Overview

At this point in the planning process, the primary health care needs of the community have been defined and agreement has been reached on the appropriate model for meeting those needs. This module presents the process for documenting the program expectations, including service and facility requirements and the functional aspects of how the center will operate.

An essential element for ensuring the success of the center will be to identify an administrator early on in the process who embodies the community's philosophy and vision. This individual must have the respect of the community and the energy and commitment to move the project forward. If not before, the administrator must be an integral participant in the planning process from this point forward.

DECISION FACTORS

The success of the primary health center will be dependent upon the level of flexibility and willingness to change. Initially, the community must decide from a diverse array of programs and services which service mix will best meet the needs of their population. Impacting on the service mix decision will be:

• health care goals for the community and what services are needed to meet those goals;
• financial considerations including cost of service, staffing and facility requirements, and reimbursement; and
• availability of resources.

For centers that are operational, the decision will be which additional services to consider, what impact any expansion of the service mix will have on the current operation, e.g., additional staff, facility implications, management team, and how to finance the expanded program.

SERVICE DESIGN

The basis for your service design will be the community's strategic plan and the analysis of the market. The goals and objectives identified in your plan will provide the framework for structuring the programs and services to be offered at the center. Key market factors influencing the service design will include:

• the demographics of the population to be served. For example:
  • a younger population may need obstetrical and pediatric services;
  • an elderly population will need access to services for more chronic medical/dental conditions; and
  • high risk populations, such as the homeless or HIV, will need other types of specialized and/or comprehensive services.
• other service providers in the community. For example (not an exhaustive list):
  • a community mental health center in the service area might preclude the need for a mental health or substance abuse program initially;
  • a local hospital outpatient center offering follow-up services to patients discharged from their acute inpatient setting;
  • dental services;
  • prevention services provided by the health department;
  • a halfway house offering primary and dental care; or
  • other primary health care centers.
• utilization patterns of the target population:
  • estimated number of visits based upon current usage; and
  • estimated number of visits for non-available service based upon other primary care center's experiences and need analysis done previously.

Another factor to be considered in designing your service program, is the funding source you may wish to use. If you are not planning to use any private foundation or public grant funding, then of course, you have maximum flexibility to design your program according to your own analysis of need. If on the other hand, you do plan to use public grant or private foundation support, you will need to accommodate all the specific requirements of your funding source(s). As an example, while an NHSC private practice, a certified Rural Health Clinic, and a Federally Qualified Health Center are all similar in the sense that each program focuses on the delivery of primary care. They are also significantly different in terms of required services that must be delivered, as well as in terms of other structural characteristics such as Medicare reimbursement. It is up to you to be sure that you understand all the requirements of your funding source(s) as you move forward with the design of your service program.

The needs analysis undertaken in Chapters 5 and 6 will provide the basis for estimating the services needed and projecting their utilization. Where possible, the projections should be service-specific.

As previously outlined in chapter 6, the "demand" for service should be forecasted for key center functions, such as primary care visits, nursing services, x-ray equipment and services, laboratory services, etc. These forecasts will also be used to develop estimates for staffing. Keep in mind that the greater the level of detail, the easier it will be to design the strategies for offering new or expanded services. Unfortunately, these more detailed estimates may be limited by the availability of data. Also, certain kinds of projections, such as services not currently being offered in the community or the impact of recruiting a new health care practitioner(s), may not be grounded in reality. This is the time to rely on your technical advisors to provide assistance based upon their experience in other similar settings.

A typical range of programs and services to be considered for direct delivery by your center (or for linkages when offered elsewhere in the community) is as follows:

Primary Health Care Services

• family practice
• internal medicine/geriatrics
• pediatrics
• obstetrics/gynecology/contraceptive care
• mental health and counseling
• health promotion and health education
• dental services

Support Services

• laboratory/radiology
• pharmacy
• physical therapy

Special Programs and Services

• substance abuse
• urgent care
• emergency care
• nutrition
• optical services
• occupational health
• transportation
• outreach
• case management
• volunteer services

STAFFING REQUIREMENTS

Now that you have determined the programs and services to be offered at your center and the projected utilization, a profile can be developed for the future. This profile will allow you to estimate the number and types of jobs/skills required. Productivity expectations/ranges can be established for each employee category: practitioners, support and administrative staff. This profile should take into consideration the scope of services to be offered, the ideal level of staffing and hours of operation. Other factors impacting on the number and type of staffing needed for your center will include, for example:

• seasonal demands, e.g., migrant workers;
• disease factors, e.g., black lung disease;
• epidemiology of disease, e.g., "flu season;"
• security factors, e.g., number of emergencies; or
• new technology, e.g., telemedicine.

