t1%GU StATEs (GEERLACCOUVTG OCFIC WASH5NGION.. DCZ cva.r.m'v i iOctober 29, 1971 De Mr, Kjoruevik: e hae re e tbe operatins of the Nei ealth Servics Program, a project operating in ochester, m Yr fo by the OffiCe£ EofI OpportUnity under thbe CIyreheSive iHealth Services lPrOram. lrig this, review-- hich covered the period from l~ebr 1967 thLrougi rch 19X7--e obseved ta allthou thie proj- ect ws serving a substantial moer of persons, the project had several short maicDk have precled it from fully meeting its g alsanod tbhe prgram's objectives. e were atssited by medical specialists from the U. S. Pblic 6alith Service, 1EE, Dio evaluated t1he qallity of medical care pro- wided by the project and the a of atient medical records. The pwrpose of this letter is to bring mur findings and observaticn to yomr atteimtioa so hat h.tappropriate correlative actioe cn Ibe taken. Sma of the findia/ are simillar to thoe incu in to recent reports oa cur resvie of the Eei g rhood ealth Services Pro- to the Congress gran for th.e por adniumistered by St. Lake's ispital Center, New York City (-ll515, Jue 15, 1971), and the Southern lnterey Cuenty Rural Bealth Parj-ect, ring City, California (3-1-305L5, July 6, 1971)- From June 1967 wheu the project was initially approved by CEO throu5i July 31, 1971s, (E had made grants totaling about $6.1 million for project operatias An additikal grant of albout $1.1 amlIlice vas - appro,_ed &a aM) for the year eading July 31, 1972. The project seek to demzstrate hown the resources and capabilities of a major medical Srol-Aiq3t o Go ¢hester--ad a large county health department-- S:it~of NE1roe C aty---ca be ccmioed to deliver comprehensive, higt quality, fzmy-orieated health services to a target population of appiroxmately iztO0 pr q',rsoss. lrimi! L'.t: first 3 progra= years, th projiect generally succeeded i iLnvoiig t:rget-areOa resdents in its plaori- a1nd971ration. lt 50 TH ANNIVERSARY 1921-1971 enrolled about three quarters of its intended target population of 12,000 persons and provided medical services that generally satisfied these enrollees. Improvements are needed, hoever, in providing preventive health care and in medical recordkeeping if the project is to make comprehen- sive health services available to its target population in the manner contemplated by the Congress and called for by OEO guidelines and approved project proposals. DOIPT OF PROECT SEICeS PRO 2YO O $0L3 The project began providing services in Jaly 1968, and as of March 31, 1970, had enrolled about 9,080 Fersons. Although it did not have information readily available to show how many of those enrolled had actually been treated since inception of the project, its records did show that many low-income persons needing health and health- related care had been served at the project site, at the sponsoring hospital (Strong Memorial), and in their homes. For example, during the 9-month period ended l/arch 31, 1970, the project reported 24,733 patient encounters, of which 21,085 occurred at the project site, 2,196 occurred in the patients' hoae and 1,452 occurred at the hospital and other sites. The project uses the health teas concept for family-oriented care and. in June 1970 there were five such te-a consisting of a pediatrician, an obstetrician, internists, a dentist, public health nurses, and family health assistants. All health care given to an individual and his family at the project, at home, or in the hospital is the responsibility of the assigned team. Patients were generally treated by the same physician or by another medical person froec their health team. We intervie'ed 53 enrollees of the p:rject to obtain their views on several aspects of the project's operations. One af our questions dealt with continuity of care, and 45 of the 53 indicated that they were generally treated by the same physician each time they visited the project. Such continuity often prevailed also when a patient was adnitted to Strong Memorial Hospital for inpatient care. Of the 53 persons interviewed, 19 were hospitalized while enrolled in the project, and !3 of then said that a project physician treated them while in the hospital. 7he project also seems to have improved the general health of children in tin project target area. An evaluation of the impact of _ I _ the project indicated a 38-percent raduction in visits by children from the project area to emergency depart ents of local hospitals between 1967 and 1970. The report on the study, made by three doctors froa the Department of Pediatrics of the University of Rochester, stated that this reduction compared with no change in the number of similar visits from other areas in Rochester and a 29-percent increase in emergency visits by suburban children. ACCEPTEACE AnD MPMTICIPMTIOK BY TARGET-AREA RESIIEITS The project seemed to have gained the acceptance of most of the low-income individuals that it serves. Forty-four of the 53 persons we talked to said they were satisfied with the medical services pro- vided by the project; and in a similar survey by the project in September 1970. 163 of the 176 persons interviewed said they were satisfied with the project's medical care. The Neighborhood Health Council, comprised of 28 representatives of organizations dealing with the poor in the target-area as well as persons eligible for project services, participated in decisions on such matters as eligibility, program priorities, and criteria for hiring nonprofessional employees. Only 10 of the 53 project enrollees w.kh we asked during our interviews whether they attended council meetings stated that they did. Project officials informed us that the council intended to increase its membership of persons eligible for project services--only 7 of the 28 members were project enrollees in February 1970--and to make itself more widely known to target-area residents. As called for by OEO guidelines and approved project proposa's, the project employed and provided training to residents of the target- area. Of the project's 134 employees as of July 30, 1969, 57 occupied nonprofessional positions such as family health aide, medical social receptionist, dental assistant, and medical records clerk; 23 of the nonprofessionals were residents of the project's target-area. The target-area residents generally filled lower paying positions