Bridging the Gap Between Clinical Practice and Community Lifestyle
I love walking in the front door of our health center. Our greeters are right in front doing a great job of extending the love of Jesus. It’s easy to feel proud of our staff and what they accomplish everyday. As the administrative leader, I’ll admit that I particularly love walking in when the waiting room is full of patients. It means that people from our community are coming to see our doctors. It means that I can feel some confidence that bills will go out and payments will come in. It means that our business and our ministry are succeeding. We’re having an impact. That is very satisfying.
For all those reasons it is easy to focus on the core of what we do well and that is the clinical practice of medicine. The felt need of our patients is to see a physician in an exam room. The health insurance industry has been built around the same idea. Payments are made for providing visits and doing procedures. So we’re rightfully pretty focused on providing those units of service. It is what everyone wants. If we do it well, everyone is happy.
And that would continue to be true except that our health center was founded by Lawndale Community Church (LCC). LCC has additional expectations. LCC’s mission pushes us to not be so easily satisfied with counting visits as the only measure of success.
From its beginning a little over 30 years ago, LCC has recognized that redeeming our struggling inner city community meant that it had to orchestrate more than a Sunday morning church service. To that end it has orchestrated many ministries ranging from residential drug treatment, construction of affordable housing, job training, a restaurant, a wrought iron fencing business, and of course the health care center where I get to work everyday. The message to me has been clear. If the Lawndale Christian Health Center (LCHC) wants to redeem the health of our struggling inner city community, we need to orchestrate more than the delivery of visits. But what does that mean? What should we do?
Or consider LCC’s mission which says that it is “to redeem the Lawndale Community, to bring Christian wholistic revitalization to the lives and environment of its residents.” This broad statement can certainly embrace exam room medicine, but it clearly calls for deeper thinking. My mind routinely hears John Perkins saying, “We have to provide more than service if we’re going to make a difference.” So what does this mean when it comes to being a health center? We’re in the service industry. Service is what we do. What does it mean to provide more than service?
CCHF members like these kinds of questions. All of us use a word like “wholistic” to describe what we’re trying to get done. For some of us the word brings to mind the need to address our patient’s spiritual needs. Others of us think about the importance of doing things like hiring from the community as a way of creating opportunities for employment and leadership development. Our efforts at wholism are diverse, but one thing that we all know is that the ingredients of a healthy community are more complicated than providing exam room visits.
Or consider the federal government’s answer. The government’s focus has often been on something called a HPSA score. The acronym refers to a Health Professional Shortage Area. It’s one of the key measures used by the federal government to determine where health care dollars should flow to solve the problems of poor health. The idea is that where there is a doctor shortage, health status indicators will also be short of where they ought to be. The focus of federal investments has been to provide more doctors and more doctor visits.
There is no question that this is a good plan, but it’s probably not good if it’s the only plan. The feds were smart to start the Community Health Center program back in 1966. CHCs were to be community-based and patient-driven organizations that serve populations with limited access to health care. The government said, “Let’s not put all the power into the hands of the professionals and bureaucrats.” It said, “Let’s counter balance that power by requiring CHCs to be community-based and patient-driven.” Governing boards made up of community people would be more likely to design programs structured to meet the broad health care needs of the community. But today’s challenge for CHC leaders is that reimbursement is the most powerful driver. And since reimbursement is designed to reward visits, the CHC model for improving health is one that looks more and more visit based. I’d even suggest that the recent growth at CHCs has a “doc in a box” kind of look. We need a better model.
When LCHC was founded, its primary target area was the neighborhood of North Lawndale, an urban African American community where many health indicators were not what they ought to be. Over the last 25 years we have accomplished a great deal at creating better access to wholistic, quality, affordable health care for North Lawndale. There are a number of health indicators like the infant mortality rate and immunization rates that have certainly improved over the years. I feel confident that our exam room based services have played a key role. But today when I think about the factors that cause our community to be less healthy than other communities, the big problems seem pretty tough to address in an exam room.
For example, North Lawndale has a smoking problem. About 41% of adult males in our community smoke and that compares very unfavorably to the national average of about 24%. Another health statistic that will challenge the future is related to weight control. In a study by the Sinai Community Institute in 2000, about 41% of adults in North Lawndale were obese, again comparing unfavorably to the CDC’s national statistics at the same time of about 20% for white adults. Worse yet, from the same study in the year 2000 we learned that 53% of the kids in our community were obese, comparing quite unfavorably to the CDC’s national averages of less than sixteen percent during the same time period. How can we address these problems? It seems to me the solution must be wider than an exam room.
If we are to have an impact on health in the next ten years, I believe that we’ll need to work at creating a culture of health in the low income communities that we serve. Creating a culture of health is not a service that we provide. Instead it is an outcome that we might be able to stimulate. Culture is the stuff that exudes from the people in the community. It is connected to the community’s energy, not to the energy that we provide as service providers.
