Undercover(ed) Nursing
Nurses reach out to nearly 2 million uninsured Americans through free clinics and hospital-based programs

By Alicia Hugg, MA, RN
June 28, 2002

When Loretta Hillmon, a 52-year-old beauty salon owner, noticed a lump under her left arm, she asked her sister, an RN, to examine it. Her sister advised her to have it checked out by a doctor right away. But the uninsured mother of six procrastinated, in part because of financial limitations.

When she finally saw a doctor months later, she was told she had the "Jackie Kennedy kind of cancer"-lymphoma. Hillmon died a little more than a year later, having endured surgery, chemotherapy and radiation treatment. She left behind two daughters, aged 17 and 11.

Cases like this are all too familiar for nurses who work in hospitals that care for the uninsured, and the demand for programs that treat this patient population is increasing.

Last year, an estimated 2 million Americans lost their insurance, the largest one-year rise in nearly a decade, according to statistics released in February by Covering the Uninsured, a new partnership of national organizations, including the American Nurses Association and the American Federation of Labor and Congress of Industrial Organizations.

Lack of affordability

The rise in the number of uninsured Americans can be attributed in part to the large number of people that earns too much to qualify for public health care coverage, but cannot afford private insurance, said John Sweeney, president of the AFL-CIO.

To tackle the problem, the government is creating programs such as the Depart-ment of Health and Human Service's Healthy Families mandate to benefit children who live in poverty. Nurses also have proved a critical part of the solution.

Nurses throughout the country are bridging health care gaps to provide services to the uninsured and indigent through nurse-run clinics, university- and hospital-based programs, public health services and community service organizations.

One of the nurses who heads up some of these programs is Roxane Spitzer, Ph.D., MBA, MA, CEO of Metropolitan Nashville (Tenn.) General Hospital. Spitzer said one of the most common ways that nurses interact with the uninsured is through hospital-based maternal/infant/child health programs, which are primarily staffed by nurse practitioners or certified nurse-midwives working under the direction of physicians.

Chris Taylor, FNP, RN, pediatric coordinator at Metropolitan, said he loves having the chance to affect the lives of children and families. "I get to be the first teacher many families have as they wade through the intricacies of raising their child," he said. "I am the person they look to for advice and support for a whole range of problems, from teething to asthma management."

Accepting responsibility

Taylor acknowledges that along with the enjoyable parts of his job comes a high degree of responsibility. "I have to be conscientious about my guidance because if I give the wrong advice or make a poor decision, it can result in complications," he said.

Spitzer is especially proud of Metropolitan's nurse practitioner-run sexual assault and rape program, which serves a large number of uninsured patients.

"Nurses there are doing a phenomenal job, not only spending time with victims and lending important emotional support, but also serving as trial witnesses," Spitzer said.

AmeriCares Free Clinics Inc. in Connecticut is another program geared toward serving the medical needs of the uninsured and underinsured working poor.

Its executive director, Karen Gottlieb, MBA, started as a volunteer at AmeriCares and later was hired to start the organization's first free clinic. About one-third of the clinic's patients are treated for episodic ailments, but the majority are seen for chronic life-threatening illnesses, such as hypertension, cardiovascular disease and asthma.

"The uninsured population is a wonderful group to work with," Gottlieb said. "They are the forgotten segment of our population who do not demand or expect anything, and are extremely grateful when they receive care."

The program has grown to include three clinics, which are staffed by more than 500 volunteer doctors, nurses and nonclinical volunteers who assist with screening, translating, outreach and various administrative duties.

The Clearwater (Fla.) Free Clinic also depends largely on volunteerism to keep its doors open. With a staff of about 120 nurses, doctors, pharmacists and clerks, the clinic provides free medical treatment to any north Pinellas County resident without health insurance.

Patients are asked to pay $1 for prescription medications. The clinic does not receive government or United Way funding; instead, it is sustained by fund-raisers, private donations and grants. The clinic operates on an annual budget of $165,000 and sees 10,000 patients a year.

Connie Bahrey, RN, the clinic's nurse manager and volunteer coordinator, said, "We are family here. Not only do our volunteers provide care and support to our patients, but they are here for one another.

"We come from diverse cultures and professional backgrounds that somehow fit together and make this place perfect. Our patients like the personal touch we provide here," she said.

The former LPN became involved with the clinic after volunteering there, and has seen the patient load triple since she started working at the facility four years ago. She said there is an increasing demand for more clinics like this.

Parish nursing presents yet another avenue for nurses to provide care for uninsured patients. Parish nurses primarily serve their own church members and work in roles ranging from educator to counselor to referral agent.

According to the College of Nursing at Marquette University, more than 6,000 parish nurses work in the United States, and receive several weeks of special training before they begin working with parish patients.

Becky Anton, MSN, RN, vice president of the Health Ministries Association, is a practicing parish nurse in Sacramento, Calif. The retired nurse manager is a facilitator for the uninsured in her parish, and works largely with Marshall Islanders from the South Pacific. She helps them navigate Medi-Cal and Medicare insurance programs, and also finds community resources for those who do not qualify for either program.

"The church becomes family to those without family," she said. "Some people are on medications they can't really afford. They are often unaware that there are resources out there for them."

Although many clinics are working to reach the uninsured before these patients face catastrophic illnesses, some nurses encounter this patient population only after a health crisis has occurred.

Gwendolyn Snell, RN, PHN, is an HIV/AIDS case manager for San Joaquin County in Stockton, Calif. She sees a large number of immigrants, including Hmong, Vietnamese and Cambodian immigrants-many of whom are HIV-positive.

Snell's duties include helping HIV-positive people as they make the transition out of prison, and working with the early-intervention program. Although she often has an interpreter on her rounds, she's learned that some forms of language are universal.

"A hug goes a long way in the art of communicating," she said.

"Some of the patients are undocumented, and most have no family or friends. These people don't have a lot of choices about whether they get what they need or not.

"Even if my clients don't say thank you, I can see it in their eyes."

Contact Alicia Hugg at rosewind09@earthlink.net.