Journal of Community Health, Vol. 30, No. 2, April 2005 (Ó 2005)

PSYCHOSOCIAL PROBLEMS AMONG PATIENTS IN NEIGHBORHOOD HEALTH CENTERS: PERSPECTIVES FROM HEALTH CARE PROVIDERS Victoria M. Rizzo, LCSW, PhD; Terry Mizrahi, PhD; Kristen Kirkland, MSW

ABSTRACT: Little is known about how health care professionals perceive and understand the psychosocial problems of individuals receiving services in neighborhood health centers (NHCs). We conducted interviews with health care professionals in NHCs in New York City. The respondents identified seven problems, including a lack of financial resources, unsafe housing, and emotional distress/depression as affecting large portions of their patient populations. Respondents reported that they are presently meeting many of the psychosocial needs of their clients, but they were pessimistic about their ability to continue to do so due to a lack of funding streams to support their provision of comprehensive health care that includes psychosocial services. The findings suggest that while NHCs may be ‘‘holding their own’’ in providing quality services to their clients, this will be harder to sustain in the future if the numbers of the uninsured served continues to increase, and the revenues generated continue to decrease. KEY WORDS: psychosocial problems; neighborhood health centers; primary care; community health centers; community-based health services.

INTRODUCTION Neighborhood health centers (NHCs) have been providing care to our nation’s most vulnerable populations, including low income families, immigrants and the medically uninsured, for more than 30 years. NHCs are typically defined as facilities located in communities where residents have (1) lower incomes, (2) less access to health care services, and (3) a lack of health insurance coverage. This definition includes all the Federally Qualified Health Centers, begun in the 1960s as part of an ‘‘anti-poverty’’ strategy of the Federal government that connected poor Victoria M. Rizzo is Research Assistant Professor and Executive Director of the Elder Network of the Capital Region at the School of Social Welfare, University at Albany, State University of New York, Albany, New York. Terry Mizrahi is Professor, Hunter College of Social Work, New York, New York. Kristen Kirkland is a Doctoral Student, Center for Excellence in Aging Services, School of Social Welfare, University at Albany, State University of New York. Requests for reprints should be addressed to Victoria M. Rizzo, PhD, Elder Network of the Capital Region, School of Social Welfare, University at Albany, State University of New York, 135 Western Avenue, Albany, NY 12222, USA; e-mail: [email protected].

125 0094-5145/05/0400-0125/0 Ó 2005 Springer Sciences+Business Media, Inc.

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health with poverty.1 In the communities where most NHCs are located, social and demographic factors such as poverty, race and ethnicity, immigration status and aging have resulted in populations with disproportionate levels of disease and poor health outcomes as well as complex social, emotional, and environmental needs.2 The psychosocial needs of these populations if left unidentified and unaddressed can contribute to, exacerbate, or even cause a variety of medical conditions because they: (1) create barriers that deter seeking early medical treatment;3 (2) interfere with patient adherence to prescribed medical treatment;4,5 and (3) act as environmental triggers that exacerbate the symptoms of an illness, such as diabetes or asthma, or diminish the effectiveness of prescribed medical treatment.6 Recognition of this has led to the inclusion of psychosocial problem assessment as an integral component of the primary medical care of ‘‘at risk’’ populations including the elderly,7–9 people with chronic illness,6,10–12 and the poor. 13–16 Furthermore, both the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have recognized the influence of psychosocial problems on health outcomes for these populations17,18 and as a result have developed disease management programs that target high risk populations. While there is a growing literature on the impact of social factors on health care use and health outcomes,19,20 relatively little has been reported about how health care professionals perceive and address the current psychosocial problems of at-risk individuals receiving primary medical care in organized healthcare systems. Studies focused on psychosocial problems in primary care, including NHCs, have examined: (1) the physician’s role in identifying and treating psychosocial problems;21–26 (2) training programs for health professionals in the use of collaborative, multidisciplinary team approaches to community-based health care to identify and provide services for psychosocial issues;15,27–30 (3) screening of individuals in high risk populations for psychosocial problems that may impact their health and health outcomes;31–33and (4) the need for psychosocial services to address the needs of high risk populations served in primary care settings.15,34–36 The fourth group, which provided the foundation for this study, included exploratory research that examined the current ‘‘state-ofaffairs’’ for identifying and treating psychosocial problems that may impact health and health outcomes within a particular health care provider type (i.e., managed care plan, outpatient medical clinic). The findings suggest that some of the psychosocial needs of poor and under-

