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Section III. Community Process

  1. Description of Community and Integration Efforts Prior to DRIS

    2. Community Characteristics

    Imperial County is the only designated rural county in southern California. The county covers 2.7 million acres and is located in the southeast corner of California. With a countywide population of approximately 140,000, the largest cities in Imperial County are El Centro (37,500 population), Brawley (21,500 population) and Calexico (25,150 population). It is bordered on the west by San Diego County (a 2 hour drive), on the north by Riverside County, on the east by the State of Arizona and to the south by Mexico. The city of Mexicali (approximately 1 million population) is located next to Calexico on the international border with Mexico.

    Imperial County has an agricultural and tourism based economy. Predominately a desert region, early settlers worked hard to claim the land for agricultural purposes through the construction of the All American Canal which brings water from the Colorado River, 60 miles away. This transformed the Imperial Valley into an important agricultural region. Leading commodities include livestock, field crops and vegetables. The County is diversifying its economy to include manufacturing and technology services. Several Enterprise Zones and Free Trade Zones exist in Imperial County, as a way of encouraging and attracting new businesses.

    Imperial County’s population trends lay the groundwork for the status of health care services and any efforts related to integration of health care delivery systems. A few of the key population trends include:

    • The population of Imperial County is rapidly growing, in contrast to the California population which is declining. There was a 27.4% population increase between 1990 and 1996. The rate of population growth has been consistent across all areas of the county. Natural increase (births minus deaths) added 12,153 (40% of the increase) and net migration added an estimated 18,247 individuals (60% of the increase). These rates contrast to California where 90% of the population increase is due to natural increase. Imperial County is expected to continue its rapid growth.

    • The age distribution of residents of Imperial County is slightly younger than California as a whole, including those over 65. The ethnic diversity of Imperial County differs significantly from the State of California. Sixty-nine point four percent of the population of the county is of Latino background, predominantly Mexican-Americans. This population group represents a higher percentage of Latinos than in any other county in California. For example in the neighboring counties, San Diego has 23% Latinos, Riverside has 32.5% and Los Angeles has 42%, respectively. In addition, the Latino population is growing at a faster pace than the rest of the population in Imperial, accounting for 83% of the population increase between 1990-1996.

    • Imperial County’s population is significantly poorer than the averages for California as a whole. 54.2% of the total population in Imperial County fall below 200% of the federal poverty level. Twenty-eight percent of the population is on the Medi-Cal program compared to 16.8% of all Californians. Per capita income is over $14,790 compared to the $24,090 for the state. Median family income in 1990 was also lower for Imperial at $25,771 compared to $42,508 for the State.

    • Imperial County ranked 58th of California’s 58 counties for the percentage of residents 25 years and older who had not finished high school at 46.8%. The California average is 23.8%.

  2. Health Care Delivery Systems

    3. Imperial County has a broad array of health care services. Two public hospitals provide a focus of leadership along with a well organized physician community. The two public hospitals are El Centro Regional Medical Center, a city-owned hospital with an active emergency room service, and Pioneers Memorial Hospital and Healthcare District, a district hospital with an active emergency room. These two hospitals formed a Joint Powers Authority called the Imperial Valley Health Resource Authority (IVHRA), in 1994, to allow collaboration and joint ventures necessary for the current health care environment. The IVHRA provides an ongoing opportunity for the hospitals, physicians and community (through publicly elected hospital board members) to plan for the utilization and expansion of services. In addition, IVHRA works closely with the community physicians through the Imperial Valley Medical Group (Imperial County’s IPA), representing both primary care providers and specialists in managed care contracting opportunities.

    Las Clinicas de Salud del Pueblo is a federally funded community health center in Imperial County with three clinic sites. Clinicas provides a comprehensive array of primary care services to a significant number of individuals most of whom are Mexican American. There are two 95-210 Rural Health Clinics, one in El Centro and one in Calexico, both are sponsored by the El Centro Regional Medical Center.

    The Imperial County Department of Health Services also provides services within the scope of traditional public health departments, including communicable disease identification, treatment and surveillance, as well as well-baby clinics and preventive health services for children. The Department of Mental Health Services contracts for mental health services for the severely mentally ill, both in county and out-of-county, and will assume the role as the Medi-Cal Mental Health Managed Care Plan for consolidated Medi-Cal mental health services in April, 1998.

