The Role of Multidisciplinary Community Clinics in Managed Care Systems

Abstract

Managed care, as a cost-containing system of health care administration, is here to stay. However, this system can leave most vulnerable populations - poor people, people of color, women and children, and older people - on periphery. The populations in greatest need are often selected out of managed care systems because their high-risk status (poor nutrition, inadequate income, lack of prenatal care, substandard housing, minimal preventive medical care, and so on) ensures increased costs of care (Sederer & St. Clair, 1989). Specific environments (particularly underserved rural and urban areas) are less likely to be served. The biopsychosocial and ecological systems models of intervention emphasize importance of social and environmental aspects involved in providing health care. This perspective is critical in an era of managed care, where psychosocial and environmental factors are easily lost in a sea of economic diligence. These frameworks are particularly useful in examining role of social worker in community clinic. Social work's involvement in primary care is not new, as demonstrated by Cincinnati Social Unit, which functioned from 1917 to 1920 (Betten & Austin, 1977); New York State Charities Aid Association, which focused on public health issues from 1893 to 1948 (Kane, 1985); and Henry Street Settlement House of New York, which assisted with control of infectious diseases (Kane, 1985). These forerunners of 1960s neighborhood clinics promoted recognition that poor people, people of color, and special populations deserve access to comprehensive health care (Gropper, 1987). In 1967 Office of Economic Opportunity provided for establishment of neighborhood health centers. Neighborhood clinics of 1960s perceived disease as an interplay among physical, social, psychological, and environmental factors, forming basis for current biopsychosocial model. Their mission was to provide comprehensive care to poor people, people of color, and socially disenfranchised people (Bassoff, 1982). A community clinic provides a setting in which underprivileged people can receive primary health care services within their own communities. Vine Hill Community Clinic Experience The Vine Hill Community Clinic is a primary care clinic established by Vanderbilt University School of Nursing and Metropolitan Development and Housing Authority of Nashville. Kellogg Foundation funding enabled its inception in October 1990. The Foundation initiative involved funding clinic to facilitate provision of health care to low-income families and to create a model for community empowerment. Simultaneously, clinic served as a multidisciplinary learning laboratory. The clinic, which is located in a public housing development in Nashville, is staffed by a multidisciplinary team of family nurse practitioners, mental health clinical specialists, a medical social worker, a community outreach nurse, a medical assistant, a business manager, a janitor, and a receptionist-secretary. Physician preceptors include an adult primary care specialist, a pediatrician, and a psychiatrist who are on call for consultation and who review charts weekly. The clinic provides primary health care for a medically underserved, low-income, urban neighborhood and serves as a training site for nursing, medical, and social work students. The type of patient seen in clinic has changed since project began. Initially, people most frequently seen resided in immediate high-rise housing complex (referred to as the Tower) and surrounding cottages, both of which make up Vine Hill Homes. The Tower was originally constructed as senior citizen housing, but it has become home to an increasing number of people with mental and physical disabilities (including some residents with AIDS). The Tower also houses a shelter for homeless men and a branch of a large community mental health center that includes a geriatric day treatment program. …