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served populations are being identified and met by health care providers. For example, in a recent survey of pregnant, poor women living in a rural county, several barriers to prenatal care, such as transportation, were identified, as were the uses of social services in overcoming these barriers.37 Weiss, Haslinger, and Cantor38 conducted an exploratory study to determine the availability of enabling services (i.e., transportation and after hours coverage) to address patients’ psychosocial problems. Those surveyed identified the need for psychosocial services, but the researchers reported that these services were provided informally and the extent to which they were provided varied greatly across medical settings. In its study of the psychosocial services provided to managed care enrollees in New York State (NYS), the Center for Workforce Studies 34 asked executive directors of NYS’ 49 managed care plans to identify the psychosocial problems that most impact the ability of enrollees’ to access and appropriately use health care services. These administrators identified psychosocial issues, including but not limited to, transportation, translation, housing, and follow-up. The investigators recommended that the research agenda for the provision of psychosocial services include: surveys of providers to identify their perceptions of their patients’ psychosocial needs and service delivery; studies of the current delivery of psychosocial services to identify what works; and studies of what types of professionals are providing what types of psychosocial services and under what conditions (p. 6). We located only a few studies that examined the perceptions of medical professionals from different disciplines (i.e., doctor, nurse, administrator) about their patients’ psychosocial problems and the provision of psychosocial services to address them.35,39,40 To more fully understand how health care professionals in NHCs perceive and address the psychosocial problems of their patients, we interviewed NHC administrators (ADs), physicians (MDs), and social workers (SWs), or staff providing social services, in New York City (NYC). We chose these three groups because each of them has a somewhat different but nonetheless important role in identifying and addressing the psychosocial problems of the individuals they serve. The ADs were chosen because they have the most in-depth knowledge of the NHC system and have ultimate decision-making power in matters of financing and staffing. The MDs were chosen because they have ultimate responsibility for patients’ medical treatment including the referral process; and SWs were chosen because they are generally perceived as the professionals responsible for handling most psychosocial problems of patients in those systems.

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METHODS In this exploratory study, we conducted telephone interviews with ADs, SWs, and MDs in NHCs in NYC to answer the following research questions: (1) what are the types and extent of psychosocial problems that administrators, social workers, and physicians are seeing in NHCs that serve high risk populations? And, (2) what are some of the challenges faced by these professional groups in meeting the psychosocial needs of their patient populations? Sample Selection The total sampling frame for this study consisted of all NHCs (N ¼ 33) in the five boroughs of NYC. The Community Health Care Association of New York State (CHCANYS) agreed to formally support this study and assist with encouraging their member NHCs to participate. Therefore, only NHCs that were listed as active members on the CHCANYS membership roster at the start of the study were eligible for participation. Of the 33 NHCs in the five boroughs of NYC, 29 were active CHCANYS’ members at the start of the study, making them eligible for participation. The 29 eligible NHCs represented all five boroughs of NYC and only one provided specialized services to a select population type. Based on available information at the time of the study, the only difference between the 29 eligible NHCs and the 4 ineligible NHCs was their CHCANYS’ membership status. To engage the 29 eligible NHCs, the following was done: First, the executive AD in each of these 29 centers was mailed a letter from the executive director of CHCANYS explaining the study and encouraging center participation. Second, the letter was followed up with a phone call to the AD from the researchers to (1) further explain the study; (2) obtain permission to include the center in the study; (3) schedule an interview time with the AD if she/he agreed to participate; and, (4) obtain the names and phone numbers of other possible center study participants (a MD and a SW) who were the most knowledgeable about psychosocial problems in the center. Interviewing the most knowledgeable and experienced professionals allowed us to obtain the most accurate assessment of their patient populations. Third, each potential participant named by the AD (who in almost all instances was the executive director of the NHC) was contacted by phone to explain the study, invite her/his participation, and schedule an interview time if she/he agreed to participate.

