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)

In preparation for the 25th National Conference on Primary Health Care Access, to be held April 14-16, 2014 at the Hyatt Regency San Francisco, we will be publishing a series of archival works of plenary faculty. The following is a presentation made to the Coastal Research Group’s First National Conference on Community Health Center-Primary Care Residency Program linkages on October 16, 1993 by Doctor Michael Prislin, who was then Chair of the Department of Family Medicine and is presently Associate Dean for Students of the University of California Irvine School of Medicine. Dr Prislin is a Fellow of the National Conferences on Primary Health Care Access.

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, September 16, 1993):

 

Terry Pitts, EdD, moderator: It is a privilege to begin this session Dr. Michael Prislin, Chair of the Department of Family Medicine at the University of California, Irvine.  His department is the academic home of the nation’s largest family practice residency program located in a community health center, UC Irvine’s 30-resident program at Community Clinic of Orange County.  He will discuss the educational perspective of family medicine residency training in a CHC setting.

Michael D. Prislin, MD, (Chair, Department of Family Medicine, University of California, Irvine): Thank you.  In examining issues pertinent to the linkage of community health centers to primary care health professions training several perspectives are important.

Michael Prislin; Chair, Deparment of Family Medicine; University of California, Irvine
Michael Prislin; Chair, Deparment of Family Medicine; University of California, Irvine

Family practice residency training programs seek relationships with other ambulatory clinical care facilities that allow the attainment of both curricular objectives which are unique to a specific program, and broader educational requirements which have been established by the Residency Review Committee for Family Practice [RRC].

It is important to realize that from the educational perspective the principal consideration is not the needs of the community’s patients or the operational requirements of the community health center, but raqther the needs of the learners.  When we consider how our educational programs will work in a community health center, meeting the health center’s patient care needs are important, but meeting the needs of our learners is essential.

We cannot begin to consider developing family practice training program linkages with community health centers if our curricular objectives are not going to be met and if knowingly violate the rules established by the RRC.

Unfortunately, in attempting to attain these educational objectives, one often comes into direct conflict with the operational mandates in place within the community health center.

In order to better understand several of the important educational issues that we have identified in our particular environment, a brief history of the evolution of the relationship between the Community Clinic of Orange County and the University of California, Irvine, is necessary.

The Community Clinic of Orange County was founded as a free clinic in 1971.  Its origins were in a community-based movement that developed in response to the riots that occurred a few years earlier in Watts.  It was an effort on the part of some individuals in Orange County to put together a program to serve some of the needs of the medically under-served in Orange County.

Historically, Orange County has been characterized by its extreme political conservatism and it is not known for its social programs.  Founding a free clinic was something that was independent of the organized political process in Orange County.  Indeed, it was also independent of the organized health care process in Orange County.

In fact, the Community Clinic started in a store-front in a commercial area of Santa Ana.  It did, however, receive a considerable degree of political visibility and eventually attracted the interest of the count government.

Initially, the staff at this facility consisted of Part-time paid and volunteer positions.  However, once the Orange County Health Department became involved, a plan was developed so that some of the staffing could come from the University of California, Irvine.  A contractual relationship was established to send residents to the clinic in order to provide adequate coverage of patient care needs.

There really was no attention paid to what academic department the house staff might come from, or what was going to happen in terms of education and supervision.  Supervision was provided by the volunteer and part-time paid providers in the facility, but there was no educational structure.  From the perspective of the Community Clinic, the University was merely a place for this center to obtain a necessary health care workforce.

About six or seven years after the establishment of the Community Clinic, the County, in an unusual demonstration of generosity, built a building.  The County recently had torn down a park in a particular neighborhood of Santa Ana which had become a community nuisance and the counter supervises figured that if they built a health care facility on this site, it would mitigate the political fall-out resulting from the closing of the community park.  The relocated health center, however, continued to run much the same way as the original free clinic.

The University of California Irvine College of Medicine has a unique history.  This is a medical school that was relocated from Los Angeles to Orange County in the late 1960’s.  Budgetary constraints forced the Regents of the University of California to purchase Orange County’s public hospital, rather than construct a new University medical center.

The same model was used for all three of the new medical schools in the UC system established during the 1960s – UC Davis, UC San  Diego, and UC Irvine.  At the time that the county hospital was purchased, the University of California also leased the new community clinic facility for $1 per year and assigned it to the Department of Family Medicine to be used as its training facility.

