Clinica Esperanza/Hope Clinic "International Healthcare on the local bus line" in Providence, Rhode Island

INTERNATIONAL HEALTHCARE
ON THE RIPTA BUSLINE
“A Place to be Healthy”
Slides by Ali Bicki, Jenn Pigoga, Jacob Buckley, Valerie Joseph, Annie De Groot,
Carmen Shulman, Jillian Peters, and Farzana Kibria

Clínica Esperanza/Hope Clinic (CEHC) Mission:
n  Offer high quality primary medical care to RI residents
without health insurance
n  Emphasis on linguistically-competent, culturally-attuned care
n  Focus on prevention and health maintenance
n  Run by highly qualified health providers and community
representatives
n  Supported by an volunteer staff and paid staff
n  Welcomes bright ideas from volunteers and patients
“A Place to be Healthy”
Mission Statement

Clinic Footprint
Built with a $90,000 Loan from the City of Providence and $60,000 from LISC

January 2010
May 2008
July 2009
May 2010
Fall 2010
With the
support
of volunteers
and the
community!

Need for Health Screening: A local example. A paper on tuberculosis (TB) transmission in Rhode Island
illustrates the importance of health prevention activities for all uninsured residents regardless of legal status.
Clusters of tuberculosis transmission among uninsured and undocumented immigrants are not uncommon in
Rhode Island []. Of the 265 TB patients included in the epidemiological analysis, 176 (66.4%) were foreign born
from 42 different countries; 68.2% did not speak English. The predominant country of birth of the foreign-born
persons in the TB clusters was Cambodia (12.5%), followed by Guatemala (10.8%), Dominican Republic (10.2%),
Laos (6.3%), the Philippines (5.1%), and Portugal (5.1%). The analysis of characteristics of the foreign-born TB
patients revealed several possible barriers to TB prevention, including language difficulties, lack of medical
insurance, young age and lack of familiarity with the health care system. The authors concluded that “expanded
TB screening services that actively move into at-risk communities outside of traditional health clinic sites
will be important in reaching these persons during the window period [for prevention].” TB testing was one
of the first preventive health programs implemented at CEHC. TB testing is one of several services, with HIV and
HCV testing and free vaccines (e.g. flu), that are offered to all walk-ins; registration as a patient is not required.
n  Why provide Free Care?
A Cautionary Tale
TB Clusters in RI:
Foreign-born

The Uninsurance Trap
The Uninsurance Trap.
Perhaps more important for the
neighborhoods that are the subject
of our work, poor health
contributes to the cycle of poverty
at the individual level. In 2006, the
total health care spending by
uninsured persons was estimated
at 6.4 billion dollars, the majority of
which (5.3 billion dollars) was paid
out of pocket.
Health Care Reform will diminish but not resolve the problem. Even after heatlh care reform,
free clinics will continue to provide an important alternative source of care to patients who might
defer care until it becomes an emergency, or seek primary care in the ER.
In Massachusetts, more than 300,000 individuals remained uninsured despite state-wide
health reform. The working poor who do not have access to, or cannot afford, either employer
sponsored insurance or state subsidized insurance, predominate among the uninsured.
..

Summary of Changes in Medicaid and Health Care
Exchanges with the Affordable Care Act
Medicaid
Exchange
Coverage

U.S.
Born
and

Naturalized
Ci3zens!
All
individuals
up
to
138%

of
FPL
in
states
that

implement
the

expansion.!
Individuals
without
affordable

employer
coverage
can

buy
coverage
through
exchange

marketplaces.
!
Lawfully
Present

Immigrants!
Many
remain
subject
to
a

five-‐year
wait
or

excluded.
States
may

choose
to
eliminate
the

five-‐year
wait
for

otherwise
eligible

children
and
pregnant

women,
but
not
for
other

adults.
!
May
purchase
exchange
coverage

and
receive
tax
credits
on
the

same
basis
as
ci3zens.
Individuals

with
incomes
below
100%
of

poverty
who
are
ineligible
for

Medicaid
based
on
immigra3on

status
may
purchase
exchange

coverage
and
receive
tax
credits!
Undocumented

Immigrants!
Remain
ineligible
for

Medicaid.!
Prohibited
from
purchasing

exchange
coverage
and

receiving
tax
credits.!
Source:
Kaiser
Family
Founda3on.
hTp://kaiserfamilyfounda3on.files.wordpress.com/2013/03/8279-‐02.pdf.
Table
1.

