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Tuesday Aug 12, 2014

Sense of Community: CHCs Offer Way to Battle Health Disparities, Social Injustice

Editor's Note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the seventh post in an occasional series of blogs that will look at the different roles family physicians can play.

I am coming up on the two-year anniversary of starting my first clinical practice in a community health center. The joys have been great -- as have the challenges.

I've been passionate about working in a community health center (CHC) since I first learned about the opportunity as a medical student. The biopsychosocial model of care that is a hallmark of family medicine strongly resonated with me, and it made perfect sense that a CHC would be the ideal place to bring that model of health care to life given that these centers provide comprehensive primary care to medically underserved communities and vulnerable populations.

The team-based model of care used in our community health center helps me meet the complex needs of my patients. Here I am (far right) with my medical assistant, team assistant and case manager.

With a directive for half of a CHC's board of directors to hail from the local community, there is a built-in mechanism to ensure these clinics are responsive to the greater context from which their patients come. They were founded on a basic social justice mission of promoting health care equality by addressing not only medical care for individuals but also the social determinants of health within a community.

When it was time to choose a residency, I couldn't imagine training anywhere but a community health center. And as a National Health Service Corps scholarship recipient, I knew I needed to be prepared to practice in a CHC. My alma mater, the Family Medicine Residency of Idaho in Boise, is affiliated with a community health center that was designated one the of the country's first teaching health centers.

Training in a CHC, where fees are adjusted based on a patient's ability to pay, was an invaluable experience. I not only learned how to care for a panel of patients, I learned how to care for patients with no insurance or means to get certain medications or testing and patients with concurrent mental illness who lack access to higher levels of psychiatric care. And it's all amid the day-to-day battle against the social determinants of health that can foil delivering even the best evidence-based medicine.

There are times when even the most starry-eyed, optimistic types (such as me) can feel burned out. I can't always get my patients the medications or tests they really need or the subspecialist visit that might help augment their care. Mental illness is prevalent and presents a challenge for many patients in navigating their health care and the community at large. Sometimes, I'm not sure how to intervene.

But even with these daily roadblocks, I still believe in the mission of caring for anyone who walks through my office door regardless of their payer source, and I love the moments when patients say our clinic was the first place in the health care system where they felt they were treated with dignity.

I like the challenge of figuring out if I really need to order a particular lab or test -- especially if my patient might be getting the full bill. At times, I feel I am trying to live the mission of social justice and equality, and also of the triple aim (improving population health, enhancing the patient experience and reducing costs) to which our whole health care system should strive.

CHCs also are already designed to follow the patient-centered medical home model using team-based care, which at our site includes physicians, nurse practitioners, physician assistants, nurses, medical assistants, clinical pharmacists, therapists, case managers and dietitians. I could not take care of the complex needs of my patient panel without this team!

Although CHCs can be a challenging environment in which to practice, I am grateful to be a physician among those serving in our nation's community health centers. I cannot imagine another place where I could better live the values of family medicine in the biopsychosocial model of care while addressing health disparities and social injustice on a daily basis.

Amy McIntyre, M.D., M.P.H., is a family physician at the Butte Community Health Center in Butte, Mont., and her practice includes full-scope outpatient care, maternity care, and long-term care and hospice.

Comments:

Family physicians are indeed the multiple times workforce solution for CHCs 2004 CHC Workforce (Rosenblatt, JAMA) can be compared to US Workforce using the 2005 AMA Masterfile 767,219 All Active Physicians 6,496 Physician FTE in CHCs 0.85% of active physicians are found in CHCs 86,090 All Family Medicine Trained Physicians 3084 Family Physician FTE in CHCs 3.58% of FM trained physicians are found in CHCs This is a 4.2 times multiplier for CHC location compared to all active physicians. Internal medicine trained physicians are 1.08 times as likely as all physicians to be found in CHCs, 1.9 is the multiplier for pediatric trained physicians, 1.6 for ob-gyn, 0.7 for psychiatry. The FM multiplier is even greater for rural CHCs as FM is even more important in these locations as noted by Rosenblatt. Teaching CHC and other residency expansions specific to family medicine are the most likely to result in CHC workforce. Expansions for more nurses (0.14% in CHCs), more advanced nurses (0.58% in CHCs), more physicians (0.85% in CHCs), more nurse practitioners (1.49% in CHCs, or more physician assistants (1.68%) are limited for CHC workforce result. Designs highest yield for family practice are required for most efficient result for CHC, rural, underserved, elderly, Veteran, and other populations in most need of workforce. A direct route to permanent family practice position result for MD, DO, NP, and PA has been avoided, but is most specific for health access recovery at the current time. All years of preparation, medical school, and residency training should be at CHC or other site in need of workforce for optimal health access contributions before, during, and after training. The pieces such as Teaching CHC, continuity longitudinal integrated curricula, and origins shared with populations in need of workforce should be unified into a specific family practice result beginning before admissions and lasting throughout a career.

Posted by Robert C. Bowman, M.D. on August 14, 2014 at 01:41 AM CDT #

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