How one rural clinic addressed its patients’ complex health and social needs successfully—and cut emergency room use and costs drastically.
There’s no bus service in his small town in rural North Carolina, so Dean* drives 10 miles to The Free Clinics ("Clinics") in Hendersonville every couple of weeks whenever he has money for gas.
Staff there helped him find affordable medications and treatments for cancer and for his shoulder, which he injured by falling 20 feet on a construction site. He’s unable to read due to learning disabilities, so they’ve also helped him find lawyers to file disability claims.
Dean is also one of the patients who attends the Clinics’ Bridges to Health ("Bridges") program, a drop-in group session where patients can discuss their social and emotional concerns as well as medical problems. He has battled depression since the age of five after enduring early childhood trauma. He credits the Bridges sessions, along with the Clinics’ holistic care, with easing his depression and improving his physical health, as well as “opening up avenues for me to get help.”
“They make you feel like you’re wanted. The Bridges program has saved quite a few lives. I know people who had a tough hard lick with things like substance abuse that can lead you down a path where you don’t know how to get out. The people at the clinic help you see the light. They provide that light,” he says.
Addressing Complex Needs
Nestled near the Blue Ridge Mountains, the Clinics serves Henderson and Polk counties, agricultural communities with many residents who live in rural areas or are migrants living in tent camps. Thirty-eight percent of the adult population live in families with incomes below 200% of the federal poverty line.
While volunteering with the Clinics, Steven Crane, M.D., discovered that about 255 low-income, uninsured patients in the prior year accounted for 90% of the emergency room billing at a county hospital with a population of 100,000 people.
“These were very complex patients. Almost all of them had severe mental health or behavioral problems, or both,” Crane says. Seventy percent of the patients had experienced adverse childhood experiences such as poverty or abuse that can affect mental health and learning for a lifetime. They were typically uninsured, and had difficulty making and keeping appointments and following medical advice, compounding severe medical issues and turning into “frequent flyers” to the ER, as Crane puts it.
To address these interrelated and complex needs, Crane developed Bridges. Through the program, staff remove barriers to accessing care and screen each patient to determine their health needs, willingness to engage with a group process, and openness to embracing growth and change. The staff then create an individualized care plan.
Patients work with an integrated care team, which erases specialty silos. Available staff include physicians, registered nurses, a family nurse practitioner, addiction specialist, behavioral health provider, pharmacist, occupational therapist, and patient-health advocate. Patients get free bus passes and a lunch voucher, and have immediate phone access to a case manager. Many walk two miles to the Clinics from a homeless shelter.
The Clinics are a literal haven, too, especially for those living in turbulent households or without a place to live. “For many of these folks, it was the only safe place they had. Some would come to sleep here during the day because they couldn’t at home,” Crane says.
The heart of the Bridges program is the drop-in group care visits. Participants begin with a meditative centering exercise, then talk with group leaders and each other about life problems as well as how to handle their obstinate medical issues.
Results were swift and significant. In its first nine months, the Bridges program reduced per-member ER use by 72%, and about 80% of the patients saw their underlying health conditions improve. They also made progress in social determinants of health like housing and employment. The National Association of Free & Charitable Clinics presented Crane with the RWJF Award for Health Equity in 2017 for his vision, drive, and impact
Tapping Cultural Strengths
Community support is vital to the Clinics, which has more than 1,960 patients and many other programs in addition to Bridges, including an urgent care clinic. Approximately one-third of its operating funds are raised from local donations, a third from state and local funds, and the other third from private foundations. People donate time as well as money; the program has some 250 volunteers, many licensed professionals who recruit their peers.
“Volunteers started realizing that a lot of people who get services here are the working poor. I don’t go into meetings anymore and hear them talk about ‘those people,’ they talk about ‘our people.’ That’s a groundbreaking cultural shift,” Crane says.
The patients themselves are a source of strength and support. “It’s amazing how resilient many are. When they get together they help each other with resources,” Crane says. That may include talking about how to get kids out of foster care, for example, or finding good local legal help.
Asking patients to make life goals like these helps them make holistic progress, the Clinics’ Executive Director Judith Long says, adding, “If patients merely set clinical goals for themselves, they don’t have much improvement, but if they add social, relational, or resource goals to the mix, not only do they improve on those measures, they also have health gains.”
Patients help their own communities, too. Three of the Clinics’ programs began by patient request and investment. A patient-staffed community garden on site provides hundreds of pounds of free, fresh produce to patients. Donated, repaired bicycles are available for free for patients, thanks to a Bridges participant who inspired the program and assists with some repairs.
One woman, Maria*, was devastated to receive a diagnosis of diabetes, as her native Mexican culture regards it as a death sentence. Clinics' staff responded with clinical, educational, and behavioral interventions, and also addressed social determinants with home visits from a diabetes case manager and a patient health advocate, what Long calls “whole patient engagement on multiple levels.” Maria’s health drastically improved and she no longer needs medication. She then wanted to share what she has learned with her own largely migrant community.
So in 2017, following a model developed by Microclinic International, the Clinics started a program called HealthWays that trains lay people, including patients, to deliver health education programs on chronic conditions like diabetes. In its first program year that ended in June, 77% of the 177 participants had an improvement on at least one clinical indicator such as body mass index, blood pressure, cholesterol, blood glucose, or waist circumference. Seventy-seven percent lost weight, 100% increased their activity, and 81% completed the program. Maria is now a community teacher.
“We’re looking at how we can reach our vulnerable neighbors to help them live more healthfully, so we can keep them from needing us,” Long says.
Completing the Circle
The Clinics give back. Half of its interventions are community-wide. For example, Long recently helped gather 30 local leaders to work on a community behavioral health plan. Clinics’ staff are partnering to bring in nationally recognized trainers to lead trauma-informed programming, and are supporting the Henderson County schools with their trauma-informed schools process, assisting teachers to help them access appropriate care when children need extra support.
In November, Long and Crane will open the Bridges program in the Henderson County detention center. “It will give folks a place to land. The biggest problem many [inmates] have is to transition out. Bridges will help them build relationships,” Crane says.
Rob* can vouch for that. After he got out of jail two years ago, the Clinics provided him with medicine for his emphysema and bi-polar disorder, and counseling to help with addiction and alcoholism, which “had me whupped,” he says. In the Bridges sessions, “If you’re having a problem with your meds or with somebody, you can share it and get it off your mind.”
Rob relapsed a couple of times, but says he has been clean and sober for a year now. He has a place to live and supports himself as a handyman.
“If I hadn’t gone to the Clinics I would be dead now. They rescued me,” he says.