Inner-City Primary Care Centers Built as Models for N.Y.C. Health Infrastructure
Starting in 1992, with the Robert Wood Johnson Foundation (RWJF) as the lead funder, the United Hospital Fund (UHF) of New York created the Primary Care Development Program (PCDP), which organized a consortium of NYC foundations and raised $1.9 million to add to the $2.1 million contributed by RWJF.
PDDP directed the development of five centerpiece primary care programs intended to improve services to the predominantly low-income and minority residents of four communities the South Bronx; Jamaica, Queens; Bushwick, Brooklyn; and Harlem in Manhattan.
It also worked on seven smaller projects to enhance existing primary care capacity in New York City and test new models of outreach, education and training.
- By the end of the RWJF grant, the PCDP had provided $2.2 million in grants to 12 projects, including five centerpiece projects, to develop new primary care capacity.
- The projects served more than 20,000 clients per year and increased NYC's primary care capacity by an estimated 145,000 annual visits.
- PCDP contributed to the development of five new primary care sites in the South Bronx and one in Bushwick, Brooklyn.
RWJF supported this project with a grant of $2,099,578 from September 1992 to July 1996.
By the early 1990s, large cities such as New York, Los Angeles, Chicago, and Philadelphia were finding it increasingly difficult to sustain an adequate primary care service delivery system. Among the barriers were a lack of support systems to recruit and retain primary care practitioners, a high proportion of medically indigent residents, and low reimbursement rates to physicians for care provided to Medicaid clients.
UHF, a nonprofit organization providing philanthropic aid to NYC's health care community, documented the need to address primary care deficiencies in a RWJF-supported study (ID# 016739). That study found that an undersupply of primary care resources was closely associated with excess hospitalization for conditions that could otherwise have been better managed. The study also documented an overutilization of already overtaxed emergency rooms in communities with insufficient primary care resources.
In the three years prior to this grant, UHF developed an initiative that enhanced its capacity to help rebuild NYC's primary care service delivery system infrastructure. Using its own resources, as well as those of other private foundations, UHF awarded grants to help eight community-based hospitals plan for primary care expansion. UHF also used its resources to develop expertise in the areas of financing, provider recruitment and retention strategies, community-focused planning strategies, facilities planning, and capital funding.
Prior to the grant, New York State and NYC had both developed initiatives to rebuild NYC's primary care infrastructure. In 1990, the state legislature created a new statutory authority to promote community-level primary care services.
A $20-million grants program to build primary care capacity enhanced Medicaid reimbursement for physicians, a program of insurance subsidies for the medically indigent, and a capital financing initiative for primary care facilities. The Department of Health (DOH) initiated a competitive application process in 1990 to 1991 through what came to been known as the New York State Primary Care Initiative, and awarded almost $20 million in grants for service expansion.
At the same time, NYC Mayor David Dinkins announced plans to open 3 new primary care health centers and to convert 17 city health department or hospital-based sites into primary care health centers. DOH joined the New York Community Trust in encouraging UHF to establish a special program to provide the necessary technical assistance to interested communities, hospitals, and related health and social service providers through a blend of direct staff support, contracted consultation services, and grant funds.
This grant from RWJF provided funds to UHF to organize a multiple-foundation partnership to direct and manage the development of five "centerpiece" primary care programs to better serve the predominantly low-income and minority residents of four communities in NYC.
These were the South Bronx (two programs); Jamaica, Queens; Bushwick, Brooklyn; and Harlem. Each primary care program developed a service model tailored to the needs of its particular community. The grant goal was to serve a minimum of 20,000 additional clients per year, with an increased service capability of at least 100,000 visits per year.
To accomplish this, the UHF created PCDP and raised funds from local philanthropies to add to the lead funding contributed by RWJF. Each centerpiece primary care site received a grant of up to $500,000 to support design and implementation of the primary care program.
A number of smaller grants were also awarded to address challenges to primary care development in low-income communities such as financing, training, outreach, and physician recruitment. In addition to selecting the grantee institutions, UHF provided technical assistance, monitored the progress of each project, and identified relevant policy issues that could be documented and disseminated through its publications and conferences.
- UHF, through its PCDP, organized a consortium of NYC foundations and raised more than $1.9 million in a three-year period. Funds came from UHF itself, four charitable organizations, and NYC's PCDC, a public/private partnership formed to provide capital financing for primary care services in medically underserved communities of NYC. RWJF funds were instrumental in the creation of the PCDC. (See the Grant Results on ID#s 021312 and 028538.) (See Appendix 1 for a list of PCDP funding sources.)