Post ACA: Many
remain uninsured

Time Since Incoming
Patients were Last Seen by
a Healthcare Provider.
Nearly 40% of patients not seen
by MD in 3 years despite chronic
health problems
20% of currently uninsured
patients were last seen outside of
the U.S. prior to seeking care at
CEHC.
0-6
Months
24%
7-12
Months
32%
2-3
Years
29%
>3
Years
14%
Unknown
1%
Previous
Access to Care

n  Primary Care Clinic
n  Criteria for becoming a patient
ü Uninsured
ü First come first served
X Lottery
X If already in care at another practice
CEHC Overview
n  CHEER walk-in clinic
ü Non-urgent health issue
X In need of urgent care

n  Primary Health Care Tuesday, Thursday, Saturday
n  Women’s Clinic Monday Night 1x/month
n  Vida Sana Program – Health Literacy/Metabolic Syndrome
n  PIMHA – “whole patient” job skills etc.
n  Financial Literacy, Job Skills – Dorcas Place/CWE/LISC
n  Diabetes Club / Group visits with Nurse Practitioners
n  Outreach at in South Providence/ North Providence
n  Health Screens at CEHC/outreach once per month
n  Regular chart reviews – research - quality assurance
CEHC Overview

n  Volunteer base
n  10 in 2008- 20 in 2009
n  30 in 2010- 40 in 2011
n  >175 in 2014
n  Board actively involved as volunteers
n  Volunteer Medical Director/ Executive Director
n  Donated labs, radiology, specialty services, and
medications from WIHRI, Lifespan, local MD providers.
n  New volunteers and providers always needed
n  (next orientation session is … this Tuesday!)
Clinic Overview:
Organizational Structure

14%$
22%$
20%$
26%$
18%$
Chronic(Condi*ons(of(Con*nuity(of(
Care(Pa*ents(at(CEHC(201082014(
Diabetes$%$
HTN$%$
Chol$%$
Overweight$BMI$%$
Obese$BMI$%$
81%$
8%$
8%$ 3%$
Race%and%Ethnicity%of%Pa0ents%at%
CEHC%201072014%
Hispanic$
Non/Hispanic$
Black$
Asian/Other$
Patient Demographics:
Race & Ethnicity
Types of Conditions

Demographics:
Level of School completed
8th Grade or lower
Some high school
Graduated from high school
Some University
University graduate
But these patients have high aspirations
for their children!

Annual Income
If undocumented, work in jobs that do not provide
Health insurance, benefits, etc, low hourly wage:
$15k per year = $284 per week (if they get that)

Clinic Overview
0"
100"
200"
300"
400"
500"
600"
700"
800"
900"
1000"
0"
1000"
2000"
3000"
4000"
5000"
6000"
7000"
2010" 2011" 2012" 2013" 2014"
EMR$Visits$
CEHC$Visit$Trends$201032014$
Visits"in"EMR"
Individual"visits"
Pa;ents"in"con;nuity"of"
care"(12"months)"
Pa;ents"in"EMR"
A
C
A

Clínica Esperanza/Hope Clinic
Community Outreach Pilot Survey
Do we serve our Neighbor’s needs? Summer 2014

Introduction
●  What did we do?
o  A community outreach study to assess key factors
including insurance status, lead awareness, and
community health needs
●  How did we do it?
o  By going out into the community in pairs of at least 2
to administer verbal surveys in a convenience
sampling format

Why did we do the survey?
●  Compare results from “pre-Obamacare”
survey (Spring 2009) to today’s “post-
Obamacare” environment
●  Evaluate health care access in the
community
●  Determine whether or not CEHC is
serving the community’s needs
●  Assess the awareness of lead paint
hazards and testing
●  Funded by the RI DOH

