Funding the ties that bind

To link safety-net health clinics, start small, go slowly and stay close to community stakeholders

When Hurricane Katrina swept into the Gulf Coast last summer, it destroyed New Orleans’ public health care infrastructure. Whatever health care safety net that had existed for the city’s poor and uninsured residents, including nine community clinics funded by the federal Health Resources and Services Administration (HRSA), was wiped out with clients’ health records.

A network of similar community health centers, many of which were also funded by HRSA grants, quickly arrived on the scene. HRSA Administrator Elizabeth Duke said HRSA-funded health centers located near the hardest-hit areas treated 42,000 evacuees from New Orleans within two weeks after Katrina hit.

The centers faced funding uncertainties and the challenge of working with patients who were often low income, uninsured or homeless. The community clinic movement’s response to Katrina is the result of a bottom-up approach to community building. That strategy preaches incremental progress — building on small successes, staying flexible and meeting regularly with stakeholders.

“You don’t want to let the perfect to be the enemy of the good,” said Erin Grace, senior vice president of health informatics at the Primary Care Coalition (PCC), a Montgomery County, Md., nonprofit health care funding and development organization that works to link the region’s safety-net clinics together. “It’s an incremental process — you ask for input from everybody. You try to get their engagement. But ultimately, you take the ones that are willing to come and hope the rest will ultimately follow.”

As a self-proclaimed facilitator, PCC funnels donations and grants from private foundations, local governments and federal agencies to eight county community health organizations. It also receives HRSA Community Access Program grants, and Montgomery County has agreed to fund PCC through a program called Montgomery Cares. The county contributed about $4 million to Montgomery Cares in 2005 after starting the program with $250,000 in 2000. Plans call for increasing the program’s funding to $15 million to $20 million in five years to help the county achieve its goal of becoming the healthiest in the country.

But the goal is fraught with problems. Many of the region’s clinics are bare-bones operations that rely on volunteer doctors and nurses to cover an uninsured population of 80,000 to 100,000 residents.

Most do not have a primary medical home, Grace said. Instead, they use hospital emergency rooms as their primary care facilities. PCC estimates that more than one-third of visits by uninsured patients are considered non-emergency.

PCC plans to use some of its funding to build an electronic health record system to link the area’s safety-net clinics to one another and, eventually, to others throughout the Washington, D.C., region. The result will be a wide-area virtual clinical network that would bridge the service and resource gaps that are typical of an ad hoc community health care system.

The backbone of the network is CHLCare, a Web-based electronic health records system that runs on a Linux operating system. Six local clinical organizations use the system at more than 30 sites. CHLCare lets physicians share basic patient records between clinics when authorized by patients.

Clinical perspective
CHLCare has helped community providers raise the quality of health services offered to uninsured patients. The Spanish Catholic Center, a nonprofit group that helps immigrants during their transition to the United States, has used CHLCare to coordinate records and appointments of clients it sends to its network of volunteer physicians — a surgeon who works in Washington, D.C., and a cardiologist and pulmonologist based in Montgomery County.

“We send patients back and forth, and the program recognizes them as unduplicated,” said Dr. Anna Maria Izquierdo-Porrera, the center’s medical director. “In effect, the patient has one single record.”

The center uses CHLCare to share demographic data and maintain some patient financial records. She said she envisions the system providing some disease management and decision-support functions. For example, the center operates a preventive care clinic called the Preventorium. There, clients can get a blood test, cholesterol check, Pap test or prostate cancer check in one visit.

Izquierdo-Porrera would like the system to prompt caregivers with clinical care reminders so that when they enter a note in a patient’s file, the system would flag upcoming treatment dates or milestones.

But given the complexity of providing care, she recommends adding new applications slowly and only after considerable discussion among stakeholders.

As PCC officials look ahead, they plan to add features to CHLCare, including better metrics, program accountability and connections to emergency rooms. PCC’s most far-reaching goal is to link the CHLCare system to mainstream health care supply lines in the Washington, D.C., area via the Metro D.C. Health Information Exchange. According to the plan, PCC will link hospitals and some safety-net providers in Montgomery County, the District of Columbia, Northern Virginia and Prince George’s County, Md.

As its first connection, the coalition will likely link health centers and hospital emergency rooms in Montgomery County and Washington, D.C.

Lack of basic IT is one of the biggest hurdles to setting up such connections. Most community clinics have few or no technology assets, said S. Orlene Grant, director of special projects and strategic planning at the District of Columbia Primary Care Association. The association works with local government leaders to develop those resources.

“It’s really to the city’s benefit to have their most critically vulnerable patients tracked and documented as much as possible,” Grant said. “We can then make public policy decisions based on informed information vs. gut-level and break the ER cycle for treatment that can be done in the clinics.”

In the end, quality health care for the uninsured will depend on the emerging clinical networks, observers say. “You can’t have a good system of care without information and infrastructure,” Grace said. “They support each other.”

Connecting the safety net:
3 general rules
1. Give safety-net providers basic information technology and training.
“That begins to get the clinics brought in because they need those resources and they can see the benefit of even that piece of it,” said Erin Grace, senior vice president of health informatics at the Primary Care Coalition.

2. Understand how the clinics work.
“Find out what are their needs, what data they’re collecting, what is their workflow,” Grace said. “You need to understand those things before you can build or implement a system that’s going to work for them.”

3. Be patient.
“It’s an incremental process that takes time,” she said. “You’ll have one or two that are chomping at the bit, one or two that will swear they will never do this, and most of the rest will be in the middle. You don’t want to overwhelm them.”

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