Community health centers, proven to be an effective way to provide health care in low-income, minority communities, currently serve nearly 20 million individuals annually, many of whom are either uninsured or rely on public health insurance programs. Most well-run community health centers serve as a “medical home” for patients, where their needs are met across a variety of specialties and the staff helps with preventive care and management of chronic health issues. The Patient Protection and Affordable Care Act (ACA) is predicted to double the number of patients served in community health centers.
To talk about the implications of the growth of the community health center model, Jeanne C. Marsh (top left), SSA ’s George Herbert Jones Distinguished Service Professor, spoke with Donna Thompson (right), the chief executive officer for Access Community Health Network (ACCESS), and Linda Diamond Shapiro, AB ’77, AM ’78, MBA ’88 (Booth) (bottom left), ACCESS ’s vice president for strategy, planning and external affairs. ACCESS offers primary and preventive care in more than 40 community health center locations throughout Chicago and the surrounding suburbs, serving as the medical home for nearly 200,000 patients each year. Director of SSA ’s Center for Health Administration
Studies (CHAS), Marsh has published broadly on issues of substance abuse, social service provision for women and children, and evaluation of social work interventions.
Thompson is a registered nurse with more than 30 years of experience in health care; in 2009 she was named a Robert Wood Johnson Foundation Executive Nurse Fellow. Diamond Shapiro has served in the president’s office at University of Chicago Medical Center and as executive director of Health and Medicine Policy Research Group.
Marsh: In my view, ACCESS is on the cutting edge in many ways. But I am most interested in hearing today about how you are thinking about what the Affordable Care Act will mean in terms of having people who will be properly prepared and trained to take advantage of this expansion in health care.
Diamond Shapiro: When a patient comes in with high blood pressure, that might not be the only thing on his mind. When we are having great conversations with a patient, it is not always the physicians who are doing the listening and talking. It could be the medical assistant. It could be the social worker. And now as a nation, the health care system is saying, “Let’s implement a patient-centered medical home model.” I think that putting patients and community front and center in health care is what we’ve been saying in community health centers for years. With health reform, we now have the opportunity to construct workforce roles that elicit those conversations [with patients] and make sure care is coordinated by really listening. Does the patient have access to the next level of care? What would keep the patient from getting there? And what are the institutional barriers? One of the things that we did early on was look at the role of our medical assistants in fostering these conversations.
Thompson: On our teams of providers and staff, the glue is our medical assistants. They are basically our largest group. Many come from the community. Many are from immigrant families. Many have wanted to go to college, but could not afford to. So we created a scholarship program for those who would be in line to become professional nurses or social workers or get an advanced degree.
Marsh: So what is the role in ACCESS and in the future in health care for social workers?
Diamond Shapiro: I think that role is very much evolving as the country is looking at what is the best way to deliver primary care. [ACCESS is] looking at the social work role from a number of perspectives. First and foremost, in addition to case managers, we absolutely need clinical social workers to provide direct services to our patients.
Marsh: Are they the supervisors of the case managers?
Diamond Shapiro: No, they are clinicians working with individuals and groups to address problems such as coping with chronic disease, and with issues that affect health, such as depression and anxiety, as well as helping patients with parenting and with addressing substance abuse issues. When I was at SSA decades ago there were some active discussions about the social work role. As we all move forward with health care reform and with implementing the patient-centered medical home, we’ll need to be even more clear on what is the role of professional social workers in the team. We just received Strong Start funding from the Centers for Medicare and Medicaid Innovation, a national program for maternal and child health. We are looking to have both a social work role and a nurse role to provide care coordination, and we look forward to defining who should be deployed for each patient population in different settings. If there is a health education element needed for care coordination, the role would tilt toward nursing. If there is a concern about behavior, the role would tilt toward social work. If there are psycho-social problems that could be put on a list and addressed by a case manager, the case management work might tilt in that direction.
Marsh: Oh, that is fascinating.
Thompson: Nursing and social workers have always had this uphill battle: How do you quantify their impact? Strong Start is a great example of how we can learn more about care coordination and start working with our payers in more of a managed care arena.
