The State of Recovery: An Update on Community Health Centers in Puerto Rico and the Virgin Islands Geiger Gibson / RCHN Community Health Foundation Research Collaborative Jessica Sharac, MSc, MPH Sara Rosenbaum, JD Acknowledgements The authors thank Asociación de Salud Primaria de Puerto Rico, Inc. (ASPPR) for their ongoing assistance throughout this project. About the Geiger Gibson / RCHN Community Health Foundation Research Collaborative The Geiger Gibson Program in Community Health Policy, established in 2003 and named after human rights and health center pioneers Drs. H. Jack Geiger and Count Gibson, is part of the Milken Institute School of Public Health at the George Washington University. It focuses on the history and contributions of health centers and the major policy issues that affect health centers, their communities, and the patients that they serve. The RCHN Community Health Foundation is a not-for-profit foundation established to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the U.S. dedicated solely to community health centers, RCHN CHF builds on a long- standing commitment to providing accessible, high-quality, community-based healthcare services for underserved and medically vulnerable populations. The Foundation’s gift to the Geiger Gibson program supports health center research and scholarship. Additional information about the Research Collaborative can be found online at https://publichealth.gwu.edu/projects/geiger-gibson-program-community-health-policy or at www.rchnfoundation.org. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 2 The State of Recovery: An Update on Community Health Centers in Puerto Rico and the Virgin Islands Jessica Sharac, MSc, MPH and Sara Rosenbaum, JD This Issue Brief follows up on our earlier report By early March 2018, water and electricity had been restored to 99 percent and 88 percent of Puerto Rico on Puerto Rico’s community health centers in customers respectively;2 electrical power was back for all the wake of Hurricanes Irma and Maria. It also USVI “eligible customers.”3 But only two months before the presents information about the recovery status 2018 hurricane season begins, residents in both Puerto of the two health centers that serve residents Rico and the USVI face serious threats. They are contending with limited health care access, hazardous living of the U.S. Virgin Islands (USVI). conditions, and heightened risk of infectious disease and mental illness.4 One report from Puerto Rico found that Background between 2016 and 2017, the number of suicides increased In November 2017, we issued a report on the status of by 18 percent.5 The USVI’s two main hospitals, in St. Puerto Rico’s community health centers1 following Thomas and St. Croix, along with a health care facility in St. Hurricanes Irma and Maria. One month after Hurricane John, sustained so much damage that they will need to be Maria, health centers were beginning a massive recovery rebuilt.6 While all 68 of Puerto Rico’s hospitals7 and all effort. Nearly all clinical care sites had reopened at least community health center sites are open,8 as of mid-March, partially, but frequently with limited services; electricity was 11 percent of health center sites have no, or only limited, critically unavailable, and health centers reported an grid power and remain reliant on generators or, in the case extensive need for supplies and equipment and repairs of of one site, solar power. structural damage. 1 Shin, P., Sharac, J., Gunsalus, R, Leifer, B., & Rosenbaum, S. (2017). Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington University. Policy Research Brief No. 50. https://www.rchnfoundation.org/?p=6156 2 http://status.pr/Home?lng=en (Accessed March 8, 2018). 3 Federal Emergency Management Agency (FEMA). (March 9, 2018). Power restored to all eligible electric customers in U.S. Virgin Islands. https://www.fema.gov/news- release/2018/03/09/power-restored-all-eligible-electric-customers-us-virgin-islands 4 Rudowitz, R. & Foutz, J. (2017). Navigating Recovery: Health Care Financing and Delivery Systems in Puerto Rico and US Virgin Islands. Kaiser Family Foundation. http:// files.kff.org/attachment/Issue-Brief-Navigating-Recovery-Health-Care-Financing-and-Delivery-Systems-in-Puerto-Rico-and-US-Virgin-Islands 5 Johnson, S.R. (March 3, 2018). The road to recovery: prospect of federal funding could reshape Puerto Rico's health system. http://www.modernhealthcare.com/ article/20180303/NEWS/180309961 6 Gov. Kenneth E. Mapp. (November 14, 2017). Written Testimony of Governor Kenneth E. Mapp of the United States Virgin Islands Before the Senate Committee on Energy and Natural Resources. https://www.energy.senate.gov/public/index.cfm/files/serve?File_id=A2538A49-2953-4BA1-8C94-0807E62050A5 7 Johnson, S.R. (March 3, 2018). The road to recovery: prospect of federal funding could reshape Puerto Rico's health system. http://www.modernhealthcare.com/ article/20180303/NEWS/180309961 8 Kaiser Family Foundation. (March 16, 2018). Health centers in Puerto Rico: operational status after Hurricane Maria. https://www.kff.org/medicaid/fact-sheet/health-centers-in- puerto-rico-operational-status-after-hurricane-maria/ Geiger Gibson / RCHN Community Health Foundation Research Collaborative 3 Community Health Centers in Puerto Rico and the US Virgin Islands In 2016, Puerto Rico’s 20 federally funded health centers operated 86 sites and served 352,172 patients, 10 percent of all Commonwealth residents. This percentage will likely grow when patient care data for 2017 become available, since the statistics will include information from Puerto Rico’s 21st health center, a recently-designated “look-alike” health center.9 