Improving access to quality health care final

Improving Access to Quality Health Care ExpAndIng FEdErAlly QuAlIFIEd HEAltH CEntEr SErvICES In tHE grEAtEr dEtroIt ArEA

detroit Wayne County Health Authority Chris Allen, Executive Director & Chief Executive Officer In Cooperation with: prIMAry CArE nEtWorK CounCIl Sr. Mary Ellen Howard, Co-chair Richard Bohrer, Co-chair SAFEty nEt ExpAnSIon WorKgroup Wayne Bradley, Chair WorKForCE dEvElopMEnt WorKgroup Anthony King, Chair Improving Access to Quality Health Care ExpAndIng FEdErAlly QuAlIFIEd HEAltH CEntEr SErvICES In tHE grEAtEr dEtroIt ArEA Prepared by: MICHIgAn prIMAry CArE ASSoCIAtIon Kim Sibilsky, Executive Director Neal Colburn, Technical Assistance Consultant DeAnna Warren, Workforce Program Director March 11, 2009 Improving Access to Quality Health Care | 2

TA B L E O F C O N T E N T S IntroduCtIon.......................................................................................................................... 3 Chart: Comparative FQHC Funding ...............................................................................3 FQHCs: A SIgnIFICAnt CoMponEnt oF tHE SolutIon .........................................6 Chart: Population Served by FQHCs ...............................................................................7 Chart: FQHC Services ........................................................................................................7 Impediments to Growth ....................................................................................................7 CrItErIA For EvAluAtIon ...................................................................................................8 Chart: FQHC Sites by Zip Code (Wayne County) .........................................................9 proxIMIty to An FQHC dElIvEry SItE ..........................................................................9 Chart: FQHC Users Compared to Zip Code Population ..............................................10 Map: FQHC Users as a Percentage of the Population ...................................................13 Map: Primary Care Health Professional Shortage Areas (Ratios) .............................. 15 lACK oF HEAltH InSurAnCE CovErAgE.......................................................................15 Map: Wayne County MUA/P Census Tracts ..................................................................16 Map: Medicaid Beneficiaries as Percent of Population .................................................17 Chart: Designated Health Professional Shortage Areas ...............................................18 Chart: Zip Codes/VODI Estimated Uninsured Outliers ...............................................19 Chart: Poverty Rate & Probable Uninsured by Zip Code (Detroit) ........................... 20 Chart: Poverty Rate & Probable Uninsured by Zip Code (Suburbs) ......................... 22 povErty ........................................................................................................................................23 Map: Uninsured Population by Zip Code .....................................................................24 Chart: Patient Insurance Status (FQHCs 2007)...............................................................25 Map: Wayne County Poverty Levels ...............................................................................26 HEAltH StAtuS IndICAtorS ...............................................................................................27 Charts: Infant Mortality & Age Adjusted Death Rates .................................................28 Charts: Low Birth Weight & Infant Mortality Rates ......................................................29 ABIlIty oF FQHCs to ExpAnd SErvICES, InCrEASE SItES .................................... 29 Chart: FQHC Capacity .......................................................................................................31 Chart: Patient Income Status (By FQHC) ........................................................................32 nEW SItE rECoMMEndAtIonS ...........................................................................................33 Chart: Recommended Sites ...............................................................................................34 Charts: Recommended Sites..............................................................................................35-40 StAtIStICAl rAnKIng oF prIorIty ArEAS ................................................................. 41 InItIAl FIndIngS & AnAlySIS ........................................................................................... 41 Chart: High Need Zip Codes ........................................................................................... 42 Chart: Data Summary of High Need & Suggested New Site Areas........................... 44 Chart: Numeric Ranking of Priority Zip Codes ............................................................ 46 AddItIonAl WorKgroup SuggEStIonS ................................................................... 47 Chart: Priority Areas by Rank.......................................................................................... 47 prIorIty ArEAS: rECoMMEndAtIonS .......................................................................... 49 Chart: High Need Areas without FQHCs ...................................................................... 49 Chart: High Priority Areas with FQHCs ....................................................................... 50 Chart: Workgroup Suggestions, Not Among Selected Zip Codes ............................. 50 Improving Access to Quality Health Care | 1

poSSIBlE AltErnAtIvE SuggESttIonS .........................................................................51 ExpAnSIon StrAtEgIES..........................................................................................................51 New Access Points ...............................................................................................................51 Expanded Medical Capacity and Service Expansion .....................................................52 Change of Scope...................................................................................................................52 FQHC ‘Look-Alikes’ ............................................................................................................52 Chart: Zip Codes with over 10,000 Medicaid Beneficiaries....................................53 Chart: Detroit Zip Codes with Largest Estimated Uninsured ...............................53 Practice/Clinic Acquisition .................................................................................................53 Emergency Department Diversion....................................................................................54 School-Based and School-Linked Health Centers...........................................................56 Collaboration—Behavioral Health ....................................................................................56 Collaboration—Dental Services.........................................................................................57 Other Collaborations ...........................................................................................................57 Contracted Services .............................................................................................................57 Community Outreach and Marketing ..............................................................................58 IMprovIng ACCESS/rEduCIng FInAnCIAl IMpEdIMEntS...................................59 Extended Hours ...................................................................................................................59 Convenient Access ...............................................................................................................59 Hospitality—A Welcoming Environment ........................................................................59 Transportation ......................................................................................................................60 Sliding Fee Scale...................................................................................................................60 ExpAnSIon CHAllEngES .......................................................................................................60 Medicaid, Medicare Health Plans .....................................................................................60 Special Challenges to FQHC Development .....................................................................61 New Site, Services and Service Expansion Requirements .............................................61 Capital Development ..........................................................................................................61 Cooperative Effort (DWCHA) ...........................................................................................63 rECoMMEndAtIonS, plAnS & StrAtEgIES .................................................................63 High Need Areas without FQHCs ....................................................................................63 High Need Areas with FQHCs ..........................................................................................64 Other Workgroup Recommendations ..............................................................................65 WorKForCE dEvElopMEnt.................................................................................................66 Recommendation #1 ............................................................................................................68 Recommendation #2 ............................................................................................................70 Chart: Barriers/Advantages ........................................................................................71 Recommendation #3 ............................................................................................................72 SuMMAry: SAFEty nEt ExpAnSIon plAn ......................................................................73 Chart: High Need Areas without FQHCs ........................................................................73 Priority Areas for Development and Expansion .............................................................74 Map: Priority Areas ......................................................................................................75 Chart: High Priority Areas with FQHCs ...................................................................76 Chart: Workgroup Suggestion ....................................................................................76 prIMAry CArE nEtWorK CounCIl StAtEMEnt oF prInCIplES: SAFEty nEt ExpAnSIon ...............................................77 Improving Access to Quality Health Care | 2

INTRODUCTION The Detroit Wayne County Health Authority (DWCHA) engaged the Michigan Primary Care Association (MPCA) to work with the Primary Care Network Council (PCNC) to develop a 3-5 year safety net expansion plan for the DWCHA. MPCA includes in its membership all of the Federally Qualified Health Centers (FQHCs) in Michigan, including FQHCs located in the Detroit Wayne County area. The membership includes Community Health Centers, FQHC ‘look-alikes’ and one Urban Indian Health Care Clinic, all of which have a similar mission, organizational structure and services. The DWCHA has focused on expanding FQHCs, since they have distinct advantages to meet the challenge of providing comprehensive, quality primary care to a population with an inordinately high rate of uninsured, Medicaid, Medicare and public program coverage. FQHCs were selected as a key element in addressing the unmet health care needs in the Detroit Wayne County area due to their history of providing quality care to the uninsured and their unique funding and reimbursement methodology. This enables them to sustain the delivery of comprehensive quality primary care in underserved areas with low-income populations and high concentrations of Medicaid beneficiaries and uninsured. Beyond this, FQHCs are also cost-effective. In Michigan, the Michigan State University Institute for Health Care Studies obtained permission to utilize de-identified 2003-2004 Medicaid data to study the cost-effectiveness of FQHCs. Its 2006 report found that, “Comparing per-member-per-month costs for FQHC users and non-FQHC users, FQHCs produced a per-member-per-month cost savings of $44.87.” This is also echoed in a number of reports on FQHCs completed over the last decade. In addition, FQHCs’ comprehensive set of primary care services provide a complete medical home, including preventive care, chronic disease management, outreach, translation, case management and other enabling services to help improve access and the quality of care provided. Presently, 32 FQHCs provide care to nearly half a million patients in Michigan, over two-thirds of which have incomes below the Federal Poverty Level (FPL), and 40% of which are covered by Medicaid. The Detroit Wayne County area is served by eight Health Center organizations with 22 clinics serving in excess of 70,000 patients. In addition, services are provided to the homeless in various locations. These include: n Five Community Health Centers with full Section 330 funding: Advantage Health Centers, Community Health and Social Services, Covenant Community Care, Detroit Community Health Connection, and Western Wayne Family Health Center. n Two FQHC ‘look-alikes’ that provide similar services: Health Centers Detroit Medical Group, The Wellness Plan Health Centers n One Urban Indian Health Care Clinic: American Indian Health and Family Services All FQHCs receive Medicaid and Medicare payment improvements in return for complying with specific quality, access and operational requirements of the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). Community and Migrant Health Centers also receive federal grant funding to cover the costs of providing a sliding fee scale to adjust fees to patients’ ability to pay, as well as Federal Tort coverage to minimize or eliminate the need for malpractice costs. Indian Health Clinics receive Indian Health Service (IHS) grants and Improving Access to Quality Health Care | 3

improved Medicaid and Medicare payment rates. As a result, these safety net providers of primary care services have distinct advantages in responding to the health care needs of the underserved populations of the Detroit Wayne County area. For brevity, the term “FQHC” will be used in this report to reference Health Centers. The specific terms of Community Health Center (CHC), FQHC ‘look-alike’ (LA), and Indian Health Service (IHS) clinic will be used when distinction is required. All have similar missions and operate under many of the same federal requirements. Despite their advantages, these providers face substantial challenges. One of the most significant challenges is financial in nature. Caring for a very high rate of uninsured patients challenges the limited resources available for their care. Private medical practices are able to control their patient mix. By agreement with HHS, FQHCs must open their doors to all patients, regardless of insurance coverage, making the challenge of financially sustaining their Health Centers a primary concern. In addition, competition from private practice and emergency departments for a limited number of patients with some type of insurance or public program coverage intensifies the financial challenge. As a result, FQHC safety net provider expansion in the Detroit Wayne County area has been limited. The number of organizations, clinics and services has been identified as smaller than expected for the size of the area’s population and its need for quality services. Recognizing this unmet need, the DWCHA is now working in cooperation with MPCA, the PCNC and other health care and community organizations to make quality health care more accessible to the area’s uninsured, Medicaid beneficiaries and underserved populations. The Greater Detroit area is in critical need of improved access to quality health care. Once one of the financially healthiest cities in the nation, Detroit was the center of the automobile industry and home to the Big Three’s headquarters and primary manufacturing base. Workers enjoyed relatively high wages and generous benefits, including health benefits. The City of Detroit’s population approached 2 million at its peak. With GM, Ford and Chrysler’s loss of market share and downsizing, Detroit’s unemployment is often reported as triple the national rate. Detroit remains the 11th largest U.S. city with an estimated 950,271 residents (U.S. Census, 2005), or about one-half of its peak population. A Centrum Healthiest Cities study of the largest 50 cities based on 2003 data rated Detroit 44th for overall quality of health (www.bestplaces.net/docs/studies/healthy.aspx). The study utilized data from the Centers for Disease Control and Prevention (CDC), U.S. Census and American Medical Association and considered several factors, including mental wellness, lifestyle pursuits, physical activity, health status and nutrition. The Detroit metropolitan area also has limited resources with which to respond to the primary health care needs of the underinsured. On page 5 is a chart comparing Detroit’s FQHC funding to the funding of FQHCs in other Midwest cities (Michigan Department of Community Health, 2007). Wayne County (Detroit) receives a paltry $11.10 per low-income resident compared to Ramsey County’s (St. Paul, MN) receipt of $46.41 and Marion County’s (Indianapolis, IN) receipt of $37.32 per low-income resident. It will be very important for FQHCs and other organizations in the Detroit area to successfully compete for Health Center funding to better meet the needs of the area’s low-income residents. Improving Access to Quality Health Care | 4

FQHC Funding Fy 2006 Midwest Counties with Large Cities County (City) FQHC Grants Population Funds per Population Funding % Funding Awarded Resident <200% FPL Per Low- Population Income <200% FPL Resident Wayne $7,399,592 4 2,061,162 $3.59 666,726 $11.10 32.9% (Detroit, MI) Cook $42,110,988 20 5,376,741 $7.83 1,558,780 $27.02 29.5% (Chicago, IL) Marion $8,818,535 5 860,454 $10.25 236,321 $37.32 28.1% (Indianapolis, IN) Cuyahoga $11,591,092 3 1,393,978 $8.32 397,268 $29.18 29.1% (Cleveland, OH) Hamilton $5,312,123 4 845,303 $6.28 214,755 $24.74 26.0% (Cincinnati, OH) Hennepin $5,969,180 7 1,116,200 $5.35 216,570 $27.56 19.8% (Minneapolis, MN) Ramsey $5,707,577 2 511,035 $11.17 122,994 $46.41 24.8% (St. Paul, MN) Milwaukee County $6,855,224 4 940,164 $7.29 297,565 $23.04 32.5% (Milwaukee, WI) Source: Michigan Department of Community Health, 2007 The 2000 Census reported that over one in four of Detroit’s population was at or below the Federal Poverty Level (FPL), and nearly half (48.5%) was at or below 200% FPL. A 2006 American Community Survey named Detroit as the poorest city in the U.S. with an estimated 32.5% of residents living in poverty. In the last quarter, it was reported that the State of Michigan experienced the second highest unemployment rate in the nation with the City of Detroit having the highest unemployment rate in the state. More recently, the major employers—the Big Three auto manufacturers—reported their critical financial status and the possibility of bankruptcy. Layoffs from the auto industry, centered in Detroit, have already negatively impacted the city. Further deterioration could be economically catastrophic for the area. Since most health insurance is employer-based, this leaves an ever increasing number of Detroit residents without health insurance coverage and without the income to purchase needed health care services. The purpose of the DWCHA’s plan is to be a significant catalyst in improving universal access to quality health care services for all, including primary, specialty, ancillary and tertiary care in cooperation with the area’s many health care planning, coordinating and provider organizations. This element of the overall plan is focused on expanding access to comprehensive, quality primary care services. Improving Access to Quality Health Care | 5

FQHCs: A SIGNIFICANT COMPONENT OF THE SOLUTION There are compelling reasons to look to Federally Qualified Health Centers as a significant part of the solution to the HEALTH CENTER FACTS primary health care needs of the Detroit Wayne County area. FQHCs have a history of generating cost savings in the care of patients as evidenced in national and state studies. Much of Number of organizations this is the result of FQHCs focusing on comprehensive quality 1,200 primary care, similar to what is now being called a medical home. In addition, more recent studies have shown that FQHCs Number of delivery sites eliminate health disparities, producing similar health outcomes regardless of cultural or racial differences. Finally, FQHCs 7,000 contribute to the local economy by providing employment and purchasing goods and services in low-income areas. Total Patients 18 million FQHCs are non-profit, community-directed organizations governed by boards whose majority of members are users of Percent of all vulnerable U.S. the FQHC’s services. The benefits of FQHCs have been well residents served by FQHCs documented: Low income uninsured n Are located in high-need areas with elevated poverty, infant 21% mortality and physician shortages Medicaid beneficiaries Are open to all residents regardless of insurance status or 6% n ability to pay Population below 100% poverty 16% n Tailor services which are culturally and linguistically appropriate to meet specific community needs Economic benefits of FQHCs n Provide comprehensive primary care and other needed Value of avoided emergency services such as transportation, translation and case department visits in 2006 management $18.4 billion n Provide high quality care and improve patient outcomes Economic benefits for local communities in 2006 n rovide cost-effective care that reduces emergency room P $12.6 billion visits, hospital stays and referrals to specialty care, saving the health care system $9.9 to $17.6 billion a year (Access Granted 2007, released by NACHC, Robert Graham Center, and Capital Link) Improving Access to Quality Health Care | 6

Health Center population Served (united States, 2007) FQHC Services A History of Services to the Medically Underserved professional Services Income, insurance status, race/ethnicity Health U.S. Center Population General Primary Medical Care Population Prenatal Care At or below 100% FPL 70% 17% Preventive Dental Care Mental Health Treatment, Counseling Under 200% FPL 91% 36% Substance Abuse Treatment, Counseling Pharmacy Uninsured 39% 12% Hearing Screening Vision Screening Medicaid 35% 13% preventive Services Medicare 8% 15% Smoking Cessation Program Hispanic/Latino 34% 15% HIV Testing & Counseling Blood Pressure Screening African American 28% 13% Blood Cholesterol Screening Weight Reduction Program Asian/Pacific Islander 4% 5% Glycosylated Hemoglobin Measurement Diabetes Management American Indian/Alaska Native 1% 1% Enabling Services White (including Hispanic, Latino) 62% 80% Case Management Eligibility Assistance Health Education Transportation IMPEDIMENTS TO GROWTH Translation FQHCs face a number of obstacles to fulfilling their role, including lack of available capital and workforce, particularly professional workforce. They are experiencing growth in their uninsured populations (55.5%) at double the general U.S. rate (22.3%) (NACHC Chart Book 2008). Their percent of low-income patients is growing dramatically faster than the U.S. low-income population in general: (48.7% versus 6.2%) (U.S. Census, Bureau of Primary Health Care Uniform Data System). These national rates are even more pronounced in Detroit. The growth rate in the uninsured increases the amount of uncompensated care provided, outstripping the fixed grant allocations for this purpose. As a result, FQHCs are facing increasing financial challenges that are diminishing their ability to plan for and carry out further development and expansion. Another element exacerbating this trend is the inappropriate use of emergency departments (ED). While patients receive acute care, greater emphasis on prevention and aggressive management of chronic disease is needed. This will require substantial change from the traditional episodic acute care that often results from the overuse of hospital EDs in lieu of establishing a primary care medical home. EDs often have a number of incentives for caring for a non-emergent patient population, including qualifying for disproportionate care hospital funds, providing patients to physician training programs, Improving Access to Quality Health Care | 7

maintaining sufficient volume to support established ED physician group contracts or maintaining a referral stream of new patients to affiliated physician groups. Hospitals often position themselves as acute care providers, advertising short wait time, professional staff and facility expertise to attract patients. Although it is generally accepted that establishing an on-going relationship with a primary care physician or medical home is of great benefit to the patient, as well as a more cost effective use of limited health care resources, establishing EDs as convenient 24-hour acute care services is a significant factor in their use for non-emergent services. As a result, FQHCs find themselves in direct competition with well-funded hospital EDs. This tends to diminish FQHCs’ access to Medicaid beneficiaries, which is their primary source of patient revenue. This revenue is not only necessary for FQHCs to provide medical services and comprehensive chronic care management, but also to provide enabling services such as case management, translation, health education and community outreach. Diminished Medicaid revenues also hinder the ability of FQHCs to care for the increasing number of uninsured that are in need of a medical home in today’s economic environment, as well as planning for new clinic sites or expanded services. The DWCHA is committed to addressing these challenges. It also intends to seek opportunities that may help the area’s FQHCs expand services and even establish new sites of health care delivery. It plans to facilitate the development of Patient Centered Medical Homes for all, particularly the uninsured and otherwise underserved populations of the Detroit Wayne County Area. C R I T E R I A F O R E VA L U AT I O N Developing criteria for growth targets for FQHC services and sites is a process that utilizes a number of sources of information. U.S. Census updates and studies have been reviewed, as has Uniform Data System (UDS) data that FQHCs submit to both HRSA and MPCA on an annual basis. Data from the State of Michigan and local health department, as well as published reports from local planning agencies, the DWCHA, and the East Side Planning Team of the PCNC, have also been reviewed. Finally, inquiries have been made and discussions initiated with the executive staff of area FQHCs regarding their present capabilities, views regarding the area’s needs, perceived opportunities for expansion and the many challenges they face. There is no one criterion that can be used alone to prioritize areas of underservice. For example, health status may be one indicator, but personal income, insurance coverage, educational level and available access to health care are also important considerations. In addition, such factors as health status data are not generally available on a sub-municipal basis. As a result, other criteria, utilizing various statistical proxies, have been selected to identify sub-municipal areas of highest need. The criteria for evaluating growth targets for FQHC services in this plan will include: proximity to an FQHC delivery site; existing federal designation as a Medically Underserved Area/Medically Underserved Population; existing designation as a Health Professional Shortage Area; lack of health insurance; poverty; health status; and ability/plans of existing FQHCs to expand to meet identified needs within 3–5 years. Improving Access to Quality Health Care | 8

