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care services and case management, while avoiding duplication.

Reducing Organizational/Operational Barriers

A number of service delivery programs, in conjunction with State and local health departments, are working to coordinate services and resources available from multiple and varied programs, thus enhancing the accessibility of service delivery. This includes case management of the medical continuum, as well as of a broad range of welfare and other support services. The Office of Maternal and Child Health is currently funding demonstration projects to implement one-stop shopping programs at C/MHCs and other sites. This involves co-location of health, social, and welfare services from different agencies in the same physical location. C/MHCs have historically jointly addressed the social and clinical aspects of health care. Currently, 113 C/MHCs receive WIC funding, and many more provide WIC services directly or by arrangement. Three to four demonstration projects of new one-stop shopping approaches are planned for FY 1990. Finally, 35 State and Regional Primary Care Associations and 33 State Primary Care Cooperative Agreements are working with their respective States on presumptive and on-site Medicaid eligibility. C/MHCs in at least 20 States are eligibility determination sites.

These efforts to coordinate various programs help to avoid duplication, and increase the likelihood that individuals will access all that is available to them. Such integration is critical to a disadvantaged population faced with a patchwork of programs at different sites and with oftentimes inconsistent requirements.

Reducing Cultural/Social Barriers

Subsidized service delivery programs have effectively focused their efforts on minority groups. Approximately 64 percent of those served by CHCs are members of minority groups, and those served by MHCs are 50 percent Hispanic and 35 percent black. 62. 63 Similarly, over 50 percent of those served by hospital outpatient and health departments are minorities. 64 Finally, there is considerable support for

62 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 16.

63 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 16.

64 Kovar, "Background Paper for the Select Panel for the Promotion of Child Health."

education of minority health professionals, since these professionals often serve minority, underserved populations. The NHSC recruitment program has developed a recruitment plan to increase the number of Hispanic officers by 150 within 2 years. Additionally, the National Medical Association, under a contract with the Health Services and Resources Administration, actively promotes education for minority health professionals by visiting and providing informational materials to minority students in colleges.

In addition to the delivery of medical care, primary care programs can offer a wide range of outreach services which facilitate the receipt of care which is available. C/MHCs are governed by consumer-based Boards of Directors. These volunteers, who represent a broad spectrum of community concerns, encourage outreach activities which will help to ensure culturally sensitive and appropriate care. Examples of innovative approaches of C/MHCs to outreach are a "mom-mobile" for Indianapolis centers and use of athlete celebrities to reach school aged youth in Detroit.

The effectiveness of culturally sensitive outreach services is illustrated by a 1974 study which compared pregnant women who used health centers with outreach services, traditional hospital outpatient departments, and Medicaid physicians, and found that the women who used health centers were most likely to be satisfied with their obstetric and pediatric care and most likely to make postnatal visits. 65 More recently, several CHCs in Pennsylvania which sponsor lay home visiting programs have shown that since implementation of home visiting services, the rates of prenatal visit compliance, the return rate for postpartum care, returns for routine pediatric care, attendance at prenatal and parenting classes, compliance with family planning appointments and WIC registration have all improved. 66

In addition to outreach activities, primary care programs can provide a wide range of social services which address language, educational, environmental, and other cultural barriers. An example is the "Women's Residential Program," offered by the Economic Opportunity Family Health Center in Miami, Florida. This program, which was developed to respond to the problem of substance abuse among women of child-bearing age, provides detoxification and preventive health services (i.e., individual and group therapy) as well as GED preparation, job training and placement, parenting education and coun

65 J. Birch, and S. Wolfe, "New and Traditional Sources of Care Evaluated by Recently Pregnant Women," Public Health Reports 91 (SeptemberOctober, 1976): 412-422.