  3. Introduction of the DRIS Initiative

    4. In 1996, the James Irvine Foundation visited Imperial County on several occasions to assess whether or not Imperial County would be an appropriate county for the DRIS Initiative. During those visits, representatives of the James Irvine Foundation met with hospital board members, hospital staff, local elected officials, employers, county health and mental health professionals, physician leaders and staff of community based organizations, including La Clinicas. IVHRA coordinated and convened the meetings. All participants seemed excited about the potential progress that support from the James Irvine Foundation would stimulate, particularly in the area of health-related data.

    The James Irvine Foundation chose Imperial County as one of 5 communities for the DRIS Initiative based on a site visit that gave high points for the community, its health care providers and the apparent compatibility of the community’s health care situation with the goals of the DRIS project. In addition to the enthusiasm of the community, the Irvine Foundation also identified a high outmigration of health care services and a historically low impact of outside resources from other foundations as indicators that a project in the Imperial Valley could be successful.

    In February 1997, Imperial County, through the IVHRA and its hospital administrators, received notification of the award of the Irvine Foundation determination that Imperial County would be one of the five sites for the DRIS program. In March 1997, the California Institute for Rural Health Management (CIRHM) Executive Director and the Community Consultant visited Imperial and met with IVHRA, physician, clinic and health department representatives to describe the first steps in the process of initiating grant activities. From this first visit until early in September 1997, there were a number of meetings and telephone consultations with IVHRA and physician leaders as well as with the health department to explore how the program would be implemented. These discussions were informal and did not clearly identify the roles and responsibilities of each group. There were open questions about the project, CIRHM and the consultants. However, there was continual interest in the potential results of such a project. The collection, analysis and dissemination of the health related data was of most significant interest to all parties in Imperial County.

    After many meetings, IVHRA agreed to move forward on the project and to convene a community health council made up of community leaders, employers, educators, and a wide array of health providers. The James Irvine Foundation’s local staff and community consultant provided input on the selection of the council members who were invited to participate by IVHRA. It was agreed that Phase I of the project would move forward.

    The first meeting of the Imperial Valley Healthcare Advisory Council was held in September 1997 during which time the council members discussed the purposes of the James Irvine Foundation project. The Council also created a mission and goals statement:

    MISSION: The mission of the Council is to develop a community consensus as to the health care status of the residents of the Imperial Valley.

    KEY VALUES: The pre-eminent value of the Council will be the establishment of consensus. The founding principle is that the Council will be an educational entity whose purpose is to be inclusive and expansive in its participants’ understanding of health care issues.

    MEMBERS: The Council members include the Director of the Imperial County Public Health Department, an Imperial County Board of Supervisors member, the Director of Imperial County Department of Mental Health, both CEOs and Chiefs of Staff of Pioneers Memorial Hospital of El Centro Regional Medical Center, the former Chief of Staff of the El Centro Regional Medical Center, a local pediatrician, the Medical Director of the IPA, the Director of the County Social Services Agency, several representatives of large employers and the Assistant Supervisor of the County Office of Education. It was agreed that additional members would be invited to participate as time progressed. In the fall of 1997, the Council was joined by the Benefits Manager for the Imperial Irrigation District.

    Council members were provided with a binder with new information added at each monthly meeting. The key leaders of each health care organization attended the majority of the meetings. Dr. Horacio Rodiles, the past Chief of Medical Staff of El Centro Regional Medical Center, assumed the Chair of the Council and conducted all meetings.

    The Council’s work was supported by a Local Coordinator hired by CIRHM and housed first at the Imperial County Planning Department and then at IVHRA. Early in Phase I it was anticipated that the Local Coordinator would work closely with the IVHRA staff. Late in 1997, CIRHM and the Community Consultant agreed that in order to move forward more effectively, staff support to the project should come directly from IVHRA in order to coordinate collaboration and work between the Council and the IVHRA.