In 2016, the USVI’s two health centers delivered care in five locations in St. Croix and St. Thomas and served 17,154 patients, 16 percent of residents.10 Presently, the 23 health center organizations in Puerto Rico and the USVI operate a total of 99 separate clinical locations, with 93 in Puerto Rico11 and six in the USVI.12 Table 1, which displays information from the 2016 Uniform Data System (UDS, the official federal health center reporting system), provides patient and revenue data for health centers in both Puerto Rico and the USVI and those serving U.S. residents in the 50 states and Washington, D.C. Compared to stateside health centers, Puerto Rico and USVI health centers serve a poorer patient population and report a higher proportion of patients insured through Medicaid and CHIP,13 but a lower proportion of privately insured patients. Compared to health centers in the 50 states and D.C., Puerto Rico health centers derive a higher proportion of Source: Bureau of Primary Health Care. (2017). 2016 Health Center Data: Puerto Rico their annual operating revenue from Medicaid (including Data. Health Resources and Services Administration. https://bphc.hrsa.gov/uds/ datacenter.aspx?q=tall&year=2016&state=PR; Bureau of Primary Health Care. (2017). CHIP revenue), while USVI health centers’ share of Medicaid 2016 Health Center Data: Virgin Islands Data. Health Resources and Services Admin- revenue is somewhat lower. USVI health centers receive a istration. https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2016&state=VI. far greater proportion of their operating revenue from local GW analysis of 2016 UDS data; percentages for the 50 states and D.C. do not sum to 100% because non-CHIP other public insurance (0.5% of health insurance) and other governmental grants as compared to those in Puerto Rico public insurance (including non-Medicaid CHIP and accounting for 1% of revenue) is and the 50 states and D.C.14 not shown. 9 Look-alike health centers must abide by health center program requirements but do not receive BPHC health center program funding. https://bphc.hrsa.gov/ programopportunities/lookalike/index.html 10 http://www.worldometers.info/world-population/united-states-virgin-islands-population/ Kaiser Family Foundation. (March 16, 2018). Health centers in Puerto Rico: operational status after Hurricane Maria. https://www.kff.org/medicaid/fact-sheet/health-centers-in- 11 puerto-rico-operational-status-after-hurricane-maria/ The USVI currently operates six health center sites, five in St. Croix and one in St. Thomas (https://findahealthcenter.hrsa.gov). The Frederiksted Health Care Inc. health center in 12 St. Croix had four sites at the time of the survey but opened a new site on March 19, 2018 (personal communication, CEO of Frederiksted Health Care, Inc.) Puerto Rico and the Virgin Islands both receive CHIP funds, but Puerto Rico is the sole US territory to use CHIP funds to cover children above the income eligibility line for Medi- 13 caid (https://www.macpac.gov/wp-content/uploads/2016/09/Medicaid-and-CHIP-in-Puerto-Rico.pdf), while the Virgin Islands uses its CHIP funds to cover the costs of Medicaid children once its Medicaid funds are spent (https://www.macpac.gov/wp-content/uploads/2016/09/Medicaid-and-CHIP-in-the-US-Virgin-Islands.pdf). Bureau of Primary Health Care. (2017). 2016 Health Center Data: Virgin Islands Data. (Table 9E). Health Resources and Services Administration. https://bphc.hrsa.gov/uds/ 14 datacenter.aspx?q=tall&year=2016&state=VI Geiger Gibson / RCHN Community Health Foundation Research Collaborative 4 NOTE: Percentages may not sum to 100% due to rounding. SOURCE: GW analysis of data from the Survey of Community Health Centers’ Post Hurricane-Recovery Operating Sites Purpose and Methods Health centers report that, as of the time of the survey, 91 In order to gauge the pace and extent of recovery, we percent of sites were open and operating at full capacity sought to survey health centers in both Puerto Rico and the and with a full range of services. Another nine percent were USVI to learn more about their recovery experiences and to open but operating at only partial capacity and/or able to identify ongoing, unmet needs. In our earlier analysis of offer only a partial range of services. Respondents also health center recovery in Puerto Rico, we combined UDS report that eight percent of all sites will need to be rebuilt.15 data with information obtained from the Health Resources Thus, while all sites may be operational, some may be and Services Administration (HRSA) as well as from the doing so under significantly diminished conditions. All Asociación de Salud Primaria de Puerto Rico, Inc. (ASPPR), sites, even those in need of repair, were judged the primary care association representing Puerto Rico’s recoverable; that is, respondents did not expect that they community health centers. For this brief, we conducted a would need to close any site permanently. detailed survey which was designed to capture information Infrastructure and Supplies about health centers’ current state of recovery. It was distributed to the CEOs of Puerto Rico’s twenty federally Health centers were asked about the status of their funded health centers as well as its newest look-alike building facilities, communications infrastructure, health center. The survey also was administered to the equipment, and supplies. Sixty-one percent of health USVI’s two health centers. The survey was conducted centers indicated the need for repair or replacement of between late January and early March, 2018. physical building facilities (such as roof or wall repair) at some sites and four percent indicated the need for replacement/repair at all sites (Figure 1). Nearly half (48 Findings percent) of health centers reported that all or some sites All 23 health centers responded to the survey, resulting in a needed telephone and internet repair or replacement. One 100 percent response rate. Data are presented in the third (33 percent) of respondents reported that some sites aggregate for health centers in Puerto Rico and the USVI. needed IT infrastructure/hardware repair or replacement. Nearly one quarter (23 percent) reported that some sites 9 Note that percentages sum to more than 100% because sites can be open and operating while also needing repairs. