Federally funded since 1965, community health centers (CHC) began as a grass-roots initiative to provide primary healthcare within a growing number of urban and rural poverty-stricken communities. Today, there are more than 1,200 CHCs in more than 9,000 facilities across the United States, each a nonprofit organization lead by a volunteer board of directors comprised of no less than 51 percent active patients, according to the U.S. Department of Health and Human Services’ Health Resources and Services Administration.

Understanding your client
A CHC’s mission is twofold: To improve the health status of the community through advocacy, education, and access to preventive health services, and to improve the health of individuals by facilitating their ability to carry out a plan tailored to their health status, culture, and resources. How it is this accomplished? By developing processes and programming aimed at breaking down access barriers. Though financial barriers continue to be a central focus, other barriers arise daily from transportation, language, and cultural and social dynamics. The four primary care services addressed by all centers are medical, dental, behavioral health, and facilitation, or “support, education, and outreach.” Expanded services are always in response to local challenges and needs, resulting in wide programming variability from one center to another.

Centers receive funding through state and local initiatives, private grants/donations, and third-party reimbursement for services. Federal funding is competitively granted to increase access through programming as well as to provide health services to eligible persons on a sliding-fee basis.

Historically, CHCs start small, dependent upon those grants and donations for sustainability, and expand only in response to community demand. They adapt facilities that are available for reuse, discarded and broken, or simply gifted. As community needs dictate growth, more space is sought, often leading to a maze of facilities that neither efficiently function nor effectively express the local culture.

The current healthcare reform environment will demand a change. Although what lies ahead for the delivery system is still unclear, the need for entire communities to have access to coordinated, facilitated primary healthcare—the hallmark of community health centers—is now a politically universal charge. Uncertain demand expectations and reimbursement levels within an increasingly competitive environment present a challenging scenario for CHCs as they position themselves to take a central role in this process.

Helping your client understand themselves
Like any facility project, the initial task for CHC projects is to define a program plan. Because health centers are responsive organizations, existing program elements have evolved over many years based on operational experience, grant or cooperative agreement opportunities, licensing or funding requirements, and community needs assessments. To initiate an assessment of the current program, start by answering four questions for every service element:

• Why did we start this?
• Is our reason still relevant?
• How effective are we being?
• Can we support the cost?

Then move to new opportunities that reorganized and expanded space may make possible.

• Does the health center provide the four elements of primary care services onsite?
• Are heavy or difficult referral patterns indicating a need for expanded onsite services?
• What coordinating community services would benefit from an onsite presence?

As systems responsive to the monitoring requirements of multiple agencies, including federal and state governments, while addressing the needs of an ever-changing and diverse patient population, CHCs are well versed in the principles and tools of quality improvement. Familiar process tools, though often relegated to clinical evaluation, can be repurposed to build a communication bridge between the clinical and design teams. Color-coded single-line or spaghetti flow diagrams work well to evaluate new layouts as new procedures are defined. For example, the definition of the patient visit is being challenged, both for its operational efficiency and clinical effectiveness. However, the daily challenge of responding to a packed schedule and, many times, a long waiting list can hinder centers’ ability to explore more promising models. Trying alternatives on a small scale, with just one team or at one satellite office, is not only more manageable operationally but less threatening. A pilot may be altered, discarded, or implemented, as it’s used to introduce new concepts for everything from exam room layouts to registration processes.

Also consider exploring the local environments created by the facility’s target population. Community centers, churches, and local businesses give clues to comfortable wayfinding techniques, the integration of interactive technology, the cultural division between interior and exterior spaces, and the cultural balance between private and public spaces—each specific to the local patient population. Site visits to other health centers are most effective when they’re similar in size, scope, and model of care.

Facilitating the development of owner teams
In lieu of permanent facility teams seen in large healthcare systems, the creation of a team ranging from five to nine members is essential to serve as a point of contact on a project and as a vehicle for synthesizing input and defining priorities. The team should initiate pre-planning concept development with the staff, function as the owner work team for design development, refocus internally during construction to prepare the staff to function effectively within the new environment, lead the transition for staff and patients to the new facility, and monitor operational targets during the first 12 months, initiating process changes if targets are not met.

Consider the following to achieve staff buy-in and provide clarity to the project within the facility team:

• Is every program and every staff person represented? Rather than a large team with members from each department and role, it’s most effective to keep the team small, utilizing staff that have worked in multiple roles and interact daily with multiple services so employees are confident that someone on the team understands their needs and can serve as a point person for their ideas. The team serves as a funnel of information to the design team, recognizing the role of consensus building within a center.

• Is there a balance of formal and informal leaders? Encourage owners to not simply delegate this project to the management team. The most effective design will be created with a balance of those who manage and those who deliver services. This isn’t the time for “them” to create a place for “us” to work, but for an integrated team to create a place supporting integrated team care.

• Is the health center “historian” included? Every center has someone who’s been there “since the beginning” and is cognizant of the historical significance of decisions. Site selection, program integration, points of entry, and staff respite areas are design elements that all benefit from having this perspective.

• Is there a balance of community insiders and outsiders? At the core of CHC culture is responsiveness to and reflection of the community. It’s critical that some members live within the community; however, as continuous inward reflection can sometimes become too narrow, including staff from outside the community can bring a fresh perspective that leads to innovative design solutions.

• Are the members available
  and willing? As this team is created from existing staff, it’s essential that members allocate time for the project. Remember, this is a team created from staff not specifically focused on facilities. Team exercises demonstrating the relationship between environment and outcomes will serve to ignite a passion for the task at hand, supporting timely, creative problem-solving with the design team.

Measuring success
Effective planning is measured by successful outcomes. All health centers have a common vision with a unique interpretation that responds to the culture and values of its community, so each facility, as a reflection of that uniqueness, should and will be different. As a project transitions from concept through design, the following should be monitored:

• Does the design of the facility look like a community center that provides healthcare rather than a healthcare facility located within a community?
• Are elements incorporated that continuously decrease the patient’s stress level from entrance to exam/consultation room?
• Does the facility maximize technology in a culturally competent manner?
• Does the layout facilitate the function of an integrated multidisciplinary clinical care team?          

A positive response to these questions is an excellent measure of an effective planning process that will result in a design that respects the uniqueness of CHCs while allowing clients to take hold of new possibilities within new environments.       

Cindy Barr, RN, EDAC, is a project consultant with Capital Link, a nonprofit organization that provides capital-related technical assistance to health centers and primary care associations on a national basis. Capital Link headquarters are located in Boston. Barr works in the Shepherdstown, W.V., office.  She can be reached at cbarr@caplink.org.