Assessing primary care content: four conditions common in community health center practice

Under managed care, community health center (CHC) care patterns will be increasingly subject to outside scrutiny. This article discusses results of medical records reviews assessing quality of care at CHCs for acute otitis media, diabetes, asthma, and hypertension. As a group, these safety net providers meet or exceed prevailing practice across other health care settings; however, there is substantial variation among sites. Regression analyses indicate that the individual CHC used by a patient is the most consistent determinant of whether a patient receives recommended care. Drawing on these results, the article explores approaches for improving care and discusses the implications for performance measurement among CHCs and other safety net providers.     

Collaboration among community members,local health service providers,and researchers in an urban research center in Harlem,New York

The Urban Research Center at the Center for Urban Epidemiologic Studies brings together community members and researchers working in Harlem, New York. A Community Advisory Board (CAB) composed of community members, service providers, public health professionals, and researchers was formed to assist the Center's research and interventions and to guide community partnerships. Through a collaborative process, the CAB identified three public health problems-substance use, infectious diseases, and asthma-as action priorities. To deal with substance use, the Center created a Web-based resource guide for service providers and a "survival guide" for substance users, designed to improve access to community services. To deal with infectious diseases, the Center is collaborating with local community-based organizations on an intervention that trains injection drug users to serve as peer mentors to motivate behavior change among other injection drug users. To deal with asthma, the Center is collaborating with community child care providers on an educational intervention to increase asthma awareness among day care teaching staff, enhance communication between staff and families, and improve the self-management skills of children with asthma. The Center's experience has demonstrated that active communities and responsive researchers can establish partnerships that improve community health.     

Is low cost really conducive to primary care utilisation: An empirical analysis of community health centers in China

Despite community health centers (CHCs) having many potential benefits, their utilisation rate is still low in urban China. Using the health belief model, the study conducted cross-sectional survey to examine factors that affected individuals' intentions to use primary care services in China. This study on 942 participants from Shanghai revealed that low cost had insignificant effect on the choice of CHCs once other key factors were accounted for. Older age, greater perceived susceptibility to contracting common diseases and more benefits of individualised care greatly increased the likelihood of using primary care services. Perceived low competencies of medical personnel along with outdated medical facilities had significant negative relationships with the intention of choosing CHCs. Based on these findings, some policy recommendations are proposed such as promoting education on prevalence of common diseases, recruiting qualified medical personnel, increasing professional training and cooperation, updating medical facilities, and offering high-quality individualised care in order to improve efficiency of primary care utilisation.     

Characteristics of ambulatory care patients and services: a comparison of community health centers and physicians' offices

The overall aim was to determine whether health care delivery for vulnerable populations served by community health centers (CHCs) was comparable to care for mainstream Americans primarily seen in physicians' offices (POs). Data came from the 2006 National Ambulatory Medical Care Survey. Patient visits occurring in CHCs were largely from younger, uninsured or Medicaid-insured, minority populations, while POs catered mainly to older, Medicare- or privately-insured, White patients. Communities served by CHCs were more often in low-income, low-education, urban regions. A greater proportion of visits to CHCs were from diabetic, obese, and depressed patients; CHCs also offered more evening/weekend visits and provided more health education during visits, but spent less time per visit than POs and had more difficulty referring patients to specialists. Results affirmed the significant role of CHCs as safety-net providers for vulnerable populations, and indicated that CHCs provide adequate care compared with POs although there remains room for improvement.     

Clinic Workload,the Quality of Staff Relationships and Diabetes Management in Community Health Centers Catering to Latino and Chinese Patients

We examine whether workplace climate-quality of staff relationships (QSR) and manageable clinic workload (MCW) are related to better patient care experiences and diabetes care in community health centers (CHCs) catering to Latino and Chinese patients. Patient experience surveys of adult patients with type 2 diabetes and workplace climate surveys of clinicians and staff from CHCs were included in an analytic sample. Comparisons of means analyses examine patient and provider characteristics. The associations of QSR, MCW and the diabetes care management were examined using regression analyses. Diabetes care process were more consistently provided in CHCs with high quality staff relations and more manageable clinic workload, but HbA1c, LDL cholesterol, and blood pressure outcomes were no different between clinics with high vs. low QSR and MCW. Focusing efforts on improvements in practice climate may lead to more consistent provision of important processes of diabetes care for these patients.     