66 Marcella E. Lingham, Ed.D., Letter to Natalie Levkovich, Quality Community Health Care, Inc. (Philadelphia, Pa.: November 13, 1989).

seling, long-term follow-up, and child care on the premises. As another example, Beaufort-Jasper Comprehensive Health Services, in South Carolina, provides a broad range of medical as well as social support services in a community with a very high infant mortality rate, and predominantly poor residents. A high proportion of the population lives in substandard housing. In addition to health care, the center provides environmental services. One very tangible result, which has an obvious impact on health status, is the fact that the center has installed or updated well over 100 water systems for families who previously had poor water systems supplies.67

Clinical Outcomes/Health Status

A number of studies have shown that, in their impact on the underserved families they were intended to serve, primary care programs have been quite successful. Many of these studies included control groups who used Medicaid but not a service delivery program. Unfortunately, most of the research noted below was conducted in the 1970s and early 1980s. There has been little analysis on the effectiveness of primary care models in the last ten years.

Efficiency and Cost-Effectiveness-CHC patients have lower hospital admission rates, shorter lengths of stay, and make less inappropriate use of emergency rooms than similar patients not using CHCs. 68, 69 For example, an extensive study in five cities found hospital days were reduced by 25 percent for child and adult users of CHCS compared with all similar nonusers in control groups and 22 percent for users compared with those in control groups using a private physician.70 Similar results have been found by others. The effect of primary care service delivery programs was demonstrated in a three-city study which found that Medicaid recipients who were users of community health centers had total annual Medicaid costs of 6-58 percent less than a control group of Medicaid recipients who relied on hospitals and private physicians for their usual source of care.71 Additionally, emergency room visits by children were reduced 38 percent by primary care centers in

67 Lefkowitz and Andrulis, "The Organization of Primary Health Services," Better Health for Our Children, 475.

68 Schorr, Within Our Reach, 132.

69 Andrea McCrensky-Kremer and Richard Kremer, “Overview of DRGs: What they are and How They Work," (draft unpublished report, Harrisburg, Pa.: September 27, 1989), 13-15.

70 L.M. Okada and T. Wan, "Patterns of Health Services Utilization in Urban Low Income Areas." Paper presented to the Institute of Management Science/Operations Research Society of America, Joint National Meeting, New Orleans, La.: April 30-May 2, 1979.

71 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 21.

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The provision of comprehensive primary care services by health departments has also been associated with improvements in the area of low birth weight and infant mortality.75 For example, between 1970 and 1978, the Cincinnati Health Department reduced infant mortality by eight percent. Also, during provision of primary care services between 1970 and 1977, Maricopa County (Arizona) had its low birth weight rate reduced by 16 percent, and Pickens County (South Carolina) had its nonwhite infant mortality rate reduced by 38 percent, from 40.7 to 25.3, between 1970 and 1973. Finally, Denver's Neighborhood Health Program (a joint CHC/health department effort) resulted in a 25-percent reduction in infant mortality.76

Childhood Diseases-Primary care programs have reduced rheumatic fever and untreated middle ear infections, and have brought about an increase in the number of immunized children. For example, one study attributes a 60 percent decrease in rheumatic fever in Baltimore areas served by primary care centers to early detection and treatment of streptococcal infections. 77. 78

72 L.E. Hochheiser, "Effect of the Neighborhood Health Center on the Use of Pediatric Emergency Departments in Rochester, New York," New England Journal of Medicine 285 (1971): 148–152.

73 E.J. Sussman, "Can Primary Care Deliver?" Journal of Ambulatory Care Management 2 (August 1979): 23–29.

74 Michael Grossman, Ph.D., and Fred Goldman, Ph.D., "An Economic Analysis of Community Health Centers," National Bureau of Economic Research (January 1983).

75 Lefkowitz and Andrulis, "The Organization of Primary Health Services," Better Health for Our Children, 460.

76 A. Chabot, "Improved Infant Mortality Rates in a Population Served by a Comprehensive Neighborhood Health Program," Pediatrics 47 (June 1971): 989-994.

77 Schorr, Within Our Reach, 132.

78 L. Gordis, "Effectiveness of Comprehensive Care Programs in Preventing Rheumatic Fever," New England Journal of Medicine 290(8) (August 16, 1973): 330-336.