FQHC Sites by Zip Code FQHC Site/Clinic Address Zip Code Advantage Health Centers Thea Bowman Community Health Center 20548 Fenkell, Detroit 48223 Advantage Family Health Center 4777 E. Outer Drive, Detroit 48234 Waller Health Care for the Homeless 2395 W. Grand Blvd, Detroit 48208 American Indian Health American Indian Health & Family Services 4880 Lawndale, Detroit 48210 & Family Services Community Health CHASS Southwest Center 5635 W. Fort St., Detroit 48209 & Social Services CHASS MidTown Center 7436 Woodward, Detroit 48202 Covenant Community Care Covenant Community Care 559 W. Grand Blvd., Detroit 48216 Southwest Solutions 1700 Waterman, Detroit 48209 detroit Community East Riverside Health Center 13901 E. Jefferson, Detroit 48215 Health Connection Eastside Health Center 7901 Kercheval, Detroit 48214 Bruce Douglas Health Center 6550 W. Warren, Detroit 48210 Woodward Corridor Family Medical Center 611 MLK Blvd., Detroit 48201 Nolan Family Health Center 111 W. Seven Mile, Detroit 48203 Health Centers detroit Health Centers Detroit Medical Group 7633 E. Jefferson, Suite 340, Detroit 48214 Medical group University Health Center 4201 St. Antoine 7-A, Detroit 48201 Advance Building 23077 Greenfield, Suite 489, Southfield 48075 the Wellness plan Gateway Medical Center 2888 W. Grand Blvd., Detroit 48202 Health Centers East Area Medical Center 4909 E. Outer Drive, Detroit 48234 Northwest Medical Center 21040 Greenfield, Oak Park 48237 Western Wayne Family Western Wayne Family Health Center 2500 Hamlin Court, Inkster 48141 Health Centers Source: Michigan Primary Care Association Guide to Michigan Community Health Centers PROXIMITY TO AN FQHC DELIVERY SITE Convenient availability of a FQHC is the first criteria in determining the optimal growth and location of new services. Convenient access is critically important to the poor, since those with limited income and resources tend to have fewer transportation options. With the rise in gas prices and inadequate public transportation, the more immediate and convenient access to quality care the better. In addition, those working at the bottom end of the wage scale tend to have less paid leave time and very structured work schedules. Many are raising children in two-wage-earner families, making time and convenience a critical factor in obtaining appropriate primary and preventive care for both parents and children. Therefore, proximity is a key factor. Since FQHCs are created to provide access to primary care services regardless of ability to pay by adjusting fees according to family size and income as well as accepting Medicaid, Medicare and insurance, it is a reasonable assumption that convenient availability to an FQHC improves access to primary care. The existence of a FQHC in the zip code has been chosen as an indicator of proximity and convenience. The existence of a FQHC in a contiguous zip code can also be taken into consideration on Improving Access to Quality Health Care | 9

FQHC users Compared to Zip Code population (Impact) Detroit, Hamtramck, Highland Park City Zip Code Population # FQHC % Population Population % Uninsured Users in FQHCs <200% FPL detroit *48201 15,080 1,019 6.8% 10,721 30.1% detroit *48202 21,870 1,267 5.8% 11,636 15.0% Highland park/detroit *48203 45,260 2,178 4.8% 25,855 18.6% detroit 48204 42,316 2,103 5.0% 21,444 14.0% detroit 48205 67,012 2,640 3.9% 36,176 17.8% detroit 48206 32,378 2,042 6.3% 17,562 15.9% detroit 48207 25,614 964 3.8% 13,093 12.3% detroit *48208 12,867 1,170 9.1% 8,360 17.9% detroit *48209 38,895 6,919 17.8% 22,505 17.4% detroit *48210 39,671 5,781 14.6% 23,663 16.3% Hamtramck (part) 48211 10,886 380 3.5% 6,897 24.3% Hamtramck 48212 46,136 1,139 2.5% 23,414 9.7% detroit 48213 43,996 2,194 5.0% 26,193 20.3% detroit *48214 32,845 1,760 5.4% 18,455 18.8% detroit *48215 19,224 1,233 6.4% 10,894 16.0% detroit *48216 6,668 819 12.3% 4,029 23.1% detroit 48217 10,515 474 4.5% 4,666 10.8% detroit 48219 59,447 1,629 2.7% 19,964 2.4% detroit 48221 45,381 1,134 2.5% 12,291 2.4% detroit *48223 36,037 1,182 3.3% 15,575 13.7% detroit 48224 55,437 1,957 3.5% 19,076 1.6% detroit 48226 6,138 163 2.7% 1,517 7.6% detroit 48227 61,118 2,356 3.9% 28,035 11.1% detroit 48228 65,051 2,108 3.2% 29,404 7.8% detroit *48234 45,797 2,302 5.0% 20,257 7.6% continued on page 11 Improving Access to Quality Health Care | 10

FQHC users Compared to Zip Code population (Impact) continued Detroit, Hamtramck, Highland Park City Zip Code Population # FQHC % Population Population % Uninsured Users in FQHCs <200% FPL detroit 48235 53,353 1,719 3.2% 16,835 1.4% detroit 48238 44,909 2,087 4.6% 23,618 14.7% other/unknown 994 total/Average % 983,901 51,713 5.3% 472,135 11.9% Source: Chart & FQHC User Data-Michigan Primary Care Association; Demographic Data-U.S. Census, 2000 *FQHC located in zip code a case basis, depending if it is located close to the border of two zip codes or on a direct bus line serving a substantial number of those in the contiguous zip code. However, it would be preferred to have a FQHC in each zip code as long as each organization can function in a reasonably defined service area for effective delivery of care. FQHCs currently have facilities delivering health care in nine of Detroit’s 25 zip codes. There are 16 zip codes to be potentially considered for FQHC development. In addition, the suburbs of Hamtramck and Highland Park do not have FQHC sites within their boundaries. These are land-locked suburbs located within the outer boundaries of the City of Detroit, with similar demographics and health care needs. Beyond this, there is one FQHC health care delivery site, Western Wayne Family Health Centers, in a nearby suburb (Inkster) located in Wayne County). It is a Section 330 funded Community Health Center. Proximity is not the only important factor. The degree to which a FQHC impacts the area’s population is also important, as is the percentage of the population served by the FQHC. If it is not significant, FQHC capacity, extended hours, cultural competence and language services, and types of services provided are important factors in making services accessible. There may also be a need for increased and more effective community outreach for services to be appropriately accessible. The actual utilization of any FQHC by the community will be a mitigating factor. Low utilization may indicate lack of capacity or some other form of barrier to accessing care. Expanding services or a New Access Point may be a strategy to respond to lack of capacity. Other factors, such as hours of operation, scheduling policies, and appropriate providers may also need to be reviewed. FQHCs may also need to engage more comprehensively in community outreach in order to make their services known to the community and to encourage the proper utilization of the comprehensive preventive primary care services they provide. Outreach activities may range from providing health education experiences and informational material and presentations in community venues to developing collaborative health care projects and programs with other health care providers, schools, businesses, social groups, churches and other organizations. Improving Access to Quality Health Care | 11

FQHC users Compared to Zip Code population (Impact) Suburbs in Near Proximity or with Over 4% FQHC Users City Zip Code Population # FQHC % Population Population FQHC Users in FQHCs <200% FPL Population vs. <200% FPL Southfield 48034 31,699 170 0.5% 6,285 2.7% Southfield 48075 22,598 123 0.5% 3,797 3.2% dearborn 48120 7,480 17 0.2% 3,912 0.4% Melvindale 48122 10,755 58 0.5% 2,844 2.0% dearborn 48214 33,257 31 0.1% 3,611 0.9% dearborn Heights 48125 22,648 59 0.3% 4,276 1.4% dearborn 48126 46,535 196 0.4% 22,714 0.9% dearborn Heights 48127 35,600 84 0.2% 5,566 1.5% dearborn 48128 10,519 5 0.0% 820 0.6% Inkster *48141 30,115 674 2.2% 11,498 5.9% lincoln park 48146 39,775 187 0.5% 8,901 2.1% romulus 48174 29,937 157 0.5% 7,528 2.1% taylor 48180 65,868 314 0.5% 16,901 1.9% Westland & Wayne 48184 19,121 88 0.5% 4,261 2.1% Westland 48185 49,003 214 0.4% 8,528 2.5% Westland 48186 37,995 178 0.5% 7,491 2.4% river rouge 48218 10,060 210 2.1% 4,666 4.5% Harper Woods 48225 14,413 129 0.9% 1,997 6.5% Ecorse 48229 11,088 219 2.0% 5,120 4.3% grosse pointe & park 48230 18,183 72 0.4% 1,454 5.0% oak park *48237 32,493 418 1.3% 8,643 4.8% redford township 48239 37,608 156 0.4% 5,810 2.7% redford township 48240 19,151 71 0.4% 3,326 2.1% total/Average % 622,495 3,580 0.6% 145,073 2.5% Sources: Chart & FQHC User Data-Michigan Primary Care Association; Demographic Data-U.S. Census, 2000 *FQHC located in zip code Improving Access to Quality Health Care | 12

FQHC users as a percent of the population Improving Access to Quality Health Care | 13

EXISTINg FEDERAL DESIgNATION AS A MEDICALLY UNDERSERVED AREA OR MEDICALLY UNDERSERVED POPULATION Nearly all of the City of Detroit is designated as Medically Underserved Area (MUA) or Medically Underserved Population (MUP), except for an area roughly corresponding to zip codes 48219, 48235 and part of 48238, and a small section of 48204. All other areas of the City of Detroit have the existing designations that qualify them for possible FQHC establishment and federal funding (see map on page 16). In addition, other Wayne County areas are also federally designated including part of the City of Dearborn corresponding to zip codes 48126 and 48120; all of Inkster (48141); Van Buren and Sumpter Townships (48111); Brownstown Township (48173); Huron Township (48164; parts of 48174 and 48134); Romulus (48242, 48174); and part of Taylor (48180). Two zip codes in Dearborn contiguous to Detroit have underserved designations and also have heightened rates of poverty. This is a key element in qualifying for grant awards. Although there are non-FQHC community-based health services in the area, it is an area to be considered for review for an FQHC. Two other areas, River Rouge and Ecorse, are not designated MUAs or MUPs at this time, nor do they have an FQHC, but they are worth considering for designation since they have heightened rates of poverty. They are also contiguous to a southern projection of Detroit with a MUA designation. This zip code (48217) could be a potential site to serve this cluster of zip codes. These areas have been thoroughly reviewed by the Shortage Designation Branch of HRSA and have been designated as having high need under federal criteria. In addition, they have the necessary designation for establishment of FQHCs. The existing designation of an area of high need provides the possibility of initiating applications for federal assistance for additional medical services as well as establishing additional service delivery sites in these areas. MUA designation takes into consideration the percentage of the population with income below the FPL, the percentage of population 65 years and older, infant mortality (5-year average), and the ratio of the current number of physicians providing primary care to the target population (primary care physicians per thousand). Both MUA and MUP designations involve application of the Index of Medical Underservice (IMU) to data on an underserved population group. These groups have economic or cultural and/or linguistic access barriers to primary medical care services. For an MUP criteria similar to the MUA, the data is made specific to the target population and those who presently provide it with health care services. These criteria are used to qualify areas for application for FQHCs including Community Health Centers, FQHC ‘look-alikes’ and other FQHCs defined in Section 330 of the Public Health Service Act. SHORTAgE OF HEALTH CARE PROVIDERS The Shortage Designation Branch of HRSA designates Health Provider Shortage Areas (HPSAs). HPSAs may be designated as having a shortage of primary medical, dental or mental health providers. Although population-to-medical provider ratios exceeding 2000 to 1 are often seen as maximum acceptable ratios (1,500 to 1 are preferred), with few exceptions, HPSAs require population-to-medical provider ratios of 3,500 to 1 for designation. There are exceptions in areas with populations with documented low income. Lacking a sufficient number of medical providers available to provide health care services to the underserved is by definition an impediment to appropriate access to care. HPSA designation is not required for areas to be eligible for FQHC funding consideration; however, this designation does make facilities located in them eligible to apply for National Health Service Corps personnel. Large areas of Improving Access to Quality Health Care | 14

primary Care Health professional Shortage Area ratios, Wayne County Detroit are designated as HPSAs; they are listed in the chart on page 18 and shown in the map above. As can be readily seen, population-to-medical provider ratios exceed reasonable maximum ratios for good access to primary medical care. MPCA, in cooperation with the State of Michigan, systematically reviews available data to identify areas that may be eligible for HPSA, MUA, and/or MUP designations. It then proceeds to seek designations. Once designated a MUA or MUP, the area may apply for FQHC funding or for clinical staff if designated as a HPSA. LACk OF HEALTH INSURANCE COVERAgE The lack of health insurance is somewhat problematic as a criterion, since data at the county and sub-county level has presented a challenge. Therefore, a statistical proxy is utilized to identify areas with high numbers of uninsured individuals. The formula identifies the remainder of the population below 200% FPL, less those covered by Medicaid, including Medicaid-Medicare dual-eligible beneficiaries. This is not intended to represent a definitive result, but rather to be a relative indicator of need. Since most of the potentially uninsured have incomes below Improving Access to Quality Health Care | 15

Wayne County MuA/p Census tracts Improving Access to Quality Health Care | 16

Medicaid Beneficiaries as Percent of Population Improving Access to Quality Health Care | 17

200% FPL, this number is taken as a factor indicating the potentially uninsured. There are others uninsured, particularly those under 300% FPL, and there are some individuals with incomes below 200% FPL who are covered by insurance. However, this number is an indicator of probable uninsured. Therefore, the population with incomes below 200% FPL less the population covered by Medicaid is recommended as a reasonable proxy to identify the degree to which the population in an identified area (zip code) is in need of insurance or public program coverage. The U.S. Census Bureau reported that the nation’s medical uninsured rate was 15.3% in 2007. Due to Detroit’s history with the auto industry setting the employer standard, Michigan, including Detroit, has enjoyed higher than average insured rates. This is due to a higher than average number of area employers that continue to provide health insurance benefits. In addition, comparison between the 2000 uninsured rate and the 2007 census national uninsured rate in designated Health professional Shortage Areas a deteriorating economy tends to make Detroit look healthier than Service Area Type Population to Provider Ratio it is. However, specific areas of high rates of unemployment do Inkster Geographic 11,952 to 1 emerge, and these can be useful. Chene Low-income population 3,085 to 1 Using the methodology noted Eastside detroit Geographic 4,401 to 1 above, 12 of Detroit’s 27 zip codes exceed the national uninsured tireman/Chadsey Geographic 8,973 to 1 rate of 15.3% (U.S. Census McKenzie Brooks Geographic 9,031 to 1 2007). In addition, three Detroit zip codes exceed 150% of the Southwest detroit Geographic 4,071 to 1 reported national uninsured rate. Brightmoor Geographic 5,689 to 1 One of these zip codes includes part of Highland Park. Since the numbers are based on a statistical proxy, this statistic is best used as one factor with which to prioritize heightened need, rather than to determine baseline need. Other estimates, including those by Kaiser Foundation and Gallop, indicate substantially higher uninsured rates. In comparing this calculation against the Voices of Detroit Initiative (VODI), there are some instances in which VODI collected registrations of uninsured in excess of the numbers of estimated uninsured (see chart on page 16). VODI pioneered a system that tracks registered patients lacking insurance with participating providers willing to provide medical services to the uninsured. In most cases, the differences were minor and confirm the methodology. Although minor variation in estimated uninsured versus identified uninsured is expected, a few cases where there are large differences are somewhat problematic and may be worth additional investigation in order to assure that areas of high uninsured are not overlooked. However, in most instances, the relatively small differences are understandable, since the estimates made use of data from different years, and the number of those with incomes below 200% FPL may have increased substantially between the 2000 census used in the estimates and the most recent VODI data collection. Improving Access to Quality Health Care | 18

The Kaiser Commission on the Uninsured has reported that 17% of the non-elderly population is uninsured. *Kaiser also recently reported that 66% of the non-elderly under 200% FPL in Michigan are uninsured. In Detroit, this would be approximately 279,202 uninsured (472,135 [<200% FPL] x 89.6% [age 65+] x 66% uninsured). This estimate greatly exceeds the 117,353 uninsured estimate of the methodology using the remainder of the <200% FPL less the Medicaid population. (*Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau’s Zip Codes Where vodI registered March 2007 and 2008 Current Population Survey uninsured Exceed Estimated uninsured (CPS: Annual Social and Economic Supplements). City Zip Code Probable VODI Uninsured Registered A May 23, 2008, Gallop Poll reports Detroit as (<200% FPL- Uninsured having 15% uninsured or 147,585 uninsured Medicaid) (15% x 983,901). Both of these alternate methods detroit 48205 11,915 13,491 exceed the 117,353 uninsured estimate of the methodology using the remainder of the 2000 U.S. detroit 48224 874 11,984 Census <200% FPL population less the average 2007-08 Medicaid population. So, it would appear detroit 48234 3,461 7,936 that the methodology has underestimated the detroit 48235 748 4,830 actual number of uninsured. However, it remains useful in conservatively identifying areas having romulus 48174 0 284 the highest percentages of uninsured populations Westland/Wayne 48184 0 131 and establishing priority rankings for response to highest need. Westland 48185 531 643 Westland 48186 172 375 It is the mission of FQHCs to provide quality, comprehensive care to all and to eliminate barriers Harper Woods 48225 0 2,733 to accessing health care. Those who are not covered by insurance or do not have adequate insurance grosse pointe/ 48230 598 2,965 grosse pointe park coverage may qualify for step discounts based on family size and income for coverage by the oak park 48237 1,508 3,017 FQHCs’ sliding fee scale program. Federal funds are provided for this purpose; however, these funds redford twp. 48239 778 1,152 are limited and are not increased with the growth redford twp. 48240 414 677 in the number of uninsured. The funding formula does not take into consideration the challenge of caring for high concentrations of uninsured that substantially exceed the average, nor does it provide for increased base funding to meet annual increase in cost. Some of the FQHCs in the Detroit area serve high percentages of uninsured, and this has presented significant financial challenges that not only burden them in the delivery of present services, but also diminishes their ability to plan for expansion to new areas of need where additional uninsured populations are located. Therefore, collaboration with other organizations and new sources of funding will be needed for expanding FQHCs. As can be ascertained by the percentage of patients without insurance, the percentage of patients without insurance far exceeds the national average of 39.8% (NACHC Chart Book) in all but two Health Centers—Health Centers Detroit Medical Group and The Wellness Plan Health Centers (chart page 25). Improving Access to Quality Health Care | 19

poverty rate & probable uninsured by Zip Code, detroit Includes Land-locked Suburbs Zip Code Population 200% % Medicaid % Population Probable % Uninsured Poverty Poverty Beneficiaries Uninsured at 200% FPL 48201 15,080 10,721 71.8% 6,178 41.0% 4,543 30.1% 48202 21,870 11,636 56.6% 8,354 38.2% 3,282 15.0% 48203 Highland park 45,260 25,855 57.8% 17,445 38.5% 8,410 18.6% 48204 42,316 21,444 52.1% 15,535 36.7% 5,909 14.0% 48205 67,012 36,176 54.4% 24,261 36.2% 11,915 17.8% 48206 32,378 17,562 54.8% 12,406 38.3% 5,156 15.9% 48207 25,614 13,093 52.9% 9,953 38.9% 3,140 12.3% 48208 12,867 8,360 65.2% 6,056 47.1% 2,304 17.9% 48209 38,895 22,505 58.7% 15,754 40.5% 6,751 17.4% 48210 39,671 23,663 60.0% 17,198 43.4% 6,465 16.3% 48211 Hamtramck (part) 10,886 6,897 67.7% 4,250 39.0% 2,647 24.3% 48212 Hamtramck 46,136 23,414 54.1% 18,923 41.0% 4,491 9.7% 48213 43,996 26,193 60.2% 17,281 39.3% 8,912 20.3% 48214 32,845 18,455 58.1% 12,267 37.3% 6,188 18.8% 48215 19,224 10,894 57.8% 7,827 40.7% 3,067 16.0% 48216 6,668 4,029 60.5% 2,489 37.3% 1,540 23.1% 48217 10,515 4,666 44.8% 3,528 33.6% 1,138 10.8% 48219 59,447 19,964 45.6% 18,519 31.2% 1,445 2.4% 48221 45,381 12,291 34.2% 11,185 24.6% 1,106 2.4% 48223 36,037 15,575 27.8% 10,624 29.5% 4,951 13.7% 48224 55,437 19,076 43.8% 18,202 32.8% 874 1.6% 48226 6,138 1,517 24.7% 1,052 17.1% 465 7.6% 48227 61,118 28,035 46.3% 21,254 34.8% 6,781 11.1% continued on page 21 Improving Access to Quality Health Care | 20

poverty rate & probable uninsured by Zip Code, detroit continued Includes Land-locked Suburbs Zip Code Population 200% % Medicaid % Population Probable % Uninsured Poverty Poverty Beneficiaries Uninsured at 200% FPL 48228 65,051 29,404 45.8% 24,362 37.5% 5,042 7.8% 48234 45,797 20,257 44.9% 16,796 36.7% 3,461 7.6% 48235 53,353 16,835 31.9% 16,087 30.2% 748 1.4% 48238 44,909 23,618 53.1% 16,996 37.8% 6,622 14.7% total/% 983,901 472,135 53.1% 354,782 36.1% 117,353 11.9% National average: 29.6% Sources: Population data-U.S. Census, 2000; Medicaid Beneficiaries-Michigan Department of Community Health (Monthly average 7/2007–6/2008; Chart-Michigan Primary Care Association poverty <200% uninsured <35% 0-9.9% 35 – 49.9% 10 - 14.9% In fact, Detroit Community Health Connection 50 – 59.9% 15 - 19.9% has reported that its percentage of uninsured is now approaching 50% and this is a potential 60%+ 20%+ severe financial challenge. Health Centers Detroit Medical Group and The Wellness Plan Health Centers are FQHC ‘look-alikes’. FQHC ‘look-alikes’ don’t receive federal grant funding, but they do receive improved Medicare and Medicaid payments for the provision of a bundle of FQHC services, including enabling services provided to Medicaid and Medicare patients served. Therefore, the bulk of funding for uninsured patients must come from other sources, such as charitable donations, pay- for-performance, gain-sharing or use of the group’s unobligated revenue, potentially resulting in diminution of its operating capital or investment capital for expansion. Health Centers Detroit Medical Group and The Wellness Plan Health Centers have not indicated receiving significant sustaining donations or other non-patient revenue sources of funding at this time. Fortunately, both presently enjoy higher than normal Medicaid beneficiary patient populations. The Wellness Plan Health Centers has an unusually high Medicaid percentage since its clinics were previously part of The Wellness (Medicaid) Health Plan clinic system. It has recently become an FQHC ‘look-alike’, and is now responsible for providing the full range of FQHC services to all its patients. It is reasonable to expect this atypical Medicaid percentage will be reduced as the FQHC ‘look-alike’ begins to serve more uninsured patients. The enhanced Medicaid reimbursement of FQHC ‘look- alikes’ contributes to maintaining their financial health, and it provides opportunity for them to care for additional uninsured and to establish additional services and service delivery sites in the future. The Improving Access to Quality Health Care | 21