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 5 NOTE: “Not applicable” responses were excluded. SOURCE: GW analysis of data from the Survey of Community Health Centers’ Post Hurricane-Recovery needed electronic health records (EHR) systems repaired or pharmacy staff; 67 percent, substance abuse staff; and 44 replaced. All health centers reported that medical supplies percent, mental health staff. Six and eight percent of health were fully restored at all sites. centers indicated it was not possible to hire mental health and substance abuse staff, respectively. When asked about Staffing Changes and Current Recruitment and their current ability to retain staff, 57 percent reported that Retention of Staff it was difficult to retain physicians; 47 percent, pharmacy Despite the magnitude of the destruction and the massive staff; 46 percent, substance abuse staff; and 25 percent for exodus of residents including health care professionals, mental health staff. Puerto Rico and the USVI health centers have remarkably been able to maintain pre-hurricane staffing levels, Services and Functions notwithstanding major losses experienced by their own All health centers reported that the following services and staff. Only one health center reported that physician functions are currently available at all sites that provided staffing had decreased significantly enough to reduce them before the hurricanes: general primary care services; services, while two health centers reported the same for medical records; referrals to other community providers for nurses. One health center reported that staffing for a needed testing or treatment; and community outreach quality improvement technician decreased significantly services (data not shown). Forty-six percent of respondents enough to reduce services while another health center reported that emergency department services, night or reported that dentist staffing had decreased substantially weekend hours (43 percent), and specialty care services enough to eliminate services. (40 percent) are currently available at only some sites Even as they have held onto their staff, health centers in where they were offered before the hurricanes (Figure 2). both Puerto Rico and the USVI not surprisingly face major Nine percent of health centers reported that offsite services recruitment challenges. Ninety percent of respondents such as mobile vans are unavailable at all sites that reported difficulties in hiring physicians; 88 percent, provided this service before the hurricanes. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 6 SOURCE: GW analysis of data from the Survey of Community Health Centers’ Post Hurricane-Recovery Major Challenges and Estimates of Time to Fully Discussion Recover This survey suggests that health centers – part of the Health centers reported the three top challenges facing health care backbone in both Puerto Rico and the USVI – their staff. By far, as shown in Figure 3, the most commonly continue to recover, but that serious challenges remain. reported challenges facing staff included the loss of their Many face rebuilding efforts; for some, the effort will be homes, the lack of navigable roads or transportation, long term. Telephone and internet connections, IT increased demand for workers to provide community infrastructure and hardware, and the ability to use outreach services, and the lack of child care and care for electronic health records all remain a significant concern. other family members. Other challenges noted by some Perhaps most importantly, health center staff, whose health centers involved the ongoing lack of electricity at response to catastrophic events has been nothing short of staff members’ homes and limited supplies of gasoline. remarkable, face grave problems themselves – the loss of More than one-third of respondents (35 percent) reported homes, the inability to travel, the lack of basic services for as a top-three challenge concerns regarding the ability of their families, and the lack of child care. Part of the recovery their staff to remain in Puerto Rico or the USVI. needs to be aimed at the recovery of the human capital that makes health centers what they are today. Health centers need support to recruit and retain staff, particularly Health centers were also asked to gauge the rebuilding for physicians, pharmacy staff, substance abuse staff, and time they would need to restore their organization to full mental health staff. This also means direct support to capacity. Over 80 percent reported that they expected to health center staff; this support might come in the form of take less than one year to fully rebuild, repair, or restore additional compensation as a form of hardship duty normal facility and service capacity. The rest (17 percent) through supplemental federal grant funding, improved estimated one to two years to achieve full recovery. access to emergency grants and loans, and direct support from relief organizations and charitable foundations. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 7