History of community health center affiliations with The New England College of Optometry

Article Outline

• Abstract
• Optometric education and the clinical system of The New England College of Optometry
• Boston area community health center affiliations in 2008
• NEEI and the academic medical center link to CHCs
• Blended business models could be the future of CHC affiliations with NEEI
• Summary: The benefits and challenges of CHC affiliations
• References
• Copyright

Abstract 

Background

Since the 1970s, The New England College of Optometry (NECO) has been a leader in community-based educational programming. This was accomplished through the development of affiliation agreements with health care facilities that care for the underserved, notably community health centers (CHCs). The college's clinical system, the New England Eye Institute (NEEI), develops CHC programs, manages professional services agreements, initiates teaching affiliation agreements, and leads staff recruitment and retention efforts.

Overview

CHC collaborations, which effectively address disparities in access to health care and visual health status, represent a significant component of the college's primary care clinical training venues. Since their inception in 1972, these CHC academic–community partnerships have provided more than 650,000 eye examinations to the underserved and have trained more than 3,200 graduates in community-based eye care, interdisciplinary care management environment, clinical prevention strategies, and population health.

Conclusions

This report describes NECO's longstanding success with CHCs, explains the scope of practice at CHCs, explains how students are involved in the CHCs' eye care services, and discusses the various management and business arrangements. The benefits and challenges of CHC affiliations with optometry schools and colleges are also discussed.

Keywords: The New England College of Optometry, Community health centers, Clinical education, Academic affiliations

Community health centers (CHCs) are multidisciplinary primary care ambulatory community-based and community-governed health care facilities. Community health centers provide primary medical, referral, and enabling services to poor and underserved communities. They were initially created as “neighborhood health centers” in 1965 by the Office of Economic Opportunity to provide care to the nation's poor and underinsured.¹ Since 1996, health centers included a consolidated group of public and nonprofit community-based health care organizations, which are defined within the Public Health Service Act.² Many receive the designation “Federally Qualified Health Centers,” which entitles them to “cost-based” reimbursement through Medicare and Medicaid.¹ Community health centers are administered under the Bureau of Primary Care, within the Department of Health & Human Services' Health Resources and Services Administration. Health centers are located in all states and territories of the United States and share a common mission to increase access to health and related services and to improve the health status of underserved populations in a culturally and linguistically competent manner. Health centers are also defined by their governance structure in that the entity must have a governing board with the majority of board members being patients of the center. This form of majority community governance assures that programs are responsive to community needs.¹

Health centers are ideal settings to deliver frontline professional health care education. Over the years, several health care professions and professional degree programs have established successful academic affiliations with CHCs. In the 1970s, the Forsyth School for Dental Hygienists instituted a highly successful training agreement with the Martha Eliot Health Center in Boston, Massachusetts.³ In a 1999 article by Cooksey et al.,⁴ Illinois CHCs were surveyed to assess the extent of academic affiliations for professional health care training programs. That report indicated that nursing, medicine, physician assistant, social work, pharmacy, and other health care–related disciplines, with the exception of optometry, had training programs at Illinois CHCs. More recently, Brown et al.⁵ described academic affiliations between community and migrant health centers and schools and colleges of pharmacy. This article reported that one third of the 1,260 CHC/migrant health centers had affiliation agreements with academic pharmacy programs, with more than 50% of the nonaffiliated CHCs expressing a desire for establishing similar academic–CHC pharmacy programs. The benefits cited for having an affiliation with a school or college of pharmacy included on-site education for students, staff, and patients, recruitment of potential future workforce, and having students serve as part of the CHC provider staff.

Optometric clinical education training programs at CHCs is not a new model, having begun in the early 1970s in Boston at The New England College of Optometry (NECO). At that time a decision was made to broaden the clinical education for students and increase practice opportunities for faculty by reaching out to the community and forming academic affiliations with community-based programs, with an emphasis on CHCs. This article reviews the history of NECO's CHC affiliations and describes the successes and mutual benefits derived from these enduring community–campus partnerships.

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Optometric education and the clinical system of The New England College of Optometry 

In 1972, NECO signed its first affiliation agreements with 3 Boston area CHCs, including the Dimock Center, the Dorchester House Multi-Service Center, and the South End Community Health Center. In these first affiliations, the college contributed the ophthalmic equipment to establish the eye service and provided faculty at no or little cost to the CHC to serve as attending optometrist(s). This was possible because of federal grants that were being awarded to the college at that time. Because of less stringent laws pertaining to compliance and privacy, some aspects of the program were shared, notably records and revenues. At that time, uncompensated care was commonplace, with little or no emphasis placed on the patient's insurance status or ability to pay for services.