    From September, 1997 through March,1998, the Council met monthly (except in the month of December,1997) to review the data contained in the Community Health Assessment prepared in coordination with the Community Consultant and the Data Consultants and to explore new opportunities in health care delivery systems development. Each month and each step of the way, the Community Consultant met with the IVHRA and physician leadership as well as the county health and mental health department to discuss upcoming issues and the progress of the project. Key participants included the Department of Social Services, the County Office of Education, El Centro Chamber of Commerce and the Imperial Irrigation District, in addition to the health care providers. Slowly, trust and enthusiasm was building among the participants.

    The DRIS learning objectives were covered in a variety of meetings and throughout Phase I. The information related to the objectives was presented in the context of the data organized by the Data Consultant and presented each month by the Community Consultant. Because of the demographics of Imperial County, the consultants chose to display all data in relation to the population as a whole in Imperial County, in relation to the Latino population as a significant majority in the county and in relation to California as a whole. The learning objectives and the data covered the following subject areas:

    • principles and philosophy of James Irvine Foundation and the DRIS Initiative;
    • demographics of Imperial County;
    • important ingredients of the rural integrated health system;
    • essential health care services;
    • managed care, its impact on access and outmigration for services;
    • employer health benefits and concerns; and
    • physician and clinic access to services.

    The Imperial Valley Healthcare Advisory Council was particularly interested in how the data and information about the health care environment impacted community health improvement. For example, additional data was reviewed related to which leading causes of death could be impacted by early intervention and prevention services. As a result of the Council’s interests in community health improvement and the County Health Department’s efforts to secure outside funding for health education services, the Council endorsed the health department’s efforts to conduct a consumer health survey - a direct result of the Council’s Phase I efforts.

    As Phase I of the DRIS Initiative entered its final quarter, the Council spent time exploring the potential functions that it could support for Phase II of the project. The January, February and March 1998 council meetings included information and discussions about the new Healthy Families Insurance Program for Uninsured Children. Data, gathered as part of Phase I, identified an estimated 25,000 children under 200% of the federal poverty level who might qualify for this program. A member of the Managed Risk Medical Insurance Board is a local Imperial County businessman and he joined the council for many of its discussions regarding Healthy Families. Blue Cross made a presentation regarding Healthy Families and several community physicians attended those particular sessions. The Council and IVHRA hosted a Healthy Families certification training attended by 120 individuals in late May, 1998.

    As Phase I came to an end, the Council expressed gratitude for the resources provided by the James Irvine Foundation in this process. The Council also acknowledged its interest in continuing and moved toward identifying a project for Phase II. Several projects were considered:

    • consumer health survey
    • Medi-Cal managed care
    • Healthy Families
    • administrative services organization

    On April 20, 1998, the Council voted as its principal DRIS function to study the feasibility of implementing an Administrative Services Organization in Imperial County. The study will be conducted in three parts:

    • Preliminary Feasibility Study Report on Potential ASO Functions, Benefits, Risks and Related Costs (Part One)

    • In-depth Feasibility Study Report on Selected ASO Functions (Part Two)

    • ASO Implementation Plan and Budget on Selected ASO Functions (Part Three)

    The process of approval at each step of the feasibility study will require an endorsement by Imperial Valley Health Advisory Council in conjunction with Imperial Valley Health Resource Authority (the business partner).

    The Council, using the DRIS $10,000 milestone grant, will support the Imperial County Health Department’s community health survey which is being primarily funded by a grant from the California Endowment. The Council members are individually participating in the Healthy Families outreach effort as one of the ongoing community benefit projects of the Council. Through the efforts of the Council and IVHRA, the Imperial County Health Department was enrolled with Blue Cross Healthy Families, which is the Community Health Plan. This will allow them to continue providing CHDP exams. The Imperial County Health Department is the largest CHDP provider in the County.

    In Phase II of the DRIS Initiative, the Council agreed that it would continue its partnership with IVHRA who would provide management services, coordination with the James Irvine Foundation and DRIS, and would implement any business activities that the Council might endorse. The Council would provide community input and support for identified projects and would be a focal point for information about community health priorities, new health initiatives and collaborations between health providers and other community organizations. The Council acknowledged the role that the DRIS project had played in providing data, fostering coordination and disseminating information and expressed enthusiasm for continuing the effort with the James Irvine Foundation.

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