Improving Population Health Through Integration of Primary Care and Public Health: Providing Access to Physical Activity for Community Health Center Patients

摘要

Objectives. Our community health center attempted to meet public health goals for encouraging exercise in adult patients vulnerable to obesity, diabetes, hypertension, and other chronic diseases by partnering with a local YMCA. Methods. During routine office visits, providers referred individual patients to the YMCA at no cost to the patient. After 2 years, the YMCA instituted a $10 per month patient copay for new and previously engaged health center patients. Results. The copay policy change led to discontinuation of participation at the YMCA by 80% of patients. Patients who persisted at the YMCA increased their visits by 50%; however, more men than women became frequent users after institution of the copay. New users after the copay were also more likely to be younger men. Thus the copay skewed the population toward a younger group of men who exercised more frequently. Instituting a fee appeared to discourage more tentative users, specifically women and older patients who may be less physically active. Conclusions. Free access to exercise facilities (rather than self-paid memberships) may be a more appropriate approach for clinicians to begin engaging inexperienced or uncertain patients in regular fitness activities to improve health. Integrating preventive recommendations into clinical work with individual patients is a complex and multifaceted obligation with competing priorities. Addressing preventative recommendations alone for patients in a typical day requires in excess of 7.4 hours. 1 Health care providers in community health centers (CHCs) are well aware that chronic medical conditions disproportionately afflict low-income and minority inner city residents, and are only able to address dietary and exercise recommendations at about 32% of preventive visits. 2 Nevertheless, clinicians acutely understand their public health obligation to address sedentary lifestyle and poor nutrition as contributors to the burgeoning public health problems of obesity, diabetes, and cardiovascular conditions. Lifestyle changes are initial steps toward preventing and addressing chronic disease though facilitating lifestyle interventions for disadvantaged urban patients is complicated. 4 While problems concerning dietary choices and changes for this population have been intensively investigated, 5–14 the specific barriers to increased physical activity for low-income minority adults have received less attention. 15–20 With few exceptions, research on strategies to increase physical activity among at-risk populations has focused on psychological or behavioral or motivational approaches to physical activity as opposed to alterations in the availability of access to exercise. 21 Low-income minority adults face a multitude of potential barriers to exercise. Some are personal, such as childcare issues; some are ethnic or cultural, such as lack of models of exercise for women; and some are structural, specifically lack of convenient, safe, low-cost or public indoor sites for physical activity. 22–24 Moreover, clinicians are still a major source of advice to patients and play catalytic roles in helping them initiate changes in diet, exercise, and smoking. At the same time, providers cannot easily alter the difficult economic, social, and environmental challenges that discourage healthy behaviors. Even when clinicians discuss exercise with patients, they are unlikely to assist them in setting goals for physical activity and even less likely to help arrange access to fitness centers. 3 Thus, we established a partnership with a community fitness center and arranged access to determine whether arranged access and referral leads to regular patient usage. In this context, our federally qualified community health center in New England arranged for adult patients (aged 19 years and older) to have open access to swimming and exercise facilities at the local YMCA through a contract between the 2 agencies to subsidize patients’ access. This project meshes with the expressed preferences of low-income minority women, in particular, for free gym access. 25 Initially, access was free for referred health center patients; after 2 years, the YMCA began to charge patients $10 per month for access (full members paid $30/month). The imposition of the copay on an already functioning program provided the opportunity for a natural experiment. We questioned how a new copay influences usage among patients who had already had free access for 2 years. Would the knowledge of the copay before initiating exercise alter the demographics of the patients who chose to go to the YMCA? The aim of our study was to describe patient demographics and utilization patterns among those who attended before the copay and stopped (precopay), those who attended before the copay and continued afterward (persisters), and those who began to use the YMCA after the imposition of the copay (copay). We also continued a similar but smaller open access project at the local YWCA tha