Community Health

On Friday of last week I had the opportunity to go with my boss from the Asthma program, Desire La Tempa, to conduct peak flow meter screenings at a geriatric outreach event on Long Island.

A peak flow meter measures the amount of air the large airways in your lungs can expel and by doing so also measures the amount of air those large airways can intake. A good and average number for a peak flow screening depends on one’s weight and age. For instance, I am a relatively petite person and am 21, I can blow a peak flow reading of 450. That’s pretty exceptional and I probably owe that to the large amount of time I spend playing sports, specifically with Haverford field hockey. Lower numbers in the 100 to 200 range are not so good. But, someone who knows they have asthma also generally knows what their best score is and by knowing this can also tell when they are at risk for an attack. When the number drops below your personal best and continues to drop, or remain at that spot, that is a pretty good indication that a patient is at risk for an attack.

The event took place at Sunken Meadow Park. We set up a table and conducted the screenings for senior citizens over the course of the day. It was really nice to work with other  hospital members at this health fair. I really enjoyed interacting with the seniors and providing them with the screening and information on asthma.

If a senior citizen knew that they had asthma I helped to reinforce concepts regarding their care and management of the chronic condition. We explained the importance of carrying an inhaler around wherever you go and taking the necessary medications required every day for their asthma.

We also provided those senior citizens with spacers if they used a pump inhaler. A spacer helps to trap a large portion of the medication from the pump. It also allows the patient to take normal breaths to inhale the medication. If the pump is used normally, a large portion of the medication can be lost in the air and  the treatment will not be as successful. Spacers help to improve the quality of care a patient administers to themself.

The last two weeks have presented some interesting opportunities as I have continued to work with patients in the Asthma specialty clinic, attended more CIDP trainings and finished up my report on the We Are New York video series screenings and surveys.

About a day after I wrote my last post I attended and participated in a training session with Hospital to Home team members and a program called Common Ground, that H2H will be working closely with once the program gets fully under way.

This session with Common Ground was incredibly eye-opening. Common Ground works with homeless individuals to get them off the streets and into a stable living situation with the main long-term goal being to eventually permanently house those individuals who agree to work with Common Ground. The respresentative from Common Ground who ran the training session with H2H was Ed. He does street outreach and shared a lot of tools with H2H on how to approach people eligible for H2H who are homeless.

There was a lot of discussion on how to initially forge a safe relationship with those H2H candidates and we talked about a lot of hot button issues. The main question surrounding these discussions was: How do you approach a homeless person? The most basic answer but, also the most correct one is to start out by saying “Hi, how are you? My name is Ariel. What’s your name?” A homeless person is a person first and homeless second. We should learn to treat everyone with equal respect no matter what there living conditions are like.

When a homeless person refuses help, there is a lot of factors that play into their response. It’s not necessarily that they don’t like you or that they don’t want to talk to you although often times that is the case. But more often than not it’s a homeless person’s sense of what is safe and what makes them comfortable that often limits their interest in receiving help. When you have known one style of life, one church stoop, one park bench and you’ve been able to survive on it, you become comfortable with it and often times you don’t want to leave. It’s like being a young kid and told it’s time to pick up and move to a new neighborhood. You’ve known the house you’ve lived in, the kids next door and even with the promise of new friends and a bigger room, you can’t necessary trust or believe the outcomes of the move will be what people say they are because you are comfortable with what you have and what you know.

Potentially, the candidates for H2H’s services will be homeless. Knowing and understanding where their emotions and attitudes come from will be very important in order to successfully supply these candidates with the quality of care and social services they deserve. We worked on these interactions with role-playing scenes between a H2H employee and a candidate living on the streets.

Just a few days later I attended another presentation on psychiatric outreach to the homeless. There was a lot of interesting information and statistics presented by Dr. Van Yu who with the Center for Urban Community Service that works with Common Ground as well. Some of statistics were very surprising. On a given day in the United States, 750,000 people are homeless. In a 12 month period, 3 million people will experience some form of homelessness. In New York alone 2,382 people are street homeless. But in comparison Los Angeles has an alarming 40,144 people living on the street.

