Optometric Care within the Public Health Community 2009 Old Post Publishing 1455 Hardscrabble Rd. Cadyville, NY COMMUNITY HEALTH CENTERS

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COMMUNITY HEALTH CENTERS Roger Wilson, O.D. Overview and History of Community Health Centers In the United States community health centers (CHCs) were born out of the War on Poverty, during the Kennedy
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COMMUNITY HEALTH CENTERS Roger Wilson, O.D. Overview and History of Community Health Centers In the United States community health centers (CHCs) were born out of the War on Poverty, during the Kennedy and Johnson administrations in the 1960s. This was at the height of the civil rights movement, which included a focus on raising people out of poverty through initiatives such as community involvement and the creation of job training programs, business development and improvements in health care for poor people. 1 One physician activist, Dr. Jack Geiger, had just returned from South Africa, where in the late 1950s he witnessed a remarkable strategy for the delivery of primary care health services at community based clinical settings in rural and urban settings. 2 By the 1960s Dr. Geiger was collaborating in Mississippi with Dr. Count Gibson of Tufts Medical School in Boston, MA, providing health care to civil rights workers. 3 It was during this time that Jack Geiger s vision of community health centers emerged. Dr. Geiger presented his idea to government bureaucrats and was instrumental in securing funding for the first community health centers in the United States. In 1965 the Office of Economic Opportunity approved funding for Tufts Medical School to open a health center program at a housing development in the Columbia Point area of Boston and at an unspecified site in the southern part of the country. 3 The Mississippi site was later designated to be in the rural area of Mound Bayou, which today is home to the Delta Health Center. In December, 1965 Columbia Point Health Center, the first of it kind in the country, opened its doors. 2 The Columbia Point program has been in continuous operation since 1965 and is now known as the Geiger Gibson Community Health Center. Community health centers were officially designated by the federal government in 1965 to provide care to the nation s poor and underinsured and were originally referred to as neighborhood health centers by the Office of Economic Opportunity. 4 Since 1996 health centers have been redefined and include public and non-profit community based health care organizations defined within the Public Health Service Act. 5 Administratively CHCs fall within the Department of Health and Human Services, under the Health Resources and Services Administration s (HRSA) Bureau of Primary Health Care (BPHC). While each health center program is tailored to meet the needs of its community, all CHCs share a common mission to increase access to primary health care (and related services) for underserved populations, and to improve the health status of the populations served in a culturally competent and linguistically appropriate manner. In 2008 approximately 1,200 organizations have been designated as community health centers, with about 7,000 access sites (some CHCs have multiple locations), serving approximately 18 million patients. 6 Community Health Centers Roger Wilson 1 Community health centers (sometimes simply referred to as health centers ) are community-based and community-governed multidisciplinary public and nonprofit health care organizations that play a vital role in the provision of ambulatory primary contact health services. They provide preventive approaches to improve the health status of communities, as well as social and enabling services to the populations they serve. Health centers are located in every state and territory of the United States. In 2008 CHCs provided nearly 71 million patient visits to approximately 18 million unique users. 7 Most health center users are people at or near the Federal poverty level. They are often uninsured and may be homeless, frail older adults, racial and ethnic minorities, or other underserved, at risk and vulnerable populations. Thus CHCs play a vital role as a safety net provider within the health care system of the United States. The community health center governance model appears to be unique among health care delivery models in the United States. This form of governance is considered to be highly effective. By assuring that a majority of board members come from the surrounding community and are themselves patients of the health center, health centers are better able to identify and respond to the needs of their communities and achieve their missions. 5 For example, it is the governing board that is ultimately responsible for determining the scope of services offered at their health center. If there is a determination of need for a new service which is outside of the scope of federally mandated services, such as optometry, the decision to add this service would be made at the board level. The health center s management team, including the chief executive officer, chief medical officer, chief financial officer and other senior managers, would then be responsible for following the board s mandate through the development of a plan to add the new service. Paraphrasing Dr Jack Geiger, the editors of the book Moments in Leadership 2 note that Geiger likes to say that there is a difference between an institution in a community, such as a subway stop, and a true community institution. By definition, a health center is a community institution. First, in its own staffing, a center generally reflects the diversity of the population for which it works. Second, while a center is not the only institution in a community providing access to care, its ongoing care makes it a much more integral part of the community. The center impacts the health of the whole community, not just the individual. In a paper by Hunt 6 the impact of community health centers on the overall well-being of communities is further elucidated, citing examples of how health centers in Massachusetts have evolved into true community centers. For example, Hunt discusses how the health centers have contributed to the economic growth of communities through jobs creation, fostering leadership opportunities, stabilization of local economies, contributed to business revitalization, and by serving as a hub for neighborhood organizing efforts. While this chapter is limited to a discussion of community health centers as defined by the federal mandate, the reader should be aware that there are other local health care organizations across the nation that serve parallel and sometimes complimentary roles to health centers. These