A 1976 article by Charles F. Mullen, O.D., described the changes to the clinical system of NECO as follows: “The clinical system was charged with the educational responsibility of developing optometric students into competent patient care professionals who could apply scientific knowledge, tempered by clinical insight and overall concern for the patient…Coincident with this education mission, was a commitment to providing eye care to indigent and inner-city residents who either could not afford to meet this health need or were unable to do so…”⁶ Dr. Mullen's contributions to the development of NECO's community-based clinical system laid the foundation for the college's future enduring successes with CHCs.

Eventually, as was true of the other services offered at the health center, the eye clinics became fully owned and operated by the CHC, with the center assuming responsibility for all aspects of the program. This encompassed the ownership of equipment and its maintenance (NECO often made a donation of the original equipment initially placed at the health center), administrative aspects of the practice, medical records, billing for services, and collection of revenues. NECO's formal relationship with its CHC affiliates had changed, with a “blended” affiliation agreement having been developed to cover the terms of both faculty appointments and responsibilities to the center and the teaching program. By the 1980s, NECO began negotiating more formal annual professional services fees with CHC to cover a nominal portion of the faculty salary expenses. In this manner, both organizations continued to benefit; CHCs were able to provide patients with professional eye services of the highest quality at a reasonable cost, enabling NECO to benefit from the opportunity to train its students in a setting with a large number of patients from diverse backgrounds and complex health care, eye care, and social needs.

In 1994, Hoffman et al.⁷ reported on the state of NECO's CHC affiliations and relationships. By that year, the number of CHC programs affiliated with NECO had grown to 10. The mid-1990s also saw other changes to the college's clinical education approach with CHCs. NECO began to assign some third-year students to a part-time clinical rotation alongside the fourth-year students. By the end of the 1990s, some second-year optometry students were also assigned to clerkships, and by the year 2000 some first-year students were assigned for clinical observations of both optometrists and primary care physicians. To complete the 1990s comprehensive clinical education reform initiatives at CHCs, NECO began its first CHC-based residency programs. The Dimock Center's residency was established in 1994, and the Dorchester House Multi-Service Center residency began in 1995. Both of these programs have since been accredited by the Accreditation Council on Optometric Education. Also in the 1990s there were sufficient numbers of CHC affiliations in NECO's clinical system to allow for all fourth-year students to be assigned to at least one 3-month full-time clinical rotation. NECO now mandates a full-time CHC rotation as a graduation requirement (see Table 1).

Table 1. Number and year of students and residents assigned in academic year 2007-2008 at each health center

The 1990s brought about other changes to the affiliation agreement between NECO and the CHCs. The professional services fee base was re-evaluated, and the base fee was reset such that it was approximately 40% to 50% below the salary for a clinical faculty member. The CHC continued to receive a financial benefit for contracting with NECO for staff optometrist(s), and the college was beginning to cover some of its personnel expenses while assuring ongoing access to large numbers of patients for its students.

During this era, rather than a unified NECO–CHC strategic approach to workforce, each center's eye care service had evolved based on what the CHC leadership team and governing boards felt were in their best interests. Some CHCs preferred to hire their own staff optometrists, whereas others preferred the NECO professional services contract mechanism. Thus, by the end of the 1990s, even though all CHC affiliates had a formal teaching affiliation agreement in place, some CHCs had NECO faculty appointed to them (via the professional services agreement), and some had their own employed optometrists who had NECO adjunct faculty appointments. In this manner NECO ensured the quality of teaching for its students.

