Born of the war on poverty of the 1960s, federally qualified community health centers combine resources from local communities with federal funds to provide care in low-income and rural neighborhoods, lightening the workload for nearby EDs.
Governed by community boards with a patient majority, the centers are located in federally designated, underserved areas, and are nonprofit, public, or tax-exempt. They provide comprehensive health care services, including dental care, mental health programs, and pharmacy assistance, along with other services that facilitate access to care, which is available to everyone regardless of ability to pay.
In recent testimony before the Subcommittee on Primary Health and Aging, Committee on Health, Education, Labor, and Pensions of the U.S. Senate, Debra A. Draper, PhD, the director for health care of the U.S. Government Accounting Office, told senators that such centers have already reduced the load on the nation's overburdened emergency departments. In some instances, they have partnered with hospitals to make patients aware of when they should go to the emergency department and educated them about the services available in the community health centers. They encourage patients to seek care at the health center first, reduce the need to go the ED by treating patients with chronic and non-emergency conditions. Health centers have extended their hours and days of service and provide same-day and walk-in appointments, which make them a more acceptable substitute for the ED.
“Emergency departments are convenient places to go 24 hours a day, seven days a week,” Dr. Draper said. “People perceive care in the emergency department as being free, and I think that even though the clinics have a sliding scale and are required to treat people regardless of ability to pay, people have a different perception.”
In addition, she told EMN, people are often unaware that such community health centers exist. “These issues make hospital emergency departments the place to go,” she said.
And that's what makes coordination with hospitals so important, said Mary Bufwack, PhD, the chief executive officer of United Neighborhood Health Services. (www.unitedneighborhood.org.) “Sometimes, hospitals know about us, but to get our services known, we have to interact with emergency room directors. Different hospitals are organized differently. Academic medical centers are going to be staffed with residents and faculty, but private hospitals are staffed differently.”
Dr. Bufwack said the public hospital in Nashville, TN, uses contract management for ED care, which means the health center must work with hospital administration and the contracted emergency department providers. “In that three-way relationship, it's going to depend on the commitment of all those parties,” she said. It is not enough if the hospital administrator is committed, but the emergency department physicians are not, she said. “That's where the change has to happen.”
Just as hospitals are different, the strategies for working with them are as well, Dr. Bufwack said. “Sometimes you can have a champion, as with an academic health center, but sometimes there's so much teaching going on that the advantage of actually seeing patients for the teaching part of it can become more important than bringing about the types of behavioral changes we would like to see in the patients,” she said. To address that, they partnered with a family practice residency, and are increasingly working with academic medical centers to bring residents into the health centers for teaching.
Beyond that, the clinics operated by United Neighborhood Health Services, a private, nonprofit network of primary care clinics and health programs in Nashville, have adapted their operations to patient needs. If patients are going to the emergency department because it is the only place open outside of business hours, then the clinics extended their hours into the evening and on Saturday. In December 2009, United Neighborhood Health Services opened the Wallace Road Family Clinic on the campus of Southern Hills Medical Center in Nashville. “If patients need us right then, they can come to us,” Dr. Bufwack said. “We are working with a third party to post open appointment slots, and the emergency room can actually make real-time appointments for patient at any hour.”
That can help emergency physicians who often want to complete the ED visit but ensure the patient can be seen later, she said. “They can discharge them to us, and say, ‘Here's where we want you to go for your follow-up.' Here's where you can call to get an appointment so that the patient knows that the next time they can come to one of our clinics for what they used to get in the emergency department.”
While only one of the eight clinics operated by United Neighborhood Health Services is actually on a hospital campus, most are located near them. “Many of these do refer to our clinics,” she said. “This was accomplished by establishing the relationship and the doctors finding out that we are reliable, that their patients, once referred, actually would go there and get treated.”
About 40 percent of the patients who are referred and who make appointments from the ED actually show up and make the clinic their medical home, but those have a high rate of satisfaction, Dr. Bufwack said. “It really can work if you make it convenient for the client. We have a very open-door policy. If you come in, you are going to be seen. We don't say if you don't have an appointment, you cannot be seen. We almost function like an urgent care center sometimes.”
Her clinics have contracts with Medicaid managed care providers in Tennessee to make that possible. They also operate on a sliding scale for the uninsured. “You have to make it affordable for clients,” she said. “If it's not affordable or there's another barrier, they will wait until they are sick enough to go to the emergency department.”
In May 11, 2011, Dana Kraus, MD, a family practitioner at the St. Johnsbury Family Health Center in Vermont, testified before the U.S. Senate Health, Education, Labor and Pension's Subcommittee on Primary Care and Aging that its program, the Chronic Care Model, was designed to reduce the burden of chronic care in the community and emergency departments. Patients are given regular follow-up visits, and labs and tests are scheduled beforehand so the doctor and patient can review them during the visit. They have also established medical home certification for their four clinics, providing enhanced access to a primary care provider and an electronic medical record that helps physicians stay abreast of their patients' needs. This expands the Chronic Care Model concept by addressing preventive care, better access to treatment, and continuous quality improvement.
“Recent data gathered from hospital statistics have shown a significant downward trend in both ER visits and hospitalizations in the last two years compared to the two years prior to the Medical Home Pilot,” said Dr. Kraus. “The decrease in ER visits is due to both avoiding illness exacerbations that would have lead to necessary ER visits and to decreasing nonurgent ER visits.”
Timothy Seay, MD, the president of Greater Houston Emergency Physicians, said volume in the emergency department went down and volumes in the clinic increased after a federally qualified health clinic opened near one of the hospitals his group staffs in west Houston. “The payer mix switched as well,” he said.
After Hurricane Katrina forced New Orleans residents to evacuate to Houston in 2005, many Louisianans settled west of the city. In the emergency departments, the acuity of patients seen went down, and many of those patients had no insurance or only Medicaid.
“Federally qualified health centers are super-important,” Dr. Seay said. The problem is purely mathematical. A few years ago, he said, Houston had two such clinics while Cleveland had 11, although Houston is the fourth largest city in the United States. The disparity in numbers persists today. “They are a way to decrease the unnecessary burdens on the emergency departments, and these burdens will only increase when health reform is fully implemented,” he said. “We need to build more, but who is going to staff them?” Although primary care programs are seeing increased enrollment in recent years, the dearth of primary care physicians is well documented. And state funding for primary health care education programs have been slashed because of the current economic environment.
“There won't be enough doctors, and there already aren't enough nurses or midlevel practitioners,” Dr. Seay said. “There is even a shortage of providers such as x-ray technicians.”
Emergency department burdens will also grow once national health reform goes through, he said. Massachusetts provides a gloomy example: emergency department volumes rose dramatically once most people got health insurance.
Health centers will have to extend their hours and be open on weekends when people are off work and can get transportation, Dr. Seay said and those with chronic ailments will need better care to keep them out of the emergency department.
“We in the emergency department can't get the safety net of the globe anymore because we don't have enough money,” he said. “We'll start becoming the non-safety net for emergencies and that would be a bad mistake for the emergency community.”
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