Beyond Primary Care: Renewing the Community Health Center Vision for Today's Health Crisis.

United States community health centers address socioeconomic and environmental conditions and provide comprehensive primary care despite market forces that reinforce a medical model. Collaborating with 14 health center organizations, the RCHN Community Health Foundation promoted the original and broader health center vision of health, launching its population health management initiative in 2015. Although participating organizations were recognized as patient-centered medical homes and achieved rewards for quality, most identified gaps in their capacity for population health management. These challenges, addressed through peer learning and local initiatives, included engaging target populations, care coordination, socioeconomic and clinical data collection, and working with nontraditional local organizations. With relatively small funding, the zeal and enthusiasm for population health was revitalized among health center staff. The current pandemic and growing national concern for health disparities represents an opportunity to expand this broader vision of population health and to sustain it as the COVID-19 pandemic eventually subsides.

For many patients who use large amounts of health care services, the need is intense yet temporary.

Patients who accumulate multiple emergency department visits and hospital admissions, known as super-utilizers, have become the focus of policy initiatives aimed at preventing such costly use of the health care system through less expensive community- and primary care-based interventions. We conducted cross-sectional and longitudinal analyses of 4,774 publicly insured or uninsured super-utilizers in an urban safety-net integrated delivery system for the period May 1, 2011-April 30, 2013. Our analysis found that consistently 3 percent of adult patients met super-utilizer criteria and accounted for 30 percent of adult charges. Fewer than half of super-utilizers identified as such on May 1, 2011, remained in the category seven months later, and only 28 percent remained at the end of a year. This finding has important implications for program design and for policy makers because previous studies may have obscured this instability at the individual level. Our study also identified clinically relevant subgroups amenable to different interventions, along with their per capita utilization and costs before and after being identified as super-utilizers. Future solutions include improving predictive modeling to identify individuals likely to experience sustained levels of avoidable utilization, better classifying subgroups for whom interventions are needed, and implementing stronger program evaluation designs.

Addressing adolescent immunization disparities: a retrospective analysis of school-based health center immunization delivery.

OBJECTIVES: We compared completion rates for adolescent immunization series administered at school-based health centers (SBHCs) to completion rates for series administered at community health centers (CHCs) within a single integrated delivery system. METHODS: We performed a retrospective analysis of data from an immunization registry for patients aged 12-18 years. Patients were assigned to either an SBHC or a CHC during the study interval based on utilization. We used bivariate analysis to compare immunization series completion rates between the 2 groups and multivariate analysis to compare risk factors for underimmunization. We performed subanalyses by ages 12-15 years versus ages 16-18 years for human papillomavirus (HPV) and for the combination of HPV; tetanus, diptheria, and pertussis (Tdap); and tetravalent meningococcus virus. RESULTS: SBHC users had significantly higher completion rates (P<.001) for hepatitis B, Tdap, inactivated poliovirus, varicella, measles/mumps/rubella, and HPV for ages 16-18 years, and for the combination of HPV, Tdap, and MCV4 for ages 16-18 years. CHC users had higher completion rates for tetanus and diphtheria. CONCLUSIONS: SBHCs had higher completion rates than did CHCs for immunization series among those aged 12-18 years, despite serving a population with limited insurance coverage.

"Dyading" in the pediatric clinic improves access to care.

OBJECTIVE: This project evaluates the effect of "dyading" on pediatric outpatient care. METHODS: In "dyading," the medical assistant (MA) works with the provider in the exam room during the chart review, history taking, and patient education. In sequential care, the patient interacts with the MA, then the provider, then the MA again, with waiting in between. The authors measured visit time (from the MA starting with patient to the end of visit), the mean number of patients seen in a clinic session per provider, and patient satisfaction. RESULTS: After implementation of "dyading," mean visit time decreased from 37 + or - 14 to 25 + or - 11 minutes, the mean number of visits/session increased from 8.24 to 9.25, and waiting in the exam room reported by families decreased from 77% to 46%. CONCLUSIONS: "Dyading" decreased visit time, which increased the number of patients seen, thereby improving access to care. Patient time in the exam room decreased, which freed up exam rooms.