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.     

Willingness to use and satisfaction of primary care services among locals and migrants in Shenzhen,China

The Chinese government has been reforming the health care system by developing a primary care system. The objectives of this study were to compare the willingness to use and satisfaction with community health care centres (CHCs), a component within the Chinese primary care system, between locals and migrants living in Luohu, Shenzhen, China. A 2019 cross-sectional survey data that interviewed 1,205 adult residents living in Luohu district were used for secondary data analysis. Two identifications of migrants were used for analysis, Shenzhen hukou status and urban village status. Linear probability models were used to determine relationship between migrants' status and the outcome variable of willingness to use CHCs and order logistic regression were used to determine the association between migrants' status and the outcome variable of satisfaction with CHCs. Among participants, 37.6% of the participants had Shenzhen hukou. Using the classification of urban village status, 29.1% of participants were urban villagers. Urban villagers were less likely to know the location of nearest CHCs and less likely to select CHCs as their frequently used health care institutions. No statistically significant difference was found on willingness to use CHCs or satisfaction with CHCs between Shenzhen hukou and non-Shenzhen hukou. But urban villagers were more satisfied with attitude and medical skills of health care workers. Our findings indicated that policymakers and social professionals need to adjust the organization and functioning of primary care institutions in the community to increase awareness and utilization of primary care services.     

基层和公共卫生人员实际收入与期望收入比较分析

目的：通过分析基层和公共卫生服务机构卫生人员的实际收入和期望收入情况,为完善卫生人员经济激励制度提供政策建议。方法：采用定量问卷调查的方法调查了县CDC、乡镇卫生院、社区卫生服务机构、村卫生室的卫生服务人员,共1020人。分别计算平均月收入,期望月收入和期望收入指数。结果：基层和公共卫生人员的实际收入与期望收入之间存在较大差距。县CDC卫生人员实际月收入最高,乡镇卫生院和社区卫生服务机构医生收入水平仅略高于护士和公共卫生人员。村医平均月收入仅为1204元,期望收入指数最高,达3.22。乡镇卫生院和县CDC内不同学历的卫生人员收入没有统计学差异。结论与建议：提高基层和公共卫生人员的工资水平,建立合理的绩效考核制度。同时,应特别注意村医报酬补偿和保障问题。     

A qualitative study of two management models of community health centres in two Chinese megacities

Two common public models of community health centres (CHCs) exist in China, i.e. the ‘government-owned and government-managed’ CHCs (G-CHCs) and the ‘government-owned and hospital-managed’ CHCs (H-CHCs). Shanghai and Shenzhen are two Chinese megacities that lead the primary care development on the G-CHC and H-CHC models, respectively. Using a qualitative case study design, this study compares the management of the G-CHC model in Shanghai and H-CHC model in Shenzhen, through perspectives of a range of health providers. In each city, we randomly selected four CHCs and in total conducted 31 interviews with officers from the municipal health authorities, directors, GPs, nurses and public health doctors of the CHCs. When comparing with the H-CHC model in Shenzhen, the G-CHC model in Shanghai, a model with more simplified but accountable structure tended to present better management conditions, in terms of financial transparency, recruitment autonomy, community health workforce development (CHC staffing and family medicine training), funding and priority for public health. However, regardless of the models, staff retention remained a challenge. While our study tends to suggest that the G-CHC model in Shanghai presents better management conditions, future study can test whether and to what extent the model itself can lead to such differences.     

Adoption of health information technology in community health centers: results of a national survey

To the extent that health information technology (IT) improves health care quality, differential adoption among providers that serve vulnerable populations may exacerbate health disparities. This first national survey of federally funded community health centers (CHCs) shows that although 26 percent reported some electronic health record (EHR) capacity and 13 percent have the minimal set of EHR functionalities, CHCs serving the most poor and uninsured patients were less likely to have a functional EHR. CHCs cited lack of capital as the top barrier to adoption. Ensuring comparable health IT capacity among providers that disproportionately serve disadvantaged patients will have increasing relevance for disparities; thus, monitoring adoption among such providers should be a priority.     