Clinical Management-Studies of clinical management and quality of care, measured by recordkeeping, indicate that Federal primary care programs are at least equal and sometimes superior to other established providers, including private physicians, and that health department primary care programs are superior to private physicians and outpatient departments. 79, 80, 81 Many Federal primary care centers pioneered the team approach as well and have found it effective. 82, 83, 84

Social Services-Social support services offered through primary care programs are critical in protecting an individual's health. For example, programs to counteract certain environmental hazards through organized health settings have been effective in reducing morbidity and mortality. 85, 86

FUTURE DIRECTIONS

Although the successes to date are encouraging, more remains to be done. A range of activities is needed to reduce barriers to care, and ultimately improve health status. These activities, for the most part, are not new. They are currently being implemented at innovative organized primary care delivery sites. However, implementation is far from universal. A model for reform, which describes an optimal continuum of activities, is described below. Additionally, the interaction between financing and delivery system reform is discussed. Finally, strategies for continued targeted direct support of organized primary care delivery programs are presented.

79 M.A. Morehead, R.S. Donaldson, and M.R. Servalli, "Comparisons Between OEO Neighborhood Health Centers and Other Health Care Providers of Ratings of the Quality of Health Care," American Journal of Public Health 61(7) (July 1971): 1294-1306.

80 M.A. Morehead and R.S. Donaldson, “Quality of Clinical Management of Disease in Comprehensive Neighborhood Health Centers," Medical Care 12 (1974), 301-315.

81 M.A. Morehead, Final Report 1968-1976 of Review of Federally Supported Neighborhood Health Centers, Contract Number 105-74-170 (Albert Einstein College of Medicine, Bronx, N.Y.: 1977).

82 Morehead, "Review of Federally Supported Neighborhood Health Centers."

83 M.H. Becker, R.H. Drachman, and J.P. Kirscht, "A Field Experiment to Evaluate Various Outcomes of Continuity of Medical Care," American Journal of Public Health, 64 (November 1974): 1062-1070.

84 K. Davis and R. Marshall, "Personal Health Care Services for Medically Underserved Populations," Papers on the National Health Planning Guidelines, Health Resources and Services Administration, Department of Health and Human Services (Washington, D.C.: 1977).

85 C. Spiegel and F. Lindaman, "Children Can't Fly: A Program to Prevent Pregnant Childhood Morbidity and Mortality From Window Falls," American Journal of Public Health 67 (1977): 1143-1146.

86 P. Peacock, A. Gelman, and T. Lutins, "Preventive Health Care Strategies for Health Maintenance Organization," Preventive Medicine 4 (1975): 183-225.

Model for Addressing Barriers

For optimum effectiveness, a model service delivery program would include the components described below.

Medical Primary Care-Comprehensive medical primary care should be offered in an environment that is physically accessible to the population it is intended to serve, and that has a sufficient number of appropriately trained professionals who are sensitive to cultural, ethnic, and language differences.

For many services, the manner of delivery is as important as the fact of delivery. For this reason, in addition to increasing the numbers of health care providers, organized primary care programs should increase efforts to recruit and/or train professionals that are perceived by those they serve as people who care about them and respect them. Schorr states in Within Our Reach that "staff must be able to respond to the individual needs of those they serve. The nature of their services, the terms on which they are offered, the relationships with families, the essence of the programs themselves—all take their shape from the needs of those they serve, rather than from the precepts, demands, and boundaries set by professionalism and bureaucracies.” 87

