January/February 2004 · Volume 86 · Number 1

Health Services: Client-Based or Population-Based?

Kathy Rice 
Waco, Texas (117,000 population), the largest city in the five counties of central Texas, had been paying all of the local match for the local health department. The county included 19 incorporated cities and the county government, which paid no local match. 
To acquire grants from the state health department, each city in the county had signed an interlocal agreement 20 years earlier, allowing it to participate in the local health department. This agreement, however, had been crafted so that no city had to pay the local match except for Waco. As budget pressures grew and Waco began to examine its services, the health department was reviewed. Eventually, questions were asked about why no other locality was funding the local portion of this department.
Waco’s city council, health officials, and this author, while serving as Waco’s city manager, began meeting with the remaining local governments, along with local groups and hospitals, to discuss future funding. Invitations to join these discussions were sent to all citizens who had expressed an interest. It became clear that not many people had a good idea of how public health was defined, how it was funded, or how the health department related to the communities that were part of it.
Large-group techniques were used to set the tone and to teach us how to ask the questions and listen to the responses; included were the tools of appreciative inquiry and asset building.
So, a series of public meetings, workshops, and discussions was undertaken to define what the McLennan County Public Health Department did and should do. These meetings were held in numerous venues, with a variety of facilitators; all were videotaped so that the tapes could be distributed to citizens.
One of the first steps that Waco took was to join a nationwide effort that uses a software program to collect data from a variety of service providers, which would help the staff determine what the health trends were in the county. While this effort was not successful in its original mission, it did get hospitals and health care providers thinking about which public health issues were important to the community. Several entities purchased this software, but there were major holes in the data, as only a few medical entities were entering data and those that purchased the software were not consistent in keeping the data current. 
National initiatives were studied to discover what other states and local governments were doing so that we could start asking the right questions of our elected officials and citizens. Large-group techniques were used to set the tone and to teach us how to ask the questions and listen to the responses; included were the tools of appreciative inquiry and asset building.
Asset building is a technique that maps all the specific assets in a geographic area. This process then identifies programs based on the assets that exist and where they can be found in a community. They can be used to identify where and what additional programs are needed. Appreciative inquiry is a way of interviewing and questioning that looks at possibilities rather than at identifying a problem and trying to find a solution. Thus, the outcomes of appreciative inquiry are a focus on solutions that already exist, an amplification of what works, and a concentration on the future of what can and will be.
Regular meetings were held with elected and health officials. These meetings, which were open to the public and recorded, took place almost bimonthly for two years. Nine task forces that enlisted a combination of professionals and local citizens met frequently to look at specific issues, such as funding possibilities, communications, data gathering, needs assessment, and the possibility of a county-wide taxing district. Each task force reported recommendations to the core group.
The core group of decisionmakers included elected officials from the cities and the county because they would be asked to fund part of the local share and because some of the services would affect them. A major reason to keep people talking was to keep the health department in operation. The discussions were difficult to keep on track, as representatives with different agendas would appear at different meetings. Meeting notes were widely distributed, however, so that any person not attending a meeting would be able to see the context of all conversations. 
Ongoing communication strategies were devised and revised often to keep participants involved in the discussions. Strategies included newsletters, minutes, videos, editorial board meetings, community newspaper stories, and other distribution points.
Giving More Details
Many people assumed that Waco was providing services to low-income pregnant women and that these services were mainly for Waco’s residents. These assumptions were partially correct; this was a large portion of what the health department did. But many citizens from outside the city also received services. So the department began reporting statistics on where its clients lived. Waco’s Family Practice Clinic also began to offer prenatal services, under a federally funded program.
In cooperation with the city’s cable-television department, health department staff prepared a series of videos describing the 10 essential elements of public health; the local community was used to illustrate the health department’s accomplishments. These videos, which were funded by the Texas Department of Health and are now shown statewide, also are given to communities without cable-TV access and loaned to citizens at city halls and libraries.
A major reason to keep people talking was to keep the health department in operation.
 