- By the end of the grant, the PCDP had provided $2.2 million in grants to 12 projects, including 5 centerpiece projects to develop new primary care capacity; enhance existing capacity; and test new models of outreach, education, and training. After becoming fully operational in 1997, these projects served more than 20,000 clients a year and increased NYC's primary care capacity by an estimated 145,000 visits annually.
- Contributed to the development of five new primary care sites in the South Bronx. The PCDP awarded two centerpiece grants totaling $725,000 $400,000 to the Institute for Urban Family Heath and $325,000 to the Morris Heights Health Center to support the development of four new family practice sites and a new satellite site of an existing neighborhood health center.
- Contributed to the development of a primary care site in Bushwick, Brooklyn. In Bushwick, the PCDP awarded the Coalition for Hispanic Family Services and The Brooklyn Hospital Center a $450,000 centerpiece grant to support their collaborative agreement to develop a primary care center tailored to the needs of Bushwick's Hispanic families. In addition, it provided technical assistance and a $25,000 grant for a feasibility study to the Coalition for Hispanic Family Services to assess options for involvement in primary care.
- Supported the expansion of services at three existing primary care centers in Central Harlem and East Harlem as well as the development of a patient referral network among hospitals and health centers in East Harlem. In Central Harlem, the PCDP awarded a centerpiece grant of $250,000 to North General Hospital to redefine and expand services at a satellite health center. In East Harlem, the PCDP awarded a $250,000 centerpiece grant that included grants of $100,000 each to two community health centers Boriken Neighborhood Health Center and Settlement Health to support planning activities related to site expansion and managed care readiness, and a grant of $50,000 to the Mount Sinai School of Medicine to develop an improved referral network among East Harlem's health providers. Second-year grants of $50,000 and $100,000 were awarded to Boriken and Settlement, respectively, to continue their planning activities.
- Provided technical assistance and a $35,000 grant for a feasibility study to the Abyssinian Development Corporation in Central Harlem to assess options for involvement in primary care.
- Awarded two planning grants totaling $155,000 to Jamaica Hospital. The planning process included undertaking a feasibility study and financial analysis to determine the best financing and organizational model for delivering services in the community.
- Supported projects to develop models for health care personnel training, community outreach, and school-based primary care. The PCDP provided a grant of $100,000 to the Women's Housing and Economic Development Corporation to support a health careers training program for low-income minority women in the South Bronx. In addition, PCDP awarded a $40,000 grant to New York Medical College in 1994 to support its RWJF Generalist Physician Initiative with a medical school program that emphasized primary care teaching and health services research in community-based practices in low-income areas of NYC. The PCDP also awarded the Montefiore Medical Center a grant of $60,000 to address the issue of access in school-based health programs.
- Leveraged funding for operational and capital support from two public programs that represent the largest sources of primary care funding in the state. Grants from UHF's PCDP helped leverage $3.5 million in additional funding commitments from New York State's Primary Care Initiative and $15 million from NYC's PCDC.
- Promoted a community development strategy that resulted in partnerships between community groups and health providers. In Bushwick, for example, PCDP staff worked closely with two community groups and the Brooklyn Primary Care Network to create a partnership aimed at coordinating primary care development in North Central Brooklyn.
- Helped to define issues to policymakers, health providers, health planners, community leaders, and other stakeholders in primary care. PCDP staff met on a quarterly basis with key city, state, and federal officials to share information about planned primary care projects, discuss upcoming initiatives and financing opportunities, and address problems related to service development and delivery in low-income communities.
UHF published five reports about primary care in low-income communities, and it issued two community profiles and a provider database for another community. UHF also has featured PCDP in its annual report and several issues of its newsletter, and many of the primary care project sites have produced formal and informal papers, information reports, and briefing documents. In May 1994 UHF sponsored the conference "A Service Delivery Perspective on Health Care Reform," drawing on the experiences of PCDP grantees to discuss models of primary care. Staff from project sites have also made presentations at a variety of forums, symposia, and conferences, including the National Primary Care Conference and the American Public Health Association. (See the Bibliography for details.)
- Communities lacking the strong presence of health care providers often need significant outside support to develop new primary care projects. A higher number of health care providers in a community creates more opportunities for facilitating partnerships with community organizations. Conversely, support from strong community organizations cannot compensate for a lack of health care providers.
- A strong source of capital funding is crucial to the viability of primary care practices in low-income communities. Because most of these practices generate an operating deficit, they must have access to enough start-up capital through an institutional partner, government funding, or private sector grants to relieve them of the added burden of loan repayment.
