National Partnership for Women & Families

Monthly Women's Health Research Review

Study Assesses How Community Health Centers Organize, Deliver Family Planning Services

Summary of "The Organization and Delivery of Family Planning Services in Community Health Centers," Goetz Goldberg et al., Women's Health Issues, May/June, 2015.

"Over the last four decades, there have been dramatic improvements in access to family planning and reproductive health services for women" via expansions in the Title X and Medicaid programs, according to Debora Goetz Goldberg, of the Department of Health and Policy Management at George Washington University's Milken Institute School of Public Health, and colleagues.

Despite these improvements, the researchers noted that "access to family planning services remains a concern," especially for women who are uninsured, have low incomes and live in medically underserved areas. According to the researchers, the "dramatic expansion" of federally funded health care centers "under the Bush administration and the" Affordable Care Act (PL 111-148) has positioned the centers "as one of the leading providers of primary care services, including family planning, to low-income women and those living in medically underserved areas." However, they wrote, "Little information is available on how the centers organize and provide family planning services."

The authors explained that their study aimed to "examine systematically the design, organization, and operation of women's family planning services at health centers" and "characterize how care is coordinated on site and through referral arrangements," and "understand challenges health centers face in providing family planning services, as well as identify areas for improvement."

Methods

The researchers conducted the study from 2010 to 2012. In the study, "family planning" was defined as "outreach to at-risk populations; education and counseling; screening, testing, and treatment for conditions that can affect reproductive health; and access to a range of birth control methods."

For the study, the researchers developed a 30-question survey that "included questions on the range of contraceptive services offered; onsite availability of prescription drugs and devices; staffing arrangements; screening, testing and treatment practices; and collaborations with community providers serving the same population." The survey was emailed to 959 health centers in 2011, garnering responses from 423 (44%).

Meanwhile, the authors conducted case studies in 2011 and the beginning of 2012, selecting sites "based on a maximum variation of size, geographic area, urban/rural location, and receipt of funding through Title X of the Public Health Service Act [PL 91-572]." According to the researchers, nine sites were selected for "in-depth case studies." For the case studies, the researchers interviewed "a range of staff" on site about "services and contraceptive methods provided on-site, referral arrangements for services, and successes and challenges of providing a full range of contraceptive services."

Results

The authors "found a wide range of organizational approaches for delivering family planning services in health centers." They organized their findings according to "staffing arrangements, referral networks for care, and organizational structure."

Staffing and Training

"Staffing is generally consistent across health centers, except for the delivery of counseling services, which varies considerably," the researchers wrote. Specifically, the authors found that:

~ 92% of centers used advanced practice nurses and 91% used physicians to perform clinical examinations and Pap tests;

~ 89% of centers used advanced practice nurses and 91% used physicians for prescribing contraception; and

~ 88% of centers used advanced practice nurses, 85% used physicians, 44% used nurses and 22% used health counselors to provide family planning counseling services.

Meanwhile, the authors found a "significant difference ... with the use of health counselors" under Title X, "with 44% of Title X-funded health centers and only 14% of non-Title X-funded health centers using health counselors for family planning." At the same time, "No difference was found between Title X-funded health centers and non-Title X-funded health centers on the use of advanced practice nurses and/or physician assistants, or physicians to deliver family planning counseling."

Through the case studies, the authors found that physician assistants and advanced nurse practitioners "provide the majority of family planning services, whereas physicians attend to more complex patients." The cases studies also revealed every site that lacked Title X funding "identified the lack of staff training as a barrier to offering a full range of contraceptive devices and methods," while case study sites with such funding "did not indicate staff training as a critical issue."

Further, the case studies showed that "small rural health centers may not have a physician or other clinicians dedicated to women's health and frequently rely on referrals to regional [ob-gyns]." Such sites "also were less likely to have resources for outreach and education specific to family planning."

Referral Networks

In terms of referral networks, the authors found that while "[m]ost health centers are organizations with multiple delivery sites and often refer within their own network of providers ... the majority (75%) report referral relationships with outside organizations to offer patients access to specialized family planning services." Further, 52% "report one or more contraceptive methods available only through referrals."

Specifically, the researchers found that 72% of health centers "report referring patients to outside organizations for vasectomies"; and 67% "report referring patients for female sterilizations." Meanwhile, only 2% of centers reported referring patients to outside organizations for STI and infectious disease services, while only 4% said they referred patients for the human papillomavirus vaccine.

In terms of where patients were referred, the researchers found that:

~ 83% of health centers reported referring family planning patients to private ob-gyns;

~ 74% reported referring them to health departments;

~ 72% reported referring them "to other private physicians/group practices";

~ 69% reported referring them to family planning clinics; and

~ 57% reported referring them to STI clinics.

