Investigators received 1006 surveys from 153 health centers, for an overall survey response rate of 67% with 88% representation of centers that were invited to participate (). Nurses and physicians comprised 27% and 16% of respondents, respectively. Twenty-five (2.5%) respondents were nurse practitioners and 47 (4.7%) were physician assistants. Forty-seven percent of the centers were rural. The median number of patient visits per health center per year was 35,000. On average, each health center had participated 2.5 years in the HDC, and 2.7 sites per health center were involved. The most common disease foci for the official Collaboratives were diabetes (78%), cardiovascular disease (31%), and depression (18%). Fifty-five percent of health centers had participated in more than one HDC disease initiative.
Health Center Respondent Characteristics (n = 1006)
Barriers – Time, Funding, Personnel, Staff Morale
Team leaders spent nearly 11 hours per week (27% of their time) working strictly on Collaborative activities, team members nearly 8 hours (19% of their time), chief executive officers nearly 3 hours (6% of their time), and physicians nearly 5 hours (10% of their time). Ninety-one percent of health centers designated personnel to spend at least some of their time on data entry, 80% for using registry data to determine patient needs, and 85% for leading quality improvement interventions. Most centers had someone with paid protected time for each of those activities, but approximately 20% of centers did not for each respective task. Those latter centers had persons spending extra, unpaid time completing the tasks, typically less than 20 hours per month. In contrast, only 24% of centers that had one person with paid protected time had persons spending extra, unpaid time on the activity.
A substantial proportion of respondents reported that lack of resources was a significant barrier to the HDC in 2003. Approximately half disagreed that there was sufficient funding and personnel to run the Collaboratives (). While 44% of respondents agreed that Collaborative workload was shared fairly, a sizable minority of 35% disagreed or strongly disagreed. Similarly, while 33% of respondents agreed that team member burnout was occurring, 31% disagreed. Most respondents noted that staff morale and finances either remained unchanged or improved, but significant minorities noted decreases in morale (18%) and health center finances (20%) due to the HDC.
Perceptions of the Health Disparities Collaboratives (%)
Incentives and Assistance: Principal = Community Health Center Leadership, Agent = Health Center Personnel
Team members, team leaders, medical directors, and chief executive officers agreed that more release time (60%) and additional money (39%) would help increase their ability to achieve Collaborative goals (). Improving the quality of care, professional development, personal recognition, and personal satisfaction were other important motivators for involvement in the Collaboratives, while relatively few respondents were motivated by career promotion opportunities (10%) or fear of negative consequences (18%).
Participants reported needing an average of 12 hours of release time per month to work on the Collaboratives, but only 22% of respondents actually received any. Half of the respondents thought that receiving no release time was acceptable. Only 3% received extra money for their Collaborative work from their health center. Among the respondents who were either team leaders or team members, physicians requested, on average, $825 per month extra beyond their salary for their Collaborative work, and non-physicians requested $444 per month extra. For the nonmonetary incentives, many respondents noted that they had received “none or a little bit” of personal recognition (62%), career promotion opportunities (82%), and skill/education development (55%).
When asked about areas where assistance from health center leadership was most needed, medical directors, team leaders, and team members thought that funding for direct patient care services was most important (45%), with significant support also for training in quality improvement techniques, data entry, assistance for getting buy-in from providers, creating an environment where the Collaboratives are high priority, and staff time for quality improvement. Respondents agreed that they needed additional support or resources to help patients with self-management (73%), improve information systems (77%), and get providers to follow practice guidelines (64%).
Incentives and Assistance: Principal = Bureau of Primary Health Care, Agent = Community Health Center
Chief executive officers and team leaders most frequently selected direct patient care services (44%) as an area where Bureau of Primary Health Care funding was most needed to improve the Collaboratives (), followed by funding for data entry (34%) and staff time spent on quality improvement (26%).
Preferred Targeting of Funding and Assistance from Bureau of Primary Health Care and Health Center Leadership for Success of Health Disparities Collaboratives
Variation by respondent type and by paid protected time
Perceptions of the HDC and attitudes toward incentives differed according to respondent type, most notably in the areas of finance and motivation. Chief executive officers, medical directors and team leaders were more likely to disagree that funding was sufficient to run the Collaboratives as compared to team members and non-team staff (71%, 59%, 64% vs. 46%, 29%, p<0.0001). Chief executive officers were also less likely than team members and non-team staff to respond that center finances had improved as a result of the Collaboratives (12% vs. 21%, 33%, p<0.0001). Team leaders and team members were more likely than chief executive officers and non-team staff to report that the workload was not shared fairly (47%, 38% vs. 24%, 23%, p<0.0001).
Forty-one percent of centers that responded had no paid protected time for at least one of the following activities: data entry, use of registry data for patient needs, and leading quality improvement interventions. Centers with paid protected time for data entry, and use of registry data for patient needs, were less likely to report burnout compared to those centers without paid protected time (61% vs. 83%, p=.01 and 56% vs. 84%, p<.01, respectively).