Rooted in Compassion
Shade Tree Clinic Keeps Pace with Changing Health Care Landscape
For most of her adult life, Tina Stephens was a chronic user of the most expensive form of health care: the emergency room. Before age 50 she didn’t have insurance for preventive care and developed uncontrolled emphysema and high blood pressure—along with a serious mistrust of health care providers.
“I would call a doctor and even if I told them I had no insurance, they would say ‘Come in.’ But once I got there, I wouldn’t even make it past the receptionist,” Stephens said. “It would bring me to tears that I had to go to the emergency room because I couldn’t get into a doctor’s office. It didn’t matter what kind of shape I was in; they didn’t want to help.”
Stephens is just the kind of patient that health care reform and the Patient Protection and Affordable Care Act (ACA) are designed to address. The ACA goes into full effect Jan. 1, 2014, offering more affordable health coverage to millions of previously uninsured Americans. But there is great concern about whether the system is prepared to meet the need.
Stephens doesn’t have to wait until the first of the year to have her health care needs met. She found the Shade Tree Clinic, Vanderbilt’s medical student-run clinic for the uninsured located in East Nashville. It’s where the next generation of medical providers is learning a new model of care, and where Vanderbilt faculty can put a new theory of experiential teaching and learning into action. The hope is the future care providers may turn things around for patients like Stephens, and perhaps the system as a whole.
Patient-centered medical home
Rising second-year medical student Kelly Wolenberg volunteers twice a week at Shade Tree, working under physician supervision to start patients like Stephens on the right medications. She also works on important details, like whether patients have a ride to the clinic for appointments, or if they are having trouble paying for their medicines.
“Because of Shade Tree I think about the social and insurance situation and how that will impact their care,” Wolenberg said.
An interdisciplinary patient-centered medical home refers to a primary care provider offering coordinated care throughout a patient’s lifetime as part of a team. Patients take an active role in decision-making about their health. The primary care provider serves as the manager of care, working closely with other qualified health care professionals from multiple disciplines to provide treatment of acute and chronic illness, specialty care when needed, patient education and social services among other things. The goal is clear and coordinated communication between the care providers and the patient to make sure everyone is fully informed about what is going on.
For example, at Shade Tree, an onsite pharmacy student fields questions about medications; medical students research and develop patient education; and nurse practitioner students work to provide prenatal care and referrals for pregnant patients. A new medical/legal partnership with law students offers legal assistance, and licensed social worker Shannon Jordan helps a team of 10 students address complex social needs.
“If the health care system is confusing to us, you know it’s confusing to our patients. Then you throw in housing problems, addictions, criminal problems, domestic violence, untreated mental health; it all is so complicated. We teach students to recognize what else is needed for our patients and try to teach the students to function as an interdisciplinary team,” Jordan said.
Outgoing social work team director, Cooper Lloyd, a rising third-year medical student, said the lessons she is learning at Shade Tree early in her medical training are shaping her future practice.
“It’s been valuable to learn about the limitations and opportunities of the system. I don’t think all doctors right now are very tuned in to what insurance patients have and what is covered. Our decisions as providers need to reflect what will be available to patients,” said Lloyd.
Living at the edge
The students are learning critical lessons as millions of Americans finally gain health coverage and enter the “big system,” as the insured health care system is called by one of Shade Tree’s Medical directors, Robert Miller, M.D. He and co-director, Michael Fowler, M.D., said few primary care practices today are prepared to advocate for the large number of disengaged and disenfranchised patients who will be entering the system. (Tennessee will decide by the end of summer whether to expand TennCare, the state’s Medicaid program.)
“Getting a medication to someone in a homeless shelter, or getting them to clinic from a shelter isn’t always that easy. But it’s all part of medicine. That’s what drives people like Mike and me, is teaching that advocacy,” said Miller, associate professor of Allergy, Pulmonary and Critical Care Medicine.