probable uninsured by Zip Code, Selected detroit Wayne County Suburbs Suburbs Near Detroit Zip Code Population <200% % Poverty Medicaid Medicaid Probable % Uninsured FPL <200% Beneficiaries % Population Uninsured East pointe 48021 33,405 6,414 19.9% 5,765 17.3% 649 1.9% Southfield 48075 22,598 3,797 17.3% 3,644 16.1% 153 0.7% Warren 48089 34,268 10,223 30.4% 9,766 28.5% 457 1.3% Warren 48091 31,985 8,747 27.4% 8,423 26.3% 324 1.0% Warren 48092 25,345 4,421 17.5% 3,797 15.0% 624 2.5% Allen park 48101 28,762 3,106 10.7% 2,281 7.9% 825 2.9% dearborn 48120 7,480 3,912 52.6% 3,156 42.2% 756 10.1% Melvindale 48122 10,755 2,844 26.5% 2,697 25.1% 147 1.4% dearborn 48124 33,257 3,611 10.9% 2,676 8.0% 935 2.8% dearborn Heights 48125 22,648 4,276 19.1% 4,015 17.7% 261 1.2% dearborn 48126 46,535 22,714 49.1% 21,028 45.2% 1,686 3.6% dearborn Heights 48127 35,600 5,566 15.8% 6,681 18.8% -1,115 -3.1% dearborn 48128 10,519 820 7.8% 864 8.2% -44 -0.4% garden City 48135 29,416 4,263 14.5% 3,265 11.1% 998 3.4% Inkster 48141 30,115 11,498 38.6% 10,669 35.4% 829 2.8% lincoln park 48146 39,775 8,901 22.5% 7,615 19.1% 1,286 3.2% livonia 48150 28,069 2,684 9.7% 2,021 7.2% 663 2.4% livonia 48152 32,142 3,459 10.8% 2,336 7.3% 1,123 3.5% livonia 48154 40,556 3,782 9.5% 2,115 5.2% 1,667 4.1% romulus 48174 29,937 7,528 25.5% 7,612 25.4% -84 -0.3% taylor 48180 65,868 16,901 26.0% 14,490 22.0% 2,411 3.7% Westland/Wayne 48184 19,121 4,261 22.7% 4,430 23.2% -169 -0.9% Westland 48185 49,003 8,528 17.6% 7,997 16.3% 531 1.1% Westland 48186 37,995 7,491 19.9% 7,319 19.3% 172 0.5% continued on page 23 Improving Access to Quality Health Care | 22

probable uninsured by Zip Code, Selected detroit Wayne County Suburbs continued Suburbs Near Detroit Zip Code Population <200% % Poverty Medicaid Medicaid Probable % Uninsured FPL <200% Beneficiaries % Population Uninsured Wyandotte 48192 44,894 8,617 19.5% 3,489 7.8% 5,128 11.4% Southgate 48195 30,136 4,562 15.3% 3,700 12.3% 862 2.9% river rouge 48218 10,060 4,666 44.8% 3,582 35.6% 1,084 10.8% Ferndale 48220 25,170 6,152 24.7% 3,853 15.3% 2,299 9.1% Harper Woods 48225 14,413 1,997 14.0% 2,382 16.5% -385 -2.7% Ecorse 48229 11,088 5,120 46.3% 4,304 38.8% 816 7.4% grosse pointe/ 48230 18,183 1,454 8.0% 856 4.7% 598 3.3% grosse pointe park grosse pointe/ 48236 31,366 2,048 6.6% 1,070 3.4% 978 3.1% grosse pointe park oak park 48237 32,493 8,643 26.7% 7,135 22.0% 1,508 4.6% redford township 48239 37,608 5,810 15.5% 5,032 13.4% 778 2.1% redford township 48240 19,151 3,326 17.8% 2,912 15.2% 414 2.2% total 1,019,716 212,142 182,977 17.9% 29,165 2.9% National average 29.6% Sources: Population-U.S. Census 2000; Chart-Michigan Primary Care Association; Medicaid Beneficiaries: Michigan Department of Community Health (Monthly average 7/2007 – 6/2008) combination of additional FQHC federal funding, FQHC ‘look-alike’ enhanced Medicaid and Medicare revenues, significant philanthropy and other revenue sources will be required to significantly expand area FQHC services. Also, the provision of such funding will need to be stable and reoccurring if it is to create the environment needed to address the risks inherent in service and facility expansion. POVERTY Since numerous studies have consistently found that poverty is correlated with lowered health status, and since this data is available by both census tract and zip code, it is an excellent factor by which to identify high need areas. A review of Detroit area data indicates clearly defined areas of high poverty and near poverty, as opposed to significantly more affluent areas of quality health care. Rates of infant mortality, low birth weight and common diseases have been reviewed for indicators of lower than average community health status. Lack of income is a crucial factor in identifying areas with barriers to accessing health care services. Based on the CDC’s Health, United States, 2007, the National Center for Health Statistics reported in a press release (December 3, 2007) that nearly one in five Americans say they can’t afford needed health Improving Access to Quality Health Care | 23

uninsured population percentages by Zip Code Improving Access to Quality Health Care | 24

care. “The report…shows that nearly 20 percent of adults reported that they needed and did not receive one or more of these services in the past year—medical care, prescription medicines, mental health care, dental care, or eyeglasses—because they could not afford them.” In the same report, it was also noted, “In 2005, one out of five people under the age of 65 reported being uninsured for at least part of the 12 months prior to being interviewed. The majority of this group reported being uninsured for more than 12 months.” Beyond this, the report noted that about one-third of all children living below the poverty level did not have a dental visit in 2005. The CDC Chartbook on Trends in the Health of Americans sums up the influence of health on poverty. “Children and adults in families with income below or near the federal poverty level have worse health than those with higher income. Although in some cases illness can lead to poverty, more often poverty causes poor health by its connection with inadequate nutrition, substandard housing, exposure to environmental hazards, unhealthy lifestyles, and decreased access to and use of health care services.” Using 2000 U.S. Census data, poverty rates were identified by zip code. The stark differences in income within relatively short distances made identification of potentially high need areas relatively simple. This criterion quickly and clearly identified nearly all of the City of Detroit; two land-locked suburbs within the city, three nearby suburbs, and two zip codes of another near-city suburb as having high poverty rates compared to their neighbors’ relative affluence. Areas of potential high need indicated by poverty rates include the City of patient Insurance Status, 2007 Detroit, Hamtramck*, Highland Park*, Ecorse, FQHC No Medicare Medicaid Other Public Private Insurance Insurance Insurance River Rouge, and Inkster. (*Land-locked suburbs Advantage Health Center 82% 2% 10% 3% 3% of Detroit, within its American Indian Health 76% 2% 11% 8% 3% exterior borders.) & Family Services If, for the purpose of Community Health 82% 2% 13% 0% 2% this plan, we define & Social Services heightened poverty Covenant Community NR NR NR NR NR rates as those exceeding Care 150% of national average poverty rate, then 21 of detroit Community 44% 7% 39% 0% 11% Health Connection the 25 Detroit zip codes exceed this rate. Two Health Centers detroit 24% 10% 50% 6% 10% exceed triple the national Medical group average (48201, 48216). the Wellness plan 1% 1% 97% 0% 1% Furthermore, if a similar Health Centers parameter is applied to rates of near poverty Western Wayne Family 54% 7% 25% 0% 14% including those with Health Centers incomes below 200% Sources: Michigan Primary Care Association 2008 Guide to Michigan Community Health Centers FPL, 20 of 25 Detroit zip NR: Covenant is new and has not yet reported Improving Access to Quality Health Care | 25

Wayne County poverty levels codes meet this criteria, with another zip code within 0.6% of this parameter. If this marginal zip code is accepted and both poverty parameter criteria are accepted to qualify a zip code for inclusion, then only two Detroit zip codes would not be considered in heightened poverty. Consideration of those with incomes between 100% and 200% FPL is important. This group is often identified as the working poor. Many in this group have low-wage jobs with no health insurance. As a result they are often lack the ability to purchase health insurance coverage due to their low income, but what income they do receive makes them ineligible for Medicaid or public assistance. As a result, they often have less ability to pay for regular access to quality health care than those who are very poor, many of whom have access to publicly funded health care coverage. The Cities of Hamtramck and Highland Park are geographically encircled within the outer perimeter of the City of Detroit. They have separate municipal governments but share similar poverty statistics. Both meet the heightened poverty parameters. Hamtramck has a rate double the national poverty rate and Highland Park has a rate nearly triple the national poverty rate. Improving Access to Quality Health Care | 26

Two zip codes in the suburb of Dearborn, contiguous to Detroit, have substantially heightened poverty rates. These (48120, 48126) have rates exceeding double the national Federal Poverty Level (>200% FPL). About half of their residents of this area have incomes below 200% of poverty. These residents are also reported (U.S. Census, 2000) to have very high second language rates, indicating need for translation services and organizations with culturally competent medical staff. The Cities of Ecorse (48218) and River Rouge (48209) also have heightened poverty rates. These are small communities downriver of Detroit nestled between the southern most projection of the City of Detroit and the Detroit River. These cities easily meet the heightened poverty parameters. Finally, the City of Inkster (48141) also has a heightened rate of poverty. Poverty is a key indicator of need. It is recommended that these areas be reviewed for possible designation and potential FQHC development. HEALTH STATUS INDICATORS Poor health status is generally accepted as an indicator of need. Lack of access to health care on a regular basis is a significant factor in contributing to poor health status as shown in the charts from MDCH on pages 28 and 29. The scope of this review is limited to the areas identified with heightened poverty rates. Data was not published or available for River Rouge. Infant mortality and the incidence of low birth weight is a commonly utilized indicator of health status and the degree of need for health care. Age-adjusted mortality rates for heart disease, cancer and diabetes are other useful indicators. Heart disease and cancer rates are included here. Diabetes rates are only available for the state, Wayne County, Detroit and Dearborn. Statistically valid mortality rates for other leading causes of death are not readily available for small areas. With regards to infant mortality, it should be noted that the statistical confidence interval for small populations is less in smaller communities. However, these infant mortality rates were made available by MDCH with varying parameters of confidence. Please refer to MDCH’s Community Health Statistics for more information. It is apparent that Detroit, Ecorse and Highland Park have substantially higher (>150% of Michigan) infant mortality rates. The chart on page 29 reports a 5-year average of births by low birth weight, 2002-2006. The overall Wayne County low birth weight statistics are only slightly heightened over the Michigan rate. The cities of Detroit, Ecorse, Highland Park and Inkster clearly indicate heightened rates of low birth weight with rates exceeding 150% of the state norm. Detroit, Ecorse, Highland Park, Taylor and the City of Wayne have substantially higher than average (>150% of Michigan) health disease death rates and generally higher than state average cancer and Diabetes Mellitus rates. This may indicate need for greater access to comprehensive quality primary care services, including such other health and enabling services as health education, community outreach, case management and other assistance. The East Dearborn zip codes also have high poverty rates, which may be an indicator of lower health status. There are substantial poverty rate differences between the eastern and western zip codes of Dearborn. The eastern zip codes of 48120 and 48126 have large populations with incomes under 200% FPL of 52.6% and 49.1% respectively. Western Dearborn zip codes of 48124 and 48128 have minimal low-income populations below 200% FPL of 10.9% and 7.8% respectively (U.S. Census, 2000). The blending of the overall Dearborn health statistics may tend to mask possible lower health status in these eastern zip codes contiguous to Detroit. Another consideration is health disparities. Minority populations tend to have diminished access to quality health care, increased rates of poverty, and lower rates of health insurance coverage. Living and Improving Access to Quality Health Care | 27

working in areas with greater environmental stressors and having less healthy lifestyles also tend to contribute to lowered health status. A recent Kaiser publication (Key Facts, Race, Ethnicity & Medical Care, January 2007) reported that, as of 2005, nearly one-third of the U.S. population identified themselves as a member of a racial or ethnic minority group. It also noted that, “People of color are more likely than non-Hispanic Whites to have low incomes, which may have implications for both their health and insurance status.” This has significant implications for Detroit and some of its nearby suburbs, since they have a high percentage of minority populations and the incidence of poverty is well documented. The U.S. Census reports about 90% of Detroit’s population to be non-white with the largest ethnic group being Black or African American (81.6%). The U.S. Census also reports over three-quarters of Inkster’s population as non-white, two-thirds (67.5%) of which are identified as Black or African American. Inkster is a near-Detroit suburb. Similarly, River Rouge and Ecorse located immediately to the south of Detroit have significant Black or African American populations (42.01% and 40.56% respectively). These and other near-Detroit suburbs have growing rates of non-white populations with correspondingly above average rates of poverty. Both of these are indicators of lower than average health status and a heightened need for access to high quality primary health care services. Infant Mortality, 2002-2006 Age-Adjusted death rates, 2006 5-Year Average Community Heart Disease Cancer Death Diabetes Community Neonatal Post Neonatal Infant Death Rate* Rate Mellitus Rate Morality Rate Mortality Rate Morality Rate Michigan 226.7 190.8 26.7 Michigan 5.5 2.4 7.9 Wayne County 286.5 212.0 29.8 Wayne County 7.9 3.2 11.1 dearborn 201.5 158.1 25.3 dearborn 3.4 1.5 4.9 detroit 331.3 229.4 33.0 detroit 11.0 4.7 15.6 Ecorse 397.9 198.3 * Ecorse 11.9 * 15.5 Hamtramck 318.6 155.5 * Hamtramck 5.4 * 6.8 Highland park 404.3 255.1 * Highland park 13.3 * 16.2 Inskter 279.1 211.1 * Inskter 7.2 2.7 9.9 river rouge n/a n/a n/a river rouge n/a n/a n/a taylor 309.2 221.3 46.8 taylor 7.8 2.3 10.1 City of Wayne 315.8 273.5 * City of Wayne * * 6.8 Source: Michigan Department of Community Health Source: Michigan Department of Community Health *Number too small for comparative purposes *A rate is not calculated when there are fewer than six events. Age-adjusted death rates per 100,000 population in specific group. Improving Access to Quality Health Care | 28

This ethnic-related income correlation has implications regarding access to health care. low Birth Weight, 2002-2006 The Urban Institute and Kaiser Commission 5-Year Moving Average on Medicaid and the Uninsured (March 2006) Community Total Births Low Birth Very Low Birth estimates the percent of ethnic populations with Weight % Weight % incomes below 200% FPL as Hispanic 58%; African American 54%; American Indian/Alaska Native Michigan 129,026.6 8.3 1.7 57%; two or more races 41%; Asian and Pacific Wayne County 28,221.2 10.6 2.4 Islander 33%. The same study states, “American Indian/Alaskan Natives, African Americans, dearborn 1,876.2 6.5 1.2 Hispanics, and those who identify themselves as detroit 13,646.2 13.6 3.4 of two or more races are more likely to rate their health as fair or poor compared to Whites and Ecorse 168.0 12.7 2.6 Asians.” It also states, “Infant mortality rates, considered one of the most sensitive indicators Hamtramck 410.2 9.9 1.9 of the health and well-being of a population, are Highland park 209.8 16.0 4.9 higher among African Americans and American Indians/Alaska Natives than among other racial/ Inskter 444.0 12.8 2.5 ethnic groups, even when comparing women of river rouge n/a n/a n/a similar socioeconomic conditions, as measured by years of education completed.” As reported in taylor 868.2 7.8 1.8 the chart on page 24, Detroit, Highland Park and City of Wayne 263.0 6.9 1.1 Ecorse have more than double Michigan’s infant mortality rate. These communities and Ecorse also Source: Michigan Department of Community Health have heightened incidence of low birth weight. *A rate is not calculated when there are fewer than six events. AbILITY OF FQHCs TO EXPAND SERVICES, INCREASE DELIVERY SITES TO MEET Infant Morality rates for Mothers Age 20+ IDENTIFIED NEEDS wITHIN 3-5 YEARS By Race/Ethnicity and Education, 2001-2003 Site visits were conducted, discussions were initiated and questionnaires were sent to identify Race/Ethnicity < High High School College+ School issues and develop indicators of the area FQHCs’ ability to expand to meet identified needs. In African American/ 15.1% 13.4% 11.5% non-Hispanic addition, FQHC Uniform Data System (UDS) reports were reviewed as was information American Indian/ 10.7% 9.2% 7% provided in the 2008 Guide to Michigan Community Alaska native Health Centers, an annual report of MPCA. During White, non-Hispanic 9.2% 6.5% 4.2% discussions and reviews it became apparent that the high rate of uninsured in the city was a Asian/native 5.0% 5.6% 3.9% serious matter for the FQHCs to consider in terms Hawaiian/Pacific of expanding. Serving large numbers of poor, Islander uninsured patients who can pay little or nothing for Hispanic 5.2% 5.3% 4.6% care seriously strains FQHC resources. Historically, FQHCs have served patient populations that Source: National Center for Health Statistics, National Vital Statistics System, National Linked Birth/Infant Death Data. include about one-third uninsured. However, this Improving Access to Quality Health Care | 29

is changing. The most recent National Association of Community Health Centers (NACHC) Chart Book reports that nationally this rate is now approaching 40% (39.8%). Locally, a number of the FQHCs have patient populations exceeding these national uninsured rates. For example, three Detroit area FQHCs report serving patient populations exceeding 70% uninsured. Federal grant funding has been relatively stable and less than 15.8% of FQHC income is generated by private insurance (NACHC) . Most of the remaining sources of income are publicly funded programs including Medicaid, Medicare and SCHIP. Medicaid and Medicare provide special payment formulae for FQHCs, which have been helpful in providing a degree of financial stability to FQHCs. However, with the growing number of uninsured in the Detroit area, the patient mix has placed some of the area’s FQHCs under financial stress. This not only presents an immediate challenge to the delivery of existing services, but it also weighs heavily upon decisions to expand, since expansion of services of the addition of new sites may well present an FQHC with a new population of uninsured for which it has inadequate resources to serve. The primary challenge identified by the present providers is lack of capital. Since it is generally more efficient to expand an existing FQHC’s services to new sites, as well as introduce new services in present locations, this would be the first option to consider. However, if no existing organization is prepared to establish services in an identified high-need area, providing assistance to a new organization to meet identified need may be considered in the planning process. Should an area be in an FQHC’s plans for a New Access Point, this would be a solution to their primary health care needs. If need is identified and no FQHC plans to respond to the need, it will be important to encourage an FQHC to add the area to its plans or to encourage and assist a new organization to respond to the need. Other considerations would include language, ethnicity and culture, and availability of appropriate transportation. As mentioned above, on-going input received from the safety net primary care provider organizations, the many organizational representatives of the DWCHA, the PCNC, and community organizations is very important. These organizations have been responding to the many challenges of providing quality health care for the area’s underserved population for many years and their experience and observations are of great value. These criteria will be valuable in identifying need, the ability of organizations to respond to need, and the resources, opportunities and challenges of the community in establishing achievable growth targets. Once these needs are identified by area and the ability and plans of organizations to respond are known, a reasonable set of benchmarks can be established to measure progress. FQHCs are of various sizes and capabilities. As can be ascertained, the Detroit area FQHCs are primarily providing medical services. However, they do provide preventive dental services and routinely arrange for referrals for dental and behavioral health services. Three (Advantage Health Center, Community Health and Social Services, and Detroit Community Health Connection) directly provide dental services. In addition, a few of the FQHCs have reported developing dental and behavioral health services. FQHCs are also required to provide enabling services, such as case management, eligibility assistance, community outreach, translation and health education in order to assist patients in their access to, and utilization of, quality services. FQHC ‘look-alikes’ are required to provide similar services. Improving Access to Quality Health Care | 30

