Chicago's primary care safety net and breast cancer services for underserved women: Variation in access, organizational readiness, and referral coordination

Background/Significance: Access to patient-centered medical homes is one mechanism in the Affordable Care Act (ACA) to integrate care for newly insured Americans. Currently, safety net providers focus on comprehensive primary care for underserved populations. However, there are important differences at the local level in access to health care and its delivery and coordination that are not evident when we study the safety net as a whole. Using breast cancer care as an example, the University of Illinois at Chicago's Center for Population Health and Health Disparities is exploring the variation in primary care and access to breast cancer services in Chicago. Objective: Collect data from Chicago's diverse safety net providers at the delivery-site level in order to analyze variation in organizational characteristics, range of breast cancer services, and referral networks. Method: A 32-item survey was mailed to Chicago's 27 safety net providers that are comprised of federally qualified health centers, publicly owned clinics, free clinics, and family planning agencies. These organizations operate 120 different primary care sites in the city. The survey covers founding year, service area, clinic operations, patient volume, demographics, staffing levels, and utilization. Breast cancer-related questions include mammography services, referral sites, case management, care coordination, patient education, and risk assessment. Results: Survey respondents reported data for 41 delivery sites or 34 percent of primary care safety net clinics. These clinics served a median of 2,500 female, uninsured or Medicaid patients in 2010. Clinics operate with 0.25 to 13 physician FTEs. An estimated 35 percent of appointments are missed. Few sites provide mammograms, but more than half refer almost all their patients to only one hospital. Primary care clinics are not able to report patient mammography rates and only two-thirds of clinics have some type of electronic health record. Discussion: There is variation among clinics serving Chicago's underserved women with regard to overall capacity and resources and staff to support care coordination and referral networks for breast cancer prevention and screening. As with breast cancer in Chicago, determining which of these factors contribute to variations in access to preventive services and outcomes is needed to effectively expand the nation's primary care system.