CENTRAL FALLS – As Stephen Larrick, Central Falls’ director of Economic Development and Planning, explained it, the major impetus behind the square-mile city becoming a municipality in 1895 was the cost of fire insurance.

The surrounding communities, mostly dominated by farmers, refused to pay the costs of maintaining a fire department within the growing urban district.

Originally, Central Falls was one of many villages within the town of Smithfield. In 1871, it split into three smaller towns: Smithfield, North Smithfield, and Lincoln, with Central Falls becoming part of the town of Lincoln.

“The farmers [in Lincoln] didn’t want to pay for the fire insurance that was needed,” Larrick said, talking with his fellow volunteer painters at the Central Falls High School health clinic. [See link to ConvergenceRI story below.]

“The farmers didn’t want their taxes to go for firefighters,” Larrick continued, explaining why there was a city within only one-square mile.

In the early 20th century, Central Falls was the veritable melting pot of the modern industrial revolution, home to numerous manufacturing plants and, for a while, the most densely populated city in the U.S.

However, in recent years, Central Falls had become the poster child of an urban city in decline: manufacturing plants closed, the city went into bankruptcy, the school system was taken over by the state, and the mayor was convicted of corruption.

Now, as Central Falls is being reborn, it is not the cost of fire insurance but the high costs of health insurance and delivery of health care services – and the innovative changes underway in response to those high costs – that is helping to reshape Central Falls as a new community model for health care, leading the way in Rhode Island.

In the best tradition of Don Bousquet Rhode Island-ese [and with a nod to Casey Stengel], “Who would have thunk it?

Beyond the doctor’s office
The underlying premise is that “medicine and health are much bigger than what happens in the doctor’s office,” said Dr. Jordan White, assistant director of Medical Student Education in the Department of Family Medicine at Memorial Hospital of Rhode Island and the Alpert Medical School of Brown University.

The training for all Brown med students involves a six-week rotation in Family Medicine, whether they decide to go into primary care or not. Some of these students will become the next generation of primary care physicians to practice in the world transitioning from free-for-service to global payments, Accountable Care and Neighborhood Health Stations. Family Medicine training now emphasizes health beyond the doctor’s office.

Med students, as part of their six-week rotations in Family Medicine, are being asked to think about the social and community context of health care, and how they would do a needs assessment of their community in which they’re working, according to White.

The primary focus of the training is in outpatient care – little or no hospital work is involved in the rotation placement. The students are tasked, White continued, with figuring out what the important issues of that community are. “Access to food, to be able to have a good diet,” she said. “They interview their clients and come up a theoretical proposed intervention.”

The med students are placed in a variety of practice settings – traditional group primary care practices, solo practitioners, patient-centered medical homes – as part of their rotation. There are also a series of lectures given on patient-centered medical homes as part of the curriculum.

New emphasis is being placed on understanding the barriers to health care – finances, language barriers, family issues – that often impede delivery of care for teenage pregnancy, end of life issues, and chronic diseases such as diabetes. “Our focus is on helping the family navigate the system,” White said.

The plan to restart the collaborative health-clinic at Central Falls High School grew out of just such a project envisioned by two third-year Brown med students working with the Family Care Center at Memorial, according to White.

The med students saw that there were a number of pregnant students at Central Falls High School, who found that with a child, it was difficult to navigate the demands of school and family.

More than just providing access to health care from a school-based clinic, the nature of the relationship with the care provider and the student becomes a determining factor. “The provider and the people that work there, the teams that provide the care, need to be trusted by the students,” she said.

While all Brown med students have iPads, so that the resources and curriculum are almost paperless, the dream of a common language in health IT is still elusive, according to White. “There are as many EMRs [electronic medical records] as there are practices,” she said. With 20 students, she continued, there are often 20 different EMRs, all with their own log-ins.

There are also medical and insurance compliance issues that restrict the ability of a medical student to write notes and document events, so often the students are required to write paper notes to assess their note-writing skills, she said.

Changing role of nurses in delivering family care
To date, while there is some coordinated efforts to integrate med student training at Brown with that of nursing curriculum at the University of Rhode Island and Rhode Island College, within the Family Medicine clerkship, there is not yet any formal coordinated training.

Nor has there been any coordination between the nursing programs and Johnson & Wales University’s new physician assistant degree program.

The immediate focus of the two nursing schools is to develop a strategic plan for the newly planned joint nursing education facility in the former Jewelry District. [Where the budget will come from to pay for the additional staffing required, the transportation and parking costs for students and faculty, and the day-to-day administration of the new facility is still not clear. See link to ConvergenceRI story below.]

The new collaborative school-based health clinic at Central Falls High School may provide an on-the-ground opportunity to develop such coordination, according to Lynn Blanchette, program director of the BSN program and an assistant professor at the Rhode Island College School of Nursing,

RIC has already established an ongoing educational partnership with Central Falls, “Achieving Together, The Innovation Lab,” involving both teaching and social work students. Two nursing faculty have been assigned to the task force, working on doing a needs assessment and program design.

Blanchette said that a bilingual nurse had just been hired to work with the Central Falls project as part of the effort to have nursing students engaged.

“Our effort has been to expand the partnership to include nursing with the aim of meeting the health needs of the community and the families that live in Central Falls,” Blanchette told ConvergenceRI. “There are other factors [beyond what happens in the classroom] that lead to school failure and lack of success in school,” she said, pointing to the health of a community.