Putting communities first
As a child, Ramón J. Terrazas, MD, MPH ’05, and his family began using La Clínica de La Raza’s health care services after their family doctor retired. During the 1970s, it was the only medical provider in Oakland, Calif., serving the needs of the Latino community, where monolingual families could obtain care from a provider able to speak to them in Spanish. It was just a store-front, volunteer operation at the time, striving to serve a disenfranchised population.
Forty years later, La Clínica de La Raza is the largest Federally Qualified Health Center (FQHC) in northern California with 26 sites in three counties, and Dr. Terrazas has returned home to become one of its leaders. He is a Director and Past President of La Clínica’s board, fulfilling a calling he began to hear as an undergraduate.
“It became clear at that time that I not only wanted to impact the lives of individuals, but also I wanted to be part of the process that addressed issues of access to quality medical care for entire communities and populations,” he said. “By volunteering as a member of the Board of Directors at La Clínica de La Raza, I am able to give back to my community and help make policy decisions that will improve the quality and access to culturally appropriate care for underserved communities.”
This type of practice environment forces the center to be creative to remain viable financially. A full 60 percent of its patients are underinsured or uninsured, and 70 percent of La Clínica’s revenue comes from Medicaid. As a FQHC, it receives a higher reimbursement rate, but the clinic thrives through the aggressive pursuit of external funding and exercising conservative fiscal monitoring to ensure fiscal health. Keeping patients healthy is another contributing factor, Dr. Terrazas said.
“We practice preventive medicine on a daily basis as a means of keeping our patients well and employ best practices for monitoring patients who have chronic illnesses such as asthma, diabetes and heart disease,” he said. “La Clínica’s successes are measured by the health of the communities we serve.”
Further adding value, La Clínica hires from within the communities it serves, increasing that community’s economic foundation, said Dr. Terrazas, whose day job is also community-focused. He is Department Physician for the San Francisco Fire Department.
Many Medical College of Wisconsin alumni share the commitment to community demonstrated by Dr. Terrazas.
Among them, Amy Riese, MD ’04, just completed a three-year service obligation to the National Health Service Corps (NHSC). As a NHSC Scholar, she followed her psychiatry residency in Toledo with an appointment at an approved site located in a Health Professional Shortage Area, as designated by the U.S. Health Resources and Services Administration.
The area is Eureka, Calif., where she continues to practice at Open Door Community Health Centers, comprising nearly a dozen clinics spread across two rural counties in the northern part of the state. It is a FQHC that provides care primarily to the underserved, most of whom are Medicare, Medicaid or uninsured patients. Dr. Riese practices general psychiatry with a routine panel of patients while working as a consultant to the clinic’s primary care providers.
“Our patients’ needs are great and not being able to always take care of their basic needs, such as housing and food supply, can definitely have an effect on their mental and emotional well-being,” she said. “We work hard to make sure patients have access to medications they need and that cost isn’t a barrier to making appointments.”
Since 1971, the Open Door Clinic system has provided care to one in every four people in Humboldt and Del Norte counties. Without its presence, Dr. Riese said, many would simply forgo care or be left only with high-cost alternatives, such as the emergency room. Working in an isolated area is challenging, but building relationships and supporting her patients is rewarding, she said.
“I really like the fact that I can enjoy my practice and at the same time, help people who are most deserving of comprehensive medical care but are often the least likely to receive it,” Dr. Riese said.
Dr. Robert J. Werra discusses the concerns of a patient at the Friday evening clinic held at the Ukiah Valley Rural Health Center.
On the other end of a career, an alumnus has found an alternative to retirement by serving at a Friday evening clinic in Ukiah, Calif. Robert J. Werra, MD ’57, was a full-range family doctor for 45 years in addition to being the physician for a boarding school for troubled teens and a hospice medical director, but when the evening clinic opened nearly three years ago, he got in on the ground floor.
The clinic offers care to anyone in the community, regardless of ability to pay. Sometimes his patients can’t get an appointment with their primary provider or they don’t have one. With a timely evening clinic visit, they can avoid more serious complications and also reduce the strain on the local emergency department, he said.