Insurance Status
2014 Study (200 participants)
●  Significant changes since 2009
o  Fewer uninsured (38% vs.
92% in 2009)
o  9% private insurance (vs. 5% in
2009)
o  17% have Obamacare only
●  Today, 33% covered by “public”
insurance…including “free care”
o  Medicaid/RIte Care, Medicare,
Free Care, or some
combination of “public”
sources (vs. ~1% in 2009)

Survey: Why did uninsured participants not
have Obamacare?
Among the uninsured,
having an undocumented
immigration status was the
most common reason for
not obtaining Obamacare
coverage.

n  Established with support from BCBSRI “Blue Angels” Funding
n  The Navegantes/Navigators plan, organize and implement church-
based community health fairs and advocate for members of their
community.
n  Navegantes/Navigators meet with patients and help them navigate
the system to obtain preventative services, chronic disease
management, support for medication adherence, health care
access, and other essential health information.
n  The clinic now has five Navegantes health access coordinators.
They received intensive training sessions to become competent
referral sources, organizers and community educators.
The Navegantes

Percent of Patients
Experiencing Improvement in
their Chronic Condition
EMR records were reviewed and health indicators
(HbA1C, fasting glucose, blood pressure, weight, and
cholesterol) were tracked. Greatest improvements in
overall health indicators were observed in patients
with hypertension: 83% of patients with hypertension
reduced their blood pressure.
Almost three-quarters of patients with diabetes and
high cholesterol improved during the time period of
this review.
Over half of overweight or obese patients lost weight
while under care at CEHC.
Overall, about 63% of CEHC patients improved at
least one of their chronic conditions during the study
time period.
*Number of patients identified as having the health condition
with at least two measurements of the associated biomarker.
54.24%
(32 of 59*)
82.22%
(37 of 45*)
72.73%
(16 of 22*)
70.83%
(17 of 24*)
62.92%
(56 of 89*)
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
%PatientsthatImprovedConditionatAll
Chronic Condition

Systolic Blood Pressure
Changes among
Hypertensive Patients.
According to EMR records, patients in
care over four months experience
improvements in their blood pressure.
Patients in care at CEHC for over four
months decreased their systolic blood
pressure by, on average, 12 more
points than patients under care for less
than or equal to four months (N = 47, P
< 0.001).
CEHC Navegantes provide one-on-one
positive reinforcement sessions to
patients. Patients matched with
Navegantes decreased their systolic
blood pressure by, on average, 24 more
points than patients not matched with
Navegantes (N = 38, P = 0.008).
-21.7
-9.4
-19.5
4.3
-25
-20
-15
-10
-5
0
5
10
Under Care
>4 Months
Under Care
≤4 Months
With
Navegante
Without
Navegante
AverageSystolicBPPointChange

THE HYPERTENSION PROJECT
An Assessment of Our Adherence to AHA Guidelines &
an Evaluation of Our Performance
By Carmen Shulman, Jillian Peters, and Farzana Kibria

Blood Pressures at Goal
55%
46%
59%
33%
53%
62%
0% 20% 40% 60% 80% 100%
Clinica Esperanza/Hope Clinic
Charlestown Area Medical Center
Rush University Hypertension Clinic
6 Texas Urban Community Clinics
44 US Community Health Centers
Winthrop University Hospital
Outpatient Clinic

CEHC Positives
n  Increasing Volunteer Supply
n  More Collaborations and Networks
n  Improved access to free resources
n  $97,000 in donated free care 2010; $163,000 in
2011; more in 2012
n  Demonstrated need for services as state funding
for core services (for example, TB clinic) is cut

Access to Care Constraints
n  Increasing demand – waiting list at > 150
n  Many of the requests for care are for minor
medical problems (back pain, rash, STD)
n  These patients wait > 4-6 months to be seen
n  “Walk In Clinic” may solve this issue
n  “Walk In” will also reduce ER use

THE CHEER CLINIC
A Nurse-Run walk in clinic for the Uninsured

n  CHEER program runs out of CEHC as a free walk-in clinic
for uninsured Rhode Island community members. Staffed
by volunteers and nursing providers, CHEER provides
non-urgent health care services every weekday!
n  A goal of CHEER is to save patients thousands of
unnecessarily spent dollars by deterring them from going
to local emergency rooms for non-life-threatening
problems.
n  Nurse-Run!
CHEER clinic

Evaluation
1.  Measure use of walk-in non-acute
healthcare to the uninsured provided by
expanding clinic hours at CEHC
2.  Determine whether providing prospective
ER visitors the option of walk-in non-
acute care will reduce ER use
3.  Calculate impact in terms of costs
avoided and QALYs.