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Data Collection From Fall 1999 to Spring 2000, telephone interviews were conducted by the principal investigator and a trained research assistant with three senior staff members (an AD, a SW, and a MD) in each NHC using an interview protocol designed for this study. Six interviews were conducted in person rather than by telephone. Each interview was approximately one-half hour to one hour in length with a few exceptions. The instrument consisted of questions about: (a) the professional background of the respondent; (b) the facility’s revenue sources, managed care contracts, operations and staffing patterns; (c) psychosocial problem identification and interventions; (d) current staffing arrangements for the provision of psychosocial services; and (e) the assessment of, and challenges in, meeting patients’ psychosocial problems. Although each respondent was asked background questions about the NHC they worked in, many of the MDs and SWs reported that they did not know the answers to these questions, or there were major discrepancies between their responses and those of the ADS. For this reason, we used the ADs’ responses to background questions, including sources of the NHCs income, numbers of patient visits, and enrollments, assuming their answers were most likely to be the most accurate.

Definition of Psychosocial Problems To collect data about the type and extent of psychosocial problems, we developed a checklist of 12 different specific psychosocial problems (see Table 1). The selected categories were based on a review of the literature and interviews with 10 experienced health social workers. There is no one universal definition of psychosocial problems or psychosocial services. In our identification of psychosocial problems and services, we aimed for an inclusiveness that ranged from what some would classify as mental health problems/services, such as counseling, to what others describe as enabling or concrete services. These services include, but are not limited to, outreach, eligibility planning and determination, and supportive services, such as counseling, case management, and prevention and education services, as well as assistance with securing associated services such as transportation, child care, and foreign language interpretation. 34,41 Participants were asked to rank the extent/frequency of each problem in their settings using a Likert scale ranging from 1 (hardly ever) to 5 (very often). We also asked two open-ended questions to identify which staff addressed psychosocial problems and the extent to which

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TABLE 1 Psychosocial Problems in Neighborhood Health Centers N = 75 Very Often/Frequently

Sometimes

Infrequently/Hardly Ever

Psychosocial Problem

N

%

N

%

N

%

Lack of financial resources Emotional distress/ depression Cultural practices affecting health Non-adherence Adjustment to illness/ disability Substance abuse Unsafe or unstable housing Unable to maintain insurance eligibility Physical abuse Marital/domestic problems Can’t maintain self at home No one at home

46

61.3

25

33.3

4

5.3

41

56.2

25

34.2

7

9.6

39

52.7

29

39.2

6

8.1

37 35

51.4 48.6

29 25

40.3 34.7

6 12

8.3 16.7

34 29

45.9 42.0

28 37

37.8 51.4

12 25

6.2 4.7

24

33.3

33

45.8

15

20.8

21 17

28.4 23.9

31 31

41.9 43.7

22 23

29.7 32.4

13

18.6

31

44.3

26

37.1

10

13.9

37

51.4

25

34.7

they felt they were meeting the psychosocial needs of clients. Each interview was taped and transcribed verbatim. Data Analysis We used quantitative and qualitative approaches to data analysis. Responses to all closed ended questions were coded and entered into the Statistical Package for the Social Sciences (SPSS). We also categorized the qualitative data for use in quantitative analyses. The two senior authors read through 10 transcripts and identified a range of themes or categories. We developed these inductively from the participants’

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responses. This was accomplished through the use of constant comparison, a component of grounded theory methods.42,43 We independently coded the same ten interviews. After comparing, and reconciling differences in coding, we developed a codebook for use in the analysis of all the interviews. Data from each interview were entered into an SPSS database. The Study Participants Of the 29 eligible NHCs, 27 participated with a NHC response rate of 93.1%. One NHC chose not to participate and one served too specialized a population. Of a possible 81 participants (1 AD, 1 SW, and 1 MD in each NHC), a total of 75 people from the 27 NHCs participated in this study with a participant response rate of 92.5%. Twenty-four participants were ADs; 27 participants were SWs (in one instance, the person providing psychosocial services was a nurse by profession and title); and, 24 participants were MDs. In 22 of the 27 participating NHCs, three senior staff members (AD, SW, and MD) were interviewed. In four of the NHCs, two of the three staff members were interviewed; and, in one NHC, the SW was the only person interviewed. Slightly more of the participants were female (55%) than male (45%). The study participants were quite diverse in terms of ethnicity (35% white; 31% African American; 20% Latino/a; 14% Asian). For the most part, this ethnic diversity held across subject categories with social workers (41% white; 30% African American; 22% Latino/a; 7% Asian) representing a much smaller percentage of Asian ethnic groups than physicians (38% white; 30% African American; 16% Latino/a; 16% Asian) and administrators (25% white; 33% African American; 21% Latino/a; 21% Asian). The respondents were an experienced group of health care providers with 39 respondents reporting that they had worked in the health field for more than 10 years. Furthermore, 53 participants had been at their current work site for at least four years and thus appeared to know their patient populations well. The Neighborhood Health Centers Of the 27 participating NHCs, one-third delivered services from a single site, while the rest had from two to ten sites. Seventy-two percent had been in existence for more than 20 years, and 90% of them were designated as Federally Qualified Health Centers and were licensed in New York State under Article 28, known as ‘‘Diagnostic and Treatment

