Community Health Care: Quality That Goes Beyond Access
In Connecticut, providing high-quality health care to the poor involves addressing life challenges that keep patients from following doctors’ orders. The holistic approach can translate into healthier families.
Experts working in health care for low-income patients are increasingly focused on providing integrated approaches that can help patients cope with life challenges-issues that affect health but generally fall outside the scope of traditional care. At the Boston Medical Center, for example, patients have access to legal assistance that might be used to press a landlord to make asthma- reducing heating improvements. BMC patients may also request help with translation, transportation, and bureaucratic tasks that can help them take full advantage of available health-care options and achieve good compliance with treatment plans. In Connecticut, Community Health Center Inc., an affordable-care organization founded in 1972, also believes in treating the whole patient. Per its motto "Health care is a right, not a privilege," the organization views individual health as inextricably linked with the inalienable rights to life, liberty, and the pursuit of happiness asserted in the U.S. Declaration of Independence.
Embracing New Models
Many emerging models of care concern themselves with an increasingly broad array of patient circumstances. One such model is the team-based patient-centered medical home, generally "led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes." 
Health and Community Development
by Sol Carbonell, Federal Reserve Bank of Boston
The Boston Medical Center partners with Health Leads, an organization that mobilizes college volunteers to connect patients and their families with the basic resources they need to be healthy. Check out a video of Co-Founder and CEO Rebecca Onie describing the organization's model at the Boston Fed's Healthy Communities Conference in 2011.
The conference was an opportunity to address the social determinants of health, brainstorm ways to promote better health outcomes for lower-income communities, and start a dialogue among leaders from community development corporations, health centers, government agencies, banks, and nonprofit organizations concerned about health in lower-income communities. The resulting partnerships are ongoing.
When a patient at a patient-centered medical home confronts an emotionally devastating diagnosis, for example, she is not simply referred to a behavioral health specialist. Instead the patient is escorted over to a specialist within the same health facility, thereby receiving immediate support and advice. Community Health Center offers such "warm handoffs" as a way to overcome some patients' hesitation to follow up on recommendations to see a behavioral- health specialist. The face-to-face introduction makes a difference.
Another aspect of integrative care involves cultivating healthful behaviors. Rather than merely advising patients to eat more-healthful foods, innovative providers are increasingly working to offset environmental factors that keep patients from adopting lifestyles that can keep them healthy. For example, many low-income people live in so-called food deserts, areas with limited access to reasonably priced produce and other nourishing, unprocessed foods. Experts agree that if good affordable food is hard to find, nutrition advice is of little use, and unhealthy eating patterns become inevitable.
Among the approaches being undertaken to address the food-desert problem is supporting farmers markets. Community Health Center is one organization that now subsidizes farmers markets in urban areas that lack easy access to fresh produce. Meanwhile, the U.S. Department of Agriculture (USDA) is enabling farmers to accept Supplemental Nutrition Assistance Program (SNAP) vouchers, also known as food stamps, at farmers markets. In addition, the USDA offers the Women, Infants, and Children (WIC) Farmers Market Nutrition Program (FMNP) and the Senior Farmers Market Nutrition Program.
During fiscal year 2010, the agency reports, 18,245 farmers, 3,647 farmers markets, and 2,772 roadside stands were authorized to accept FMNP coupons. Coupons redeemed through the FMNP resulted in more than $15.7 million in revenue to farmers for fiscal year 2010.
Health-care entities with a holistic outlook also believe in helping the patient learn how to prepare recommended foods and incorporate them into family diets. Some health centers offer cooking demonstrations that include ideas for using more-nutritious ingredients in favorite dishes. Simple changes, such as using Greek yogurt instead of sour cream, whole wheat flour instead of white flour, or herbs instead of salt, can improve people's diets.