Patient Home by
Neighborhood
Olneyville
30%
Smith Hill, Elmhurst,
Mount Pleasant
15%
Elmwood, Reservoir
14%
Total Providence ZIP Codes: 87%
Other ZIP Codes: 13%

Willingness and Ability
to Pay for Care
n  Concordance between what CHEER patients were
willing and able to pay for their healthcare
n  54 (59% of respondents) had no difference between
what they were willing and able to pay
n  35 (38%) were willing to pay more than they could
afford—with an average shortcoming of $22.94
n  3 were willing to pay less than they could afford
n  Distribution of what patients would be able to pay:
n  $0 43 patients (45%)
n  $1-10 21 patients (22%)
n  $15-25 26 patients (27%)
n  $30-60 6 patients (6%)

Patients’ ER Utilization
32
10
8
13
2
1
0
5
10
15
20
25
30
35
Past Year Past Month Past Week
Number of patients who had been to ER in timeframe
65 CHEER patients
(49% of respondents)
reported they would
have gone to the ER
for their chief complaint
if the CHEER clinic had
not been available.

Estimated* Costs Avoided
Total visits (5 months)** 252
Total visits discounted by 20%* 202
Average cost per CHEER visit $32
Average cost per ER visit in Rhode Island $792
Cost avoided per CHEER clinic visit $760
Costs avoided (5 months) $153,216
Costs avoided (12-month projection) $367,718
*See reasoning in Oriol et al., 2009
**Excluding four patients who were, in fact, referred to the ER

Value of Preventive Services
Service, by most QALY-Saving
Services
Provided (N)
QALYS
(Years)
Estimated Value
of QALYS ($)
Hypertension Screening and Treatment 145 13.05 $618,426
Vaccinations (excluding Flu) 63 5.67 $268,696
Obesity Screen 123 3.46 $163,936
Flu Vaccine 28 1.91 $90,395
Cholesterol Screening 7 0.63 $29,855
Other* 12 0.23 $11,195
Diabetes Screen 79 0.15 $7,019
5-Month Totals ** 25.1
(22.03-27.34)^
$1,189,523
($0.55-1.91 million)^
12-Month Projection 60.24
(52.87-65.62)^
$2,854,855
($1.32-$4.58 million)^

5-Month
Return on Investment (ROI)
Operating Cost of CHEER Clinic $37,870
Tests, Other Operating Expenses $11,070
Wages and Taxes $26,800
Costs Saved = ER Costs Avoided + QALYS
Value
$1,313,053
Costs avoided by preventing ER visits $123,530
Value of potential life years saved by CHEER $1,189,523
5-Month ROI
= (Costs Saved – Operating Cost)
$1,275,184
($0.60-2.03 million)^
5-Month ROI Ratio
= 5-Month ROI ÷ Operating Cost
34:1
(16:1 – 54:1)^^Using other QALY estimates available in the literature, we calculated these conservative and liberal estimates

Designing a place-based health intervention
that addresses community needs.
Vida Sana / Healthy Life

A Place to Be Healthy
n  Vida Sana was created to promote a healthier lifestyle in
Health Disparity Populations (HDPs) at risk for
metabolic syndrome
n  HDPs in Providence, particularly the up to 50,000 undocumented
immigrants and other uninsured populations, face limited access
to care, poor health education, and other socioeconomic barriers
which worsen long-term outcomes of metabolic syndrome and
other chronic conditions
n  Focus on
n  Improving health literacy
n  Creating a social learning environment (“A Place to Be Healthy”)
n  Measuring metabolic outcomes in participants
n  Funded by the RI Department of Health’s “Center for
Health Equity and Wellness Grant”

Vida Sana Mission
n  Create a fun social learning environment
where participants learn about nutrition
and other healthy lifestyle choices
n  Curriculum developed by Susan Oliverio, MD
n  Designed to be accessible for either English-
or Spanish-speaking participants with low
literacy