It was interesting that once the University of California had purchased the county hospital and had leased this particular clinic, a very rapid decline in interest on the part of the county in providing health care services, or even financing health care services for the medically under-served, occurred.  This decline culminated in the early 1980s with a community clinic that basically was financially insolvent, and which the University was threatening to close.

Meanwhile, the county had a few other ambulatory health care facilities operating, and one was a Public Health Service Act Section 330 supported facility that had two roles:  to provide general primary care services to the medically under-served in central Orange County, and, to conduct the refugee screening program for Orange County.

In the mid-1980s, an arrangement was made between Orange County and the University of California to close this latter county clinic and to consolidate its operations at the Community Clinic of Orange County.  Simultaneously, an agreement was reached with the Public Health Service so that the funding through the Section 330 grant would be linked to this new consolidated operation at the Community Clinic.

Thus, the Community Clinic of Orange County did not start out as a community health center, nor even as an educational facility.  It began as a free clinic with a residency program eventually added as a sideline activity.  Then, through a series of external political events, things came together.

These events were very important, both to the  Department of Family Medicine and to the College of Medicine, because, if they did not occur, the Department’s principal training site would have closed due to financial insolvency.  Indeed, from the University’s perspective it was seen as a significant contribution to stabilizing the funding situation.

The total budget of the community health center in those days was approximately $1.7 million dollars.  Although the amount in the Section 330 grant was approximately $330,000, it assumed a critical importance in the overall financing of the clinic.

From the community health center viewpoint, this arrangement provided an opportunity for them to broaden the range of services to its patient population and to further bolster their provider workforce.

Where does the Community Clinic of Orange County stand today?  We operate in what we consider to be a small and cramped facility of about 12,000 square feet.  This facility serves as the continuity family medicine center site for 29 residents.  Twenty-nine resident physicians are roughly equivalent to ten full-time faculty at the Clinic who each spend approximately 50% of their time in direct patient care.

We have an average of 12 medical students who rotate through the Community Clinic in the course of completing their primary care clerkship, which is half a day a week per clerkship.  We have one or two additional medical students who rotate through the Clinic at any given time on elective rotations.

We have, or have had in the past, at least one nurse practitioner or physician assistant student from the University of California, Davis, program completing a required ambulatory preceptorship in our clinic.  So the facility is crowded; we have a lot of people squeezed into a very limited space, and we manage approximately 40,000 patient visits per year.

The Community Clinic has a long-range health care plan that (hopefully) identifies some of the needs of its service population and also addresses the health care needs mandated by the Section 330 grant.  Community Clinic provider staff commit a lot of energy to administering the refugee health screening program in Orange County.

We continue to have a high influx of immigrants from Southeast Asia, and more recently we have had a significant amount of immigrants from Eastern Europe and Russia.

The Community Clinic serves a relatively young patient population.  Like many other primary care practices, this patient population tends to be oriented toward the female home provider.  So we have a great deal of patient volume in the areas of reproductive health and child health.

Pediatric care, family planning, prenatal care and cancer screening are the predominant diagnoses seen in this population.  The Community Clinic also servers an older population which is predominantly Hispanic.  The clinical profile of this population is heavily weighted towards hypertension and type II diabetes mellitus.

The Community Clinic has an interesting geographic proximity to the Rescue Mission in Orange County.  The Rescue Mission is directly across the street.  It is always virtually fully occupied and quite often the street and sidewalk outside are with 30 to 40 homeless people.

Thus, the Clinic also serves a sub-population of homeless, whose care should be approached comprehensively, but who, in fact, receive purely episodic care predominantly for infectious disease related problems.

The Community Clinic of Orange County is located in probably the most densely populated segment of Orange County, and is in the area of highest poverty.  The population served by the Clinic is strongly affected by the consequences of drug abuse, domestic violence, and other sorts of intentional violence.

We have an ambitious health care plan that targets these community health concerns and attempts to reach out to the populations at risk.  But these are very difficult issues and at the present time we only wish we had the answers.