Hoffman et al.⁷ were prophetic by speculating about the future significance of CHCs to NECO's mission of community-based clinical care and education by noting: “Many Boston hospitals are familiar with the NECO–health center relationship and collaborative programs. As hospital–health center partnerships evolve and health care reform is implemented, NECO and the neighborhood health centers will benefit from their record of productivity, compatibility and commitment. As partners, they will play an expanded role in the delivery of primary care services. As we enter the next century, NECO will continue its participation in the Boston health care reform movement, ensuring the continued training of its students and faculty, the well-being of the citizens of Boston and the advancement of the optometric profession.”⁷

In 2002, NECO's Board of Trustees made a determination that the complexities of delivering eye care, including issues pertaining to potential professional liability claims, compliance with state and federal laws pertaining to health care, quality of care, patient rights, payer credentialing, clinical productivity, and clinical revenue cycle management, would be better served by creating a separate 501(c)(3) corporation for its clinical system. This newly created subsidiary corporation was named the New England Eye Institute, Incorporated (NEEI). Under this structure, NEEI is wholly owned by the college. Furthermore, because NEEI is a nonprofit health care organization, it is able to apply for certain types of grants that are not available to a college. Although there are plans to merge the governing boards of NEEI and NECO to ensure NEEI representation on key college board committees, the separate legal structure of NEEI will be preserved in order to focus on the patient care, clinical education, and community service aspects of the college's mission.

NEEI has grown into an extensive clinical network, with more than 45 fee-based (owned and operated) and contract-based (professional service agreements) practice locations and programs. In 2007, NEEI organized into 3 distinct patient care departments, with one wholly devoted to relationship management with CHCs and its principal hospital affiliate, Boston Medical Center (BMC). NEEI's work with CHCs includes the negotiation and updating of professional services contracts, arranging for teaching affiliation agreements with NECO, professional staff development, professional credentialing for clinical privileges within the NEEI network, assisting CHCs with payer panel credentialing, new CHC program development, best practice initiatives, sponsoring of seminars (such as for coding and billing), and personnel management including professional staff recruitment and retention.

The college is responsible for the quality of teaching and clinical education at CHCs, faculty appointment and recredentialing for the teaching appointment for all clinical faculty, quality of teaching, assignment of students to clinical rotations at CHCs, postgraduate residency programs at CHCs, faculty development pertaining to clinical teaching, and assisting CHC-based faculty in educational planning at their facilities. Thus, with NEEI and NECO working in concert, there is an appropriate balance between striving for excellence in patient care and excellence in clinical education at CHC affiliates.

The teaching affiliation agreements, managed out of the college's academic affairs offices, have evolved into distinctly separate legal documents, with specific language pertaining to how students are appointed to CHCs and how professional liability coverage extends to clinical teaching by optometrists who have faculty appointments (regardless of employer). This approach clarifies the differences between responsibilities of the optometrist(s) as professional staff members (outlined within the professional services agreement) versus teaching responsibilities as clinical faculty.

There were also compelling legal reasons that necessitated distinguishing between caring for patients and clinical teaching. The involvement of students in patient care remains strong, with students being able to conduct most of the examination testing and procedures. Attending optometrist faculty are fully responsible for patient care and directly supervise each patient encounter, as with any other clinical education program.

Regarding professional staffing, in 2008, 9 of the 13 CHC affiliates hire and appoint 100% of their professional optometric staff via an exclusive NEEI professional services agreement, 2 hire nearly all of their optometric staff directly while contracting a small component of staffing with NEEI, and the remaining 2 programs exclusively hire their own optometrists, with no NEEI staffing relationship. Every CHC staff optometrist, regardless of employment status, has a faculty appointment with the college (see Table 2).

Table 2. NECO/NEEI affiliation agreements at each health center in 2008

The Massachusetts League of Community Health Centers estimated that between 1972 and 2007, NEEI's CHC affiliates have provided approximately 650,000 eye visits. These affiliations have also enabled NECO to train approximately 3,200 optometric graduates in the field of community-based eye care (Hunt JW Jr. [president and chief executive officer of the Massachusetts League of Community Health Centers], personal correspondence to Elizabeth Chen [president, The New England College of Optometry] September 11, 2007). In 2008, NECO's CHC affiliations numbered 13, with 3 additional CHC programs in development. All 13 have teaching agreements with the college, and 2 have optometric residency programs under the category of “Community Health Optometry,” which was recently added by Association of Schools and Colleges of Optometry (ASCO) in 2006 (Wall M [executive director of the Association of Schools and Colleges of Optometry], personal correspondence to Wilson R [vice president, Health Center Programs, New England Eye Institute] Nov 26, 2006) (see Table 3).

