The Problem: Inadequate Healthcare Access
In Eastern North Philadelphia, when you ask community members about their experiences seeking healthcare, you may hear people say, “You can wait to see a doctor until you’re at the point of dying or you can go [to the emergency room], get treated in a timely manner, and save yourself” (Focus Group 2009). You may hear people recount stories about waking up at 4 a.m. to wait in line to be handed one of 30 numbers to determine whether they will be able to access care that day.
These stories give life to the grim reality that there are 116,200 residents in Eastern North Philadelphia who do not have access to healthcare services (UDS Mapper 2010). Eastern North Philadelphia, which is 60 percent Latino, is home to the most vulnerable census tract in all of Pennsylvania; almost 64 percent of children 0-17 in this area were living in poverty in 2009. The poverty level for adults is nearly twice as high as that of the city average (American Community Survey 2009). Over 25 percent of the residents in the area have not seen a primary healthcare provider in the past year, compared to only 16 percent of the City population (Community Health Database 2008).
The Solution: Bringing a New Healthcare Delivery Point to the Community in Need
In the heart of this community is Congreso de Latinos Unidos, Philadelphia's largest Latino social service agency, the 14th largest of its kind in the United States. Established in 1977, Congreso's mission is to strengthen Latino communities through social, economic, education and health services, leadership development, and advocacy. Congreso serves approximately 15,000 people a year in the areas of education, employment, family safety and health.
Congreso's health services are numerous, including a family planning clinic, behavioral health services for adults and children, HIV counseling, testing, and education, nutrition programming, domestic violence services, and maternal, infant and child health programs. At this point in time, Congreso is now working to add "health center" to that extensive list.
Close to 3 years ago, Congreso began hearing repeated stories from clients about being unable to access healthcare. Although there were quite a few sites in the area providing high quality care, demand for these services outstripped the supply available.
It became abundantly clear that the one thing missing from the vast array of services Congreso offered was primary care. After careful consideration, Congreso decided that establishing a health center on-site would be the best way to provide complete, continuous care to the community and embolden the agency's mission of strengthening Latino communities.
Building Solid Partnerships
From the outset, Congreso realized that it could not establish a health center on its own. Congreso's expertise had always been in serving the Latino community and in providing high quality social and health promotion services, but not in the direct administration of healthcare. The agency had an ambitious goal: establish a Federally Qualified Health Center (FQHC). FQHCs are special health centers that are located in medically underserved areas specifically to serve the uninsured and underinsured and are funded by the Department of Health and Human Services, Health Resources and Services Administration (HRSA). They are open to all patients, regardless of their citizenship and insurance status, and serve all ages. These health centers operate based on a sliding fee scale where patients pay what they can afford and are funded by a mix of state and federal Medicaid and Medicare dollars. Congreso wanted to pursue FQHC status because of the low-income demographics of the community and the sustainability that this support from the government brings.
Congreso wanted a partner not only familiar with FQHCs but also with nurse-managed health centers. Nurse-managed health centers are run not by doctors but by nurse practitioners. Nurse practitioners are health professionals who have pursued their master’s degree or doctorate in nursing. In Pennsylvania, nurse practitioners can prescribe medications, diagnose and make referrals independently. When there are complicated cases, they consult with a physician via phone or in-person to seek advice but they are relatively autonomous otherwise.
There are many reasons why health centers decide to pursue nurse-managed models of care. For Congreso, the community-based, family-oriented, holistic training and outlook that nurse practitioners have fit with the agency and the culture of the surrounding community. Congreso's family planning clinic had long been led by a nurse practitioner and clients always responded positively to her approachable nature and the way in which she was able to integrate their physical, mental, emotional and social needs in the care she provided.
In looking for a partner with experience with FQHCs and nurse-managed models, Congreso did not have to go far. Congreso found everything that it was looking for in a partner in the Public Health Management Corporation (PHMC). PHMC is a public health institute and nonprofit corporation with over 200 programs serving 50,000 individuals. PHMC has operated four successful nurse-managed FQHCs in the Philadelphia region for the past two decades.