In addition, we learned a large number of psychiatric problems and mental illnesses exist among homeless individuals. Younger individuals tend to have more psychiatric illnesses as well. Suicide is also high among homeless individuals. We also learned how to approach someone with a psychiatric illness and added that to the tool bag to take into the field.

Unfortunately, I won’t get the opportunity to watch the H2H team members hone these skills in the field. But, I found the sessions to be incredibly informational and eye-opening. I learned a lot about outreach to the homeless and  really enjoyed learning about the services of Common Ground and CUCS.

Over the last two weeks, I’ve been continuing my work with the Asthma program and  CIDP.

With the Asthma program, I have been working in the clinics, especially the pediatric one, to educate children and their parents about how to manage their care. I’ve been working with my co-workers to educate patients on the use of inhalers, medication regimens and how Asthma works within their body so that they understand the purpose of taking their medications daily. We have to educate patients every time they come into the clinic. It’s incredibly important to ensure that they understand how to properly take their medication so that they don’t have an Asthma attack. Someone put it this way: when we were all kids, our parents had to typically remind us all the time to brush our teeth, to wash our face, etc.  After a couple of years, we finally had it down and it’s been second nature to us ever since. No one has to remind us how to do these important things ever. So, that’s the point of continually educating patients on Asthma care. They need to be competent in it and it should be come second nature to them.

I have also written several draft letters for mass school mailings from the Asthma program to inform parents of planned Asthma workshops, screenings for students and smoking cessation workshops that will be held at the school for families, school staff and community members. This is another step of outreach to patients with Asthma that will help the program to contribute to the reduction of the current rates of absenteeism in schools and the consequences that arise for children with Asthma.

I have also been working on a spin-off project with the Diabetes registry. This registry tracks patients diagnosed with diabetes and their test results. It tracks the patients’ diabetes as controlled or uncontrolled and passes along the information to their provider. It is an assessment to see how the hospital is doing on managed care for diabetes. There is also a registry for Asthma. I have been working to assign patients with Diabetes, who are new to the registry, to a care team in order to track the patient’s managed care.

In addition, I have been screening the We Are New York videos to patients in waiting rooms and clinics in order to gain a good number of reviews to submit to the project. I will be submitting an aggregation report on the reviews.

I have also been attending more CIDP meetings. Last week we had a meeting on common chronic diseases and the process of care for patients with those diseases. Some of the diseases included were COPD, Cellulitis, Diabetes, Chronic Rheumatoid Arthritis, etc. 

This was very imformative because it helped me to understand how these conditions can become so unmanaged and why a majority of patients develop a theory of inevitability:  “It’s going to get worse. It’s out of my control. I am just going to end up in the Emergency Room again.  How can I ease the pain (with drugs, alcohol, etc)?” There are two theories that a lot of patients with chronic illnesses have:  fatalism (that fate will inevitably lead a patient to reach another bad point in their illness) and stoicism (knowing it will get worse but, waiting until it gets too bad).

But, I think the biggest highlight of the last two weeks was a kids bike ride I participated in that is sponsored by the hospital to promote healthy lifestyles. The bike ride took place on Friday and in conjunction with the New York  Cycle Club, North Brooklyn Health Network and Woodhull Medical and Mental Health Center and Recycle a Bicycle. We rode from Queens over the 59th street bridge to Lincoln Center in Midtown. At Lincoln Center, we introduced the kids to a world-reknown flautist and a bassist from the New York Philharmonic. The kids were really excited and enthusiastic along the 15 mile bike ride and upon reaching Lincoln Center.  They were singing “Just keep pedaling, just keep pedaling” along the route.  It was really a great experience.