Table 3. Health center visits for fiscal year 2007 and scope of on-site eye services

NECO continues to benefit in many ways from its longstanding relationships with CHCs, especially because CHCs enable the college to train students in settings in which specific public health curriculum components can be both practiced and experienced. Indeed, according to the National Association of Community Health Centers, CHCs take a proactive stance in addressing health disparities by developing strategies to identify, confront, and respond to disparities in access and health status.⁸, ⁹ The college places great importance on training its graduates to engage in community service and public health awareness efforts in their practice settings. NEEI's mission is devoted to improving the visual health of populations through collaborative and community-oriented patient care, education, and research. The college views that health centers are at the leading edge of public health initiatives aimed at improving the health status of communities. Thus, CHCs are viewed as ideal partners to meet some essential curriculum goals. The principles of healthy community concepts¹⁰ and clinical prevention and population health¹¹are common strategies used by health centers and are in harmony with curriculum objectives at the college.

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Boston area community health center affiliations in 2008 

Boston CHCs continue to operate as primary care multidisciplinary health care facilities, with comprehensive patient care services delivered using a variety of administrative and business models. Some CHCs maintain free-standing independent status with nonexclusive referral relationships to local area hospitals for advanced care and surgery cases. Others are more formally affiliated with hospital partners and academic medical centers, sometimes even operating as a department of the hospital, whereas others operate under the license of a hospital affiliate but maintaining relative independence.

Even as CHCs have evolved and become more mainstream as health care organizations, NECO and NEEI have maintained and strengthened their relationships (see Table 4 and Figure 1, Figure 2, Figure 3). Professional services' contracting with NEEI is in yet another new phase of development, consistent with changes in health care management. It is common practice for NEEI senior management to meet with the senior managers of the CHCs to negotiate and develop jointly agreed-upon performance agreements for the eye service, including productivity goals and revenue targets. The chief executive officer, chief medical officer/medical director, chief operating officer, and the chief financial officer of the CHC are typically at the table. Legal counsel reviews the agreements before final approval and signatures.

Table 4. NECO/NEEI-affiliated Boston area health centers

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• Figure 1. 

  Martha Eliot Health Center.

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• Figure 2. 

  Codman Square Health Center.

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• Figure 3. 

  Optometric intern examining a patient at Codman Square Health Center.

In an attempt to assure continuing success linked to the negotiated goals for the eye care programs, NEEI often charges the CHC an administrative retainer fee, which is usually embedded into the professional services agreement. The CHC pays the retainer fee to NEEI to secure the services of certain professional staff optometrist(s) from NEEI with an associated expectation that the NEEI optometrist will work with the CHC leadership team to achieve the agreed-upon goals. NEEI then negotiates its employment contracts with its professional staff to include an administrative stipend, which is paid in addition to base pay, for meeting or exceeding the agreed-upon goals for their CHC eye service. According to the terms of the NEEI contract with its optometrist(s), the administrative stipend remains in place as long as the optometrist agrees to work at the CHC as a NEEI optometrist and as long as the CHC agrees to pay the administrative retainer fee to NEEI. In this manner all stakeholders participate in the establishment of goals and the subsequent success of the CHCs' eye care service.

Other clauses under development in the professional services agreement include performance compensation eligibility, bonuses and language discouraging the direct negotiation of employment between an NEEI optometrist and the health center.

Even though the majority of CHC optometrists are employed by NEEI, some centers offer performance compensation and bonuses to their staff. In the revised agreements, NEEI requires any eligibility and payouts for performance compensation and bonuses to be paid directly to NEEI and NEEI then rewards its staff accordingly. Finally, in the past, some CHCs and NEEI optometrists entered into nonsanctioned direct-employment negotiations. The new professional services agreement and the appointment letters to NEEI staff both expressly forbid direct employment inquires from either party.

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NEEI and the academic medical center link to CHCs 

In 2004, NEEI developed another component to its professional services staffing, this time strategically linking NEEI with BMC, the principal hospital affiliate of many Boston-area CHCs. This was accomplished through negotiating a professional staffing agreement with the chairman of the Department of Ophthalmology at BMC. NEEI professional staff optometrists provide full scope eye care within the department's faculty practice plan, providing adult comprehensive care, pediatric care, advanced contact lens practice, and low vision care to BMC's patients. The optometrists have staff appointments in the Department of Ophthalmology and are fully credentialed providers within the BMC system. (NEEI optometrists who work at the CHCs that operate under BMC's license also have BMC staff appointments and appointments to the Department of Ophthalmology.) Thus, NEEI and BMC have collaborated at both the frontline level of care (CHCs) and at the level of the academic medical center (BMC) to assure that patients have access to and continuity of the highest quality of care offered by both professions.