Marsh: I’m really interested in your discussions about working in teams and how that is an important professional skill. Our Graduate Program in Health Administration and Policy [GPHAP], which is part of CHAS, is pretty amazing in the sense that it trains, in an interdisciplinary way, graduate students from SSA, public policy, business, law and we are hoping to add the medical school. They come together for a series of courses and they have a truly interdisciplinary experience, which they report is extraordinarily valuable. I think it helps them to understand what is the role, in a health care context, of a social worker verses a policy planner versus an attorney versus the business perspective. SSA Professor Colleen Grogan and GPHAP Director Laura Botwinick are giving a new course this year that is very exciting to me, which they are calling a case course. The students work in a team and they come to this mentor, who says, “I have this issue.” And then it is the students’ job to define the problem, find what the appropriate intervention is and put it together in a set of recommendations. But the main thing they are doing is working across disciplines. What is it like to work with someone from the Booth School of Business if you are social worker? What did you learn when a future lawyer was sitting there and what did you think you have to offer? Students have an amazing ability to go where the most interesting action is. And health care is clearly a place where that is, for all professions.
Thompson: Are the skill sets going to be looked at differently when you talk about being able to work in teams?
Marsh: We think a lot about that at SSA. We get our best information through the field education program, where our students are evaluated for their teamwork skills by the field educators. So, it is not just an academic experience for us.
Diamond Shapiro: What I have been trying to do for students is form a bridge between their academic work and the real roles and real challenges right here at ACCESS. As recently as last week we had an extern here. During her spring break she shadowed me for three days. She is an undergrad from The College who wants to go on in medicine. She loved sitting in on a senior leadership conversation with our CFO, chief information officer, our corporate compliance officer, our chief medical officer and our head of operations. We all have really different perspectives.
Marsh: How eye opening! I am sure her idea of health care has moved far beyond just walking into an examining room, right?
Diamond Shapiro: Right, and she did that too.
Marsh: This is a creative, cooperative, interdisciplinary environment you are describing. My experience in social work is that professionals can be adversaries instead of cooperative colleagues. You have obviously created an environment here that fosters innovation and cooperation that will serve you well as you are moving into a whole era of health care.
Thompson: Well, we are not a medical-only model, and we take our work beyond the walls of the centers. So a lot of what we are talking about is not only about when [patients] walk into our doors. Linda has a whole team of staff whose focus is on patients in their community. We are still committed to working with a population that is very, very invisible. The other piece at ACCESS is that we are in so many different communities, so our approaches in Bronzeville or in Chicago Heights are not necessarily what we are going to do out in Bloomingdale. If you ask a lot of our staff what frustrates them, they will clearly say, “You might go to one health center and it has a social worker, but we go to another health center and the social workers are not there, and we want them.” But it is through grants and this quilt of support that we put together [that builds] what is available for each location. That is not the best, but in the world we are in, that’s what we have to do: We add one social worker at a time. The roles of social workers at ACCESS are diverse. When Linda was recruited over a decade ago, it was to do program planning and grant writing. When you asked the question earlier, “What is the role of the social worker?” that role could range from the CEO to a direct care provider to running programs. I would encourage social workers not to go by what has traditionally been done, but to think big and out of the box on what needs to be done. To me, that is the challenge for that future group.
The following is a continuation of this "Conversation" and is online-only content from the Summer 2013 issue of SSA Magazine.
Thompson: We are always so excited to host students [at ACCESS] because we really want them to understand how to figure out [for their patients] where that healthy grocery store is and where mom is going to get off public transportation and how many blocks she is going to walk. Sometimes our patients don't make an appointment because they are working two or three jobs or they have transportation issues. It is our role to help address and navigate these issues, because there is no sense in me talking about your blood pressure if you can't afford your meds. We have to take into account if you are about homeless half the week, you are on your sister’s couch two nights a week and you are in another part of town the other three…or if you are hungry, or if you are food insecure.
One of our nurses who works with diabetics was talking with a patient about exercising, and the patient kind-of glared at her and said, "I'm not going outside my house. It is too violent." So she says, "You’ve got kids. What kind-of music do they listen to? Hip-hop? Well, three days a week, jump around with them for an hour doing their hip-hop music in the house." And so it is also very practical approaches to where the patients are at that can make an effect on health.
Diamond Shapiro: Internships have always been the hallmark of clinical social work, but SSA also allows students an administrative internship. We continue to take administrative interns from SSA, and we hire a fair number of graduates, as you know. I think administrative internships are very important, especially in a nonprofit like ours, where we are always negotiating between our mission and the values and business decisions. Our issues are very real, and I think exposure to our hard decisions teaches students what kind of information and data do you need to guide us going forward. And how should we respond to the data to meet our mission? How do business decisions get made in a setting where mission is really so important and prominent in leadership thinking?
Marsh: This conversation only reinforces the social work perspective that the best results come from addressing the whole person. It goes beyond just social concerns or medical concerns and requires responses that are tailored to the needs of that person.
