By Anna Gorman, Los Angeles Times
October 28, 2012
Nurse practitioner Matt Tomlin steps into a small patient exam room, logs on to a computer and pulls up a formidable list of ailments for the 57-year-old woman sitting in front of him.
Hypertension. Diabetes. Congestive heart failure. Obesity. Anxiety disorder. Multiple heart attacks.
Rosemary Ricks, hunched over in a bright yellow dress, moans and describes a fall she took earlier in the week. Dropping her head in her hands, she says she can't take the pain and needs some of her prescriptions refilled. For emphasis, she pulls a dozen medicine bottles, most empty, from her black purse.
"Wow, you are on a little bit of everything," Tomlin says.
After a quick exam, Tomlin steps out to call the pharmacy. "I'm pretty overwhelmed, to tell you the truth," Tomlin says, letting out a sigh. "She's got a lot going on."
Nonprofit community clinics like this one in South Los Angeles are part of medical safety net created a generation ago to help fill the unmet needs of poor, uninsured and chronically ill patients in struggling rural and urban communities.
With the major elements of President Obama's healthcare reform set to begin in 2014, they are being tested like never before.
There are 1,250 federally funded clinics nationwide that provide healthcare and social assistance, surviving on a mix of grants, fundraising and reimbursements from government insurance plans.
The Great Recession brought waves of additional patients who had lost jobs and health insurance, and the federal government provided $2 billion in stimulus money to help with the influx.
Millions more low-income Americans are expected to begin seeking out doctors and routine healthcare in 2014 when they become eligible for insurance coverage. The Obama administration sees the clinics as a proven model for serving disadvantaged neighborhoods and, just as important, a cornerstone of efforts to control costs.
Federal officials are investing $11 billion to increase the clinics' capacity and help address the major shortage of private doctors in poor communities. Health centers serve more than 20 million Americans and by some estimates could add 10 million more as health reform rolls out.
It's a big bet that assumes the centers can attract new, insured customers and deliver cost-effective care that keeps low-income patients out of high-priced hospital emergency rooms.
The clinics are already feeling the pressure of competition, aware they won't be able to survive solely as providers of last resort for those who remain uninsured after healthcare reform is implemented. California clinics launched a new marketing campaign earlier this month, calling themselves California Health+, a community health service network offering complete care "under one roof."
"This is our future," said Dan Hawkins, senior vice president of the National Assn. of Community Health Centers. "We're going to have a lot more paying customers, and whether they come back or not is going to depend on how we treat them."
The clinics' future also depends in part of on the outcome of state and national elections, which could affect healthcare funding and policies.
Ricks gets her medical care at the To Help Everyone Clinic — T.H.E. Clinic — where the name frames the challenge: Will such centers be able to help everyone?
T.H.E Clinic — a community fixture at 38th Street and Western Avenue for more than 30 years — is a place where the grand expectations of Washington policymakers meet the sobering realities of treating patients who often have poor health habits, limited resources and complex illnesses.
Patients often line up outside the two-story brick building before the doors open. They crowd into the waiting rooms and often chaotic lobby. Security guards direct traffic and administrators calm frustrated patients. Sometimes, paramedics must be summoned for those who need to go to the emergency room.
One recent morning, Theresa Day, 50, had been waiting two hours for her appointment. A bus driver who lost her job and insurance, she tapped her finger on the chair and flipped through a novel. More than once, she walked down the hall to ask how much longer she would have to wait.
"This is awful," said Day, who suffers from rheumatoid arthritis and used to go to Kaiser. She says she never thought "in a million years" that she would need to come to a clinic for medical care.
As it struggles to care for existing patients, nearly 55% of whom are uninsured and 30% covered by Medi-Cal, the clinic is trying to prepare for more.
The main clinic is being remodeled and a new satellite office is being planned. To become more competitive, administrators are trying to shrink wait times and nurture stronger personal relationships. In the past, patients were randomly assigned to any available medical care provider. Now, the clinic is trying to ensure that patients see the same professional each visit.
To improve efficiency, the clinic invested in electronic record keeping so healthcare workers can better track patients' health, assess their needs and document improvement. They also set up an online system for patients to check lab results, make appointments and contact their doctors.