Patient education may also include culturally competent information about how to handle health and nutrition issues during the holidays. For example, Stefanie Nigro, an assistant clinical professor at the University of Connecticut School of Pharmacy, posted an entry on the Community Health Center blog with advice for diabetic patients who are Muslim about managing fasting during Ramadan.
Beyond Clinic Walls
Providing access to better nutrition is just one area where health-care practitioners need to go beyond the walls of the clinic. Good nutrition is a first step in fighting obesity, diabetes, and food-related maladies. Physical activity also contributes centrally to health. Unfortunately, recent funding cuts may be inhibiting exercise opportunities. Parks are being closed in some areas, and schools are cutting back on gym classes and recess periods.
Cutting-edge health-delivery systems are constantly improving their models. Sometimes that involves increased use of technology. Hartford Business Journal has covered the technology side of Community Health Center.*
"As patients walk into the Community Health Center in New Britain, they are greeted by an electronic kiosk, ready to scan a patient's license so they can quickly check in. Flat-screen TVs provide health tips. Technology has changed the experience for medical practitioners too. They all carry laptops so they can easily access or input patient clinical data into an electronic medical records system. Video conferencing capabilities expand the training and consulting options available for staff."
The organization, notes the magazine, "has more than 200 locations and serves 130,000 patients in 13 cities across the state [and] may be one of the most cutting- edge primary care practices in Connecticut.
"But it's not because the center caters to a wealthy patient base. In fact, the organization primarily serves the uninsured or underinsured, which account for 90 percent of its patients. CHC is a Federally Qualified Health Center (FQHC), which means as part of its funding it receives grants from the federal government to provide primary care, including medical, dental and behavioral health services, to people regardless of their ability to pay. Organizations like this are expected to take on a greater role in the health care system under federal health care reform, especially as insurance coverage is expanded to those who previously lacked it."
* Greg Bordonaro, "State-of-the-art: Statewide health center system leading the way through technology," Hartford Business Journal, November 7, 2011, http://www.chc1.com/News/
To counter the cutbacks-and promote the notion that exercise is good not just for weight control but for improved academic performance and self-esteem-Community Health Center offers Recess Rocks, a national comprehensive movement program for elementary school children. In addition, Community Health Center is among the organizations that support exercise for all by advocating for safer parks, bikeways, walkto- school initiatives, and similar efforts to make physical activity safer and more enjoyable. The city of Somerville, Massachusetts, with its citywide campaign, Shape Up Somerville, provides a great example of how different stakeholders can work together "to increase daily physical activity and healthy eating." 
Interactions between health-care providers and the educational system are also important. Too often, students miss school and parents miss work for routine medical visits. To minimize the amount of time that students are out for doctor appointments and to ease the burden on parents, more and more health centers are partnering with schools to create school-based community health centers. Today some centers include both medical and behavioral- health providers.
The integrative approach to health care also recognizes English literacy as an important factor in health outcomes: patients must comprehend written medical instructions, prescription inserts, and other materials in order to comply with treatment plans. Accordingly, some health centers collaborate with English as a Second Language programs, going beyond the requirements for federally funded health organizations to provide medical translation services. Giving people assistance to master verbal and written English helps them deal with stresses outside the medical facility, and that, too, can improve health.
It's important to recognize just how much health affects individuals' ability to enjoy life, liberty, and the pursuit of happiness. Forward-thinking providers will remain vigilant to ensure that health care-and the diverse factors that affect health-are properly addressed for all Americans.
Eliza Cole is a media specialist at Community Health Center Inc. in Middletown, Connecticut.
 See Stephanie Nigro, "To fast or not to fast? How to manage diabetes during Ramadan," http://community.chc1.com/2011/07/fasting-and-diabetes-during-ramadan.
 Alice Hm Chen, Mara K. Youdelman, and Jamie Brooks, "The Legal Framework for Language
Access in Healthcare Settings: Title VI and Beyond," Journal of General Internal Medicine 22
(November 2007): 362-367, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2150609.
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