A handle on chronic illnesses

California’s community health centers -- a key resource for people without medical insurance -- vary widely in their ability to control their patients’ chronic diseases, including diabetes and high blood pressure, according to federal data.

Clinic directors and observers say the variation is due in part to how much time the centers have invested in quality improvement and whether they use electronic medical records to measure patient progress.

The federal government has been tracking quality indicators on the centers since 2008. The U.S. Health Resources and Services Administration has made the data on each center publicly available in an effort to improve care, said Jim Macrae, who oversees the health centers for the federal government.

Seeing how centers compare on childhood vaccinations, asthma treatment, prenatal care and other indicators “creates some peer pressure,” Macrae said. “They want to do better than their neighbor.”


Health centers, which are federally subsidized, provide primary healthcare and other services to many of the nation’s poor and uninsured. The centers recognize that providing high-quality medical treatment will be critical to retaining their patients once they become eligible for coverage in January under the national healthcare overhaul.

The federal government has invested $11 billion in the clinics and has set high expectations for them to expand access and lower costs. In California, more than 3 million patients received care at about 125 community health centers in 2011, the most recent year the federal data is available.

California clinics as a whole perform higher than the national standards on the quality measures, according to the data. For example, 63% of patients seen at California’s clinics were provided timely cervical cancer screening, compared with 58% nationwide. About 65% of California clinic patients with hypertension had their blood pressure under control, compared with 63% nationwide.

But the California centers fall short of meeting national quality indicators, set based on the Healthy People 2020 benchmarks for improving people’s health. For example, 44% of centers met or exceeded the national average for controlling diabetics’ blood sugar but still failed to meet the national goals. About 47% of centers met or exceeded the national average for cervical cancer screening but fell short of the national goals.

The federal government acknowledges that the benchmarks are high, but Macrae said they provide targets for the centers to work toward, especially on diabetes management and cervical cancer screening.

The federal government is an important funder and centers take the quality measures very seriously, said Carmela Castellano-Garcia, chief executive of the California Primary Care Assn. The association is working with the clinics to improve data collection and help clinics use the information to produce better health outcomes. The group is also trying to identify high performers so others can learn from their success, she said.

In an effort to measure both quality and cost-effectiveness, the association commissioned a report by John Snow Inc. The study found that clinic patients had fewer emergency room visits and hospital stays than non-clinic patients, lowering healthcare costs for everyone.

Castellano-Garcia said the association is trying to get the word out that community health centers provide low-cost and high-quality care, despite treating patients who are sicker and poorer than the general population.


“In this environment of healthcare reform,” she said, “it is more important than ever.”

A Times reporter spent several months at one health center in South Los Angeles, To Help Everyone (T.H.E.) Clinic, and found that some of the greatest challenges to improving quality included provider burnout, lack of specialty care, patients’ reluctance to change behaviors and neighborhoods without enough places to exercise or to buy healthy food.

T.H.E. Clinic exceeded the national average for four quality measures that The Times analyzed: providing early prenatal care, screening for cervical cancer, controlling high blood pressure and managing diabetics’ blood sugar levels. The clinic, however, didn’t meet the national target for two of the measures.

Chief executive Rise K. Phillips said she has placed a high priority on quality of care and has been able to work with staff to raise the center’s scores. In anticipation of healthcare reform, T.H.E. Clinic has also remodeled, expanded and worked to create stronger relationships between patients and providers. In addition, the center also recently decided to take “clinic” out of its name and replace it with “health and wellness center” to reach a broader audience.


With healthcare reform, Phillips said, data are going to be available to patients at an unprecedented level. “That can be good, but that can also be a little bit scary,” she said. “Patients are going to become much more savvy users of healthcare.”

At Petaluma Health Center in Northern California, one of the higher-performing centers in the state, the medical providers are “data junkies and quality junkies” and use electronic medical records to monitor patients’ progress and help them become healthier, said chief executive Kathryn Powell. Powell said she and her staff are relentless about improving quality and recently completed a big push to give all women patients a Pap test.

Powell said there is a friendly competition among local health centers to raise their scores, and the leaders speak often about what works and what doesn’t. High scores and high-quality care can attract patients, she said, adding: “We can use it as a marketing thing.”

At Family Health Care Centers of Greater Los Angeles, chief executive Al Pacheco said he would like to devote more attention to quality but doesn’t have enough resources. The center just started switching from paper to electronic records this year, he said.


Pacheco said he and other clinic administrators know that quality is more important than quantity -- both to the federal government and to patients. Under healthcare reform, he said, “it will not be how many patients we see. It will be about how much better off they are after having come here.”