Community clinics have odds stacked against them

STONE MOUNTAIN, Ga.�At Oakhurst Medical Center here, just 20% of children have received all their recommended immunizations by age 2.

Adults don't fare much better at this community health center, which provides primary care to 14,000 mostly poor people in a town famous for its granite monolith and "Confederate Mount Rushmore," just east of Atlanta.

Fewer than half of its diabetics and a little more than a third of those with high blood pressure had their conditions under control in 2010 � far below national averages for the U.S. population, according to a Kaiser Health News-USA TODAY analysis of the latest federal data.

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But 65 miles east of here in Greensboro in rural central Georgia, it's a different story. At TenderCare Clinic, almost all children get the appropriate immunizations, and eight out 10 diabetics have normal blood sugar levels.

The marked differences between Oakhurst and TenderCare underscore the wide variability in how well community health centers are caring for millions of people nationwide.

"There is tremendous performance variation within community health centers and also tremendous variation among any health providers, hospitals, nursing homes, doctors," says Deborah Gurewich, a Brandeis University researcher. "That's the American health system."

Lower-performing centers typically have a higher proportion of uninsured patients and more staff turnover, she says. Most also lack electronic record systems, which makes it harder to track patients.

Oakhurst has many of those challenges. It is one of eight community health centers nationwide whose patients fell below the U.S. average for all six quality care indicators in 2010 � diabetes and blood pressure control, cervical cancer screening, childhood vaccinations, timely prenatal care and low birth-weight babies.

"We can do better," says Oakhurst Chief Executive Officer Jeffrey Taylor.

The difficulties he faces include high rates of obese patients; many African immigrants are unaccustomed to seeking preventive care such as vaccinations; and 40% of patients don't have health insurance.

Another issue: Patients who don't follow recommendations. Candy Armstead, 36, who has been coming to Oakhurst for three years, illustrates the challenge. Despite her doctor's urgings, she refuses to take blood pressure medicine after having a bad experience with one drug. "It caused my hair to shed, so I stopped taking it," says Armstead, who is on Medicaid like almost half the center's patients.

Taylor says the center is doing a number of things to boost care. Staff members now routinely ask parents about getting their children immunized, no matter why they came in. The same goes for women who are due for a Pap test. And an electronic health records system is being installed, which will help monitor patients.

But it is an uphill battle. Last year, Oakhurst identified more than 300 patients as high-risk because they are obese, diabetic or have high blood pressure and asked them to enroll in a free nutrition class. Only 18 signed up.

In rural Georgia, some of those same issues bedevil TenderCare � no-show rates top 30% overall and 70% for Medicaid clients because of transportation difficulties, says CEO Lisa Brown.

But TenderCare uses case managers and counselors to make reminder calls, do in-house counseling and troubleshoot other issues that might interfere with patients' care � efforts that have helped the center achieve some of the best quality scores in Georgia.

Medical assistant Jackie Davis plays a starring role. Using a phone in a corner of the room reserved for minor surgical procedures, Davis calls parents who are late bringing in kids for immunizations, women behind on getting their annual Pap tests and the diabetics who have neglected their monthly checkups.

In a nearby office, Health Education Coordinator Pamela Luke intercepts patients after they meet with doctors to advise them about nutrition, set exercise goals and put them through "diabetes school."

Still, says Dave Ringer, a family doctor, it's not unusual for patients to tell him they cannot keep appointments because they couldn't pay a family member for a ride.

The center also has trouble finding specialists and hospitals willing to provide surgery to its uninsured patients. While many health centers have trouble finding specialists and hospitals to do surgery on patients without insurance, TenderCare is in a more precarious spot because it is outside the areas covered by Grady Memorial, the large public hospital in Atlanta, and Medical College of Georgia in Athens.

In the past year, an uninsured man waited more than eight months to find a neurosurgeon to operate on a brain tumor, Ringer says. An uninsured woman died of cervical cancer after waiting a year to find a surgeon.

The clinic's remote location also has some pluses, though. As one of the few health providers in town, TenderCare has been able to attract patients with Medicare and private insurance that pay higher rates than Medicaid. That helped the center privately finance a new $3 million building in 2009.

TenderCare is also more advanced than most rural health centers with its computerized pharmacy dispensing system to reduce errors.

Some patients still struggle. Josiette Ellison, 39, a heavyset woman from nearby Eatonville, Ga., is uninsured. On a recent visit her blood sugar was 456, almost three times normal. Her blood pressure is also high, and her vision has started to blur because of her decade-long struggle with diabetes.

"I can't avoid the sugars and sweets," she says. "I see the chocolate cake, and it's hard to resist."

Brown pats Ellison's leg and tells her the staff will help her get healthier. Ellison says she's grateful. "It's my bad decisions that are to blame," she says.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communication organization not affiliated with Kaiser Permanente.