and, consistent with general conditions in the health services tield, opportunities for their career advancement were somewhat limited. The jobs, however, according to project officials, offered certain advantages to the residents such as comparatively good salaries and proximity to their homes. - 3 - PROJECT SERVICES IN NEED OF IMPROVEMENT PROFESSIONAL STAFF PROIUCTIVITY NEEDS TO BE INCREASED The relatively low average number of patients seen by project physicians and dentists during the period covered by our review indicated that the project was not making maximum use of available professional health manpower. Our analysis of the project's reported statistics for a 3-month period ended December 31, 1969, showed that, on the average, a project physician treated an equivalent of 12.4 patients a day and a project dentist treated an equivalent of 4.6 patients a day. In its guidelines for space allocations for neighbor- hood health centers, OEO suggests that, with adequate space, a physician could be expected to treat four patients an hour, or 28 in a 7-hour day, and a dentist could be expected to treat two patients an hour, or 14 a day. Project officials acknowledge the problem but attributed it, in part, to the number of appointments missed by patients, to the inade- quate space, and to the additional time required for hospital visits. We recommend that the Director, Office of Health Affairs, review the project's professional staffing pattern and take whatever actions can reasonably be taken to increase the professional staff's productivity. OVERLL HEALTH CARE PROVIDED NOT ACHIEVING PROJECT OBJECTIVES Improvements are needed in preventive health care and medical recordkeeping if the project is to make comprehensive health services available to its target population in the manner contemplated by the Congress, and called for by OEO guidelines and approved project proposals. Public Health Service medical specialists reviewed patient medical and dental records and concluded: --The health care rendered was primarily episodic. In general, documentation did not indicate that care was prevencive- oriented. --There were no treatment plans for a full assessment of either the individual or the family care needs. --The history and physical findings recorded related primarily to the episodic visit. In only a small percentage of records was a meaningful, complete workup (coaplete physical examination) available. - 4 - --Except on occasion, the dental documentation did not show evid nce of routine semiannual examinations. Visits to the Center seemed to be in response to specific dental need such as filling and extraction. --Documentation of the diagnostic results was fragmented. Project officials told us they were aware that some patients come to zhe Center only when they are ill and do not return for scheduled medical checkups. They said that they are striving to improve this situation by having the doctors, nurses, and family aides impress on their patients the importance of medical checkups and follow-ups. The project director said that e committee of project doctors had been established to review the patients' medical records and documentation to ascertain where improvements are needed. We recommend that OEO, through the Office of Health Affairs, stress to project officials the need to improve its recordkeeping and expand preventive health care and dental services and to educate the poor to seek such care. ADMINISTRATIVE MATTERS NEEDING IMPROVEMENT NEED FOR FEE SCIIEDULE OEO guidelines provide that whenever a project proposes to serve individuals who have income above the standard for free care, the appli- cation should include a schedule of the amounts to be charged for services to such individuals. The schedule should also indicate at what income levels the full costs of services are to be billed and how these costs are to be determined. The June 10, 1969, proposal for the third year of operation mentioned for the first time services to individuals whose income was above the standard for free care. About 13 percent of the patients treated during the period July 1, 1969, through September 30, 1969, were charged $3.00 for the clinic visit. The proposal had stated that the project and the Neighborhood Health Council would develop a sliding fee scale for these patients. In the grant for the third year, OZO required that the project obtain advance approval from the OEO Office of Health Affairs of the proposed sliding fee schedule. The council, which had been working on a fee schedule since June 1969, submitted one to OEO during SMarch 1971. OEO did not approve it and returned it for revision. As of September 1971, a revised schedule had not been submitted to OEO for approval. - 5- We recommend that the Director, Office of Health Affairs, take the necessary action to have the project expedite the submission of the required fee schedule. AUDIT OF INDIRECT COST RATE NEEDED OEO had not audited the tentative indirect cost late of 20 percent of project direct costs (excluding renovations) charged by the Univer- sity of Rochester during the project's first three program years ended July 31, 1970. Under this arrangement, which was accepted by OEO subject to audit, the University of Rochester was paid $37,288, $172,721, and $134,479 for the first, second, and third program years, respectively, for pro- viding administrative, personnel, and payroll services. Although OEO officials informed us in September 1970, that OEO was planning to review the University of Rochester indirect cost rate, no such audit had been made as of September 1971. We recommend that the Director, Office of Health Affairs, arrange for an early audit of the indirect costs. We would appreciate being advised of any actions taken on our recommendations. Our staff is available to meet Trith you or your representatives to discuss them further should you so desire. We wish to acknowledge the courtesies extended to us during this review. Sincerely yours, HenryEschwege Henry'Eschwege Associate Director Mr. Wesley L. Hjornevik Deputy Director Office of Economic Opportunity -6-
Opportunities To Improve the Neighborhood Health Services Program, Rochester, New York
Published by the Government Accountability Office on 1971-10-29.
Below is a raw (and likely hideous) rendition of the original report. (PDF)