Reynolds, P. Preston MD, PhD
Editor’s Note: This is a commentary on Chen C, Chen F, Mullan F. Teaching health centers: A new paradigm in graduate medical education. Acad Med. 2012;87:1752–1756.
The neighborhood health center (NHC)—now known as the community health center (CHC)—was one of the innovations developed under President Lyndon Johnson’s War on Poverty to meet the needs of poor Americans in urban and rural areas.1,2 NHCs were designed to provide comprehensive health care, functionally defined at the time as
the organized provision of health services to family groups, including a full spectrum of services from prevention through rehabilitation, continuity of care for the individual, emphasis upon social and personal aspects of disease and its management, use of the health-team concept with personal physician responsibility, and coordination of the diverse elements of modern scientific medical practice.3
NHCs were intended to be a remedy to the fragmented, overspecialized, and research-oriented care that developed out of the specialty movement in the mid-20th century and had come to dominate health care delivery in medical centers.
Remarkably, this innovation in health care delivery has survived subsequent administrations, in part because of strong, bipartisan congressional staff advocacy. From the pilot group of 8 NHCs funded under the Office of Economic Opportunity in 1965, the number of CHCs has grown to more than 1,100 health centers in 2012 serving over 19 million people, most of whom have no other access to health care.1,2,4 Of the original defining characteristics, nearly all have stood the test of time, as has CHCs’ additional unique feature of community oversight and governance.
Today, both Federally Qualified Health Centers (FQHCs; CHCs that receive federal funding under Section 330 of the Public Health Service Act5 and meet specific federal requirements) and FQHC Look-Alikes (CHCs that do not receive Section 330 funding but provide the same range of services and meet federal CHC guidelines6) are an integral part of the health care safety net in the United States. Their capacity to meet the needs of the uninsured and underinsured patients they serve, however, is limited by the lack of health professionals to adequately staff them. A 2006 survey of 890 CHCs found that at least 400 more family physicians were needed and that 40% of vacancies remained open longer than seven months.7
In many parts of the country, the pressure to place additional clinicians in CHCs has only intensified since the start of the 21st century. Despite predicted primary care workforce shortages, President George W. Bush’s Federal Health Center Growth Initiative increased the number of FQHCs by 800 during his administration alone.7 At the same time, Congress imposed disastrous cuts to the Title VII and Title VIII health professions programs that support the education of physicians, physician assistants, and nurses in primary care fields, as legislators searched for dollars to help the Gulf Coast communities in their post–Hurricane Katrina (and Rita and Wilma) clean-up and rebuilding efforts.8 These health professions training funds have not been restored to their pre-Katrina levels. With passage in 2010 of the Patient Protection and Affordable Care Act (ACA),9 Congress authorized $9.5 billion across five years to further expand the capacity of FQHCs. Fortunately, health professions education received some financial support in the ACA, particularly $1.5 billion across five years for expansion of the National Health Service Corps.
In addition, the Teaching Health Center Graduate Medical Education (THCGME) program funded under the ACA aligns the graduate medical education (GME) mission of preparing competent professionals with the CHC mission of providing quality and comprehensive care; it also helps address health care reform and the need for more primary care clinicians. Unfortunately, the National Health Service Corps as well as the Title VII and Title VIII health professionals training programs again face cuts to their discretionary appropriations under a deficit-conscious White House and Congress, and there are concerns that funding for the THCGME program will not be continued after its mandated funding period of five years.
For more than 30 years, family medicine educators have promoted the use of CHCs in medical education and residency training. Several studies7,10–12 conducted in the 1990s and 2000s laid the groundwork for the THCGME program. These studies—most from family medicine authors—identified the benefits of using CHCs in residency training, particularly the retention of graduates in CHCs and other urban and rural sites of care for the underserved as well as the development of their skills in the ambulatory care of culturally diverse and socioeconomically disadvantaged populations. When done correctly, these studies suggested, such CHC–residency program collaborations could enhance the financial strength of both the CHC and training program and improve the quality of care delivered. The studies also elucidated the barriers to success, which included finances, the different missions of the residency program and the CHC (education versus clinical care), and administrative complexity. Not surprisingly, the most successful collaborations started with the development of a shared mission and vision statement that reinforced sustainability, financial solvency, high quality and continuity of care, and longitudinal learning.10,12 Research and nationally sponsored conferences in the 1990s also quantified the amount of funding needed to offset the educational costs of training residents in these settings.
Focusing on CHCs’ mission of compre hensive patient care rather than their role in health professions education, the Health Resources and Services Administration (HRSA), which admin isters the Section 330 grant program, launched several initiatives over the past decade to improve the quality of health care delivered in FQHCs. As part of an HRSA health disparities collaborative, FQHCs were expected to start collecting and reporting data in a uniform way to facilitate comparison across clinical sites; this effort continued under HRSA’s Office of Performance Review. Many FQHCs underwent on-site reviews by trained federal staff and expert consultants.