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Centers’’; approximately 25% of them also had Article 31 licenses permitting them to provide and receive funding for mental health services. Approximately half of the NHCs (N ¼ 14; 52%) had between 10,000 and 20,000 enrolled patients and more than 50,000 patient visits per year (N ¼ 14; 52%). The Patient Population The patient populations in the NHCs in this study were remarkably similar when compared to NHC populations described elsewhere in the literature.2 They were primarily people of color. Respondents reported a large, and in most cases, growing number of immigrant groups from Central and South America, Asia, and Africa. The overwhelming majority of patients were women under the age of 65 and their children. Many participants commented on the need to enroll more men as patients before they developed, or presented with, serious health conditions, such as diabetes, hypertension and HIV/AIDS. Men and women over the age of 65 accounted for less than ten percent of the patients. The most common medical problems identified by more than 75% of the respondents were asthma, diabetes, and hypertension.

RESULTS Psychosocial Problems of Patient Populations in NHCs As described earlier, the respondents were asked to rank 12 problems from a pre-determined list included as part of the interview. Other studies include a similar continuum of problems.34,44–46 The aggregate results are presented in Table 1. The rankings for each respondent category (AD, SW, and MD) were not treated as independent because correlation analyses of site by respondent answers revealed high with-in site correlation for respondent answers. When asked if anything was left off the list of psychosocial problems, most participants indicated that it was complete; a few added the symptom of ‘‘stress.’’ Several respondents said that coping with daily stressors of life went beyond, and was more common than the category of ‘‘emotional distress/depression,’’ which itself was the second highest of the problems identified most frequently by 61% of the study participants. The pervasiveness of patients’ psychosocial problems as perceived by all three respondent groups was stark. Of the 12 problems, seven were

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identified as adversely affecting large percentages of their patient populations, ranging from 61% of the participants who found ‘‘lack of financial resources’’ to 42% who cited ‘‘unsafe or unstable housing’’ as frequently/often seen among their patients. ‘‘Cultural or ethnic practices of patients affecting their health, compliance or utilization of health care’’ also loomed large in problem identification. More than half of the respondents said it occurred very frequently, most often describing issues related to diet, alternative healing practices, and health beliefs among Latino/a, African American and Caribbean groups. Payment for Services To understand the impact of reimbursement for services on the provision of psychosocial services, we also asked an open-ended question about financing and insurance coverage. In 12 of the 27 NHCs, Medicaid was identified as the payment source for the majority of enrolled patients. With this question, we hoped to elicit information that would shed some light on the influence on NHCs of mandatory managed Medicaid and the de-linking of Medicaid from public assistance when the federal public assistance program, Aid to Families with Dependent Children (AFDC), was replaced with Temporary Assistance to Needy Families (TANF). At the time of this study, New York State’s Child Health Plus Program was relatively new and accounted for less than ten percent of the patient revenue in these NHCs. However, several respondents indicated that increasing numbers of their patients were uninsured. Many of these uninsured patients were described as the ‘‘working poor,’’ who were ineligible for Medicaid but lacked the necessary means to purchase health insurance in the private marketplace. These findings are supported by the Bureau of Primary Health Care,47 which reported that the rate of uninsured Americans increased at a rate of one million people per year in the decade from 1990 to 2000. Most respondents reported that less than 30% of their patients were currently Medicaid managed care enrollees. While almost all of these NHCs had a sliding fee scale, they indicated that they did not collect enough revenue to cover the cost of the services they provide to uninsured individuals. For the most part, the cohort described the negative impact of immigration regulations, welfare reform, managed care and other restrictions on their ability to enroll and provide services to the most vulnerable patient populations, especially immigrants, the uninsured and the working poor. Many respondents were pessimistic about the ability of neighborhood health centers to financially sustain them

