Chapter 2

FQHC Start-up Part A - Mission and Strategy

When starting a new FQHC it is imperative that you have a well-defined mission statement and a carefully planned strategy for achieving your goals.  Because the overall aims of these centers is to bring primary health care to those who most need it and to do so in the most equitable and efficient ways, this chapter covers the methods by which to identify your target population, recognize their particular needs, and  develop a plan to address those needs.

Sections include:

• Identifying your community
  • MUA parameters
  • Cultural considerations
  • Special populations
  • Identification Methodologies
     
• Community Involvement
  
  
• Developing a Community Needs Assessment
  • Demographic and Health Status Trends
  • Managed Care and Utilization Rates
  • Barriers and Access to Care
  • Resource Availability
  • Health needs assessment toolkit
     
• Making Strategic Considerations
  • Long-term and Operational Planning
  • Statewide Strategic Planning
  • Networking and Affiliations
  • Market Considerations in the Planning Process

Identifying your community

The most important first step in the creation of an FQHC is properly identifying the parameters of the community you intend to serve.  FQHCs are designated to provide health care services to populations considered medically underserved (MUA.

When assessing the traits of a health center’s target population, emphasis should be placed on the specific cultural considerations of that community.  Because many of the barriers underserved individuals face are related to cultural factors (i.e., language, gender, age, sexual orientation, socio-economic status, etc.) it is of utmost value that a health center gauge the diversity of its community on a broad scale and develop an informed plan that is respectful and appropriate for its client base.

A particular health center designation can be that of serving “special populations.”  These groups of people, ordinarily medically underserved, are considered to have additional challenges in meeting their health needs.  Special populations include: migratory/seasonal farm workers and their families, at-risk school children, residents of public housing, and the homeless.  Health centers considered to be serving special populations still meet all the requirements of FQHCs, but make additional accommodations to address the added barriers of that population.

Identification Methodologies

The first step in defining your community is detailing your service area, or the geographic area which your center will be serving.  This must be, but is not limited to, a medically underserved area (MUA and can be designated by county, census tract, or divisions that comprise an ordinary neighborhood.  The area can also be measured by characteristics of the setting such as language issues, geographic barriers to access, transportation models, and other services available in the area. 

• Census Data - For basic demographic information, income,    housing, and poverty statistics
• MUA Designation Site - Provides MUA designation data by state, region, locale
• HPSA Link - Health Professional Shortage Areas query services gives information on HPSAs by region, state, or medical discipline
• PCA Directory - Contact the Primary Care Association in your State
• Medicaid State/Territory Site - Provides coverage stats and program information by State
• CDC Website - Offers data on disease and health status trends across the US
• BPHC Home - The Bureau of Primary Health Care website is an additional resource for all health centers and provides a variety of information

Another integral component in understanding your target community is analyzing the surroundings in which your health center will operate.  A complete community analysis accounts for all of the various factors that make up the environment for a particular center.  It includes consideration of the different sectors of a community (i.e. business, government, health care, etc.) along with their components and influences. For a sample of a community analysis outline, see the NACHC Sample Community Analysis Outline

Community Involvement

Community involvement is a feature that is present throughout the creation, establishment and operation of a health center.  Community members are a crucial resource in the identification of need and planning for programs and expansion and should be included in a health center’s start-up planning and continued development.  Although connecting with the community is often the first step in planning a new health center, locating and retaining participants can be challenging.  Some ideas to keep in mind for approaching and including community members in the FQHC process include:

• Assemble a list of all possible community contacts and assign the appropriate person to approach them
• Hold public forums to gain community opinion and support
• Use word of mouth to effectively spread information about meetings
• Consider language and cultural variations in holding your sessions (i.e., bilingual staff for Spanish-speaking populations)
• Make sure your forum locations are accessible to the community members both by time and transportation (consider offering transportation to and from meetings)
• Keep a record of contact information for those attending meetings and those who wish to continue their involvement
• Follow through on questions and concerns of the community, and maintain contact with key    elements in the population

Determining a Community’s Needs

As a follow up to “identifying your community,” a CHC should conduct an in-depth analysis of a community’s specific health needs.  By this process, a health center will be able to determine both the services most required by the population as well as the areas in which disparities and difficulties linger.

