Programs run by a pair of Robert Wood Johnson Foundation (RWJF) Community Health Leaders were recently profiled by the U.S. Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) on its influential Healthcare Innovations Exchange. The AHRQ profiles highlight programs that implement "new and better ways of delivering health care," and are intended by the agency as a tool for improving the quality of care and reducing disparities.
In the spotlight are Shira Shavit, MD, and Andru Zeller, MD. Both were named RWJF Community Health Leaders in 2010.
Health Care for Returning Prisoners
Shavit's San Francisco-based Transitions Clinic provides care and case management services to recently released inmates suffering from chronic conditions that have gone either untreated or under-treated during their incarceration. She says a number of factors combine to leave prisoners with inadequate care and without connections to health care in the community. "Prison is a punitive environment," she says. "So there's very little sense of health and wellness … In fact, it took a court order in the 1970s to force the system to provide health care. Until recently, when the system came under federal receivership, we had doctors in the prisons who'd had their medical licenses revoked elsewhere, and could only practice in the California prisons. It's hard to have a caring model embedded within a punitive system."
Shavit notes that prisoners have higher rates of chronic conditions, mental illness and substance abuse, and that the majority have no primary care provider, and lack insurance or the resources to pay for care in the community. "There is no continuity from the prison to the community," she says, "and sick inmates are released without connections to care. Most prisoners use the emergency room as their regular source of care."
When patients leave prison, their health care problems do not disappear, and in fact, they can grow worse for the lack of access to care on the outside. That is where Shavit's Transitions Clinic comes in. Starting at San Quentin prison, Shavit connects paroling patients to primary care in more than 35 counties throughout California. Prisoners who come to San Francisco can see Shavit four half-days a week for medical care, and get help connecting to a variety of social services from specially trained community health workers with a history of incarceration.
Providing Care to Albuquerque's Underinsured
A thousand miles to the south and east, Andru Zeller's Casa de Salud clinic in Albuquerque, New Mexico, provides low-cost, culturally competent medical care to a different group of uninsured or underinsured patients: immigrants. The clinic relies on work-study students, volunteer help and cost savings from electronic medical records to hold down its overhead costs, and then passes those savings on to patients in the form of a low, fixed price for all.
Because the great majority of the clinic's patients are Mexican immigrants, staff members speak both Spanish and English. In addition to conventional medicine, the clinic provides a range of alternative medicine services, many of which are more culturally familiar to its patients. Casa de Salud also provides mental health and substance abuse treatment, including a needle exchange program, and operates a clinic at a local charter school, providing medical services to students on site.
Zeller helped launch the clinic in 2004, with a personal investment, and a number of significant grants have helped keep the clinic in operation over the years. Zeller's plan, however, is to work to generate a more stable financial base by developing a "membership model" that would provide what he describes as "benefits above good quality care" to patients who can afford to pay an additional $100 to $150 per year. "We don't plan to reach a new market with the model," he says. "It will allow our existing patients to invest in us and stabilize our clinic. I'd say that financially speaking, we're 'stressfully' successful. And we'd like to be smoothly successful. In the health care business, you don't want to be stressed. It's bad for everyone.”
The Power of Community Health Leader Program Recognition
Both Zeller and Shavit credit the RWJF Community Health Leaders program for giving their work a powerful boost. "We came to AHRQ's attention because of the Community Health Leaders program," says Zeller. "But beyond that, it also helped lift us to a place where we could get a different perspective on our work, and shifted our internal thinking and dynamics. The program's selection process alone was a terrific experience. They really dig in, and reflect with you on the work you are doing, and it just helped remind us of the value of what we're doing and the potential for growth."
Shavit also says that AHRQ came her way as a result of the Community Health Leaders program. "It's brought a lot of positive attention to us from our community, and that's given us some increased leverage as we try to create systems to help the returning prison population get the care they need." That effort is particularly timely in California, she notes, because the state is now under court order to reduce the population in its chronically overcrowded prisons by 34,000. Some prisoners face time in county jails, which have their own challenges in providing health care, while others will be released to the community. "We're already seeing growing numbers of patients at the clinic," she says, and many more will need care in the months and years ahead. She says Transitions' increased visibility from her Community Health Leaders recognition has "put us in a position to work more closely with local leaders to see how to care for this population, and create best practices for providing care."
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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