A Community Health Center Blueprint for Responding to the Needs of the Displaced after a Natural Disaster: The Hurricane Maria Experience

Background

Federally qualified health centers (FQHCs) serve as the health care delivery sites for more than 25 million Americans across the United States, including Puerto Rico and territories.¹ Federally qualified health centers have been shown to provide higher quality of care at lower cost, per patient, compared with private practitioner offices.^2,3 Despite the prevalence of FQHCs and the high-value care provided, many community health centers have extremely small operating margins⁴ and experience clinical vacancies as a regular occurence.⁵ This background presents challenges when an FQHC is tasked with quickly responding to the health care needs of people who are victims of a natural disaster.

This ACU column focuses on a blueprint created by Fair Haven Community Health Center in New Haven, Connecticut that allows for other health centers rapidly to develop and scale a strategic, flexible, and successful clinical response to a community crisis.

Situation: Hurricane Maria

Hurricane Maria was a severe, Category 4 hurricane that ravaged the islands in the Caribbean, including Puerto Rico, on September 20, 2017. Within weeks, survivors were leaving Puerto Rico, a population of 3.4 million people in 2016, and coming to the United States mainland, to areas with strong, pre-existing family and community presence.⁶ Far from being over, it is estimated that up to 6% of the Puerto Rican population on the island, or 212,607 persons, will migrate to the United States over the next year as a result of Hurricane Maria, and that by 2019, one in seven residents may have relocated to the mainland.⁷ The largest impact of this exodus is likely to affect Florida; Connecticut is likely to have the sixth largest influx of people who were displaced by the hurricane.⁷

Given that more than 49% of individuals and families on the island of Puerto Rico had Medicaid as their health care insurance, and another 6% were uninsured, the ability for FQHCs on the U.S. mainland to respond is critical.⁸ With hurricanes, forest fires, and floods having displaced millions of Americans over the past decade, it may well be that these catastrophic events will continue, and perhaps increase.⁹

Fair Haven Community Health Care (FHCHC) is a federally qualified health center in the Fair Haven neighborhood of New Haven, Connecticut. The Fair Haven neighbhorhood has a high concentration of Hispanics and Latinos, with many of New Haven's 27.4% Hispanic or Latino population residing there.¹⁰ A blueprint to respond to the needs of the displaced was not available to FHCHC as it began to respond to the crisis, and this report documents the experiences and lessons that can be applied more broadly to other scenarios across the United States so that community health centers can efficiently and effectively respond to future disasters.

Pilot DPClinic

Many recently displaced Puerto Ricans who came to New Haven after Hurricane Maria sought care at FHCHC. The organization quickly realized that normal workflows would not suffice to address the resulting increased demand. All patients were new to the clinic, most had significant social determinant of health needs, many required complex care coordination and management, and nearly everyone had some degree of mental health need. Scheduling this demographically unique population in the normal new patient registration process quickly overwhelmed the normal system of care.

Approximately one month after the hurricane, FHCHC created an evening clinic team comprising a social worker, a behavioral health (BH) provider, and two medical providers with full nursing support staff. Not knowing how best to respond to the influx, clinic personnel conducted multiple Plan-Do-Study-Act (PDSA) cycles on all facets of the clinic. All team members met weekly to debrief and respond using a PDSA framework for the following week.

Within a week, the workflow was altered such that, prior to seeing a medical provider, a patient was seen by the behavioral health provider and social worker. Health conditions (post-traumatic stress...