programs have similar missions to health centers and may offer a blend of medical, social, health Community Health Centers Roger Wilson 2 education, outreach and and/or other services. Yet they generally do not provide the full scope of mandated services that define a community health center nor do they meet the more stringent requirements of a health center (see section on Program Requirements and Characteristics) as established by federal statutes. Nevertheless, they serve a vital role in communities by acting as another type of safety net for people in need by connecting those individuals to other community organizations, including health care and the other services delivered through CHCs. The goal of this chapter is to provide the reader with background information about community health centers and how they fit into the health care delivery system of the United States. The reader will further understand how health centers identify and respond to disparities in access to care and disparities in health outcomes. This chapter gives the reader background knowledge regarding how optometry is presently positioned within the array of clinical services offered by health center system, and how the addition of optometric services could favorably impact the health status of health center patients. Challenges facing health centers regarding the addition of optometric services will also be discussed. The chapter will end with the author s perspective on what needs to change at the federal level so that policies could be developed to name optometry as a mandated health center service. While this chapter provides the reader with background information on CHCs, additional independent study and research is encouraged to gain further knowledge of community and populations health. OBJECTIVES Possess a fundamental knowledge of the health center system of the United States Understand the governance of health centers, range of services provided by CHCs, patient demographics, insurance status, and CHC revenues/funding Understand how CHCs function as a safety net provider to the nation s poor and vulnerable, by identifying, confronting and responding to disparities in health Understand the need for on site optometric services at health centers Understand why optometric care is an integral part of the care management team at CHCs Demonstrate why on site optometric services at CHCs effectively address disparities in access to eye care and disparities in visual health Through a case study, learn the start-up components of an on site optometry service at a health center Community Health Centers Roger Wilson 3 Snapshot of Health Center Fundamentals How many health centers there are over 1,200 unique primary sites, some with multiple service locations, resulting in over access points 7,000 service locations in every US state and territories. 7 Patient demographics, insurance status, patient visits The majority of patients served are racial and ethnic minorities. Health center patients are poor with incomes at or near the federal poverty level and most are either uninsured or publicly insured. Health center users represent all ages with the majority being under age 44. (Figures 1-4) Note that 2006 patient visit data is illustrated by service. (Figure 5) Data on optometry visits has not been collected. Racial and Ethnic Minorities Make Up Two-Thirds of All Health Center Patients African American 23.0% White 36.3% American Indian/ Alaska Native 1.1% Hispanic/ Latino 36.1% Asian/ Pacific Islander 3.5% Note: Based on percent known. Percents may not total 100% due to rounding. Source: NACHC, Robert Graham Center, and Capital Link, Access Granted: The Primary Care Payoff, August 2007, Figure 1: Racial and ethnic representation of health center patients Community Health Centers Roger Wilson 4 Health Centers Serve Patients That Are Predominately Low Income % FPL 6.6% Over 200% FPL 8.1% % FPL 14.6% 100% FPL and Below 70.7% Note: Federal Poverty Level (FPL) for a family of three in 2006 was $17,170. (See Based on percent known. Percents may not total 100% due to rounding. Source: NACHC, Robert Graham Center, and Capital Link, Access Granted: The Primary Care Payoff, August 2007, Figure 2: Income of health center patients relative to federal poverty level Most Health Center Patients are Uninsured or Publicly Insured Private 15.2% Other Public* 2.3% Medicare 7.5% Uninsured 39.8% Medicaid/ SCHIP 35.1% *Other Public: May include non-medicaid SCHIP and state-funded insurance programs. Note: Based on percent known. Percents may not total 100% due to rounding. Source: NACHC, Robert Graham Center, and Capital Link, Access Granted: The Primary Care Payoff, August 2007, Figure 3: Insurance status of health center patients Community Health Centers Roger Wilson 5 Health Center Patients Range in Age Ages % Under % Ages % Ages % Ages % Ages % Ages % Note: Based on percent known. Percents may not total 100% due to rounding. Source: NACHC, Robert Graham Center, and Capital Link, Access Granted: The Primary Care Payoff, August 2007, Figure 4: Health center patients by age Health Center Patient Visits by Type of Service, 2006 Medical Care 76% Behavioral Health 5% Dental 10% Enabling Services* 7% Other 2% Total = 60 million encounters in 2006 Encounters for enabling services include visits to case managers and health educators. Source: NACHC, Robert Graham Center, and Capital Link, Access Granted: The Primary Care Payoff, August 2007, Figure 5: Health center visits by service in 2006 Community Health Centers Roger Wilson 6 Funding of Health Centers CHCs derive revenue from a variety of sources including grants, contracts, fees from patients and payers and other sources. (Figure 6) Medicaid Revenue is Directly Proportional to Medicaid Patients 39.8% 41.1% Grants/Contracts/Other Uninsured/Self-Pay 2.3% 15.2% 7.5% 6.8% 7.0% 6.0% 2.3% Private Other Public Insurance Medicare 35.1% 36.8% Medicaid Patient Insurance Status 2006 Health Center Revenue Notes: Percents may not total 100% due to rounding. Source: NACHC, Robert Graham Center, and Capital Link, Access Granted: The Primary Care Payoff, August 2007, Figure 6: Comparison of insurance status of health center patients to revenue sources Health Center Designations Community health centers must meet specific program requirements (below) set forth in Section 330 of the Public Health Services Act which entitle them to costbased reimbursement through Medicare and Medicaid. 