FQHC Capacity FQHC Type # Clinics # Medical Users # Dental Users Behavioral Health Advantage Health Centers CHC/HCH 3* 8,016 1,034 By referral American Indian Health & Family Services IHS 1 6,159 # not reported # not reported Community Health & Social Services CHC 3 11,189 1,368 By referral Covenant Community Care CHC 2 2,340 Service begun By referral detroit Community Health Connection CHC 5 16,203 2,114 By referral Health Centers detroit Medical group LA **3 # not reported By referral By referral the Wellness plan Health Centers LA **3 24,753 By referral By referral Western Wayne Family Health Centers CHC 1 614 By referral By referral *Also provides care at homeless facilities **One clinic is in Oakland County Key: CHC = Community Health Center (FQHC with federal grant funding) HCH = Health Center for the Homeless (FQHC receiving federal grant for serving the homeless) IHS = Indian Health Service (receives funding to serve Native Americans LA = FQHC ‘look-alike’ (receives special Medicaid and Medicare payment rates; provides FQHC services) Patient income status varies. However, it is readily apparent that the percentage of those unable to pay for their services is very substantial. Few are covered by private insurance. To the degree this patient population is not eligible for Medicare, Medicaid or public programs, the FQHC must utilize its federal grant to deliver services. Federal grant funding for continuing services is relatively fixed and does not increase proportionately to the cost of caring for increasing numbers of uninsured patients. FQHCs are paid enhanced rates for delivering care to Medicare and Medicaid patients. However, these additional payments are for a specific set of additional FQHC services provided to the Medicare and Medicaid beneficiaries. Funding uninsured is not a specific goal of enhance reimbursement, nor is it included in the cost-based formulae. Rather, federal grant funding is provided to cover the cost of serving the uninsured using a sliding fee scale to adjust fees to a patient’s ability to pay. When the percentage of uninsured far exceeds the norm, the federal grant is often found to be insufficient to cover the costs of offering the sliding fee scale and serving the uninsured and underinsured population. Two FQHCs (Advantage Health Centers, Community Health and Social Services) and an American Indian Health Center (American Indian Health & Family Services) have reported serving critically high uninsured patient populations. These three also have a low percentage of patients covered by Medicare Improving Access to Quality Health Care | 31

and Medicaid. Therefore, the enhanced payments and grants that they receive are below average and insufficient to offset the costs of caring for these populations. In combination with other factors, these circumstances can contribute to substantial financial challenges. Unless such FQHCs are the recipients of additional sources of funds or have the advantage of substantial retained earnings, they probably are not in a position to consider expansion to meet the area’s unmet needs in the near term, particularly the unmet needs of the uninsured patient population that increases the provision of uncompensated care. Various grant programs are made available annually, and expansion could be part of a stabilization plan. One FQHC has indicated plans for a modest expansion of services, requiring minimal additional staff. Another plans some expansion of services, dependent upon the outcome of its application for Community Health Center federal grant funding. They plan to apply in the next competing round. Still another FQHC has reported plans to replace its facility with a larger one. One of the FQHCs was formerly a free clinic. The transition to an FQHC will change its patient mix to include those covered by Medicaid, Medicare and private insurance as well as those contributing their adjusted payments for service on the sliding fee scale. They presently report a very high number of uninsured patients. As a relatively new FQHC, it is in the process of developing additional services including dental and integrated behavioral health. Finally, two other FQHCs have higher than average uninsured patient populations and relatively small Medicaid and Medicare populations. However, one is expanding and its patient mix is improving. This organization has applied for expansion funding, and it is working on expanded services in its present facility. The availability of additional resources, such as future grant awards, retained earnings and non-federal philanthropy will be key factors in mitigating potential financial challenges. patient Income Status All of the FQHCs have endured in financially FQHC <FPL 100-200% > FPL challenging times and FPL have provided needed services in challenging Advantage Health Centers 84% 15% 1% circumstances. It is American Indian Health & Family Services 80% 9% 1% reasonable to assume (2007) that the opportunities for federal grant awards Community Health & Social Services 54% 44% 2% and area philanthropy Covenant Community Care 84% 14% 2% combined with the area’s ongoing organizational detroit Community Health Connection 87% 12% 1% support and technical Health Centers detroit Medical group (2007) 60% 30% 10% assistance can substantially enhance their ability to the Wellness plan 99% 0% 1% grow and meet a greater share of the Detroit Wayne Western Wayne Family Health Centers 53% 44% 4% County area’s primary care Source: Michigan Primary Care Association 2008, except as noted health care needs. Improving Access to Quality Health Care | 32

One factor that may contribute to possible FQHC or FQHC ‘look-alike’ development feasibility is the number of Medicaid beneficiaries. These organizations receive enhanced Medicaid reimbursement rates. Due to their mission and location they usually receive very limited reimbursement from private insurance. Therefore, most of their patients are covered by Medicaid or not insured. Since federal funding available to fund the write downs for the uninsured covered by the sliding fee scale are limited and generally static, it is essential that FQHCs have a patient mix with sufficient Medicaid beneficiaries to generate the funds to cover the cost of delivering services in these underserved areas. FQHC ‘look-alikes’ do not receive federal funds and must depend on other sources of revenue to cover the uninsured, making this an even greater consideration with planning for potential expansion. Therefore, the number of Medicaid beneficiaries identified in potential areas of new FQHCs is another factor to be considered in planning for FQHC expansion. A corollary to this factor is the consideration of hospital emergency department diversion programs. Since many Medicaid beneficiaries use hospital emergency departments for primary care, hospital cooperation in the development of formal agreements to divert Medicaid patients to FQHCs as their medical home will be an important consideration in planning possible FQHC expansion. N E W S I T E R E C O M M E N D AT I O N S Statistics indicate a substantial need for additional health care services across most of the City of Detroit. There is clearly a mismatch between the population in need of comprehensive primary care services and the availability of these services in reasonable proximity for regular use, particularly for regular preventive care and chronic disease management services. Some areas do have very capable FQHC facilities. However, many zip codes with high need do not have services available. In response, the FQHC Safety Net Expansion Workgroup of the PCNC was formed. Its membership includes experienced FQHC leadership, with substantial knowledge of the Greater Detroit area. Their purpose is to review available data, make recommendations regarding the potential locations of new primary care delivery sites and expansion of services to meet identified health care needs for primary care. Intersections are used to indicate general areas, rather than a determination of specific clinic sites. Site selection will depend upon many factors. Such a process would proceed out of the planning process without limitation regarding specific identification of these intersections. This group made initial recommendations regarding potential locations. There was substantial consideration of geographic distribution to assure services are conveniently available and to avoid creating new sites too close to existing FQHCs. This initial selection was primarily for the purpose of identifying areas that had health care need, as indicated by the factors already discussed, but did not presently have FQHC services conveniently available to them. Such convenient access is an important factor in the effective provision of quality primary preventive care, as well as the appropriate management of populations with chronic conditions and disease. The development of facilities in these areas could potentially meet many of these needs and positively impact the health status of these populations. See the chart on page 34 for a list of these areas. Please note that the numbers are for convenient reference only. They do not represent priority. Area priority will be address later in this plan. Improving Access to Quality Health Care | 33

Sites recommended for Consideration for new Access points by the Safety net Expansion Workgroup Target Intersection City Zip Code Additional Nearest Interest Target Zip Access Expressed by Code Point Zip FQHC Code or ‘look-alike’ 1 Kelly & Hayes Detroit 48205 48205 48234 2 I-94 & Conner (Samaritan) Detroit 48213 48214 48215 3 Mt. Elliott & Forest Detroit 48207 48211 4 Conant & davison Hamtramck 48212 48203 48234 5 Wyoming & 6 Mile rd. Detroit 48221 48235 48223 6 Greenfield & Plymouth Detroit 48227 48223 7 Schaefer & Michigan Ave. Dearborn 48120 48209 8 Southfield & Fort St. Ecorse 48218 48209 48229 (part) 9 oakwood & dix Detroit 48217 48209 Community Health and Social Services 10 Inskster & Eureka Taylor 48180 48141 Western Wayne Family Health Centers 11 Wayne & van Born Wayne, Romu- 48184 48141 Western Wayne lus Family Health Centers Improving Access to Quality Health Care | 34

1. kelly & Hayes (Detroit) The Kelly/Hayes intersection area is in zip code 48205 on the upper east side of Detroit. This area does not have an FQHC at this time. Presently 2,640 of 67,012 residents utilize FQHC services; Zip Code 48205 (Detroit) over half (36,167) have incomes below 200% FPL. FQHC in Area No; FQHCs in contiguous zip This includes the population with incomes below code 100% FPL and the near poverty population with income below 200% FPL. As noted above, those in MUA/MUP Designated Yes the near poverty group typically include substantial Provider Shortage (HPSA) Yes; part working poor without health insurance coverage. As is calculated above, zip code 48205 is estimated Heightened Poverty Rate Yes; 54.4% <200% FPL to have 11,915 uninsured (20.1% of population), and it has 24,261 Medicaid beneficiaries. Only 2,640 Heightened Uninsured Rate Yes; 20.1% (11,915) (7.3%) of this population presently receives FQHC Lower Health Status Yes; Detroit infant mortality rate/ services. Part of the zip code is a designated HPSA zip code poverty rate with a population-to-medical provider ratio of 4,000-5,000 to 1. FQHC Expansion Planned Recommended by expansion workgroup 2. I-94 & Conner (Detroit) Notes Limited use of FQHC services The I-94/Conner intersection area is in zip code (7.3%); high concentration of 48213 located south of I-94, which tends to serve Medicaid beneficiaries (36.2%) as a barrier to neighborhood interaction and convenient travel. This site is also contiguous to another high need area to its west, the southern Zip Code 48213 (Detroit) portion of zip code 48211. These areas also share the FQHC in Area No; FQHCs in contiguous zip east-west transportation corridor of Warren Avenue. code Although only the bottom third of zip code 48211 is located below I-94, it is an area of high need and MUA/MUP Designated Yes easily accessible from the proposed site. A high Provider Shortage (HPSA) Yes proportion (60.2%) of its population have incomes below 200% FPL. It has a high concentration of Heightened Poverty Rate Yes; 60.2% <200% FPL Medicaid beneficiaries (39.3%) and the probable Heightened Uninsured Rate Yes; 20.3% uninsured approach one in four (24.3%). There is presently a free clinic at this location that may be Lower Health Status Yes; Detroit infant mortality rate/ the basis for FQHC development. zip code poverty rate FQHC Expansion Planned Recommended by expansion 3. Mt. Elliott & Forest (Detroit) workgroup; interested parties The Mt. Elliott/Forest area is located in zip code 48207. This zip code presently does not Notes Limited use of FQHC services have an FQHC facility. Few presently access FQHC (5.0%); high concentration of Medicaid users (39.3%) services (964 of 25,614 = 3.8%). In addition, it is also an area of high need that was identified by the East Side Planning team. Zip code 48207 has a population of 25,614, over half (52.9%) of which Improving Access to Quality Health Care | 35

have incomes below 200% FPL. Over one-third (38.9%) of the population is covered by Medicaid (9,953). There are 4,666 under 200% FPL (44.8%). However, due to the high rate of Medicaid Zip Code 48207 (Detroit) coverage, it appears that a relatively small number (1,138) are uninsured. This area is designated both FQHC in Area No; FQHCs in contiguous zip as an MUA and a HPSA with a population-to- code medical provider ratio exceeding 4,000 to 1. MUA/MUP Designated Yes 4. Conant & Davison (Detroit) Provider Shortage (HPSA) Yes The intersection of Conant and Davison is located Heightened Poverty Rate Yes; 52.9% <200% FPL in the city’s center between the land- locked suburbs of Hamtramck and Highland Park. It Heightened Uninsured Rate Yes; 12.3% marginally high is located in zip code 48212. There are FQHCs in contiguous zip codes of 48202 (The Wellness Lower Health Status Yes; Detroit infant mortality rate/ zip code poverty rate Plan Health Centers), 48203 (Detroit Community Health Connection) and 48234 (The Wellness Plan FQHC Expansion Planned Recommended by expansion Health Centers and Advantage Health Centers). workgroup, no interest noted However, these are some distance from this central Notes Very limited use of FQHC city location. Presently, only 1,139 (2.5%) of the zip services (3.9%); high code’s population of 46,136 receive service from concentration of Medicaid an FQHC. The area is designated as a MUA and beneficiaries (38.9%) a HPSA. Over half (54.1%) of the population has income below 200% FPL. The rate of uninsured is relatively low at 9.7%; however, there are an Zip Code 48212 (Detroit) estimated 4,491 uninsured in the zip code. The Detroit health status indication and the percentage FQHC in Area No; FQHCs in contiguous zip of poverty would indicate lower than normal health code status. The workgroup did not indicate an FQHC MUA/MUP Designated Yes having an interest in the area at this time, but did recommend the location as appropriate in part due Provider Shortage (HPSA) Yes to its central city underserved location. It also has a Heightened Poverty Rate Yes; 54.1% <200% FPL substantial concentration of Medicaid beneficiaries (18,923 of 46,136 population or 41.0%). Heightened Uninsured Rate Yes; 9.7% relatively low 5. wyoming & Six Mile Road (Detroit) Lower Health Status Lower than normal The Wyoming/Six Mile Road intersection is in FQHC Expansion Planned Recommended by expansion zip code 48221. One FQHC is located in the workgroup; no interest noted contiguous zip code of 48203 (Detroit Community Health Connection). However, it is located on the Notes Very limited use of FQHC services (2.5%); high east side of the Woodward Corridor that generally concentration of Medicaid separates neighborhoods. This zip code is beneficiaries (41%) designated a MUA, but it is not presently designated as HPSA. More recent data is being obtained to update information for possible Improving Access to Quality Health Care | 36

designation. This area of the city is one of the more financially stable areas. About one-third (34.2%) of the population has incomes below 200% FPL. However, the estimated rate of uninsured is very Zip Code 48221 (Detroit) small at 2.4% (1,106 of a population of 45,381). Health status is undoubtedly higher than average FQHC in Area No; FQHCs in contiguous zip code given the Detroit area statistics, one-third of the population is below 200% FPL and the zip MUA/MUP Designated Yes code’s 93.7% Black population which correlates statistically with lowered health status. This area Provider Shortage (HPSA) Yes was recommended by the workgroup. Only 1,134 Heightened Poverty Rate 34.2% <200% FPL of 45,381 residents (2.5%) presently receive FQHC services. Of the 45,381 population there are 11,185 Heightened Uninsured Rate No; 2.4% Medicaid beneficiaries (24.6%). Lower Health Status Detroit infant mortality rate/zip code poverty rate 6. Greenfield & Plymouth (Detroit) The intersection of Greenfield and Plymouth FQHC Expansion Planned Recommended by expansion is located in zip code 48227. There is a FQHC workgroup northeast of this location in zip code 48223, but the Notes Very limited use of FQHC location is some distance and the neighborhoods services (2.5%); high are separated by a freeway (I-96). Zip code 48227 concentration of Medicaid is designated a MUA and a HPSA. Nearly half beneficiaries (24.6%) (46.3%) of the population has income below 200% FPL. The estimated uninsured is about average (11.1%). The combination of the general Detroit Zip Code 48227 (Detroit) health status statistics, the rate of poverty, and the 96.1% Black or African American population FQHC in Area No; FQHCs in contiguous zip would indicate lowered health status. The code workgroup recommended this area for a site; MUA/MUP Designated Yes however, no organization has yet expressed plans for development in the area. Only 2,356 of 61,118 Provider Shortage (HPSA) Yes population (3.9%) receive FQHC services Heightened Poverty Rate Yes; 46.3% <200% FPL at this time. Of the 61,118 population there are 21,254 Medicaid beneficiaries (34.8%). Heightened Uninsured Rate 11.1%; about average 7. Schafer & Michigan Avenue (Dearborn) Lower Health Status Detroit infant mortality rate/zip code poverty rate The intersection of Schafer and Michigan Avenue is located in zip code 48120. This intersection is FQHC Expansion Planned Recommended by expansion located in Dearborn, contiguous to zip code 48209 workgroup; no interest on the southwest side of Detroit. There is no Notes Very limited use of FQHC FQHC located in zip code 48120; however, services (3.9%); high there are two (Covenant Community Care and concentration of Medicaid Community Health and Social Services) located in beneficiaries (34.8%) 48209. The 48120 zip code is designated a MUA; however, it has not been designated a HPSA. It has Improving Access to Quality Health Care | 37

a heightened poverty rate with over half (52.6%) of the population having income below 200% FPL. However, the probable uninsured rate is moderate at 10.1%. There are 3,156 Medicaid beneficiaries (42.2% of the population). Health status information Zip Code 48120 (Dearborn) is not available by zip code and the substantial differences in income between the east and west FQHC in Area No; FQHCs in contiguous zip sides of Dearborn make municipal information code unusable for this purpose. FQHC expansion is not MUA/MUP Designated Yes planned by any organization at this time. The area has a large Middle Eastern population with many Provider Shortage (HPSA) No households speaking languages other than English, which would indicate a need to plan for translation Heightened Poverty Rate Yes; 52.6% <200% FPL and a culturally competent program. Zip code Heightened Uninsured Rate No; 10.1% lower than average 48120 joins another Dearborn zip code (48126) with a large population that is also contiguous to Lower Health Status Data comingled with all of Detroit, having similar demographic and income Dearborn (not useful) characteristics of zip code 48120 and Detroit: FQHC Expansion Planned Recommended by expansion (49.1% poverty; no FQHC; MUA; 45.2% [22,714] workgroup Medicaid). A clinic located in zip code 48120 would be relatively convenient to residents in both of these Notes Very limited use of FQHC services (0.4%); Medicaid zip codes. In a addition, there is an FQHC located in beneficiary rate is substantial Detroit zip code 48210 which is contiguous to 48126 (42.2%) providing some access, particularly to those located in the eastern section of this zip code. Zip Code 48229 (Ecorse) 8. Southfield & Fort (Ecorse) The intersection of Southfield and Fort in Ecorse FQHC in Area No; none in contiguous zip code is in zip code 48229. This is contiguous to the MUA/MUP Designated No southern most projection of Detroit, River Rouge, Lincoln Park and the Detroit River. None of the Provider Shortage (HPSA) No adjoining communities have a FQHC. It has not been designated a MUA, MUP, or HPSA. It has a Heightened Poverty Rate Yes; 46.3% <200% FPL heightened poverty rate with 46.3% of the Heightened Uninsured Rate No; 7.4% lower than average population having incomes below 200% FPL. It has a population of 11,088 of which 3,858 (38.8%) are Lower Health Status Yes Medicaid beneficiaries. The estimated uninsured FQHC Expansion Planned Recommended by expansion rate is 7.4%. Health status of the population is lower workgroup than average as indicated in available health data and poverty data. Ecorse has heightened rates of Notes Medicaid beneficiary rate is infant mortality, low birth weight and heart disease substantial (38.8%) death rate. No organization has expressed plans to develop an FQHC in the area at this time. River Rouge is immediately north of Ecorse and has similar low income and demographic characteristics. Improving Access to Quality Health Care | 38

The other zip code in Ecorse, 48218, has similar characteristics. This zip code is contiguous to Zip Code 48128 (Ecorse) adjoining River Rouge and zip code 48218 with a population with similar demographic and income FQHC in Area No; none in contiguous zip code characteristics: (no FQHC; 48.8% <200% poverty; 4.4% receiving FQHC services). Zip codes 48229 MUA/MUP Designated No (Ecorse) and 48218 (River Rouge) have a combined Provider Shortage (HPSA) No population of 21,148 of which 9,786 are Medicaid beneficiaries. This less populated area may be Heightened Poverty Rate Yes; 45.6% <200% FPL suited for an expansion site (spoke) of an existing Heightened Uninsured Rate Marginal FQHC system. Lower Health Status Yes 9. Oakwood & Dix (Detroit) FQHC Expansion Planned Recommended by expansion The intersection of Oakwood and Dix is in Detroit workgroup zip code 48217. It is the southern projection contiguous to Ecorse and River Rouge. There Notes Limited use of FQHC services is no FQHC located in the zip code. There are (3.8%); Medicaid beneficiary rate two FQHCs in Detroit zip code 48209 located is substantial (38.8%); contiguous to adjoining River Rouge immediately north. Due to the lengthy shape of this (48218) whose population and peninsula-like projection of the Detroit boundary, demographic characteristics are the FQHCs are somewhat remote from the similar: no FQHC, 48.8% <200% proposed site. This area is designated a MUA and a FPL, 4.4% receiving FQHC services); this less populated area HPSA. It has a heightened rate of poverty and near may be suited for an expansion poverty (44.8%). It has a probable uninsured rate site of an existing FQHC system. of 10.8% (slightly below average), and about 33.6% (3,528) of its population are Medicaid beneficiaries. Presently, 10.1% are utilizing FQHC services. As Zip Code 48217 (Detroit) evidenced by the Detroit health statistics and the area’s heightened rate of poverty, the population FQHC in Area No; two located in contiguous zip code, remote has lower health status. No organization has expressed plans to develop an FQHC in this MUA/MUP Designated Yes location. Due to the size of the population, it may be considered a location for a new delivery site of Provider Shortage (HPSA) Yes one of the existing FQHCs, using a hub and spoke Heightened Poverty Rate Yes; 44.8% <200% FPL model. As noted there are two FQHCs located in the zip code immediately north of this southern Heightened Uninsured Rate No; 10.8% slightly lower than projection of Detroit. Another consideration may average be the development of a larger site to serve this Lower Health Status Yes area of Detroit, River Rouge and Ecorse. The underserved of the contiguous communities of FQHC Expansion Planned Recommended by expansion Melvindale, Allen Park and Lincoln Park could workgroup also be served by an FQHC at this location. In Notes Limited use of FQHC services all, it could centrally serve the underserved of six (10.1%); Medicaid beneficiary closely clustered communities, three of whom have rate is substantial (33.6%) inordinately high poverty rates. Improving Access to Quality Health Care | 39