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once mandatory managed Medicaid is fully implemented. For example, one AD stated: [Managed care] . . .was based on a health care system for healthy people. Medicaid patients are not healthy people. They’re not middle class. . .They’re people with chronic illness; they’re people who move around a lot, it puts a big strain when you’re not reimbursed for something like social services. Then eventually you have to make a decision to stop providing the service and the patients lose out. Meeting the Psychosocial Needs of Patients in NHCs Participants were asked three open-ended questions regarding the ability of their NHCs to meet their psychosocial needs in the past, present and future. We wanted to answer the following questions: (1) how did these professionals perceive that their NHCs had the resources available to fully identify and address patients’ psychosocial problems currently? (2) Did they perceive that these were more readily available in the past? (3) If there were differences in these perceptions, did they attribute these differences to changes in financing, changes in the population, or changes in psychosocial problems? And finally, (4) did they anticipate meeting those psychosocial needs better in the future or not? They focused most often on the financial viability of NHCs and their ability to provide services to address the psychosocial needs of their populations. They rarely blamed the patients for the myriad of problems that they faced. However, frequency distributions of these responses revealed that 21 of the respondents (31%) thought they were meeting the psychosocial needs of their clients better now than in the past. One AD remarked: We are better able because they are expanding services and providing more comprehensive services based on the needs of the community-daycare, mother and children programs, vocational training, on-site, WIC, labs, pharmacy; even the establishment of our own Medicaid HMO company. And, one MD commented: We meet about 30–40% of our patients’ psychosocial needs. . .It’s almost like moving them around the board a lot of the time. This impacts on medical care; for example, diabetes, HIV. You need someone paying attention to their eating and lifestyle. And you’re going to get complications and decrease longevity unless you can manage it, and that takes a lot of resources and effort. Although many respondents thought that they were meeting the psychosocial needs of their clients, one MD’s comment aptly reflects the difficulties they have in doing this: My sense is a lot of these services are not explicitly reimbursed—they’re hidden; but given the population we deal with, these are legitimate costs of taking care of people’s health needs. . .it becomes extraordinarily difficult to effectively run a place like this. . . because you have third parties

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who aren’t interested in paying, and a government that’s cutting back on rates of reimbursement. . .So it’s a real problem. Even though these respondents thought they were meeting patients’ needs currently, 37 respondents reported that they had met the psychosocial needs of their patients better in the past; and 17 respondents said it was about the same. Two SWs’ comments reflect this well. One stated: We probably see 60–70% of the pregnant women we should see; maybe 10% of the families who are very high risk for child abuse and neglect; and maybe 10% of the older folks; and in pediatrics we’re missing a whole bunch of stuff. . . There are a lot of people who aren’t properly evaluated... who can’t get medication, who we can’t see in psychotherapy and we can’t get outside agencies because they’re too high function; a lot of people if we could get on meds and into case management supervised by a social worker, we could really make a little bit of money go a long way. The other SW said that: . . .It’s not a happy environment right now. Everybody is being stretched to the max because of understaffing. I have to manage three facilities and still see patients. . .We’re still doing it, but it’s much harder. We’re doing it under such stress and pressure. For example, I have one social worker who can easily see 15 high risk patients a day. You can’t follow up every single case. Someone’s going to fall through the loophole. Moreover, 41 of the respondents predicted that they would be less able to meet the needs of their clients in the future. One AD commented: [I’m not sure it will get better.] Ten years ago we were better off. We had a smaller population to handle. I think the issues may have been a little less demanding. The community was more homogeneous. I think the needs overall have increased and there’s more of them, such as AIDS. . .it touches our whole community. . .we surveyed that everyone had some relative affected by AIDS; I think the increase in immigrants brings along with it different needs. I think welfare reform, managed care, other policies that have impacted our communities and as a result we need to do more for the patients and that has become difficult for us to handle. And, a SW said: [About the future] Whether you look at it morally or selfishly, if we want to be able to walk these streets, we’d better be sure that these people are assisted now. Because if you think we have some predators out there right now riding the trains, we haven’t seen anything if we don’t take care of these people. . .You don’t want people to go off the deep end; you don’t want them to feel there is no way out. Only 25% of the participants thought the future would be brighter. This appears to be based more on perceptions of the resourcefulness, commitment and creativity of the neighborhood health center leadership than on projected data or a sense that political and economic conditions would favorably change. Instead they anticipated that their