The program works with Recycle a Bicycle to provide kids who ride with bikes. Woodhull promotes healthy living by distributing weekly exercise cards for children to keep track of the amount of exercise they are getting and the New York Cycle Club brings in riders to ride with the kids and protect the bike horde as we storm the streets of Manhattan and the rest of New York. In the summertime, the Kids Ride Club as it’s called, runs a ride every Friday and on Sundays during the school year. Kids who participate 3 times get a bike jersey and those who continue to participate up to 6 times get matching bike shorts.  It’s a great way to promote healthy lifestyles among young kids and to get them confident about exercising. Studies show that if you are confident in exercise as a child, whether it’s because you loved playing soccer on a team as a kid or you enjoyed playing basketball in the city park, you are more likely later on in life to continue those healthy habits because you don’t associate them with negative feelings of self-consciousness and weakness.

Over the last couple of weeks I have been working more and more closely with the CIDP /Hospital to Home project. I am really enjoying this opportunity to work with such a new and exciting project that will hopefully lead the way in improving quality of care for patients with chronic illnesses or diseases.

So, instead of giving the daily/weekly summary of my work at Woodhull, I wanted to make this post, and others that I’m brainstorming as I type this entry, about how this experience is making me more concerned about the health care system as it currently stands but, also how impressed I am with the innovative ideas Woodhull Medical and Mental Health Center, under the omnipotent and omnipresent (love those words) support of the New York State Department of Health and New York City’s Health and Hospitals Corporation, is working to put into action to challenge the situation.

I think what I have witnessed this summer is what I hope to be an indication that the health care system is changing slowly but surely to better serve its patients and citizens and that hopefully the impending Health Care Reform from the White House and the Department of Health and Human Services will only expedite this major overhaul that is much needed.

After a large amount of observations day in and day out that often times that I think might bore some (except for my parents)  if I were to take you minute by minute through my days here for the last 6 weeks, I feel all the more enlightened from them.  I’ve begun to do some continuous  research. I scan the front page of the NY Times in the mornings.as I sit and eat my breakfast with my eyes half open, for updates on Health Care Reform. I’ve also begun to click forward to Whitehouse.gov for any updates (staying away from Twitter these days because one line headlines don’t really cut it) and I have also begun to read the DHHS’s website, more specifically “Health Disparities: A Case for Closing the Gap.” You can visit it here: www.healthreform.gov/reports/healthdisparities/index.html

But, I wanted to highlight something really important from it:

Lack of a Primary Care Provider and Usual Source of Care
A primary care provider and a facility where a person receives regular care substantially improve health outcomes. However, Hispanics are only half as likely to have a usual source of care as Whites. What’s more, half of Hispanics and more than a quarter of African Americans do not have a regular doctor, compared with only one fifth of Whites.¹⁴

Low-income Americans are three times less likely to have a usual source of care compared to those with higher incomes – and almost half of low-income Hispanics lack a usual source of care.¹⁵

Communication with a Health Care Provider
Poor communication with health care providers results in a host of problems including less access to preventative care and higher rates of re-hospitalization. Asian Americans, African Americans, and Hispanics all reported having poor communications with their doctor more often than Whites. For Asians Americans, the gap has increased over time.

( Courtesy of the Department of the Health and Human Services Website: www.healthreform.gov/reports/healthdisparities/index.html)

This comes from the DHHS’s case for Health Care Reform. They are certainly strong points. Who could argue against them? Taxpayers who don’t want to fork over the money to change the situation and their faithfull law makers who represent them in Congress. It’s obviously far more complicated than that, and I acknowledge it, even  based on my experiences at Woodhull. Health Care Reform will certainly be expensive as we try to cut the costs for patients while still improving their quality of care. 

It’s too bad for them because Health Care Reform has already begun in small stages, especially here at Woodhull and most certainly within the city of New York. More to the point, I wanted to acknowledge how realistic these statistics are and why they make such a strong case for reform.

