Overview

At this stage of the planning process the community may want to seek outside technical assistance to help clarify the program needs and service mix. The activities undertaken during the start-up phase of the project developed the groundwork for the decision making process discussed in this Module. The objective of this Module will be to establish the major priority areas for realizing the vision defined by the community for its primary health care services. The next steps in the process are to decide and prioritize the health care needs of the community, to select the service delivery model and define the location where services will be delivered.

PLANNING

The needs assessment is an important first step in the process of developing a successful primary care center. Before getting into identifying the service needs for the community, it will be important to establish the planning process. Planning is an on-going, dynamic, interactive process that will set the course of action for the center's growth and provide the parameters for measuring where you are in achieving your objectives.

During the initial development stage, the community prioritizes its goals for the health status of the population. The intent of the planning process is to formalize these goals into a mission statement, a vision for the future, and goals and objectives for achieving that mission and vision. During this process, the following things need to be discussed:

• Organizing the center, e.g., the role of the board members and committees, administrative staff and clinical staff;
• Setting the priorities once the needs have been identified and balanced against the community resources;
• Establishing program objectives that reflect these priorities;
• Setting outcome expectations for evaluating the achievement of the objectives; and
• Establishing a feedback mechanism with the community and providers.

Initially, this planning process should include representatives involved in the community's health care issues such as:

• The community council;
• Local health care providers (if any), (e.g., practitioners, dentists, clinic or hospital administrators, social workers and mental health counsel);
• Department of Health;
• Community Mental Health Center; and
• Advocacy groups, (e.g., Alcoholics Anonymous).

Once the center is operational, on-going planning will involve community representatives, board members, the administrative staff and practitioners. It is important to involve the community leaders and other health care representatives in the initial planning process. Soliciting their views concerning the unmet health needs in the community is important for directing and facilitating the future direction of the primary care center.

A variety of approaches are used for the planning process including individual interviews, a series of focus groups and a day-long retreat. The main point is to be sure that all interested parties have an opportunity to express their opinion and that consensus is reached on the overall objectives.

NEEDS ASSESSMENT

The needs assessment process allows you to focus your resources on those priority areas that are most pressing in the community. The components that are included in determining the health care needs of your community are presented in Exhibit 6-1.

An essential ingredient of the needs assessment is a clear description of the user population, including any differences between your target population and the community as a whole. You will need to identify the major health problems for each segment of the user population group:

• Perinatal (includes both pregnant women and infants);
• Pediatric;
• Adolescent;
• Adult;
• Geriatric; and
• Special populations (e.g., HIV, homeless, etc.).

There are a number of approaches for evaluating the health care needs of the community:

• The National Association of Community Health Center's Basic Guide to Planning and Needs Assessment for Community and Migrant Health Centers provides one model approach that includes the key components for planning a primary care center. Exhibit 6-2 presents examples of health status indicators frequently used to describe mortality and morbidity. Additional health planning and needs assessment resources may be obtained from NACHC by calling (301) 347-0400 or by visiting the NACHC Web site at http://www.nachc.com.
• Another commonly used approach is to conduct interviews with those at risk for a given health care problem within the community. For example, if the rate of low birth weight babies is extremely high among your target population, it would help to identify and interview the women at risk during their hospitalization for delivery. Similarly, to assess the unmet health care needs of the homeless, it is best to get information from shelters and meal-sites that serve the homeless.

The steps in identifying the service needs of your community include:

• defining the major issues confronting the community;
• reviewing your community's goals and objectives;
• reviewing and prioritizing your community's health care needs; and
• selecting basic core primary services to be provided.

Selecting the health care problems to be addressed at your primary care center and deciding how to structure your program may be challenging. It depends on a number of factors, including the priorities established during the planning process, the resources available and the complexity of the intervention. A complete inventory of what is and what is not available in your community will allow you to identify significant gaps in service.

GAPS IN SERVICE

Most communities looking to develop a primary care center are experiencing a shortage of providers. The first step in defining the core services is to identify any gaps in health care service in the community. Service gaps can exist for a variety of reasons, such as:

• the lack of primary care providers (medical, dental, social workers, mental health); or
• barriers to access (geographic, economic, language, culture).

