With clinics throughout the city, Providence Community Health Centers (PCHC) is the only Federally Qualified Health Center in the city of Providence. With almost 60,000 patients (20,000 under the age of 18), about 90% of patients and families live at or below the 200% Federal Poverty Level. PCHC offers high-quality care regardless of a patient’s ability to pay. Services include family and adult medicine, pediatrics, behavioral health, OBGYN, asthma/allergy care, optometry, podiatry, dental care, health education, dermatology and nephrology. We interviewed Andrew Saal, MD, MPH, Chief Medical Officer and Jonathan Gates, MD, Chief Medical Officer of Accountable Care to learn more about their work.
How have you responded in the last 15 months to both the COVID crisis, while adapting and preparing for the future of health care delivery?
“For the last 7 years, we have challenged the assumptions of primary care delivery and tried to improve the system. If there are more effective way to improve the health of a population, then we want to explore those possibilities. We’ve been living in the fee-for-service world for 6 decades – most people assume that all care must be provided face-to-face in 15-minute increments. Primary care delivered only in a fee-for-service model basically means that health care is only provided only to those who show up. That’s not population health, that’s survival of the fittest (or at least limited access for those with the knowledge and the resources to interface with the healthcare system). Our team addresses the access paradox with a deeper question: Who isn’t showing up? And perhaps more importantly why aren’t they accessing care? What other visit types could we do to promote population health? We were already redesigning primary care with an eye on alternative visit types and access when the COVID-19 pandemic hit. In the space of a few days, we pivoted all of the clinics to meet the pandemic’s challenge ‘What if no one can show up to be seen today, how can we still deliver care?’ Our population health data and clinical infrastructure allowed us to better identify high-risk patients and deploy resources,” explained Dr. Saal.
“We have a process now where we can find our patients who are likely to need help for a variety of reasons – it could be from a chronic condition or because we haven’t seen them in a while. We’re shifting away from dependence on the day-to-day schedule as a way to manage our population. We are moving towards using technology to identify and deliver the right care to the right person at the right time,” added Dr. Gates.
How is PCHC approaching the challenges of improving maternal child health among your patients and in the community?
“As the largest community health center in RI, we deliver about 10% of women giving birth in the state, and also have about 10% of the overall pediatric volume. During the pandemic “rebuild,” we identified two foundational populations we were going to see if at all possible and with as few barriers to care as possible – pregnant women and children who needed vaccines. These goals gave our planning teams the compass point they needed to redesign the triage and direct care systems for all of the clinics. Our teams found ways to safely triage pregnant women and children and get them safely into the clinics for care. PCHC has been averaging about 1,100 deliveries per year. Though the number of pregnancies dropped in the first half of 2020, we saw the pregnancy rate rebound in the latter half of the year. Deliveries are now increasing again. We were pleasantly surprised to see that our pediatric vaccine rates remained fairly stable despite the restrictions of the pandemic. I am proud of our pediatricians, family physicians and care teams – PCHC is in the top tenth percentile in the nation for vaccinating children. Our maternal child health data tracks low birthweight, vaccines, postpartum depression screening, and a dozen other measures by race and ethnicity. This allows us to better identify and address healthcare disparities in our community. I’m happy to report that the teen pregnancy rate continues to slowly decline. There are still significant disparities in maternal child health outcomes between women who are Latinx, Black, and White right here in RI – so we all still have a lot of work to do to address these here in our community,” said Dr. Saal.
What are the specific ways that you identify, and respond to, the various needs of patients and families?
“We screen everyone for social determinants of health. Our clinics universally screen at least once every year for food insecurity, housing instability, domestic violence, legal issues, and more. If a person identifies or requests assistance, our community health advocates will follow-up after their visit to make sure they can get through any application processes or hurdles. It’s not enough to just screen for the social determinants of health. The real public health begins when we link the people to community resources and partner agencies,” said Dr. Gates.
Dr. Saal added, “Universal screening is one of our core strategies to work with a population. We don’t screen when we suspect someone has a problem, we screen everyone at least once per year and sometimes more often."
“We couldn’t do as good a job if it weren’t for our community partners like ONE Neighborhood Builders, the Center for Southeast Asians, Family Services of RI, Farm Fresh RI, Roger Williams Center for Justice, Medical-Legal Partnership Boston, and many others. They provide the expertise to help us understand the barriers that our patients face when they’re not in front of us, and to empower our patients to help themselves,” said Dr. Gates.
How has engagement with CTC-RI supported your work?
“Participating with CTC-RI allowed us to collaborate with other primary care practices and experience different perspectives on primary care delivery and advanced practice medical home models. For example, our pharmacy initiative work on initiation of depression medications. That revealed to us that patients often don’t even pick up their medication, even though we think we had started them on it. With the talented people and the organizations at the table with CTC-RI, you really start to understand how fragmented the health care system is here in RI. But we have an idea of where we need to go, and we’re moving the needle on healthcare! It’s less about being really good at facet of healthcare, and more about being really good at collaborating with many people across the healthcare system. That’s the only way patients will experience overall better health care,” said Dr. Gates.
Dr. Saal added, "Our relationship with CTC-RI has been an innovation catalyst for redesigning primary care. Our colleagues have inspired us to look at the broader concept of the advanced-practice medical home model to better manage a population. When a colleague describes a system problem that is stressing out their care teams, we can all relate. It’s good to know that you’re not alone and possibly you can even share some pointers from your own experience that may help them. But sometimes you hear about a best practice or innovative new way to approach a problem… that has been priceless. When we sit with our colleges from the private sector and the other community health centers and share ideas, the entire healthcare system benefits.”