Meanwhile, the researchers found that health centers received "patient referrals from their local health department" (79%), as well as "from private physicians/group practices (75%), private obstetricians (65%), family planning clinics (62%), and ... STI clinics (57%)."

Among the case study sites, the authors found that the facilities "reported that their ability to offer specific contraceptive methods is often limited by funding, staff capacity and training, and whether the health center has a pharmacy on site." The researchers noted that sites with and without Title X funding "established referral networks to enhance patient access to family planning services." Generally, the case study sites said they had "strong referral relationships," although several sites said they had "a small number of incidents where patient information was not transferred and/or patients did not return to the health center for follow-up care."

Organizational Structure

In terms of the health centers' organizational structure, the authors noted that the case studies showed "that the organization of family planning services is largely based on health centers' leadership philosophy, commitment to providing family planning services, and funding."

They observed two models of family planning delivery and related reproductive health care: The "most common approach is an integrated service delivery model in which family planning services are incorporated within a full scope of primary care" and "delivered in family medicine clinics and [ob-gyn] clinics during general medical examinations or during specific visits for family planning services."

Alternatively, the authors wrote that some health centers instead used "a separate service line for family planning," which "was displayed by most Title X-funded clinics to separate family planning from other activities." According to the researchers, health centers using "a segmented model of care had separate clinic times, separate staff, and separate space for family planning services."

Challenges Faced by Health Centers

The authors also assessed common challenges facing health centers, with most centers (57%) "report[ing] barriers to providing family planning services." Barriers included financial challenges, "issues related to access," staffing issues, "limited facility space, difficulties in providing care to adolescents, transportation issues in rural areas, and patients' lack of awareness of health centers['] services."

Further, many centers said they faced barriers to "providing family planning services linked to the political and/or cultural environment." According to the researchers, such barriers included "provider refusal to provide a service or fill prescriptions, conservative social values toward family planning in the community, and conservative state laws."

The authors noted that the survey data and the case studies indicated that "Title X funding generates a substantial difference in the ability of health centers to offer a full range of family planning and related productive health services." Specifically, centers that had Title X funding reported that the money helped them "offer more family planning education," as well as "provide additional staff training, provide outreach to patents from specific cultural backgrounds, and deliver a wider range of contraceptive methods." Meanwhile, many centers that lacked Title X funding "reported a limited range of family planning services" because they lacked staff training on certain delivery methods.

Discussion

Overall, the authors found several factors influence health center family planning design and operation, including "leadership philosophy, organizational structure, commitment to providing family planning services, sources and extent of funding, cultural environment, and patient demand."

According to the researchers, "both the integrated model and the segmented model" of family planning service delivery "can be suitable organizational approaches for delivering" such services. They wrote that funding and staff capacity were more influential than organizational structure in terms of the ease of access to family planning services.

Still, they noted their findings "suggest that organizational structure is an important consideration for managing family planning services." They wrote that centers with integrated family planning "may need to take extra steps to ensure that women have timely access to a full range of family planning services," while centers that offer family planning separately or refer patients to outside organizations "may need to focus attention on providing seamless care through additional effort around communication and care coordination."

The authors also noted that many centers face both organizational and structural barriers when trying to meet patient needs, including difficulties that "centers face in attracting, retaining, and supporting sufficient staff suggest[ing] that not all family planning services are available at all locations." According to the researchers, such challenges "could be reduced if training programs for primary care physicians and advanced practice clinicians incorporated a full range of family planning services." Further, centers could address these issues "with guidance from federal and state health agencies and assistance in sharing innovative practices with one another."

The researchers also discussed financial concerns, which they said "represent the principal barrier to provision of comprehensive family planning services in health centers." They noted that the ACA's contraceptive coverage provisions hopefully will help reduce the number of women who cannot access contraceptives because of cost, although they acknowledge that "a substantial proportion of health center patients will remain uninsured."

They wrote that the ACA offers a "major opportunity to increase access to family planning services" in "states that fully embrace the" law, although fiscal challenges facing centers in states that do not expand Medicaid under the ACA "will remain high." According to the authors, "[i]ncreased direct public funding is needed from public sources to expand training of current providers, hire appropriate staff such as counselors and other clinicians, and to expand the scope of family planning services at health centers."

The researchers concluded that contraceptive and family planning coverage expansion under the ACA "provides the opportunity to further expand access to these services," though primary health care access issues "are significant" across the U.S. "Health centers will need direction in the form of technical assistance and policies that emphasize how health centers can incorporate quality family planning as a fundamental element of primary care," they wrote.