“A number of the patients seen on Friday night would otherwise go to the ER for evaluation of their acute problem,” Dr. Werra said. “This distracts the ER from true emergencies and costs the health care system thousands of dollars each night.”
Dr. Werra finds that patients often visit the clinic with an uncomplicated problem, yet this leads to opportunities to address important, unresolved problems, for example, obesity, psoriasis or depression. He can then alert the patient’s primary physician or facilitate referral. The setting is also conducive to discussing prevention, including lifestyle choices, immunization and screenings, like colonoscopies.
Notably, however, one third of the people he sees do not have a primary care provider, even though they may be eligible for subsidized care.
“I stress that this evening clinic is a medical motel, but what they really need is a permanent medical home,” he said. “Coming from an uninvolved, retired doctor, this carries weight with the patients.”
Dr. Werra takes it upon himself to match patients with the appropriate clinic or primary physician, and he helps facilitate the transition. Because of his semi-retired status, he has the time to follow up with them to assess their clinical progress and their success in reaching their new medical home.
Amy Zosel, MD ’03, is dedicated to helping an entire segment of southeastern Wisconsin by partnering with local agencies. Dr. Zosel is Assistant Professor of Emergency Medicine at the Medical College of Wisconsin and, through a grant from the College’s Healthier Wisconsin Partnership Program, is developing interventions to decrease the burden of self-injury and suicide in Kenosha County. Partners in the Kenosha County Suicide Prevention Initiative include the College’s Injury Research Center, Kenosha County Division of Health and Mental Health America of Wisconsin.
“The long-term outcomes for this project are reductions in the numbers of poisonings, suicides and self-harm in the area through supporting evidence-based interventions that work to increase screening, referrals and treatment, and reducing access to lethal means,” Dr. Zosel said.
The initiative seeks to address evidence in recent reports revealing that injuries are the leading cause of death for Wisconsin residents 1-44 years of age and that suicide was the second leading cause of injury-related death in the state. Kenosha County has a suicide rate of 11 per 100,000 individuals, with 300 people seen annually in emergency departments for self-harm. Intentional and unintentional poisoning is emphasized in the project as this rate is elevated in the county.
First focused on education, the partners are now expanding their focus to implement interventions at the individual, organizational, community and system levels. This will include exploring social media as a case management or treatment tool, enhancing existing partnerships with local emergency departments to change ED-specific policies for poisoning and self-harm cases, and reaching out to organizations to which people might turn during times of economic distress, such as churches or workforce development centers.
“Although I am new to this particular initiative, I am already impressed by the successful collaboration between the Medical College and community partners as well as improved health outcomes that can result from innovative decision-making and open, consistent communication between these groups,” she said.
Dr. Zosel is collaborating with other Medical College faculty on the project, including Chairman of Emergency Medicine Stephen Hargarten, MD ’75, MPH; Amy Schlotthauer, MPH, also in Emergency Medicine; and David Clark, PhD, in Psychiatry and Behavioral Medicine.
"Guardian angels" in the community
A semi-retired family practitioner who now sees underserved patients in an evening clinic setting in northern California, Robert J. Werra, MD ’57, has also been Medical Director for the Ukiah Volunteer Hospice for more than 30 years. The hospice and palliative care agency benefits the community by providing comprehensive team care and support to patients who are ineligible for insurance or government aid from its sister Medicare hospice. Such cases include those receiving chemotherapy, radiation or dialysis or who are not terminally ill.
“The hospitals and health care community recently awakened to the value of palliative care for non-terminally ill, chronically debilitated patients,” Dr. Werra said. “However, government and insurance funding for this service is scant.”
The volunteer agency primarily provides palliative care services in patients’ homes, extended care facilities and nursing homes, Dr. Werra said. They do not charge for the services, but the community tries to support the hospice with donations and proceeds from its thrift and gift store.
“Our accountant tells us we have a two-year financial life expectancy, but we will continue on because we believe in giving service, and we believe in guardian angels,” he said.
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