Diamond Shapiro: And I think that all goes back to the idea that concepts such as the patient centered medical home are easier to create on paper than you find when you go to execute. What we have found in our health centers across many different communities is that no cookie-cutter really works. One size does not fit all. We have a lot more to learn about how we can then translate some of the best approaches in the field to really making patient-centered ideals come alive each time we apply them..
Donna, I wanted us to also talk a little bit about our facilities investments and some of the things we have done to make the patient experience more welcoming and, again, create places where patients are going to want to talk a little bit about themselves and their personal experiences.
Thompson: I will never forget once, years ago, during the holidays, we put up ornaments in a health center in the Robert Taylor Homes and a patient came in and told her friend, "Look, this is like Michigan Avenue. They did this for us." So we knew we were on to something, and we’ve learned a lot more by asking our patients more through our patient satisfaction surveys.
In our design, we pay attention to quality, safety and interaction—from the comfort room to the hall, where we have soft colors like a living room, but a comfier living room, not the living room of our parents.
Diamond Shapiro: Even reception areas need attention. Traditional reception areas have a kind-of Plexiglas barrier. Well, is that really welcoming? So can we get rid of those? We are in neighborhoods where traditionally we have had security guards. Is that welcoming? We are looking at a concierge model, where the security guards might also have a broader role, knowing who is in the waiting room and how to make their visit productive and comfortable.
Thompson: A lot of [health centers] can talk about being patient-centered, but how many people have security in the middle of their living room? You are already telling people, "I don't trust you. I think you are going to take anything I have of value. But come here and trust me and let me plan your future. Take your clothes off."
We have talked to the staff about how many of our patients might not use the best skills, they might not know how to manage when they get frustrated. And so we are looking at roles where we can help nurture people, to guide people. If someone has a behavioral health issue and they can get quickly agitated, then how do we really make sure that that person gets in quickly and gets her needs met?
Marsh: This is really very exciting. You are really very well positioned to make the most of the Affordable Care Act.
Diamond Shapiro: I think we are. Call us in five years and we will tell you.
Marsh: Well, that brings up something else: You say call us in five years—unlike many health centers or community health centers you actually evaluate your services to find out how they’re performing.
Diamond Shapiro: That is another piece that is evolving, and it really came from the fact that many of our funded programs or program officers asked for a formal evaluation. We’ve used a combination of approaches. We have external evaluators who are academics, but over time we realized we have very specific questions about how to make our programs better and with an external evaluator, sometimes we were not getting the kinds of material that really helped us in a continuous improvement modality, which is more in line with our culture.
So we thought, why not experiment with bringing this evaluation activity in house? Now we have a research enterprise at ACCESS and it focuses more on finding out what is the best way to deliver medical care to our populations, with a focus on the fact that our populations are affected by racial and ethnic health disparities. There are some national level, “big science-type” investigations that we either participate in or, in one or two cases, even lead.
In addition to that, we do have evaluators that we specifically hired to evaluate programs that we implement largely with federal and state funds. As an example, for the Strong Start program, we will have a local evaluator who will be part of our continuous feedback process, so that as we look at issues like role clarity, as we look at how and what the patient experience is, we will really be asking our own questions and getting great answers that we can use, but we will also be part of a national evaluation associated with the national initiative.
Marsh: I'm not an expert, but I am familiar with community health centers elsewhere, and my knowledge suggests that this patient-centered approach, tailored approach, the emphasis on research is not broadly shared. I think the ACCESS model is quite amazing.
Thompson: The average health centers are normally four to five clinics. And since they are required to have a lot of the same infrastructure we do—a CFO, a CEO, a CMO—they don’t have the ability to have a lot of the resources that we do with their smaller footprint.
Back in 2008, when the economy really tanked, there were a lot of companies that were telling their employees, "Sorry to let you go. By the way there are these places called community health centers. They will see you for little or nothing." [Faced with that growing demand], we could have really frozen our resources for caring for adults, but we said, "No." Because we knew, especially in the suburbs, especially in Du Page County, there was a tremendous growth of the uninsured and by mission, we did not want to turn our backs on them
We are really excited [for the opportunities with] the Affordable Care Act, because so many of our patients have been really invisible. We are talking about people, many of whom have college degrees, many used to have jobs with benefits. They are paralyzed with worry because they see they are one family illness away from going bankrupt. So we feel good that we have been there to welcome these patients.
We have fabulous providers, really professional staff, and the investment that we have made in our health centers really welcomes all in the community. This isn't the pit stop you make when you don't have anything else, so as soon as you get a little cash and a card you are out of there. Our model is really that we want to anchor ourselves in the community and really be their solution for wellness.