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Chapter 4
FQHC Start-up Part C - Clinical
Program
The clinical program of a health center must provide all of the
aspects of care and attention needed to ensure increased access and
quality of care amongst the underserved. Services must be
appropriate, available, and tailored to the needs of the particular
community, an achievable goal with the proper clinical system. This
chapter focuses on the wide range of details that go into an
effective health center clinical program including:
- System of Care
- Service Delivery Models
- Location/Hours/Transportation
- Type of Services/ Service Providers
- Clinical Staff
- Clinical Systems
Services
In creating a system of care, the basic outline is determined by
the services required of an FQHC. Each health center acts first and
foremost as a primary care center, but the greater goal of an FQHC
is in ensuring increased access to the entire continuum of care as
well as services aimed at improving the status of its community.
This can be achieved through the provision of all required services,
specialized services, and linkages to a range of health care
services.
By grant requirement, all health centers must provide the
following, either directly or through contract arrangement:
Basic Health Services:
- Primary care
- Diagnostic laboratory and radiologic
services
- Preventive services (including
prenatal/perinatal services)
- Cancer and other disease screening
- Well child services
- Immunizations against vaccine-preventable
diseases
- Blood lead level screening
- Communicable disease
- Cholesterol
- Eye, ear and dental screening for
children
- Family planning
- Preventive dental services
- Emergency medical and dental services
- Appropriate pharmaceutical services
Social Services and additional services:
- Case management
- Assistance with financial support for
social and health services
- Referrals to substance abuse and mental
health services
- Outreach
- Transportation
- Interpretive assistance
- Health education, where appropriate
Specialized services can include additional considerations made
for special populations and those with specific health needs. For
example, those health centers serving migrant health workers could
create added programs to address environmental/occupational health
hazards, or a focus on mental health services for health centers
serving homeless populations. Non-special population health centers
can also make adjustments to program services according to the added
needs of their population; for instance, a community with high HIV
prevalence may require increased disease and screening services. The
priorities and specialized services should ultimately be determined
by the needs of the community and the availability of resources.
Health Care Continuum
Though the foremost role of health centers is to provide primary
care, they are expected to facilitate access to the entire range of
health care services through a continuum of care. Linkages with
local health care provider networks as well as a comprehensive
system of referral and case management can increase efficiency and
quality in service provision. The offer of continuous care also
extends to after-hours services. At the every least, health centers
should provide telephone access to physicians after office hours and
should establish mechanisms for delivering needed services through
other providers and health networks.
Contracting for Health
Referral arrangements for complete coverage measures should be
made through contracting with hospitals and specialists in the area.
These procedures are to ensure that patients of a health
center have their complete health needs met even if the necessary
service is not provided directly at the center.
- Contracts and agreements with alternate
providers should be made in writing and should state:
- time period during which agreement is in
effect
- specific services covered
- any special conditions under which
services are provided
- terms and mechanisms for bill payment
- additional requirements such as data reporting, adherence to
CHC standards, and others
Health Care Planning
As with any operational system, the clinical program should
develop a comprehensive plan by a process of careful consideration
and effective prioritization. Health care planning requires creating
goals and objectives aimed at addressing the needs of the community
while properly allocating limited resources. To do this in the
clinical setting, a health center should properly identify needs and
follow through with the establishment of programs and services that
are achievable, reasonable, and appropriate. A method of measurement
should be included in the clinical plan as a means of assessing and
improving quality of care.
Service Delivery Models
Owing to the diversity of a health center’s population, service
delivery models must account for a wide range dynamics such as
population resource availability, transportation, and marketplace
characteristics. These variations can dictate such details as
location, service hours, mix of services and types of providers.
The subsequent service delivery models are examples set forth
by the Bureau of Primary Health Centers:
- Location: Health centers must provide
services at locations and times that ensure services are
accessible to the community being served, details to be decided by
the governing board. Most FQHCs operate at fixed locations while
others offer services in appropriate locations such as homeless
shelters and migrant farm worker camps. Most health centers engage
in outreach efforts to bring patients into the center including
the use of personalized transportation services such as vans and
busses.
- Hours: The hours of operation in a health
center should aid access to services and should include early
morning, evening or weekend hours. As mentioned above, plans
should extend to include services after hours.
- Mix of Services: The mix of services
offered by health centers is influenced by several factors
including demographic, epidemiologic, resource and marketplace.
The best mix of service must be determined individually for each
health center and should aim to address the community needs in an
efficient and appropriate manner.
- Type of Service Provider: The type of service providers at a
health center depends on the mix of services provided at the
center. Various disciplines and levels of providers should be
utilized where appropriate, but it is the responsibility of a
health center to maintain a core primary care team while making
specialists and alternate services accessible. The health center
staff should also be properly educated on the specific cultural
needs of the community.