BMC has become a key collaborator with NEEI, enabling several NEEI practice locations to add new or additional access to on-site comprehensive ophthalmology and introducing on-site subspecialty ophthalmology services to some of NEEI's CHC affiliates. The BMC relationship between CHCs and NEEI plays an important role for CHC patients, acting as a bridge for CHC patients between primary medical care services and advanced medical and surgical services. By fostering a patient-centered collaboration, NEEI, CHCs, and BMC have strengthened access to a full scope of eye care services to Boston's most needy residents. This unique collaboration has also allowed the college's students, residents, and optometric faculty to benefit from exposure to a wide range of clinical and social problems, including the co-management of complex patients with advanced medical and surgical needs with their colleagues in ophthalmology.

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Blended business models could be the future of CHC affiliations with NEEI 

In 1997, a marketing study commissioned by a greater Boston area health center identified eye care services as one of the most desired programs requested by the center's patients (unpublished data). The health center, Greater Roslindale Medical and Dental Center (GRMDC), a health center that was technically structured as a department of BMC, was planning a new 2-story building in the heart of the neighborhood's thriving square, with the health center to be located on the top floor of the facility. The entire first floor of this highly visible, centrally located building was to be left unfinished, with the hope of enticing a complementary (but noncompeting) health care partner, ideally eye care. In 2002 and 2003 the health center's governing board made the bold move to deploy its resources out of the upper floor, anticipating that its tenant–partner would be responsible for the build out of the first floor. This ideal street level location, along with the appeal of an “upstairs” referral opportunity from GRMDC, and the prospects of a highly favorable long-term lease arrangement was the health center's strategy for attracting potential partners.

During 2002, NEEI conducted a strategic planning retreat. In conjunction with key stakeholders from the college community, students, and affiliate constituents, NEEI's senior management team developed a strategic plan that included meeting clinical program needs through further growth in the clinical system. As part of the planning process, need for additional clinical placements, particularly for third-year students, emerged as one of the most critical issues. To meet this need, it was concluded that efforts should be directed toward owning another clinical facility (in addition to the college's principal clinical practice, which already served as the primary placement location for third-year students). There was an additional planning goal to adding this new practice site—that it somehow be linked to a multidisciplinary health care entity to assure a high level of cross referrals.

Thus, in early 2003, NEEI's Board of Directors made an initial inquiry to the governing board and executive director of GRMDC, with a request to discuss adding eye services to the health center's first floor. Once that initial contact was made, NEEI management and health center management embarked upon the negotiation of terms for the program. The final terms included NEEI having a long-term lease for the health center building's entire first-floor space, NEEI's agreement to build out the space for a comprehensive eye service to be owned and operated by NEEI, and a Clinical Collaboration Agreement to be signed by NEEI, GRMDC, and BMC to assure the quality of the patient care relationships. In 2007, having worked in concert with NEEI's board of directors and ultimately the college's board of trustees, NEEI negotiated the final terms of the project, commenced the build out, and opened New England Eye Roslindale (NEER) in mid-2007.

NEER became NEEI's first wholly owned and operated full-scope eye care program located within a CHC. To assure a seamless provision of health care and services, the Clinical Collaboration Agreement laid out a framework of cooperative and collaborative initiatives between NEEI, GRMDC, and BMC to assure ease of access to all services for local area residents, without regard to insurance status or ability to pay and in compliance with all state and federal laws. NEER offers the full scope of eye and vision care services, including comprehensive eye care and a full-service optical. On-site consultative ophthalmology services are being planned in collaboration with BMC.

Because NEEI wholly owns the eye care practice, NEEI is free to market its services to the community and accept any person as a patient. NEER serves patients of GRMDC and the surrounding community. To further assure its success, NEEI contracted with a marketing consultant to develop and oversee the implementation of a professional marketing approach at NEER. Monthly marketing meetings are held with the consultant, the director of eye care at NEER, and NEEI senior management. As a result, NEER and its staff are highly visible in the community, being members of numerous community groups, presenting patient education programs throughout the community, and providing screenings to local area school children.

