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It Takes a Village 

Community health centers could make a hospital like Charity a last resort rather than a first stop for the uninsured.

As the debate continues over the revamping of the Charity Hospital System and how many beds a new Charity Hospital in New Orleans should have, Mike Andry has a suggestion: Keep people out of the hospital.

Andry, CEO of EXCELth Primary Care Network, an umbrella organization for community health centers in the metro area, says there is a dramatic shortage of hospital beds in the city, partially due to Charity's closure. Some experts in the past felt Charity had too many beds, but now the lack of space for patients to be admitted is the weakest link in health care for the poor.

"That's where we're most vulnerable," Andry says. "Our best bet is to treat people in the community -- do prevention servicing, keep them healthy and keep them out of the hospital.

Andry and other public-health experts believe community health centers are the answer. The centers are primary-care clinics that treat mild illnesses, manage chronic disease and provide preventative care. The services are offered to the economically disadvantaged, usually individuals at or below 200 percent of federal poverty guidelines. More importantly, these centers are located in the prospective patients' neighborhoods. What was Charity Prior to the storm, Charity Hospital, with its numerous specialty clinics and hospital beds, was considered the "safety net" for the city's poor. As Dr. Karen DeSalvo, executive director of the Tulane Community Health Center at Covenant House, points out, the system wasn't renowned for its efficacy.

"We've had a particular problem in Louisiana where we've had very high costs and very low quality with the underlying association of very low rates of primary care in the community," DeSalvo says. "We sort of stood out in the country as being one of the best examples of what happens when you have more specialty care, and patients don't have a way to prevent them(sevles) from getting sick or (being) hospitalized."

With the lack of available clinics close by, many people before the storm would let their conditions worsen rather than traveling to Charity, or they would go to local hospital emergency rooms to seek care for nonemergency situations such as a bad cough or a sprained ankle. Increasing instances of both scenarios drove up costs because patients came to Charity sicker and emergency room care is much more expensive than community health center care. Hospital vs. health center DeSalvo describes the difference in care between a hospital clinic and a community health center as "just in case" care versus "just in time" care. In the former, the specialty clinic patient, who for instance has diabetes, will be scheduled for a follow up visit in three months "just in case" and will be given a phone number to call if he has any problems. DeSalvo says the community health center diabetic patient will have a place to go "just in time" -- rather than a phone number to call -- should their blood sugar level get out of control. Since the community health center deals with a smaller population than a large hospital, the community health center staff would be more familiar with patients' histories and could tailor hours and services to the particular group it serves.

When Tulane's community health center at Covenant House opened in September 2005, it was set up as a clinic to treat first responders. After the city reopened in October, the clinic gradually became a community health center. Although Covenant House is a shelter and service provider for homeless, runaway and at-risk youth, the center, serviced by Tulane doctors and staff, normally sees patients 40 to 60 years old. Most of the clinic's patients reside in Treme or the French Quarter, and are, as DeSalvo describes them, working poor -- construction and service-industry workers -- living with chronic disease. Like many community health centers, the clinic offers some specialties, including geriatric care, mental health counseling and women's health services (gynecological examinations and pap smears, but no prenatal care).

The Tulane center is not a federally funded clinic. Much of its funding comes from private entities -- Johnson & Johnson Health Care Systems provided the original seed money -- and other granting sources. Those that do receive federal funds are designated as Federally Qualified Health Centers (FQHC). There are many categories of FQHCs, but the basic type receives funding from the federal government's Health Resources and Services Administration and is mandated to provide services regardless of ability to pay, has discount prescriptions and a governing board, which is required to have at least 51 percent clinic consumers on it.