Adolescent immunization delivery in school-based health centers: a national survey.

PURPOSE: Vaccinating adolescents in a variety of settings may be needed to achieve high vaccination coverage. School-based health centers (SBHCs) provide a wide range of health services, but little is known about immunization delivery in SBHCs. The objective of this investigation was to assess, in a national random sample of SBHCs, adolescent immunization practices and perceived barriers to vaccination. METHODS: One thousand SBHCs were randomly selected from a national database. Surveys were conducted between November 2007 and March 2008 by Internet and standard mail. RESULTS: Of 815 survey-eligible SBHCs, 521 (64%) responded. Of the SBHCs, 84% reported vaccinating adolescents, with most offering tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and human papillomavirus vaccines. Among SBHCs that vaccinated adolescents, 96% vaccinated Medicaid-insured and 98% vaccinated uninsured students. Although 93% of vaccinating SBHCs participated in the Vaccines for Children program, only 39% billed private insurance for vaccines given. A total of 69% used an electronic database or registry to track vaccines given, and 83% sent reminders to adolescents and/or their parents if immunizations were needed. For SBHCs that did not offer vaccines, difficulty billing private insurance was the most frequently cited barrier to vaccination. CONCLUSIONS: Most SBHCs appear to be fully involved in immunization delivery to adolescents, offering newly recommended vaccines and performing interventions such as reminder/recall to improve immunization rates. Although the number of SBHCs is relatively small, with roughly 2000 nationally, SBHCs appear to be an important vaccination resource, particularly for low income and uninsured adolescents who may have more limited access to vaccination elsewhere.

Evaluation of community-based health projects: the healthy tomorrows experience.

OBJECTIVES: To address the "millennial morbidities," pediatricians must partner with community-based organizations to develop interventions. Little is known about the capacity of the resulting programs for program evaluation or the importance of evaluation in project success and sustainability. The objective of this study was to examine the capacity of community-based health programs to conduct project evaluations and determine the impact of project evaluation on project outcome. METHODS: Project directors from 149 community-based programs funded from 1989 to 2003 through the Healthy Tomorrows Partnership for Children Program were surveyed regarding their project experience with evaluation and documentation of project outcomes and the current status of their project. RESULTS: Program directors from 123 (83%) programs completed the survey. Despite barriers to the evaluation process, 83% of the respondents indicated that their evaluations produced useful information. Programs that were described by respondents as "well evaluated" were more likely to report that the evaluation was implemented as planned and that the evaluation included outcome measures. Projects were more likely to be sustained in their original form when at least 1 outcome was reported on the survey. CONCLUSIONS: Evaluation of community-based programs, although challenging, is beneficial to project success and sustainability. Policy makers and funding agencies should consider ways to encourage community partnerships to incorporate evaluation into their planning process.

School-based health centers: improving access and quality of care for low-income adolescents.