After a discussion on what a good public health system for McLennan County might involve, a national expert in population-based public health conducted workshops that were open to the public. These meetings were attended by the Family Practice Center management staff, hospital managers, members of the local American Medical Association, health department staff, city councilmembers, and members of the local health advisory board.
After these meetings, discussions began to center on a population-based program for McLennan County and on alternatives to the dental and childbirth programs for low-income residents that were being provided by the health department. All meetings were televised on the city’s cable channel, and copies of the transcripts were made available for distribution to cities and citizens without cable channels.
Ultimately, the advisory group decided to move from a client-based health program to a population-based one. Such a program uses health statistics, needs assessments, and tools to aid in keeping people healthy rather than treating them only when they become patients. 
Waco began to make the transition and moved low-income pregnant clients to the federally funded Family Practice Center. This was a slow process, but with grants, current budget funding, and some one-time capital costs covered both by Waco and by the county government, the change was accomplished. The center, which already was in charge of delivery but not the prenatal care of children, was able to take on the health department’s prenatal caseload. By attrition, the health department changed the nursing positions to health educator positions.
The dental clinic was even more difficult to reestablish, as it was the only low-income dental clinic in five counties, with a long waiting list and lots of volunteers. A business plan was developed that included a combination of fees and a change in personnel that would make the clinic self-sufficient within four years.
There was a concern, however, that if patients had to pay a set fee rather than a sliding scale based on income, the neediest folks would be denied care. When preparing the trend and analysis studies, we had found that to some extent this already was happening, and that having a set fee that everyone paid would not affect the client base more than it already was being affected. A close watch will see if this trend continues.
A five-year business plan was developed to cover the entire health department, informing patients about what to expect and what the costs would be. It was flexible, and when the West Nile virus arrived in our region, we were able to find the funds to educate people and do some minimal spraying of mosquitoes, as well as identification and testing.
The 20 local governments approved a new interlocal agreement, which gave all of them the opportunity to pay a portion of the cost and form a new governing board. Waco gave up control of the health board and made it independent; it retained the staff so that no benefits were lost, but some of the control was shifted to the board.
The cities and the county now are paying a portion of the costs and are part of the new public health board. A second interlocal agreement with a higher payment schedule has just been approved.
This change, which has taken two years, has succeeded because the transition was smooth and because the larger cities and the county government now share the funding. 
Lessons Learned 
Getting elected officials and interested citizens to meet regularly for two years. Waco’s core group of staff changed frequently, except for several extremely committed people who kept working on the project, including professional staff members from the health department. But placing people in small work groups or task forces, with work commitments and scheduled recommendations sent back to a larger core group, made people feel that their participation was vital.
Language and levels of understanding of this complicated issue are varied and not broadly agreed upon. Many hours and thoughtful planning went into bringing people’s understanding of public health to a consistent level. It was time well spent to build a fuller, richer comprehension of what the department could be.
Flexible, multiyear plans are important so that funding entities know what to expect. Understanding objectives and pro formas on a multiyear basis gives funding entities the assurance that they can see what costs are doing and what effects anticipated changes will have on the costs and the services. Such providers as the hospitals and the Family Practice Center used these plans to show their expectations in their planning efforts.
But placing people in small work groups or task forces, with work commitments and scheduled recommendations sent back to a larger core group, made people feel that their participation was vital.
Change takes lots of conversation and time. Written and oral communications should appear in various media formats and be delivered in numerous directions so that people can join the conversation on many levels and in many ways. Cable television, study circles, community talks, videos, reports in the news media, and the Internet were all used in Waco to provide information for discussion.
Using new tools for facilitating large and small groups is important. Crucially, staff members, politicians, and others who will have to talk about these issues must understand them and have some new and proven tools to use to present the central ideas to groups of people. Appropriate tools are extremely helpful in raising people’s understanding, finding alternatives, getting needed input, and letting people know they are being heard and are valuable to the effort.
Employees can be effective in making positive changes when they are involved from the beginning, even if their jobs are going to be eliminated or changed. Employees understood from the beginning what was happening and that their input was needed. The dental clinic found ways to stay open, even though the first recommendation was to eliminate this cost center. Nurse practitioners had one and one-half years to find other jobs or to get the required courses to become health educators. Clerks who knew the Texas and U.S. Medicare and Medicaid laws had time to make the transition to other programs or find other jobs. Employees had the time and a place to discuss concerns and alternatives.
Mistakes or wrong roads taken are valuable instructors. Celebrate mistakes, and use the information to your best advantage. While our information-gathering system looked good initially, it didn’t work because of large data gaps. However, all the information that eventually was gathered was used, and the focus it gave to the planners was invaluable to Waco’s project. 

Kathy Rice is interim planning and development director, Temple, Texas (KRice@ci.temple.tx.us), and is a former city manager of Waco, Texas.