South Cove Community Health Center

At-a-Glance

Location: Quincy, MA
Practice Type: Independent, federally qualified health center with four sites
Primary Care Physicians: 11 internists
Approximate Annual Patient Visits: 40,000
Reimbursement Model: Fee-for-service; for Medicare and Medicaid, FQHCs receive an all-inclusive, per-visit payment based on average costs incurred per visit

South Cove Community Health Center (SCCHC) serves a predominantly Asian immigrant population of roughly 30,000 patients from throughout the Boston area. The clinic’s staff is fluent in several languages, with 98 percent of the staff speaking at least one Asian dialect.

In additional to internal medicine, the practice provides pediatrics, behavioral health, obstetrics/gynecology, dental, optometry, and pharmacy services. Each physician is supported by one medical assistant. The staff also includes five registered nurses (RNs), two nurse practitioners (NPs), three front desk staff and two referral coordinators.

What Makes the Practice a Provider of America’s Most Valuable Care?

The Center aims for maximum patient accessibility. It’s open every day of the week and readily accommodates walk-ins. In addition, a 24-hour advice line is staffed by nurses who can contact one of the primary care physicians at any time.

Leadership has selected 14 internal quality measures, which are embedded in the electronic medical record (EMR). A member of the IT staff creates regular reports identifying gaps in patient care, including annual physicals, which physicians and other clinicians work to address. Having an on-site pharmacy helps to ensure each patient goes home with his or her medications. The physicians spend extra time with patients to ensure they understand how to take their medications, and written instructions are always given in both Chinese and English. Patients with chronic diseases receive three months of refills at a time to ensure they come back to the clinic for ongoing care and management. The Center can easily track when a patient has not refilled a medication and contacts patients to provide education and support to increase medication adherence.

The physicians are trained to manage complex medical illnesses, which helps maintain continuity, ensure care is provided in a culturally and linguistically appropriate setting, and avoids unnecessary referrals to specialists. When referrals outside the clinic are necessary, they are carefully coordinated, often include a translator, and are stratified by urgency. To ensure continuity of care, the physicians take the time to brief other providers on their patients, and send translators to the hospital when needed to help patients overcome language barriers.

How Do They Do It?

Two referral coordinators and a ‘closing the loop’ staff member ensure that all patients attend their appointments with specialists, and that the clinic receives information after the appointment. Urgent referrals and diagnostics tests have a two-week flag attached to them. If the expected information is not received within the two-week period, the ‘closing the loop’ staff member will follow up with the patient by phone or contact the specialist directly.

The Center ensures patients’ social and behavioral needs are met through a social services team that addresses non-medical needs, such as maintaining health insurance coverage and selecting a physician. In addition, because mental health care is stigmatized and rarely sought out in the Asian community, the practice screens patients for mental health issues during their required annual physical. Three psychiatrists, one psychologist and two social workers are available on-site to treat mental health needs in a culturally sensitive manner.

Q&A:

Eugene Welch, executive director, answers questions about SCCHC’s model for providing high-quality care while keeping costs low.

Q: Your practice has outstanding patient access. Why is this so important to your patients?

A: “We have found that if our patients can access the Center whenever they need to and speak with someone in their native language, we can triage them much better. We can determine immediately if a hospital visit is needed, and if it is, prepare the hospital with medical records and a translator before sending the patient. If the Center is closed, we can still triage over the phone using our 24-hour access line; and with technology, we can access patient medical records in the EMR via laptop or smart phone. We have one of the lowest emergency department usage rates in the area, because we are available to our patients all day, every day.”

Q: Does serving this population pose staffing challenges for you?

A: “It is a challenge. We have to hire based on language knowledge, and sometimes that means spending a significant amount of time training staff to fill the roles we need. We found that it takes six individuals to support one doctor, so we work hard at finding people who are committed to quality patient care and willing to be trained. Additionally, it’s a tough market to compete in, but because of our status as a federally qualified health center, we’re a good place for young doctors to begin their career. They can obtain free federal malpractice insurance, and are eligible to have some of their school loans paid. “

Q: How do you track referrals?

A: “Keeping close track of referrals is very important to us. Since our patients don’t speak English and aren’t familiar with our medical system, we need to remain very hands-on when we send them outside of our facility. Our coordinator makes the referral via computer and typically sends patients to whichever hospital can get them in the fastest. The coordinator then calls the hospital or specialist directly to set up an interpreter. The patient’s records from the hospital are fed electronically back to our EMR system and flagged so we can track their progression from that point on. Our system works like a bridge, and we make sure there is someone on both sides holding it up.”

Q:  Do you have any advice for primary care practices serving a non-English-speaking community that may want to deepen patient relationships?

A: “If you are going to serve a specific population within a community, you must go all the way into the pool, not just dip in a toe. Our patients are willing to travel many miles past other health centers, because they trust the culturally sensitive, high-quality care we provide. This means that we need to deliver in everything that we do—from the front desk staff to the primary care physicians. Everyone must be committed to caring for every unique need of this patient population.”

Features Highlighted:

  • Always on
  • Fulfilling quality guidelines
  • Moderately adjustable care intensity
  • Closing the loop