Congreso also found a second partner in the National Nursing Centers Consortium (NNCC). An affiliate of PHMC, the NNCC's mission is to advance nurse-led care through policy, consultation, programs and applied research to reduce health disparities and meet people’s primary care and wellness needs. Since its inception, NNCC has providing technical assistance on how to establish and sustain nurse-managed health centers, first informally and then formally through a cooperative agreement from HRSA. NNCC's technical assistance arm, a program known as Community Health Partners for Sustainability, became a focal partner in helping to plan the health center, serving as the bridge between Congreso and PHMC.
Planning the Health Center
In the spring of 2009, the partnership began to formalize when NNCC, with Congreso's and PHMC's help, submitted a grant to HRSA to fund one year of strategic planning for the health center. In August 2009, NNCC was awarded the only planning grant in all of Pennsylvania for the project.
At this point in time, the partnership also benefited from the addition of an AmeriCorps VISTA, who would complete a year of service by serving as the liaison between the organizations, assisting solely in health center planning.
The Needs Assessment
Health center planning began with a crucial step: conducting a needs assessment. Congreso had heard from clients anecdotally about the long wait times for care. However, prior to the planning grant, no extensive information on healthcare access had been collected. Before deciding to move forward with the project, everyone needed to know that this was something that the community wanted and needed.
In conjunction with the AmeriCorps VISTA, staff from Congreso and NNCC worked to create a survey in Spanish and English for agency-wide distribution, asking clients for their demographic information, where they accessed care (including the emergency room) and how often, if they had a chronic condition, and if they would be interested in having a health center on-site at Congreso. Congreso also considered, with NNCC and PHMC, having a smaller satellite of the health center at Congreso's HIV services building. A shorter survey was created and administered to these clients to gauge interest.
The needs assessment also included seven bilingual focus groups, reaching 120 people from across Congreso's programs. In each focus group, clients discussed their medical needs, what healthcare meant to them, where they currently accessed healthcare, what barriers they faced in accessing healthcare, their level of interest in a health center at Congreso, and ideal health center services and hours.
The needs assessment revealed that 51 percent of the children of Congreso did not have access to timely health care services, 60 percent of clients had chronic conditions, and more than 1/3 of adults accessed care in the emergency room, if anywhere (Healthcare Access and Utilization Survey 2010). Clients overwhelmingly expressed their desire to have a health center at Congreso. One client, representative of so many others, told staff, “It would be a one stop shop; I already get all of my other services here” (Focus Group 2010).
Laying the Groundwork
After the needs assessment conveyed the importance of having a health center at Congreso for the surrounding community, all three parties set to work to lay the groundwork for the project.
Congreso, NNCC and PHMC created Letters of Intent and Memorandums of Intent to outline the relationship in a legal framework. Having the primary care expertise, PHMC would be responsible for oversight of the nurse practitioners, laboratory, pharmaceuticals and diagnostic services. PHMC would also be responsible for certain crucial health center operations, such as the credentialing of staff and billing at the FQHC rate. Congreso would be responsible for clinical oversight of behavioral health, case management, outreach, advocacy, health promotion/education and social work, and would provide the space for the health center and the cadre of health promotion and case management services already available. The partners agreed to joint sharing of risks and rewards. NNCC agreed to continue to provide technical assistance to the two partners, and will contribute its expertise in electronic health record implementation for the future health center.
With these legal documents in place, the partners created financial models and staffing plans for multiple funding scenarios. They also began to fundraise, reaching out to private foundations, both regional and national in scope.
A health center has multiple working parts that require funds, including personnel, construction costs, equipment and supplies, electronic health record implementation, and marketing. Congreso worked with NNCC and PHMC to plan for each of these different aspects of the health center, having preliminary meetings with NNCC about which electronic health record vendor to use and how this electronic health record would be integrated with Congreso's existing data system, Efforts-to-Outcomes (ETO). Congreso also had meetings with PHMC to discuss the equipment and supplies needed, and all three organizations discussed potential plans for marketing once the health center was operational. After meeting with architects and general contractors, Congreso created a potential floor plan of how the health center would look at Congreso's headquarters, including space for multiple exam rooms, a lab, an open workspace for students and nurse practitioners, and a reception area.
During the entire year of strategic planning, one aspect remained at the forefront: the community. Shortly after finishing the needs assessment, Congreso created an advisory board composed of community members. Congreso recruited members using case managers who recommended clients they thought would be a fit for the board based on their history with Congreso, passion for health, and ability to commit to monthly meetings. The first advisory board meeting, held in April 2010, had an incredible turnout of nearly all participants who were invited. Throughout the planning grant, advisory board members continued to meet monthly and to advise about the health center's services, hours and layout, among other aspects.