From the educational perspective, there are four important issues in terms of the linkage between the community health center and the family practice residency program.  These include:

  1. the ability to be responsive to the community health care needs and yet meet residency program curricular objectives and accreditation requirements;
  2. the ability to reconcile community health center workforce productivity requirements with the educational needs of students and residents’;
  3. the ability to achieve unity in addressing issues relative to the governance of the community health center;
  4. the ability to achieve satisfactory financial relationships between the community health center and the educational program.

The first issue that I would like to discuss is the impact of the community health center’s health care plan on the curricular objectives of family practice residency training.  The health care plan is targeted towards meeting the very specific needs of the population being served.  The community health center is organized around the clinical services that the health plan identifies as constituting the community’s paramount needs.

On the other hand, the rules established by the Residency Review Committee on Family Practice require that a balance of clinical experiences occur during the course of the ambulatory family medicine center training.

Obviously, if you have residents doing nothing each day but refugee screening exams, prenatal care, family planning visits and well child care, there will b a wide range of clinical experiences in family medicine that are missing.  So there is a potential conflict between serving the needs of the community in terms of the provision of targeted patient care services and serving the needs of learners in terms of providing the required breadth of clinical experiences.

One of the things that we have attempted to do is to identify whether there are community needs that might be targeted in such a manner as would facilitate the addition of clinical breadth to the patient care population serviced by the community health center.  For example, during the last few years we have sought to establish a multi-cultural geriatric assessment program at the Community Clinic.

From the health care plan perspective, the objective of this geriatric assessment program is to address the needs of an identified sub-population within our community, and, at the same time, to bring more patients with a wide variety of chronic medical problems into the community health center.

A second critical issue has to do with the potential conflict between provider productivity and the educational and teaching needs of residents.  Community health center grants contain specific productivity relative to the center’s providers.  Unfortunately, in our facility, we have a hard time defining exactly who is and who is not a provider.  There are problems such as the concern that a junior resident cannot be permitted to see 14 patients per session.  This does not work educationally.

Perhaps a third year resident can achieve this level of productivity, but it is virtually impossible for second year residents, let alone a first year resident or a medical student, to meet CHC productivity criteria.  Even if the learners could achieve those productivity levels, the residency program would not have the ability  to offer any sort of meaningful teaching in that particular workload environment.

A potential solution that we have developed in collaboration with the regional office involves how we calculate provider productivity.  We align our learners with our full-time faculty in teams.  We then count team productivity rather than individual productivity.  That works very effectively, yet is is interesting that in the course of preparing for a site visit by a consultant hired by the hospital has informed us categorically that calculating team productivity is not acceptable.

The consultant noted that we will have to figure out ways that we can calculate productivity on an individual basis at both the medical student and at the resident level.  It is clear to us that we can count the numbers, but they will not meet CHC productivity guidelines.  So one message of this discussion today is that there must be sufficient flexibility in interpreting the rules at the community health center so that the educational needs of the training program are not compromised.

Perhaps the most interesting and complex issue relative to the linkage between the community health center and the family practice residency program is that of governance.  The issue of who is in charge is never ending.

The Department exerts academic governance in terms of what we are tying to do in our educational programs for the residents and the medical students.  The community exerts governance, appropriately, through the Community Health Center Advisory Board.  The latter governance process provides for meaningful community input in terms of the clinical program and, hopefully, also provides some degree of financial oversight.

However, in our particular environment beyond the Department and the Community Health Center Advisory Board is a bureaucratic monster called the Academic Medical Center.  The Medical Center is responsible for the Community Health Center’s financial bottom line.  As I mentioned earlier, at the time the consolidation between the Section 330 Community Clinic of Orange County and the University occurred, the total budget was approximately $1.7 million.

The current budget for the Community Clinic of Orange County is now approximately $2.5 million. The section 330 grant presently accounts for approximately $270,000 in annual revenue support.  Patient care revenue generated at the Community Clinic accounts for an additional $1.4-$1.5 million.  The remainder of the support for the Community Clinic must come from somewhere else.  And that somewhere else, in our case, is the UCI Medical Center.

The Medical  Center is paying a large portion of the clinic’s operating expenses.  They are providing the employment security for the staff who work at the Community Clinic. The Medical Center naturally has some ownership responsibilities and, therefore, also posses a desire to manage the facility.

Thus, the need to balance revenues and expenditures can lead to a great deal of conflict, particularly between the Medical Center and the  Department of Family Medicine, but also some conflict between the Community Health Center  Advisory Board and the Department, and the Advisory Board and UCI Medical Center.