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NHCs could continue to utilize the competency and vitality of staff. One SW commented: It’s really amazing how she, my boss, operates on the budget and resources that she does and has been able to grow, even with all of those obstacles. So the kind of things that hurt you—reimbursement rates, turnarounds that are very slow, payments, managed care issues that are so complicated that you need a whole slew of [professionals], things like that could hurt us . . .[but] I think the way things are going and the expansions that we are doing here, and knowing the boss, we’re going to do better and better. Yet, participants were adamant about providing services regardless of an individual’s ability to pay for them. No one saw as a solution, abandoning their patient base (i.e., only a few were attempting to diversify their patient base in order to attract ‘‘paying customers’’). When they did outreach, it was to recruit and retain patients no one else was serving, or to attract patients with the greatest needs; hence the dilemma. The patients with the greatest needs were often the patients who could not pay and who had complex medical and social problems. Many were eloquent verbalizing the importance of their mission and the impact of the facility on patients’ lives. One MD commented: The staff here is a very dedicated staff. Not a one of them is here to put in their time but are here out of their own conviction about meeting the needs of the community and the people are here. And, an AD stated: When I’m interviewing people [for jobs] I stress the idea of being a good servant. We’re here to serve people. . .they must get fulfillment from that. People have to feel good about that because it is the patient who allows each of us to put bread on our table. . .We have to celebrate these patients for having walked through our doors.

DISCUSSION Andersen’s model20 of access to health care identifies individual level factors, such as predisposing characteristics (i.e., race/ethnicity, socioeconomic status), enabling factors, (i.e., availability of transportation and translators), and need factors (i.e., Medicaid eligibility workers, health care education) as factors that greatly influence an individual’s ability to access health care. In this model, health care organizations and the professionals working within these organizations are major factors that can influence individuals’ abilities to access psychosocial services as part of their medical treatment in NHCs. Our findings suggest that the health care professionals in this study have a good understanding of the range and extent of the psychosocial problems in neighborhood health centers in NYC. Furthermore, the majority of the respondents felt that

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they were currently meeting the psychosocial needs of most of their patient populations. In the qualitative comments, many respondents said they currently provided better quality services because of their own or the collective ability of the staff to make more efficient use of staff, and their development of needed programs. Overall, they did not cite an increase in resources from the past to present as a reason for better quality services despite a reported increase in the allocation of funds to NHCs by the US Congress during the last decade.48 Our findings clearly suggest that these NHCs are providing services to many more uninsured individuals without the ability to pay. Furthermore, patients are not presenting with fewer psychosocial problems because the professionals interviewed identified a myriad of psychosocial problems that their patients face. Therefore, it is important to understand better this perception that better quality services are being provided despite an increase in the provision of services to uninsured patients and an increase in, and/or change in the type of, psychosocial problems that patients present with. Despite the finding that most respondents felt they were meeting the psychosocial needs of their patients, almost all administrators identified a lack of funding or reimbursement for basic psychosocial services as a major problem in their ability to meet these needs. Two other recent studies of community health centers have reported similar reimbursement and provision of psychosocial services issues.38,49 President Bush has asked for an increase in total funding allocation of 1.6 billion dollars to build 1,200 new NHCs to serve an additional six million poor and uninsured individuals over the next six years.50 Our findings suggest that the Bush Administration’s allocation of funds to expand and build more NHCs to address the health care access problems of the medically uninsured is incomplete at best. There has been minimal articulation of increased resources to fund the uninsured including those using NHCs, and the Bush Administration is proposing major cuts and changes in Medicaid that may exacerbate the budget crises of many existing NHCs. Current and proposed funding will not address the lack of reimbursement mechanisms for services to meet the psychosocial needs identified in this paper that create many of the access barriers these clients’ experience. Certainly, there has not been a political commitment to address the issues related to housing, lack of income, and stress, all of which require policies and funding that go way beyond the funding of health care. Because the participating NHCs and the respondents in this study were a non-randomly selected sample from one geographic location, our

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findings must be considered suggestive and not readily generalizable to all NHCs. We caution against overstating the significance of our findings, or generalizing too far beyond our limited sample. Sample size was also a limitation because the small number of respondents in each category (AD, SW, and MD) did not allow us to conduct rigorous quantitative analyses to examine the differences in responses between professional groups. Overall, the findings of this study suggest that while most NHCs are ‘‘holding their own’’ in providing quality services to their clients despite current financial constraints and increasing numbers of patients without the ability to pay, they are doing so largely because of their commitment to this patient population. Within the context of Andersen’s model20 of access to health care, our findings suggest that this group of health care professionals (administrators, social workers, and physicians) is not the major health care systems barriers to the access of psychosocial services within NHCs. Rather, it is the financial constraints on NHCs coupled with an ever increasing uninsured population that create system barriers requiring systematic attention. Unless their ability to generate revenue increases, NHCs will not be able to sustain their current level of attention to the psychosocial needs of their patient populations, which will result in increasing negative patient and population health care outcomes.

