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)

                                 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--
             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

     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.


     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

     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 -


     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

     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.


     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

     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-

     --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)

                                                               - 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.



     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.


     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,

                                     Associate Director

Mr. Wesley L. Hjornevik
Deputy Director
Office of Economic Opportunity