A large portion of patients lack a primary care physician and rely on Medicaid/Medicare/HHC Options for support.

I would argue a majority of patients don’t have a primary care physician. Sure, by coming to the clinics they see the necessary attending doctor but, that doesn’t mean those doctors are their primary care physician. Those are mostly specialty doctors besides of course the Internal Medicine doctors and the pediatricians. The statistics that I cited above certainly wave their flags at me every day as I walk the halls of Woodhull, “Hispanics are only half as likely to have a usual source of care as Whites. What’s more, half of Hispanics and more than a quarter of African Americans do not have a regular doctor, compared with only one fifth of Whites.”

Day in and day out, the language barrier is evident among patients and their providers. Woodhull hospital has a translation service with two way phones and works with interpreters constantly to help surmount this issue. However, it’s still difficult, no matter the effort,  for patients to fully understand doctors if not for language barriers, for cultural ones.

Every day on my way into the hospital and up to the 6th floor where I work I pass HHC options, Medicaid/Medicare offices and the long row of health insurance providers’ booths beckoning interested patients with their wide variety of options.  I pass hundreds of patients every day, probably most who rely on the former options for health insurance than the latter.  For those who are not familiar with HHC options, it stands for Health and Hospitals Coorporation Options and it is a program designed for patients who do not meet the income requirements for Medicaid but, can not afford insurance based on their income. They must meet a specific income requirement to be a candidate client. The program is fee for service, meaning that the patient pays a certain amount for the medical services they receive based on their income.

So, when someone can not afford health insurance, does not have a primary care provider and/or can not take off work to make visits to the hospital they can easily wind up going to the emergency room for care or using the hospital care on almost an abusive basis. Don’t get me wrong, hospital care exists to help those who are sick but, having a primary care physician who can manage your care with you over the years and understands your medical history, can vastly improve your quality of life and of care.  Statistics from the DHHS agree:

Routine Care
People who do not have access to a usual source of primary preventive health care are more likely to end up in the emergency department or in the hospital. Indeed, African Americans use the emergency department at twice the rate of Whites.¹⁶

Low-income adults and children struggle to obtain routine but needed care that serves to prevent the occurrence of more serious health problems. Twenty percent of low-income Hispanic youth have gone a year without a health care visit – a rate three times higher than that for high-income Whites.¹⁷

( Courtesy of the Department of the Health and Human Services Website: www.healthreform.gov/reports/healthdisparities/index.html)

Routine care is incredibly important. Learning and understanding the appropriate way to take care of yourself and the illnesses you might have must come from a primary care physician who can closely monitor and continuously alter your care according to developments or changes in your health. Working in Woodhull, it’s very easy to understand how patients without a primary care physician, who have a low income, possibly work two jobs, have children and relatives to take care of, don’t have time to be concerned with regular appointments and instead rely on the ED when the going gets too tough.

But, I am witnessing improvements and changes to the care for patients who lack a primary care physician, especially those with chronic illnesses or conditions. Hospital to Home is a program that directly exemplifies the changes that are taking  place for patients with these obstacles. As I have detailed before in an earlier post, each patient receives a care team that includes a primary care physician and this group works with the patient to improve all aspects of their life because in reality all aspects play into one another. Whether it’s getting a patient with Chronic  Obstructive Pulmonary Disease to stop smoking, or a patient with liver disease to stop drinking, getting a homeless man with chronic cellulitis out of the bacterial cesspool that is life in the streets and  into a home, it’s always the small things that end up fixing the big things. For example,  Mr. T who could never make his appointments because he never could walk far enough and make it on time to the bus, reduced his dependence on the emergency room for leave-it-to-the-last-minute care because his team from Hospital to Home helped to get him ambulatory service to make his appointments.

We should sweat the small things.

I haven’t been as good at keeping up with this blog as I had originally hoped. But, I think that in someways that is a good thing. I’ve been really wrapped up in working at the hospital and my second project is well underway.