REFERENCES 1. Institute of Medicine. America’s Health Care Safety Net: Intact But Endangered. Washington, DC: National Academy of Sciences, 2000. 2. Davis SK, Collins KS. Community Health Centers in a Changing U.S. Health Care System; 1999. 3. Geldberg L, Gallagher TC, Anderson RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health 1997; 87:217–220. 4. Fillenbaum G, Horner R, Hanlon D, Landerman L, Dawson D, Cohen H. Factors predicting change in prescription and nonprescription drug use in community-residing black and white elderly population. J Clin Epidemiol 1996; 49:587–593. 5. Kutner N. Improving compliance in dialysis patients: Does anything work? Semin Dial 2001; 14:324–327. 6. Rubin R, Petrot M. Psychosocial problems and interventions in diabetes. Diabetes Care 1992; 15:1640–1657. 7. Berkman B. The emerging health care world: Implications for social work practice and education. Soc Work 1996; 41:541–551. 8. Netting FE, Williams F. Can we prepare geriatric social workers to collaborate in primary care practices? J Soc Work Educ 1998; 34:195–210. 9. Tirrito IN, Langer N. Elder Practice: A Multidisciplinary Approach to Working with Older Adults in the Community . Columbia, SC: University of South Carolina Press, 1996. 10. McGrath P. Update on psychosocial research on leukaemia for social work practitioners. Soc Work Health Care 1999; 29:1–20. 11. Rich M, Beckham V, Wittenberg C, Leven C, Freedland K, Carney R. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995; 333:1190–1195.

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12. Claiborne N, Vandenburgh H. Social workers’ role in disease management. Health Soc Work 2001; 26:217–225. 13. Rabkin J, Balassone M, Bell M. The role of social workers in providing comprehensive health care to pregnant women. Soc Work Health Care 1995; 20:83–97. 14. Perloff J. Medicaid managed care and urban poor people: implications for social work. Health Soc Work 1996; 21:189–195. 15. Margolis P, Lannon C, Stevens R, et al. Linking clinical and public health approaches to improve access to health care for socially disadvantaged mothers and children. Arch Pediatr Adolesc Med 1996; 150:815–821. 16. Francouer R, Copley C, Miller P. The challenge to meet the mental health and biopsychosocial needs of the poor: Expanded roles for hospital social workers in a changing health care environment. Soc Work Health Care 1997; 26:1–13. 17. Joint Commission on Accreditation of Health Care Organizations. The Chronic Care Model: Model Components . http://www.improvingchroniccare.org/change/model/components.html, 2003. 18. Haizlip J. Disease management expands home care opportunities. The Remington Report 2002:10–13. 19. Cohen S, Underwood L, Benjamin G. Social Support Measurement and Intervention. New York: Oxford University Press, 2000. 20. Anderson RM. Revisiting the behavioral model and access to medical care: Does it matter? J Health Soc Behav 1995; 36:1–10. 21. Badger LW, Ackerson B, Buttell F, Rand EH. The case for integration of social work psychosocial services into rural primary care practice. Health Soc Work 1997; 22:20–29. 22. Callahan E, Bertakis K, Azari R, Robbins J, Helms LJ, Miller J. The influence of depression on physician-patient interaction in primary care. Fam Med 1996; 28:346–351. 23. Campbell T, Franks P, Fiscella K, et al. Do physicians who diagnose more mental health disorders generate lower health care costs? J Fam Pract 2000; 49:305–310. 24. Gross R, Rabinowitz J, Feldman D, Boerma W. Primary health care physicians’ treatment of psychosocial problems: Implications for social work. Health Soc Work 1996; 21:89–95. 25. Scheff R, Rand W, Paterson JC, Ellis G, Weeks S. Psychosocial problems in primary care: Pilot study of a new taxonomy. J Fam Pract 1994; 38:393–399. 26. Wissow L, Roter D, Larson S, et al. Mechanisms behind the failure of residents’ longitudinal primary care to promote disclosure and discussion of psychosocial issues. Arch Pediatr Adolesc Med 2002; 156. 27. Siegler E, Hyer K. Geriatric Interdisciplinary Team Training. New York: Springer, 1998. 28. Thomas CP, Payne SM. Home alone: Unmet needs for formal support services among home health clients. Home Health Care Serv Q 1999; 17:1–20. 29. Cooksey J, Danzinger L, Ervin N, Groves S, Tyska C, Kirk G. Problem-based learning in an interdisciplinary community-based primary care course. Teach Learn Med 1995; 7:241–245. 30. Carlton W. The health team training model: A teaching-learning approach in community health. Health Monographs 1977; 5:62–74. 31. Berkman B, Shearer S, Simmons WJ, et al. Ambulatory elderly patients of primary care physicians: functional, psychosocial and environmental predictors of need for social work care management. Soc Work Health Care 1996; 22:1–21. 32. Pilossoph-Gelb S, Mower WR, Ajaelo I, Yang SC. Psychosocial difficulties and emergency department use. Acad Emerg Med 1997; 4:589–592. 33. Shearer S, Simmons J, White M, Berkman B. Physician partnership project: social work case managers in primary care. Continuum 1995; 15:1–10. 34. Center for Work Force Studies. Support and Social Services Provided by Managed Care Plans in New York State: A Study Prepared for the New York State Department of Health, Office of Managed Care . Rensselear, NY: School of Public Health, University at Albany, 2000. 35. Friedmann P, D’Aunno T, Jin L, Alexander J. Medical and psychosocial services in drug abuse treatment: Do stronger linkages promote client utilization? Health Serv Res 2000; 35:443–465. 36. Perloff JD, Rizzo VM. Social Work Services in Community-based Health Care Settings: Inroads and Impediments. American Public Health Association 127th Annual Meeting. Chicago, IL. 1999. 37. Young-Pistella C, Bonati F, Mihalic S. Rural women’s health perceptions of community prenatal care systems: An empowerment strategy. J Health Soc Policy 2000; 11:75–87. 38. Weiss E, Haslanger K, Cantor J. Accessibility of primary care services in safety net clinics in New York City. Am J Public Health 2001; 91:1240–1245.

