As a first-year medical student, I have had the privilege of completing my Longitudinal Ambulatory Care Experience (LACE) at the Lake Elsinore Family Health Center, which is a designated federally-qualified health center (FQHC). LACE is an initiative by the University of California, Riverside School of Medicine that allows first-year medical students to gain clinical experience in a primary care clinic under the supervision of a preceptor. I have learned a lot from the population we serve and from my LACE physician, who has dedicated the majority of his career to addressing health disparities in underserved communities. I have also learned how health care is positively impacted by the creation of FQHCs.
These clinics can be traced back to President Lynden Johnson’s administration, which created Neighborhood Health Centers as a part of the War on Poverty initiative in 1965. The federally-funded neighborhood health centers provided health and social services to impoverished communities. Several measures were subsequently passed in Congress to provide primary care to the underserved, coining the term “federally qualified health center” in 1989. These health centers receive federal grants under the Public Health Service Act in order to provide health care to medically underserved populations regardless of their ability to pay. FQHCs are an accessible source of care in low-income communities that offer a full suite of services in a culturally competent manner, which decrease costly emergency department visits.
The Lake Elsinore Family Health Center, an outpatient facility of the Riverside University Health System, is one such clinic. It is located in Lake Elsinore, California, a designated medically underserved area by the Health Resources and Services Administration. As of 2016, the population of Lake Elsinore was 64,205, with an average income per capita of $21,191 and over 50% identifying as Hispanic or Latino, and 4.4% Black or African American. A total of 14.2% are without health insurance, and 15% of its population live in poverty.
Patients who are racial and ethnic minorities in the Lake Elsinore community contend with the markers of a lower socioeconomic status, such as lower education levels, a lack of well-paying jobs, a lack of health insurance, poor nutrition, access to transportation, language barriers and difficulty trusting health care providers. Lower socioeconomic status is also associated with poor health outcomes that include higher mortality rates from cancer, diabetes, asthma, hypertension, and cardiovascular disease.
The clinic provides adult primary care, pediatrics, maternal and child health, behavioral health and a host of preventative services. It provides services to community members of all ages regardless of their health insurance status or their ability to pay. By providing comprehensive health care in one location, patients are able to make multiple appointments in one day, which saves on transportation costs, time away from work or family and daycare expenses. The location also allows for continuity of care.
The Lake Elsinore Family Center also provides culturally competent services by employing clinicians and staff reflecting the racial diversity of its patients. Research suggests that patients increase their health services utilization and are less likely to postpone or delay health care appointments when the patient and the provider are of the same race or ethnicity. FQHCs are also mandated to have translation services to allow for easier and accurate transmission of health communication and to build clinician-patient trust. This is an improvement over using relatives to translate sensitive information to a non-English speaking patient, which can affect the actual message and the relationship between the parties involved.
FQHCs serve complex patients, many with multiple comorbidities that have worsened due to lack of health care, health insurance or distrust of the health care system. These patients are more likely to seek care in emergency departments, which drives up the cost of health care. Frequent visits to the emergency department is considered a marker for unequal access to health care. However, research has shown that having a FQHC within a community reduces the number of non-urgent visits to the emergency department, reducing the overall cost and burden to the health care system.
One patient that demonstrates the importance of having this FQHC clinic in this community is an unemployed Lake Elsinore resident in her late fifties with public health insurance. She suffered from a mix of complex diseases. She was visibly cachectic, diabetic, hypertensive, with constant diarrhea, cramps in her extremities and above all overwhelmed with managing her health. She had referrals to several different specialists to address her multiple diagnoses. She was understandably confused about which specialist was her next appointment, how to get to the appointment and with whom she should meet. For these reasons, she returned to her primary care physician for help.
My LACE physician and I thoroughly reviewed her case and proceeded to slowly walk her through her appointments. She was appreciative of the time the physician took to ensure they both developed a plan she understood, and that it was one to which she could commit. My LACE physician developed a great relationship with this patient and she felt comfortable returning to the clinic for a simple clarification instead of the more costly route of delaying care until her condition has worsened significantly. I was grateful to play a small part in her care and hope she will be able to get the required care beyond what this clinic can provide.
Although FQHCs are an essential part of health care, they face some challenges. Due to the large volume of patients that these clinics serve, wait times for an appointment as well as delays during an encounter can be lengthy, negatively impacting patient encounter satisfaction. In addition, there is usually a high turnover of providers at FQHCs, which impacts continuity of care.
Despite challenges with scheduling and provider turnover, FQHCs are currently playing a major role in ensuring equitable care for the underserved. Like the Lake Elsinore Family Center, they not only address the inequities in our health system, but also provide a necessary safety net for the most vulnerable in our society.