- The rapidly changing health care environment may make it necessary to undertake mid-course changes during a grant period. In particular, the state's rapid transition to Medicaid managed care and increased competition from other providers have threatened the financial feasibility of many primary care projects. In tight times, the acute-care, specialty-oriented medical system may put primary care low on its list to preserve.
- The paucity of available and appropriate commercial real estate can be an obstacle to developing new primary care services in low-income communities. A number of PCDP's centerpiece projects encountered significant setbacks due to difficulties such as acquiring sites, obtaining permits and approvals, and conforming to zoning requirements. In addition, the need for regulatory approval at the federal, state, and local levels can add substantially to the process of site development.
- Primary care delivery depends not only on building capacity, but on finding ways to make the system financially viable. Now that the necessary infrastructure has been built, it needs to be tuned up in order to meet the challenges created by low Medicaid reimbursement rates, the number of uninsured patients, and the relative inefficiency of resource use.
AFTER THE GRANT
Grants from foundation consortium members permitted UHF staff to provide technical assistance to the primary care project sites after the RWJF grant period ended. In addition, PCDP awarded $350,000 in new grants in late 1995 through its collaborative efforts with NYC's PCDC. This work, which built upon and extended the activities supported by RWJF, promoted a development strategy more consistent with a managed care, market-oriented environment.
In a June 2006 interview, project director David Gould reported that around 2000 the Fund closed the primary care development program because they believed primary care capacity and access in New York City were now adequate. State investment in primary care, federal funding and the maturation of Medicaid managed care helped expand access, according to Gould. Among the Fund's continuing concerns is assuring care for uninsured New Yorkers.
GRANT DETAILS & CONTACT INFORMATION
Project to Help Rebuild New York City's Primary Care Infrastructure
United Hospital Fund of New York (New York, NY)
Dates: September 1992 to July 1996
David A. Gould, Ph.D.
Primary Care Development Program (PCDP) Funding
The following is a list of Primary Care Development Program (PCDP) funding sources and the amount of funds contributed to the project:
- The Altman Foundation A private foundation in New York City that supports programs aimed at providing long-term solutions for the needs of the disadvantaged.
- The Edna McConnell Clark Foundation A private philanthropic organization in New York that provides grants to disadvantaged youth in New York City, among other areas of interest.
- J.P. Morgan The New York-based charitable arm of J.P. Morgan & Co that makes grants to nonprofit organizations working to improve and strengthen communities.
- The New York Community Trust A New York City-based philanthropic organization that provides grants to New York City communities in the areas of children, youth and families, community health, education, and health.
- The United Hospital Fund (UHF) of New York
- The Primary Care Development Corporation (PCDC)
- Total Amount: $1,906,643
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Books and Reports
Gould D, Haslanger K, Halper D, et al. Access to Primary Care in Low-Income Communities, Discussion Paper synthesizing findings from several United Hospital Fund (UHF) grant initiatives that addressed barriers to access and circulated among the UHF's primary care grantees for discussion at an invitational meeting. New York, N.Y.: United Hospital Fund of New York, 1994.
Gould D, Haslanger K, Halper D, et al. Assessing the Primary Care Resources of Five New York City Neighborhoods Targeted for the Initial Phase-in of Medicaid Managed Care to Illustrate the Lack of Available Primary Care Capacity, Working Paper. New York, N.Y.: United Hospital Fund of New York, 1995.
Krasner MI. Monitoring Medicaid Managed Care: Developing an Assessment and Evaluation Program. New York, N.Y.: United Hospital Fund of New York, 1995.
Walker MH. Building Bridges: Community Health Outreach Worker Programs. New York, N.Y.: United Hospital Fund of New York, 1994.
Rebuilding New York City's Primary Care Infrastructure, Blueprint. New York, N.Y.: United Hospital Fund of New York, 1993.
Brochures and Fact Sheets
"Community Profiles South Bronx." United Hospital Fund of New York, 1993. Profiles of community districts in the South Bronx, containing demographic and socioeconomic data, health status and utilization data, health resources, perceived barriers to delivering primary care in the community, and potential opportunities for primary care development.
"Community Profiles Bushwick." United Hospital Fund of New York, 1994. Profiles of community districts in Bushwick, containing demographic and socioeconomic data, health status and utilization data, health resources, perceived barriers to delivering primary care in the community, and potential opportunities for primary care development.
"South Bronx Provider Database." United Hospital Fund of New York, 1993. Comprehensive listing of health care facilities in the South Bronx, with information on service areas, utilization, affiliations, financing, primary care services, and school health programs.
