Are primary care groups and trusts consulting local communities?

Primary care groups and trusts (PCG/Ts) in the English NHS were established in 1999 and have responsibility for providing and commissioning health-care for around 100 000 people. PCG/Ts are dominated by health professionals, but are responsible for representing the interests of the local community. This paper assesses how they have informed and consulted local communities and the perceived impact of this consultation on decision-making. The paper uses evidence from the National Tracker Survey of PCG/Ts, a longitudinal survey of 72 (15%) of the PCG/Ts in England, using data from telephone interviews with chairs and chief officers, and postal questionnaires to lay board members and representatives of Community Health Councils (CHCs). Eighty-one per cent of PCG/Ts had public involvement working groups. Methods of consulting the community included consulting CHCs (87%), holding public meetings (75%) and consulting local patient groups (67%). Only 31% of chairs felt they were effective at consulting. Ninety-two per cent of CHC representatives attended all board meetings. Most CHC representatives reported that there had been little or no consultation with the CHC in areas such as commissioning, service development or clinical governance. Only 14% of CHC representatives rated PCG/T consultation with the public as effective. Eighty-seven per cent said that local communities were largely unaware of the existence of PCG/Ts, and 70% commented on the weaknesses in PCG/T efforts at public consultation. Public participation is being taken seriously by PCG/Ts, but most are struggling to develop effective ways of involving local communities. Efforts to involve the public may become little more than token gestures. The proposed abolition of CHCs may make it more difficult for PCG/Ts to obtain a lay perspective. Effective consultation requires the development of new methods and adequate resources, but a stronger lay voice in the governance structures of PCG/Ts is needed.     

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

ABSTRACT: Context: Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. Purpose: We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence. Methods: We analyzed data from 100% of ED visits occurring in 117 rural (non‐metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all‐cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. Findings: Counties without a CHC primary care clinic site had 33% higher rates of uninsured all‐cause ED visits per 10,000 uninsured population compared with non‐CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11‐1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02‐1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01‐1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92‐1.22). Conclusions: The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.     

Patient Engagement in Community Health Center Leadership: How Does it Happen?

Patient engagement in primary care leadership is an important means to involve community voices at community health centers. Federally qualified health centers (FQHCs) are mandated to have patient representation within their governing boards, while practices seeking patient-centered medical home certification receive credit for implementing patient advisory councils (PACs). Our objective was to compare and contrast how community health centers engage patients in clinic management, decision-making and planning within governing boards versus PACs. Qualitative study conducted from August 2016 to June 2017 at community health centers in California, Arizona and Hawaii. We interviewed practice leaders of patient engagement programs at their site. Eligible clinics had patient representatives within their governing board, PAC, or both. We assessed patient demographics, roles and responsibilities of patients participating, and extent of involvement in quality improvement among governing boards versus PACs. We interviewed 19 sites, of which 17 were FQHCs that had governing boards. Of the 17 FQHCs, 11 had also implemented PACs. Two non-FQHC safety-net sites had PACs but did not have governing boards. Governing board members had formal, structured membership responsibilities such as finances and hiring personnel. PAC roles were more flexible, focusing on day-to-day clinic operations. Clinics tended to recruit governing board patient members for their skill set and professional experience; PAC member recruitment focused more on demographic representation of the clinic’s patient population. Both groups worked on quality improvement, but governing boards tended to review clinic performance metrics, while PAC members were involved in specific project planning and implementation to improve clinical outcomes and patient experience. Patient involvement in clinic improvement in CHCs includes higher-level decision-making and governance through mechanisms such as governing boards, as well as engagement in day-to-day practice improvement through PACs. These roles offer differing, but valuable insights to clinic programs and policies.     

The Role of Consumers in Health Care Decision Making

This paper focuses on the results of a survey of chief executive officers and consumer board members of Ontario hospitals and community health centres regarding the role of consumers in health care decision making. The opinions of both the chief executive officer and consumer board member respondents were elicited regarding the value of consumer input in decision making for the organizations studied. Results indicate that consumer board members feel that their input into organizational decision making is valued, chief executive officers value the input of consumers, and consumer involvement in decision making is increasing. More women are now involved on boards of the organizations studied, but visible minority representation remains low on hospital boards. Consumer board members feel that their decision making is influenced by providers on the board.     

Impact of community health centers and Medicaid on the use of health services.