Once a profile is developed, a staffing plan can be organized. Staffing ratios have been established in the health service industry for most of the major functions in a primary care center. The type and number of staff to be considered for your center initially will depend upon the size, volume of patients and type of services to be provided. A listing of types of administrative, support and clinical staff is presented here only to illustrate the range to be considered:

• Provider Staff
  • Physicians (M.D., D.O.)
  • Dentists
  • Dental Hygienists
  • Nurse Practitioners
  • Certified Nurse-Midwives
  • Physician Assistants
  • Psychiatrists
  • Health Service Psychologists
  • Psychiatric Clinical Nurses
  • Clinical Social Workers
  • Marriage and Family Therapists
  • Licensed Professional Counselors
• Administrative and Support Staff
  • Administrator
  • Case Manager
  • Receptionist
  • Scheduler
  • Billing/collections
  • Finance/bookkeeping
  • Medical records
  • Clerical
  • Housekeeping/maintenance
• Clinical Support Staff
  • Medical Assistants
  • Nurse Aides
  • Dental Assistants
  • Mental Health Aides
  • X-Ray Technicians
  • Laboratory Technicians
  • Pharmacy Assistants
  • Quality Assurance
  • Outreach Workers

If the determining variables can be identified and quantified, a projection of needed personnel can be made. For example, knowing the number of square feet in a new facility allows accurate projections of the number of housekeepers needed. Projecting the volume of visits for each service allows a determination of staff needed for that service as illustrated in Exhibit 9-1. A staffing plan for your center can be developed which delineates the number of health care professionals needed by specialty and the number of full-time equivalent administrative and clinical staff required.

SERVICE LINKAGES

One way to expand the amount and level of services available to your target population is by establishing linkages with other providers and organizations, either within your own community or from out of the area. One good example of such a linkage is to establish a relationship with a tertiary care institution for transfer and oversight of complex cases to specialized services. Occasionally, a telecommunications network can be accessed whereby your center can have immediate access to specialists. Linkages with schools of nursing, medicine, dentistry and others are particularly desirable ways to enhance and/or expand services.

Primary health care providers and other related organizations are increasingly looking for opportunities to integrate and/or form cooperative relationships. This trend toward networking is especially important for centers providing services to the underserved. Some of the reasons for coordination and linkage include:

• there are few economies of scale in small practices, networking allows enhanced marketing and development of purchasing cooperatives;
• linkage encourages managed care or case coordination;
• insufficient health center providers to assure referral/back-up coverage; and
• sharing of services and avoiding duplication to reduce the cost of providing health care.

Remember, you must think regionally when developing your service package. Through integration, you might be able to pool your energies and resources to:

• respond to larger, more difficult problems;
• coordinate and increase the efficiency of previously uncoordinated processes;
• collaboratively reduce overlapping services and other waste; and
• reduce cost.

Through integration, community organizations can potentially relate to one another in new ways, creating a basis for additional improvement in how the community plans, allocates resources and acts toward the general goal of caring for its people. There is often an array of network structures you should consider. Exhibit 9-2 presents one example of an integrated model for a migrant health program.

Opportunities for collaboration with other primary care centers/ agencies might also include the following examples:

• coordination with health department for HIV support, immunization, biological tests and tuberculosis/infectious disease referral follow-up and health education and materials;
• linkages with regional and/or state primary care associations and the Area Health Education Center (AHEC);
• prenatal, high-risk maternity and specialty referrals with other providers;
• coordination with local and regional training programs to place students and residents at your site;
• contract with your state for the Early Periodic Screening and Diagnosis and Treatment (EPSDT) certification for maternal support services, outreach services, nutrition and modified presumptive eligibility;
• collaborative relationships with the health department, education department and Project Head Start; and
• dental referrals and services for prevention.

FACILITY REQUIREMENTS

Your primary care center should provide an environment that is attractive and pleasing to both patients and staff. The acceptability of the center as a place to receive care and as a place of employment is greatly enhanced by a well designed and efficiently laid out structure. The kind of primary care facility to be developed or expanded is dependent upon the community's goal for the center and the type of health care services to be provided. Resources available when planning the facility include health facility programmers and architects, state health planning agencies and professional societies. A summary of the overall facility planning process is outlined in Exhibit 9-3.

