Rural Clinic Provides Care to Underserved

SILVER CITY, N.M. — Beatrice Resendiz grew up in this small town of miners, artists and college students near the Gila National Forest. A diabetic, she set aside her own needs to work, care for her four granddaughters and help minister to her mother, who had Alzheimer’s disease.

Only when Resendiz ended up in the emergency room without vision in one eye, her left arm numb, did she pay attention to her own health. “I thought it was an aneurysm, “ Resendiz said. “But it was stress and diabetes. “
A similar fate befell Cynthia Marquez, who moved to Silver City from Houston in 2012. Several weeks later, she ended up in the hospital, diagnosed with diabetes. “I had no clue what was going on and I had nowhere to go, “ Marquez said. “I could have died. “

Both women credit their survival to Hidalgo Medical Services, a nonprofit public health clinic that has set out to develop a model for delivering quality, affordable health care to rural communities, reported The New Mexican.
New Mexico needs such models. Of the state’s 33 counties, 32 lack enough health care providers, such as doctors, nurses, nurse practitioners, mental health counselors and dentists. It’s hard to attract primary care providers to the state’s rural areas and harder still to keep them.

Increase in Costs

Financing public health care poses another problem: Although the state’s Medicaid program has expanded, trips to the emergency room for non-emergencies such as colds and ear infections have increased. Costs ballooned to $116 million in 2015 from $99 million in 2014, according to New Mexico’s Human Services Department.

Hidalgo Medical Services is well positioned to address those separate, but related, problems. The group was founded in 1995 by a coalition of community leaders, led by health policy expert Charlie Alfero, to fill the gap left after the only public health clinic in Hidalgo County closed a decade before. “We had a blank slate, “ Alfero said. “We asked the community what they needed. Over time, we decided that primary care was medical, dental, behavioral health and social needs. “
Although the group has grown since, it hasn’t wavered from its long-term goal: providing a better health care system focused on patients’ needs. Hidalgo Medical Services now provides primary care through 13 sites to residents in Hidalgo and Grant counties. It also houses the Southwest Center for Health Innovation, a health policy and advocacy organization run by Alfero.

So what makes it revolutionary? The clinic’s model has four main components: It builds a health care team for each patient, expands the number of medical residencies offered at the clinic, shares an electronic record program among all providers and promotes health care careers to young people.

“Our vision is fundamentally about changing health care delivery across the state and the nation, not just in Hidalgo and Grant counties, “ said Dan Otero, chief executive officer of Hidalgo Medical Services.

Teaming Up for Care

Resendiz and Marquez monitor their diabetes daily, and they will have to do so for the rest of their lives. It can be overwhelming to track their blood sugar levels, diets, work and doctor appointments.
Fortunately, they each have a team to help.

Five years ago, Hidalgo Medical Services created integrated health care teams at its clinics in Silver City and Lordsburg. Each patient has a primary care provider who is assisted by a nurse, a medical assistant and a community health worker. The teams also work with behavioral health specialists and dentists.

The cooperative approach helps share the load of a managed care system now heavy with paperwork and performance requirements under the federal Affordable Care Act.

“The whole pay per performance under the federal requirements? You can’t do it on your own, “ said Dr. Joyce Troxler, a physician who serves as associate program director for residency program. “The old-fashioned, hang-out-your-shingle with a physician, nurse and front-desk receptionist isn’t enough. You aren’t going to be able to meet the measures in a way that means you are paid enough to keep the lights on and keep food on the table. “
“Having an integrated model is going to make that possible, “ Troxler said.

Hidalgo Medical Services staff credit the team model with a no-show rate for clients of 9.5 percent in the last year, half the national average. The teams have helped increase the number of diabetic patients able to bring their blood sugar levels down to healthier levels. They also say the team approach has increased screenings among patients for cervical and colorectal cancer by 20 percent. Early detection is key to more effective treatments.
Taking Care to Communities

Central to the integrated teams are community health workers, trusted locals trained to educate people about basic health care, diabetes and nutrition. Community health workers have been around for years, but “they were never really accepted into the house of medicine, “ said Dr. Arthur Kaufman, head of the Primary Care Physicians Consortium at the University of New Mexico Office for Community Health. “We put them into the middle of clinics like HMS. It’s been transformative. We’ve shown that they save a lot of money. “

Community health workers address the “social determinants“ of health, such as transportation, food, home life and insurance. They are the front line, identifying all the issues that can prevent a patient from making appointments or following up on treatments. If the client needs a dental checkup, food stamps, housing, a job or help obtaining home care, the community health worker is there to coordinate.

“We provide a lot of support and encouragement for people who find themselves stuck with a lot of problems, “ said Marsha Rippetoe, the community health worker assigned to Marquez.

Rippetoe helped Marquez obtain insurance quickly and qualify for a sliding-scale fee. Rippetoe also helped Marquez acquire a machine for testing her blood sugar, and she even attended a diabetes education class with her. “I don’t know what I would have done without her,“ Marquez said.

Resendiz worked with Elva Quimby, who’s served as a community health worker for 13 years. When Quimby saw her client falling deep into depression, she alerted the physician, medical assistant and nurse on Resendiz’s team. They quickly got Resendiz to a mental health specialist housed at the clinic.