“So many people like Tina Stephens have no insurance coverage, and we take care of a ton of patients who are working uninsured. They work hard, they work full time, or nearly full time, but if they get sick they lose everything they own,” said Fowler, assistant professor of Medicine in the Division of Endocrinology, Diabetes and Metabolism.
According to the Centers for Disease Control and Prevention, one in three people are in a family that is experiencing financial burden from medical care, and one in 10 are in a family with medical bills they are unable to pay.
For Tina Stephens financial catastrophe came when a short stay at a local
hospital generated thousands of dollars in bills she could not pay.
“In 2011 our hot water tank caught fire while I was asleep and I couldn’t wake up. My dogs kept barking to get me out, and the house was full of smoke. I had carbon monoxide poisoning,” Stephens recalled.
Shade Tree students and volunteers quickly helped Stephens apply for disability and TennCare Medicaid health insurance. She was accepted into the program and her medical bills were covered retroactively. The only catch was that with insurance coverage, Stephens would have to leave Shade Tree for a regular primary care practice.
“It’s not easy to transition from a clinic like ours. To some extent it’s easy to ask for assistance for people who have no insurance, but not so easy for those who do have access. For example, many primary care offices don’t take TennCare. That’s a challenge,” Miller said.
The students have a list of nearly 100 newly insured patients who, like Stephens, are being transitioned from Shade Tree into regular primary care practices. In order to usher patients into the “big system” systematically, and with great care, Lloyd organized what is called the TennCare Transitions task force.
Wolenberg, current student director of social work, and classmates MariaSanta Mangione and Emily Krainer work to find primary care providers who accept TennCare or Medicare and are accessible for patients. Then students create individualized plans for each patient to allow for continuity of as many services as possible.
“Tina Stephens is in our smoking cessation program, which is really important for her. If they’ve been benefiting from seeing social work and patient health education, we keep that in mind,” Wolenberg said.
“We believe we have been providing good care, but ultimately they will be better off with one primary care provider and active health insurance to cover any future, unexpected hospitalizations,” Lloyd said.
They helped Stephens find a doctor at United Neighborhood Health Services (UNHS). The UNHS clinics recently received Patient-Centered Medical Home status through the Joint Commission. It is a great solution for Stephens, but she says she will miss being cared for at Shade Tree.
“I knew with Shade Tree that’s what they did, help you and try to get you on insurance. It makes room for another person to come on in to Shade Tree. I have a stepson with seizures who has gone down (to Shade Tree) and he’s getting help now,” Stephens said.
Outside these walls: the future
Wolenberg, Lloyd and their student colleagues continue to witness the benefits and challenges of the system. They say they greatly value learning how to function as part of an interdisciplinary team, and they are excited to have the opportunity to work on real-world problems and develop critical thinking skills. But they realize Shade Tree Clinic’s ability to provide supportive and nurturing care is only possible because of support from the University, the Medical Center and community volunteers, grants, donations and fundraising events. It’s what lies outside the clinic’s walls that concerns them.
“I am not sure if the primary care providers will be there by the time all our patients get coverage. We are already finding it difficult to find primary care providers because many don’t take TennCare. I hope it gets to the point where more people can tap into social services, dental care and eyeglasses. I hope all these things will be easier,” Wolenberg said.
VUSM instructors say these concerns are exactly what their students need to experience. They are learning to be the leaders of tomorrow, the people who will have the chance to change how health care is delivered and paid for.
“Older physicians may be rolling their eyes at what is to come. They don’t see solutions, but students say ‘Here’s the need, here are the resources, we’ll find a way.’ That’s satisfying for us,” Miller said.
Miller and Fowler say as they watch students work through these difficult problems at Shade Tree, they see a hopeful future.
“And they are much more adaptable to a new system than older physicians,” Fowler adds. “The students learn the new rules quicker and they develop a sense of professionalism earlier than they would because they are learning how to advocate and protect at an earlier stage. That gives me great hope.”