The New Access Point Application
The year of strategic planning culminated in the perfect timing of a Request for Proposals from HRSA for new FQHCs, called a New Access Point application. PHMC, Congreso and NNCC jointly worked together on an application that proposed Congreso as the fifth FQHC in PHMC's network. Submitted in December 2010, this application outlined every aspect of the health center, from referral relationships, to organizational structure, to copious statistics on community need, to letters of support and commitment from various community agencies. All of the work done during the year of the planning grant laid the foundation for the submission of this comprehensive proposal.
On August 9, 2011, Congreso received the news that PHMC had been awarded 1 of 2 New Access Point grants across all of Pennsylvania. The health center at Congreso was one of 67 projects funded across the country and one of very few nurse-managed health centers funded in that cohort.
The Innovation Behind the Project
The success of the Congreso Health Center project is attributable to the strength of the partnership between the three agencies and their collective ability to engage the community. From the get-go, this project was unique in that normally most FQHCs establish primary care services and then build a social service infrastructure. Congreso, with its cadre of 50 programs, provided that infrastructure from the project's inception. The agency's cradle-to-college pipeline just needed healthcare services to be complete to affect true community change.
PHMC's two decades of experience with FQHC credentialing, billing and marketing and other health center aspects enabled Congreso to focus during the planning process on what it does best, engage the community. In turn, NNCC's expertise in nurse-managed care and providing technical assistance helped Congreso to leverage resources and bridge the divide between social services and healthcare more efficiently and effectively.
Having the planning grant also made the project unique in that it provided the necessary foundation for acclimating the partners to one another more formally, empowering and energizing the community, and laying the groundwork for submitting a winning proposal.
Additionally, the plan to merge the data system Congreso has had for nearly a decade with an electronic health record added to the uniqueness of this particular project. Integrating ETO with an electronic health record is something that is entirely new to ETO’s creator, Social Solutions. With the proper privacy precautions in place, enabling specific programmatic and health center staff to have access to clients’ health and social service needs ensures complete, holistic service delivery.
Finally, the community support utilized throughout this project differentiates it from others. The community was involved in every step of the process, from the needs assessment, to the advisory board, to the relationships established with hospitals and other providers. This community involvement cannot be underscored because at its base, the Congreso Health Center is one built by, for, and with the community.
Expected Social Impact
Although the health center is not yet operational, it is expected to serve 2500 clients in its first year and at least 3,000 clients annually at full capacity with primary care services, behavioral health and lab services provided on-site, as well as pharmaceutical, dental and vision care provided via contract. The services provided will be fully bilingual, bicultural and will incorporate the deep understanding of the community that Congreso has and the extensive experience in providing primary care that PHMC has.
The health center will be a home for the community for generations to come. Longstanding community advisory board member Jose Gonzalez said it best when he said, "The clinic is the best thing that people will have in this community, and that Congreso will have in its whole life. I'm so happy because there are so many people [in this community] that need to see [health professionals]…and can't get help anywhere. The Latino community will be very happy when Congreso has a health center."
Jennifer Atlas is the Manager of Primary Care Projects for Congreso de Latinos Unidos. Waleska Maldonado is the Vice President of the Health Promotion and Wellness Division for Congreso de Latinos Unidos.
American Community Survey, U.S. Census Bureau, 2005-2009 Estimates. “Poverty Status in the Past 12 Months of Related Children Under 18 Years” and “Imputation of Poverty Status for the Past 12 Months for Families,” Philadelphia County. Available at http://factfinder.census.gov.
Focus Group. (2009). Crisis Assistance Program, Congreso de Latinos Unidos.
Focus Group. (2010). Latina Domestic Violence Program, Congreso de Latinos Unidos.
Community Health Database Household Health Survey, Public Health Management Corporation. (2008). Healthcare Access and Barriers, Online Data Analysis Tool. Available at. www.chdbdata.org.
Healthcare Access and Utilization Survey. (2010). Congreso de Latinos Unidos.
Uniform Data System Mapper. (2010). Health Resources and Services Administration. Available at http://bphc.hrsa.gov/healthcenterdatastatistics/statedata/index.html.