Overview
A unique and important requirement of all HRSA-supported health centers is “governance by and for the people served.[1]” The governing board (often referred to as a board of directors) plays a critical role: it is responsible for overseeing the operations of the health center. Involving patients in this role helps ensure that health centers meet the unique needs of their communities. This Technical Assistance Brief describes specific strategies for increasing the participation of farmworkers and other underserved populations in health center governance. It offers concrete examples of how outreach programs can contribute to this goal. Finally, it shows how patient and community data, particularly data obtained in an outreach setting, can enhance the board’s decision-making processes.
Governing Boards and Community Advisory Boards
At least half of the members of a health center governing board must be “consumers,” or patients, of the health center. Health centers that receive funding to serve “special populations” (such as migrant and seasonal farmworkers or the homeless) must also include individuals from these groups on their boards. If the health center cannot meet this requirement, there is another way to fulfill it. A separate governing board, called a Community Advisory Board (CAB), must be established. The CAB should advise the health center board on the needs of the community and advocate for health center clients. The CAB must also pick a consumer representative to serve on the board or advise the board in some manner.
Finding Board Members from the Community
A health center can find it difficult to recruit consumers for their board or an advisory group. Issues such as migration or unstable housing, long work hours, lack of transportation, fear, lack of trust, and language barriers can make it difficult to get and keep members of vulnerable communities on governing boards or CABs. Outreach workers often have close ties to the community and can be very helpful in identifying potential board members. They may approach farmworkers or others directly, or they may work with local partner organizations. For example, a health center in Bakersfield, California, has a farmworker consumer advisory group consisting of 20-25 community members. The outreach department at the health center partnered with Centro Binacional Para el Desarollo de Indigena Oaxaqueno (Binational Center for the Development of Oaxacan Indigenous Communities) to find members of the indigenous farmworker community to participate in this group.
Another strategy includes organizing an outreach event that will help identify community leaders. A health center in Quincy, Washington, organizes an annual migrant parent leadership conference sponsored by the state Head Start Association. Those who attend develop key parenting and life skills. This conference has proved to be a great place to find health center board members and in some ways “pre-trains” participants for board membership.
Supporting New Members
At first, new board members, especially those who represent consumers, may feel uncomfortable and not prepared to serve on a board. Therefore, it is important to offer trainings for new and existing members from time to time. Trainings should include strategies and skill-building techniques that help board members fulfill their responsibilities. Board members and advisory committee members should be familiar with what is required of them as well as the relationship between the board and executive staff. These trainings, along with all board meetings, should be held in languages that are appropriate for the board members. Outreach staff can often act as interpreters and help facilitate meetings.
Some consumer board members may experience additional fear or anxiety if meeting materials and other documents are not in their primary language or at an appropriate reading level. Develop easy-to-read and language appropriate guides and tools for understanding important documents, such as financial reports and health center policies. Outreach staff can also help with translation and offer suggestions on how to make documents accessible and readable to farmworkers. For example, a health center in Quincy, Washington, provides financial updates in basic and simple terms so that everyone on the board can understand.
Cultural Competency
It is important that governance activities take into account the cultural context of the patients served by the health center. The outreach department at a health center in Hendersonville, North Carolina, provides cultural competency trainings annually to all staff and board members. The outreach coordinator gives a comprehensive overview of the outreach department, farmworker-specific lifestyle issues, and the history of the health center. Tours of the agricultural areas and visits to farmworker housing are also included in the training.
Creating opportunities for board members, health center staff, and patients to meet formally and informally can also help to make farmworkers on the board feel more comfortable. Since advocacy and sharing opinions in public may be unfamiliar or culturally unacceptable to some farmworkers, opportunities that allow people to meet on their own terms can create a more comfortable environment. For this reason, CABs are often an excellent way to involve consumers in health center governance.
A health center in Bakersfield, California, has a farmworker community advisory group that meets once a month in farmworker camps. The agenda is set on the day of the meeting to feel more informal, and the only decision made before the meeting is about food. By doing things in a more informal way, the topics discussed depend on the farmworker consumer group’s preferences. After each meeting, the attending outreach director writes a report summarizing the meeting and shares it with the board of directors and the chief operating officer.