As suggested in the previous chapter, facility requirements are determined by a variety of factors, such as:

• Needs of the population: special needs of children, the elderly, disabled, and the mentally ill all have facility implications;
• Programs/services offered: conference room for education and prevention programs, radiology/ mammography, etc.;
• Special design requirements: dental operatory suites, etc.;
• How care is provided: onsite, visiting professional team, internal and external telecommunication;
• Estimated workloads: visits, number of treatments, procedures or tests, prescriptions, deliveries, counseling sessions, scans, etc.; and
• Plans for the future: design current space with an eye toward future growth and technology.

Keep in mind that some states and cities have requirements for development of primary care facilities, such as size and number of examination rooms, parking and space. During the facility planning stage, do not assume anything. Be sure to share your program plans and designs with the appropriate local, regional, state and federal agencies to ensure that they are comfortable with your plans, and that the design is in conformance with planning, development and construction requirements. If a Certificate of Need (CON) is necessary, contact your state health planning and development agency or CON office for the necessary procedures to follow. Also, be sure to talk to your architect regarding Public Law 504, Accessibility Standards and Life Safety Codes and American with Disabilities Act (ADA) requirements. Exhibit 9-4 contains an illustration of health center space programming. You may need to follow a similar protocol in designing your own center.

As recommended in the previous chapter, establishing a relationship with an architect is a crucial step in the planning process. It is important that this activity occur early to gain assistance with the budget, scheduling, space need projections and site evaluation. When selecting an architect, the following criteria should be considered:

• demonstrated knowledge and experience in the design of primary care centers;
• understanding of the community's goals and objectives;
• knowledge of local building codes and regulations;
• knowledge of particular site characteristics;
• demonstrated sensitivity to providing a high-quality environment;
• commitment to meeting schedule and budget; and
• reasonable fees.

Sample forms for soliciting, evaluating, and contracting for architectural services are included in Exhibit 9-5.

FINANCIAL PROJECTIONS

Now that you have designed the programs and services, identified the staffing and defined your facility requirements, it is time to put it all together from a financial perspective in light of the following parameters.

• baseline volume and revenue assumptions - the program, the utilization unit (visits, users, procedures, deliveries, number of x-rays, etc.), and revenue unit;
• payor mix assumptions - Medicare, Medicaid, managed care, self-pay, low income, other. Please note there are certain reimbursement issues you should be aware of for rural health clinics (RHCs) and Federally Qualified Health Centers (FQHCs). For example, through December 31, 2003:
  • Provider-based RHCs were subject to an upper payment limit of $66.72 per visit.
  • Urban Provider-based FQHCs were subject to an upper payment limit of $103.58 per visit.
  • Rural Provider-based FQHCs were subject to an upper payment limit of $89.06 per visit.

Current updates to the aforementioned Medicare reimbursement levels can be obtained from the following Web site:
http://www.ugsmedicare.com/Audit&Reimbursment/AuditReimbursmentIndex.asp

• expense assumptions - fixed expenses (salary, benefits, and other administrative costs), variable expenses (those expenses related to volume of service, use of specialty referrals, etc.); annual capital expenditure estimates; and depreciation assumptions.

The next step is to develop the revenue and expense projections for the first three years of operation based upon the assumptions specified above. The following generic template may be useful to you.

It is always a good idea to run "best case" and "worst case" projections so that your board will have a better appreciation of the impact, especially if your projections turn out to be overstated. At this point, the reader may wish to refer back to Chapter 6, Exhibit 6-3 for a methodology to make "high" and "low" estimates of demand for primary care.

These financial projections will not only provide information on the viability of your proposed project, but also on the amount of financial assistance to seek. In addition to raising capital to fund your facility and equipment, you may also need funding for your operations, at least initially.

Keep in mind that a well thought out and documented financial plan is extremely important when talking to funding sources. It will add immensely to your credibility with the lender, and will engender political support when applying for grants. Sample financial planning forms for entities contemplating Federal grant support for Community Health Centers are included as Exhibit 9-6. A full complement of CHC financial planning forms may be accessed from the BPHC Web site, http://bphc.hrsa.gov, next click on "Documents" and select Program Information Notices (PINs) and locate the most current PIN entitled, "Funding Opportunities for Health Center New Access Points Grant Applications."

