Prescriptions for Poverty 

Children's Hospital Oakland and Highland Hospital are trying to shift the paradigm of urban medicine by tackling some of the root causes of illness — like the lack of housing and food.

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Ruelas, who receives food stamps, also does not currently have health insurance — and, like many people across the country, has had trouble signing up online for the Affordable Care Act, also known as Obamacare. The navigators helped her with her Obamacare application while she waited for information from the doctor.

Jose Rubio, a forty-year-old Berkeley resident who last month brought his five-month-old daughter to Children's primary care clinic, where he was first introduced to FIND, said that it can be challenging to even ask for help. "It's hard to be assertive," he said. "You don't have the confidence to speak up or sometimes you're embarrassed." But the clinic, he added, is a good place to talk through personal problems — confidentially.

Those problems can be multi-faceted and, at times, seemingly unsolvable. In another room in primary care on the same day, 33-year-old Niama Bagaga, who lives near Lake Merritt, explained that her landlord is trying to evict her family — from a home that has a serious mold problem that has greatly contributed to her two children's asthma for years. "We cannot stay outside and I'm worried about the shelters," the mother of an eight-year-old boy and three-year-old girl said, noting that she is currently fighting her landlord in court. "Both of my kids are sick."

It is cases like these that can be especially difficult for physicians who may not have the time or information to help. "I see doctors and social workers get burnt out," said Joey Crottogini, a medical case manager at Children's Hospital. "It gets emotional." He cited the "vicarious trauma" that some medical practioners suffer when they provide care for families with immense challenges. "I can't tell you how many times doctors and residents will call me up ... not knowing what to do, saying, 'Someone just told me they're homeless.' They're doctors and they are there to address medical issues and health issues."

At Highland, there is one social worker on call 24 hours a day, 7 days a week, who may see 12 to 15 patients on a single shift, and is typically working with those suffering from intense trauma, explained Gloria Jenkins, director of social services and the program manager of Highland Health Advocates. "Our goal is really to relieve those social workers." Often, she said, patients "are hurting emotionally and physically, usually both, and I think that it is very difficult for an emergency room to address."

Dennis Hsieh, an emergency room doctor overseeing the help desk at Highland, also pointed out that social determinants of health are not emphasized in medical school. "Doctors are often afraid or don't ask about these important issues, because even if they do come up, it's like, 'Oh, there's nothing we can do for them,'" he said. "We feel badly about that."

In its training curriculum, the consortium cites one national survey showing that four out of five physicians say unmet social needs directly lead to poorer health — and most are not confident in their capacity to address these needs. For some patients, trained college students can help fill in the gap. Combined, the new Bay Area help desks now have nearly 120 trained volunteers beginning to work with patients.

The help desks are housed in institutions in which most patients need social services. Children's Hospital is a federally qualified health center that works with mostly low-income patients. About 90 percent of its primary care patients are "government sponsored," primarily on Medi-Cal, the state welfare program, and in 2012, nearly 70 percent of emergency department cases were government sponsored. At Alameda Health Systems, about 45 percent of patients are on Medi-Cal; 25 percent are on HealthPAC, the county program for the uninsured; and about 14 percent are on Medicare.

Several local studies also illustrate clear links between poverty and health. A 2010 Alameda County report examining the public health impacts of the foreclosure crisis, for example, showed that about four in ten residents experiencing foreclosure had limited spending on food and household utilities — with more than three in ten foregoing medical care. The significant disparities in asthma hospitalization rates in the county are also well documented.

"Health-care costs are rising, and we are increasingly recognizing that addressing only the downstream medical needs is not a successful model and not an economically viable model," said Laura Gottlieb, who is spearheading the consortium and is a family doctor with the Center for Health and Community and the Department of Family and Community Medicine at UCSF. "My thirty-year view is that health care settings will be an important ... member of the teams that are helping to address social and behavioral risks for safety-net populations."

From a systems perspective, investments in these services could translate to savings, Hsieh said. He noted that efforts like the help desk are becoming more relevant "as the focus turns to, 'how do we save money in health care?' as opposed to 'how do we get people coverage?'" As Obamacare moves forward, it is expected that more of these needier patients will be seeking care from the participating hospitals.

"People are actually going to have access to health care," Long said. "With the influx of new patients, it can't just be business as usual."

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