The magazine of the UW School of Public Health

Transitioning Public Health Clinic Services to a Federally Qualified Health Center

Marni Storey and Alan Melnick

Over the past decade, local public health departments have struggled with defining core public health services while facing significant reductions to revenue. In response, the priority for local health departments has been to honor commitments to their communities. This article describes how Clark County Public Health (CCPH) transitioned clinical services, including successes, challenges, and lessons learned.

In 2006, over 40,000 low-income residents in Clark County, Washington had no health insurance, and many providers were not accepting Medicaid. CCPH provided categorical clinical services to a small portion of the population. Services included refugee health, family planning, immunizations, and STD clinical services. CCPH served 7,744 clients with in approximately 13,500 visits (Table 1). These services required $627,000 of county general funds per biennium in addition to state and federal grants.

Table 1

Number of Visits
Percent of Total Visits

Immunizations

6,495

47.9%

Refugee 1,689 12.5%
Reproductive Health 3,619
26.7%
STD
1,779 13.1%
TB    756   5.6%
Refugee TB
   223   1.6%

 

In 2006, CCPH faced decreased revenue and increased staff and program costs. For example, the Department received $250,000 less in annual General Fund contribution in the 2005-06 biennium compared to the 2003-04 biennium. In addition, regulatory changes to the Family Planning Take Charge Medicaid program resulted in revenue shrinking from $30,000 per month to $30,000 per quarter, a 67 percent reduction that caused an additional annual $240,000 loss. In response, CCPH identified health policy as an important area of focus that could improve health outcomes for Clark County and fit within current resource levels. CCPH also recognized the necessity of transitioning out of direct care provision. To do this in a considered manner, CCPH worked with community partners to identify an innovative, cost effective service delivery model that would not only maintain current access levels for low-income residents but exceed them.

Community-Based Methodology

Based on review of the literature and expert consultation, CCPH identified the chronic care model, with primary care integrated with behavioral health services as the best way to improve access, health outcomes, and cost control.

CCPH hired an expert on Medicaid reimbursement for primary care clinics, Federally Qualified Health Care (FQHC) clinics, and behavioral health services.  CCPH proposed a medical home provided directly and through coordination of care with other community health professionals. This home would offer services based on the National Council for Community Behavioral Healthcare Four-Quadrant Mental Health/Substance Abuse (MH/SU) model which provides services for patients with both low and high physical and behavioral health needs. Behavioral health services would include screening, assessment, medication treatment, care coordination, and on-site psychotherapy and would foster collaborative relationships between behavioral health and primary care providers.

Stakeholder Engagement

The next step was to engage stakeholders, including managed care plans, providers, the local FQHC, and the Regional Support Network (RSN). In April 2007, CCPH facilitated a community meeting to describe the access problem, introduce the four-quadrant chronic care model, obtain feedback, and gauge partner interest. Based on financial modeling, including FQHC reimbursement rates, stakeholders agreed that expanding access while implementing the chronic care model would require contracting with a FQHC.  

Consequently, CCPH and the RSN issued separate requests for proposals (RFP) to support expansion of a FQHC. The CCPH RFP described service requirements and staffing. The contract deliverables identified three goals: financial sustainability, implementation of the chronic care and integrated behavioral health models, and increased access. To evaluate sustainability, the quarterly reporting requirements included quantitative information such as number of clients, number of visits, payer mix, and provider recruitment and retention.

CCPH provided technical assistance and funding, including a base amount to support the start-up cost until the provider could establish financial viability, as FQHC expansion funds were not available.

Successes

The Vancouver Sea Mar Community Health Clinic successfully responded to the RFP. The resulting transition of clinical services increased access to comprehensive care for low-income clients in Clark County. Before the transition, CCPH provided categorical services to 7,744 clients through 13,500 encounters (Table 1). In the first year of operation, Sea Mar provided comprehensive primary care, including preventive services, integrated with behavioral health, to over 8,100 clients in more than 15,000 encounters. In addition, Clark County saved over half a million general fund dollars, which CCPH reinvested in population services and strategies to influence systems, policies, and environments.

Challenges

Although the transition was successful, CCPH faced three significant issues: (1) developing a contractual relationship with the FQHC, (2) managing change within the department, and (3) facilitating workforce development.

CCPH worked through contract issues by articulating clear expectations, providing technical support, and communicating directly and frequently. Transparency was essential because the transition resulted in a reduction of 14 staff filling 13.5 FTE positions. Even with transparency, the transition understandably created a morale challenge for staff.

To communicate, CCPH leadership used memos, e-mail updates, team meetings, all-staff meetings, and individual meetings. Department managers from all levels, including the Director of CCPH, John Wiesman, provided consistent messaging and made sure that union representatives were included and well informed.

CCPH brought in employee assistance for teams and individuals, provided workforce skills training for staff facing layoffs, and provided information from human resources on unemployment, retirement, and benefit impacts. To reduce the impact of layoffs, CCPH negotiated that Sea Mar would provide public health staff interview opportunities and give them preference over outside candidates.

CCPH ensured that remaining department staff who transitioned to new community-based roles learned new skills. Staff members have embraced their new roles and support CCPH leadership in influencing important local health policy issues, such as smoke-free work environments and access to outdoor spaces and healthy food.

Conclusion

This example demonstrates that local public health agencies with diminishing resources can leverage community partnerships to increase access to health care.  Low-income residents in Clark County now have increased access to integrated behavioral health and primary care.  The partnership between CCPH and Sea Mar Community Health Clinic demonstrated to county policy makers the importance of public health’s role in responding to new opportunities to shape access to care through the Patient Protection and Affordable Care Act.

Authors

Marni Storey, MS, RN, is Deputy Director at Clark County Public Health.
Alan Melnick, MD, MPH, CPH, is Health Officer for Clark, Cowlitz, Skamania, and Wahkiakum Counties.

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