(1) Train and Certify Navegantes

Gloria Dei Church
Since March 2013
# of Participants: 20
# of Navegantes: 3
Site Based Action Team
Contact: Kayla Rodriquez,
Mercedes Batista
Open Table of Christ
Church
Since 12/12/2012
# of Participants: 33
# of Navegantes:
Contact: Anna Vargas
Clinica Esperanza/Hope
Clinic
Ongoing since 08/22/2012
# of Participants : >50
# of Navegantes: 5
Site Based Action Team Contact:
Ingrid Castillo
Empowerment
Temple
Under Development
# of Participants
# of Navegantes:2
Contact: Akosua Adu-
Boahene
Timeline of Vida Sana
v  Group 1 at CEHC (Spanish) ~ Aug 2012
v  Group 1 Completion of Program ~ October 2012
v  Group 2 at OTC (Spanish) ~ Dec 2012
v  Group 2 Completion of Program ~ Feb 2013
v  Group 3 at CEHC (Spanish) ~ Jan 2013
v  Group 3 Completion of Program ~ Mar 2013
v  Group 4 at OTC (Spanish) ~ Mar 2013
v  Group 4 Completion of Program ~ May 2013
v  Group 5 at CEHC (English) ~ Mar 2013
v  Group 6 at Gloria Dei Start March 2013
v  Group 5 Completion of Program ~ May 2013
v  Group 6 at Gloria Dei Completion -- June 2013
v  Group 7 at CEHC started June 4, 2013
v  Group 8 (English) at CEHC scheduled June 15
v  Group 9 S(Spanish) at CEHC scheduled June 18
(2) Establish Outreach Sites

Vida Sana Open Table of Christ

English-Language Sessions for
North African Immigrants

n  Definition of completion: attended at least 6/8 sessions,
at least one social event, and at least one educational
event
10/24 11/20 12/14N: 8/10 12/15 20/20 5/13 13/18 10/11
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
GROUP 2 GROUP 3 GROUP 4 GROUP 5 GROUP 6 GROUP 7 GROUP 8 GROUP 9 GROUP 10 GROUP 11 GROUP 12
Percent Completion by Group
4/10 5/8
Completion (Groups 2-12)

Program Completion: Year 2
n  Approximately two-
thirds (69%) of
participants completed
the program
n  Slight improvement
over Year 1 (66%)
1 Session
4%
2 Sessions
17%
3 Sessions
6%
4 Sessions
2%
5 Sessions
2%
6 or More
Sessions
69%

Factors Affecting Completion
n  Health Disparity Populations face several
socioeconomic barriers to program commitment
n  Unable to afford to leave children at home unsupervised
n  Need to maintain jobs which conflict with scheduling
n  (YEAR 1 DATA) Only 41% of age 30-40 participants
completed the program, in comparison to between
70% and 78% for other age ranges. This population is
more likely to get a new job, have changes in family
dynamics, or have instability in living/transportation situations
n  (YEAR 2 DATA…relationship did not hold) Those aged
51-60 years had the lowest program completion rate (62%),
followed by those <30 years (67%); those aged >60 years had
the highest program completion rate (75%)

Impact of Intervention
n  Patients had metabolic syndrome, but not all
patients were overweight (they may have been
normal weight but had HTN, diabetes, and high
lipids).
n  Thus – some results did not need to change.
Results are therefore shown as “percent stable
or improved”
n  Mainly improved waist circumference, systolic
BP, and health literacy
n  Slight improvement in other results such as weight

Results Overview: Year 1
n  Percent outcomes stayed stable or improved
over 8 week period
82.7% 79.8%
61.1% 59.6%
82.5%
92.2%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Weight Waist Circumference Glucose Cholesterol BP HL Test
Percent Stable/Improved

Waist Circumference Results
n  Many kept waist circumference steady
n  Those that improved had quite dramatic
improvements
N=109 Waist Circumference
Average Start 38.7 in
Average End 38.1 in
% Stable/Improved 79.8%
Average decrease for those that
improved
2 in