Case Management and Coordination of ServicesCase management activities should include proper and timely referrals to medical specialists, as well as to programs for mental health and substance abuse services. Additionally, there should be case management, and where possible, co-location of a broad range of welfare and other support services, including income support, housing, and job training. Successful programs are those that provide services that are coherent and easy to use. Relying too heavily on referrals to other agencies interferes with getting needed services. 88 Thus efforts to integrate services should in particular encourage co-location of related services and development of common eligibility requirements, rather than simply an active referral network. The importance of integrating a wide range of available services has been noted by David Rogers, former President of the Robert Wood Johnson Foundation. He states that service programs cannot respond to intertwined and interconnected needs without regularly "crossing traditional professional and bureaucratic boundaries." 89 Other support services are necessary to encourage at risk populations to maintain participation in care, and arrange for additional care

87 Schorr, Within Our Reach, 259, 269, 278.

88 Schorr, Within Our Reach, 258.

89 Schorr, Within Our Reach, 257.

as needed. Examples of such services which organized primary care programs should work to enhance include on-site day care, health education programs, bilingual services, and environmental services.

Community Outreach-In order for needy populations to best benefit from the facilities, services, and coordinating systems which may be in place, it is critical that there be a strong outreach program which fosters health prevention and promotion behavior, encourages early entry into the health and social services systems, and includes rigorous and continuous follow-up activities. These outreach activities are more effective if they are linked to a service delivery program, rather than existing independently. The solution lies in helping communities implement their own change in health behaviors, so that available services and resources will be used more often, and more effectively. Ways for primary care service delivery programs to increase their outreach efforts include use of volunteer outreach workers, public information campaigns directed at high-risk groups, telephone hotline services, transportation and home visiting programs, and periodic review of office or clinic procedures to make certain that access is easy and prompt, bureaucratic requirements minimal, and the atmosphere welcoming.90

Community Input and Responsiveness-Primary care programs should address unique local circumstances and health care problems, and should be flexible enough to meet the diverse needs of the underserved.

Evaluation-There has been a recent dearth of studies on the effectiveness of primary care models and services. Part of any model should be the capability to study reforms and provide short term feedback and longer term evaluation of impact.

The Interaction Between Financing and Delivery System Reform

Expanding health care insurance coverage should reinforce-not replace-support for primary care delivery systems. Specifically, insurers should not be allowed to discriminate against subsidized organized settings such as CHCs. Currently, organized programs may not be recognized as providers by insurers or HMOs, and if they are recognized they may be paid only for physician services rather than via an institutional rate. Depending on their design, financing reforms can increase the capacity of direct delivery

90 Sarah S. Brown, Ed., Prenatal Care: Reaching Mothers, Reaching Infants-Summary and Recommendations (Washington, D.C.: Institute of Medicine, National Academy Press, 1988), 14.

providers. If insurance covers patients previously uninsured or underinsured, delivery systems can then use their State, Federal or private funds to develop additional facilities, to expand types of services and the number of patients served at existing facilities, and to provide additional outreach and case management services. These support and facilitating services are often not appropriate for reimbursement through a general insurance program because they are difficult for insurers to validate and control.

Recent Federal financing legislation has been moving in directions which will increase Medicaid reimbursement to community based programs, and therefore enhance their ability to use other funds to reduce barriers to care. Specifically, the Medicaid program has been revised several times to expand eligibility to mothers and young children. Also, under the Reconciliation Act just passed by the Congress, effective April, 1990, all Federally funded C/MHCs as well as other primary care centers that meet similar qualifications will be reimbursed by Medicaid at 100 percent of reasonable costs. Additionally, effective April 1990, centers in all States are recognized as a provider for purposes of Medicaid reimbursement. Unlike the previous rules, in which CHCs in certain States have been paid based on individual physician fees and/or rates considerably less than cost, the new legislation acknowledges and pays for the increased expenses associated with providing comprehensive, case-coordinated primary care.

Table 1 illustrates the relationship between Federally funded C/MHCs and financing reforms. With significant increases in insurance coverage, for the same amount of grant funds, the number of persons served could be increased from 6.2 to 8.4 million and the range of services increased to provide outreach, prevention and support services for all users. This assumes that (1) insurance will cover clinical services and case management for all persons served, (2) grant or other funds will be used for special outreach, health promotion/disease prevention, support and facilitating services, and (3) the total number of users is determined by the availability of grant and other funds.

