Nurse-led clinic provides a medical home to Savannah's uninsured

October 1, 2011

Seven years ago, St. Mary's Community Health Center in Savannah, Ga., opened in a 10-by-10-foot, curtained corner of a computer lab at St. Mary's Community Center, an outreach of St. Joseph's/Candler Health System.

In its first year, a pair of nurse practitioners — teachers from Armstrong Atlantic State University — volunteered two mornings a week to screen for high blood pressure. Their patient load consisted of 65 high-risk residents in Cuyler-Brownsville, one of the most impoverished neighborhoods in the city.

That modest service has bloomed into a primary care health center that occupies a 5,000-square-foot facility in another high-poverty area about a mile away. It serves as a free medical home for more than 680 uninsured patients, ages 19 to 64.

The growth of St. Mary's Community Health Center — and the clinic's success in managing patients with complications from chronic disease — make it a good example of a mission-driven, nurse-led medical home at a time when there is a national focus on the care model. The Joint Commission began accrediting primary care medical homes in July, including those led by nurses. (St. Mary's clinic operates as a department of St. Joseph's Hospital and will not seek to be accredited separately, according to administrators.)

The concept of medical homes is not new, but the Patient Protection and Affordable Care Act passed last year raised their stock as a cost-effective, patient-centered model to promote disease prevention and coordinate specialty services across multiple settings.

Active listening
Health care reform is certainly not what Sr. Patricia Baber, RSM, the center's director, had in mind when she and Sr. Donna Marie Coward, RSM, first opened St. Mary's Community Center a dozen years ago.

"When we first went in, we did not go in with any programs," Sr. Baber recalls. "We said, 'We will listen to the people, and they will tell us what they think they need," and in what order of priority.

Today, the center maintains a food pantry, and it helps clients find jobs and prepare their taxes. A social worker helps clients and patients qualify for food stamps and connects people with social services and financial aid. The center operates a preschool and offers preparatory classes for high school equivalency certificate exams.

Its services are in line with an expansive view of public health held by Paul Hinchey, president and chief executive of St. Joseph's/Candler. He "recognized that illiteracy, substandard housing and lack of workforce skills all contributed to poor health in a community," Sr. Baber says.

Advanced practice philanthropy
It was the relationship between Sr. Baber and the original Armstrong Atlantic State University volunteer nurse practitioners — Linda Tuck and Anita Nivens — that helped define the role St. Mary's Community Health Center would come to play in its disadvantaged neighborhood, a historic African-American district that many civil rights activists once called home.

In 2006, St. Joseph's/Candler renovated a historic home behind the community center and opened a medical triage clinic with three exam rooms. "Many of our high blood pressure patients also had problems with diabetes, and our original intent was to identify these people and send them to a safety net clinic," says Sr. Baber.

As it turned out, the city's safety net providers were operating close to capacity and couldn't absorb the quantity of patients St. Mary's sent their way. "If we have a diabetic with very high blood sugar, they should not wait four to six months to be seen in another clinic," Sr. Baber says. "It became very obvious, very fast; people weren't getting the help they needed as soon as they needed it."

When, in July 2007, the clinic moved again into its present location on Drayton Street, Sr. Baber says it did so as a full-fledged primary care medical home able to manage care across a care continuum.

With the help of a Health Resources and Services Administration grant, the health center and Armstrong Atlantic established a training program whereby nursing school faculty members would provide care in the clinic while nursing students rotated through it to receive practical experience treating poor and underserved patients.

St. Mary's will apply in December for a HRSA continuation grant that would enable it to provide mental health support and case managers through the ongoing partnership with Armstrong Atlantic. The service could help clients cope with day-in and day-out, poverty-related life stressors, which can make individuals more prone to illness or disease complications.

"Through our experiences with patients, we realize that the continual stress that comes from living in poverty 24/7, 365 days a year affects emotional well-being and impacts chronic disease," Sr. Baber says. "If we want to promote wellness in the community, we are going to need to promote mental as well as physical health. It's another part of the holistic approach."

Volunteer power 
The staff of the clinic consists of a clinical nurse manager, a medical assistant, two full-time nurse practitioners and a part-time volunteer medical director, as well as volunteer nurse practitioners and nursing students. The primary care clinicians manage multiple chronic conditions in one patient like hypertension, diabetes and asthma, and they offer gynecological care.

Dr. Eduard Docu, the medical director, consults by phone with physician specialists, who volunteer their services. It's the specialist's call if he or she needs to examine a patient face-to-face. "We have been told over and over again, that is a best practice," says Sr. Baber of the stair-step consult system. She said the clinic tries to keep the specialists' costs of delivering care at a minimum, since they are unreimbursed. It does so in part by conducting diagnostic tests at the clinic at St. Joseph's/Candler's expense for patients who have been referred to specialists.

The clinic tries to maintain a long list of volunteer specialists so no one is called upon too frequently.

Sr. Margaret Beatty, RSM, St. Joseph's/Candler's vice president of mission, has a role in recruiting physician specialists for consults. "I run into them and they say, 'If there is ever anything I can do for you, let me know.'" To which she replies in jest, "You will be so sorry you said that." And, when the time comes and a patient needs a referral, she calls and asks, "Do you remember me?"

Sr. Beatty says requests for pro bono consultations for clinic patients are met graciously. Physicians are happy to support the system's mission to treat illness and promote wellness for all people, in God's name, she says.

Holistic care
Stephanie Alston, clinical nurse manager at St. Mary's, attributes the clinic's excellent outcomes to its holistic approach to care.

The diabetes management program at St. Mary's, for example, includes patient education, diagnostic testing, eye care and follow-up every three months. "As a result, over 70 percent of our diabetics have their blood sugars under control, which lowers the risk of complications," she says.

Reaching immigrants
St. Joseph's/Candler is building on the success of St. Mary's with a second outreach program, Good Samaritan Clinic, in Garden City, a Savannah suburb with a large and underserved Hispanic population.

"Three years ago, we had extra doses of flu vaccine which we offered to administer after the Spanish-language Mass at Our Lady of Lourdes parish," says Sr. Beatty. "The priest asked if there was any way we could help the Hispanic people in the parish with ongoing medical care. He and I and the lady from the state of Georgia's free clinic sat down and figured out a way to do it, and St. Joseph's/Candler gave us the space, which is the most wonderful part."

Good Samaritan — with a staff of three and more than 100 volunteers, including 21 volunteer interpreters — offers clinic services on Wednesday evenings, every other Tuesday evening and Thursday mornings.

"We really try to look around, see the needs of each particular community and respond to them," says Sr. Baber.


Copyright © 2011 by the Catholic Health Association of the United States
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