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39. Mullan P, Stross J. Sensitivity to patients’ psychosocial concerns: Relationships among ratings by primary care and traditional internal medicine house officers and patient self-assessments. Soc Sci Med 1990; 31:1337–1345. 40. Egan M, Kadushin G. Rural hospital social work: Views of physicians and social workers. Soc Work Health Care 1997; 26:1–24. 41. United Hospital Fund. Enabling services at ambulatory care sites: Trends and outlook. Curr Medicaid Managed Care 1999; 4:1–3. 42. Corbin J, Strauss A. Grounded theory research: Procedures, canons, and evaluative criteria. Qualitative Sociol 1990; 13:3–21. 43. Glaser B, Strauss A. The Discovery of Grounded Theory. Chicago: Aldine, 1967. 44. Dobrof J, Umpierre M, Rocha L, Silverton M. Group work in a primary care setting. Health Soc Work 1990; February:32–37. 45. Jackson J, Kroenke K. Difficult patient encounters in the ambulatory clinic: Clinical predictors and outcomes. Arch Intern Med 1999; 159:1069–1075. 46. Rosenbach M, Young C. Care Coordination in Medicaid Managed Care: A Primer for States, Managed Care Organizations, Providers, and Advocates. Princeton, NJ: Center for Health Care Strategies, Inc., 2000. 47. Bureau of Primary Health Care, Division of Community and Migrant Health, United States Department of Health and Human Services. Community and Migrant Health Centers: Experts with Experience 1990–2000 . Rockville (MD): Government Printing Office, 2001. 48. Dailard C. Community Health Centers and Family Planning: What We Know. Washington, DC: Guttmacher Report on Public Policy, 2001. 49. Gusmano M, Fairbrother G, Park H. From the field: Exploring the limits of the safety net: Community health centers and care for the uninsured. Health Aff (Millwood) 2002; 21:188–194. 50. Health Resources & Services Administration, United States Department of Health and Human Services. President Bush’s Fiscal Year 2004 Budget Proposal for HRSA. vol. 2003: http://newsroom.hrsa.gov/features/HRSA-FY04-proposed-budget-htm, 2003.