Establishing unified positions on any fundamental financial or governance issue can be a very difficult process.  As an example, the Medical Center has established plans to move the Community Clinic into a new facility.  These plans have the enthusiastic support of both the Department and the Community Health Center Advisory Board.

Recently, a proposal has come forth to link assignment of examination rooms to the anticipated productivity level of the providers.  From the perspectives of the Medical Center and the Community Health Center Advisory Board this makes sense in maximizing the efficient operation of the facility.

While this makes sense from their perspective, a family practice residency program accredited by the Residency Review Committee on Family Practice follows a fundamental rule that there must be two exam rooms assigned to each resident.  Indeed, the accreditation application requires demonstration that this criterion is met, during the course of accreditation site review.  Similar sorts of issues arise throughout the course of establishing the operational environment of the Community Clinic.

The Department tries very conscientiously not to interfere with the clinical operations of the Community Clinic.  A member of our faculty serves as the Community Health Center’s medical director. He participates fully in the Health Center’s operational administration.  We try to support the clinical plan, asking how the residents and students will fit in.

Even where we can demonstrate significant violations of the commitments that must be made to meet the educational needs of our students and residents, we have pledged to work together to make the clinical plan work.  As previously noted, an example of this give and take has been the development of our multi-cultural geriatrics assessment program.

The Department has had the responsibility for developing the geriatrics program’s academic orientation, but the larger governance structure has made certain that this program conforms to the overall health care plan of the Community Clinic.

A crucial issue which is the topic of an entire discussion in and of itself is program financing.  Optimally, in a well-run family practice residency, the direct operational expenses can be covered through the generation of clinical revenue.  However, attaining this goal is quite often difficult, particularly if the reimbursement base of the patient population is restricted and the patient care needs are complex.

Further, at least in many university or other academic settings, a series of indirect costs often approaching or even exceeding  the direct operational expenses are imposed upon a residency program.  Meeting these expenses is virtually impossible in this context.  So clearly, the relationship between the educational program and the community health center will be of paramount importance in establishing any type of linkage.

In our particular situation, the Medical Center funds resident salaries and underwrites the operational costs of the community clinic.  The USPHS Section 330 grand funding supports the departmental faculty based at the clinic.

The current structure of our community health center has its basis in a series of largely external political events which produced a coordinated effort on the part of a Section 330 community supported health center, its advisory board, an academic medical center and a department of family medicine.  Those of you who have experienced working in medical schools understand that they are extremely political institutions.

Even so, it would be wonderful if we could live our lives simply inside the medical school environment.  But just as external political events have shaped the current reality of our educational community health center linkage, external political forces are influencing its future course.

Health care delivery in this community is changing very rapidly.  The various entities who provide health care are positioning themselves to succeed (or at least survive) in this rapidly changing environment.  In Orange County we are not the only community clinic.  Indeed, there are 15 distinct community clinics.

The Community Clinic of Orange County is one of two community clinics linked to the College of Medicine.  The remaining facilities are independent entities.  But the Community Clinic of Orange County is the only facility receiving funding under Section 330 of the Public Health Service Act, and the only federally qualified health center.

Orange County is one of three counties in the State of California that has been awarded a contract by the State to develop a “county-organized health care system.”  The concept is to put together a managed care program for Medi-Cal (California’s Medicaid program), which also incorporates the county-funded medically indigent program and provides services to uninsured patients as well.

There have been some notable failures in California in trying to do this, but there have been some notable successes also.  We were one of three counties selected to create a new generation of these county-organized health care systems.

Orange County has the largest population by far of any jurisdiction selected for participation in this program.  Like other interested parties responding to this initiative, Orange County’s Coalition of Community Clinics, an umbrella organization representing all 15 of the health centers, was interested in attempting to develop a strategy to position themselves appropriately for participation in this program.

For this reason the Coalition of Community  Clinics employed a consultant who concluded that the community clinics should form a single corporation having 15 offices and should be independent of any of their sponsoring entities.  Further, the consultant felt that this corporation should assume management of the Section 330 Grant and use that as a device to obtain blanket FQHC status for all 15 of the community clinic sites.

