Building “A Place to be Healthy”Clínica Esperanza/Hope Clinic (CEHC):

A new Free Clinic for the Medically Uninsured of RI

A presentation compiled by: Rachel Simon, Rebecca Gerber, Craig O’Conner,

Annie De Groot, MDClinica Esperanza / Hope Clinic Volunteers

One of our patients:

Eduardo is a baker who had/has no health insurance. He recently sustained a relatively serious heart attack that he managed at home despite having classic symptoms of angina on multiple occasions.

When asked why he did not seek emergency care, he said that it took him a long time to pay his last hospital bill ($700) for a mere thirty minute visit at the emergency. He did not want to incur any further expense. Instead of going to the ER while he was having his heart attack, he elected to stay home, taking aspirin for his chest pain to avoid incurring any debt.

This is one variation on a story we have heard many, many times.

A True Story

Growing Need

The medically uninsured of Rhode Island (RI):

120,000 uninsured < 65yo in 2005

Near doubling in % of adults < 65yo who are

uninsured*

Continued trend → 19.5% or 1/5 people by 2010

One of the 1o reasons for the increase is erosion in

employer-based insurance coverage

* ↑ from 7% (2000) to 13% (2005)

How many uninsured?

Growth in Uninsured in RI according to 2010 study

6473 76

99 103 108121

90

111122

140

0

20

40

60

80

100

120

140

160

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Proj

Number of Uninsured Rhode Islanders Under Age 65

% of Population 7.2% 8.4% 8.6% 10.8% 11.3% 11.7% 13.0% 9.8% 12.1% 13.5% 15.7%

Source: Historical data from U.S. Census Bureau Current Population Survey (CPS) and Mathematica Policy Research projection to 2010. Notes: Mathematica projection is based on analysis of Medical Expenditure Panel Survey (MEPS) data benchmarked to the RI population. Historically, MEPS estimates of the uninsured have tracked national CPS estimates closely. (Mathematica Policy Research team, March 2010).

The number of uninsured Rhode Islanders is projected to increase to more than 15% of under-65 population in 2010.

Thousands

5

Adults formerly on Rite Care will be OFF within the next 6-9 months.

From 2011 until Jan 1 2014, adults making more than 133% than FPL will most likely be uninsured.

Thus the number of uninsured will increase by 6 to 10% until “the exchange” kicks in.

Hence, free clinics are more needed than ever.

Why is Free Care More Important Than Before?

Health Care Access Problem:Disproportionate effect on Poor

Lack of insurance increases vulnerability to The impact of lack of health insurance is significant. A recent paper published in the American Journal of Public Health found that uninsurance is associated with mortality (AJPH 2009;99).

Nationally, compared with Whites, more Hispanic and Black individuals report issues associated with affording and accessing health coverage and care. Nearly 4 in 10 Hispanics (38%) report having trouble paying for health coverage or health care as a result of the economic downturn.

One in four Blacks (25%), one in five Hispanics (21%), and about one in ten Whites (13%) have lost health coverage as a result of the economic downturn. And finally, a higher percentage of Hispanics and Blacks than Whites report postponing or skipping health care due to cost.

About 1 in 2 Hispanics report relying on home remedies instead of seeking care (53%) or report forgoing dental care due to cost in the past year (48%) compared to 1 in 3 Whites (32% and 33% respectively). (KFF: The Effects of the Economic Recession on Communities of Color).

Effects

Lack of insurance increases vulnerability to poor health outcomes. According to a survey of uninsured adults performed by the RI Department of Health, uninsured Rhode Islanders are less likely to have routine health screens and more likely to participate in unhealthy behaviors.

Adults with household incomes below 200% of the federal poverty level have higher rates than households above this level for 11 of the 15 health risks that were evaluated in this survey (vaccinations, risk behaviors, health screens).

A greater percentage of these lower income adults were uninsured (20% vs. 5%), had no regular health provider (26% vs. 10%), and had never had their cholesterol checked (27% vs.12%) than the insured.

Who pays for uninsured care?

9

Looking only at the costs of uninsured Rhode Islanders while they are uninsured, we can identify who pays. The federal government pays most of the cost of care for the uninsured – ~$100 Million. Patients themselves pay the next largest share, in out of pocket expenses of $76 Million.