"A Service Delivery Perspective on Health Care Reform," May 26, 1994, New York, N.Y. Attended by 250 people, including health center and hospital administrators, health planners, health plan representatives, medical educators, and private practitioners. One presentation and three panels.
- James R. Tallon, president, United Hospital Fund of New York (New York, N.Y.); Mark R. Chassin, commissioner, New York State Department of Health (Albany, N.Y.); Michael J. Dowling, commissioner, New York State Department of Social Services (Albany, N.Y.), "The Challenge of Caring for Low-income New Yorkers."
- "Developing and Using Community-Based Primary Care Services," Neil Calman, president, Institute for Urban Family Health (New York, N.Y.); Ric Plaisance, executive director, Settlement Health and Medical Services (New York, N.Y.); Denise Rosario, executive director, Coalition for Hispanic Family Services (New York, N.Y.); Maria Uribelarrea, vice president, Program Services, Planned Parenthood of New York City (New York, N.Y.).
- "Developing and Using Primary Care Services: Hospital-Based Perspectives," Howard B. Gold, vice president, Strategic Planning, The New York Hospital (New York, N.Y.); Robert Massad, chairman, Department of Family Medicine, Montefiore Medical Center (Bronx, N.Y.); Bruce Siegel, president, New York City Health and Hospitals Corporation (New York, N.Y.).
- "Training a Primary Care Workforce," Mary O. Mundinger, dean and professor, School of Nursing, Columbia University (New York, N.Y.); Carol Raphael, chief executive office, The Visiting Nurse Service of New York (New York, N.Y.); Judith S. Simmons, special assistant to the commissioner, New York State Department of Health (New York, N.Y.).
Presentations and Testimony
During the course of the grant, United Hospital Fund (UHF) staff members made presentations about the Primary Care Development Program (PCDP) at the following forums, symposia, and conferences:
UHF staff, "Issues of Primary Care Development," at the American Medical Association Conference on Access for the Underserved.
UHF staff, " The Primary Care Development Program, " at the Grantmakers in Health Symposium.
UHF staff, "Community-wide Strategies to Assess Primary Care Needs and Develop Resources and Capacity to Meet Them," at the annual meeting of the American Public Health Association.
Marci Rosa and Bruce C. Vladeck, "Recruiting Practitioners for Inner-City Primary Care: Notes from the Field," at The National Primary Care Conference, March 2931, 1992, Washington, D.C.
UHF staff, "The Primary Care Development Program," at the South Bronx Citizens Advice Bureau Conference for Community-Based Organizations.
UHF staff, "Primary Care Issues," at a J.P. Morgan meeting of grantmakers and community development staff.
At the Edna McConnell Clark Foundation.
UHF staff, "The Primary Care Development Program," at the Women Planning for Change Conference sponsored by the American Planning Association.
UHF staff, "The Primary Care Development Program," at the Grantmakers in Health Symposium sponsored by the U.S. Public Health Service.
UHF staff, "The Primary Care Development Program," at a conference of the New York Association for Ambulatory Care.
UHF staff, " The Primary Care Development Program," at a meeting of the Women's City Club.
At the United Hospital Fund's New Leadership Group.
Local Initiatives Support Corp. seminars for project managers of the National Community Building Initiatives demonstration.
UHF staff, "The Primary Care Development Program," at the National Academy for State Health Policy Conference.
News Conferences and Briefings
UHF staff. "Action for Primary Care Legislation: A Consortium of Organizations Involved in Improving Primary Care Services in New York City," contributed to Legislative Action for Primary Care, "Achieving Better Health Care in New York State," New York, N.Y., 1993.
News Releases/Briefing Documents
Briefing document for a 1994 meeting in Washington, D.C., sponsored by the US Department of Housing and Urban Development to address health care issues that affect residents of public housing. The document, which was sent to HUD Secretary Henry Cisneros, drew on the projects supported by the Primary Care Development Program in the South Bronx in which housing corporations and health providers entered into partnerships to develop primary care facilities.
Informational materials prepared for distribution at a legislative briefing held in March 1995 to apprise New York City's elected officials on the implications of the governor's proposal to expand the state's mandate for Medicaid managed care. The materials summarized the governor's proposal, compared it to the state standing legislation on Medicaid managed care, and assessed existing primary care capacity as a basis for arguing that New York did not have a sufficient number of primary care physicians to meet the demands of the proposed mandate.
"Health Care in the South Bronx," in Newsday, February 1993.
Report prepared by: Bill Berlin
Report prepared by: David Kales
Reviewed by: David Kales
Reviewed by: Karyn Feiden
Program Officer: Michael Beachler