Urban health care in transition: challenges facing Los Angeles County.

The authors examine the Medicaid Section 1115 Demonstration Project currently underway in Los Angeles County. The waiver was designed as part of a response to a financial crisis the Los Angeles County Department of Health Services (LACDHS) faced in 1995. It provides financial relief to give the county time to restructure its system for serving the medically indigent population. Los Angeles County's goal is to reduce its traditional emphasis on emergency room and hospital care by building an integrated system of community-based primary, specialty, and public health care. This case study describes activities completed through the spring of 1997, approximately 1 year after the waiver was approved.     

Loss of Medicaid and access to health services

In this article, the authors assessed the effects of the loss of Medicaid eligibility on access to health services by the medically indigent population in two California counties. An historically derived baseline of health services received by each county's medically indigent adults under Medicaid was compared with the volume of services provided by the county to the same population after they lost Medicaid eligibility. The baseline figures were used as an "expected" volume of services which can be compared with the actual, or "observed," volume of services. The analysis found fewer hospital discharges than expected in Los Angeles and much fewer outpatient visits than expected in Orange County, suggesting that these groups experienced substantial reductions in access related to loss of Medicaid eligibility.     

Ambulatory care in the public sector: perinatal care in Los Angeles County

In planning its response to the increasing demand for perinatal services and the increasing rate of infant mortality and low-birthweight infants the Los Angeles County Department of Health Services faces a formidable set of tasks. Initiatives already in place are attempting to deal with some of the most pressing problems. However, increased services must be made available to enable the increasing number of women to access the system of care, and further outreach is necessary to encourage more women to begin prenatal care early in pregnancy. The county needs to increase the availability of perinatal care services, and these services must respond to the cultural and socioeconomic needs of pregnant women. Financial barriers to care must be eased, and the process of qualifying for Medi-Cal must be simplified. Additional private providers need to be brought into the system, and alternative care providers--such as birthing centers and delivery by midwives--should be expanded for low-risk pregnancies. The DHS has been forced to respond to staggering increases in demands for perinatal care services, and the population pressures and the widening socioeconomic gaps are unlikely to decrease in the near future. These same forces also require the DHS to respond to the increased demand for other health services. The DHS is being required to develop and maintain a complex program of health services without adequate financial resources. The solution to the perinatal care crisis in Los Angeles County and other localities with high rates of poverty cannot be found solely within local governments. It is unrealistic to expect that local taxation can support an increase of this magnitude in the need for care, and increased state and federal support is essential. Other nations, spending far less for health care, produce significantly better results: how much longer will it take this nation to recognize its responsibilities to its most vulnerable citizens?     

Crisis & commitment: 150 years of service by Los Angeles county public hospitals

The Los Angeles County University of Southern California Medical Center will open soon, replacing the county's current 74-year-old facility with a modern, although smaller, facility. Los Angeles County has provided hospital care to the indigent since 1858, during which time, the operation of public hospitals has shifted from a state-mandated welfare responsibility to a preeminent part of the county's public health mission. As this shift occurred, the financing of Los Angeles County hospitals changed from primarily county support to state and federal government sources, particularly Medicaid. The success of the new hospital will depend on whether government leaders at all levels provide the reforms needed to help the county and its partners stabilize its funding base.     

Privatizing indigent health services in Los Angeles County: understanding the effects on community-based providers.

Faced with imminent financial collapse of its public healthcare system, the Los Angeles County Department of Health Services solicited community-based providers to supply primary care health services to the medically indigent. This study highlights the effects that participation in the programme has had on these community providers. While strongly committed to the programme's objectives, community providers tended to overextend themselves financially, putting their organizations at substantial risk of failure should contractual expectations or patient demand forecasts not be met. Because of this risk, policymakers involved in public-private partnerships with community-based providers must exercise extreme caution owing to the unique status many of these providers hold as centrally positioned actors in their communities. On the positive side, we found evidence of increased levels of co-operation and innovation between community providers outside their formal roles in the county-sponsored public-private partnership programme.     