Before the storm, there were six FQHCs in New Orleans. Five were under the guidance of EXCELth, and the city's health department operated the sixth, Health Care for the Homeless. Now there are four: the Ida Hymel Health Clinic, Algiers Community Health Clinic, Daughters of Charity at St. Cecelia's and Health Care for the Homeless. Besides the FQHCs, there is a number of community health centers like Tulane's located in the city, including St. Thomas Community Health Center, Common Ground Health Clinic and three school-based clinics. These centers are often funded through a combination of available grants and private partnerships. Needs and numbers Even with the city's diminished population, there are far too few community health centers and FQHCs providing primary care services in New Orleans. In October, the Louisiana Public Health Institute, with assistance from the United States Census Bureau and the Centers for Disease Control, conducted a population survey on behalf of the Louisiana Department of Health and Hospitals and the Louisiana Recovery Authority. The survey -- the 2006 Louisiana Health and Population Survey, which has a margin of error of 11.5 percent -- reveals that there are 187,525 people living in Orleans Parish. Of this population, 37,565 or 20 percent have no health insurance; another 13 percent rely on either Medicaid or Medicare. According to Partnership for Access to Healthcare (PATH), there are only 16 primary-care facilities that are accessible regardless of the ability to pay throughout the parish.

"I believe this is inadequate to meet the needs of the community," says Clayton Williams, director of PATH. "There is an urgent need to address the primary-care capacity issues in the city." He should know. As director of PATH, Williams and other members of his collaborative -- which is made up of health and social services organizations concerned with providing quality, easily accessible services for populations in need -- have studied ways to solve the problem for five years. Williams says community health centers and FQHCs are part of the solution. "Our collective goal is to advance community health centers throughout the region."

The need to establish more community health centers and FQHCs around New Orleans seems to be something about which most public health officials agree. Preliminary plans for the rebuilding of the Charity network in New Orleans include the centers and Louisiana State University Health Sciences Center, which is in charge of the Charity system statewide. Growing Sector Katrina didn't cause this crisis in health care, but it has changed the population. As rebuilding continues, the percentage of Hispanics living in Orleans Parish has more than doubled, from 3.1 percent to 8.8 percent. Williams says the number might be underestimated since many are temporary workers residing in alternative living situations and may not have been counted in the recent survey. Many of these workers do not have insurance, and Williams says there are other complicating issues regarding service for this new emerging community, including a language barrier, eligibility for state and federal programs and cultural appropriateness.

"All of these factors are new to us in New Orleans," Williams adds.

Since the growing Hispanic population isn't easy to pinpoint in terms of where individuals live, one method of service involves mobile health units. St. Charles Community Health Center (STCCHC), which recently received a mobile medical unit courtesy of Cardinal Health Foundation and MAP International, is attempting to provide primary care for these migrant workers. Instead of the population looking for primary care, the mobile unit will find them.

In October, the STCCHC unit was part of an event presented by the Mexican Consulate for Hispanics living in the Kenner area. James Comeaux, STCCHC's chief project officer, says the unit's staff saw 35 patients in one day. Eventually, Comeaux hopes the unit will be used for prenatal care for Hispanic women.

"These women aren't currently getting any care at all, or it's spotty," Comeaux says. "When women don't get prenatal care, there's an increase in low birth weight babies and birth defects. These higher incidences are already present in minority populations and will increase if these women don't receive care." New Directions While the loss of Charity Hospital has dealt a blow to indigent health care in New Orleans, it also likely signals a change in where that care is delivered. Instead of one giant, central hospital focused on health care for the poor and a dearth of community health centers, the new model will have many more small community-based primary-care clinics throughout the city and a hospital available for those who really need it.

DeSalvo says this is the wave of the future -- reinforcing the strength of individual communities, not only for health care in New Orleans, but for the rebuilding of the entire city.

"If you look at the replanting of the city in general and the movements nationally, they're moving towards micro-communities within larger cities," DeSalvo says. "We're on the same bandwagon. What I like so much about Covenant House is that it put health care inside of a community center, so it's not just 'I'm going to the clinic,' it's 'I'm going to the community center, and I'm going to get my flu shot. And while I'm there, I'm going to stop by the library.'"

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