Delivery Reform

Financing reforms are necessary but not sufficient in improving access to health care. Even if comprehensive health care were financed completely for everyone, non-financial barriers would still prevent many people from receiving effective, timely, care. The inadequacy of financing reforms alone was noted

by the National Governors Association (NGA) following the recent implementation by many States of Medicaid expansions for pregnant women and their infants. Specifically, the NGA found that some communities in isolated rural or high risk inner city areas lacked health care providers and facilities. Even where there were providers, many physicians in the private sector were unwilling or unable to take on additional patients, and continuity of care was frequently lacking. They were not prepared to offer the broad spectrum of preventive, support and facilitating services needed by a disadvantaged population.91 Gail Wilensky has similarly noted that insurance schemes alone are insufficient. She has stated that "For some populations-those who are difficult to reach or have special needs. . . specially targeted programs directed to providers who are trained and equipped to deal with these special populations are likely to be more efficient and effective than generalized insurance programs.' "92

Table 1 How Increased Reimbursement Affects Capacity and Services in C/MHCs

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1. Figures are not adjusted for inflation

8.4 million $218

2. Clinical services represent 80% of total costs currently in columns 1 and 2; 65% in column 3. In column 1 the total cost per person is $178, of which clinical costs are 80% of that, or $142. $142 is 65% of $218, the cost/person in column 3. This increase in cost/person from $178 to $218 reflects increased outreach and support services.

3. Federal grant funds in columns 2 and 3 based on FY 1990 appropriation less program support and lag in outlays for calendar year.

Direct support of organized primary care programs is required to meet the special needs of certain population groups whose needs cannot be met solely through the provision of private or public health insurance. Strategies for this support are described below.

Facilities-Support for organized primary care delivery systems should be maintained at a level which, in conjunction with financing reforms, allows an increase in the number of sites, as well as increases in

91 Ian T. Hill, "Broadening Medicaid Coverage for Pregnant Women and Children," State Policy Responses (Washington, D.C.: National Governors Association, 1988).

*2 Gail Wilensky, "Filling the Gaps in Health Insurance," Health Affairs 7 (Summer 1988): 141.

the capacity of existing sites to serve additional persons. This could be linked to the concept of ensuring that underserved populations have a provider of last resort (i.e., local health department, freestanding clinic, reformed hospital outpatient department, or C/MHC).

Personnel-Manpower

development should be aimed at attracting and retaining health professionals in minority and other underserved areas. Strategies might include: (1) continued support of existing programs such as the National Health Service Corps and minority health education programs; (2) promotion of the appropriate use of mid-level health professionals, through the development of model state practice acts; (3) examining proposals to address problems regarding professional liability and (4) development of professional support networks (e.g., telecommunications networks with other providers to provide adequate backup and support services).

Outreach and Support Services-There should be targeted support for the development and delivery of innovative outreach and other social and support services which will facilitate access to and continued participation in health care. Strategies might include, but not be limited to: (1) demonstration grants to enlist volunteers from the community, along with the training and management necessary to ensure appropriate use and retention of volunteers; (2) encouraging communities to provide free or reduced-cost transportation for pregnant women and other high risk, underserved groups; and (3) working with States and localities to promote availability of home visits by public health nurses in underserved areas.

Coordination-Coordination could be improved through increased Federal financial, administrative and technical assistance support for coordination and co-location of services for underserved groups, particularly vulnerable special population subgroups such as the homeless, pregnant women, and substance abusers. This includes support for (1) establishing onestop shopping programs within C/MHCs and local health departments, and (2) simplifying and standardizing eligibility requirements and procedures for public programs.

Evaluation and Research-In order to ensure effective and efficient use of resources, the Federal Government should promote the development of systems to assess continuing gaps in access to care, help plan for a provider of last resort in every high need underserved area, and evaluate existing programs for their cost effectiveness and impact on health status.

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