Improving public health care: lessons on governance from five cities.

Policy-oriented investigations into public health care delivery have been limited, especially during the Reagan era of competition and profit-based health care, when the inner city was essentially forgotten. In this study, policymakers toured five urban public health care systems in different parts of the country to promote consideration of a new governance for Chicago and Cook County's complicated and uncoordinated care for the medically indigent. A comparison of patterns of governance revealed strengths and weaknesses of each model. Local leadership and the political will to evolve a system of care, with clear connections between the public and private sectors, account for each city's relative success in addressing mounting needs of inner-city populations.     

The future of home health agencies

A multidisciplinary, multi-institutional, volunteer task force was convened by the Visiting Nurse Association (VNA) of Los Angeles to perform an evaluation of the agency and, on the basis of the evaluation, to make recommendations regarding the future potential of home health service agencies in the United States. For the VNA of Los Angeles, this use of a voluntary task force as a planning mechanism was successful; we strongly recommend its application to other agencies. The recommendations made were specific to the VNA of Los Angeles, but many are applicable to home health agencies in general. They called for an expansion of the types of services currently offered, with an emphasis on the coordinated team approach to health problems, an increased emphasis on preventive and health education services, and a movement toward providing services to groups as well as individual home care patients. The task force also urged willingness to expand services to include primary care. Modern management techniques were recommended as tools to increase the efficiency of home health service agencies. Potential new sources of revenue were proposed.     

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program assures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. The authors report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services, so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence statewide and national policies affecting local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system guaranteeing access, they can substantially improve the availability of local services.     

Portal to the community. Dedicating a facility to ambulatory and long-term care completes the continuum for a New Jersey system

In 1989 Cathedral Healthcare System, Orange, NJ, began a strategic planning process that culminated in a decision to create a continuum of care. Converting one of its three hospitals from an acute care to an ambulatory care facility gave Cathedral an opportunity to address fiscal realities and at the same time further develop its continuum of care. The converted hospital (Saint Mary's in Orange) would be a key component of a full continuum of care for area residents. Saint Mary's would also serve as a portal of entry to the system's services. The community's need for affordable, accessible healthcare has been well documented. Converting Saint Mary's to alternative uses was one approach the system could take to better meet the needs of this underserved population. In addition to providing ambulatory care, Cathedral will be transforming the acute care beds into much-needed long-term care beds. The conversion will enable Saint Mary's to meet the needs of a growing aging population.     

Defining Aggregations of the Poor for Community Health Center Location

Socioeconomic indexes based on multiple criteria of education, employment, and income are constructed and applied to Los Angeles County census data closely analyzed by area. Areas are classified by socioeconomic level of their residents, and large aggregations of the indigent and other groups are identified and delineated. Minimal assumptions about the function of community health centers permit estimation of their required number and best location to serve socioeconomic groups unable to obtain adequate health care privately.     

Millions of medical care dollars for indigents

The medically indigent, a group traditionally underserved with health care, can obtain some needed free services from Hill-Burton facilities. These facilities (hospitals, nursing homes, clinics, and agencies) received Hill-Burton funds for their building programs and have, as a result, an obligation to provide a certain amount of uncompensated medical care to a defined medically indigent population.Health systems agencies (HSAS) or other interested agencies and groups can play an integral role in highlighting the Hill-Burton Program and helping the medically indigent obtain free care, This paper describes the Hill-Burton Program and explains how one HSA identified the Hill-Burton facilities in its area, determined the extent of their obligations, obtained allocation plans, and publicized and promoted the available health care services. From the interest shown by the community it was apparent that the HSA had provided a much needed and appreciated service that could be duplicated across the country by HSAS or other community groups.Lillian Emmons, Ph.D., R.D., Nutrition Consultant. James E. Burnett is Chief of Industrial Programs, National Aeronautical and Space Administration. Ruth Finkelstein, M.A., Planning Associate, Metropolitan Health Planning Corporation. Bernice Frieder, M.A., is Senior Associate Planner, Metropolitan Health Panning Corporation. Gail Long, M.S.S.A., is Assistant Director, Merrick Settlement House. Dennis Lettenauer Attorney-at-Law, is with the Legal Aid Society. Cynthia Miller is President, C.B. Miller Funeral Home. Paper presented on November 2, 1981, at the Annual Meeting of the American Public Health Association, Los Angles, Ca.     

