Cheryl Andrews lay alone on the wet tiles of her bathroom floor, blood dripping from her head after a fall in the shower. With the nearest hospital more than an hour away, the Provincetown resident relied on the only accessible health care option within miles of her home: Outer Cape Health Services.
“The joy of hitting your head is you don’t have any pain, but the downside is you have no sort of awareness of how seriously you’ve hurt yourself, so I got dressed and I walked down the street and got my head stitched,” Andrews, 65, said. “Just having [Outer Cape] right down the street… it’s a godsend, it really is.”
Andrews’ situation is common for residents on the Lower and Outer Cape and those across the state who live in rural communities and rely heavily on community health centers for primary or emergency care.
“It is quite possible that without us, people just would not have access to health care and for primary care and for walk-in care or behavioral health on the Lower and Outer Cape at all,” said Damian Archer, the chief executive officer of Outer Cape Health Services, a federally funded community health center.
In Massachusetts, 50 community health centers serve over one million patients, with a mission of providing primary care to underserved communities in urban and rural areas. However, in rural locations, such as areas of Cape Cod and western Massachusetts, community health centers face significant workforce challenges amid a statewide primary care physician shortage and, at times, may struggle to accommodate residents in their region.
“When primary care works really well, we can keep people out of the emergency departments and out of the hospitals often, which serves everybody,” said Shade Cronan, senior vice president of development and external affairs at the Massachusetts League of Community Health Centers, an advocacy organization representing the state’s community health centers.
But the centers providing primary care to rural communities have a “big issue” with their workforce as they struggle to offer competitive salaries and draw people to isolated areas, Cronan said.
Leaders and doctors in all four community health centers on Cape Cod — Outer Cape Health Services, the Community Health Center of Cape Cod, Duffy Health Center, and Harbor Health Services — identified retention and recruitment issues along with increased patient populations, offering a glimpse into the challenges of community health centers in more rural communities across the state.
Alan Sager, a professor of health law, policy and management at Boston University School of Public Health, said rural community health centers “face considerable challenges.”
“It can be hard to recruit doctors who will stay year-round,” Sager said of the Cape. “They also have enormous needs. … They have great needs for surge capacity during the summer.”
In an area like the Cape, the year-round population in “many towns is on the older side where the need for care is much greater,” Sager added.
Outer Cape Health Services tallies over 60,000 yearly visits in the 10 outermost towns on the Lower and Outer Cape, Archer said. The health center’s Provincetown location is the furthest medical facility from an emergency department in the state, he said.
“What makes us unique is that we’re really supposed to be a one-stop shop for most of your health care needs in an outpatient setting without barriers due to your ability to pay for your care,” Archer said.
Despite the reliance on the community health center in the region, Archer said since COVID-19, staff turnover has increased and with “no affordable housing” in the area, it is “almost impossible” for new staff to find a place to live.
The health center’s six locations list 30 job openings as of early December, including chief clinical operations officer, primary care physicians and licensed practical nurses.
Marie Constant, chief population health officer and Provincetown site medical director for Outer Cape Health Services, said the location is “filling a very important need” for residents in the area and needs more staff.
“We’re providing access to the most vulnerable,” said Constant, also a physician at the center. “We need more providers. We need more people to work. When I see patients, they’re so grateful because they’ve been waiting for a long time.”
Constant drives an hour to work at the Provincetown location because of the high cost of housing in the area when she took the job, she said.
Erin Mullaney, the director of dental operations and quality at Harbor Health Services, said recruiting for the Ellen Jones Community Dental Center in Dennis is also “extremely difficult.” The dental center has a waitlist of about 1,500 people, she said.
“It’s very tough to get in, and we just don’t have the staffing and the capacity to handle everybody,” Mullaney said.
For the Community Health Center of Cape Cod, which has seven locations on the Cape, between 200 to 300 patients register for care every month, according to Karen Gardner, the chief executive officer.
“From the start of COVID to post COVID, we saw about a 60% increase in the numbers of patients that we were serving, so just huge overwhelming increase in demand for services,” said Gardner, who has worked at the health center for 22 years.
At the same time, the health center has also seen staffing shortages in nursing, medical assistants, dental assistants and physicians, she said.
John McDonough, a professor of the practice of public health at the Harvard T.H. Chan School of Public Health, said every health care organization is “having trouble hiring.”
“There were staffing problems before COVID; they got especially severe during COVID, and they’re still serious across the board,” McDonough said, adding in health care, there is “always the uncertainty of change.”
“There’s always a wolf at the door,” he said.
Some Cape Cod residents, like Karen Peloquin, a cancer survivor who moved to Provincetown three years ago from Winchester, still travel over two hours to Boston to see their primary care doctors or for specialized care.
“It was really quite challenging in my mind that I was really going to be only having access to Outer Cape Health. It didn’t feel right to me,” Peloquin said on first moving to the Cape. “You’ve got the locals here that have been here generationally, and they are very, very underserved in health care.”
For Andrews, the Provincetown resident who relies on Outer Cape, the limitations of the community health centers are noticeable, she said.
“If anything, the facility could use a lot more staff, a lot more funding, and be able to provide even more services than it does,” Andrews said. “But you’re talking to one person who’s been exceedingly grateful for having the health center here in town.”
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