The impact of improved access to health care through the Federal community health center (CHC) and Medicaid programs was examined in five urban low-income areas. Data on access to care and physician, hospital, and dental services utilization were collected by baseline and followup health surveys in the CHCs'' services areas. There was a shift in use from hospital clinics to CHCs. Followup surveys indicated that 23 percent of the population reported CHCs as usual source of care. Travel time to source of care was reduced for users of CHCs. Medicaid coverage of the population in the survey areas increased from 16 to 37 percent between the baseline and followup surveys, an interval of 4 to 7 years. Increases occurred in the use of physicians and dental care between the baseline and followup surveys, but the rates scarcely kept pace with the national rates. Respondents who reported CHCs as their usual source of care, however, had a higher rate of physician visits and a lower rate of hospitalization compared with those using private physicians or hospital clinics as the usual source of care. Respondents with Medicaid coverage usually had higher physician and hospital use, irrespective of usual source of care. Both CHC and Medicaid programs contributed to increased use of dental care by providing financial and dental care resources. Although these two programs greatly facilitated the use of health services, disparity in physician and dental utilization remains between the five low-income areas and the averages for the nation.     

The role of community health centers in delivering primary care to the underserved: experiences of the uninsured and Medicaid insured

Community health centers (CHCs) have long served an important safety-net healthcare delivery role for vulnerable populations. Federal efforts to expand CHCs, while potentially reducing the Federal budget for Medicaid, raise concern about how Medicaid and uninsured patients of CHCs will continue to fare. To examine the primary care experiences of uninsured and Medicaid CHC patients and compare their experiences with those of similar patients nationally, cross-sectional analyses of the 2002 CHC User Survey with comparison data from the 1998 and 2002 National Health Interview surveys were done. Self-reported measures of primary care access, longitudinality, and comprehensiveness of care among adults aged 18 to 64 years were used. Despite poorer health, CHCs were positively associated with better primary care experiences in comparison with similar patients nationally. Uninsured CHC patients were more likely than similar patients nationally to report a generalist physician visit in the past year (82% vs 68%, P < .001), having a regular source of care (96% vs 60%, P < .001), receiving a mammogram in the past 2 years (69% vs 49%, P < .001), and receiving counseling on exercise (68% vs 48%, P < .001). Similar results were found for CHC Medicaid patients versus Medicaid patients nationally. Even within CHCs, however, Medicaid patients tended to report better primary care experiences than the uninsured. Health centers appear to fill an important gap in primary care for Medicaid and uninsured patients. Nonetheless, this study suggests that Medicaid insurance remains fundamental to accessing high-quality primary care, even within CHCs.     

Improving hospital board effectiveness: an update

This article defines governance as the making or not making of important decisions and the related distribution of legitimate power and authority to make them. A distinction is drawn between what governing boards do that is not restricted to governance, and governance that is not the exclusive function of governing boards. This article focuses on governing boards. Recommendations are made for improving the effectiveness of hospital governing boards. Discussed in detail are integrating clinician and administrative governance; supporting management in managing change; focusing and energizing the board on policymaking; and, specifying and evaluating the hospital's contribution to the health of a defined population at reasonable cost. The author surveys the current hospital environment and reconsiders and updates his 1985 recommendations on improving governance. Board effectiveness is reconceptualized, and those recommendations that have been made to improve board structure and function are reviewed. Governing boards are shown to work differently in multihospital systems, hospital alliances, and under restructuring. A research agenda to improve hospital board effectiveness is proposed.     

Community Health Centers and Emergency Preparedness: An Assessment of Competencies and Training Needs

Community health centers (CHCs) provide care to a large number of medically underserved Americans. As primary care providers and trusted members of their communities, CHCs need to be prepared to respond to emergency and disaster situations, as they may be relied upon for medical care and other support services. Focus groups were conducted with CHC medical directors and administrators from New York City. Participants discussed previous emergency preparedness training, future training needs, applicability of competencies, and usefulness of two training programs. Participants indicated that they had more experience with preparedness training than many of their colleagues, although participants still reported further training needs. In particular, emergency roles and responsibilities, decontamination and containment, and personal preparedness were given as needed training topics for staff. The training resources were reported to be useful and beneficial. Participants also reported that most of the competencies were appropriate for CHC clinicians. During an emergency, people want to receive care from their normal provider, and for many, that provider is a CHC. This and other research suggests that the emergency preparedness needs facing CHCs are significant and should be addressed.     