Planning and Logistics
Changing work schedules and housing, the need for childcare, lack of transportation, and lack of time may make it difficult for many consumer board members to attend meetings. These planning challenges may discourage someone from being part of the board. Therefore, efforts need to be made early on to address these planning challenges and avoid future problems.
Some approaches to planning meetings around different schedules and needs include the following:
- Create policies that reimburse board or advisory members for travel and lost wages. If traveling is still not an option, make sure members have easy access to technology that allows for them to participate from a distance. For example, pre-paid cell phones can be provided to migrant board or advisory members so they can participate in conference calls.
- Hold meetings where farmworker board members live. A health center in Nampa, Idaho, has a farmworker health advisory committee that sometimes holds meetings (in Spanish) at local camps.
- Provide childcare at the meeting for those who need it. Set up a separate space for children to play in, supervised by a trusted young person or adult. Another option is to reimburse board or advisory members for child care costs if funds are available.
- Reduce the number of times that a board meets throughout the year. A migrant voucher program in North Carolina holds an operational planning retreat with its board once a year. At these meetings, farmworker health outreach coordinators have an opportunity to voice their concerns about the center’s health care plan and other program goals and activities.
Using Outreach Data to Provide Community Input
Even if farmworkers cannot directly participate on the board, outreach programs can provide valuable community data and input to the board.
The migrant voucher program in North Carolina recruited a volunteer computer programmer to develop a customized system to document and track services regularly provided at its voucher sites, including medical, enabling, and outreach services. Information from the health assessment and encounter forms used during outreach are entered into this system. The system is web-enabled, so the data is updated immediately and can be viewed in real time by staff at the program’s administrative office. Administrative staff and board members use the data to: 1) examine trends in the services being provided at each of the sites; 2) review the needs of each site and its respective farmworker population; 3) plan programs and services with each of its sites; and, 4) develop relevant health education lessons that respond to emerging farmworker health issues.
Even without a formal system for data collection, entry, and analysis, outreach programs have access to very meaningful information from farmworkers that can be used by health center boards. Outreach workers who spend a great deal of time in their communities build relationships with farmworker families and other service providers. They see people’s living and working conditions firsthand and learn about people’s challenges and fears around accessing health care. They often understand cultural issues much more deeply than other health center staff, including differing beliefs about health and health care. Through connections to “natural leaders” in the community, outreach staff will often learn about people’s satisfaction – or dissatisfaction – with health center services in ways that patient satisfaction forms cannot convey. Outreach workers know when migrant farmworkers are arriving and departing. Therefore, they may have an understanding of people’s health care options in their new communities and needs regarding continuity of care. Whether the information that outreach programs collect is obtained through formal methods, such as surveys, or informal methods, such as observation and discussions, this information should be shared regularly with health center boards.
Conclusion
Although challenges exist in ensuring that consumers are well-represented on the board, the inclusion of farmworkers and other underserved populations helps the health center respond to the needs of the community and client population. Through a bit of planning and hard work, true consumer governance can be achieved.
Resources:
Building and Sustaining an Engaged Farmworker Majority Board of Directors: Challenges, Opportunities, Rewards. National Center for Farmworker Health, Migrant Health Newsline. Volume 26, number 6 (2009), pages 3-6. www.ncfh.org/newsline/09-1112.pdf
Federally-Qualified Health Center Rural Fact Sheet Series. Centers for Medicare and Medicaid Services. https://www.cms.gov/MLNProducts/downloads/fqhcfactsheet.pdf
Governance and Board Training for Board Member and Executive Staff. National Center for Farmworker Health. http://www.ncfh.org/?pid=36
Health Center Governance Information and Resources. National Association of Community Health Centers. http://www.nachc.com/hc-info-governance.cfm
Program Requirements. Health Resources and Services Administration. http://bphc.hrsa.gov/about/requirements/index.html
Contact your state primary care association for tools and training materials on consumer governance. http://www.nachc.com/nachc-pca-listing.cfm
[1] Program Requirements. Health Resources and Services Administration. http://bphc.hrsa.gov/about/requirements/index.html