In many of the more highly developed programs, the key person was an articulate, dedicated, and committed physician who had a good understanding of the community or, in some instances, was from the community. This type of physician leadership often inspired community residents, other health professionals, and students to be involved and, thus, community trust was established. Often these physicians had not received recognition and acceptance from their peers but derived a personal gratification from participation in programs designed to meet the community's needs. ADMINISTRATION AND EVALUATION The organizational structures differed widely. A few programs had a loose or informal structure while in the remainder there was a rather sophisticated and formal administrative organization. The structure of the OEO and CHP-type neighborhood health centers was very similar-usually a community nonprofit corporation or association with a board of directors of one third target area residents, one third residents of the community in general, and one third providers. Normally, these programs had an overall project director who supervised a medical director, an administrator, and sometimes a dental director. In instances where the community board controlled the project, the project director reported directly to the board. Where the community board was in an advisory position, it would only make recommendations to the project director, who worked under the direction of an outside board of directors. In the privately funded community health programs the structure was quite different. Most often, the program was administered through the Department of Community Medicine or a similar department of a medical school, or as an extension of a hospital, with a board whose members usually were not community residents. If the community was involved in these programs, it was normally in an advisory capacity. In many programs the responsibility for communication, coordination, and control had not been sufficiently delineated so that it was clearly understood by all concerned. In these cases, had these key factors been properly defined, the programs would likely have operated more smoothly, efficiently, and effectively. The evaluation efforts being conducted by the various programs ranged from nonexistent to rather sophisticated analysis. A few programs were merely providing services and there was no evidence of any attempt to evaluate these services. Some programs had only a monthly review of records and data by an in-house staff team. Other programs had a research and evaluation section as a part of the health center or had an affiliated medical school or health science school perform an ongoing evaluation of program operation. The OEO-type neighborhood health centers usually had a medical team review of patient records and a requirement for a standardized data analysis program, although in some instances few of the management staff were well informed regarding these procedures. Evaluation of any community health program is essential to determine its effectiveness in relating to the community health needs. The process of continuous monitoring, review, and rapid interchange of information that is possible at the community level offers excellent opportunities for developing individual or component parts of a system or an entire model health care program that could be used in other areas of the country. The long-range potential of such community programs lies in the opportunity to explore mech anisms in which health care delivery problems can be studied and identified, new methods developed and tested, and changes introduced that will improve the health delivery system and well-being of the community. SUMMARY This report has presented a brief summary of the information and data gathered during visits to a broad range of community health programs. Comparisons have been made among the operational aspects of the various programs. This study has served to reemphasize a firm belief that there is no single solution that will work in all areas. The problems are too complex and vary significantly from one community to another. The programs visited in this study had a variety of sponsors and organizational and administrative patterns. Each program was attempting to help solve part of the health problems of the people it served and thus was directed to a community need, since many of the people had been receiving little or no health care. The level of health care was not the same in every program but, in general, it was felt to be adequate. These community health programs clearly demonstrated that every health center does not need and should not attempt to offer directly every aspect of total health care. However, the programs also showed the necessity of firm alliances or linkages between health institutions to provide inpatient care and other services that the centers cannot offer. One of the major problems was that of funding, particularly from the standpoint of (1) being subject to annual appropriation of funds, which caused insecurity for long-term operation and presented handicaps in attracting and retaining top quality professional staff; and (2) the complexities encountered with multiple funding sources and their categorical restrictions, which resulted in extreme difficulty in integrating all funds into a single effective health program. Such problems were very evident in government-funded programs. These community health programs demonstrate clearly that participation of the dedicated physician is a vital ingredient in most successful health programs. These programs have also shown that the interdisciplinary health team is an effective means of achieving optimal efficiency of the services provided by the various health personnel. Likewise, the community health advocate concept has been shown to be successful as a means of health outreach. In general, the community health centers are serving as another effective means of providing adequate health care to more people. CONCLUSIONS From the knowledge gained from the Task Force site visits, the Council on Medical Service and its Committee on Community Health Care identified the following key elements that, when present, tended to make the community health programs more successful: 1. Active involvement of and support by practicing physicians and local medical organizations. 