10. Inkster & Eureka (Taylor) The intersection of Inkster and Eureka in zip code 48180 (Taylor) is a suburb of Detroit located somewhat southeast of Inkster. The Western Wayne Zip Code 48180 (Taylor) Family Health Center is located in Inkster. There is FQHC in Area No no FQHC located in Taylor and none in contiguous zip codes. It is designated a MUA but not a HPSA. MUA/MUP Designated Yes It is eligible for FQHC funding. About one quarter of the population is in poverty or near poverty Provider Shortage (HPSA) No (26.0%). It has a low probable uninsured rate Heightened Poverty Rate No; 26.0% <200% FPL of 3.7% (2,411). Presently, only 299 of Taylor’s population of 65,868 (1.8%) utilize FQHC services. Heightened Uninsured Rate No; 3.7% lower than average Taylor City has heightened infant mortality, Lower Health Status Yes Diabetes Mellitus and heart disease death rates. Western Wayne Family Health Center applied for, FQHC Expansion Planned Yes; New Access Point is recom- and was awarded New Access Point funding for mended. Funding awarded to an FQHC site in Taylor. The plan is for a relatively Western Wayne Family Health Centers to initiate New Access small site, using the hub and spoke model with Point supplemental and enabling services provided by the main site in Inkster. Co-location with behavioral Notes Minimal use of FQHC Services health and other services is planned. The Medicaid (1.8%); Medicaid beneficiary rate is moderate (26.0%) but number population of 14,490 to potentially be served by an is substantial (14,490) FQHC is significant. This will not only provide the opportunity to make comprehensive FQHC services available to a significant Medicaid Zip Code 48184 (Wayne) population, but it would also provide a sustainable patient mix for an FQHC organization. FQHC in Area No; nearby MUA/MUP Designated Yes 11. wayne & Van born The intersection of Wayne and Van Born in the Provider Shortage (HPSA) No City of Wayne (zip code 48184) has a population of 19,121. The zip code includes a minimal area of Heightened Poverty Rate No; 22.7% <200% FPL Romulus. There is no FQHC in the contiguous zip Heightened Uninsured Rate No; negligible codes or communities. However, Western Wayne Family Health Centers is located in Inkster just Lower Health Status No beyond the contiguous City of Westland to the east. FQHC Expansion Planned Tentative plan by Western It is designated as a MUA and is eligible for FQHC Wayne Family Health Centers; funding. It is not designated a HPSA. The poverty/ recommended by expansion near poverty rate is 22.7%. The rate of workgroup uninsured appears negligible. There are 4,430 Medicaid beneficiaries (23.2%). Improving Access to Quality Health Care | 40

S TAT I S T I C A L R A N K I N G OF PRIORITY AREAS OF NEED The initial selections of potential new FQHC sites were made by the Safety Net Expansion Workgroup of the PCNC. Area data was mapped and such factors as distance from existing FQHC delivery sites, the ease of travel and indicators of highest need were taken into consideration. Organizational linkages and potential collaborators were also considered. Additional information has been researched and key statistical factors have been reviewed by the Safety Net Expansion Workgroup to establish possible priority areas of need that may be considered in addition to the initially identified potential areas to be considered for New Access Points. Heightened concentrations of poverty, uninsured, Medicaid beneficiaries and designation as a MUA/MUP are also taken into consideration. In the chart on page 42, the zip codes are listed in order of apparent need. Additional information regarding the relative rate of FQHC users served to underserved population in these areas is also provided for reference. Ten of the 25 higher priority zip codes, and 9 of the 11 already have FQHC sites (two with two sites). This indicates that good planning has already taken place in the placement of the limited number of existing FQHCs. The area of highest need (48201) has two FQHC sites. However, use of FQHCs by the underserved population (<200% FPL) in this area is only 9.5%. FQHC services are receiving only a small percentage of the underserved. These rates range from a moderate 30.7% to a minimal 6.4% in these high need areas, when comparing FQHC users to those with incomes below the 200% FPL subset of the population. These would certainly be areas to consider service expansion. The chart on page 42 provides the size of the population and the number of uninsured and Medicaid beneficiaries. These are important considerations when planning for FQHC expansion. This will be discussed further later in the report. I N I T I A L F I N D I N G S & A N A LY S I S Most of Detroit is a high need area. However, resources are limited, so ranking of need is necessary in order to focus development efforts. To this end, the high need areas and the Safety Net Expansion Workgroup’s initial recommendations have been combined for a summary ranking of priority. See the charts on pages 44-46. All but four of the sites recommended by the workgroup were also among the 25 identified high need areas, for a total of 29 areas to be considered for final priority ranking. Each site was ranked from one (highest) to 29 (lowest). The individual ranking of selected factors has been aggregated to obtain a score for zip code ranking of the combined factors. This priority ranking is for the purpose of providing information to the PCNC to assist it in its development of final recommendations. There has been a limited number of the initial seven factors utilized for selecting priority areas. Although a number of factors were useful in setting a baseline for the initial selection of high need areas, they are not necessarily optimal for identifying a limited number of priority areas for service Improving Access to Quality Health Care | 41

High need Zip Codes Highest Rates: Poverty, Uninsured & Medicaid City Rank Zip Poverty Uninsured Medicaid MUA/ <200% FQHC Poverty + Code Rate Rate Rate MUP Poverty Uninsured + FQHC Medicaid + User % Total % detroit 1 48201 71.8% 30.1% 41.0% Yes 9.5% Yes (2) 142.9% detroit & Hamtramck 2 48211 67.7% 24.3% 39.0% Yes 5.5% No 131.0% detroit 3 48208 65.2% 17.9% 47.1% Yes 14.0% Yes 130.2% detroit 4 48216 60.5% 23.1% 37.3% Yes 20.2% Yes 120.9% detroit *5 48213 60.2% 20.3% 39.3% Yes 8.4% No 119.8% detroit 6 48210 60.0% 16.3% 43.4% Yes 24.4% Yes 119.7% detroit 7 48209 58.7% 17.4% 40.5% Yes 30.7% Yes 116.6% detroit & Highland park 8 48203 57.8% 18.6% 38.5% Yes 8.4% Yes 114.9% detroit 9 48215 57.8% 16.0% 40.7% Yes 6.4% Yes 114.5% detroit 10 48214 58.1% 18.8% 37.3% Yes 9.5% Yes (2) 114.2% detroit 11 48202 56.6% 15.0% 38.2% Yes 10.9% Yes 109.8% detroit 12 48206 54.8% 15.9% 38.3% Yes 11.6% No 109.0% detroit *13 48205 54.4% 17.8% 36.2% Yes 7.3% No 108.4% detroit 14 48238 53.1% 14.7% 37.8% Part 8.8% No 105.6% dearborn *15 48120 52.6% 10.1% 42.2% Yes 0.4% No 104.9% detroit & Hamtramck *16 48212 54.1% 9.7% 41.0% Yes 4.9% No 104.8% detroit *17 48207 52.9% 12.3% 38.9% Yes 7.4% No 104.1% detroit 18 48204 52.1% 14.0% 36.7% Part 9.8% No 102.8% dearborn 19 48126 49.1% 3.6% 45.2% Yes 0.4% No 97.9% Ecorse *20 48229 46.3% 7.4% 38.8% No 4.3% No 92.5% detroit *21 48227 46.3% 11.1% 34.8% Yes 8.4% No 92.2% river rouge *22 48218 44.8% 10.8% 35.6% No 4.6% No 91.2% detroit 23 48228 45.8% 7.8% 37.5% Yes 7.2% No 91.1% detroit *24 48217 44.8% 10.8% 33.6% Yes 10.2% No 89.2% detroit 25 48234 44.9% 7.6% 36.7% Yes 11.4% Yes 89.2% Improving Access to Quality Health Care | 42

development consideration. All of the high need zip codes have some indicator of heightened health need as indicated by published health status or poverty level, so this is not very helpful in final priority ranking and has been withdrawn for this purpose. In addition, areas of high need that have FQHC facilities remain potential candidates for Service Expansion or Expanded Medical Capacity grant funding. This is particularly important when considering the small percentage of the underserved population receiving FQHC services, even in zip codes with FQHCs. Such high need areas would benefit substantially from expanded services. Therefore, an existing FQHC site was not used as a factor to eliminate these zip codes from consideration for identification of priority areas. However, they will be identified separately for service or capacity expansion, rather than New Access Point creation. Similarly, MUA or MUP designations were relatively common to all. Only two suburban areas, River Rouge and Ecorse, lacked these designations, and they are contiguous to a MUA in Detroit zip code 48217. In addition, these two areas may well become designated. MPCA in cooperation with MDCH continue to apply for designations where they are needed, as part of an on-going process. MUA/ MUP designation was therefore removed as a ranking factor in setting priorities. Finally, since health provider shortage is one factor used in the MUA/MUP designation process, and HPSA designations are not required for FQHC funding, HPSAs were not included in this final priority ranking. It may also be noted that, similar to MUA/MUP designation, MPCA and MDCH could also assist in application for this designation, if needed. Both percentage and the size of populations were ranked, since both the concentration (%) and the potential number to benefit is important in planning for new delivery sites and expanded services. For example, an area identified with a high percentage of poverty, uninsured and Medicaid beneficiaries, but with a very small population, would be a lower priority for investing in new sites or services than an area with similar percentages but with a large population in need of services. remaining factors Since poverty is an indicator of a cluster of needs that adversely that were retained for affect health and access to health care, the poverty rate is used as an priority ranking: identifier of high need. However, the numeric size of this population is not used, since it is almost directly reflected in the combined 1. Percentage population uninsured and Medicaid populations. The uninsured percentage below 200% FPL and number of uninsured were used to reflect both the concentration 2. Uninsured percentage and size of the population needing services. Similarly the percentage 3. Medicaid percentage and number of Medicaid beneficiaries were also utilized. Both the concentration and number of potential Medicaid beneficiaries to Criteria Added: be served in an area are critical factors in planning for potential new FQHC sites or investing in additional services, since Medicaid 4. Uninsured population revenues are critical in sustaining new FQHC service delivery sites or (number) expanding services or capacity. After establishing baseline factors for 5. edicaid beneficiaries M the identification of the initial areas of need, these five factors were (number) retained as ranking factors for setting priorities. Improving Access to Quality Health Care | 43

data Summary of High need & Suggested new Site Areas City Zip Code 1 2 3 4 5 6 7 8 9 10 11 detroit 48201 X X X X 71.8 10,721 41.0 6,178 30.1 4,543 detroit 48202 X X X X 56.6 11,636 38.2 8,354 15.0 3,282 detroit 48203 X X X X 57.8 25,855 38.5 17,445 18.6 8,410 & Highland park detroit 48204 X X 52.1 21,444 36.7 15,535 14.0 5,909 detroit 48205 X X X 54.4 36,176 36.2 24,261 17.8 11,915 detroit 48206 X X 54.8 17,562 38.3 12,406 15.9 5,156 detroit 48207 X X 52.9 13,093 38.9 9,953 12.3 3,140 detroit 48208 X X X X 65.2 8,360 47.1 6,056 17.9 2,304 detroit 48209 X X X X 58.7 22,505 40.5 15,754 17.4 6,751 detroit 48210 X X X X 60.0 23,663 43.4 17,198 16.3 6,465 detroit & Hamtramck 48211 X X 67.7 6,897 39.0 4,250 24.3 2,647 detroit & Hamtramck 48212 X X X 54.1 23,414 41.0 18,923 9.7 4,491 detroit 48213 X X X 60.2 26,193 39.3 17,281 20.3 8,912 detroit 48214 X X X X 58.1 18,455 37.3 12,267 18.8 6,188 detroit 48215 X X X X 57.8 10,894 40.7 7,827 16.0 3,067 detroit 48216 X X X X 60.5 4,029 37.3 2,489 23.1 1,540 detroit 48217 X X X 44.8 4,666 33.6 3,528 10.8 1,138 detroit *48221 X X 34.2 19.964 24.6 11,185 2.4 1,106 detroit 48227 X X X 39.8 2,356 34.8 21,254 11.1 6,781 detroit 48234 X X X 44.9 20,257 36.7 16,796 7.6 20,257 detroit 48238 X X 53.1 23,618 37.8 16,996 14.7 6,622 continued on page 45 Key: 1. High need (baseline data + poverty, 4. FQHC site proposed (by Safety Net 7. Poverty population (<200% FPL) uninsured & Medicaid) Expansion Workgroup) 8. Medicaid percentage 2. MUA/MUP 5. Possible service expansion 9. Medicaid beneficiaries 3. Existing FQHC 6. Poverty <200% FPL percentage 10. Uninsured percentage (indicator) 11. Uninsured population (indicator) Improving Access to Quality Health Care | 44

data Summary of High need & Suggested new Site Areas continued Suburban Cities Zip Code 1 2 3 4 5 6 7 8 9 10 11 dearborn 48120 X X X 52.6 3,912 42.2 3,156 10.1 756 dearborn 48126 X X 49.1 22,714 45.2 21,028 3.6 1,686 Inkster *48141 X X 38.6 11,498 35.4 10,669 2.8 829 Wayne *48184 X X 22.7 4,261 23.2 4,430 -0- -0- river rouge 48218 X 45.6 4,560 35.6 3,582 10.8 1,084 Ecorse 48229 X 46.3 5,120 38.8 4,304 7.4 816 taylor *48180 X X 22.7 16,901 23.2 3,705 -0- -0- Sources: Population & Uninsured, U.S. 2000 Census; other Michigan Primary Care Association *Not included in initial calculation of top 25 high need areas; but recommended for consideration of new access points by committee taking a number of factors into consideration. Key: 1. High need (baseline data + poverty, 4. FQHC site proposed (by Safety Net 7. Poverty population (<200% FPL) uninsured & Medicaid) Expansion Workgroup) 8. Medicaid percentage 2. MUA/MUP 5. Possible service expansion 9. Medicaid beneficiaries 3. Existing FQHC 6. Poverty <200% FPL percentage 10. Uninsured percentage (indicator) 11. Uninsured population (indicator) The workgroup initially reviewed identified areas of high need. They also discussed geographic areas of the city and county in which FQHC services are lacking and generally more distant or more difficult to access. Areas with FQHCs were not initially considered by the workgroup in their initial selection. The purpose of the priority ranking was used to identify those areas with substantial populations with very high needs, regardless of the existence of an FQHC, since there are substantial underserved populations in any area of the city. The existence of an FQHC only changes the strategy from the need for New Access Points to the expansion of services. This is discussed later in the strategy section. In those areas of very high need without FQHCs, the logical first step is to seek New Access Points in which to deliver FQHC services conveniently to the population. The top six priority areas without FQHCs were chosen for inclusion. Since the scoring was tied, priority areas number 11 and 12 were included in what was originally a top five selection. In high need areas with FQHCs, there is a need for the expansion of services. This can be accomplished through grants available for this purpose and changes in the FQHCs’ scope of services if other sustainable funding can be anticipated. Similar to the first listing, a statistical break point in the ranking resulted in a selection of six priority zip codes for consideration for expanded FQHC services. Improving Access to Quality Health Care | 45

numeric ranking of priority Zip Codes Zip Code 1 2 3 4 5 Score Rank Zip Code Rank 48120 17 20 28 4 28 97 22 48213 1 48126 19 26 21 2 4 72 15 48210 2 48141 26 27 26 24 17 120 27 48203 3 48180 28 25 19 29 13 114 24 48201 4 48184 29 29 29 28 23 138 29 48209 5 48201 1 1 12 5 21 40 4 48205 6 48202 11 13 15 15 19 73 17 48208 7 48203 9 6 3 13 6 37 3 48214 8 48204 18 15 9 18 12 72 16 48211 9 48205 13 8 1 22 2 46 6 48212 10 48206 12 12 10 14 14 62 12 48238 11 48207 16 16 16 11 18 77 19 48206 12 48208 3 7 20 1 22 53 7 48215 13 48209 7 9 5 8 11 40 5 48227 14 48210 6 10 7 13 8 34 2 48126 15 48211 2 2 18 10 25 57 9 48204 16 48212 14 21 13 6 5 59 10 48202 17 48213 5 4 2 9 7 27 1 48228 18 48214 8 5 8 20 15 56 8 48207 19 48215 10 11 17 7 20 65 13 48216 20 48216 44 3 22 19 29 77 20 48234 21 48217 24 18 23 26 27 118 26 48120 22 48218 23 19 25 23 26 116 25 48229 23 48221 27 28 24 27 16 122 28 48180 24 48227 20 17 4 25 3 69 14 48218 25 48228 22 22 11 17 1 73 18 48217 26 48228 22 22 11 17 1 73 18 48217 26 Key: 1. Poverty Percentage 48229 21 24 27 12 24 108 23 48141 27 2. Medicaid Percentage 3. Medicaid Beneficiaries 48234 25 23 14 21 10 93 21 48221 28 (population) 4. Uninsured Percentage 48238 15 14 6 16 9 60 11 48184 29 5. Uninsured Population Improving Access to Quality Health Care | 46

ADDITIONAL WORKGROUP SUGGESTIONS After reviewing the initial data, the Safety Net Expansion Workgroup initially identified locations of other potential new sites that they judged might improve access due to these areas’ distance from existing FQHCs and proximity to sizeable underserved populations. Eleven were initially selected. These are the ones not listed among the priority areas. However, five were listed in the identified high need areas. priority Areas By rank Score Rank City Zip Code Notes Medicaid Uninsured Beneficiaries 27 1 Detroit 48213 No FQHC, possible new site consideration; WG 17,281 8,912 initial selection; MUA; HPSA; (5.0% population received FQHC services 2007) 34 2 Detroit 48210 FQHC (DCHC-Bruce Douglas; also AIHFS) 17,198 6,465 expansion, outreach; MUA; HPSA (14.5% population received FQHC services 2007) 37 3 Detroit 48203 FQHC (Nolan) expansion; outreach; MUA (4.8% 17,445 8,410 Highland population received FQHC services 2007) Park 40 4 Detroit 48201 2 FQHCs (DCHC Woodward Corridor; HCDMG) 6,178 4,543 MUA; HPSA; possible expansions; high poverty & uninsured rate; (6.7% population received FQHC services 2007) 40 5 Detroit 48209 FAHC (CHASS) expansion’ MUA; HPSA (17.6% 15,754 6,751 of population received FQHC services 2007) 46 6 Detroit 48205 No FQHC, MUA; HPSA; possible new access 24,261 11,915 point; WG initial selection (3.9% population received FQHC services 2007) 53 7 Detroit 48208 FQHC (Advantage-Waller HCH) MUA; 6,056 2,304 expansion; outreach; (9.1% population received FQHC services 2007) 56 8 Detroit 48214 2 FQHCs (DCHC E Side Health Center; HCDMG 12,267 6,188 E Jefferson) MUA; HPSA; expansion; outreach; (5.5% of population received FQHC services 2007) 57 9 Detroit & 48211 No FQHC; most of zip code is south of 4,250 2,647 Hamtramck Hamtramck (3.5% receive FQHC services 2007) continued on page 48 Improving Access to Quality Health Care | 47

priority Areas By rank continued Score Rank City Zip Code Notes Medicaid Uninsured Beneficiaries 59 10 Detroit & 48212 No FQHC; MUA; HPSA; possible new access 18,923 4,491 Hamtramck point; also WG initial selection (2.5% population received FQHC services 2007) 60 11 Detroit 48238 No FQHC; MUA; possible new access point; 16,996 6,622 62 12 Detroit 48206 No FQHC (6.3% received FQHC services 2007) 12,406 5,156 65 13 Detroit 48215 FQHC (DCHC – E Riverside HC) 6.4% population 7,827 3,067 received FQHC services 2007 69 14 Detroit 48227 No FQHC; WG initial selection; NW Detroit 21,254 6,781 location consideration; (3.9% of population received FQHC services 2007) 72 15 Dearborn 48126 No FQHC, MUA; possible new access point (0.4% 21,028 1,686 population received FQHC services 2007) 72 16 Detroit 48204 No FQHC (5.0% of population received FQHC 15,535 5,909 services 2007) 73 17 Detroit 48202 FQHC (CHASS Midtown) (5.8% of population 8,354 3,282 received FQHC services 2007) 73 18 Detroit 48228 No FQHC (3.2% of population received FQHC 24,362 5,042 services 2007) 77 19 Detroit 48207 No FQHC; WG initial selection (3.8% of 9,953 3,140 population received FQHC services 2007) 77 20 Detroit 48216 FQHC (Covenant Community Care-W Grand 2,489 1,540 Blvd) (12.2% of population received FQHC services 2007) 93 21 Detroit 48234 FQHC - Advantage (5.0% of population received 16,796 3,461 FQHC services in 2007) 97 22 Dearborn 48120 No FQHC, contiguous to 48126 w larger pop.; 3,156 756 WG initial selection (0.2% of population received FQHC services 2007) 108 23 Ecorse 48229 No FQHC, no MUA but contiguous to 48217 4,304 816 (MUA) & River Rouge.(1.8% of population received FQHC services in 2007) 118 24 Taylor 48180 No FQHC; MUA; application made; not funded. 14,490 2,411 (0.5% of population received FQHC services in 2007 continued on page 49 Improving Access to Quality Health Care | 48

priority Areas By rank continued Score Rank City Zip Code Notes Medicaid Uninsured Beneficiaries 116 25 *River 48218 No FQHC; No MUA; WG selection (2.0% of 3,582 1,084 Rouge population received FQHC services 2007) 118 26 *Detroit 48217 No FQHC; WG selection (4.5% of population 3,528 1,138 received FQHC services 2007); contiguous to River Rouge 48218, Ecorse 48229 and Dearborn 48120 120 27 Inkster 48141 FQHC (Western Wayne Family Health Center) 10,669 829 (2.2% of population receive FQHC services 2007) 122 28 Detroit 48221 No FQHC; WG selection (NW Detroit location 11,185 1,106 consideration) (2.5% of population received FQHC services 2007) 138 29 Wayne 48184 No FQHC; WG selection (0.4% of population 4,430 -0- received FQHC services 2007) *A combined underserved area defined by Detroit 48217, Ecorse and River Rouge may worthy of review (Geographic consideration). This combined area is somewhat isolated and without an FQHC. P R I O R I T Y A R E A S : R E C O M M E N D AT I O N S High need Areas Without FQHCs New Access Point Consideration Priority Score Zip Code City Classification Rank 1 27 *48213 Detroit 1 6 46 *48205 Detroit 2 9 57 48211 Hamtramck 3 & Detroit 10 59 *48212 Detroit & 4 Hamtramck 11 60 48238 Detroit 5 12 62 48206 Detroit 6 * Recommended as priority sites initially. Improving Access to Quality Health Care | 49