This past week I was introduced more fully to the program I am going to be working with for the last couple of weeks. The Chronic Illness Demonstration Project that is grant funded by the New York State Department of Health.

This project is more formally known as Hospital to Home and is well underway. It is a spin off of a pilot program that began at Bellevue Hospital in Manhattan. Bellevue is spear heading the project but, working closely with Woodhull and Elmhurst Hospital (in Queens).

While the program does span three very large boroughs, it is an all encompassing project. Each hospital’s branch of the program is organized and coordinated the same way and works closely with the executive board that oversees the project.

Last week I attended several interesting training sessions for Community Based Care Managers who work closely with social workers and the patients involved in the program. The patients  admitted to the program are the hospitals’ biggest customers, they are high medicare users or fee for service medicare users.

The purpose of the program is to help these patients with whatever they need in order to turn dependence on the hospital for care into dependence upon themselves and their own capabilities.

Accessibility to all kinds of services is a key component to this program and we had the privilege of hearing from one of the pilot program’s participants named Mr. T (for patient confidentiality reasons, I think it is most appropriate to use this abbreviation). Mr. T suffers from Chronic Rheumatoid Arthritis and the battle is day in and day out. However, one of his biggest problems was getting to appointments initially because it would be too painful for him to walk to the bus stop and by the time he made it he would have missed the bus and all following appointments. So, the team assigned to him worked to get him ambulatory service and now he never misses an appointment and for that his ER visits and admissions to the hospital are significantly lower.

This program is a really impressive and innovative method of care. It is also an important perspective on how the health care system can provide for it’s patients and presents a better way for patients to manage their care.

Over the weekend, before last week began,  I reviewed a series of 7 episodes from We Are New York which are to be displayed on television after they are reviewed by patients in the hospital. They deal with a wide range of topics but, their main goal is to educate people, especially Hispanic immigrants, who are new to New York on how they can take advantage of the great programs the city offers for all its residents regardless of their status. The videos focused on changing one’s lifestyle to fit a diagnosis of diabetes, how serious asthma is as a disease, the seriousness of domestic violence, being a good parent and other important messages. The shows were taped with subtitles and the actors purposely speak slowly for people who are just learning English. This coming Friday, I will be hosting a focus group with 8 patients from the HIV/AIDS Clinic. They will be reviewing two videos for the program. The videos are about 20 min in length and these patients have graciously volunteered their time to watch them.

On Monday of last week the Asthma Care program coordinators held a meeting with principals of schools in Ward 14, the school district that surounds the hospital. They presented a proposal for phase two of their program with the school district. They hope to help train all staff and nurses on the attention necessary for a patient with asthma. They discussed the importance gaining permission to disclose a student with asthma’s 504 medication sheets, filled out by their parents, to the hospital program. They hope to run training sessions on how to detect warning signs of an asthma attack.  And they proposed a way to keep data on absenteeism due to asthma (through nurse documentation)  in order to identify students who need further attention from their primary care providers and to assess the progress of the program. The next step is to receive the memorandum of understanding handed to principals that grants permission to have the asthma program work with them.

I also attended a meeting for another project on Wednesday of this past week, that I will be helping with called Hospitals to Homes. The program is in the trial phase at three New York public hospitals: Bellevue, Elmhurst and Woodhull. We are still working on creating a role for me within the framework of the project as it gets up and running. But, the basic purpose of the program is to provide care teams for patients with chronic illness. The team works with the patient helping them to understand their medications, helping to find them housing and food services and working with their provider. This seems like a great example of the good community health work done at New York City hospitals. The program is supported by a grant from the New York State Department of Health.

This past week I worked on preparing for a seminar we held called PACE, Provider Asthma Care Education. The seminar was sponsored by a grant from the New York State Department of Health and trained/educated physicians with specialties in pediatrics, family medicine, internal medicine, etc. in how to properly diagnose and care for asthma patients. A large number of the physicians were from the community.