* Note: Federal, state/local, and private estimates on this page are derived from administrative data. They exceed population-based estimates by approximately $10 million and may include some expenditures for Rhode Islanders over age 65. Out of pocket estimates are population-based.

$Million

$60m

$76m

$-

$50

$100

$150

$200

$250

$300

$350

Federal State/Local Private Out of Pocket

$19m$101m

$256m

Total

paid by other sources paid by patient

Patients

Private Physicians

Direct Care

Hospitals

MythsDispelling the myths:

MYTH: People without health coverage don't work.FACT: Eight out of 10 people who are uninsured are in working families.

MYTH: Most people without health insurance are poor.FACT: In 2005, more than 32 million of the uninsured had household

incomes of $25,000 or more, compared with 14.6 million in households earning less. (The federal poverty level for a family of four in 2005 was $19,350.)

MYTH: Virtually everyone who works for a large employer has health coverage.

FACT: In 2005, 23.1 percent of the nation's uninsured workers age 18–64 were in firms employing more than 500 people.

http://covertheuninsured.org/events/index.php?StateID=RI&CityID=Providence

The working poor:

Erosion in RI employer-based coverage due to changes in eligibility

RI vs. Massachusetts and USA, lower % of workers eligible for employer-based coverage

Disproportionately low-income, childless, self-employed 92% ↑ in the uninsured = low-incomes 300% below federal

poverty level (FPL) Includes immigrants, asylum-seekers, and refugees

Working Poor

Children

The children of RI:

In 2005, 6.8% are uninsured (↑ from 5.8% in 2004), approx. 19,000 children

Numbers due to increase (see below)

Revised S-CHIP: started October 1- Eligibility requirements set at 250% FPL- $42 million shortfall in budget- New: Non-citizen/documented children excluded

www.rikidscount.org, 3 year averages of CPS data, 2002-2004 compared to 2003-2005

What are the costs of providing health care

to the uninsured? Hospitals and physicians shoulder the financial

burden for the uninsured by incurring billions of dollars in bad debt or "uncompensated care" each year.

Fifty-five percent of emergency care goes uncompensated, according to the Centers for Medicare & Medicaid Services  

The amount of uncompensated care delivered by nonfederal community hospitals grew from 6.1 billion in 1983 to 40.7 billion in 2004, according to a 2004 report from the Kaiser Commission on Medicaid and the Uninsured.

Clínica Esperanza/Hope Clinic (CEHC) Mission:

Offer high quality primary medical care to RI-ers without health insurance

Emphasize linguistically-competent, culturally-attuned care Focus on prevention and health maintenance Run by highly qualified health providers and community

representatives Supported by an all-volunteer staff Welcomes bright ideas from volunteers and patients

Mission Statement

Evaluated the need for primary care for uninsured

Defined population

Identified space for clinic

Established infrastructure

Established policies and procedures

Ran temporary clinics (ACOS, OTC, Iglesia Esp)

Recently moved our operation to 60 Valley Street

Opened at new location November 2010.

Accomplishments

Approach Literature Review

- National and state need- Setup of other free clinics- Patient entry criteria

Meetings with core working group Site visit meetings

- Community members- Governmental representatives

Delegation of tasks and setup of committees Contact with prospective and dedicated volunteers Identification of in-kind donors

RI uninsured adults and children:

Includes working poor and undocumented adults and children of Olneyville and Washington Park

www.provplan.org Olneyville Washington Park

Demographics

Olneyville

Washington Park

Buildout Plan

Volunteer base established Board established Donated labs, radiology, specialty services, and

medications under negotiation

Infrastructure

RI Department of Health rules and regulations Clinic entry criteria managed by Medical Advisory

Admissions committee and medical need

Outreach sessions at community centers

X Lottery and 1st come 1st serve

Policies and Procedures

Clinica Esperanza Patient Profile: Visits

IncomeRace / Ethnicity

GenderCity Distribution

Total Unique Visits / Quarter

June 2009 - Jan 1 2010 June 2009-

March 2010 June 2009-June 2010 June 2009-

October 2010

Projected Dec 2010

0

200

400

600

800

1000

Unique Visits to CEHC (does not include OTC)

Total Forms Filled Out

Number of unique visits expected to reach 1,000 by Jan 2010

Based on data collected so far, 58% of our patients are Spanish speaking/ Latino, and most (85%) live well below the poverty line (make < $15,000 per year). 