High priority Areas with FQHCs Expanded Services Consideration Priority Score Zip Code City FQHC Rank 2 34 48210 Detroit Detroit Community Health Connection (Bruce Douglas site); also non-FQHC: American Indian Health & Family Services 3 37 48203 Detroit & Detroit Community Health Connection (Nolan Family Health Center) Highland Park 4 40 48201 Detroit Detroit Community Health Connection (Woodward Corridor site) Health Centers Detroit Medical Group (St. Antoine site) 5 40 48209 Detroit Community Health and Social Services (expansion planned) 7 53 48208 Detroit Advantage Health Centers (Health Care for the Homeless site) 8 56 48214 Detroit Detroit Community Health Connection (East Side Health Center) Health Centers Detroit Medical Group (East Jefferson site) Workgroup Suggestion Not Among Selected Priority Zip Codes geographic Access Consideration Priority Score Zip Code Possible Location Notes Rank 14 69 *48227 Greenfield & Plymouth Northwest Detroit area 19 77 *48207 Mt. Elliott & Forest Detroit E Side Initiative Area 22 97 *48120 Schaefer & Michigan Ave. Dearborn; 48126 possible alternate location (<population) 23 108 *48229 Southfield & Fort **Ecorse; contiguous with River Rouge & Detroit 48217 24 114 48180 Wayne & Van Born Taylor City; New Access Point application funded, WWFHC 26 118 *48217 Oakwood & Dix **Detroit; contiguous with Ecorse and River Rouge 28 122 48221 Wyoming & 6 Mile Rd. Northwest Detroit area 29 138 48184 Wayne & Romulus Wayne City; not ranked among priorities; suggest access point *Areas identified as high need, but not included in the priority areas. **The workgroup identified a rather geographically isolated and underserved cluster of contiguous zip codes in the downriver area that includes River Rouge (48218), Ecorse (48229) and a southern projection of Detroit (48217). Two locations were initially selected. A centrally located site might also be an option. See priority map. Improving Access to Quality Health Care | 50

P O S S I B L E A LT E R N AT E S U G G E S T I O N S MEDICAID FQHCs have a record of reducing the global cost of Medicaid beneficiaries through the provision of high quality, comprehensive primary care. Therefore, the Michigan Department of Community Health (MDCH) has an interest in FQHC services being more available in areas with high numbers of Medicaid beneficiaries. Fortunately, 10 of the top 12 ranked zip codes have Medicaid populations of over 10,000. It is anticipated that these will be addressed on a priority basis. The size of the Medicaid population may be a special consideration by Michigan Medicaid or other agency. The Medicaid zip codes having over 10,000 Medicaid beneficiaries are listed on page 53 for reference. Please note that the priority rank in column four is based on the high need criteria already established. UNINSURED Another possible consideration may be the size of the uninsured populations. Increasing services to the uninsured is a priority for the DWCHA, MDCH, VODI and others. For convenient reference, the zip codes with the top 10 estimated uninsured are listed in the chart on page 53. All but one of the zip codes with larger uninsured populations are listed in the top 12 zip codes ranked as priorities, using multi-factorial data. They are already under consideration. E X PA N S I O N S T R AT E G I E S There are a number of strategies that FQHCs can employ to meet unmet community needs. The first is to seek additional federal funds that are available to FQHCs under Section 330 of the Public Services Act. The administration of the program is carried out by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). There are three types of federal funding primarily designed to initiate or expand FQHC services: New Access Point, Expanded Medical Capacity, Service Expansion. Each type of funding is open for competition only at times specified by HRSA. NEw ACCESS POINTS Developing New Access Points in underserved areas is essential. This may be done through a successful application by an existing FQHC or by a qualified non-profit organization prepared to meet FQHC requirements for federal funding and operation of an FQHC. Existing FQHCs have distinct advantages. They have already incurred the expanse and expended the organizational effort to meet the operational and programmatic requirements of an FQHC. In most cases, the addition of a New Access Point is much less of a financial and organizational challenge to an existing FQHC. Existing FQHCs have developed their business and operational plans, as well as the quality and support teams to meet the complex requirements of the program. In general, organizations that have not previously operated FQHCs expend more time and expense in becoming operational. However, existing FQHCs may or may not be prepared to expand to meet identified need. In such cases, it may be prudent to assist organizations that are prepared to meet this need and submit an application. The process of obtaining funds for New Access Points is the most competitive. There are over 1,000 FQHC organizations that can potentially submit applications. In addition, the competition is open to any qualified non-profit organization, health department or other qualified entity in the nation that is appropriately structured and prepared to operate an FQHC. In the past, awards have been relatively Improving Access to Quality Health Care | 51

few in the Detroit Wayne County area. Although it is essential to compete for New Access Point funding for areas of high need that lack an FQHC, it is important to consider alternate strategies. EXPANDED MEDICAL CAPACITY AND SERVICE EXPANSION Two other federally funded competitions for expansion area available: Expanded Medical Capacity and Service Expansion. Expanded Medical Capacity is the expansion of services presently being provided by an FQHC. For example, an FQHC may have three doctors, and it can make a successful case for needing funding for additional doctors and midlevel providers (e.g. physician assistants, advanced practice nurses) along with the nurses, support staff, sliding fee scale funding, and facility renovation in order to serve an expanded population. Service Expansion funding may be awarded to initiate new health care services not yet provided by an FQHC. Included among these services are oral health (dental), behavioral health and pharmacy services. For example, an FQHC may have begun with minimal oral health services through limited contracting and referral to a dentist. It may then need funding to develop its own oral health program, including dentist, hygienist, dental assistant, dental suite, etc. The FQHC could submit an application to develop these services as a Service Expansion. In doing so, it would be competing against only those FQHCs seeking similar expansions. CHANgE OF SCOPE Another strategy for FQHC expansion is change in scope. An FQHC may submit for a change of scope at any time when a new service, expansion or location is sought and there is no need for federal funding. However, the application must demonstrate that the service, expansion or new location is needed and the business plan must show that the service is financially and operationally sustainable. There may be extended commitments by state government or other community organizations or hospital systems to provide support for such services. These may well provide the funding necessary to support a needed new or expanded service without the need for additional federal grant funding. In such a case, change of scope may be an appropriate strategy by which to proceed. In general, change of scope is approved if it continues to serve the FQHC’s medically underserved population; the FQHC board gives approval; the requested change does not reduce access or quality; and the change does not interfere with another FQHC’s operation. If new services can be sustained with only a change of scope, this is one way to meet an underserved population’s needs in a timely manner. FQHC ‘LOOk-ALIkES’ In areas that are in need of a New Access Point, the development of an FQHC ‘look-alike’ may be considered. Since federal funding for new FQHC access points is quite limited, development of a ‘look-alike’ could meet some of the needs of a priority area in a timelier manner. At the same time, it could lay the groundwork for a successful application for FQHC funding in the future, since the development of a successful ‘look-alike’ can demonstrate that the organization is capable of becoming a successful, funded FQHC and strengthen their application for FQHC New Access Point funding. Until a successful award is made, the underserved population receives FQHC services and the ‘look-alike’ organization gains valuable experience in meeting the needs of the area’s underserved population, and also in meeting FQHC governance, administrative, operational, fiscal and quality requirements. The provision of a fund to help cover the cost of the sliding fee scale for the low-income, uninsured, and free or low cost clinical space would be of great assistance to such development. Two FQHC ‘look-alikes’ presently provide services in the Detroit area. Their services are greatly needed. Their expansion or possible conversion to full-service FQHCs could bring even greater benefit. Improving Access to Quality Health Care | 52

Zip Codes with over 10,000 Medicaid Beneficiaries Medicaid Zip City Priority Medicaid FQHC Rank Code Rank Beneficiaries 1 24228 Detroit 18 24,362 No 2 48205 Detroit 6 24,261 No detroit Zip Codes with largest Estimated uninsured population 3 48227 Detroit 14 21,254 No Uninsured Zip Priority Uninsured FQHC Rank Code Rank Population 4 48126 Dearborn 15 21,028 No 1 48205 6 11,915 No 5 48212 Detroit & 10 18,923 No Hamtramck 2 48213 1 8,912 No 6 48203 Detroit 3 17,445 Yes 3 48203 3 8,410 Yes 7 48213 Detroit 1 17,281 No 4 48227 14 6,781 No 8 48210 Detroit 2 17,198 Yes 5 48209 5 6,751 Yes 9 48238 Detroit 11 16,996 No 6 48238 11 6,622 No 10 48234 Detroit 21 16,796 Yes 7 48210 2 6,465 Yes 11 48209 Detroit 5 15,754 Yes 8 48214 8 6,188 Yes 12 48204 Detroit 16 15,535 No 9 48204 9 5,909 No 13 48180 Taylor 24 14,490 No 10 48206 12 5,156 No 14 48206 Detroit 12 12,406 No Source: Michigan Primary Care Association 15 48214 Detroit 8 12,267 Yes 16 48221 Detroit 28 11,185 No 17 48141 Inkster 27 10,669 Yes PRACTICE/CLINIC ACQUISITION A number of FQHCs have successfully acquired practices and clinics and converted them to FQHCs. However, these typically require the funding of a New Access Point grant award so they are financially sustainable as FQHCs serving the underserved and uninsured. In some cases, hospital clinics struggling to provide services to the underserved have entered into agreements to provide ongoing support to the FQHC organization, continuing their commitment to the community’s health care, but containing their losses. The enhanced Medicaid and Medicare revenues and FQHC grant funding provide additional resources to not only serve an even greater portion of the underserved community, but also to expand the range of services provided. There are other examples wherein private practices have been acquired by FQHCs, with similar advantages. It is a means of expanding services quickly and enhancing community care. In either case, the New Access Point becomes part of the FQHC and is governed by its community board. The great Improving Access to Quality Health Care | 53

benefit to the community is expanded and enhanced health care and access for all. The advantage to hospitals is the expansion of community benefit, and often a means of control over the annual growth of the hospital’s contribution to this benefit while enhancing the community’s primary care services. However, a continuing commitment by the hospital to maintain a reasonable annual contribution for the provision of these community health services is an important element of such negotiated agreements. EMERgENCY DEPARTMENT DIVERSION There is heavy usage of hospital emergency departments (EDs) for non-emergent care by the underserved in the Detroit area. This not only burdens the hospital system and emergency department staff with providing inappropriate non-emergent care, but it also diminishes the probability that patients will receive comprehensive, quality care, including regular disease prevention and chronic disease management for which primary care organizations and practitioners are more organized and prepared. In addition, primary care obtained inappropriately in an ED generates greater cost to borne by individuals, insurance companies, public programs, individuals, hospitals—in short, all of us. It would be more effective if patients were diverted from EDs to appropriate primary care providers or provider organizations. FQHCs are well suited to provide medical homes for patient referral from EDs. Of course, hospital EDs must fulfill their requirement to provide an appropriate assessment of all presenting patients. However, effective referral protocols can, and have been developed between FQHCs and hospital systems. There are often impediments to such development, such as the policies regarding disproportionate share hospital (DSH) funding; state Medicaid program managed care administrative requirements; and limited Health Center funding for the uninsured. Another impediment is often a need for medical staff training programs to be able to have access to patients. The need for hospitals to access to a patient population; the need for learning experiences in treating a wide range of conditions and disease; and the structure of graduate medical education funding present another impediment to diversion program development. One option is to include primary care experience in the training program as part of any negotiated agreement. The conversion of a hospital clinic to FQHC status, combined with the development of additional training opportunities in the FQHC comprehensive primary care setting as well as enhanced Medicaid payments can be key elements in developing combined diversion and conversion programs the provide benefits for all. Programmatic and administrative adjustments and negotiation between the parties could lay the groundwork for successful emergency department diversion programs. Similar programs have been successful in other states. Under the auspices of the Detroit Wayne County Health Authority, some preliminary discussions have begun between FQHCs, the state Medicaid agency, and the area’s Medicaid health plans. Successful development in the Detroit Wayne County area could be of benefit to all parties—the patient, the hospital system, the Medicaid program, and the general health care system—while providing another means of sustaining and assisting in the growth of FQHCs and providing local residents with quality care in expanded and new FQHC patient-centered primary care medical homes. HUb AND SPOkE As noted in the beginning of this document, FQHCs provide a wide range of primary care services that can be delivered in creative and cost-effective ways by distributing services and support through a number of sites and integrating community services to supplement Improving Access to Quality Health Care | 54

the offerings. In addition, the greater health care system including hospital systems, physician groups (both single and multi-specialty), health departments, behavioral health organizations, dental groups, optometrists, physical therapy groups, imaging centers, FQHCs and individual practitioners is complex. In any community, there is great variety. In much of the system, the hospital acts as a hub, not only providing inpatient beds and emergency services, but many of the ancillary services, such as laboratory testing and imaging. These are used by the general medical community. Primary care providers, including FQHCs, also utilize the specialty physician network in the community for appropriate specialty referrals and consultation. Health departments tend to provide for the public health with immunizations and screening programs, as well as monitoring the progression of disease in the community and informing the health professionals and public. Free clinics are also a valued component of the Detroit area health delivery system. They often provide much needed acute and urgent care services; often with extended or atypical hours. The degree and continuity of care varies by the resources available to them. These clinics may have regular referral arrangements to more comprehensive medical homes, including FQHCs and of necessity with the specialty, ancillary and hospital service providers. Modern medicine is a loosely organized hub and spoke, with patients being referred to higher levels of medical intervention as needs arise. All elements need to be taken into consideration and woven into the fabric of a complete health care system serving the community. FQHCs are not only integrated into this web of professional providers and organizations, and coordinate their services utilizing these many resources, but they may also utilize similar strategies to project care conveniently into needy communities. FQHCs began as relatively small neighborhood organizations. In fact, they continue to be governed by boards of directors, the majority of members of which are themselves patients of the FQHC and members of the community the FQHC serves. However, many have developed into large, very capable health care organizations with hundreds of employees. In order to accomplish their missions successfully, FQHCs must both retain aspects of the neighborhood clinic and the high quality, sophisticated professional organizations they have become. The federally funded FQHC program requires a very comprehensive program of quality, preventive primary care services. However, it provides great flexibility in how these services are provided. For example, the local health department may provide a Women, Infants, Children (WIC) program. By agreement, this may be provided in an FQHC by the health department and integrated in the FQHC scheduling, perhaps coordinated with FQHC pediatric well child clinics for mothers’ convenience. An FQHC may not directly provide OB services but develop prenatal referral protocols with a nearby OB/ GYN group. In addition, a very comprehensive FQHC program can develop a network of access points or small clinics that function as neighborhood clinics in multiple areas of high need, staffed with a physician and a few midlevel providers and support staff. They may also have a preventive dental and screening program, as well as a behavioral health screening program. These all can provide the bulk of primary care needed in the community and also make appropriate referrals to the main clinic for many additional services, or directly to needed specialists, testing or ancillary services as developed in the quality protocols developed by the FQHC’s quality team and approved by its board. In this way, and many others, FQHCs develop very high quality, sophisticated health care delivery systems while continuing to provide the neighborhood clinic model to meet the day-to-day primary care needs conveniently located where the underserved reside. Improving Access to Quality Health Care | 55

SCHOOL-bASED AND SCHOOL-LINkED HEALTH CENTERS One alternative to strategy of the general hub and spoke approach is the development of FQHC school-based and school-linked clinics. This is where the children are; therefore, it is a logical place from which to deliver primary care. Often these clinics have clinical staff members including advanced practice nurses and physician assistants providing much needed preventive health care as well as the management of disease, such as asthma. These clinics are often located in schools or nearby with administrative links to the school to coordinate outreach, schedules, parent’s authorizations etc. This is another option of FQHC development. The State of Michigan provides support for these clinics. The School Community Health Alliance of Michigan is also an excellent resource for school-based and linked clinics. Many FQHCs have partnered with the state and developed these services. In such cases, new access point funding may be available. Otherwise, FQHC change of scope and state funding may be combined. This, along with FQHC Medicaid revenues may be the core of a sustainable business plan. A review of opportunities for this type of development is another avenue that could be explored to meet the Detroit area’s health care needs. COLLAbORATION – bEHAVIORAL HEALTH Another alternative strategy is collaboration with behavioral health organizations. The integration of medical and behavioral health services has been shown to improve the quality of treatment to a large percentage of patients. This integration has several advantages. Accessing behavioral health services in the primary medical care setting diminishes the feared stigma of seeking behavioral health services at a behavioral health facility. It provides the opportunity for large numbers of appropriate behavioral health services. Research has shown that appropriate intervention in the primary care setting diminishes the need for additional medical visits caused by underlying behavioral health issues, thus improving the quality of care and reducing treatment costs. Also, location of medical services within behavioral health facilities provides the opportunity for patients who are receiving behavioral health services to conveniently access medical care, improving compliance with medical and pharmaceutical regimens. Such arrangements also provide a venue conducive to convenient medical/behavioral health professional consultation, increasing quality and the continuity of care. The collaboration can take a number of forms. Co-location of medical and behavioral health professionals in the same facility provides for patient convenience, improved quality and continuity of care as well as promoting professional collaboration. Co-location can make visits more timely and convenient. Another approach is the direct integration of behavioral health services into the primary care treatment model, including regular interventions by behavioral health professionals into the primary care visit. For example, an FQHC could have an MSW working closely with a primary care physician and intervening in primary care visits, as requested by the primary care physician. Assessments and brief counseling can then be provided as part of the encounter. Referrals to scheduled counseling can then be made, as needed – all part of the primary care encounter. The MSW or other primary care behavioral health personnel could either have schedule counseling hours or referrals could be made to the collaborating behavioral health organization for scheduled visits. This integrated approach provides the opportunity for behavioral health services to be provided to a large number of patients, who traditionally have either not received services or have depended upon their medical professional to resolve their concerns. The interjection of appropriate behavioral health personnel in the primary Improving Access to Quality Health Care | 56

medical visit not only provides more appropriate quality behavioral health services to the patient but also much needed assistance to the primary medical professional. COLLAbORATION – DENTAL SERVICES In addition to providing direct dental services, which is encouraged by the Bureau of Primary Health Care, collaborative arrangements can also be established. Local health departments and other organizations may provide dental services and have multiple sources of revenue to sustain these services. These can be co-located with FQHC medical care or close referral relationships can be developed. These services also include programs such and screening, varnishing and sealant programs in addition to standard dental treatment. A number of sources of categorical funding programs are available for these services. These can be performed in many venues from dental and medical facilities to school and community facilities. Some screening can also take place as part of medical visits, as well as medical screening integration with dental visits. Development of comprehensive programs can be done effectively by coordinating and combining the funding and capability of FQHC, public health and other organization’s programs to meet the dental needs of the community. Michigan has the advantage of cooperation of the Michigan Department of Community Health, including the Medicaid program. In addition, a state-wide Oral Health Coalition has be formed, and its membership includes a large number of organizations seeking to improve care to the medically underserved. These are useful resources in developing comprehensive dental health strategies. OTHER COLLAbORATIONS FQHC patients have need of secondary, tertiary, ancillary and other health services for quality comprehensive care. In a number of cases, hospital systems have provided some assistance to FQHCs in obtaining these services for their patients. Coordination has been facilitated by organizations such as Voices of Detroit Initiative. However, the amount of the resource available to underserved and uninsured patients is limited. The need for increased specialty referral sources, imaging and other health services is reported as on-going. Collaboration with other organizations to more effectively use joint resources is one strategy to improve access to these services. Greater collaboration among all of the area health care providers is essential. The Detroit Wayne County Health Authority is engaged in identifying these needs and seeking collaborative partners; obtaining additional resources, and encouraging health policy changes to meet the needs of the underserved. CONTRACTED SERVICES Another strategy by which FQHC services can be expanded is contracted services. If it is financially sustainable, a plan can be developed to have services delivered in the FQHCs under contract. For example, an FQHC may not require a full time OB/GYN or simply wishes to make these services available via contract to work within an existing hospital-PHO relationship, rather than attempting to develop these services independently. Similarly, an FQHC may wish to integrate behavioral health services, and for various reasons find it appropriate to contract with an existing behavioral health program for personnel to provide these services. In such cases, the FQHC can contract for these services and have the services provided on-site in the FQHC facility. Of course, the contracted services would need to be provided in accordance with the health center’s scope of service, applicable policies and procedures and satisfy its professional standards, qualifications, credentialing and privileging. In addition, tort and malpractice issues would need to work through. This is a means for FQHCs to develop and deliver their expected comprehensive range of services. Improving Access to Quality Health Care | 57

COMMUNITY OUTREACH & MARkETINg Community outreach can take many forms. The development of a program of community outreach developing good relations with the community’s social, health care, religious and business institutions and organizations and area population is an important strategy that allows opportunities to inform the community of available services and to learn of the community’s needs and expectations. Inquiry made through the use of patient satisfaction questionnaires, focus groups, community discussion can be very valuable in developing and improving the delivery of quality, comprehensive, culturally sensitive health care services to the underserved and ensure community utilization and long term benefit. Many are familiar with the use of outreach workers in health care for the homeless programs in which outreach workers developed trusting relationships with patients and assist them in their access to needed services. However, all FQHC practices need to make their services known to the community if the residents are to benefit from the available FQHC services. Although federal policy precludes the use of federal funds for marketing (selling of services) programs, community outreach is an expected activity a comprehensive FQHC program. FQHCs may also use not federal resources for marketing their services. In addition, there is no prohibition to marketing being done on behalf of FQHCs by other entities. Collaboration is an essential element in outreach and the Authority has offered to assist FQHCs in their community outreach. Some elements of a community outreach program include: n Establishing convenient hours and locations n Developing materials (print and electronic) that provide basic information about the Health Center including its health care services; providers; enabling services (e.g. translation, eligibility assistance, transportation assistance); location and contact information; hours and after hours contact information; acceptance of all patients; acceptance of Medicaid, Medicare, public programs; commercial insurance; and sliding fee scale program n istributing materials in FQHC waiting areas, local gathering places (e.g. hair salons, coffee shops, D Laundromats, etc.), social services agencies, and churches; and through Targeted mailings, door-to- door distribution, and online dissemination n Establishing a web site n Developing and nurturing relationships with community agencies, businesses, service clubs, churches, and the like to use as venues of sharing information about the Health Center’s services n eveloping a speaker’s bureau of FQHC staff to regularly address the community at community D organizations, social organizations, other health care venues, service clubs, churches, and through the media (TV, radio, newspaper, web) n ossibly adding outreach staff who can contact and assist those in need of health care services; P provide assistance to patients, enhancing their access to needed services such as benefit qualification and enrollment assistance for medical benefits and social assistance programs and related services (i.e. Medicaid, Medicare, pharmacy programs, public assistance programs etc.; providing on-going contacts in the community n Collaborating with health care and health education programs such as other health care providers, public health, schools, and community organizations n Implementing patient satisfaction program and integrating with quality/operational improvement and planning functions Improving Access to Quality Health Care | 58