Consumer-based boards of health centers: structural problems in achieving effective control

The fact that consumers have problems in utilizing their formal power as board members is usually attributed to individual deficiencies or cultural differences. The position argued here is that such views need to be questioned and amended. Thus, the ties between a health center and the larger health care system, the relations of consumers to their community environments, and the internal organization of health centers are examined as structural factors which limit the effectiveness of consumer board members.Despite the magnitude and durability of such factors, suggestions are made for increasing the effectiveness of consumer-based boards.     

WHO's Service Availability and Readiness Assessment of primary health care services of commune health centers in a rural district of Northern Vietnam

The objective of this study was to assess the availability and readiness of the primary health care (PHC) services of commune health centers (CHCs) in Quoc Oai, a rural district of Northern Vietnam based on the World Health Organization's Service Availability and Readiness Assessment (SARA) tool. The study was done in 2 steps. First, the heads of the 21 CHCs of Quoc Oai district were interviewed using SARA, a quantitative survey, and the responses were then validated by direct observations of each facility. The results showed that although the average number of health staffs in each CHC met the national standards (at least 5 staffs per CHC), its allocation within each CHC was not properly met because some CHCs had only 2 health staffs. Several health equipment and facilities were not fully available in many CHCs, and although the majority of the PHC services were available at the CHCs, their readiness remained limited. Several significant correlates between the availability of health care workers and the availability of the facilities and the PHC services were observed, suggesting that they depend upon and affect one another in the health system. Using the SARA‐based inventory, the study helps health managers and policy makers to prioritize efforts and allocate resources more appropriately. To be effective, attention should be given to how to make facilities, services, and human resources for health ready for PHC activities—more investment and support from the system (from higher to lower level) and the government.     

Exploring the limits of the safety net: community health centers and care for the uninsured

This paper explores the extent to which community health centers (CHCs) are able to manage their uninsured patient caseloads. We found that CHCs can provide primary care, medications, and medical supplies to most of their uninsured patients on site but are limited in their ability to provide diagnostic, specialty, and behavioral health services. Uninsured patients often fail to receive additional services for which they are referred, and it is much more difficult for CHC physicians to arrange specialty or nonemergency hospital care for their uninsured patients than for their insured patients.     

Expanding care versus expanding coverage: how to improve access to care

The Bush administration has proposed expanding insurance coverage as well as community health centers (CHCs) to increase access to care for uninsured people. This paper examines the relative effects of insurance coverage and CHC capacity on access to care. Communities that have both high insurance coverage and extensive CHC capacity tend to have the best access, although the former appears more important. Funding of insurance coverage expansions is likely to produce greater gains in access than if an equivalent level of funding were invested in CHCs. Policymakers should consider CHC expansions as complementary to insurance coverage expansions rather than as a substitute.     

The substitutability of outpatient primary care in rural community health centers for inpatient hospital care.

To determine whether outpatient medical care obtained at federally funded rural community health centers (CHCs) in Maine acts primarily as a substitute or as a complement to inpatient care, a study of 36 communities served by CHCs was conducted. The hospital use of CHC users (age- and sex-adjusted admissions, days, and length of stay) was compared with that of nonusers from the same communities in 1980. Statistically lower rates of hospital admissions and days were observed for all CHC patients and for selected groups based on their age, sex, and insurance status (specifically Medicaid or Medicare). Hospital use of CHC community populations was then compared with that of 24 comparison communities without access to CHCs, using multiple linear regression in a pre/post design. The model tested, which included rates of health center use, insurance penetration, poverty, and hospital availability, among other factors, did not detect any differences in hospital use between CHC community and comparison populations. These results and additional data presented on selected hospital diagnoses and insurance coverage suggest that treatment, and hospitalization incentives, of CHC providers may reduce hospitalization. Clinic providers lack the economic, professional, and institutional incentives to hospitalize. Additional study to determine the actual substitutability effect is indicated.     

Building better boards in the new era of accountability

Healthcare boards are entering a new era of heightened accountability, scrutiny, and reform. Sarbanes-Oxley legislation, Internal Revenue Service scrutiny, pressure from creditors and bond insurers, activist state attorneys general, media attention, and other forces have sharply increased awareness of the importance of governance and have also raised the bar on what is required of boards and what is considered best-practice governance performance. Yet good governance cannot be legislated. The structure, composition, and specific required functions of boards can be legislated or mandated, but the effective function of boards cannot. At the same time that governance faces this new era of accountability, it is also being bombarded with the legions of monumental challenges in the tumultuous healthcare field. Chief executive officers and their boards must be willing to recognize the challenges and risks to the field of governance in general and to their boards in particular. Furthermore, they must be willing to implement new strategies and approaches for successful governance, including becoming compliant with Sarbanes-Oxley requirements; conducting a comprehensive audit of the structure, function, composition, and culture of the board; and seeking board members from outside the community, among many others.     