As planned, NEER serves a significant role for NECO's third-year clinical program, providing the college with 24% of all third-year CHC clinical placements as well as serving as a site where fourth-year students rotate for low vision experience. Because of NEEI's strategic approach to collaboration and marketing, NEER has proven to be immensely popular, both with providers at GRMDC and local area residents. NECO students are finding NEER to be an ideal setting to learn both patient care and best practice strategies for a “start-up” practice, as well as learning how to effectively interact with a community and build a practice.

Because the NEEI and NECO boards were cognizant of the benefits relating to the college owning and operating clinical facilities, the opening of NEER was viewed as an important turning point for how NEEI may collaborate with new CHC partners. Ownership of the practice enables the college to have greater control of the setting and increased flexibility in educational programming, such as designating NEER as a mostly third-year venue. Finally, NEER's opening and its success is contributing to and strengthening the diversification of the revenue sources generated within NEEI.

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Summary: The benefits and challenges of CHC affiliations 

Academic affiliations with CHCs can serve an important function for schools and colleges of optometry, especially those that are trying to grow patient numbers for their students. Health centers are extremely busy health care facilities, which offer a pure form of interdisciplinary care and team-oriented patient care management. Training in such an environment is an ideal venue to work with multiple disciplines, to hone clinical skills, and to gain both competence and confidence in working with diverse populations. Thus, affiliations with health centers enable a school/college of optometry to develop a more diversified portfolio of clinical programs, thereby strengthening clinical education offerings and clinical services delivery.

The professional services contracting/staffing model developed by NEEI has served the college well for more than 36 years, enabling health centers to provide a needed service to its patients by expert clinicians. These affiliations require strong leadership, constant communication, ongoing relationship management, and a commitment on the part of the educational institution to work in a collaborative fashion with the CHC so that both parties benefit from the relationship. Mutually agreed-upon management decisions and working together as peers are the keys to successful collaborations.

The primary risk to the professional services contracting agreement may indeed be the CHC's own belief of how it should execute its mission to provide the highest quality of care. Many CHCs equate high quality to mean that teaching programs should be of limited scope, with a preference for patients to be cared for directly by a health center–employed provider. Although NECO and NEEI have had good success at integrating optometry students into the CHC workforce, recently some affiliates have reduced the number of student slots. Others have limited the numbers of less-experienced students (favoring fourth-year students), and some CHCs have chosen to move to a direct-care model with their own employed optometrists.

The direct employment and direct care model is perceived to be the most significant challenge for the college's CHC programs going forward. Although health center administration and governing boards still favor having teaching programs on-site to make contributions to workforce development, the trend may be toward a combined teaching program–direct care model. This would result in an overall decrease in the number of clinical placement slots and a decrease in the number of optometrists appointed via a professional services agreement. Thus, schools and colleges of optometry that collaborate with a CHC should endeavor to develop binding legal agreements, including clauses that allow for appropriate planning in the event of a CHC's decision to scale back its commitment to a teaching program or contracting arrangements.

Perhaps a better model to adopt is the establishment of college-owned and operated eye care programs housed in CHCs, much like the NEER model described in this article. NECO and NEEI made the decision to further diversify CHC affiliations through this model as with the recent opening of NEER. This was a strategic decision to secure the college's future ability to train students in a CHC environment. The benefit to this model is that ownership of the program lies squarely with a school/college, thereby strengthening the ability to control the clinical care and teaching environments, developing educational programming to the greatest benefit of the academic program. If NEER continues to be successful, NECO may very well look at other CHC partners to develop similar programs.

The New England College of Optometry has been able to effectively meet its clinical education and service missions by collaborating with community-based organizations, notably CHCs. Health centers represent a significant percentage of the college's local teaching affiliates, uniquely providing the cornerstone of comprehensive primary care clinical education experiences for all of its students. Furthermore, CHCs offer the opportunity to teach and practice public health principles and cultural competency. Students benefit from the vast array of challenging and complex patient problems, which are often multisystem and advanced in nature because many CHC patients have never had appropriate health care. Faculty optometrists find CHCs an ideal practice environment. The numbers of unique clinical cases and the challenges of administration have enabled faculty to develop professionally and contribute to the literature of community-based scholarship and health services research. As CHC professional staff, they routinely participate in medical staff meetings, management meetings, outreach activities, and community events.

Finally as with other professional degree programs (notably in medicine¹², ¹³), it is the college's hope that the public health outreach programs implemented by CHCs and its graduates' exposure to unique populations will contribute to optometric workforce development for underserved areas across the nation.

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