Establishing Leadership
Leadership among the clinical staff is a necessary strength for
every health center. This usually takes the form of a clinical
director who works closely with the health management team as well
as the governing board to maintain a tight clinical program. The
typical clinical director is a physician, though some programs hire
different types of clinicians. The major responsibilities of the
clinic leadership are:
- to provide leadership and management for
all health center clinicians (employees,
contractors and volunteers)
- work as an integral part of the
management team
- establish, strengthen and negotiate
responsibilities between the health center and other
- clinicians, provider organizations and
payers in its marketplace
- to represent the interests of the community and health center
patients
Staffing
Staffing a health clinic can be a challenging and time-intensive
task. Because of the rigorous requirements and limited resources of
a health center, clinic staff should be carefully selected both for
the skills and for the personal capabilities that would enable them
to operate in such a setting. The task of staffing both medical and
non-medical employees is an ongoing project for any health center
and the following are some considerations to make in planning your
staff:
- Take a step-wise approach to staffing,
filling the leadership positions first, if possible. These
individuals can then assist in the recruitment of remaining staff
- Various agencies can serve as resources
in the staffing process, including the Bureau of Primary Health
Care, the National Association of Community Health Centers and
your local PCA. Other established health centers can also be
helpful in providing advice on area staffing challenges and
successful methods
- Select candidates that can best serve
your target populations, keeping in mind the cultural, language
and other needs of the community
- Don’t forget that administrative and social service staff can
be just as important to a health center’s operations as medical
personnel, so make the proper considerations in total staff
structure
Recruitment and Retention
Recruitment and retention of quality staff is of fundamental
importance to any successful health center. Due to the competitive
nature of today’s health care market, along with the resource
limitations of community health centers, aggressive
recruitment/retention strategies must be developed to attract and
maintain staff. The National Health Service Corps offers assistance
with placing clinicians and can be an important asset in provider
recruitment. For details on procedure and eligibility, health
centers should contact their PCA, PCO, or the Bureau of Health
Professions. The PCA/PCO can also offer aid in advertising openings,
referring possible hires, and assisting with organizational
employment design. In addition to the support offered by these
organizations, a health center must take steps to increase their
appeal for recruitment and retention including:
- Be familiar with the going rates of
health care salaries, and balance benefits to most closely match
health center’s competitors. For salary information contact your
local PCA
- Develop strategies to market your health
center to potential hires through promotional materials and
professional consultation
- Work to match the needs of both your
health center and potential clinicians as closely as possible. A
health center should not only offer its community the best fit
candidates for the job, but should also consider the opportunities
and skills that the health center can offer the clinicians as a
way of maximizing services as well as retention
- For free malpractice coverage, keep up to date on requirements
needed to meet the Federal
Tort Claims Act
- Create a comprehensive benefits package
to support long-term retention and increase productivity
- Include the staff in management
collaboration efforts as a way to increase involvement in
decision-making, gain valuable feedback, and commit them to the
health center mission and future
- Keep recruitment efforts active to take advantage of
opportunities and be prepared in time of unexpected staff changes
Staff Development
Offering staff development opportunities is a way for
health centers to bolster retention while keeping the capabilities
of staff current to the needs of the center.
These opportunities can take the form of training workshops, continuing
professional education, and affiliations with teaching programs and are
designed to maintain credentialing and licensing and continually cultivate the
skills of health center employees.
Policy and Procedures
The clinical policies and procedures of a health center should
reflect the current guidelines established by health agencies such
as the Agency for Health Care Policy and Research and should
describe:
- Hours of operation
- Patient referral and tracking systems
- Clinical protocols
- Risk management procedures
- Patient satisfaction guidelines
- Consumer Bill of Rights
- Patient grievance procedures
Tracking and Appointment
Systems
A health center clinical tracking and information system must be
based around patient medical records and should:
- Ensure confidentiality protection of records
- Promote thorough documentation and quality of care
- Incorporate recall methods for routine preventive services and
chronic disease management
- Allow tracking of patients who are referred to specialist and
other off-site services
- Supply data and information into a health center’s quality
improvement program
Proper budget allocations should be made to keep information
systems updated and efficient through increased technology
structures. Effective clinical tracking methods can increase the
quality of care in a health center and help better serve its
patients.
Appointment systems are another way to improve patient flow and
access to services. Appropriate scheduling and communication models
can foster continuity of care, minimize waiting time and no-shows
and could provide for emergency problems and call/walk-in patients.
Feedback and input from clinic staff can assist in the
identification of problems and the formulation of solutions to
patient appointment protocols.
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