We gratefully acknowledge the sponsorship of the Wright State University Boonshoft School of Medicine Department of Family Medicine) for funding the transcription and editing of this section of the Proceedings of the First National Conference on Community Health Center-Primary Care Residency Linkages (Lake Tahoe, Nevada, October 16, 1993):
Terry Pitts, EdD, Moderator: We’re fortunate to have Joseph Garcia who is the administrator at San Ysidro Health Center and Dr. James Cruz who is director of the Sequoia Community Health Center and the assistant director of the Family Practice Residency Program at Valley Medical Center in Fresno, joining us to talk about the role of community health centers administration and boards in establishing educational linkages.
Joseph A. Garcia (San Ysidro Health Center, San Ysidro, California): Although my topic is listed in your program is “The Role of CHC Administration and the Community Health Center Boards in Establishing Educational Linkages”, I would like to begin with a brief history of our organization, after which I will focus on how our board has involved itself in decision making about educational linkages.
I will discuss the commitment that the health centers’ administration and staff have demonstrated in terms of these linkages; outline the health centers’ present and future plans; and finally, will focus how we train our providers to work in the managed care environment of the future, which I think is critical.
In August 1994, the San Ysidro Health Center will celebrate its 25th anniversary. We were founded by the University of California, San Diego [UCSD] School of Medicine. A group of mothers in San Ysidro, a small community just North of the border between San Diego county and Tijuana, Mexico, went to the School of Medicine and said, “We don’t have any doctors down here. What can you do to help us?”
A group of physicians and administrators from UCSD got together and responded, “Let’s donate our time and help San Ysidro develop some kind of program for medical care for their community.” That’s how the health center was formed. After about three years we applied for and received Public Health Services Act Section 330 funds. As a result, we expanded to what we are today.
We have a primary care program which consists of four medical centers, all in the Southern area of San Diego county. These centers employ 25 FTE providers which include family physicians, internists, mid-level providers, nurse practitioners, and physician assistants. Twenty of these are physicians and five are PAs or NPs.
Additionally, we have the largest mental health outpatient program in San Diego county. Our focus for the last 25 years has been serving an under-served population in a culturally and linguistically sensitive manner. About ten years ago we also formed our own HMO whose clientele is strictly Medicaid, which we call Community Health Group. We currently serve 37,000 patients in that HMO.
In San Diego County there are alliances being formed for that future managed care. All of Medi-Cal itself is to be converted, in the near future, to a managed care environment. (Whether that conversion will be in two years from now, or in three to five years is unknown.) As a result of the various activities that San Ysidro Health Center and Community Health Group are now engaged, currently we are a 40 million dollar operation.
We no longer consider our selves “small”, although we’re not “big” either. If you look at the health care industry in San Diego County, we’re very small compared to the Sharp Hospital System, the Scripps Clinic System, and the UCSD clinic and hospital system.
All of the health care organizations forming alliances in the San Diego area are trying to position themselves by establishing contractual relationships with existing providers. We, the county’s largest community health center, are looking at the situation and asking ourselves which whom we should be aligned and with whom should we contract.
We are fortunate to be in a strong position of strength because of our HMO and because that HMO currently serves 37,000 of that Medi-Cal population out of San Diego County’s total Medi-Cal eligible group of 315,000. We serve another 30,000 or so uninsured patients, ineligible for Medi-Cal, who are categorized as “medically indigent adults.”
We have an active community board that has overseen all of this activity. The board has a majority (51%) of consumers, and also some professional board members. Three board members are very assertive in providing direction to the community health center, as to how it should move into the future. Two of those board members have been on the board for at least ten years and know the health center and the policy issues very well.
Several of the governing board members have been adamant about ensuring that we have a strong and aggressive volunteer program. We reach out into the community by means of a large number of volunteers from all facets of the community. I’ll talk about how that links to the whole issue of family practice residency programs in CHCs, but I want to give you this background just to have you understand where we were, where we are and where we are going.
These particular board members have attended numerous conferences sponsored by the National Association of Community Health Centers [NACHC]. They always return with prepared written reports that tell of these volunteer programs across the country. They request monthly reports of the CHC administration as to the nature and the status of our volunteer program.
How many volunteers do we have that given month? Where do they come from and what are they doing? And then they ask, most importantly, how many of them have you hired as a result of their volunteer experience? How many of them are employees? And we’re pleased to say that many of our employees started in our volunteer program, so it has been very successful in meeting that goal.
In addition to those board members, our board is fortunate to include Dr. Ruth Covell, who also happens to be an Associate Dean of UCSD School of Medicine. That medical school linkage also helps us considerably and will help us even more so as we plan for the future. Our philosophy supports linkages between family practice residency programs and CHCs.
We hope to emulate some of the successes that Ventura Huerta and the Sequoia Community Health Plan have had in Fresno, as well as the successes that other organizations across the country have had. I hope to learn more about Dr. Prislin’s program based at the Community Clinic of Orange County. Because, although we’re not there yet, we’re hoping to form a comparable linkage with UC San Diego.
For many years, we have had students from the UCSD School of Medicine rotate through our CHC on a regular basis. They are there four hours a week for six weeks as part of their family practice rotation. We have maintained that on-going relationship throughout the last decade. In some years, however, we had no students and in some years we had two or three.
