Case Study 1: Providing Culturally Appropriate Services in a Changing Community

Our Covenant Health Center is a 17-year-old nonprofit clinic in an indigent, multi-ethnic neighborhood of a once-prosperous urban community.

Our Covenant was founded as a free pediatric clinic by a consortium of churches after a sharp economic downturn left many area residents without jobs or health insurance. Through the leadership of a retired public health administrator and the volunteer efforts of other church members, the clinic grew steadily. After only a few years Our Covenant has expanded to provide a wide range of medical and social services for which patients paid on a sliding scale based on household income. By its 6th anniversary, Our Covenant had received funding from several private foundations and had hired a full-time administrator and several full- and part-time clinical staff. Our Covenant celebrated its 10th anniversary by moving into a renovated discount store building, which was donated by its owners to avoid a tax foreclosure. The mission of Our Covenant Health Center is to provide community-based primary care for area residents, and the neighborhood has long viewed the clinic and its staff as important community assets. The 10-person board of directors includes 3 long-time community residents, and the community advisory board meets monthly to review operations and take part in planning. Both boards and the administration consider community capacity building to be one of Our Covenant's basic responsibilities. Two lay health workers were recruited from among neighborhood residents, and the veteran social worker/educator lives nearby. All three participate actively in the life of the community, visiting patients in their homes and conducting education and referral sessions. Changing demographics have complicated Our Covenant's community-based efforts over the past few years. When the clinic was founded, the surrounding neighborhood and the clinic's patient population were a roughly equal mix of African American and white Anglo families; today it is about 95% African American. About 6 years ago, an influx of Mexican and Central American immigrants to the city brought new populations to the clinic. Soon the clinic needed Spanish interpreters to care for the many patients with limited English proficiency (LEP) coming from across the city. The administrator obtained private funding for 2 half-time bilingual clerks, but the availability of language assistance drew more LEP patients to the clinic, and their need for language assistance soon overwhelmed the bilingual staff members' abilities. To date the clinic has not had the money to hire additional interpreters or bilingual staff and has relied instead on uncertified volunteers to translate. After a month in which almost 60% of the patients spoke little or no English, the administrator concludes that the staff must be reconfigured to meet the clinic's current and projected need for bilingual services. She proposes that the social worker and one lay health workers each be made halftime, and that the clinic use the resulting salaries to hire a part-time bilingual social worker and a parttime Spanish-English interpreter. The board grudgingly agrees but the community advisory board objects. They insist that the social worker, an original member of Our Covenant's staff and neighborhood resident, should not be penalized for not speaking Spanish. The community advisory board points out clinic statistics that show that the majority of LEP patients come from outside the clinic's target population and that a growing number come from out of state. They propose that all patients from outside clinic's designated service area should be referred to other facilities.

Question below.

How should the board of directors and administration respond to Our Covenant Health Center's changing patient population and the language assistance needs of the new patients seeking care there? Consider the issue from both the perspective of the original mission and the reality of the current demand.