An Interview with Lander Cooney

by Beth Blevins

Lander Cooney is the CEO of Community Health Partners (CHP), a federally qualified health center (FQHC) in Montana that provides integrated medical, dental, behavioral health, pharmacy services and educational programming in rural Southwest Montana. Prior to that, she served as Clinic Director at CHP's Livingston site for five years.

Cooney holds a B.A. degree in Biology from The Colorado College and a M.S. in Science Education from Montana State University. Before joining CHP, she was a teacher and program director for The Traveling School, a study abroad semester program in South America, where she lived and taught in small communities in Ecuador, Peru, and Bolivia. After that, she taught middle school Spanish in the public school system in Montana for a year.

Cooney grew up in Kansas, but regularly visited the West with her family to go hiking and skiing, and always wanted to live there. When not working, or reading books on leadership, Cooney enjoys the mountains and rivers around Bozeman, skiing, kayaking, and biking, with her husband, daughter, and golden retriever. 

You have said that your experiences living and working in less developed countries opened your eyes to disparities in health, wealth and education, and drove you to work on disparities in your own country.  How did that lead you to CHP? And have you seen disparities in Montana that compare to what you saw in South America?

I spent three to four months a year in South America with The Traveling School. Before that I had done mission trips there—it was something I was interested in.  It was unique and interesting traveling with teenagers because they see things adults don't see. They ask questions, like “why are these people living in poverty and I don't?” Questions like this are powerful when they come from kids. It's not an easy answer to explain why some countries are less developed than others.

That became the defining feature of my life. When I was no longer traveling and I was working in the public school system, I began to see what poverty looks like in the U.S. What's different about poverty in the U.S. and Bolivia is that we hide it better. It's relative poverty we're talking about. In the U.S., we desperately believe in the American Dream, we don't want to believe class exists. But working in a public school system you can see poverty in a way that other people can't see.

I only spent one year teaching in a public school, so when I reflect on it, it's through the lens of how I understand public health now. The kids who were struggling in school didn't have dental care—they had cavities and dental pain. They didn't eat well. They couldn't concentrate because they were hungry and in pain. I think about those kids who were in sixth grade then and don't know where they are now—if they've even graduated from high school. I can only believe that those kids are going to have significant barriers in their lives, from what I was seeing in public school.

I'd love to see all our schools equipped with health centers on-site, so that kids won't have barriers to learning and can graduate from high school and have lots of opportunities in their lives. What you see in public school is that if kids don't have all the tools, they're not prepared for success. Seeing that from where I sit now, with a broader understanding of the social determinants of health, I understand that we can predict which kids will grow up to live long healthy lives and which ones will have significant barriers to achieving that. We later end up catching it in the jail system or in emergency medicine (when they get treatment for heart attacks, instead of getting care for chronic conditions), or in the Medicaid system. We ought to be making low-cost health interventions at the elementary school level. And make sure they get good elementary education, good preschool education. It's less expensive than living in jail, than treating a heart attack. Our approach in this country is backwards.

For me at this point it's hard to pull education and health apart. I feel like I ended up at CHP because I was in the right place at the right time. It offered me an amazing opportunity to work directly on some of the things that bother me about our country.

One of your clinic's goals is to help its clients earn their high school degrees. Why is this important to you?

It's not about me—it's about our mission to enhance community health and well-being. When we look at determinants of health, chronic disease and life span, we tend to believe that going to a doc makes you healthy—but that's not what the research says. It says it's your health behaviors and social circumstances, outside of genetics, that influences how healthy you are long term. When we look at health behaviors, they are intertwined with social circumstances, neighborhoods, transportation ability, access to healthy foods, education.  If you live in a neighborhood where it's hard to access fresh produce, you don't develop behaviors around eating vegetables. Or if it's unsafe to play outside, you don't develop healthy physical activities. These are strong predictors of whether people develop chronic disease, and how long they live. Our mission is to help people become healthier, but if we don't address social circumstances, if we aren't helping people change social circumstances in some way, we are going to have a hard time helping people meet their health goals.

Do you have community volunteers teach the classes or CHP staff?

The Livingston clinic site has a broad array of educational classes, not just high school equivalency. Learning Partners (part of CHP) is funded by philanthropy and grants. A part-time classroom teacher helps students take assessment tests, connects them with community volunteers, assigns them to a tutor, and helps them get to a level where they pass the high school equivalency test. There they might also learn computer skills, improve their English and take online college classes.

We also have a parenting support program, which offers weekly parenting classes, parenting support groups, and Parents As Teachers Home Visits, where we send a trained home visitor out to the home to meet with parents and children to share information about developmental milestones, safety, and to talk about whatever the parent wants to talk about, addressing their needs. The idea is addressing those root causes of poor health.

