Improving Access to Subspecialty Care for Patients at Community Health Centers

    • October 26, 2012

Health care experts have long known that community health centers face steep challenges in providing or arranging subspecialty care for their patients.  Many struggle to find highly trained health providers skilled in treating complex conditions, such as endocrinologists with expertise treating patients with brittle diabetes, and cardiologists skilled at treating patients with complicated heart conditions. Less clear has been how clinics are solving this problem.

New research by Katherine Neuhausen, MD, a Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2011-2013) and clinical instructor in the Department of Family Medicine at the UCLA David Geffen School of Medicine, sheds light on ways these centers are approaching the problem of providing subspecialty care to their patients and which model seems most effective. Her findings were published in the August 2012 edition of Health Affairs.

After interviewing executive directors and medical directors at 20 community health centers, Neuhausen and her team identified six models that community health care centers are using to provide patients with subspecialty care. They applied shorthand names to each:

  • Tin Cup, in which doctors ask subspecialists they know personally to treat patients as a favor to the doctor;
  • Hospital Partnership, in which the community health center negotiates a contract with a community hospital to provide subspecialty care; 
  • Buy Your Own Subspecialists, in which the health center hires its own subspecialists to provide care at a designated subspecialty hub;
  • Telehealth, in which health centers use telecommunications equipment to create real-time interactive communication between patients and subspecialists;
  •  Teaching Community, in which health centers rely on the collaborative dynamic created when subspecialists are integrated into a health center as teaching faculty;  and
  •  Integrated System, in which health centers are completely integrated with a local government health system or a safety-net hospital that has a comprehensive network of subspecialists.

“No one had looked at the successful models out there and how community health centers actually go about arranging subspecialty care,” Neuhausen says “I was surprised that we identified six unique models.”

Models for Accessing Subspecialty Care

Among the biggest surprises was the diversity of models and the “variety in satisfaction reported by community health center directors with patient access to subspecialty care based on the model,” Neuhausen says.

Her research team concluded that the Integrated System appeared to be the most effective model because the health centers using it reported the greatest satisfaction with access to subspecialty care. While the other models did offer benefits, in some ways they fell short.

The Tin Cup model, Neuhausen explains, was distinct in that health centers relied on personal relationships to solicit care from an informal network of subspecialists—as if doctors were rattling a tin cup seeking favors from colleagues whenever a subspecialist was needed. Its problem has to do with communication, Neuhausen says. In practice, the subspecialist often doesn't know why the patient was sent to him or her and, in many cases the primary care physician does not receive a written report from the subspecialist and doesn’t know what treatment was recommended for the patient.

“It increases the likelihood of expensive hospital readmissions when care transitions are fragmented because no information is exchanged between the community health centers, hospitals, and subspecialists,” Neuhausen says. Although community health center executives and medical directors often cited the Tin Cup model as being the most frustrating and chaotic of the six models, it was also the model used most frequently by the health centers in the study. That may be because it has fewer costs as clinics rely on the goodwill of subspecialists to “provide charity care to uninsured patients,” the study says.

The Telehealth model relies on telecommunications equipment to create real-time interactions between patients and subspecialists. It is out of reach for some community health centers, because it requires that doctors and patients have access to a high speed Internet connection, a video monitoring system and technological support specialists. Health centers pay subspecialists an hourly rate for telemedicine visits and subspecialists commit to providing the procedures that patients need in other settings, if they cannot be performed at the health center. This model makes a significant difference for people in isolated, rural areas, Neuhausen said, but still sometimes poses a challenge for those who have to travel to see a subspecialist face-to-face.

The Hospital Partnership, Buy Your Own Subspecialist, and Teaching Community models also fell short of the Integrated System model in Neuhausen’s research, with health centers that used these models reporting less satisfaction with their access to subspecialty care.

Integrated System Most Effective

The Integrated System model fared best in the study, Neuhausen explains, because “it features improved access to a comprehensive network of subspecialists, improved communication between subspecialists and primary care providers, and seamless care transitions as a patient moves between the community health center, subspecialty clinics, and the hospital.”

The model relies on health centers that are integrated with a local government health system and/or a safety net hospital that has a comprehensive network of subspecialists. The model improves coordination of care and communication between health care providers, ensuring consistent follow-up with patients, researchers found. Shared electronic health records enable primary care providers to communicate clearly with subspecialists and avoid duplication of diagnostic testing.

While the Integrated System won’t work in every community, there have been examples of remarkable success.

The Denver Health Example

One such example is Denver Health, which consists of a network of eight community health centers that are completely integrated with a public hospital and its vast network of academic subspecialists.

Neuhausen points out that no matter the patient’s status or ability to pay for services, primary care providers can refer him or her to any of the Denver Health subspecialists. A shared electronic medical record with a web-based referral system facilitates the process.

“So when a family doctor from the community health center sends a patient to the cardiologist, the cardiologist can look at the electronic medical record and referral system and know exactly why the patient was referred,” Neuhausen says. “The family doctor will receive back a full report via the electronic medical record and know exactly what treatment the cardiologist recommended.”

The Challenges of the Integrated System

So, why not implement more Integrated Systems? Despite all the benefits, Neuhausen says there are significant challenges to creating an Integrated System that includes community health centers. It requires that the community health center find a safety-net hospital to serve as a partner. Often community health centers are isolated from community hospitals and the hospital leaders may not even know a health center exists in their community.

It requires a lot of collaboration to build the necessary clinical and financial relationships, Neuhausen explains. Collaborations are critical to the success of an Integrated System, which also requires seed funding to build the shared health information technology to enable the system to work.

The current political and budget climate can make implementation of Integrated Systems difficult to achieve, but Neuhausen sees glimmers of hope.  The State Innovation Models (SIM) initiative recently announced by the Center for Medicare and Medicaid Innovation will provide $275 million for states to plan, design, and test new payment and delivery system models that aim to involve all payers and providers in the state.  These new models could include Medicaid Accountable Care Organizations and other integrated systems that incorporate community health centers.

High Stakes for Accessing Subspecialty Care

The stakes are high. Community health centers currently deliver care to more than 20 million people, 37.5 percent of them uninsured and 38.5 percent of them on Medicaid.

Neuhausen said she has RWJF to thank for making her research possible.  “The protected research time I had as an RWJF Clinical Scholar was critical to publishing the paper summarizing my findings in Health Affairs,” she says. “My experiences and training as a Clinical Scholar also enhanced the depth and relevance of my policy recommendations.”

Looking forward, Neuhausen says she plans to expand her focus on integrated systems. “I am fascinated by learning more about how community health centers can overcome the barriers to creating integrated systems, since my study demonstrated how critically important integrated systems are for subspecialty care access,” she says.

Neuhausen is teaming up with Barbara Wynn, MA, a researcher at the RAND Corporation, for a new study funded by the Commonwealth Fund. Together, they are conducting case studies of ten innovative integrated systems in low-income communities that feature partnerships between safety-net hospitals and community health centers.

Read the study here.
Learn more about the RWJF Clinical Scholars program.
For an overview of RWJF scholar and fellow opportunities, visit