COMMUNITY BASED SERVICES TO STUDY AND IMPROVE ACCESS TO CARE
I. Community Need: Increase access to primary care. Research that compared Rochester's hospitalization rates for impoverished inner city children with those of suburban counterparts found that city children are between three and five times more likely to present to the ED with complications from asthma, bronchitis, and gastroenteritis/dehydration. Delayed and/or less appropriate treatment was found to contribute to these disparities, which in turn was closely linked to access to care issues.
Health-e-Access is a creative research and patient care approach developed by the Department of Pediatrics to address this issue by helping the working poor easily access the care they need for children while in childcare through the use of technology. Research has shown that children in childcare have higher rates of common childhood illnesses like ear infections and pink eye. For parents using childcare, a child's illness accounts for 40 percent of work absence.
More than $1 million in grants have paid for the placement of telehealth units at seven inner city child care centers. Trained assistants examine children using special equipment and send live imagery via the internet to nurse practitioners located at the Medical Center, who use this input and supporting live videoconferencing to diagnose, treat and conduct follow-up visits.
Since Health-e-Access began servicing patients in 2001, clinicians have completed close to 1,400 visits. Absences due to illness have dramatically decreased at all participating centers, and surveys indicate that Health-e-Access has eased the burden for working parents. Ninety-two percent of all parents said that Health-e-Access allowed them to stay at work, and 94 percent said it helped to avoid an office or emergency room visit.
Pediatricians continue to research the viability of using the Health-e-Access unit beyond childcare centers, and have/are completing pilots in summer camps and grammar schools. The program has received numerous awards and recognitions, including the prestigious 2002 Health Care Advocacy Award from the Healthcare Trustees of New York State for its innovation in increasing access to healthcare, and grants continue to come in to support its work.
II. Community Need: Increase access to mental health services. The Hispanic community, the fastest growing segment of the Rochester population, has seen a 48% increase since 1990, and the community has struggled to keep up with the unique needs of this population. A 1999 study documented startling health disparities, showing that Hispanics, as compared to the rest of the community, had a homicide rate nearly seven times higher, a suicide rate three times higher and cirrhosis of the liver rate three times higher. The study also found that Hispanics received disproportionately fewer mental health services due to geographical and language barriers, as well as lack of access to outpatient psychiatric services.
To address the need for access to mental health services in the Hispanic community, and to also provide fertile training ground for bilingual medical students and residents interested in working with the Hispanic community, the Department of Psychiatry partnered with the Ibero-American Action League (Ibero), the area's largest social support and advocacy organization for Hispanics, to create Lazos Fuertes. Meaning Strong Ties, Lazos Fuertes seeks to improve the health of Latino families in the Rochester area by providing access to quality bilingual/bicultural mental health services.
Located in the headquarters of Ibero, Spanish-speaking families in need of behavioral health services can easily access the care they need in a trusted and convenient location. Anchored by a team of psychiatrists, master level trained therapists, case managers and administrative support, Lazos Fuertes delivers comprehensive mental health care to more than 300 individuals annually with 4,000 to 6,000 patient contacts per year.
Training and teaching are also important goals for Lazos Fuertes, as it struggles with the shortage of qualified bilingual health professionals. The program provides bilingual medical students and residents interested in the psychiatric care of Hispanic patients with a community-based learning opportunity not commonly found in a community the size of Rochester. Through a Department-sponsored scholarship program, three bilingual students studying in our internationally renowned Family and Marriage Therapy program work with patients at Lazos Fuertes. Additionally, the Lazos Fuertes medical director encourages and supports several "shadowing" sessions for students and physicians interested in working with this population each year.
III. Community Need: Increase access to oral healthcare services. Oral health is a major health issue in communities of poverty. Caries among children aged 12-23 months is found primarily in children living at 200% of the federal poverty level. Here in Rochester, 66% of residents live within a federally designated "Dental Health Professional Shortage Area," and 23% of kindergarteners have never visited a dentist.
