64... ...
mbe County is affiliated with the Tarboro Clinic. The other components of Terboro are the county health department providing ~ broad array of public health services, the Ares Belch Education Center providing medical education, continuing education and recruitment of health manpower for E:dgecombe County, the Tarboro-Edgecombe Bospital, which was operated by the county until its recent acquisition by Bospital Corporation of America, and the Community Medicine Foundation, a nonprofit corporation with ~ board of directors drawn from Tstboro Clinic physicians Id local community leaders, which receiver grants from several sources ~ conduct health services research and to operate four satellite facilities thereby extending ~ program of services to underserved areas.
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From page 65... ...
However, the East Boston is the only source of primary health care in ache geographic area, and Montefiore is the only regular provider of primary care services in its
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The board of directors of East Boston actively governs the practice and meets at the health center each week for 3 to 4 hours to review all administrative and soanagement matters. The community served by Sells participates in the health program through Me activities of the Executive Bealth Staff, with authority over all health matters delegated from the tribal government.
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In mast sites, practitioners are available around the clock, although the mix of office hours, scheduled appointments, and drop~in or emergency room care varies considerably. Several sites {East Boston, Crow Hill, and Tarboro)
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From page 71... ...
East Boston, Checkerboard, Montefiore, and Tarboro have a sliding fee scale for their patients. Crow Bill, which has no special arrangements for those unable to pay, does care for Medicaid patients and has made significant efforts to reduce financial barriers to care.
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From page 72... ...
An interesting form of accountability occurs at East Boston where the primary care providers are directly responsible to the community board that owns and governs the health center. The board holds them accountable for the quality of care provided and pays a great deal of attention to patient problems and complaints.
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From page 73... ...
By developing contractual arrangements with the Indian Health Service, the state health department, and the local school sy=tems, it has developed both the revenue base and ache mandate to perform several important public health and community Medicine functions in its community. Finally, Sells is a component of a federally supported and operated health care program, which has evolved over nearly 30 years with ache specific charge to meet ache health needs of a defined population.
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From page 74... ...
The ORD of the Indian Bealth Service was es~shlished in the late 1960s to conduct heal~ch services research and development activities to enhance the ability of the IES health care program to meet the unique health service needs of the American Indian people. In both Rites the marriage of the service delivery program and the research component was intended to produce techniques and under';tanding of health care that would not only benefit the local delivery program but improve the delivery of service; throughout the larger institution.
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From page 75... ...
~ntefiore and Tarboro have also developed clinically rich cats bases that include records for those individuals in the community who have received health services from the practice. Both sites have utilized the data systems principally for practice management, but have found them useful in augmenting assessments of the community health problems .
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From page 76... ...
Because both program include a variety of none clinic based health services, they also have the additional flexibility of initiating nonclinical interventions. The problem of financing COPC activities was greatest for Crow Bill where the practice revenue was derived largely from direct patient services.
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By incorporating into their system other elements of the health care program, they have been able to build an organization and ~ financial base that supports COPC activities. Thus, it would seem that further examination of the innovations developed in these sites would help to formulate mechanisms by which the environmental variables can be manipulated to support COPC.
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From page 78... ...
78 1 ~ o ~ o U o ~ ~ 1 v o o ~s ~: 3 C, s~ c 8 In o v c C ~ o o _ ~ ~C o V o _ ~ _ ~ sr s o ~ D K K _ >, ~C ~ c,_ ~ :' x ~— _ C V :, ~ U ~ .04 ~ ~ .
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From page 79... ...
. Checkerboard, Crow Hill, East Boston, Raiser/Oregon, and Sells could develop a listing with reasonable accuracy and varying currency.
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From page 80... ...
Due to its large urban and difficultto~define community, this is predominant strategy employed at Hontefiore. Monte fiore also collaborates with the other ten community health centers in Me Bronx to compile city , state, and federal health data that can be disaggregated for the specific census tracts corresponding to their community.
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Several of the study sites attempt routinely to monitor the health problems of a subset of their community. For example, East Boston has begun a long-term effort systematically to address the needs of its elderly population and this effort has led to several important emphasis program.
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From page 83... ...
The study sites where clinical primary care, outreach, and community-based health programs are integrated J notably Checkerboard, Sells, and Kaiser/Oregon, showed the greatest propensity to rely heavily on the use of community health strategies in developing an emphasis program. Stage II in the development of this function describes modifications made largely in response to the availability of special resources to address a particular problem, and are designed in accordance with guidelines established external to the project.
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From page 85... ...
Among the study sites, Crow Bill was the most constrained in making major program modifications and was also the site with the largest percentage of total practice revenue based on direct patient services. Instead, the Crow Hill practice developed collaborative efforts with the resources of the county health department and the school health program to extend their efforts into the community.
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From page 86... ...
86 v ~4 o e ~d o i: o C, o solo 1 ~ FlaL Pi ~ EM to Ig 's 9 . ~ So ~ ll' Of ~ o Cl _ Via ~ I~ of al IS ~4 o o o id v o so q o 3- E~ i~ , ~ ~ 55 Iglll ~ ~ ~ to _ ~ o o to o ~: ~ — e c ~ 0 _ v ~ F a ~.c ~ ~ _ — ~ ~ c 0 _ ~ ~ c, ~ `: a _ ~ ~ O a_ 0 ~ .
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From page 87... ...
Similarly, the cost of community participation also must include the time-value of the professional staf f who participate in the activities of community health programs and serve on ache board of community agencies, even if they do do on their own time. Of all the COPC functions, the cost for the modification of the health care program is most difficult to estimate .
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From page 88... ...
For example, at East Boston much of the cost of the weekly meeting with the Board would be attributable to the operation of the primary care program. Given this cost, the marginal cost of planning and implementing the COPC program modification probably would be small.
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However, there is evidence in the literature on the impact of innovations in primary care which share some of the characteristics of COPC. For example, there have been a number of studies which attempt to examine the impact of comprehensive care using community health centers and health maintenance organizations.
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and hypertension (NACHO, 1980}, general indicators of maternal and child care are the most frequently reported. Evaluations of the community health centers have frequently reported important effects on infant mortality (Davis and Schoen, 1978)
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From page 91... ...
In addition to identifying the patterns of illness in the community, this COPC function requires an understanding of the extent to which the current operations of the health care program is influencing those patterns. Thus, COPC must offer the clinician techniques for the simple examination of the extent to which his mix of primary care services is adequately serving the needs of his entire community.
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From page 92... ...
The data base could be used either to conduct limited epidemiologic studies, limited only by the variety of clinical data available, and would be useful in identifying samples of the community for further epidemiologic investigation. The data base could be used similarly to monitor the impact of modifications made in We health care program by tracking the extent of application of the program Edification and observing outcomes, again limited only by the scope and specificity of the clinical data.
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From page 93... ...
In this regard, the Montefiore Family Bealth Center was a member of a coalition of all of the community health centers in the Bronx, which gained an economy of scale in the quantitative functions of COPC through collaboration. This essentially also was accomplished at Tarboro and Checkerboard.
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From page 94... ...
Journal of Community Health 3:306-320. Galazka, S.S.
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From page 95... ...
1979. The Impact of a maternal and child health care program on the quality of prenatal care: An analysis by risk group.
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From page 96... ...
Journal of Community Health, Carol.
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