Community's voice in managing childhood asthma: the assessment phase of research

This study was designed to investigate community beliefs about caring for childhood asthma and to elicit suggestions for interventions to improve asthmatic children's health. Focus groups were conducted with parents of children with asthma, children with asthma, school staff, and health care and childcare professionals. Data were analyzed for themes, such as disruption of normal living and having to work in a chaotic system, enabling researchers to posit a core belief for each group. These core beliefs, together with encompassed other, related beliefs held by group members, guide attitudes and actions about asthma. Interventions recommended by focus group participants included creating an asthma play, asthma education, and developing a clinic-based registry to standardize asthma documentation. The community's voice is important in assessment and design of health improvement projects. Incorporating the community's suggestions gives the community a sense of contributing to the health care of their children with asthma.     

GP care for moderate to severe asthma in children: what do infrequently attending mothers disagree with and why?

OBJECTIVES: Our aim was to identify and account for areas of disagreement with GP care for moderate to severe child asthma among mothers who infrequently use this care. Identifying and understanding these areas of disagreement has the potential to improve child access to GP care. METHODS: This qualitative study in Auckland, New Zealand, used a general inductive approach to analyse 23 semi-structured, personal interviews during March-October 2001 with samples of 11 mothers of children with moderate to severe asthma, and 12 medical providers (10 in general practice and two in hospital emergency departments). Disagreement was defined by mothers' non-acceptance or disapproval of aspects of GP care they reported getting for child asthma. RESULTS: Mothers and providers described four areas in which some mothers disagree with aspects of GP care for child asthma. Contributing to infrequent attendance, the areas are the validity of the diagnosis, the level of service provision, the effectiveness of care and the level of respect from practice staff. These areas revealed three groups of mothers. GP factors contributing to disagreements among mothers were reported to be inconsistent care; information deficits on asthma and individual children; a lack of commitment to identifying the cause(s) and self-management of asthma in children; and an unmet need for asthma management plans that incorporate families' knowledge, goals and preferences. CONCLUSIONS: Disagreement, among mothers, with areas of GP care for child asthma contributes to non-attendance for this care. This paper identifies opportunities for GPs to keep disagreements to a minimum and facilitate access.     

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.     

Rural‐Urban Differences in Consumer Governance at Community Health Centers

Context: Community health centers (CHCs) are primary care clinics that serve mostly low‐income patients in rural and urban areas. They are required to be governed by a consumer majority. What little is known about the structure and function of these boards in practice suggests that CHC boards in rural areas may look and act differently from CHC boards in urban areas. Purpose: To identify differences in the structure and function of consumer governance at CHCs in rural and urban areas. Methods: Semistructured telephone interviews were conducted with 30 CHC board members from 14 different states. Questions focused on board members’ perceptions of board composition and the role of consumers on the board. Findings: CHCs in rural areas are more likely to have representative boards, are better able to convey confidence in the organization, and are better able to assess community needs than CHCs in urban areas. However, CHCs in rural areas often have problems achieving objective decision‐making, and they may have fewer means for objectively evaluating quality of care due to the lack of patient board member anonymity. Conclusions: Consumer governance is implemented differently in rural and urban communities, and the advantages and disadvantages in each setting are unique.     

Following the call: how providers make sense of their decisions to work in faith-based and secular urban community health centers

We interviewed 49 health care providers from 6 faith-based and 4 secular community health centers (CHCs) to explore the ways they relate their religious commitments to practice among the underserved. Interviews were transcribed, coded, and analyzed for emergent themes through an iterative process of textual analysis. Providers in faith-based CHCs explained the decision to work in underserved settings as a response to a religious calling to medicine as a means of ministry, and by reference to particular benefits and freedoms of working with colleagues who share an explicitly faith-informed vision for care of the underserved. Most providers from secular CHCs explained their motivations in less religious terms by reference to intrinsic rewards such as "making a difference" for the underserved. Providers from both settings emphasized the frustrations and difficulties of meeting overwhelming demands with inadequate resources. In light of prior literature regarding work orientation, our findings suggest that CHCs may provide distinctive opportunities for intrinsically motivated providers to craft their work into a calling, where a calling is understood as a deeply felt motivation for work that goes beyond the satisfaction of the worker's material and social needs. Faith-based CHCs appear to provide a context that is attractive to some minority of providers who desire to enact a religious calling to ministry through the practice of medicine. Future studies are needed to test these hypotheses using quantitative methods and broader representative sampling.     