IMPROVING ACCESS/REDUCING FINANCIAL IMPEDIMENTS EXTENDED HOURS Another element in serving underserved populations is the maintenance of extended office hours that meet the FQHC service area populations’ needs and expectations. In particular, the working poor with limited time and transportation options encounter greater challenges in obtaining care during the standard workday, diminishing their access to care. The extension of office hours throughout the week and even to the weekend greatly improves opportunities for access. It is important that these be consistent throughout the schedule, such as 8am to 8pm daily, in order to be clearly understood, remembered and regularly used by patients, particularly underserved populations with increased scheduling and transportation challenges. However, the additional expense of extending office hours has proven to be financially difficult for FQHCs in the Detroit area. Financial assistance would be helpful in establishing extended hours. Depending upon patient mix, FQHCs may be able to self-sustain extended hours over time. This is an area of improvement that could increase the use of these medical homes as an alternative to inappropriate emergency department use. CONVENIENT ACCESS Providing convenient access is imperative with a population that has a number of impediments to access. Rigid employment schedules, short-notice rescheduling, multiple part-time jobs, frequent layoff and rehire, transportation difficulties and other schedule disruptions are generally more common for those living in poverty or among the working poor. Therefore, standard daytime office hours are not optimal for many of the medically underserved. One result of this is heightened inappropriate use of hospital EDs for routine primary care services. As discussed, providing consistent extended hours is one helpful strategy. In addition, using “open access and modified wave” appointment systems are very helpful in increasing convenient access. For example, in open access systems, only a limited number of diagnoses, conditions or special circumstances are identified as requiring a return appointment. All other access is open or booked within a short time period (same day or up to two days prior to appointment). This allows for most of the day’s appointments to be “open” until each patient is relatively certain of her/his personal schedule as well as increasing walk-in availability. Not only does this increase convenience and access for patients, it has also been shown to substantially reduce “no-shows” and it’s attending time/ resource waste and wasteful appointment re-scheduling work. Similarly, the modified wave approach allows for limited open access. It monitors patient flow and allows for limited near-term and same day appointments using consistent appointment protocol. Such procedures are very helpful in not only improving access for the underserved, but also in reducing resource waste and enhancing FQHC sustainability. HOSPITALITY – A wELCOMINg ENVIRONMENT Providing services in a professional and welcoming manor is essential to develop rapport with patients and encourage patient referrals to other community members. In some cases, the demands of service delivery, competing priorities and limited funds result in hospitality training being overlooked. Providing materials and resources for improving this aspect of the patient visit can be very helpful in increasing use of primary care services. Identifying Improving Access to Quality Health Care | 59

and providing some shared resource for FQHC personnel training could be helpful in improving this element of primary care delivery. TRANSPORTATION One consideration in the location of New Access Points is transportation. Since a segment of the underserved population does not have regular access to personal transportation, FQHCs have developed a number of strategies to improve access: providing bus tokens, coordinating appointment scheduling with dial-a-ride services, and special transportation schedules. These need to be tailored to the specific needs of the patient population while considering the community transportation resources. Community organizations and public agencies may also be willing to assist in this activity. For example, the Michigan Medicaid agency includes an adjustment in the prospective payments to FQHCs to contribute to patient transportation costs. SLIDINg FEE SCALE In addition to sustainable sites and services, it is essential to provide accessible and affordable services and inform the public of their availability to enhance sustainability and initiate growth. The FQHC program has established the use of a sliding fee scale to eliminate financial impediments to patients with low-incomes (<200% FPL) by adjusting fees to their ability to pay. Although documentation of income is required, it is important that the process is sufficiently convenient to be utilized easily by all who are eligible. They cannot be so onerous as to discourage their use and the purpose of the program. E X PA N S I O N C H A L L E N G E S MEDICAID, MEDICARE HEALTH PLANS The DWCHA recently convened a committee of the Medicaid Health Plans and the FQHCs to improve cooperation. The Michigan Medicaid agency also elected to participate in this committee. One of the primary concerns that FQHCs stated was the apparent low referral of unassigned patients to FQHCs. This is of substantial concern, since FQHCs depend heavily on Medicaid revenue to sustain and expand their services. The Health Plans also inquired about member access and FQHC quality reporting. With the initiation of this forum, fruitful discussions have begun and a number of solutions have been put forward. The creation of this forum and the continuing dialogue of these parties is a strategy that has the potential to strengthen area FQHCs. It is also important for FQHCs to cooperate with, and credential staff for, Health Plan, insurance company and public program (e.g. Medicaid, SCHIP, Medicare) networks to serve their insured populations and public program beneficiaries conveniently and appropriately. SPECIAL CHALLENgES TO FQHC DEVELOPMENT In the Detroit area, there has been limited development of FQHCs relative to the population. By any factor, may it be family income, lack of insurance, race, culture or health status, there is documented high need for increased access to quality, comprehensive primary health care services. However, the Detroit area has been unable to develop a sufficient network of FQHCs to meet the demonstrated need for health care services. There are a number of factors that have contributed to this. These include a lack of applications made for federal funding, limited success in obtaining grant awards, and a limited pool of potential applicant organizations. Improving Access to Quality Health Care | 60

NEw SITE, SERVICES AND SERVICE EXPANSION REQUIREMENTS An organization must be in a position to expand services in order to responsibly proceed on such a significant undertaking. Providing health care is complex and expensive. It not only requires money, but also extensive planning and analysis. The correct location must be identified; the facility available, or commitment obtained for lease or renovation; the workforce tentatively engaged; proper services chosen; etc. This often requires assistance and consultation—certainly many hours of staff and governing board time. Grant applications also often require the engagement of professional grant writers, if the right ones are available at the time they are needed for this highly competitive process. Then, if the organization is able to bring all of these elements together, and it is successful in its FQHC application, it is expected to begin providing services within 120 days. It may be noted that it may take many months just to credential medical providers to enable them to generate paid claims from Health Plans and insurance companies, so generating initial revenue to provide sufficient operating capital for a New Access Point is a substantial challenge, not only for existing FQHCs, but even to a greater extent for new start organizations. The probability of success will not depend just upon the development of New Access Points; rather, success will undoubtedly depend upon multiple strategies as noted above. Areas of high need with existing FQHCs were also included in priority areas to be addressed, since the FQHCs have the ability to successfully apply for funding for expanded medical capacity and services. These strategies should not be overlooked. In addition, other non-funded strategies of expanding medical capacity and services also hold promise of providing additional services in a timely manner. Although New Access Point funding is desired, a collaborative strategy would appear to be the most practical to expand FQHC services in a timely manner. Often FQHCs have not been in the financial position or organizationally prepared for applications for New Access Points. The challenge is not just assisting FQHCs with preparing and submitting applications when requests for proposals are anticipated. FQHCs are challenged daily in the delivery of care and maintenance of their financial stability. Assistance in this regard is, therefore, an essential part of any strategy to expand FQHC services and strengthen the existing FQHCs so that they are able to plan, prepare and successfully apply for New Access Points and expanded medical capacity and services. It is essential that there be cooperation, collaboration and trust in the process to expand FQHC services. To this end, the Safety Net Expansion Workgroup has recommended a set of principals to be adopted by the PCNC to enhance cooperation and create transparency in an effective process of FQHC development (see page 77). Adoption of common principles will be helpful in developing trust and fair play, which are necessary for effective cooperation. CAPITAL DEVELOPMENT With few exceptions, FQHCs have experienced limited success in capital development. They are organized primarily to deliver much needed care to the medically underserved. Their staffing and resources are fully allocated for this purpose. In addition, there has often been the misperception that their programs are completely funded with federal dollars and have no further needs. FQHCs receive only limited funding to assist in covering the provision of a sliding fee scale program for the indigent and uninsured and to meet the special FQHC quality programs, federal administrative and reporting requirements. Improving Access to Quality Health Care | 61

Federal funding for most FQHCs usually constitutes less than half and often less than one-third of their revenues. The remaining income must come from fees for service. This is a daunting task when they have a patient mix far different than that of the typical private practice. FQHCs’ patient mix is primarily made up of the medically indigent, uninsured and Medicaid beneficiaries. In addition, it is expected that grant funds and revenues be utilized for direct care. Although there is some opportunity to retain some of the revenues for capital reserves, in reality this rarely approaches what is required to meet operating capital, re-investment and in particular, growth opportunity requirements. This diminishes FQHCs’ financial stability and ability to grow to meet community health care needs. With regards to operating capital, there is an on-going need for FQHCs to meet their cash flow needs, particularly in times of growth. In order to provide services, like any business, FQHCs must meet their payroll and other monthly obligations in order to continue operations. However, they must wait, often time months, for insurance companies to pay on behalf of their patients, and for patient payments of co-pays and out-of-pocket obligations, which may take some time, particularly with poor, medically indigent patient populations. Therefore, a large business line of credit or retained earnings must be utilized to meet the operating capital requirements. This is particularly critical for new start or expanding FQHCs, since any expansion of services requires sizable investment in personnel and facility prior to realizing any increase in revenues. New FQHCs are not generally in the financial position to qualify for a business line of credit and they have not yet had the opportunity to retain revenue for this purpose. This lack of operating capital often results in a financial crisis in the first few years. Even if the FQHC is performing well and has balanced its budget, it lacks operating capital to meet cash requirements to continue operations. As a result, planned service development is often postponed, often for years, until the organization is able to budget and retain earnings sufficient to meet operating capital needs. Similarly, most established FQHCs are only able to retain sufficient operating capital necessary to meet immediate community health needs. When opportunities for New Access Points or new or expanded services come available, these may not be considered, because estimated investment and projected operating capital needs are much greater than the FQHC can provide to the proposed project. As a result, FQHCs with good clinical service delivery and business operations histories are unable to apply for new site or expansion funding. Communities lose the opportunity for improved access to care, as a result. As was noted earlier in this plan, the Detroit Wayne County area receives very little FQHC federal funding compared to other Midwestern cities. The availability of capital is a very significant factor when FQHC community boards of directors are considering FQHC expansion. One strategy for responding to this need is for the greater community to develop a pool of capital for FQHC operational and investment needs, particularly when it can be demonstrated that greater FQHC access cannot only cost-effectively improve community health status, but also reduce inappropriate use of hospital EDs, saving inappropriate health care expenditures. It may be noted that access to capital is a key factor in developing any business sector within any region. It is most appropriate to develop capital sources to aid in the sustainability and expansion of FQHCs. The DWCHA and MPCA are developing plans for capital development for FQHCs. The successful development of such capital development plans have the potential to make a significant contribution to improved access to quality care, improved community health statues and positive business development in the Detroit Wayne County area and the State of Michigan. Improving Access to Quality Health Care | 62

COOPERATIVE EFFORT The DWCHA has provided forums in which various parties have begun to work together to address the specific needs of area FQHCs. It is committed to be an effective catalyst in the development of expanded health care services so health care will be available to all, particularly the uninsured and underserved. Being a health authority, DWCHA is an organization of organizations coordinating health care service development throughout the Detroit Wayne County area. The engagement and contributions of many community organizations, planning agencies, health systems, specialty and primary health care providers, Health Plans, and state and local agencies will be essential to the ultimate success of solving the primary health care services deficit. R E C O M M E N D AT I O N S , P L A N S & S T R AT E G I E S The Safety Net Expansion Workgroup stated that the existing FQHCs are committed to responding to the identified needs of the Greater Detroit area. They also provided information on their centers’ present plans for expanded services. These are included in this brief overview of the identified areas of priority need. HIgH NEED AREAS wITHOUT FQHCS Zip Code: 48213 Priority Rank: 1 Strategy: Establish New Access Point (I-94/Connor area suggested). Plans: None have been expressed at this time. (Covenant Community Care has indicated plans to develop a New Access Point in a contiguous zip code [48224] at I-94 & Moross Road east of 48213.) Zip Code: 48205 Priority Rank: 6 Strategy: Establish New Access Point (Kelly/Hayes area suggested.) Plans: None have been expressed at this time. (Covenant Community Care has indicated plans to develop a New Access Point in a contiguous zip code [48224] at I-94 and Moross Road southeast of 48205.) Zip Code: 48211 Priority Rank: 8 Strategy: Establish New Access Point Plans: None have been expressed at this time. Zip Code: 48212 Priority Rank 10 Strategy: Establish New Access Point (Conant & Davison area suggested) Plans: None have been expressed at this time. Improving Access to Quality Health Care | 63

HIgH NEED AREAS wITHOUT FQHCS continued Zip Code 48238 Priority Rank: 11 Strategy: Establish New Access Point Plans: Detroit Community Health Connection is considering establishing a New Access Point with possible co-located behavioral health linkage. Zip Code: 48206 Priority Rank: 12 Strategy: Establish New Access Point Plans: None have been expressed at this time. HIgH NEED AREAS wITH FQHCs Zip Code: 48210 Priority Rank: 2 FQHC Access Points: Bruce Douglas, 6550 W. Warren, Detroit, MI (Detroit Community Health Connection) Strategy: Expanded Medical Capacity; Service Expansion Plans: Detroit Community Health Connection plans a 2,800 square foot expansion and the addition of medical providers, expanding OB/GYN and Pediatric services. Covenant Community Care plans a New Access Point on Michigan Avenue in southern portion of 48210. Zip Code: 48203 Priority Rank: 3 FQHC Access Points: Nolan Family Health Center, 111 W. Seven Mile Road, Detroit (Detroit Community Health Connection) Strategy: Expanded Medical Capacity; Service Expansion Plans: None have been expressed at this time. Zip Code: 48201 Priority Rank: 4 FQHC Access Points: Woodward Corridor Family Medical Center, 611 Martin Luther King Jr. Blvd., Detroit (Detroit Community Health Connection); University Health Center (Health Centers Detroit Medical Group) Strategy: Expanded Medical Capacity; Service Expansion Plans: None have been expressed at this time. Improving Access to Quality Health Care | 64

HIgH NEED AREAS wITH FQHCs continued Zip Code: 48209 Priority Rank: 5 FQHC Access Points: CHASS Southwest Center, 5635 W. Fort Street, Detroit (Community Health & Social Services) Strategy: Expanded Medical Capacity; Service Expansion Plans: New building is planned providing major facility expansion with an opening date of August 2010. Two additional medical providers are initially planned. Zip Code: 48208 Priority Rank: 7 FQHC Access Points: Waller Health Care for the Homeless Center 2395 W. Grand Blvd., Detroit (Advantage Health Centers) Strategy: Expanded Medical Capacity; Service Expansion Plans: None have been expressed at this time. Zip Code: 48214 Priority Rank 8 FQHC Access Points: E ast Side Health Center (Detroit Community Health Connection); E Jefferson Clinic (Health Centers Detroit Medical Group) Strategy: Expanded Medical Capacity; Service Expansion Plans: Detroit Community Health Connection plans renovation of the East Side Health Center OTHER wORkgROUP RECOMMENDATIONS The workgroup also suggested additional sites for additional access. Although they did not rank as highly in priority, they indicated these were worthy of consideration due to their ability to serve underserved populations in areas where no FQHC presently exists. These general areas were considered central for convenient access. The strategy for all of these is the development of a New Access Point. A plan has been expressed in one zip code at this time. The general plan is to encourage an existing FQHC organization to consider developing a New Access Point in one of these areas. One is proceeding. Zip Code: 48227 Area: Greenfield & Plymouth (NW Detroit) Zip Code: 48207 Area: Mt. Elliott & Forest (Detroit E Side Initiative) Zip Code: 48120 Area: Schafer & Michigan Ave. (Dearborn) Zip Code: 48229 Area: Southfield & Fort (Ecorse, contiguous with Detroit and River Rouge) Alternate: Zip code 48217 - Oakwood & Dix (Detroit near Ecorse and River Rouge) Improving Access to Quality Health Care | 65

Zip Code: 48180 Area: Taylor City (20600 Eureka Rd Taylor, MI) Plan: New Access Point grant awarded to Western Wayne Family Health Center of Inkster. Development is planned to proceed soon. Zip Code: 48221 Area: Wyoming & Six Mile Road (NW Detroit) Zip Code: 48184 Area: Wayne & Romulus (Wayne City) This report represents the beginning of a process in which many community organizations are collaborating in order to identify the health care needs of the Detroit area with the intention addressing these needs. This is a process has just begun. Areas with indicators of greater need have been identified. Many FQHC providers have been involved in the process and are committed to responding to the identified needs over the next five years. A few FQHCs are presently proceeding with plans to expand services in their existing facilities. One has just been awarded funds for a New Access Point. Another has committed to initiating a program to apply for funding for New Access Points or expansions in each new cycle of offerings. This report is not the end of planning. This process has only begun. Specific strategies for each area will need developed and evolve. Partnerships and collaborations will need to be developed and resources will need to be obtained. The Detroit Wayne County Health Department has been instrumental in bringing key players together in this process through the PCNC and other forums and workgroups. Health care needs are being identified. Organizational relationships are developing and collaboration has begun. Sources of resources have been identified. Commitments are being made. Initial actions are being taken to increase services in the Detroit Wayne County area. The purpose of this report is to be a tool with which to facilitate this process, to provide assistance in the identification of high need areas, and to be catalyst in the development of improved access to quality health care for all. WORKFORCE DEVELOPMENT Michigan has a number of challenges in recruiting and retaining quality health care workforce. Michigan currently has the highest unemployment rate in the country at 11.6% (11.9% in metropolitan Detroit) for January 2009, compared to the national unemployment rate at 7.6% (Michigan Department of Labor and Economic Growth, 2008). This high unemployment rate is due to many factors such as the U.S. government recession, the financial woes of the Big Three automakers and the declining housing market. Along with the poor economy, Michigan’s health care industry has also suffered. Wayne County, namely Detroit, has been hard hit by the declining economy which is best illustrated by the number of hospitals left operating in the city. In 1960, Detroit had 42 hospitals fully operating, now there are only seven left within the city according to the Boston School of Public Health. Like the other employment industries, Michigan’s health workforce is facing many challenges. To understand the problems, several statewide studies have been conducted for physicians, nurses, and Improving Access to Quality Health Care | 66

physician assistants. There are a myriad of factors that affect the supply of the physician workforce. Some factors include the retirement of physicians, work pattern differences among older and younger physicians and male and female physicians, practice specialty the cost of education and training and the varying supply of international medical graduates (Michigan Department of Community Health 2008 Physician Profile). According to the Council of Graduate Medical Education (COGME), in 2007 Michigan had 272.9 physicians per 100,000 population. COGME recommends a physician ratio of greater than 300 per 100,000 population will be needed to meet future demand (Michigan State Opportunities in Rural Health Initiative Report, 2008). Of the 42,305 physicians licensed in Michigan, 31.965 are allopathic doctors (MD) and 6,550 are doctors of osteopathic medicine (DO). The remaining 3,235 MDs and 825 DOs hold an educational limited license. Of the fully licensed physicians, roughly 34% of active physicians are primary care physicians. This percentage has not changed from the 2005 physician survey, all of which suggests that since 2005 the number of primary care doctors leaving the workforce is about the same as the number entering the workforce (Michigan Department of Community Health 2008 Physician Profile). Projecting the future supply and demand for physicians has been difficult, but The Michigan Blue Ribbon Physician Workforce Committee commissioned a study by the State University of New York to quantify this number. The report projected a 6-19% increase in the demand for physicians through the year 2020. The report also projected the biggest shortages for family practice physicians, general surgeons, cardiologists, orthopedic surgeons, psychiatrists, internists and radiologists. The physician workforce has seen a sharp increase in the number of medical school graduates choosing specialty care. In the 2005 American Medical Association Masterfile, since 1987, the trend has been a decrease in the number of graduates choosing the primary care specialties. Salary differentials as well as a difference in lifestyle are major drivers for physicians, nurse practitioners and physician assistants to subspecialize (RC Bowman Measuring Primary Care: The Standard Primary Care Year, 2008). As mentioned in the previous sections, there is a strain on Wayne County safety net providers. These safety net organizations must compete with hospital systems and other larger provider groups for the dwindling health care workforce. To get a better idea of the recruitment and retention issues within the health care workforce in the safety net facilities, in October 2008 the DWCHA Workforce Workgroup invited all the Wayne County health professions programs and safety net administrators to participate in a survey to evaluate the areas of greatest shortage and how to better link the health professions training programs and the safety net facilities. The safety net administrators (Chief Executive Officer, President or Executive Director of the organizations) overwhelmingly reported that physician, and non-physician providers (nurse practitioners, physician assistants and certified midwives) were the hardest positions to recruit within their organizations. There are a number of resources available within the state of Michigan that can be utilized to assist these organizations in recruiting and retaining these providers (Primary Health Care Profiles of Michigan 2008). That same survey reported that 70% of Wayne County’s safety net facilities do not utilize provider loan programs as a means of recruiting and retaining their providers. Improving Access to Quality Health Care | 67