Weight/BMI Results
n  Most improved weight, but only slightly
n  Impressive for 8 week study period
N=110 Weight BMI
Average Start 180.5 lbs 28.2
Average End 177.2 lbs 27.7
% Stable/Improved 82.7% 82.7%
Average decrease for
those that improved
5.5 lbs 1.0

Blood Glucose Results
n  Unable to enforce fasting glucose tests, so
results varied and not statistically rigorous
n  Despite this, overall improvement seen
N=108 Blood Glucose
Average Start 124.6 mg/dl
Average End 118.0 mg/dl
improved
26.8 mg/dl

Cholesterol Results
n  Similarly not fasting tested, although
results less varied than for glucose
n  Promising overall improvement observed
N=109 LDL Cholesterol
Average Start 190.7 mg/dl
Average End 185.6 mg/dl
improved
18.6 mg/dl

Blood Pressure Results
n  Hard to observe significant and consistent
changes for blood pressure in 8 weeks
n  Most patients with >120 systolic at onset
remained stable or had slight improvement
N=63 (>120 at onset) Systolic Blood Pressure
Average Start 140
Average End 134
improved
12

Health Literacy Test Results
n  Consistent, large improvement in scores of
health literacy test
n  Impact of participants attending a second Vida
Sana program noted (contributed to increase in
baseline pre-test and post-test).
N=103 Health Literacy Test
Average Start 71.1%
Average End 90.7%
Average increase (% pts) for those
that improved
22.9%

Other Findings
n  Outcomes relatively consistent regardless of age
and starting BMI
n  Glucose and cholesterol appear to improve
based on number of sessions patients attended
n  Participants were engaged and enthusiastic
n  Navegantes proud of accomplishments and
looking for ways to improve programs
n  Some aspects of outcomes improved more
consistently in later Vida Sana programs

Goals for Future
n  Setting up “self-sustaining” Vida Sana programs
n  “See one, Do one, Teach one”
n  Expand to new sites with more Navegantes
n  Provide training, supplies, and support for sites to run
Vida Sana independently
n  Having more consistent 3-month and later
follow-up data to observe if outcomes are
sustained
n  Continue to reach health disparity populations,
with goal of having 1,000 Vida Sana “graduates”

Setting up “self-sustaining”
Vida Sana programs
n  “See one, Do one, Teach one
n  Expand to new sites with more Navegantes
n  Provide training, supplies, and support for sites
to run Vida Sana independently

Who have we reached?
n  January-May 2014
n  5 groups
n  85 total participants
n  57 completed (67%)
n  From the publication
n  13 groups
n  192 participants
n  Total to date
n  18 groups
n  277 participants

Acknowledgements
n  Initial analysis provided by
n  Jacob Buckley (Brown Undergraduate)
n  Farzana Kibria (Smith College Praxis intern)
n  Shahla Yekta, Ph.D. (CEHC Consultant)
n  Valerie Joseph, R.N. (Nurse Manager)
n  Ingrid Castillo (Head Navegante)
n  Carlos Juarez (Clinic Coordinator)
n  The Navegantes

Community Presence
n  Of those who responded…
n  50% of CHEER patients had heard of the
clinic through word of mouth—e.g., from a
friend or family member
n  19% of CHEER patients had heard of the
clinic through other community-based non-
profit organizations, their church, another
community health center or hospital, or their
school or workplace

Conclusion
n  CEHC has an important role serving a
basic need
n  CHEER program– current data
demonstrates that investment is worth it!
n  Vida Sana program appears to be an
effective intervention

Funding Needed
n  Support for CHEER
n  $100,000
n  Support for Continuity of Care clinic
n  $100,000
n  Support for Operational Costs
n  $50-60,000 per year
n  Few donors contribute to this goal
n  Need more support!

40,000 to 60,000 Uninsured in Rhode Island
Improving Access to Health Care – People Stay Healthy
Healthy People build Strong Communities
Free Clinics Are an Essential Safety Net
Especially in these Difficult Economic Times
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Clinica Esperanza/Hope Clinic "International Healthcare on the local bus line" in Providence, Rhode Island

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Clinica Esperanza/Hope Clinic "International Healthcare on the local bus line" in Providence, Rhode Island