“Chronic diseases often come with depression,“ Quimby said. “If they are depressed, they can’t get past that. Once we address the depression, it’s a lot easier for them to apply the diabetes education we give them. Bea was able to move on and help herself.“

Thanks in part to the team behind them, Marquez and Resendiz have cut their blood sugar levels in half, a critical step in treating diabetes.

And they’re hardly the only patients who have benefited from the team approach. Quimby and Rippetoe estimate they each have contact, by phone or face to face, with about 200 clients a month. That frequent contact also reduces hospital and emergency room visits. “About 70 percent of the reason people go to health care providers is socially related,“ Alfero said. “Our system relies heavily on the medical center to address social issues.“

Hidalgo Medical Services pays community health care workers from federal funds, creating more jobs in rural towns. The organization’s ultimate goal is to station community health workers at all 13 clinics in the two counties.

Designing delivery

Hidalgo Medical Services didn’t merely build health care teams. It also gave a lot of thought to how best to integrate them within its two-story clinic in Silver City, a federally qualified health center that provides on-site mental, dental and primary care.

On the clinic’s bottom floor, doctors review cases alongside medical assistants and nurses. Two doors down the hall sit their community health workers who focus on family support services. “Having a physician, medical assistant and nurse sitting side by side makes the work much more efficient,“ Troxler said.

The clinic houses a digital radiography machine, a bone density meter, a small pharmacy and a urology lab. A small, private lactation room is available to both clients and staff. Everything is housed to maximize communication, team building and efficiency. Instead of sending a patient with a sprained ankle to the nearest hospital for an X-ray and then awaiting the results, doctors at sites in Lordsburg or Silver City can simply get the tests done a short walk down the hall.

Hidalgo Medical Services also offers mental health services at nine of its 13 sites. A doctor who realizes a patient is in crisis can provide what staff call a “warm handoff “ to a counselor.

“From a business perspective, an integrated health model can definitely make health care more efficient and provides the stability to provide more timely care, “ said Otero, who grew up in Silver City.

A federal capital improvement grant and state funds have helped Hidalgo Medical Services grow over the past 20 years. With an annual $16 million budget, it now employs more than 200 providers and support staff.

The Next Generation

Like many Western states, New Mexico has a tough time coaxing providers to rural areas.

Jerry N. Harrison, executive director of New Mexico Health Resources Inc., said fewer physicians are opting to open family practices. Those who do tend to work in urban centers such as Albuquerque or Santa Fe. Clinics and hospitals compete fiercely to attract primary care providers, he said.

Making matters worse is that many of New Mexico’s remaining family physicians are nearing retirement. In each of the past four years, the state had the nation’s highest number of doctors older than 60 and the lowest number under age 40, Harrison said.

What’s more, all doctors must complete medical residencies before they begin practicing on their own. Those residencies are funded through Medicare at a cost of about $150,000 each. Since 1997, Congress has capped the number of Medicare-funded medical residencies allowed in each state, and many of those slots are for specialties, such as pediatrics, cardiology and neurology instead of family medicine, Harrison said.

Because doctors are likely to practice within 100 miles of where they complete their training, shifting some of the limited medical residencies from major teaching hospitals to rural areas is key to attracting and retaining providers in remote settings.

Kaufman’s group at UNM and clinics such as Hidalgo Medical Services have worked together to expand rural residencies with funding provided under the Affordable Care Act. They’ve created incentives such as loan repayment for medical school and housing assistance to persuade physicians, physician assistants and nurse practitioners to move to places such as Silver City and Hobbs. Hidalgo Medical Services has three apartments built into the Silver City clinic for residents.
The first two residents in the program just finished their three-year terms at Hidalgo Medical Services. According to Dr. Darrick Nelson, chief medical officer, both now practice in rural Doña Ana County, where they provide obstetric and pediatric care, internal medicine and geriatric care. “Family medicine doctors are trained to take care of families, cradle to grave,“ Nelson said.

Hidalgo Medical Services also promotes health careers to middle school and high school students.

The Right Fit

“The best solution to solving the rural primary care provider services is to train people from and in rural areas, “ said Nelson, son of a miner from a small Arizona town. The American Association of Family Practice backs up his claim. The association found doctors trained in family medicine and from rural backgrounds are the most likely to set up practices in rural areas.

Physician assistants, nurse practitioners, nurse midwives and nursing students also complete training at the clinic. Alfero is also negotiating an agreement to set aside some dental slots for qualified New Mexico students.
“There’s a lot of grass-roots encouragement,“ Troxler said. “We’re exposing people to the work that we do, hoping to grow and inspire the next generation that will come and fill the ranks as we all age and move on. “
A 2013 New Mexico Legislative Finance Committee report called Hidalgo Medical Services an “effective community-based model which brings coordinated care to the neediest patients. “

It has become more competitive than ever in a time when many rural places are losing their primary care providers. Alfero said the Affordable Care Act’s emphasis on preventive care and outcome-based payments has generated a renewed interest in primary care and family medicine. UNM once had to scramble to find enough medical school students to fill the family medicine spots. Last year, Silver City had 1,100 applications for two positions. “That’s outrageously remarkable, “ Alfero said.

While rural health care has evolved from the country doctor hanging a shingle outside an office, it still centers around providing the best care possible to patients in remote areas. “The HMS mission is focused on quality and comprehensive care, “ said Nelson, not the bottom line. “It allows us to truly put the patient at the center of what we are doing.“

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