Community Clinics
First line of defense for our over-burdened health care system
By Lorraine Steefel, RN, MSN, CTN
March 14, 2005
As a new mother, 27-year-old Xue Jin Yee* feels depressed and overwhelmed. Her family, the main support she counted on during the delivery of her first baby, is far away in Hong Kong. Her husband works long hours for little pay and is unable to help out. It’s been two months since the birth of her baby and Yee is sleep deprived and feeling further isolated because of her inability to speak English. She turns to Asian Health Services (AHS), a Community Health Center (CHC) in Oakland, Calif., for help.
Across the country
In rural and urban areas, more than 3,500 CHCs form the cross wires of the primary health care safety net. CHCs grew out of the civil rights movement in the 1960s and the desire to provide accessible and affordable health care to low-income and community residents unable to access other care. The centers are non-profit and congressionally mandated to provide this care.
“We absorb patients that the city and county cannot absorb,” says AHS clinical services manager Susan Park, RN. CHCs provide care for the growing numbers of uninsured and underinsured and homeless families at higher risk for serious illnesses than the general population, in addition to migrant farm workers, undocumented immigrants, persons with chronic illnesses, and people with substance abuse problems. Like AHS, many centers were formed to serve diverse populations and provide culturally sensitive primary care services.
Estimates are that CHCs care for more than 15 million patients across the country, as more than 45 million people remain uninsured and even more are without a regular source of care, according to the National Association of Community Health Centers. The Institute of Medicine (IOM) report, America’s Health Care Safety Net: Intact but Endangered, underscored the critical importance of the safety net to the health and well being of the nation’s most vulnerable. Park says that in 2003, AHS provided 66,000 medical and dental visits, 95% of them to patients with limited English skills. The proof of success lies not with just with the numbers, but also with the improved quality of care.
All in a day’s work
AHS interim head nurse Kimberly Woo describes the course of a typical clinic day. First there’s telephone triage and troubleshooting. Patients call for advice, need to schedule an appointment, or have questions about their test results. Then the walk-ins arrive. By day’s end, treating symptoms of a cold or chronic illness, dressing a wound, providing immunizations and birth control injections, referring people to the local ED, charting, and returning patients’ calls have all become routine. What makes the work unique is the accommodation of culture into patient care and communicating with patients in their native language, be it a Chinese dialect, Vietnamese, Mien, Cambodian, Korean, or Tagalog.
When Xue Jin Yee complained about her depressive symptoms, Woo empathized with her in Cantonese. Woo explained that she recently gave birth and knows firsthand what Yee is going through. “Hang in there a little longer,” Woo encouraged her patient. “In a month, when the baby’s sleep improves, you’ll be more rested and better able to cope.” Woo, aware of how much the patient values her family, felt it was important to intervene as a substitute support system. Yee returned later to thank Woo for her advice. And Yee is happier since her parents have moved to the States and are helping out with their second grandchild.
Culture is key
Native Americans for Community Action (NACA), an urban Native American resource and cultural center, provides advocacy, education, and support for wellness to the community. Last year, NACA’s Flagstaff, Ariz.-based Family Health Center (FHC) treated more than 10,000 patients of all ages, mostly Native Americans from the Navajo and Hopi tribes, according to Carol Barth, RN, nurse manager at the FHC. The FHC is a primary health care facility for those who may easily fall through the cracks — mainly Native Americans living “off reservation” who don’t have health care insurance or who don’t qualify for the Arizona Health Care Cost Containment System (AHCCCS), Arizona’s form of Medicaid.
Many of the Native American FHC patients work in town and are bilingual and acculturated, but others maintain their cultural ties, going home to the reservation on weekends. They attend Christian churches but also participate in Native American rituals and ceremonies conducted by medicine men. Because NACA’s vision includes preserving Native American traditions, staff and programs accommodate culture and may include traditional healing practices and other culturally appropriate activities. “Culture-based care depends on and is tailored to each client,” says Barth.
Gordon Begay* was visibly angry when asked about foods that may have elevated his blood sugar level, a question that seemed logical to the nurse. Begay was complaining about fatigue, excessive thirst, and frequent urination. Diabetes was marked on his medical record. Culture was the missing piece from this health care encounter. Begay was a Navajo medicine man, Barth explains. His defensive behavior stemmed from the turmoil he felt between adhering to his diabetic diet and not offending other Navajos who offered him food to eat before a visit or ceremony, as was customary.
When Begay next returned to the FHC, Barth began the health care dialogue. They discussed a healthy eating plan for patients with diabetes and Barth helped Begay decide what to say to his people so as not to offend them if he couldn’t accept their food. “A significant problem is he doesn’t want to refuse their offering,” says Barth.
Begay became part of Harmony Through Health, a program developed because of the high incidence of diabetes among Native Americans — the prevalence of Type 2 is 12.2%, with a 40% incidence among Navajos, according to the Association of American Indian Physicians. Harmony Through Health includes patient education and a visit with a registered dietician at least once a year. The dietician tracks and recalls patients for nutrition reviews, foot exams, and blood work. Through federal funding, the program provides diabetic supplies and medications to those with no insurance.
“For good health, Native Americans believe that everything has to be in balance or harmony,” says Barth. The program and the FHC aim to help them achieve this balance.
Respecting beliefs
On the east side of Oakland, Calif., nurses at Clinica de la Raza care for the surrounding Hispanic population — mostly Mexicans, some Guatemalans, and South Americans. They are the poor and the disenfranchised.
Scott Taylor, RN, case manager, is a jack-of-all-trades who spends his day in patient triage and tackling paperwork for the HIV Access Ryan White Program funding. Taylor also educates patients, especially those with diabetes — a disease rampant among the clinic’s Mexican clients. “CHCs are especially equipped to educate patients,” says Taylor. Spanish-speaking nurses and staff facilitate the learning.
The staff understands about culture-based illnesses. Taylor explains empacho. Mexicans believe an incorrect balance of hot and cold foods causes a lump of food to form in the gastrointestinal track, resulting in empacho. Sometimes patients go to a healer who massages the area. If that doesn’t work, they come to La Clinica. In babies or young children, empacho is colic or gastroenteritis, according to Taylor. Another common illness is aire , believed to result from air entering into the body. Patients may complain of muscular or joint discomfort. After assessment, nurses usually find a muscle strain or dyspepsia.
“We show respect for patients’ cultural beliefs and assess them for teaching or for a health care provider visit,” he says.
Watch guards
Taylor calls CHCs “watch guards” for the community. “If it weren’t for CHCs, infectious diseases like TB, pertussis, chlamydia, and others would go undetected and/or untreated until later stages,” he says.
Without CHCs, Taylor’s patients would go to the county system for care — into the overburdened and underfunded EDs.
“Patients receive better care at CHCs because we can deal with problems in a timely framework, with little waiting time, and follow-up visits are closer,” says Taylor. At La Clinica, patients return to the same health care provider, a contributing factor in reducing and eliminating health care disparities.
It’s typical for patients to return to La Clinica for years. Maria Suarez* came for diabetes-related care for some 20 years. She received diabetic teaching and nutritional counseling. As a result, Suarez had a better quality of life, says Taylor. “Everyone knew her. She became part of the La Clinica family until she passed away,” he says.
Taylor sees his work as a giving back to the community, a role that gives him great satisfaction.
Lorraine Steefel, RN, MSN, CTN, is a senior staff writer for NurseWeek.
*Names are pseudonyms.