ResultsPatients Provided Care 2009-present

Hispanic/Latino 58%

White 16%

Black 5% Other 19%

Race and Ethnicity of CEHC Pa-tients, June 2009 - Oct 2010

$0-15 86%$15-20 8%

$20-30 4%

Income (K), CEHC Patients June - Oct 2010

Income

$0-15; 86%$15-20; 8%

$20-30; 4%

Income (thousands), CEHC Patients June - Oct 2010

Majority of CEHC patients make less than $15k per year

Race / Ethnicity

Hispanic/Latino; 58%

White; 16%

Black; 5% Other; 19%

June 2009 - Oct 2010

Majority of CEHC Patients are Latino

Gender

Male; 45%Female; 55%

June 2009 - Oct 2010

Slight Majority of CEHC Patients are Women

City Distribution

80%

20%

City of Residence, CEHC Patients June - Oct 2010

Providence Other

Almost all CEHC Patients are from Providence

A Unique Outreach Program

CEHC Navegantes Provide Access to Care

Hispanic/Latino 58%

White 13%

Black 3%

Other 25%

Ethnicity/Race, CEHC Patients June 2009-March 2010

Background

Latinos are 3.0 times more likely to be uninsured and 2.5 times more likely to report not getting health care due to cost than other individuals living in RI; they were also more likely to report using the emergency room as a usual source of care.In January 2010, Clinica Esperanza/ Hope Clinic (CEHC) established a community outreach program called “Vida Sana”. Five health care Navegantes “Navigators” were hired to improve access to health care.

Target PopulationSpanish-Speaking and minority CEHC clients are the target population for “Vida Sana” Navegantes Program. Based on demographic data collected thus far, our patients are Spanish speaking Latino (58%), overwhelmingly living below the poverty line (85% make less than $15,000 per year) and from Providence (77%). Our patients come from all walks of life - homeless, construction workers, factory workers, mothers, and artists. Many of the patients recently lost their health insurance due to the current recession.

Vinnie Velazquez, Carlos Juarez, Luz Betancur, Santos Zacharias, Elaine Waite, Jennifer Jiminez, Gloria Rose R.N., Anne S. De Groot M.D.

Clinica Esperanza/ Hope Clinic Providence, Rhode Island

Contact informationwww.aplacetobehealthy.orgClinica Esperanza / Hope Clinic

Dr. Anne De Groot M.D.401 272 2123 x 122

Funded by a grant from Blue Cross / Blue Shield to CEHC

"Vida Sana” Navegantes Program: Outreach to Improve Health Care Access for the Spanish-Speaking Providence, Rhode Island Community

Lessons Learned

What the Navegantes have learned through the program?

• Lesson 1 – How to enable patients to get free health care.

• Lesson 2 – All different kinds of people need help with their health care.

• Lesson 3 – One person can truly make a difference.

Program Goals

(1) Improve access to care for uninsured RI Hispanics/Latinos and minorities;

(2) Train community-based Navegantes to provide linkages to health care at CEHC or to local area hospitals for free care;

(3) Improve community health knowledge through health education sessions; and

(4) Assist with access to non-healthcare needs for CEHC clients.

Program Activities

The Navegantes have helped individuals to obtain access to:

• Free Health Care at Local Hospitals

• Information about Diabetes through teaching Diabetes Workshops

• Free Blood Glucose Tests

• Infectious Disease Screenings

Program Outcomes

In two Months:

• Outcome 1:

Five Navegantes have been educated about Diabetes and Overweight

• Outcome 2:

48 individual CEHC clients participated in Navegantes-run Diabetes Workshops.

• Outcome 3:

120 individual CEHC clients obtain access to free tests.

Under guidance from the Access Coordinator, the Navegantes/Navigators plan, organize and implement church-based community health fairs and advocate for members of their community. Navegantes/Navigators will meet with community members 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.