The Shanghai case: A qualitative evaluation of community health reform in response to the challenge of population ageing

Shanghai's health care system is facing a serious challenge of an ageing population, as 14% of its 17 million residents are 65 or older. In 2000, a community health reform was implemented to provide comprehensive and continuous primary care to community residents with a focus on seniors. The study employed the theoretical framework of examining primary care in terms of the constellation of its four unique elements (first contact, comprehensiveness, longitudinality and coordination) and three healthcare components (structure, process and outcome). The study aimed to evaluate the extent to which the reform has achieved its process goals and how the organizational context influenced the level of implementation. In-depth interviews with 25 health providers, 15 seniors and four community leaders were carried out. The study found that the Shanghai community health reform has improved the structure and process of primary care regarding first contact, comprehensiveness and longitunality. However, the reform is constrained by structural barriers on seniors' financial access to resources and the capacity of primary care providers. The previous organization system also constrains the reform in CHCs financing and administration. The Shanghai case illustrates that a broad societal view has to be taken when analysing health reforms, which requires the involvement of multiple sectors including the government, health providers and health consumers.     

Results of a domestic violence training program offered to the staff of urban community health centers

Introduction: Domestic violence (DV) against women often goes unrecognized by health care providers due to multiple barriers. In an effort to increase screening, identification, and referral for services, the RADAR Training Project was created for the health care staff of 12 federally qualified community health centers (CHCs).Methods: A two-phase evaluation was conducted to assess the intervention. Phase one evaluated the health care providers’ perceived knowledge and comfort pre-training, post-training, and at 3 months follow-up. The second phase included a medical chart review of 4 CHCs to assess the rates of screening, documentation of abuse, assessment of safety, and referrals for help at baseline (6 months pre-training) as compared to the intervention period (6 months post-training).Results: The health care providers’ perceived level of knowledge and comfort increased significantly post-training and then later decreased at 3 months follow-up. The rate of screening for DV (25% vs. 5%), suspicion of DV (6% vs. 2%), completion of safety assessments (17% vs. 5%), and referrals (4% vs. 0%) increased significantly between the intervention and baseline periods. However, the rates of documentation of abuse did not change.Conclusions: This intervention was successful in increasing provider perceived knowledge and comfort; however, comfort decreased at follow-up. Additionally, the rates of screening and referrals increased 6 months post-training. Health care provider training and support and integrated quality assurance mechanisms may be necessary to increase the overall rate of these activities, and to sustain this effort over time. Further study is needed to identify effective methods to increase provider comfort regarding DV screening.     

Primary Health Care in Community Health Centers and Comparison with Office-Based Practice

We examine the roles of nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (CNMs) in community health centers (CHCs). We also compare primary care physicians in CHCs with office-based physicians. Estimates are from the National Ambulatory Medical Care Survey, a nationally representative annual survey of nonfederal, office-based patient care physicians and their visits. Analysis of primary care delivery in CHCs and office-based practices are based on 1,434 providers and their visits (n = 32,300). During 2006–2007, on average, physicians comprised 70% of CHC clinicians, with NPs (20%), PAs (9%), and CNMs (1%) making up the remainder. PAs, NPs, and CNMs provided care in almost a third of CHC primary care visits; 87% of visits to these CHC providers were independent of physicians. Types of patients seen by clinicians suggest a division of labor in caring for CHC patients. NPs and PAs were more likely than physicians to report providing health education services. There were no other differences among services examined. Office-based physicians were less likely to work alongside PAs/NPs/CNMs than CHC physicians. CHC staffing is contingent on a variety of providers. CHC staffing patterns may serve as models of primary care staffing for office practices as demand for primary care services nationwide increases.     

