[Noozhawk's note: This article is part of a Noozhawk special project for The California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communcation & Journalism.]
Ricardo sat in an examination room at the Eastside Neighborhood Clinic in Santa Barbara on a recent afternoon, explaining that swelling in his left leg has been bothering him.
A local taxi driver in his 30s, Ricardo told Dr. Neil Sullivan that he’s having weight problems, and the swelling gets worse when he tries to exercise.
Sullivan, who has worked at the Santa Barbara Neighborhood Clinics for 31 years, explained to Ricardo that Latinos have a higher chance of developing what’s known as metabolic syndrome, and weight gain makes it worse.
Ricardo, who asked that his last name not be used for this story, is emblematic of many patients who come into the clinic at 915 N. Milpas St.; they complain of one issue, but their entire health picture is more complicated.
“There are so many things going on,” Sullivan said.
After an exam showed Sullivan that Ricardo’s legs were filling with fluid, he asked a nurse to set up an EKG for him.
“Otherwise, he’d be up a creek,” Sullivan said. “Nobody’s going to pay $2,000 for an EKG if you don’t have insurance or Medi-Cal.”
Sullivan told Ricardo that he’s overweight and his heart is pumping too hard. He ordered a chest X-ray, also free from Sansum, a stress test of Ricardo’s heart, and he gave him some pills for the swelling in his legs.
“It’s the classic case of what’s going on in the clinics,” Sullivan remarked. “If someone needs care, you can’t just not treat them. You have to treat every patient the same, but you don’t have the same resources.”
The Santa Barbara Neighborhood Clinics are one piece in Santa Barbara County’s network of care for low-income, indigent and undocumented people, and agencies work together to improve the overall health of the Central Coast community.
“Providing care to our entire population from our top to bottom is vital in terms of public health issues,” said Gary Gray, former board chairman of Santa Barbara Neighborhood Clinics.
SBNC operates three medical clinics and one dental clinic on the South Coast, and mostly serves patients who have Medi-Cal, Medicare or no insurance at all.
“This is not just about pure charity, this is about taking care of the entire community in a way that makes it healthier, stronger and more vibrant,” Gray said. “I mean, if you have people who are walking around really ill, it is not good for the rest of us.”
The Neighborhood Clinics work closely with the county Public Health Department to provide primary care for low-income patients on the South Coast. The Public Health Department similarly relies on Marian Regional Medical Center clinics as partners in the North County.
SBNC refers patients to Sansum Clinic for specialty care, as Sullivan did for Ricardo.
Through digitized records, and a new Patient-Centered Medical Home model, a primary-care doctor will have a caseload of patients and get informed of any outside care — hospital visits, laboratory work — via the electronic health-care record system.
The records also can send prescriptions directly to the patients' pharmacy of choice.
It's a system used by Charles Condelos, 75, of Santa Barbara, who regularly visits the Neighborhood Clinics to renew his prescription for back pain medication and get checked out.
The online system double-checks prescriptions against the patient’s age, other drugs and conditions, asking the doctors if they’re certain.
“We’re supposed to know that, but it’s a good reminder,” said Dr. Charles Fenzi, chief medical officer for the Neighborhood Clinics.
The Public Health Department is getting networked with Cottage Health System, Marian Regional Medical Center and the Santa Barbara Neighborhood Clinics, so all digital health records can be easily shared among them.
Health care “has been fragmented because we don’t communicate, so technology hopefully will make that a lot easier,” said Elizabeth Snyder, deputy director of primary care for the Public Health Department.
The county’s eight clinics primarily serve patients who are uninsured, have public insurance like Medi-Cal, or are in the county-sponsored Medically Indigent Adult program.
The clinics provide primary and specialty care, and many private-practice doctors volunteer their time weekly, in addition to Cottage Health System's residency programs for physicians.
The county clinics serve 31,000 patients a year, with 120,000 patient visits. That averages out to 328 visits every day of the year.
Throughout the county, the biggest medical issue is women’s health, including obstetrics, gynecology and family planning.
In Santa Maria, Marian Regional Medical Center has about 250 births a month, and 70 percent to 75 percent of all obstetrics cases are Medi-Cal or emergency Medi-Cal patients, said Sue Anderson, the hospital's chief financial officer.
The other major diagnoses in the county are diabetes, congestive heart failure and chronic obstructive pulmonary disease, a common lung ailment.
With the current system, patients without insurance only go to the doctor when they’re sick, and they often choose the easiest, nearest option — the local emergency room.
That is the most expensive way to provide care, and a big part of federal health-care reform is to encourage patients to use urgent-care centers or clinics, Andersen said.
“We have close to 6,000 ER visits a month now, and a good portion of those are people who don’t have primary-care physicians and use the ER as their primary place of service," she said. "That’s a very costly way of providing services, obviously.”
Often, those patients could be eligible for programs, but they get frustrated with the complex enrollment process, Snyder said.
“I think they get irritated with how complicated it is, and know they have to be seen in the ER,” she said.
Throughout the county, there are efforts to expand after-hours care and access while conducting programs to prevent patients from using the emergency room as a provider of last resort.
As federally qualified health-care centers, the county clinics must take all comers, as well. To help give access to walk-in appointments, primary-care physicians keep a certain number of appointments free every day, Snyder said.
The Patient Protection and Affordable Care Act, also known as Obamacare, promotes a move back to a care model called the Patient-Centered Medical Home.
With this approach, a group of patients is assigned to a team of specialists led by a primary-care physician who is managing the care.
“Right now, services are episodic, and only when people get sick,” said Suzanne Jacobson, chief financial officer for the county Public Health Department./“That’s been the county safety net: keeping people from getting really ill and trying to keep people out of the emergency room,” she said.
“But with the Patient-Centered Medical Home, it’s bringing people in and actually having funding to keep them well, and actually give them the same kind of coverage and access to service that those of us with insurance have. That’s going to be different, I think.”
The Affordable Care Act’s emphasis on preventative care is backed up by the individual mandate that requires all taxpayers to have health insurance. It also is intended to end insurance company discrimination against consumers with pre-existing conditions.
With the expansion of Medi-Cal eligibility and subsidies for the state exchange plans, thousands of Santa Barbara residents are expected to get insurance who weren’t eligible before, which will have significant impacts on the demand on local primary-care facilities.
The Public Health Department is preparing for 6,000 more people to be enrolled in Medi-Cal by the implementation date of Jan. 1, and has pre-registration plans rolling out in October. CenCal Health, the county's Medi-Cal administrator, is preparing for 30,000 people to enroll within the first 18 months of the health-care law taking effect in Santa Barbara and San Luis Obispo counties.