OBJECTIVES: We sought to compare visit rates, emergency care use, and markers of quality of care between adolescents who use school-based health centers and those who use other community centers within a safety-net health care system for low-income and uninsured patients. PATIENTS AND METHODS: In this retrospective cohort study we used Denver Health electronic medical chart data, the Denver Health immunization registry, and Denver Public Schools enrollment data for the period from August 1, 2002, to July 31, 2003. The cohort included all 14- to 17-year-old Denver Public Schools high school enrollees who were active Denver Health patients and were either uninsured or insured by Medicaid or the State Children's Health Insurance Program. "School-based health center users" were those who had used a Denver Health school-based health center; "other users" were those who had used a Denver Health community clinic but not a school-based health center. Markers of quality included having a health maintenance visit and receipt of an influenza vaccine, tetanus booster, and hepatitis B vaccine if indicated. Multiple logistic regression analysis that controlled for gender, race/ethnicity, insurance status, chronic illness, and visit rate was used to compare school-based health center users to other users. RESULTS: Although school-based health center users (n = 790) were less likely than other users (n = 925) to be insured (37% vs 73%), they were more likely to have made > or = 3 primary care visits (52% vs 34%), less likely to have used emergency care (17% vs 34%), and more likely to have received a health maintenance visit (47% vs 33%), an influenza vaccine (45% vs 18%), a tetanus booster (33% vs 21%), and a hepatitis B vaccine (46% vs 20%). CONCLUSIONS: These findings suggest that, within a safety-net system, school-based health centers augment access to care and quality of care for underserved adolescents compared with traditional outpatient care sites.

Improving pediatric immunization rates in a safety-net delivery system.

BACKGROUND: Denver Community Health Services (DCHS)' goal was to increase childhood immunization rates in the high-risk pediatric patient population served through its safety-net delivery system. The specific goal of the initiative was to ensure that children younger than 3 years of age with at least one primary care visit received all recommended vaccines by 24 months of age. METHODS: An immunization registry was developed to accurately track patients, regular assessment of immunization levels were conducted with provision of clinic-specific feedback, and team-based quality improvement meetings were held. The computerized immunization registry assisted in implementing all the remaining improvement activities. For example, improvement of on-time delivery of vaccines in primary care clinics was accomplished through a rules engine in the vaccine registry, standing orders for vaccine delivery, and implementation of vaccine delivery protocols that eliminated missed opportunities. RESULTS: From 1995 to 2006, Denver Community Health documented a 47% increase in immunization rates for 2-year-old patients and a 26% increase for 1-year-old-patients. Two-year-old immunization rates exceeded 85% by the end of this time period. DISCUSSION: The initiative improved pediatric immunization rates with demonstrated sustainability during a 10-year period. Success is attributed to staff commitment to process improvement activities and use of a patient registry for pediatric immunization delivery.

Primary-care visits and hospitalizations for ambulatory-care-sensitive conditions in an inner-city health care system.

OBJECTIVE: Hospitalizations for ambulatory-care-sensitive conditions (ACSCs) are a marker for access barriers for children and a possible outcome measure for primary-care interventions. We assessed the relationship between primary-care utilization and subsequent ACSC hospitalization among inner-city children. METHODOLOGY: We conducted a nested, case-control study of children born in 1993 in Denver Health (DH), a "safety-net" delivery system in Denver, Colo. Utilization of preventive care and other primary-care services was compared between children hospitalized for ACSCs and nonhospitalized children, who were matched by age and duration of care. Comparisons were adjusted for demographics, payer, and chronic health conditions. RESULTS: Of 2531 children, 115 (4.5%) were hospitalized for ACSCs. Sixty-eight percent were Hispanic, and 78% were enrolled in Medicaid. Children with ACSC hospitalization and nonhospitalized children made a similar number of preventive-care visits (2.7 +/- 2.0 vs 3.0 +/- 2.1 visits, P =.30) and other primary-care visits (4.4 +/- 4.6 vs 3.6 +/- 4.6, P =.16) between birth and hospitalization (for cases) or the same time period (for controls). After multivariate adjustment, each additional preventive-care visit (odds ratio = 0.87; 95% confidence interval: 0.67-1.12) was associated with a nonsignificant reduction in the risk of hospitalization for ACSC. CONCLUSIONS: Because ACSC hospitalizations are uncommon and the association between primary care and subsequent hospitalization is weak, a reduction in ACSC hospitalizations may not be a feasible outcome measure for interventions to increase the rate of preventive- or primary-care visits for underserved children within individual delivery systems.

Use of health and mental health services by adolescents across multiple delivery sites.