Re-engineering the public hospital system: saving the safety net.

Cities across America are grappling with the problem of how to provide care for the indigent and those on Medicaid. All levels of government are reducing their public funding for health care of indigent persons, and the rapid growth of managed care is making traditional cost-shifting more difficult as it transforms the practice of medicine itself. These issues are most acute in cities like Los Angeles and New York, which traditionally have relied on public hospital systems to serve as a safety net. This article focuses on the changes being wrought at the largest health-care system in the country for indigents, the New York City Health and Hospitals Corporation (HHC), on the progress it made during the first 18 months of a major re-engineering process, and on potential options for its future reform.     

Public health week: marketing the concept of public health.

The Public Health Programs and Services (PHP&S) Branch of the Los Angeles County Department of Health Services began a strategic planning effort in January 1986 to meet new disease trends, curb rising health care costs, consolidate limited resources, and handle shifting demographics. A strategic plan was designed to assess the opportunities and challenges facing the agency over a 5-year horizon. Priority areas were recognized, and seven strategic directives were formulated to guide PHP&S in expanding public health services to a changing community. Health promotion was acknowledged as a critical target of the strategic planning process. Among the most significant results of the health promotion directive was the establishment of an annual Public Health Week in Los Angeles County. Beginning in 1988, 1 week per year was selected to enhance the community's awareness of public health programs and the leadership role PHP&S plays in providing these programs to nearly 9 million residents of Los Angeles County. Events in Public Health Week include a professional lecture series and the honoring of an outstanding public health activist and a media personality who has fostered health promotion. Other free community activities such as mobile clinics, screenings, and health fairs are held throughout the county. With intensive media coverage of Public Health Week, PHP&S has been aggressive in promoting its own services and accomplishments while also educating the community on vital wellness issues. The strategic methodology employed by PHP&S, with its emphasis on long-range proactive planning, is receiving national recognition and could be adopted by similar agencies wishing to enhance their image and develop unique health promotion projects in their communities.     

The Impact of Care Coordination on Children With Special Health Care Needs

Families of children with special health care needs face challenges in securing comprehensive health, educational, and social services. As a result, care may be fragmented, duplicative, confusing, and unnecessarily costly. Case management or care coordination is a method of overcoming some of the obstacles experienced by these children and their families. This article describes the Automated Case Management System/Community Based Care Coordination Project for California Children Services Children and Their Families in Los Angeles County (grant number MCJ 065020), a grant project funded by the Maternal Child Health Bureau from October 1987 to December 1990 in which family-centered, community-based care coordination services were provided to a select group of clients and the effectiveness of the interventions was evaluated. Care coordination was readily accepted by families and resulted in increased services, but the evaluation proved to be challenging.     

In My Opinion. Necessary But Not Sufficient Components--Training issues in Child Life

Families of children with special health care needs face challenges in securing comprehensive health, educational, and social services. As a result, care may be fragmented, duplicative, confusing, and unnecessarily costly. Case management or care coordination is a method of overcoming some of the obstacles experienced by these children and their families. This article describes the Automated Case Management System/Community Based Care Coordination Project for California Children Services Children and Their Families in Los Angeles County (grant number MCJ 065020), a grant project funded by the Maternal Child Health Bureau from October 1987 to December 1990 in which family-centered, community-based care coordination services were provided to a select group of clients and the effectiveness of the interventions was evaluated. Care coordination was readily accepted by families and resulted in increased services, but the evaluation proved to be challenging.     

