Dr. Karen DeSalvo, executive director of the Tulane University Clinic at Covenant House, and Mike Andry, CEO of Excelth Inc. Primary Care Network, an organization that operates several local federally qualified health centers, believe the testimony of these health-care community leaders was a big factor in the formation of this grant.
"From the standpoint of the community providers, the grant was dead-on responsive to what we said we needed," DeSalvo says. "They were incredibly flexible with it."
Clayton Williams, director of Urban Initiatives with the Louisiana Public Health Institute, the organization that will administer the funds, agrees. He adds that with the loss of Charity Hospital after Katrina, community health clinics have gained increasing importance in the New Orleans area as primary-care providers to the uninsured. Instead of a centralized hospital like Charity as the only option for the indigent, community centers are modeled on the idea of a "medical home," a clinic tailored to the specific needs of the neighborhood in which it is located. Centers provide primary care and disease management, specialty referrals, medication assistance and information systems for keeping track of patient records.
The centers will help eliminate long lines at other public facilities and the need for patients to use emergency rooms for nonemergencies. In addition, they should keep people from having to delay seeking health care until their condition escalates into an emergency. Grant funds also can be used to increase the number of doctors at centers.
"Everybody was saying we need more community-level primary care and the government heard that," says Williams. "[The federal government] worked hard to identify the funding and to make it available to this region to address that need. That's really the genesis of this funding."
Grant funds will be disbursed over the course of the next three years to eligible health-care providers in Jefferson, Orleans, St. Bernard and Plaquemines parishes. In order to qualify, clinics must demonstrate that they provide services to all patients regardless of their ability to pay.
The grant will be administered and technical support provided by LPHI in conjunction with the Louisiana Department of Health and Hospitals. Eligibility requirements were set by the federal government through the Center for Medicare and Medicaid Services.
"We anticipate the first payment (of grant funds) will begin flowing to clinics in September," Williams says. "This is called the Primary Access and Stabilization grant. This is the stabilization part. We want to get money to these clinics that are financially unstable or threatened as quickly as we possibly can."
Williams says that LPHI is currently reviewing applications and screening for eligibility based on the federal government's stipulations. Because the grant is to stabilize and expand existing clinics and not to build new centers, there will only be one screening process for the entire three-year duration of the program.
"I think part of the message that was conveyed by the community stakeholders on this panel was that even the existing primary-care centers that are here are threatened because we're running out of social service block grant dollars that had been helping sustain them," Williams says. "In addition to the threatened viability of the existing centers, we still have a gap to fill to meet the needs of the uninsured in this region."
LPHI estimates there are 27 community health clinics in the four-parish area not including mobile units ranging in size from one small nurse practitioner to large multi-specialty practices. The number of eligible clinics and the size of their respective practices will determine the amount of the initial payment. Approved clinics will propose a budget according to allowable expenses outlined by the federal government, and LPHI will then monitor those expenditures.
"It's supposed to stabilize and expand direct medical-care delivery," Williams says. "That's the focus. The bulk of it will be spent on things like doctors' salaries and diagnostic testing as opposed to buying a new building. You can't buy a building with this money."
Clinics can, however, renovate their existing space to increase capacity and staffing and that's something DeSalvo plans to do with the grant dollars for which her clinic has applied.
Using floating walls, making minor renovations and rearranging furniture physically increases clinic capacity, she says. In addition, DeSalvo wants to use the money to hire more support staff (including nurses, social workers and counselors), provide access to specialty services such as eye care and purchase vaccinations.
"It's really unbelievable how expensive vaccines are," she says. "We want to have 100 percent vaccination for all of our patients and that includes not just flu and pneumonia shots, but we want to be able to do Hepatitis B and HPV. ... From (the standpoint of) pure prevention, that's high up on our ticket list. We want to order those vaccines, get them in and get everybody vaccinated in the population because that's so critical for wellness."
In addition to adding doctors and other support staff and increasing capacity, funds also will support technical assistance to improve the efficiency of clinics' operations. This will include implementing electronic medical records systems, developing shared information networks and databases between clinics, and increasing efforts to screen patients for the availability of third-party funding.
"We'd like to encourage these centers to screen for existing sources of payment, so if [patients] are eligible for Medicare or Medicaid or some private insurance, we'd like to be able to access that money," Williams says. "Among the clinics we've worked with in the past, there's a range of different capabilities around screening and enrolling and billing. It's definitely one of the areas where we want to be able to provide some technical assistance in helping them establish those systems."
Community health centers operate on a sliding fee scale that can go all the way to zero depending on a person's income. Consequently, everyone technically has access to services offered at the clinics. What they pay depends on their income and existing coverage. Williams says screening will develop a mix of patients that can sustain a clinic's practice over time and will maximize existing revenue.
Grant funds to help offices make the transition to electronic medical records systems will improve a clinic's efficiency. DeSalvo says the clinic at Covenant House has greatly benefited from the EMR system it began using a few months ago.
"It makes such a big difference," she says. "We had enough data going in to it that a couple of months ago we were able to pull that data out and say, 'OK, how many patients do we have? How many are going to need vaccines based on the criteria we set?' It was a pretty exciting day for us because we could actually really plan and put a number on it and know the kinds of things we need."
Patients benefit from the EMR systems because procedures such as blood tests aren't duplicated when the information doctors need already is in the system. With patient approval, clinics can access medical records from other facilities in order to share information about X-rays or other test results, reducing the amount of time and transportation required of the patient. EMR systems also enhance communication between members of the medical home team.
Andry says Excelth, which doesn't have EMR systems in all of its locations, is working to phase it in. It also plans to use funds for the expansion of comprehensive services in the Gentilly and eastern New Orleans areas by resuming services at a clinic it opened to service both those areas prior to the storm. In addition to primary care, the clinic will provide behavioral and mental health services, substance abuse treatments, dental care, case management, transportation and medication assistance.
Some of the Excelth facilities, like the community health clinic in Algiers and the Daughters of Charity clinics, offer a variety of these services already. Andry hopes to be able to continue and expand these existing forms of care in all locations, especially those brought on or expanded after the storm.
"[The grant funds] give us a broader window to work with to stabilize them," he says. This contrasts with social-service block grant dollars, which previously supported the clinics and are now running out. The new grant will serve as a means of transition and stabilization as clinics figure out how to sustain themselves in the long term.
"It's important not only to shore up existing services, but also give some security to physicians and staff, to know the funds are in place and jobs are secure for the next three years," Andry says. Williams, DeSalvo and Andry also say that New Orleans' health-care community sees these funds as a bridge into future health- care reform.
"The next three years' funding will help, but there's a lot of work to be done in terms of seeing what comes after that," Andry says. "It's supposed to be bridge funding, funding to get us to somewhere. We have to work hard on what that is and what that looks like."
A complete map and directory of current community health centers in the four-parish area can be found online at the Greater New Orleans Community Data Center's Web site: www.gnocdc.org.