And finally this past Friday I attended a presentation given by some members of the Woodhull Asthma Care Team to the New York Chapter of the Latino Nurses Association at their conference at Beth Israel Hospital in Manhattan. Among the presenters were two of my bosses, Dr. Edward Fishkin and Asthma Care Manager Desiree La Tempa. Dr. Fishkin presented a system the hospital uses to track Asthma patients and also spoke on the high incidence of Asthma in North Brooklyn.

He mentioned that 50% of Manhattan’s waste is carried off the island and into Brooklyn, specifically North Brooklyn, daily. 5,000 waste trucks pass through the streets every day. In addition, the Brooklyn neighborhoods were poorly zoned, placing residential buildings next to factories and junkyards. All of these factors are major contributors to the high rate of asthma among children and adults in North Brooklyn. It’s amazing sometimes to here these facts because it makes me feel like we are creating our own problems day in and day out and that this is a situation that could be fixed if people started to take action about their environment. It just shows that you can’t single asthma out as the only problem. You have to attack all aspects of the situation. Starting to work in the schools and communities will reach patients and their families. It will start to improve their lives but there is a large portion of factors that is out of the hospital’s control and have to be addressed by other groups in coordination with the programs offered for asthma victims of environmental hazards.

These environmental triggers also exist in poorly ventilated classrooms, moldy environments and pests and rodents within schools. Dr. Fishkin highlighted this with statistics that indicate within the last school year 12% of students with asthma missed 28 days of school a year! and at least 75% missed one day of school! He also shared that 100 kids a day are sent home from the nurse’s office with asthma related complications. This statistics are incredible and it’s very clear that Woodhull identifies them as very important community issues. Phase II of this school program being implemented will hopefully greatly reduce these numbers by increasing asthma education among school staff.

This week was my first week as a CPGC intern at Woodhull Medical and Mental Health Center in North Brooklyn.

I was expecting to dive right in but, I got a good understanding of the day-to-day bureaucracy within the public hospital system. I arrived on Monday and was sent straight to Employee Health Services to receive medical clearance in order to obtain a permanent hospital employee ID card. I was also directed to Human Resources where I filled out several forms regarding my work in the hospital.

While all of these things seemed painful and tedious at the time, as I was itching to get started, they are really important and directly affect the services patients receive from their providers.

Afterwards, I met with my supervisor in the Asthma Care program at the hospital. She and I went over my role in the program and handed me a large packet of information to begin studying in order to be able to educate patients next week. I’ve got a lot of memorizing to do.

Next week, I will begin working with the Chronic Illness Demonstration Project program. I will be attending a meeting in the city with New York City Hospital workers. I am looking forward to learning more about that program. I have read a lot of material on it but, I can’t wait to hear about it from people who are working to make it a reality.

On Wednesday of this week, I was working in the Asthma program office and we were asked by visitors from Project Sunshine ( a non-profit that brings celebrities to visit children in hospitals) to bring children from our specialty clinic to meet and hang out with 20 members of the New York Giants. The children were so excited and it was great to see how it brigthened their day.

On Friday, I had a meeting with my supervisor in Asthma care and we spoke in Spanish about the questions I had regarding the material for patient education and my duties that I would start preforming next week.

My other supervisor, also handed me a side project to begin working on. The Mayor’s Office of Adult Education and CUNY  have developed lifestyle educational videos for Spanish speakers who are in the early stages of learning English. They are like “telenovelas” or Spanish soap operas and they have themes such as “Stay in School” and “Asthma: the Soap Opera.” I am looking forward to viewing the movies this weekend and then surveying patients on their opinions of the videos next week.

I received medical clearance and I can now interact one-on-one with patients and I will begin doing that on Monday!

Ariel Herm ’10 will be blogging about her internship with Woodhull Medical and Mental Health Center in North Brooklyn, NY.