RECOMMENDATION #1 Safety net facilities should participate in both state and federal provider programs to help recruit and retain clinical providers. n The Michigan State Loan Repayment Program (SLRP) is a program that helps primary care providers repay their professional educational loans, if they commit to working in a federally designated HPSA for a minimum of two years. Currently, MDCH operates the nation’s largest federally funded SLRP. Primary care physicians (family practitioners, internists, pediatricians, obstetricians, general practitioners), dentists, mental health practitioners, nurse practitioners, nurse midwives and physician assistants are eligible to apply and participate in this program. Candidates must be licensed or certified to practice in Michigan, and be graduates of accredited training programs. Candidates must also be able to verify loans incurred for professional education, have a signed contract of firm commitment of employment with a health care agency in a HPSA, submit an application to MDCH, and sign a 2-year contract with the department agreeing to work full-time in a HPSA for the contract period. All SLRP sites must submit a Site Application in order to become an approved SLRP site. All sites must be located in a HPSA, operate as a not-for-profit agency with an IRS code of 501(c) 3, accept Medicaid and Medicare, and participate with a Qualified Health Plan. Physicians and dentists are eligible for repayment of up to $25,000 per year. Nurse practitioners, nurse midwives and physician assistants are eligible for repayment of up to $15,000 per year. The first payment is made directly to the provider by MDCH six months after starting work at the selected site. Verification that the provider has been working is required and can be provided by the SLRP site administrator or other authorized staff. n The National Health Service Corps (NHSC) was created in 1970 to assist communities in the recruitment of health professionals. Its mission is to increase access to primary health care services and reduce health disparities for people in HPSAs by assisting communities through site development and by the preparation, recruitment and retention of community-responsive, culturally competent primary care clinicians. The NHSC began its scholarship program in 1972, awarding tuition and stipends to students in health care professions training in return for commitments to serve in areas of need. The NHSC Scholarship Program offers payment of tuition, fees, books, supplies, and equipment for up to four years of education, plus a monthly stipend. United States citizens who are enrolled or accepted for enrollment in selected fully accredited training schools/programs including allopathic or osteopathic medical schools, family nurse practitioner and nurse-midwifery programs, bachelor’s or master’s physician assistant programs, or dental training programs are eligible to apply. Medical students are required to complete residency programs in family medicine, general pediatrics, general internal medicine, or obstetrics/gynecology. Upon completion of training, health professionals must choose a practice site in a HPSA and serve in the practice one year for each year of support that was received, with a minimum of a two-year commitment. In 1987, the NHSC launched a new program of loan repayment in return for service. The NHSC Loan Repayment Program is available to selected fully trained health professionals with qualified educational loans who serve at eligible sites. Qualifying health professionals must commit to Improving Access to Quality Health Care | 68

provide primary health care services in a HPSA for a minimum of two years, be a U.S. citizen, have an unrestricted license and/or certificate to practice in the state where they will practice and meet other requirements. The maximum loan repayment amount during the initial contract is $25,000 per year. Additional loan repayment beyond two years is possible. n Through the State Conrad 30 Program, the State of Michigan is allowed to act as an Interested Governmental Agency (IGA) and sponsor up to 30 J-1 Visa Waivers annually. This waives the 2-year return home requirement for International Medical Graduates (IMG) on the J-1 Visa studying in U.S. residency programs. In exchange for the waiver of the return home requirement, the IMG must agree to work in an underserved area for three years, and may be employed in private, public or not-for-profit clinics or hospitals. MDCH will sponsor up to 30 waiver candidates per year. J-1 Visa Waiver candidates are prioritized based on the preference criteria described below. Criteria 1-Health Professional Shortage Areas: The intent of the J-1 Visa Waiver Program is to place physicians into designated shortage areas. Michigan gives preference to placements in designated HPSAs. If Michigan does not receive at least 30 requests for placements into HPSAs, it will consider placements into designated MUAs/MUPs. Federal program guidelines allow for up to five waiver placements each year into areas that are not designated as either a HPSA or MUA/MUP. Michigan will consider placements outside of HPSAs or MUAs/MUPs if it does not receive at least 30 requests for placements into HPSAs or MUAs/MUPs. All placements outside of designated shortage areas must be made in facilities that can document that a portion of their annual patient caseload resides in a neighboring HPSA and/or MUAs/MUP. Criteria 2-Primary Care and Specialists: Preference is given to primary care physicians (IM, PEDS, FP, OB/GYN) and psychiatrists. If Michigan does not receive at least 30 requests for primary care physician or psychiatrist placement, consideration will be given to specialist physician placements. Among specialist physicians, there will be no restrictions regarding type of specialist allowed, with the exception of those specialties involved in care that is not medically essential (such as cosmetic surgery). Rural specialists will be given preference over urban specialists. Criteria 3-Priority Practice Sites: Preference is given to physicians who will be employed at local health departments, state funded institutions, state-funded primary care clinics, state correctional facilities, Community Mental Health (CMH) agencies, forensic medicine centers, state psychiatric hospitals, FQHCs, FQHC ‘Look-Alikes’, Critical Access Hospitals (CAH), CAH administered clinics, and certified rural health clinics designated as facility HPSAs. Criteria 4-Urban/Rural Mix: Michigan will seek to select 16 urban and 14 rural waiver placements each year. Criteria 5-HPSA Score: For candidates with equal preference, based on the criteria above, additional ranking will be based on the HPSA score (for those candidates working in a HPSA), with preference for higher scoring HPSAs. Candidates will also receive a randomly assigned lottery number at intake in the event that there is a “tie” between two applicants. n The Nursing Education Loan Repayment Program (NELRP) is a competitive program that repays 60 percent of the qualifying nursing educational loan balance of Registered Nurses selected for Improving Access to Quality Health Care | 69

funding in exchange for two years of service at a critical shortage facility. Participants may be eligible to work a third year and receive an additional 25% of the qualifying nursing educational loan balance. The purpose of the NELRP is to assist in the recruitment and retention of professional RNs dedicated to providing health care in facilities with a crucial shortage of nurses and to provide an opportunity for RNs to consider a career in such facilities. The program offers RNs substantial economic assistance to repay a portion of their qualifying nursing educational loans in exchange for full-time service at a health care facility with a critical shortage of nurses. The eligibility for this program is as follows: • as received a baccalaureate or associate degree in nursing (or an equivalent degree), a diploma H in nursing or a graduate degree in nursing from an accredited school of nursing in a State; • as outstanding qualifying educational loans obtained for qualifying nursing education leading H to a degree or diploma in nursing as specified above; • Has completed the nursing education program for which the loan balance applies; • Is a U.S. citizen, U.S. national, or a lawful permanent resident of the U.S.; • Is employed full-time (32 hours or more per week) at a critical shortage facility; • as a current permanent unrestricted license as an RN in the State in which he/she intends H to practice or is authorized to practice in that State pursuant to the Nurse Licensure Compact (Please refer to the Nurse Licensure Compact State listing ; and has submitted a complete electronic application and banking information through BCRSIS, all required supplemental forms (including the “BCRSIS Receipt of Submission”), and all required supporting documentation by the NELRP application deadline. The Health Professions training programs themselves are key in recruiting and retention efforts. The DWCHA survey found that 100% of the survey respondents thought that arranging a clinical experience within a community-based setting was the most important in retaining their graduates within the greater Wayne County area. The survey found that while the health professions programs are rotating their students through the safety net facilities, they are doing so for about 0-20% of their total rotations. There is an opportunity for the safety net facilities to become a preferred employment option for these health professionals. There is currently a large disconnect between the needs of training programs and the safety net facilities. RECOMMENDATION #2 Safety net facilities and health professions training programs can serve as training sites which in turn will assist in the recruitment and retention of the health care workforce in Wayne County. The DWCHA Health Professions Program survey found that all the health professions programs indicated that there needs to be a better and more direct relationship with the Safety Net Facilities in order to market employment opportunities available. These respondents found that on average 81-100% of their program’s graduates remained in the state after graduation. These programs have the ability to help place much needed providers within the safety net organizations. These training programs also indicated the following resources would enable them to adequately market the employment opportunities within Wayne County’s safety net facilities: open houses, education about safety net organizations, safety net organizations/health professions training program collaborative body. Improving Access to Quality Health Care | 70

Wayne County’s safety net facilities, particularly the FQHCs and FQHC ‘look-alikes’ also can be the training ground for medical residents. According to the Accreditation Council for Graduate Medical Education (ACGME), there are more than 7,700 residency programs and 700 institutional sponsors of graduate medical education in the U.S., training approximately 100,000 residents (www.acgme.org). In training primary care physicians there is an increasing need for collaboration between FQHCs and teaching hospitals that sponsor residency programs by serving as training sites for the programs and providing preceptors for those program through FQHC clinicians. According to the Southeast Center for Medical Education, there are 12 different hospital systems within southeast Michigan; of that 12, five of the hospital systems are within Wayne County that serve as residency and fellowship training programs for primary care residents (www.semcme.org). There are many motivating factors for developing collaborations for both the academic institutions and FQHCs. Rotations within FQHCs would give residents a diverse educational experience, enhancing their learning experience. FQHCs are community-based and serve a diverse group including an underserved patient population (NACHC Issue Brief #26, Systems Development Series). The FQHC- based rotation serves as a recruitment tool for the graduating residents. In addition, the collaboration between the FQHC and teaching hospital could also expand to include collaborations in other areas such as clinical research. Barriers Advantages Governing institutional barriers Recruitment There is also a recent trend in which FQHCs and teaching hospitals have negotiated more Administrative challenges Improved quality of care complex arrangements in which the FQHC Enhanced teaching assumes ownership of hospital-based clinical environment sites while the hospital provides some clinical capacity within the FQHC through operation Mission of the residency programs. This particular Money situation is not a typical hospital and FQHC arrangement; it just shows how these entities Leadership can collaborate to create a win-win situation. There are various operational, management, financial and legal issues that need to be addressed before a FQHC and teaching hospital consider clinical teaching program collaborations. There are many barriers and advantages to this arrangement (see chart above). This collaborative relationship between FQHC and teaching hospital is not a simple arrangement and may vary in each organization. It is recommended that this issue be explored in greater depth by a steering committee. The steering committee would identify and recommend high level policy changes that would need to be changed at both organizations. It would be function of the committee to make infrastructure and program development recommendations to develop and strengthen partnerships between organizations. Ultimately, this collaborative relation could benefit each organization due to the shared mission of promoting service and education. Improving Access to Quality Health Care | 71

RECOMMENDATION #3 to increase the continuity of care and decrease employee turnover rates, each safety net organization should develop a recruitment and retention plan and utilize existing resources. Ultimately the combination of promoting service, education and combined with the provider loan repayment programs could increase the retention rates of providers within the safety net facilities. Of physicians who leave their organization, the top reason cited (44% of physicians surveyed) was practice issues (“poor cultural fit, work pressure and hours not compatible with a quality lifestyle”). The second most cited reason was disappointment in compensation and the third reason was to be closer to extended family (Physician’s News Digest 2006). It is most beneficial to implement retention practices at the time of physician recruitment and throughout the physician’s career. Successful practices include: n Effective communication n Personal calls from leadership upon hiring n Extra communication with new physicians n Formal organizational mentorship programs n Clear expectations about compensation n Bringing back newly hired providers for a ‘return visit’ to the facility n Seeking feedback from new physicians about hiring process n Involving family and spouses within the recruitment phase Nationally, the average cost to recruit a new physician is approximately $24,500 and does not include the intangibles: the physician experience, building relationships with patients and the time and effort it takes to train and orient a new provider. Each organization needs to develop a retention plan; due to the cost that is required in recruiting new providers, it is within an organization’s best interest to develop a retention plan (Recruitment and Retention Best Practices Model 2005). The following documents should be used in supporting the effectiveness of recruitment and retention within an organization: n Needs assessment n Strategic plan n Business plan n Health care plan n Recruitment and retention plan n Quality improvement and management plan n Clinician satisfaction survey n Patient satisfaction surveys and results n Sample provider contract and position description n Provider productivity reports n Clinicians’ salary ranges, benefit package Due to the changing employment climate, it is becoming more and more difficult to recruit qualified candidates; the national average of $24,400 to recruit one new physician cannot be sustained by the safety net facilities. Resources available through MPCA will decrease the cost in filling these vacancies. Improving Access to Quality Health Care | 72

MPCA posts vacancies for its members via a number of non-traditional web-based job banks. Through MPCA, FQHCs and FQHC ‘look-alikes’ can advertise their vacancies for the following provider types: n Primary Care Physicians n Dentists (DDS, DMD) n Non-Physician Providers (Nurse Practitioners, Physician Assistants, and Certified Midwives n Nurses (LPN, RN, BSN) n llied Health (including Medical Technicians, Pharmacy, Pharmacy Technicians, Physical A Therapists, Physical Therapist Assistant, Occupational Therapists, Occupational Therapist Assistants, Radiologic Technician, Respiratory Therapists and Surgical Technologists) It is apparent that a number of strategies must be employed to keep the safety net facilities properly staffed. The major strategies must be to create and strengthen existing partnerships with the health professions programs and to utilize major recruitment and retention programs available at the state and federal level. S U M M A R Y: S A F E T Y N E T E X PA N S I O N P L A N The Detroit Wayne County Health Authority (DWCHA) was established High need Areas without FQHCs by Governor Jennifer Granholm in 2003 New Access Point Considerations with recommendation of the Wayne Priority Rank Score Zip Code City NAP County Stabilization Workgroup in Classification response to clear indications of a health 1 27 *48213 Detroit 1 care safety net crisis in the Detroit Wayne County area. One area that needed to be 6 46 *48205 Detroit 2 addressed was the loss of primary care 8 57 48211 Hamtramck/Detroit 3 services in the region. It was determined by the DWCHA and the Primary Care 10 59 *48212 Detroit/Hamtramck 4 Network Council (PCNC) that increasing the number of Federally Qualified Health 11 60 48238 Detroit 5 Centers (FQHCs) and expanding FQHC 12 62 48206 Detroit 6 services in the Detroit Wayne County area were important for improving *Workgroup initially recommended as sites to consider for New Access Points. and sustaining overall primary care services. The mission of FQHCs to care for the underserved, particularly the uninsured, Medicaid beneficiaries and recipients of public benefit programs, make the FQHC model an excellent model to respond to the area’s needs. In addition, FQHC federal grant funding and special Medicaid payment methodology enhances the ability of FQHCs to sustain delivery of comprehensive primary preventive care services. They also provide enabling services, such as translation and case management, as well as a sliding fee scale to diminish financial barriers to accessing health care. Improving Access to Quality Health Care | 73

DWCHA entered into an agreement with the Michigan Primary Care Association (MPCA) to work collaboratively in cooperation with the PCNC to develop a plan for expanding FQHC services. The PCNC established a Safety Net Expansion Workgroup and a Work Force Workgroup to develop recommendations for the plan. The Safety Net Expansion Work Group recommended that a set of principles be established to encourage cooperation in a transparent process of primary care service development. Based on the review of data and the geographic distribution of services, it recommended locations to be considered for the development of new FQHC service delivery sites, known as New Access Points. In addition, the Workgroup identified and ranked specific geographic areas of very high need and recommended that organizations be encouraged and assisted in establishing and expanding services in these areas. It also placed under consideration areas of potential New Access Point development based on geographic distribution (convenient to underserved populations). PRIORITY AREAS FOR DEVELOPMENT AND EXPANSION The workgroup reviewed and identified areas of high need. They considered geographic areas of the city and county in which FQHC services are lacking and generally more distant or more difficult to access. Subsequently, they also reviewed all areas of high need and prioritized them. The purpose of the priority ranking was used to identify those areas with substantial populations with very high need populations, regardless of the existence of an FQHC. In those areas of very high need without FQHCs, the logical first step is to seek New Access Points in which to deliver FQHC services conveniently to the population. The top six priority areas without FQHCs were chosen for inclusion. In high need areas with FQHCs, there is a need for the expansion of services. This can be accomplished through grants available for this purpose and changes in the FQHCs’ scope of services if other sustainable funding can be anticipated. There are some areas located greater distances from FQHCs that might be worthy of special consideration, even though they were ranked to have lower need, since transportation challenges can be a barrier to accessing care. The workgroup identified sites in northwest Detroit (48221, 48227). Similarly, the workgroup identified possible locations of other potential new sites that might improve access due to their distance from existing FQHCs and proximity to underserved populations. The Safety Net Expansion Workgroup completed the task of identifying areas in greatest need of services based upon multiple factors. It recommends that those priority areas without FQHCs be studied in detail, and where feasible, encourage and assist organizations in applying for FQHC New Access Point (grants to establish new facilities from which to deliver comprehensive FQHC services. Since these awards are limited, an alternate strategy is encouraging the establishment of FQHC ‘look- alikes’ where New Access Point awards are not awarded or organizations are not prepared to apply for full FQHC funding. In addition, to making services available relatively quickly, ‘look-alike’ operational development can demonstrate an organization’s ability to deliver FQHC services and strengthen its application for FQHC section 330 grant funding. The workgroup also identified areas of high need within which there are existing FQHCs. However, a relatively small percent of the population is currently receiving FQHC services in each of these areas. It is recommended that these areas be studied in detail, and where feasible, FQHCs be encouraged and assisted in applying for FQHC Expanded Medical Capacity and Service Expansion funding as well as considering change of scope for services that are self supporting. Improving Access to Quality Health Care | 74

priority Areas Improving Access to Quality Health Care | 75

High priority Areas with FQHCs Expanded Services Consideration Priority Score Zip Code City FQHC Rank 2 34 48210 Detroit Detroit Community Health Connection (Bruce Douglas site); also non-FQHC: American Indian Health & Family Services 3 37 48203 Detroit & Detroit Community Health Connection (Nolan Family Health Center) Highland Park 4 40 48201 Detroit Detroit Community Health Connection (Woodward Corridor site) Health Centers Detroit Medical Group (St. Antoine site) 5 40 48209 Detroit Community Health and Social Services (expansion planned) 7 53 48208 Detroit Advantage Health Centers (Health Care for the Homeless site) 8 56 48214 Detroit Detroit Community Health Connection (East Side Health Center) Health Centers Detroit Medical Group (East Jefferson site) Workgroup Suggestion Not Among Selected Priority Zip Codes; geographic Access Consideration Priority Score Zip Code Possible Location Notes Rank 14 69 *48227 Greenfield & Plymouth Northwest Detroit area 19 77 *48207 Mt. Elliott & Forest Detroit E Side Initiative Area 22 97 *48120 Schaefer & Michigan Ave. Dearborn; 48126 possible alternate location (<population) 23 108 *48229 Southfield & Fort **Ecorse; contiguous with River Rouge & Detroit 48217 24 114 48180 Wayne & Van Born Taylor City; new access point application unfunded, WWFHC 26 118 *48217 Oakwood & Dix **Detroit; contiguous with Ecorse and River Rouge 28 122 48221 Wyoming & 6 Mile Rd. Northwest Detroit area 29 138 48184 Wayne & Romulus Wayne City; not ranked among priorities; suggest access point *The workgroup identified a geographically isolated and underserved cluster of contiguous zip codes in the downriver area that includes River Rouge (48218), Ecorse (48229 & 48192-part) and a southern projection of Detroit (48217). A centrally located site might also be an alternative to separate development. Improving Access to Quality Health Care | 76

PRIMARY CARE NETWORK COUNCIL S TAT E M E N T O F P R I N C I P L E S : S A F E T Y N E T E X PA N S I O N 1. Establish the Primary Care Network Council (PCNC) as a forum for the encouragement and support of expanded Federally Qualified Health Center (FQHC) services through a transparent and cooperative process. The purpose of this process is to encourage cooperation between FQHCs, organizations and agencies in the expansion of FQHC services, and to establish the reputation of the PCNC as a collegial membership engaged in meeting the needs of the community. a. dd Safety Net Expansion as a standing agenda item of the PCNC, and allow 10–15 minutes in A which plans and progress of members engaged in expanding or establishing new services are shared and discussed. b. Establish two rules of conduct regarding this transparent process: i. No information shared in this forum should be independently released to the public or shared outside the PCNC without the agreement of the contributor and concurrence of the membership. ii. No member shall take advantage of any of the contributed information for competitive advantage over the contributor or use the information to the detriment of the contributing member’s project or organization. 2. Identify and prioritize geographic areas on the basis of need for new or expanded health care services, with priority given to areas of highest need. 3. Adopt a multi-faceted strategy for safety net expansion, taking into consideration statistical indicators of need; input of the Safety Net Expansion Work Group and the PCNC membership, encouraging and supporting: a. Establishment of new access points (NAP) i. Initial consideration given to existing FQHCs planning to establish new access points in the identified areas ii. Encouragement of other organizations’ plans to establish new access points in high need areas in which there is no commitment by an FQHC to do so. b. Service expansion (FQHC eligibility only) c. Expanded medical capacity (FQHCs eligibility only) d. Change of Scope (FQHC eligibility only – no new federal funding) i. Establishment of new access points ii. Expanded medical capacity iii. Service expansion 4. Encourage any organization seeking to expand access to quality health care as long as its proposal will not result in a diminution of services to the underserved. Improving Access to Quality Health Care | 77

S A F E T Y N E T E X PA N S I O N P L A N A D O P T I O N Adopted by the Primary Care Network Council: Date: Signed: Name: Signed: Name: Improving Access to Quality Health Care | 78

Coordinating efforts to meet the health needs of the uninsured and underinsured residents in the City of Detroit and wayne County by assuring access and improving the health status of all people. www.dwcha.org 3031 West Grand Blvd., Suite 545 Detroit, MI 48202 313.871.3751 Improving Access to Quality Health Care | 80

Improving access to quality health care final

by MPCA on Mar 08, 2010

Accessibility

Categories

Upload Details

Usage Rights

Statistics

Improving access to quality health care final — Document Transcript