5 Based upon a recommendation from the BPHC, health centers are also classified by the Centers for Medicare and Medicaid Services (CMS) into Federally Qualified Health Centers (FQHCs), which account for approximately 90% of health center programs, and FQHC Look-Alike Health Centers (Look-Alikes), comprising the remaining 10%. While both FQHCs and Look-Alikes offer similar services and both are eligible to receive cost based reimbursement from Medicare and Medicaid and are eligible to participate in the 340B pharmaceutical program, there are differences. Only FQHCs receive federal grant support from Section Community Health Centers Roger Wilson 7 330 and only FQHCs have access to malpractice coverage through the Federal Tort Claims Act. 4 Whether designated as a FQHC or as a Look-Alike, health centers may be further subdivided into specific categories representative of the populations served: Community health centers including urban, rural and school-based sites Migrant health centers which care for seasonal workers and their families Homeless program centers which provide both outreach and on site services to homeless populations Public housing based centers providing care for resident families of those housing facilities Program Requirements 8 and Characteristics of Health Centers According to the Health Center Program of the Public Service Act, a health care organization must meet specific requirements and follow accountability and governance requirements in order to be eligible to apply for FQHC status. The following synopsis is the minimum set of requirement and standards in place for FQHCs: The center must be located in a federally designated high-need and underserved area The center accepts all patients, regardless of insurance status, and provides either free care or fee for service care that is adjusted based on ability to pay The center is required to provide primary health services 9 defined below.* Below adapted from 9 : The Health Center Program: Section 330 of the Public Health Service Act (42 USCS 254b) Authorizing Legislation of the Health Center Program In general, the term required primary health services means: Basic health services which, for purposes of this section, shall consist of Health services related to family medicine, internal medicine, pediatrics, obstetrics, or gynecology that are furnished by physicians and where appropriate, physician assistants, nurse practitioners, and nurse midwives; Diagnostic laboratory and radiologic services; Community Health Centers Roger Wilson 8 Preventive health services, including-- Prenatal and perinatal services; Appropriate cancer screening; Well-child services; Immunizations against vaccine-preventable diseases; Screenings for elevated blood lead levels, communicable diseases, and cholesterol; Pediatric eye, ear, and dental screenings to determine the need for vision and hearing correction and dental care; Voluntary family planning services; and Preventive dental services; Emergency medical services; and Pharmaceutical services as may be appropriate for particular centers; o Referrals to providers of medical services (including specialty referral when medically indicated) and other health-related services (including substance abuse and mental health services); o Patient case management services (including counseling, referral, and follow-up services) and other services designed to assist health center patients in establishing eligibility for and gaining access to Federal, State, and local programs that provide or financially support the provision of medical, social, housing, educational, or other related services; o Services that enable individuals to use the services of the health center (including outreach and transportation services and, if a substantial number of the individuals in the population served by a center are of limited English-speaking ability, the services of appropriate personnel fluent in the language spoken by a predominant number of such individuals); and o Education of patients and the general population served by the health center regarding the availability and proper use of health services. The center offers enabling services that facilitate care utilization, such as interpreting and translation, outreach, case management, transportation, and health education; The center customizes its services to meet specific health care, cultural, and other needs of patients The center develops and maintains an ongoing quality improvement program to ensure continuous performance improvement in both clinical services and management The center is community governed by a patient-majority board Community Health Centers Roger Wilson 9 *Note that optometry is not included in the mandated scope of primary medical services at a FQHC or Look-Alike health center. Optometry and ophthalmology are designated as specialty services. To add optometry, a health center board may seek a change in the scope of service. 10 However, when adding a non-mandated service, a CHC is required to justify how the additional service will result in improved health status for CHC patients and to make it available to all patients without regardless of ability to pay and available on a sliding fee scale. A reasonable justification for optometry might, for example, be to augment diabetes care management. (See section: Summary of How to Get Started with Optometric Services at a CHC for further information on change in scope.) Public Health Principles Related to Community Health Centers There are a series of complex issues in health care and public health which serve to illustrate why health centers play such a vital role in the nation s health care delivery system. The fact that health centers provide care to the underserved is at the heart of their existence. Further, it is a CHC s unique ability to identify and respond to disparities in access to care 11 that contributes to improved health outcomes and ultimately overall improved health status. These impressive and well documented results are further substantiated by a look at quality and performance measures, cost effectiveness, care management and continuity of care delivered to patients by health centers. Taken together, health outcomes for CHC based patients are equal to or better than the health outcomes at more costly settings such as hospitals or emergency rooms Another effective way that health centers seek to decrease barriers in accessing care is by engaging the community in its mission, first through the shared community governance model and then by working with the community to identify potential barriers to care. The community is thus an integral partner and stakeholder in developing appropriate strategies and access solutions. For example, if language and culture are identified as factors that may influence a person s decision to the seek or avoid care at the center, then hiring a multicultural staff reflective of the demographics of the community, providing care using bilingual staff and interpreters (who also serve as patient care advocates and care coordinators), and marketing s
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