PURPOSE: To assess the role that school-based health centers (SBHCs) play in facilitating access to care among low-income adolescents and the extent to which SBHCs and a community health center network (CHN) provide similar or complementary care. METHODS: A retrospective cohort design was used to compare health care service use among adolescents relying on SBHCs compared with adolescents relying on a CHN. The study sample consisted of 451 inner-city high school students who made 3469 visits between 1989 and 1993. Encounter data were abstracted from medical records. Frequency of use and reason for use are examined according to various sociodemographic and health insurance characteristics. RESULTS: SBHC users averaged 5.3 visits per year. Minority youth who used the SBHC had the highest visit rates (Hispanic, 6.6 visits/year; African-American, 10.6 visits/year). Visits to SBHCs were primarily for medical (66%, p <.001) and mental health services (34%, p <.001). Visits at CHN sites were 97% medical (p <.001). Visits by adolescents were 1.6 times more likely to be initiated for health maintenance reasons (p =.002; confidence interval [CI], 1.17-2.06) and 21 times more likely to be initiated for mental health reasons (p = <.001; CI, 14.76-28.86) at SBHCs than at CHN facilities. Urgent and emergent care use in the CHN system was four times more likely for adolescents who never used a SBHC (p <.001; CI, 3.44-5.47). CONCLUSIONS: This study supports the view that SBHCs provide complementary services. It also shows their unique role in improving utilization of mental health services by hard-to-reach populations. The extent to which community health centers and other health care providers, including managed care organizations, can build on the unique contributions of SBHCS may positively influence access and quality of care for adolescents in the future.

Immunization registry accuracy: improvement with progressive clinical application.

BACKGROUND: Healthcare systems have been challenged to ensure the timely administration of immunizations. Immunization registries have been proposed to improve the accuracy and completeness of immunization information and to promote effective practice. METHODS: Comparison of randomly selected samples from two birth cohorts (1993 and 1998) from Denver Health Medical Center. Chart review and immunization registry information for these groups were compared; a composite immunization was recorded and up-to-date (UTD) status established. Registry data were compared with this composite using a sensitivity measure to assess completeness and accuracy. RESULTS: Among 818 children in the 1993 cohort and 1043 children in the 1998 cohort, there were 6386 and 6886 valid immunizations, respectively. The registry recorded 71.4% and 97.7% of these for the 1993 and 1998 cohorts, respectively (p <0.001). The apparent UTD rate, as measured with registry data alone, improved from 37% to 79% between the two time frames (p <0.001). Composite UTD status was 83.1% and 78.9% (1993 vs 1998, respectively). Accurate registry-defined UTD status improved from 44.4% to 100% between the two intervals. CONCLUSIONS: Immunization registry accuracy improved dramatically for recorded immunizations and UTD status. However, after 3 years of registry use, the overall proportion of children who were UTD had not significantly improved. The mere presence of a registry does not ensure more complete vaccination coverage. Other registry-based strategies, including use of the data for reminder, recall, and audit, may further improve immunization coverage.

Welfare to work: the effect of a health-care program in child-care centers.

OBJECTIVE: Welfare reform has increased pressure on welfare recipients to enter the labor force. When they become employed, former recipients often do not have paid leave that can be used to care for their young children when they are sick. We wished to determine whether an on-site health-care program in child-care centers serving low-income families affected the amount of time parents took off of work to care for mildly ill children. METHODS: We surveyed parents in 6 child-care centers with an on-site health-care program and in 2 comparison centers without such a program. To analyze survey results, a regression model including demographic and other variables was used to determine which, if any, variables were associated with time taken by parents from work to care for sick children. RESULTS: Analyzing the variables of employer leave policy, poverty level, age of child, and enrollment in the health-care program, only the variable of health-care program enrollment was associated with taking less time from work to care for sick children. CONCLUSION: Health-care programs in child-care settings can help parents meet the health needs of their children while reducing absenteeism from work, thereby contributing to job stability.