So what can we do? How can we stimulate a culture of health? I certainly don’t know all the answers, but I can describe a few things we’re doing that seem to be headed in the right direction. And what I can say for sure is that we’re having fun. Our employees and our patients are excited about our direction. These new efforts create energy not just for our community but also for our staff.
In 1984 our church renovated an old Cadillac dealership in an old bow truss building that was built around 1900. The renovated building included three sections: a church meeting room, a six exam room clinic, and a gymnasium. Over the years we filled up the meeting room with exam rooms so that by 2000, the building contained a health center with 38 exam rooms and a gymnasium.
The gym was a place for basketball with little direct connection to the health center, but that began to change in 2001 when we joined the Diabetes Collaborative sponsored by the federal Bureau of Primary Health Care. We organized a motivated team of people and gave them the assignment of championing changes in how we provided chronic care.
The team organized our first disease oriented registry and began keeping score on our performance. They hired lay diabetes educators and began talking about issues like depression and its impact on patients with chronic illnesses. They made me come to their meetings and taught me about odd abbreviations like the HbA1c. It took me months to verbally put those letters and numbers in the right order, but I began to get the picture. A theme that really caught my attention was the relationship of obesity to diabetes.
When someone volunteered the obvious idea that we ought to use our gym to start an aerobics program it was pretty easy to think, “Why didn’t we think of that a few years earlier?” From there the idea of being in the fitness business began to percolate. We had some good fortune raising money, so we added a 9,000 square foot addition to our building. Within that addition we dedicated about 3,000 square feet to fitness.
The space includes just what you’re picturing: treadmills, elliptical machines, and weight training equipment. We didn’t have a lot of ready made expertise, but the Lord has led the right people to us. Over the years I’ve certainly learned that the success of our programs depends so heavily on who the Lord brings to us and certainly our fitness initiative is another example of the Lord bringing the right people at the right time.
We opened Lawndale Christian Fitness Center in February of 2005. In our first full year of operation we registered nearly 29,000 visits. Now we’re registering over 55,000 visits per year. So we’ve gone from 0 to 55,000 visits in four years—not bad. Our success has easily exceeded my imagination. And here is what I love about it. We provide the resources, but our patients/members are the ones who do the work of improving their health. We create lots of opportunities. We’re open six days per week, starting at 5:30 A.M. and ending at 9:00 P.M., Monday through Friday, with slightly shorter hours on Saturday. We offer classes with names like: Cardiopunch, Salsaholics, Silversneakers (funded by two managed care companies), and Dr. Aerobics, led by one of our pediatricians. You can see a full list of our classes on our website at http://www.lawndale.org/fitness.html.
The capstone of our success occurred with our First Annual Lawndale 5K this past September. It was designed to be an urban run through North Lawndale, a neighborhood many people have arguably avoided by running around it. When our Fitness Staff volunteered the idea of hosting a 5K, my answer was, “Sure. Go for it.” I must admit that I wasn’t completely confident. To be successful our staff would need to obtain city permits, obtain the alderman’s support, get the police to shut down major streets, market the event, and pray that people would sign up.
It worked. We had over 400 runners and over 100 volunteers. You can still find the results on our website. You’ll find my name listed as coming in 267th place. So I obviously have some room for improvement. But the better news is that I wasn’t the only one to have that thought. As we ran through the neighborhood our neighbors took to their porches with more than a few voicing support, calling out to say they would join us next year. You could feel something changing. There was a crack in the door and a new culture of health was peaking out from their doors.
Our fitness center has lots of stories. I think of my neighbor Mr. Pearson, a man in his 70s, who when he found out that we were building a fitness center asked me several times to let him know when it would open. I’d smile kindly and say sure, never once thinking that he would ever use our fitness center. But boy did I get an earful when he learned that the fitness center had been open for three weeks and that I hadn’t informed him. Since the first month he has been our most frequent user. He arrives every morning sometime before 6:00 A.M. to get in his work out. He’s taught me not to underestimate anyone on the topic of fitness. He was waiting for us. All we had to do was provide the resource. He would supply the energy.
Or how about the Pegues family—another great story. They are a family of four and live just a few blocks from LCHC. The mom, Marla Pegues, candidly admits that her family had been couch potatoes. Marla attends Lawndale Community Church. Following the invitation of friends, she joined one of our Saturday morning aerobic classes. From there she got her whole family involved. As a family they have now lost over 100 pounds. I see them often. They’re still working at it. When I think about their story, I’m reminded that those who reached out to Marla were fitness center members, and then it was Marla who reached out to her own family. The only thing that LCHC did was provide the opportunity. The energy for participation came from the community and the Pegues family. We’re stimulating a culture of health and it’s exciting to watch.