Community health center integration: experience in the State of Ohio

In the face of severe financial challenges and demands to improve quality and service to patients, many community health centers (CHCs) have aligned or integrated with other CHCs, physician groups, or hospitals. Yet the nature of and rationale for these organizational decisions are not well understood. Our research applied an organizational theoretical framework to test whether strategic adaptation theory or institutional theory best describes the integration activity of CHCs in Ohio. We collected primary data from case studies of seven CHCs selected for geographic representation and studied December 2000-January 2001. Semi-structured interviews and a case study database supported our chain of evidence. We found that CHC integration activity was substantial (five of seven CHCs integrated) and extremely varied. Consistent with strategic adaptation theory, we determined that CHC integration actions were predominantly center-specific, rational responses to environmental challenges and were initiated to improve operations or financial performance. Rarely did CHCs initiate major organizational change merely to mimic other CHC actions, as might have been expected of highly institutionalized organizations. Understanding the basis for CHCs' strategic decisions while monitoring financial health will remain critical as lawmakers and administrators work to develop policies that both maintain progress made and improve primary care access for the poor, the uninsured, and those with special health care needs served by these important safety net providers.     

Caring for Young Children with Asthma: Perspectives from Urban Community Health Centers

Asthma disproportionately affects low-income, minority youth, with notable disparities among children <5 years of age. Understanding the perceptions of urban community health centers (CHCs) regarding treating young children with asthma could improve care for these patients. This study uses data from semi-structured focus groups with staff from eight urban CHCs. Themes emerged in three domains. Within the parent/family domain, providers noted low rates of follow-up visits, low health literacy, and—for young children specifically—misunderstanding about the diagnosis. At the CHC level, providers needed more staff, space, and comfort with applying the guidelines to infants and young children. CHCs reported asthma registries, population health oversight, and an asthma champion improved care. At the system level, providers wanted improved communication with emergency departments and community outreach programs. Reducing these multi-level barriers may improve care.     

Specialty care referral patterns for the underserved: a study of community health centers on the South Side of Chicago

Little is known about the primary-specialty care interface for underserved patients. In order better to understand inter-physician communication patterns in urban community health centers (CHCs), we conducted a retrospective chart review of specialty care referrals for patients from four South Side Chicago CHCs. Of the 406 identified referrals, 74% (n=301) were made from CHCs that employed referral coordinators and 64% (n=258) were made to affiliated specialists. Chart documentation of whether or not the patient attended the referred specialty visit was present for 43% (n=176) of referrals, and communication from the specialist to the referring clinician was present for 31% (n=127) of referrals. Employing CHC referral coordinators was positively associated with documented specialty clinical communication (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-3.2). Use of referral coordinators to facilitate care and integrating delivery systems to increase information sharing appear to improve care coordination, but further investigation is warranted.     

Better information for the board

Healthcare managers are making quicker, riskier decisions in an increasingly competitive and regulated environment. Questions have been raised regarding the accountability and performance of boards of these organizations, as board members are not always selected based on their competencies to guide such decisions. Adapting mission and strategy and monitoring organizational performance require information that boards get mostly from management. The purpose of this study was to examine the information that boards regularly get to carry out their functions. I obtained board documents from four not-for-profit hospitals and health systems in different boroughs of New York City. At each institution, I conducted one-hour interviews with at least three board members and three top managers. I also attended at least one board or executive committee meeting and one additional meeting, usually of the finance committee. Principal findings were that the boards get too much data, the same data that management gets, and little comparative data on performance of similar benchmarked organizations. Board members and managers are satisfied with the information that board members get and have no plans to improve their system of shaping, or the quality of, information. Key recommendations to boards and managers are: (1) boards must take greater responsibility for identifying the information that they get and how they wish to get it, (2) managers must ensure that measurable objectives are developed, against which organizational performance can be evaluated, (3) boards must get information that is targeted and shaped to better fit board functions, (4) managers must develop information sets for main service lines, (5) boards must get information on the expectations and satisfaction levels of key stakeholders, (6) boards must get better and more focused information on performance of benchmarked institutions, and (7) boards must get less hospital operating data on a monthly basis.