At first glance this appears to be a very good idea.  Unfortunately, this proposal was developed without the benefit of discussions involving the  Department of Family Medicine or the Medical Center.  The consultant felt very strongly that UC Irvine would go along with it because (a) it would relieve the medical center of the burden of managing the Community Clinic of Orange County, and (b)  it would eliminae Medical Center’s financial obligation to provide its current level of educational support to the Department.

Unfortunately, the consultant did not account for the other $400,000 that the hospital provided to support the training facility, nor the nearly $500,000 that the hospital provides in support of resident salaries.

The consultant also did not consider the salary and benefit packages of the University employees who staff the facility, nor did he consider the relationship that the Community Clinic has with the University that allows us to be virtually the only free-standing ambulatory care facility in our county that has no difficulty in referring for specialty consultation or hospitalization.  So from the University’s perspective, there were several difficulties with this proposal.

In fact, the University, far from wanting to unburden itself from the Community Clinic, has decided that this is quite a valuable asset.  There are approximately 250,000 eligible lives in Orange County within the Medi-Cal program.

There are approximately another 40,000 lives categorized as medically indigent adults and there are untold numbers of uninsured lives within the County.  It is an objective of the University to develop comprehensive managed care programs in order to support its clinical service activities.

In fact, at the present time approximately 80 percent of all privately insured patients residing in Orange County are already in managed care.  And there are a small number of organizations within the County that dominate the private managed care market.  The University is not one of these programs, but the proposed new county organized health system will develop a new managed care program that may cover up to 300,000 lives.

The University, which is significantly behind in the competition in terms of participation in private managed care programs, in in a much stronger position to take advantage of the opportunity to become the provider for up to 300,000 new patients.

Indeed, it is imperative that the UCI Medical Center take advantage of this opportunity.  In fact, this is the reason the Medical Center is moving aggressively to relocate the Community Clinic of Orange County into a 50,000 square foot comprehensive primary care center which will be shared by the departments of Family Medicine, General Internal Medicine, General Pediatrics and Obstetrics and Gynecology.

The Medical Center is anxious that the Department of Family Medicine expand its present 40,000 patient visits a year to 65,000-70,000 patient visits a year.  A similar target of patient visits has been established combining the efforts of the departments of General Internal Medicine, General Pediatrics and Obstetrics and Gynecology.

Interestingly, many of the other community clinics also found the consultant’s proposal difficult to live with.  Several of the community clinics in Orange County have cultivated very specific patrons.  These clinics feared that they would lose their patronage under the consultant’s proposed scheme.  Therefore, when it came to a vote, the consultant’s proposal was defeated overwhelmingly.

Unfortunately, the long-term impact of the consultant’s proposal has been the development of an irreconcilable split among the participants within the Coalition.  Eleven clinics have remained with the original coalition forming a new staff structure and have resumed the process of strategic planning.  It is anticipated that a network of providers designated to provide care to the medically under-served will be developed and supported through the county organized health care system.

The University remains heavily invested in this process.  The four remaining clinics have formed the so-called Association of Community Clinics.  This group sent forward and put together a competitive bid for the Section 330 US Public Health Service Grant.  This approval was not approved and the 330 grant remains at the Community Clinic of Orange County.

However, the University received a very strong message from the Public Health Service, that it must go forward and put together a viable county-wide network.  Indeed, the competitive proposal featured just such a system.  While our facility has a strong track record of accomplishments the new proposal promised “pie in the sky.”

So, today, our community health center confronts a number of critical issues.  It must try to preserve a relationship, a legacy with the community, in terms of its unique origins and heritage.  From the Department’s perspective, it must maintain the integrity of its education programs.  From the hospital perspective, it must become an integral component of an ambitious plan to capture a large number of managed care lives.

While this is a particularly challenging time for all of the parties involved in this process, we believe the linkage between the community health center and the Department of Family Medicine continues to present a unique opportunity for addressing the needs of both students and residents and the patient community that they serve.

Dr Pitts:  There sill be plenty of time for us to follow up on some of the questions that we have.  But, in interest to keeping us on schedule and having some other time for speakers, I want to move on.  We have Mr. Garcia and Dr. Cruz come up to join us.

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 roles of community health centers administration and boards in establishing educational linkages.

 

This presentation follows: Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, “Community-Oriented Primary Care and the Role of Community Health Centers” (Part 4, Strange, Q and A)

This presentation is followed by: 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 2, Garcia)