2. Active participation and support by all elements of the community and provision for the community to share in nonmedical decisions. 3. Provision of a broad range of health services of high quality which are equally accessible to all people. 4. Utilization of the health care team approach, including full use of community outreach workers. 5. Defined arrangements for appropriate supportive and consultative services that are convenient and that have coordination to ensure continuity of care. 6. Financial support from a variety of sources, with integration of all funds, and with a goal of obtaining additional or alternative funds so that the program can become self-sustaining as soon as possible. 7. Hospital staff privileges for physicians working in community health programs. 8. Acceptable and available transportation services. RECOMMENDATIONS The Council on Medical Service and its Committee on Community Health Care have formulated the following recommendations which are offered in an effort to improve the effectiveness of community health programs in relating to the total community and its health needs. The first group of recommendations pertains to suggested activities for initiation by the medical profession. The second set of recommendations concerns activities that, although initiated by others, deserve physician support. RECOMMENDATIONS FOR ACTIVITY BY THE MEDICAL PROFESSION 1. Physicians, both as individuals and as members of medical societies, should actively participate in the planning, development, implementation, and operation of health programs at the community level, particularly in areas where there is a shortage of medical and health services. Medical societies are urged to establish committees that can provide technical advice and assistance to providers and community residents who are involved in developing community health programs. 2. Physicians should use all means at their disposal to ensure that all people are afforded equal access to adequate medical and health care. 3. The medical profession at all levels should actively support public and private programs to eliminate factors that are harmful to health, such as lead poisoning, malnutrition, drug abuse, poor housing, poor sanitation including improper sewage and solid waste disposal, the use of unsafe pesticides, and air and water pollution. 4. The medical profession should be actively involved in and support health planning that will promote the development of programs to meet the specific health needs of communities. They should support activities that will avoid the unnecessary duplication of facilities and services and wasteful expenditure of financial and manpower resources. These planning efforts should seek maximum utilization of exisiting health programs and the availability of adequate transportation systems. 31-151 O 74 Pt. 1 - 37 5. The medical profession at all levels should assist in establishing and expanding mechanisms that will allow for continuing communication and dialogue with community residents. Such mechanisms should also provide a meaningful role for the public in the planning, development, and operation of medical and health programs that will affect them. 6. The medical profession should strongly support general health education programs in the schools, at home, and in mass media to increase the awareness of what constitutes good health in order for people to make optimal use of the health delivery system. General health education programs should include information concerning proper utilization of health resources, emphasizing the appropriate and expanding roles of the various members of the health care team. 7. The medical profession should continue to provide support for programs intended to help solve health manpower shortages by (a) increasing the output of medical schools and related health education programs, (b) mobilizing inactive trained personnel and providing refresher courses to update their knowledge, (c) maximizing the productivity of all types of health manpower through realignment of tasks and application of new technology, and (d) maintaining experimentation with new types of health manpower. 8. The medical profession, in cooperation with communities and government, should assist in developing incentive programs that will attract physicians and other health personnel to locate in rural and urban areas of need. 9. Practicing physicians should consider the feasibility of utilizing the health care team approach through the delegation of appropriate tasks to qualified health personnel and help educate their patients to recognize that some personal health services can be delivered by personnel other than physicians. RECOMMENDATIONS FOR ACTIVITIES THAT SHOULD BE 10. The medical profession should support public and private efforts that will help people escape from poverty and near-poverty, including job training and placement, and development of an adequate and sustaining income program with built-in work incentives that will encourage poor people to become self-sufficient. The costs of attaining such sociological goals should not be factored into the costs of medical care. 11. Medical schools and other schools of the various health professions should be urged to include suitable sources and practical experience in community health programs as a part of their curricula. This training would provide a means of gaining a better understanding of the social, psychological, economic, and cultural needs of patients and the interrelationships of the various health disciplines. 12. The federal government should be encouraged to consolidate all federal health programs under one department that has line authority and responsibility for program development, implementation, and operation. 13. The federal government should be encouraged to provide long-range approval and multiple-year funding for research and demonstration health programs in order to provide assurance of continuity of operation which will assist in recruitment and retention of top quality professional staff. 14. The federal government should be encouraged to offer increased incentives and assistance to provide employers who establish programs to employ poor people, with company-sponsored job training, job placement, and day care centers in order to make more people self-sufficient. |