Los Angeles public clinics: A cure for the county's ills?

A new emphasis on wellness care in Los Angeles County is bringing changes to nursing as it creates new job classifications, placing nurses on hospital re-engineering committees, emphasizing the role of public health nurses—and costing some nurses their jobs, according to public officials.

By the end of this year, 83 outpatient clinics will be open in the county, almost doubling the number operating in September.

The county hopes to reach this goal by creating partnerships with private medical groups. Although all the clinics will be part of the county healthcare system, only 29 will be county operated. Private partners will run 10, and there will be 36 new private clinics. There will also be eight clinics for general relief recipients.

The changes fulfill the county’s 1995 promise to emphasize preventive outpatient care to qualify for the federal government’s $364 million bailout. Since then, Washington has also given $172 million to refurbish the county’s public health system, a task the county promised to accomplish in five years. That promise allowed it to obtain a waiver of federal Medicaid regulations; the county is now permitted to use federal dollars for outpatient service instead of hospital care.

Los Angeles County Public Health System Outpatient Visits
1994-95	4.0 million
1995-96	3.2 million
1996-97	3.65 million (projected)
mid-2000	6 million (goal)
SOURCE: Los Angeles County Department of Health Services.

As the number of clinics grows, the shift in priorities is affecting county hospitals.

One fallout of privatization was layoffs at the county-run Rancho Los Amigos Medical Center in Downey. The county is negotiating with two private medical groups to take over Rancho Los Amigos. Three hundred and eighty county health workers—primarily at Rancho Los Amigos, County-USC, and Olive View/UCLA Medical Centers—received layoff or reassignment notices in late September. Most of the Rancho Los Amigos workers who were laid off were transferred to other facilities according to their skills, said Karen Wunch, MSN, RN, chief nursing officer and director of professional services at Rancho Los Amigos.

The downsizing has been hard on nurse-patient relationships. “You can lose a whole unit,” Wunch said. “There is some immediate impact to overall flow of work, and the immediate need to establish effective nurse-patient relationships.”

As part of the facility’s restructuring, a new employee category is being created. The “rehabilitation associate” will be trained to combine the skills of the rehabilitation therapy technicians and nursing attendants, reducing the number of employees. “This new job would be clinically cross-trained, where one person would do more activities,” Wunch said.

To help direct its re-engineering efforts, Rancho Los Amigos has done work-flow studies, including analyses of nursing duties, to determine whether some activities could be performed by lower-cost employees, such as LVNs or attendants.

“We believe as we get through the transition process, our nurses will be pleased with what they can do,” Wunch said. They will be coordinators of care, advocates for patient and family. They will be expected to do educating and training and be a major participant in discharge planning.”

The county also has pledged to stop funding to High Desert Hospital in Lancaster, a hospital north of Los Angeles in the Antelope Valley, by July 1. The county has contacted close to 80 groups about taking over services at the hospital, which costs the county $8.3 million annually.

Once privatized, Rancho Los Amigos and High Desert Hospital will no longer be part of the county system. The number of county hospitals will be reduced to four. But the county’s services will be expanded by the establishment of private clinics. One is slated to open in Lancaster by the end of the year, while the 35 others will span the Los Angeles Basin, with many concentrated in the city’s poor areas, where many residents lack insurance.

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In October the first six clinics that were privatized marked their one-year anniversary. These clinics have survived through charitable contributions, Medi-Cal and other government funds, and subsidies from private operators.

Elizabeth Forer, MPH, MSW, is executive director of the Venice Family Health Clinic, which took over two of the six clinics. She called the past 12 months “our year of infrastructure development” and looks forward to more collaboration, especially with the UCLA School of Nursing. The nurse practitioner clinic has two nurse practitioners and two nurse assistants and also runs a teaching program for the UCLA nursing school. “They’ve been fantastic. That school is a marvel. They have bolstered the care we provide there,” Forer said.

An array of groups will run the new private clinics, which will be considered part of the county system. For example, the Tarzana Treatment Center will run primary care clinics in Tarzana and Lancaster, Sarkis-Broadway Family Medical Center will operate a Glendale facility for general relief recipients, and the social service group El Proyecto del Barrio will run a primary care clinic in Arleta, according to a county health department report.

The county restructuring with its emphasis on wellness has been good for public health nursing, said Kathleen Hunt, MS, RN, director of public health nursing for the county Department of Health Services. “We are excited about the prospect of networking and collaborating with the private sector in perhaps integrating some public health services in those partnerships. That process of dialogue is going on now.”

Before the reorganization, personal and public health services were provided in more than 40 health centers. But about 18 months ago during the budget crisis, the public health field staff was consolidated at 10 health centers.

The recent changes in the county health system have given the public health nurses a little more breathing room. “We are starting to integrate some of our services back into some of the centers we left,” Hunt said. “This is a whole process that is going to take a long time to evolve. This transition has been a positive and progressive one.”

Public health nurses are no longer being pulled into clinics to keep them running, which happened “all the time” before the reconfiguration, Hunt said. “Now, the cadre of public health nurses are 100 percent in the field doing health promotion and disease control on actual, reported communicable disease,” Hunt said.

Los Angeles County is not alone in its restructuring. Because of the high managed care enrollment in California, the state leads the nation in the shift toward outpatient care. The trend is evident in public systems throughout the state, said Peter Abbott, MD, MPH, acting deputy director of health information and strategic planning for the California Department of Health Services.

Several other county hospitals in the state are being leased, taken over by private firms, or shut down. San Luis Obispo is downsizing while Merced, Fresno, and Sonoma facilities are being privatized, Abbott said. As part of its reorganization, Los Angeles County is also trying to reduce its hospital beds by a third, to no more than 1,719.

“The whole outpatient movement is happening very quickly,” Abbott said. “You can see it in terms of large numbers of outpatient providers. You can see it in debates on how many days new moms should be allowed in the hospital. All those reflect trends in the industry and the medical community.”

Yet public health systems have been slow to change because of their unwieldy size and the sometimes slow pace of a public enterprise. “Being the provider of last resort means you are not on the cutting edge of change,” Abbott said. |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||

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