Consider tiny Santa Rosa, N.M., as a prototype for a community healthcare network.
"There are those who think the sense of community has declined, but it hasn't declined here," said Karl Yordy of the Washington-based Institute of Medicine, which is looking at Santa Rosa as it pursues its second "Study on the Future of Primary Care." Its first study on the subject was published 20 years ago.
With 16-bed Guadalupe County Hospital at its epicenter, Santa Rosa's health network includes everything from local public health agencies and the county agriculture extension office to a strategic plan involving the local elementary-school nurse.
Community involvement encompasses volunteer efforts and whatever financial commitment can be mustered.
"It would be nice to survive on our pretty financial sheet, but we don't have one," said Christina Campos, Guadalupe County Hospital's finance officer.
The local Rotary Club, for example, annually provides six $500 scholarships for nurses, and Colorado Springs, Colo.-based Telephone Express gives the hospital a 50% discount on rates.
The scholarships have been successful in getting a half-dozen nurses to Santa Rosa and another six to practice in other communities.
For their part, providers have become involved in outreach. They often make house calls and participate in health fairs. The hospital also plans to purchase a van to facilitate contact between patients and providers.
About 84% of the population in Guadalupe County is Hispanic, and about 15% is older than 65.
"Older Hispanic residents equate going to the hospital with dying," said Randal Brown, M.D., a hospital-employed physician who is bilingual and a native of Santa Rosa. "They don't like to go to the doctor's office. We have to make them feel comfortable with us.
"We had a lady who knew she had breast cancer for seven years," Brown said. "We could have done something about it before if we would've gotten to her. We're working to prevent those kinds of things from happening."
The Institute of Medicine, a nationally known not-for-profit think tank, calls Santa Rosa's struggle an effort to take its healthcare personally.
"Healthcare is a personal thing," study director Yordy said. "It's the values of the community that make things go."
Officials of the Institute of Medicine, a 25-year-old offshoot of the National Academy of Sciences, have been touring the country as part of a $1.1 million study to come up with a new definition for primary care. In the 1970s its first message touting primary care as a preferred method of delivery "fell on deaf ears," Yordy said. Another look is warranted because of unprecedented changes in the healthcare market and the development of integrated systems.
The study, scheduled for release in January 1996, is expected to affect physician reimbursement and primary-care graduate medical education.
Members of the institute's primary-care committee visited Kaiser Permanente and FHP International in Southern California; managed-care-intense Minneapolis and St. Paul, Minn.; the Mayo Clinic in Rochester, Minn.; and inner-city clinics in Los Angeles.
Six committee members checked in on Santa Rosa.
"I may be a hospital CEO, but my background is in public health, and that infrastructure is needed," said Pete Duarte, chief executive officer at 299-bed R.E. Thomason General Hospital in El Paso, Texas, and a committee member.
Infrastructure has come to Guadalupe County Hospital with help from 318-bed University Hospital in Albuquerque, N.M., as well as the state and federal governments.
A telemedicine link between Guadalupe County and University hospitals provides for teleradiology and consultations with specialists. In addition, a long-distance learning program has been set up to help train nurses and other providers.
Guadalupe County Hospital's rural health clinic could get a boost if it achieves not-for-profit status and earns HCFA certification. That will be yet another tool to recruit nurse practitioners and physician's assistants. Once a rural health clinic is federally certified, it can be staffed by physician's assistants or nurse practitioners who are reimbursed at the same Medicare and Medicaid rates as physicians.
Guadalupe County Hospital also has benefited from $150,000 in federally funded rural transition grants over three years. The grants help healthcare facilities come back from a crisis situation through strategic planning and goal setting.
In addition, the hospital was awarded $167,000 from HCFA in 1994 to develop outreach programs. Now executives are waiting to hear from the federal Rural Utilities Services, formerly the Rural Electrification Administration, on whether they will get a $336,000 grant to subsidize their telemedicine venture.
But Republican congressional cuts threaten transition grants. For Guadalupe County Hospital, the projected cuts could mean a loss of $200,000, or about 13% of revenues.
"That could be enough to tip this one over," said Pamela Galbraith, administrator of medical services at University Hospital. "But I won't let that happen. We'll find a way."