The needs assessment takes into consideration data on various levels of interest discussed below:

     
        Managed Care and Utilization Rates
        Barriers and Access to Care
        Resource Availability
        Health needs assessment toolkit

Demographic and health status trends are the most basic of elements in evaluating the needs of the community.  An understanding of the make-up of the population and their specific health requirements will provide the CHC with a basis of information upon which to build its treatment programs and allocate its resources.  Some of the basic demographic traits and their resource links are listed below:

• Age                                     U.S. Census Data
• Sex                                       
• Ethnic/Linguistic distribution       
• Poverty Percentages              , DHHS Federal Poverty Guidelines
• Employment Data                   State Departments of Labor
• Housing Information                State Dept. of Economic Development
• Migrant Population Estimates    State Office of Migrant Health

Managed Care and Utilization rates provide clues to the levels of health care access that exist within the community.  Evaluating the coverage trends of your population and their tendency to seek care can clarify the areas of unmet need and inform programmatic and outreach activities.  Methodology for assessing these characteristics may be available through your PCA as part of their SSP process.  Some of the individual data can be found at the sources below:

• Insurance coverage and Medicaid rates      State Medicaid Agency
• Health Care Utilization Data                      National Center for Health Statistics

Barriers and Access to Care are elements that can be both formal measurements and perceptions of the community.  They can include any detail that contributes or detracts from the ability of an individual to access the primary care delivery site.  Some common barriers can include language, transportation, knowledge, fear, etc., and are often assessed through contact and data gathering from the community itself.  Concrete barrier data, such as that relating to transportation schemes and linguistic characteristics, can be located from census and state-level sources but the most reliable resource is in the population itself.

Resource Availability determines the presence of health care resources within the community in terms of existing providers and service organizations.  Often times a PCA will have primary care data available, but it is important to obtain as thorough a picture of the local health care landscape as possible. This includes measuring doctors, both generalists and specialists, gauging their direct patient care hours or full time equivalencies (FTE), and learning their market share of managed care and Medicaid patients.  These data, detailed further in the Market Analysis and SSP methods, when compared with the health needs data of the community can demonstrate the true nature of unmet need within the underserved population.

Much of this general information can be obtained from health data sources discussed above such as State health departments and your PCA, but for a more precise and thorough analysis a health center should conduct its own detailed needs assessment.  Proper methodology for primary care needs assessment is available in the Health Needs Assessment Toolkit, developed by the Mid Hampshire Primary Care Trust.

Making Strategic Considerations

The strategy of a health center acts as the guiding principle in almost every aspect of its operations.  Having identified the target community and assessed its needs, a health center must

• identify long-term and operational strategic plans
• network and develop affiliations with other area service providers
• consider the market environment in the planning process
• Statewide Strategic Planning

Strategic Planning

In identifying the long and short term goals of your health center, you must first prioritize programs according to both the needs of your community and the resources available to the health center.  You should also take into account the priorities of the community itself by incorporating their input and feedback into the planning process. 

When it comes to planning, there are two main areas for a health center to consider.

The first is long-term strategic planning, a process by which a health center develops a long-range proposal for its role in the community. The strategic proposal serves as a guide for establishment and implementation of health center programs and generally foresees activities in a five-year span.  An essential element of long-term strategic planning is the integration of continuous evaluation and feedback into program development.  By tracking responses and changing needs, health centers can make the proper modifications needed to keep their programs current and effective.

The second planning system is annual or short-term operational planning.  This model focuses on short-term goals within the context of the long-range plan.  In other words, the operational plan provides a year-by-year comprehensible view into goals and strategies on a smaller, more logistically imaginable scale.