Community clinics aren't a first choice for many patients, just the best option available in their neighborhoods. But the clinics have considerable experience and training in how to manage and treat patients with chronic illnesses. Unlike private physicians, they offer additional services, such as help with transportation to appointments and finding housing.
Although community clinic patients tend to be sicker and poorer, the quality of care at community clinics rivals that of private practice physicians, according to a recent Stanford University study. Other research has found that patients who receive most of their care at community health centers have lower annual medical costs than other patients.
But the challenges are daunting. T.H.E. Clinic, like others across the nation, struggles to recruit and retain doctors because the pay is comparatively low, the pressure is high and the cases are difficult. Motivating patients to change unhealthy behaviors, show up for appointments and take medications is difficult.
Nurses and medical assistants can tell obese or diabetic patients about the necessity of healthy eating, only to see some later show up drinking soda and eating chips. "You can't help them if they don't want to help themselves," says Sandy Canas, a medical assistant.
Socioeconomic and neighborhood conditions exacerbate health problems. South Los Angeles residents don't have the ready access that wealthier communities do to healthful foods and safe parks. Generational poverty, lack of education and homelessness are prevalent.
"For many of the people in this population, health sometimes takes a back burner on their priority list," said Dr. Derrick Butler, a family physician and associate medical director at the clinic. "There are always competing priorities here."
To help patients manage their health, T.H.E. Clinic offers a nutritionist, a social worker, family planning counseling, diabetes classes and HIV support groups.
With the economic slump, T.H.E. Clinic already has seen a more than 50% increase in patients to nearly 12,500 since 2008, said President and Chief Executive Officer Rise Phillips. The number is expected to grow by an additional 25% next year.
Doctors, nurse practitioners and other care providers are expected to see about 25 patients each day, many with multiple chronic illnesses such as diabetes, hypertension and asthma. They race between patients as backlogs grow.
Some patients are willing to wait if they can regularly see a doctor they like.
Meredith Booker, with shiny hoop earrings and a worried expression, waited about 2 1/2 hours to see Butler one morning. Booker, 47, has migraines, depression and high blood pressure, problems that got worse eight years ago, after her 20-year-old daughter was killed.
"I like this doctor," she said. "He cares about his patients."
Butler, who has worked in community clinics a dozen years, tries to make his patients comfortable, chatting with them as peers. He was raised by a single mother in a poor neighborhood in Portland, Ore. "I understand this community," he said.
Opening the door to a bright, clean exam room, he greets Debra Greene, 52, a regular with dyed red hair and fashionably ripped jeans who takes more than 20 medications a day. She ticks off her illnesses for a visitor. Hypertension. Hypothyroidism. Endometriosis. Pulmonary hypertension. Allergies.
"How are you doing? What's the word?" Butler asks.
Butler scans her medical chart and congratulates her for lowering her blood pressure. They talk about her acid reflux and her trouble breathing, and about seeing a lung specialist. He gently reminds her she needs to lose weight.
"You seem like you are doing better, as a package," Butler tells her.
"Yeah, I was a mess," she says.
"You said it — not me," he responds, smiling.
Greene was uninsured and had few options for medical care until she recently received Medi-Cal coverage. But she plans to stick with the clinic. "When I had nothing, didn't have insurance, they really took care of me," she said.
But another patient in the waiting room, Jesus Sarellano, 63, with thick glasses and a salt-and-pepper mustache, said he plans to leave when he qualifies for Medicare. Sarellano first came to the clinic four years ago when he lost insurance coverage at the hardware store where he worked.
He likes that the clinic is free and he can get his medications for hypertension, high cholesterol and asthma, but he wishes it had more specialized staff and equipment. "When I need an X-ray, they have to send me somewhere else."
In his call to the pharmacy, nurse practitioner Tomlin discovers Rosemary Ricks isn't due for a refill for two more weeks. Back in the examination room, Ricks admits she had been doubling up on pills to manage the pain. Tomlin tells her she'll have to wait for a refill.
"What am I supposed to do for the pain?" Ricks asks, her eyes welling with tears. Without medication, she says, she has only one option — the emergency room.
"Sorry, Mrs. Ricks, there is not much I can do for you," he says apologetically. "Come back and see me in two weeks, if you are still having problems."
Times staff writer Anna Gorman reported aspects of this story while participating in the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School of Journalism.
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