When I used to work in a hospital I was often impressed at the number of nurses I’d see smoking. Similarly I’ve been impressed that health professionals are not inoculated from obesity. The good news at LCHC is that we’re seeing change. Since opening our fitness center in 2005 we have run a program around Christmas time called the Corporate Challenge. It’s a fitness challenge. Over 50 staff members compete. Many staff members have lost a significant amount of weight in the past year. I am among them. I shed fifteen pounds. The culture of health is penetrating our staff and it’s starting to influence the circle of people around us.
Our fitness staff is creating an exciting employee wellness program. In their introductory materials, they wrote this next paragraph.
“Wellness can be described as an expanded idea of health that reaches beyond illnesses, disabilities, or even weight loss. According to Fahey, Insel, & Roth, authors of ‘Fit & Well’, wellness gives us ‘the ability to live life fully with vitality and meaning’. Simply stated, wellness brings out the best in us. It brings out the best in our relationship with our spouse and children, increases job performance, and most importantly helps us to be better men and women of God fulfilling what we are called to do.”
I’m excited that LCHC is giving occasion for our staff members to write paragraphs like this one. It makes me feel like we’re headed in the right direction. So where are we going from here? Our involvement in fitness has changed us. I’m hopeful that the idea of being able to bridge the gap between clinical practice and community lifestyle will become infectious within the minds of our leaders. If it does, we’ll see change. Here are some of the ideas that we’re working on.
- More Fitness: Our goal is to expand on the theme. We currently charge fifteen dollars/month for our membership. We spend about $150,000 to run the program and it produces 55,000 visits. We lose about $30,000 compared to our direct expenses. We hope to increase our volume and run the program at close to breakeven. We’ll keep it simple. We’ll add space, but no pools, hot tubs, or fancy locker rooms.
- Group Visits: For the last year we have been testing and building a method for seeing patients called “Centering”. The centering method incorporates the value of engaging our patients in their care at a whole new level. In a two hour group visit a few things are happening. Our staff members are providing some service, but I believe more importantly patients are engaging each other on the topic of health. They are learning the language of health. They are not sitting in a classroom with chairs facing the teacher. They are in a relational circle, helping each other, learning the language through self expression. They’re being equipped. They even learn to take their babies' vital signs. After a series of group visits they will be verbally skilled in a language that will help to change the culture.
- Building Design: I believe that health centers need to look more like community centers. All three of our locations are connected to community center type buildings with gymnasiums and fitness centers. We intend to build on that idea. We’re currently working on several building projects and each of these will be designed to accommodate fitness, group visits, and learning environments. In one case we’re evening looking at including a bookstore and a café. We want our buildings to be places where people in our community hang out, where they are engaged in the language of health. Our impact on the community will be directly related to the amount of energy that our patients expend at our buildings.
- Relocation: We will value this word that we learned a long time ago from John Perkins. It is a fundamental principle for Christian Community Development. It contains the idea that living out the gospel means desiring for one’s neighbor and neighbor’s family that which one desires for one’s self and family. To me relocation still seems like the best strategy for being in touch with your neighbor’s needs. I said earlier that our diabetes initiative was the primary driver for our endeavors in fitness, but that is not the whole story. My family lives about half block from our main health center on Ogden Avenue. The fitness initiative was so exciting to me partly because I knew it would benefit my family. When staff leaders relocate to the community of need we will be more creative in recognizing and addressing the changes necessary to impact health beyond the exam room.
- Capitation: We will continue to value managed care. I have described that fee-for-service reimbursement has created a focus on exam room based health care. Managed care contracts can change that focus. They often reimburse through a system called capitation. LCHC receives capitation payments for about 11,000 patients. This means we are paid a set fee per member per month no matter if we see the patient or not. Visits are not the only economic driver. Capitation coupled with new “pay for performance” incentives are also helping. We can look at alternative strategies. For example, we’re considering using senior advocates to get seniors engaged with aerobics, educational services, and even doctor visits. Fee-for-service reimbursement doesn’t encourage this type of thinking. Capitation coupled with pay for performance has a very valid place in our future strategy.
We need to change from being sick care centers to being health care centers. A “health center” is a place that provides resources. At LCHC we picture being a place where patients come to work out, where a mother might bring her kids to our book store, where our neighbors might discuss fitness in our café, where patients leave from group visits energized about their health, and of course where patients come to see their doctor in an exam room.
I started this article by saying that I love walking into our health center. These days I don’t just see patients waiting to see their doctor. Now I can look directly from the waiting room into our gym and often see 30 - 40 seniors doing their aerobics. They’re creating a new culture of health in our community and I love watching it happen.
Bruce Miller is CEO for Lawndale Christian Health Center in Chicago, IL.