FUNDING/PAYOR SOURCES

You are now wondering, "Where will I get the funding for the center?" The two major sources of funding are the Federal/State Government and private foundations. There are a number of health care related grant programs funded by the Federal government that you should consider as you plan your center. The grant programs typically most useful to new health centers are authorized under Section 330 of the Public Health Service Act as amended by the Health Centers Consolidation Act of 1996, and are as follows:

• Section 330(e) Community Health Centers;
• Section 330(g) Migratory and Seasonal Agricultural Workers;
• Section 330(h) Homeless Population;
• Section 330 (i) Residents of Public Housing.

Additional information pertaining to the aforementioned programs may be obtained from http://bphc.hrsa.gov, or contacting the Bureau of Primary Health Care, U.S. Department of Health and Human Services, East West Towers, 4350 East West Highway, Bethesda, Maryland 20814; (301) 594-4110.

In addition to the above resource, rural communities may wish to contact the DHHS/HRSA Office of Rural Health Policy for information about their Rural Health Outreach Program. Further information may be obtained from http://ruralhealth.hrsa.gov or by contacting Office of Rural Health Policy, Health Resources and Services Administration, 5600 Fishers Lane, 9A-55, Rockville, MD 20857; (301) 443-0835.

Your state may also support the establishment or expansion of primary care services. Check with your State Health Department or Primary Care Association.

There are also a number of excellent publications and resources available which list funding agencies and/or request submission of proposals. The most useful resources for federal funding include:

• The Government Clearing House, http://www.ri.gov/government/fed.html
• The Federal Register (published daily) Superintendent of Documents U.S. Government Printing Office Washington, DC 20402-9325, http://www.gpoaccess.gov/fr
• Catalog of Federal Domestic Assistance (published annually) A copy of the database can usually be accessed through your County Extension Office or library, http://www.cfda.gov
• Commerce Business Daily
  Superintendent of Documents
  U.S. Government Printing Office
  Washington DC 20402-9371
  http://cbdnet.access.gpo.gov
• Health Grants and Contracts Weekly
  Capital Publications, Inc.
  1101 King Street
  P.O. Box 1454
  Alexandria, Virginia 22313-2054
  http://www.uncwil.edu/ora
• NIH Guide
  Distribution Center
  National Institutes of Health Room B4B-08
  Building 31
  Bethesda, Maryland 20892
  http://grants1.nih.gov/grants/guide

Small and rural primary health centers often do not explore foundation funding because they harbor the notion that these funds are designed for large, sophisticated organizations. Quite the contrary is true. Many foundations restrict their activities to smaller grants and smaller communities, or focus on specific activities such as education or community development. Often foundations will provide funds to match those raised locally. This is one way the foundation can be assured of the community's support for the project.

Examples of national and regional foundations that fund health care programs include:

• The Robert Wood Johnson Foundation - http://www.rwjf.org
• W. K. Kellogg Foundation - http://www.wkkf.org
• Commonwealth Fund - http://commonwealthfoundation.org
• NW Area Foundation - http://www.nwaf.org
• Kaiser Family Fund - http://www.kff.org

The most comprehensive resource for identifying private funding is:

The Foundation Directory - http://fconline.fdcenter.org
The Foundation Center - http://fdncenter.org
Department GC
79 Fifth Avenue
New York, New York 10003

• The Fundraising Bazaar - http://www.fundraisingbazaar.com
• The Grantsmanship Center - http://www.tgci.com
• National Network of Grantmakers - http://www.nng.org
• Foundations On-Line - http://www.foundations.org

Note: A catalogue of publications can be obtained by calling 1-800-424-9836.

Other methods commonly used to solicit funds for primary care health services include:

• participant sponsors - sponsors can contribute cash as well as in-kind contributions, such as free space, desks, telephones, utilities, services, etc.;
• corporate gifts - large employers, banks, insurance agencies and other business establishments may have a policy of charitable giving. Also organizations with a strong vested interest in the health of the underserved population may have a grant program, e.g., Rural Electric Cooperatives;
• community sponsored events - raffles, bazaars and craft fairs, and sales of candy, cookbooks, etc. People in the community usually have a good time raising money once they get started. Getting started is half the battle; and
• individual contributions.

Other resources often overlooked are those at the state and local levels. These include your Congressperson or state representative, departments at the state level that have a similar focus, local community organizations, and even national businesses that have their own foundations in which someone in your community is employed. There are many small local foundations which support health care. Check to see if your area has any of these and contact them personally.