The Community Dentistry and Oral Disease Prevention Division in the Department of Dentistry continues to expand and enhance its dental clinics and outreach efforts to care for underserved adults and children. In 2003, the division's clinical operations provided care to approximately 33,000 patients, of which 90% were underserved and medically compromised. Seven clinics are dispersed throughout the inner city, and one rural location. In addition, clinics also operate to meet the needs of specialized populations, such as older adults, infants and children with chronic disabilities, and the developmentally disabled.
An education model has been developed for all residents to carry out rotations in community settings. The goal is to sensitize residents to the social context of people living in poverty and to have extensive clinical training in outreach programs for the underserved. These programs provide 80 dental residents with a rich and diverse training experience, with most completing rotations ranging from two weeks to six months.
Two other programs bear special mention. The first is the Daisy Marquis Jones Foundation Outreach Dental Clinic at School 17 in the Jay/Orchard Street area. A state-of-the-art dental clinic was built adjacent to the grammar school in 2002, and provides dental care for approximately 1,500 disadvantaged inner-city children and their families annually. The clinic has had a profound effect on oral health awareness among children in this neighborhood, as it registered an astonishing 76% increase in enrollment for school children that previously did not have a dentist. We are in the process of adding more equipment to enable us to provide an additional 1,800 visits per year and decrease the wait time for appointments by 2-3 weeks.
The SMILEmobile Program is an innovative Community Health mobile dental program. Three fully equipped dental vans provide oral healthcare 15 urban elementary schools and other community-based sites annually. It is funded with institutional dollars and provides services to approximately 3,500 individuals ages 1-19 per year. As a result of this outreach initiative, there has been an 18% increase in enrollment of children who previously did not have a dentist.
IV. Community Need: Increase access to preventive services to eliminate disparities in children's immunization levels. In 1993, based on marked disparities in immunization rates in the city of Rochester, as well as rates of other preventive services between city and suburban children, the Department of Pediatrics embarked on a community wide intervention to raise immunization rates for children (ages 0-2) and reduce health disparities. The core of the program was a community-wide reminder, recall and outreach system for childhood immunizations. Outreach workers, based in 17 primary care practices, tracked children's immunization levels and preventive services, doing reminders, recall, and if necessary, home visits to ensure timely receipt of preventive care. The simplicity of the program yielded startling results. At the start of the study, the difference between inner city and suburban vaccination rates was 18%. At the end of the study, city rates were found to be nearly identical to suburban rates, as were immunization rates between white and African American children and between white and Hispanic children in Monroe County.
This intervention has since evolved into the Primary Care Outreach Program, a community-wide initiative that serves 70% of children 0-3 years of age. Pediatric faculty were able to bring together the region's three hospital systems and two insurers to commit to long-term funding for the program, even in a contentious, competitive environment. Today, our city-wide immunization rates are substantially higher than childhood immunization rates across New York State and the nation. In 2000, the program was honored by the Healthcare Association of New York State for its achievements in community health improvement.
V. Community Need: Increase access to preventive services to eliminate disparity in adult immunizations. A similar situation exists with disparities in preventive immunizations among adults in the Rochester region. Particularly disturbing are flu and pneumococcal vaccination rates: just 38% of African Americans aged 65 years and older are vaccinated for the flu compared to 90% of whites. For pneumococcal vaccination coverage, 75 percent of older whites received the vaccine versus 42 percent of older African Americans. Due to our successful pediatric immunization intervention, the Medical Center once again took a leadership role and helped Rochester be selected by the CDC as one of five demonstration programs in the country to increase flu and pneumococcal vaccination rates among African Americans.
The intervention was launched in 2002, and is led by the Center for Rochester's Health, a unique partnership between the Medical Center and the Monroe County Health Department. Modeled after our successful pediatric immunization intervention, the program is guided by a 17 member Community Advisory Board comprised of various social service and health care organizations. While the program is still in progress, early research indicates it too is successful. At the start of the study, 72% of the target group received the pneumococcal vaccination. Now, that rate is 90%. Flu vaccine data are not yet available.