As chief of the HRSA Primary Care Medical Education Branch with responsibility for the Title VII Training in Primary Care Medicine and Dentistry grant program (2004–2006) and later as an expert consultant, I joined with other HRSA staff in conducting these on-site reviews. At CHCs with a Title VII training grant, I would oversee the evaluation of the CHC’s educational program outcomes. Although I may have wanted to emphasize the importance of the CHC’s educational role, the focus of the review was always on clinical care and financial solvency. Our efforts were directed toward helping FQHC staff develop the skills to collect data to measure quality of care and identify sources of income, including community and patient revenue. What became apparent to me in these discussions with CHC physicians and administrative staff was that many CHCs with long-standing affiliations with medical schools and residency programs were being forced to terminate these arrangements to meet new productivity targets and financial goals.
These various HRSA initiatives culminated in 2008 when the agency launched a program-wide clinical quality improvement initiative to measure and demonstrate quality of care across all FQHCs. Recently published research shows that these efforts have resulted in a quality of care that is comparable to, if not better than, that delivered in private and community settings.4 Many CHCs now qualify as patient-centered medical homes (PCMHs), another indication that they continue to provide care that is coordinated and comprehensive with good access for the disadvantaged population of patients they serve.
Funding for GME, structured primarily as Medicare payments to hospitals for hospital-based residents’ clinical services, has long been an impediment to training family medicine, internal medicine, and other residents in community settings.11,12 This payment structure has also served as a barrier to moving residency education out of hospital-based ambulatory teaching clinics. The ACA’s THCGME program eliminates this structural problem by allowing federal dollars supporting residency training to flow directly to eligible CHCs, which serve as accountable entities. With family medicine’s history of successful collaborations with CHCs, it is not surprising that of the first 21 THCGME grants awarded, 15 (71%) were to support family medicine residency training programs.13
When I am asked whether a CHC is adequate as a clinical training site to prepare one to deliver compassionate, comprehensive, quality care as an internist, family physician, pediatrician, obstetrician–gynecologist, or psychiatrist, my answer has always been an emphatic “Yes.” And now that many FQHCs achieve quality outcomes comparable to those of other settings and have been recognized as PCMHs, the learning environment they offer may be better than that of hospital-based residency ambulatory clinics, which struggle because they lose money caring for disadvantaged patients with little or no insurance and, thus, drain departmental and hospital reserves. Some CHC administrators and residency program directors have argued for years that placing residency training programs in FQHCs could actually help address the financial problems of departments of family medicine and internal medicine because additional dollars are available to FQHCs through the Section 330 grant program (and other sources of federal funding) and because malpractice waivers are provided to all FQHC clinical staffs.11,12
In reflection, I was one of many residents in the Johns Hopkins internal medicine residency who had their continuity clinic at the East Baltimore Medical Center, a CHC located down the street from the Johns Hopkins Hospital. My clinic was scheduled for Friday afternoons, beginning in my internship. My last day as a resident was spent in this same clinic. Like so many other senior physicians, I can still remember the last patient I saw that last afternoon: Miss Laura, a 90-year-old woman who had just returned by bus from a gospel revival in South Carolina. We chatted, talking about recent events, her health, and my next steps into fellowship as a Robert Wood Johnson Clinical Scholar. She prayed for me and my journey toward physicianhood; I arranged for her pacemaker to be interrogated to make sure it kept functioning. Before we left the clinical area, we embraced one another, both feeling blessed by the relationship. I am now a tenured professor of medicine who precepts residents regularly in the University of Virginia’s resident–faculty clinic that provides care to underinsured and uninsured patients. I am sure I remained a general internist—despite the constant coaching and persistent pressure to subspecialize—partly because of patients like Miss Laura and the ease of learning medicine and caring for patients at the CHC. My continuity clinic gave me much to appreciate. I came to deeply respect my mentor, who worked alongside me and the other resident also assigned to this session. We were a team, and our work was made easier by the nurses, pharmacists, laboratory technicians, social workers, and secretaries who made up the CHC staff. And today, I remain so very thankful that I shared the privilege of caring for the disadvantaged in one of Baltimore’s poorest neighborhoods with other health professionals who were as committed as I wanted to be.
As Candice Chen and her colleagues14 illustrate in their article “Teaching health centers: A new paradigm in graduate medical education,” the academic CHC is an idea whose time really has come, an innovation long in the making. Perhaps it is a model of residency training that can finally succeed in pushing medicine beyond confines of the hospital walls, and physicians beyond the limits of specialized, high-tech care to enable them to doctor and heal patients as well as communities once again.
Acknowledgments: The author would like to thank the many colleagues and patients who have inspired her and many others to work for and advocate on behalf of federal programs such as this one.
Other disclosures: None.
Ethical approval: Not applicable.
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13. Bolon S. Chief, HRSA Primary Care Medical Education Branch. Funding history of teaching academic health centers. Personal communication with P.P. Reynolds. 2012
14. Chen C, Chen F, Mullan F. Teaching health centers: A new paradigm in graduate medical education. Acad Med. 2012;87:1752–1756