Do you know of any other FQHCs that do this or do you think yours is unique?

I'm not sure if others have exactly what we have. We were featured in a study funded by the Kresge Foundation and the Institute for Alternative Futures that presented 10 case studies of health centers ”leveraging the social determinants” of health.

One example was a health center in the South that was seeing children with intestinal bugs, coming from their water source. They decided, we can treat them every two months for diarrhea, but the problem is clean water. So they drilled wells, which helped a significant number of families in their area. You don't think this is a problem in the U.S., but community health centers (CHCs) are places where they see this type of thing. Another example was a CHC in Boston that saw local kids there had a low high school graduation rate—so they started their own high school at the health center. They are creating a pipeline of kids who go on to college. They offer them behavioral health counseling and internships in the center so they can see what a nurse or doctor does, and see more opportunities in this world.

Around 40 people last year got their GED through our program. The local high school graduated 110 students that year. You'd think, given that, that everyone here would eventually get their high school degrees, but we always have people traveling through, in transit situations, with more people still coming in.

How many patients does CHP see each year? And what are they coming in for?

We have four CHC sites, two dental clinics and four medical clinics that see 45,000 visits a year. We serve over 12,000 patients in a two-county service area that is the size of Connecticut. We rent space to folks who do WIC, housing support and energy assistance at our Livingston Clinic. There folks can get their medical, dental, pharmacy, housing support, WIC and counseling all in one place. We like to think of it as a warm hand off to another professional. It's amazing how significant a barrier it is to arrange a ride to another facility. There's also a significant barrier between medical and dental. We've reduced ER visits by giving injectable antibiotics to patients who are swollen and infected. In most dental offices that would be an ER visit, but we have a nurse give the injection.

People will wait so long for dental because they don't have access—and will wait until it's an emergency. We end up extracting teeth. We pull over 200 teeth a month in our dental clinics—we can't do root canals because of the cost (a root canal can cost up to $2,000). That is a clear indication of a health disparity in our country. So that's their only option. But when we take out a front tooth, it's hard to get a job as a waitress or cashier, where you're working with people.

You display graphs on your clinic walls. What do they show? And how does that help in your effort to improve efficiency and quality at CHP?

Sharing data in a timely, transparent manner assists us in maintaining focus and making forward progress on quality improvement initiatives. For example, are patients with diabetes getting better? What we've done is to use data to engage all of our employees in quality improvement (QI) efforts, to be constantly looking at systems and processes. So by sharing data transparency regularly, we can engage people at the front desk, and elsewhere, on how the processes are working.

All of our patients are organized in panels, so they see the same team (provider, nurse, medical assistant and administrative support) every visit. We can give that team info about those patients. We show each team a list of their patients with a certain diagnosis, like high blood pressure, and whether each patient's blood pressure is in control. With that data they might decide to call in those whose blood pressure wasn't in control. They can provide proactive care from a population perspective, so they provide patient care before the patients come in.

We use data in our education programs, pharmacies and HR department to make sure that people doing the work have the tools to make a change and are being successful. I have a couple of graphs on my window; other people have specific data outside their offices. Each clinic has specific measures that we rotate. We want patients to see it too, to show that we're trying to improve.

How does CHP promote health literacy?

We're constantly talking in the clinic about health literacy. Patients may be able to read, but for health literacy, you need to process a lot of words and numerical info at once—many people have been shown to walk out of their doctor's office without understanding what was said.  To help, we print out instructions, use plain language in talking with patients (like “high blood pressure” vs. hypertension), and have patients ”teach back” instructions. Medical professionals aren't necessarily trained in school to communicate with health literacy in mind. We use so many medical terms as common language, and we know that patients aren't understanding us. Changing those behaviors is hard.

How is your clinic funded?

As a FQHC, all of our services are available on a sliding fee scale to those who demonstrate that their income is 200 percent of the federal poverty level or below. Federal funding provides about 40 percent of our revenue, the remainder comes from patient fees—we charge $10 for a medical visit and $35 for a dental visit. Revenue from these self-pay encounters is a significant revenue source for us. We also bill Medicaid, Medicare and private insurance. We do some fundraising for our educational programs.  Our state is not one that funds CHCs in any significant way, and it doesn't have a robust Medicaid program. Over half of our patients are uninsured.

Is being a CEO like being a teacher in any way?

I think that as a teacher, I was a facilitator.  I helped students gain skills and do their best work. And that's my job here. That's how we achieve our mission, through employee engagement. I see lots of similarities—or I wouldn't be here.

What's your favorite part of your job?

Hands down, we have incredibly mission-driven employees. I get to come to work with people who are smart, patient-centered, who work very hard, and are dedicated. It's incredibly fulfilling.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Fall 2013 Issue