But it was not very formal, nor of particular strategic interest, either to the medical school or CHC, until the last couple years. We’re now looking at strengthening this bond and taking it to the next step. Can one develop new predoctoral and residency linkages that improve upon these previous student experiences, and are structured in a way that all parties benefit?
The UCSD School of Medicine also sponsors a summer program for medical students. The school pays the student to go out into the community and work at CHCs. We’ve been fortunate to have one or two students every summer who work with our CHC physicians, who learn our protocols and procedures and how medicine is practiced in our clinics.
We hope this experience will encourage these students to chose to enter the CHC style of medical practice. Those of you who are involved in CHCs know it is always a struggle to recruit physicians. CHCs are competing against the large medical groups – the Kaisers and Sharp HealthCares of the world – in terms of compensation and other issues.
We’ve also worked with the Health Promotion/Disease Prevention program sponsored by the American Medical Student Association [AMSA]. Over the last four years we have been fortunate to have medical students paid through the AMSA program work for us during the summer. They work closely with our health education staff. They assist in actual patient counseling about the types of problems which are very common in a large Hispanic population – diabetes, hypertension, obesity and cardiac problems.
In addition they develop community-based health promotion projects such as the American Heart Association’s Great American Smokeout or the American Red Cross’ Healthy Kids Faire – whatever they are most interested in. We try to be flexible in working with the students so that they get a valuable experience. Hopefully, when they graduate from medical school, they will choose a primary care specialty, and, after residency, will think back about the good experience they had at the San Ysidro Health Center and consider us or other CHCs a practice option.
Because we have a large mental health program, we work with San Diego State University’s doctoral programs in psychology, including the joint doctoral clinical psychology program that SDSU conducts with UCSD. Just in the last six weeks we are fortunate to have hired as director of our mental health program one of the professors from San Diego State’s School of Psychology.
He is much involved with the Sand Diego State – UCSD clinical doctorate program. He will retain his professorship there and, hopefully, further strengthen the bonds between SDSU and our health center. WE also work closely with all of the local vocational schools in the recruitment and training of medical assistants, LVNs, and RN’s.
We participate with the community’s high schools through a youth training initiative called the Regional Opportunities Program. Every summer, between 20 and 30 high school students are paid for at least 30 hours a week in different aspects of the CHC. They work in human resources, in the medical records office, in the laboratory, with the dental staff, and elsewhere. Our philosophy is to start orienting high school students towards a health career.
Hopefully, at some point they will want to be an LVN, an RN, a pharmacist or a physician. They will know something about the profession so that it’s not a big question mark to them. In fact, students who did work with us during high school are now ready to enter practice. One former student volunteer is completing an Internal Medicine residency at UCLA School of Medicine.
We are attempting to match him with a loan repayment program that would allow him to work with us and receive payment for his medical school loans. Another success story is a practicing physician in San Diego who started with us a a nurse many years ago. Because of her experience with us she decided to go on to medical school. She works for us in the evenings at one of our clinics. She has been medical director for a local CHC in another part of San Diego County and is now working for a large health promotion project.
For the future, we are looking at developing a linkage with the UCSD family practice residency program. We’ve had several discussions with the UCSD medical school dean and our board member, Associate Dean Covell. We are also talking to the Sharp HealthCare organization, which is developing its own family practice residency programs in the region.
We are trying to negotiate with both Sharp and UCSD to develop some collaboration between the two in order to avoid a competitive situation. We hope to bring all the other groups together and be the mediator so that we can move forward in the collaborative fashion to form a strong family practice training program in San Diego County that will benefit us all.
Also, we are seeking accreditation through the Joint Commission on Accreditation of Ambulatory Health Care Centers to position us in the future as a strong quality-oriented CHC. The accreditation process is difficult, and similar to the hospital accreditation process. But, we believe in the future, HMOs will not longer contract with non-accredited CHCs.
So we are preparing for that future and hope that, by 1994, we will be submitting our application for accreditation. Lastly, we have begun to work closely with the San Diego County private industry council. We have long term plans with the MAC project, which is a large social service agency, to develop a project similar to the one currently underway in Boston.
Various non-profit educational foundations, in cooperation with private industries, negotiated contractual arrangements with health care providers in the Boston area to work with students starting at the high school level, especially in the high risk areas of town. The project provides them with a paid orientation to potential clinical careers.
Beyond that exposure, the project has allowed many students who otherwise would not have had the opportunity – to enter allied health professions which do not require the long educational commitments of medical, dental, pharmacy or nursing school. They can go to school for say, one and a half years to become a pharmacy technician or licensed vocational nurse, dental assistant or laboratory technician. These entry level careers are the stepping stones to their future and to ours.
Thank you very much for your attention.
This presentation follows: Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, “Centering Primary Care Residency Training in a Teaching Community Health Center: Adventures in Academic Processes and Community Politics” (Part 1, Prislin)
This presentation is followed by: Proceedings of the 1st National Conference on Community Health Center – Primary Care Residency Program Linkages, “Centering Primary Care Residency Training in a Teaching Community Health Center: Adventures in Academic Processes and Community Politics” (Part 3, Cruz)