Health and Ambulatory Care Use Among Native American Veterans

In 1995, the Veterans Health Administration reorganized its health services structure to emphasize ambulatory care. Successful health care planning and improving access to ambulatory care services now depends upon a better understanding of health care needs and outpatient services. Because the veteran population is heterogeneous, it is important to understand the health, access issues, and utilization of ambulatory care services in order to develop effective strategies and interventions to ensure access to and utilization of ambulatory care. Drawing on a focus group methodology with 86 Native American veterans, representing 34 tribes, this study is a qualitative examination of the health, access, use of the Department of Veterans Affairs Health Care services, barriers to health care, and satisfaction with care experienced by Native American veterans. Results reveal problems in accessing care, receiving appropriate care, and coordinating care within the VA health care system. Policy and program recommendations include increasing outreach and education efforts regarding the availability of benefits and services, improving coordination of services between the Indian Health Service and the VA, and reemphasizing the importance of patient-centered care.     

Health and ambulatory care use among Native American veterans

In 1995, the Veterans Health Administration reorganized its health services structure to emphasize ambulatory care. Successful health care planning and improving access to ambulatory care services now depends upon a better understanding of health care needs and outpatient services. Because the veteran population is heterogeneous, it is important to understand the health, access issues, and utilization of ambulatory care services in order to develop effective strategies and interventions to ensure access to and utilization of ambulatory care. Drawing on a focus group methodology with 86 Native American veterans, representing 34 tribes, this study is a qualitative examination of the health, access, use of the Department of Veterans Affairs Health Care services, barriers to health care, and satisfaction with care experienced by Native American veterans. Results reveal problems in accessing care, receiving appropriate care, and coordinating care within the VA health care system. Policy and program recommendations include increasing outreach and education efforts regarding the availability of benefits and services, improving coordination of services between the Indian Health Service and the VA, and reemphasizing the importance of patient-centered care.     

Utilization of Health Care Services Among Adults Attending a Health Fair in South Los Angeles County

A bilingual survey was developed to collect information regarding socio-demographics, access to medical and dental care, health insurance coverage, perceived health status, and use of folk medicine providers from 70 adults presenting to a health fair in South Los Angeles County. Ninety-seven percent of respondents were foreign-born. Seventy-nine percent reported having no health insurance during the year prior to survey. Of the uninsured, 61 percent lacked a doctor visit and 76 percent lacked a dental visit during the previous year. The high cost of care was the most frequently cited barrier to seeking medical (58 percent) and dental (67 percent) care even when respondents felt it was necessary. Respondents who felt they needed medical attention but did not seek it had a lower perceived health status (7.0 ± 2.2) than those who did (8.0 ± 2.0). Among respondents perceiving themselves in poor health, only 17 percent were insured. Relatively few respondents (7.2 percent) reported seeing a folk healer during the past year. Our results support the argument that the medically indigent in some localities face serious financial, as well as less salient, barriers to access. These local conditions reflect inadequate enforcement by local governments in correcting the difficult problems indigent populations face in accessing medical and dental care.     

Access to primary care for patients with diabetes at an urban public hospital walk-in clinic

The purpose of this study was to determine the regular source of primary care, the content of care, and barriers to accessing primary care for 218 medically indigent adults with diabetes mellitus. Patients were surveyed at a public hospital walk-in clinic and were queried regarding demographics, regular source of care, and the content of care they received during the preceding year. Seventy percent of the patients were medically uninsured, and 60 percent had household incomes under $10,001. Forty-three percent reported no regular source of care, and 18 percent named an episodic care site as their regular source. Patients with a regular source of primary care had twice as many annual ambulatory visits as those without primary care. Patients with a regular source of primary care reported more diabetic-related services than those without. This patient population is largely poor and uninsured and has difficulty accessing primary care.