Strengthening Public Health and Primary Care Collaboration Through Electronic Health Records

Electronic health records (EHRs) have great potential to serve as a catalyst for more effective coordination between public health departments and primary care providers (PCP) in maintaining healthy communities.As a system for documenting patient health data, EHRs can be harnessed to improve public health surveillance for communicable and chronic illnesses. EHRs facilitate clinical alerts informed by public health goals that guide primary care physicians in real time in their diagnosis and treatment of patients.As health departments reassess their public health agendas, the use of EHRs to facilitate this agenda in primary care settings should be considered. PCPs and EHR vendors, in turn, will need to configure their EHR systems and practice workflows to align with public health priorities as these agendas include increased involvement of primary care providers in addressing public health concerns.Electronic health records (EHRs) have great potential to serve as a catalyst for more effective coordination between public health departments and primary care providers in maintaining healthy communities. As prominent health risks to the community continue their shift from contagious diseases to chronic illnesses, public health departments are increasingly focused on conditions such as diabetes and obesity. At the same time, serious threats persist from traditional public health concerns, such as communicable disease outbreaks.Primary care providers, and particularly community health centers (CHCs), that provide care for low-income populations are on the front lines in treating and containing both communicable diseases and chronic illnesses that are more prevalent in these communities. Traditional models of primary care are also evolving, with increased focus on community-based approaches in response to changing financial incentives and formal recognition programs, such as the Patient-Centered Medical Home certification offered by the National Committee for Quality Assurance and the Joint Commission.1,2 Use of these models is facilitated by the parallel increase in adoption of EHRs.Federal incentive programs have been a proponent of EHR implementation and “meaningful use” of EHRs among primary care providers, with targeted funding to support their adoption among CHCs.3 The promotion of health information technology to improve the public’s health is 1 of 5 focus areas for meaningful use of EHRs. Finally, 1 of the 3-part aims of the Centers for Medicare and Medicaid Services (CMMS) is the improvement of population health—a goal that will only be met through improved coordination of primary care and public health.4,5In 2003, the potential for addressing community health needs with the aid of EHR data exchange initiated a partnership between The New York City Department of Health and Mental Hygiene (NYC DOHMH) and The Institute for Family Health. Together, these organizations have developed, tested, implemented, and monitored the use of an EHR in meeting public health and primary care goals. NYC DOHMH is one of the world’s largest public health agencies, operating programs in disease control, environmental health, epidemiology, health care access, health promotion and disease prevention, and mental hygiene. It also makes public health-enabled EHRs available to over 2500 primary care providers throughout New York City as part of its Primary Care Information Project (PCIP).The Institute for Family Health is a nonprofit organization that provides care to more than 80 000 patients in 26 federally qualified health center sites in New York City and New York State’s Mid-Hudson Valley. The Institute’s goal in establishing an EHR system was not only to enhance the quality of patient care in its own practices, but also to improve the health of the communities it serves. Recognizing that the 2 organizations had parallel missions to maintain healthy communities, the Institute and NYC DOHMH partnered in EHR data exchange initiatives to meet the shared goals of improving the surveillance and management of both communicable disease and chronic disease. Projects addressing these goals are described below.     

Access to primary health care for Australian adolescents: How congruent are the perspectives of health service providers and young people,and does it matter?

OBJECTIVE: To explore the extent of congruence between the views of service providers and young people (on adolescents' health concerns, barriers to accessing health services and ideal service model) in order to improve and increase the appropriateness, quality and usage of primary health care services. METHODS: A qualitative data collection technique was used. During 2001/02, focus groups were conducted in urban and rural locations with adolescents (in and out of mainstream education), general practitioners, community health staff and youth health workers. RESULTS: Service providers and young people identified a similar range of health concerns for young people, with young people adding additional issues of great importance to them that service providers felt were not in their 'domain of treatment'. There was reasonable congruence in regard to 'ideal service model' with some differences relating to methods of information delivery. However, for 'barriers to accessing services' there were major discrepancies. CONCLUSIONS: While there is some common understanding between young people and service providers on certain aspects of health services, there are clearly areas where perceptions differ. This discrepancy matters because it may adversely affect the quality of provider-adolescent interaction and the willingness of adolescents to access services. IMPLICATIONS: To deliver optimal health services to young people, the differences in understanding regarding services need to be addressed. Strategies could include promotion to, and encouragement of, young people to seek help, continuing professional education of providers and changes in remuneration policies.