We gratefully acknowledge the sponsorship of the Valley Consortium for Medical Education (Modesto. California) 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):
Lil Anderson, (Yellowstone Health Department, Billings, Montana): Thank you, Marc. It’s always difficult to have to follow Marc when he does this presentation. He’s so dynamic and committed to community-oriented primary care. When you do have to follow him, you have to talk about implementation. What do you do with COPC when you’re in a community setting? And how do you get all of this done when your concern is the provision of care to individual clients?
I’m always relieved that I’m a health department based program and that the clinic that we manage is also health department based. It’s an overwhelming task when you have a large department and a fair amount of resources to devote to the development and ongoing care of a system as Marc just described.
I think it would be much more difficult to implement COPC if you have a freestanding physician practice that is not in the loop of all the community service providers within the local government setting.
Our health department was actually established formally in 1974, Prior to that time, public health services were provided in a rather “hit and miss” manner through a variety of of county and community entities. So, in 1974, we developed a city/county health department that came under the auspices of a Board of Health.
All of the employees are actually employed by the County of Yellowstone. We did not start providing primary care in a clinical site until 1983. That was the first year we received grant funding through the Bureau of Community Health Development and Assistance to establish a clinical site to provide services for the low-income, unserved and underserved people in our community.
Because we were health department based and had many years of experience in doing community needs assessments, providing health education, both in groups and one-on-one through home visitation, and working cooperatively in the community, we brought with us all of the principles of public health.
When we established our practice, we brought with us the community-based focus. So we were, probably, two, three, ten steps ahead of some community health centers when they had to establish their practice. We approach everything from a community needs assessment rather than an individual needs assessment.
Because we are health department based, we also have thew ability to leverage and access other financing mechanisms. This assists us in assuring that the programs that we are involved in and the services that we provide are really community-oriented and that we don’t get narrowly focused on clinical practice only.
For example, at our clinic we provide services on-site for AIDS patients and clients who are concerned about AIDS. We do testing and counseling. We do all of the health education and risk reduction classes. We have a community-based organization of volunteers that works with families of AIDS clients. We provide all of those services at the clinic, and they are funded by State grants, rather than through Federal dollars.
Our maternal and child health services are another good example of how we can provide clinical services on site. There, we can do low-birth weight prevention classes and childbirth preparation classes. We can do very intensive follow-up for high risk infants and children, and high risk pregnant women through home visitation, that is also funded through other Federal and State grant dollars.
On an on-going basis, we have either policy-making boards or advisory boards that work with us in every one of the services and programs that we provide. We have representatives from our hospitals, from large and small physician practices and from all of the community service providers for social service and educational components within the community.
They sit on our boards and we sit on their boards, so that we have the capability and the capacity to consistently monitor what’s happening in the community and to develop programs and services that will meet those needs. Those services are not always provided through our department, as the health department or as the clinic.
They are sometimes provided through the hospital. They are sometimes provided by a large group practice in the community. Whenever we identify an unmet need, we try to also identify the best service provided to meet that need and to work with the provider and support them in developing whatever program is necessary.
So we have covered, fairly well I think, what Marc described as a community-oriented primary care practice. We do have difficulties, because of the numbers of clients we see. We do a lot of preventive education, one on one, in the clinical setting. We find that we are always struggling with, as Marc described, the “going from room to room to room”.
We have the system in place. But, we constantly have to pay attention to the system to make sure that we don’t forget what we’re all about, that we don’t focus on individual clients only, but that we maintain that broad focus that Marc talked about. Collaboration is essential.
If you are working with people in private practice, if you’re in practice yourself and you’re teaching residents who are going out in the community, it will be essential for them to collaborate. They will never be able to do it on their own. They have to learn how to take advantage of the opportunities that are available in the communities where they are working. They have to be active with other community providers within that community in order to develop a true broad-based community-oriented primary care system.
It’s now my opportunity to introduce Mike Holmes who is the Executive Director of Cook Area Health Services in Northern Minnesota, a rural practice that has three clinical sites.
This presentation is preceded by: 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 1, Babitz)