Gaps in health care services are determined by comparing the demand for primary care with the resources available, both professional and institutional. Gaps in service may be determined by:

• resources unavailable because they do not exist or have long waiting lists;
• problem areas verbalized on a continual basis by providers of service;
• services that are not accessible due to location, limited service hours, etc; and
• services that are not affordable and, therefore, not accessible.

In order to document health service gaps in your community, you may wish to conduct an actual inventory of what is both present and absent, as well as survey current provider recommendations regarding the magnitude of the gaps. Exhibit 6-3 is therefore provided as a useful tool to help you get started. Further information about this particular tool as well as other community health decision making tools may be obtained from the National Network for Health, Mountain State Group in Boise, ID by calling (208) 322-4880 or visiting the following Web site: http://www.nnh.org.

SCOPE AND MIX OF SERVICES

The first step in determining the scope and mix of services to be offered is to prioritize the health care problems to be addressed at your primary care center. Obviously, at the onset, your center cannot be all things to all people. Realistically, your center will probably have to address only the most pressing needs in the beginning. Each health problem identified during the planning process must be assessed to determine:

• how important the problem is (e.g., the relative importance depending upon the needs and circumstances of the community);
• what can be done about the problem - selection of problems that can realistically be expected to make a difference in your community;
• what resources will be needed - determine funding/personnel availability; and
• how health problems match the objectives for your center (e.g., if a significant health problem identified in your community is infant mortality, addressing this need may not be appropriate if your main goal is to serve the elderly population).

From this prioritized list of health care problems to be addressed by the center, a profile of services to be offered can be developed. Broad categories of service may include the following:

• prevention;
• primary care;
• mental health and substance abuse;
• emergency and crisis intervention;
• dental; and/or
• enabling.

OUTCOME

The outcome of your planning and needs assessment activities should address the following factors:

• a description of the community in which the primary health center will be developed and the population to be served;
• an accurate description of the needs of the members of that community;
• a program prioritizing the primary care services for meeting the identified needs; and
• a delineation of the relationships your center should strive for, both on a service delivery and a planning level, with other community agencies with similar or overlapping concerns.

Good planning and needs assessment are vital to keeping in touch with your target population so that your center can be strategically positioned and viable in the future health care environment.

The next step is to estimate the demand for services by the target population. We know that demand for care differs widely depending on a variety of factors (age, gender, geography, barriers to access, special circumstances, etc.). The National Network for Health's Healthy Futures Development Kit presents two widely used worksheets for determining best case and worst case scenarios of demand for and supply of primary care and are included here as Exhibit 6-4. Completing these worksheets will enable you to make a high/low range of estimates of potential need for both primary care services and providers in your community.

SERVICE OPTIONS

Having identified the service needs of your target population, the next step is to determine how best to meet that need. The answer to the question "what is preventing provision of the needed services?" may involve a number of factors such as:

• lack of available resources, personnel, capital or other;
• providing these services locally would be prohibitive from a cost, quantity or quality standpoint; or
• lack of commitment on the part of the community.

This is the time to bring the community back together to share the information gleaned from the needs assessment to determine and to prioritize the:

• services to be provided locally;
• services to be provided by visiting health care professionals;
• and services to be referred to providers out of the area.

Your goal is to develop a Health Center with the following characteristics:

• Primary Care Services accessible to all members of your community:
  • affordable;
  • convenient hours of operation, (e.g., evenings and weekends); and
  • culturally sensitive staff.
• Comprehensive services:
  • referrals for specialty services and hospital care;
  • preventative as well as episodic care;
  • support services, (e.g., counseling, outreach, nutrition, transportation, translation); and
  • dental service.
• Service coordination:
  • regularly scheduled meetings of the health care team; and
  • coordinated approach to patient services in the center and in the community.
• Continuous care:
  • follow-up or aftercare; and
  • referral by specialists back to primary care center.

Please refer to Exhibit 6-5 for several worksheets to help you organize the planned scope of your health center's primary care services.