The proposed program, Vida Sana, has trained and deployed five Navegantes health access coordinators. These residents of Providence communities, received intensive training sessions (over four weeks) to become competent referral sources, organizers and community educators.

The Navegantes

The Navegantes/Navigators will plan, organize and implement church-based community health fairs and advocate for members of their community.

Navegantes will meet with community members 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.

The Navegantes have also helped patients complete surveys that we will use to learn more about the CEHC patients.

The Navegantes

The Navegantes performed a “street survey” to assess the need for the CEHC.

100 persons are being interviewed by the Navegantes. All gave their consent. The interview report is anonymous.

Preliminary results are reported here. N=87

The Survey

Olneyville Population Breakdown (N = 5,138)

Hispa

nic or

Lat

ino

Whi

te a

lone

Black

or A

frica

n Am

erican

alo

ne

Amer

ican

Indi

an a

nd A

lask

a Nat

ive

alon

e

Asian

alo

ne

Native

Haw

aiia

n an

d Oth

er P

acifi

c Is

land

er a

lone

Some

othe

r rac

e al

one

Popul

atio

n of

two

or m

ore

race

s:0

500

1,000

1,500

2,000

2,500

3,000

Hispanic or Latino, Non Hispanic or Latino by Race - Olneyville

Med

icai

d-Rite

Care,

Med

ical

Ass

ista

nce

Med

icar

e

Privat

e In

sura

nce th

rough jo

b

Uninsu

red

Other

0

20

40

60

80

Type of Insurance N=85

Citizen of USVisa for stay in

US UndocumentedTotal

0

10

20

30

40

50

60

70

80

45

1421

80

4

10 5

Insurance status by Legal Status

Uninsured Insured

Creole English French Spanish other0

10

20

30

40

50

60

70

80

Primary Language

Health

Cen

ter

Privat

e Doc

tor

RI Fre

e Clin

ic

Hospi

tal C

linic

Emer

genc

y Roo

m

Other

0

10

20

30

40

Source of Health Care by Insurance Status

Uninsured

Insured

Summary

The CEHC: Is developed by a highly motivated group of volunteer

medical professionals and community members Will serve the uninsured, including the working poor and

children of Olneyville and Washington Park

The need to provide a new medical home for Free Care is evident by the devastating and growing number of medically uninsured Rhode Island residents.

Current statistics likely grossly underestimate the number of medically uninsured RI adults and children.

Medical Home for the uninsuredOne patient, one providerLinguistically appropriate, culturally attuned care

Navegantes (Community Outreach) Program- Street outreach- Church/CBO outreach- Assistance with health care access

Predominantly Volunteer- Including Administrative, Provider, IT

Unique Programs

Sustainability- 501c3 status- Compensatory growth of volunteer base- Community involvement: Board, committees

Quality Control- Appropriate management and follow-up

Fundraising- Leasing, operational costs, furnishing

Other Aspects

References

Clínica Esperanza/Hope Clinic Mission Statement

National Association of Free Clinics, 2006

The Poverty Institute, “Rhode Island Will Have Insufficient Federal SCHIP Funding in 2007 Congress Must Act Now to Avert the SCHIP Funding Shortfall”, September 10, 2007

www.covertheuninsured.org

www.dbr.state.ri.us/documents/divisions/healthinsurance/070910%20Final%20Uninsured%20Report.pdf

www.freeclinics.us

www.rikidscount.org

www.provplan.org

Conclusion

Eduardo will have “a place to be healthy” instead of having to go to the ER for care.

Our motto: Healthy people, healthy families, healthy neighborhoods.

CEHC wishes to thank the City of Providence for support, and to acknowledge the following inspiring, dedicated individuals: Ethan Colaiace, Tom Deller, Bill Struever, the SBER team, Pastor Duane Clinker, Chris Camillo of PNHC and ONHC, Gloria Rose, Pastor Israel Mercedes, Paul Fitzgerald and ACOS, Blue Cross Blue Shield RI,BankRI, Ninedot, Tom Lopatsky Painters, Computer Telephone (wiring), SBER (furniture), Mauricio Barreto our Architect, our Navegantes, and our wonderful Board and Volunteers.

Acknowledgements