Nurses and Community Clinics

Federally Qualified Health Centers (FQHCs)—the nation’s community, migrant, and homeless health centers—serve over 20 million patients yearly, according to the National Association of Community Health Centers (NACHC). FQHCs provide comprehensive primary health, oral, and mental health/substance abuse services to people across their lifespan. On the front line of these centers, which often serve patients from low-income and medically underserved communities, are nurses. “In a community health center like this one we are moving toward nurse case management,” says Mildred McIntosh, R.N., C.D.E., B.S.N., the Director of Nursing at the Henry J. Austin Health Center (HJAHC) in Trenton, New Jersey.

FQHCs offer affordable, comprehensive, and cost-effective primary and preventive care. In Trenton, HJAHC serves a population of patients who are uninsured or underinsured. “It draws people who always have not had access to health care. They can’t afford [the care] and so when they do come in they have comorbidities, which require a lot of care, and that requires a lot of management,” McIntosh says.

Health centers that fall under the designation of FQHC provide services not typically given in other primary care settings, such as dental care, behavioral health, and pharmacy. The NACHC notes that health centers also help remove barriers to care, such as transportation, case management, interpretation, and home visits. Given the patient population, these additional services are critical. Compared to other providers, the NACHC also reports that health centers disproportionately serve more chronically ill, uninsured, publicly insured, and minority patients, as well as those in poor health.

Designated a FQHC facility, HJAHC patients are 54% African American, according to McIntosh, while Latinos and immigrants from around the world make up a vast majority of the other 46%. As economic and (often, consequently) health care disparities still plague minorities, nurses working in community clinics frequently treat these communities.

The effects of health care reform

Since the health care reform law went into effect, McIntosh says there has been an uptick in patients served at HJAHC. “Absolutely, we have had an increase. We have been trying to enhance primary care,” she says. “[Now] everybody is being given access to care, and that is what we are trying to do, to make sure patients have access and can get an appointment.”

HJAHC is the largest non-hospital based ambulatory care provider in Trenton. It is seeking to become a patient-centered medical home, McIntosh says. Adult medicine, gynecology, pediatrics, HIV treatment, dental care, podiatry, and ophthalmology are the primary health care services offered. Nutrition, social service, substance abuse assessment and intervention, behavioral health, translation services, transportation, and an on-site pharmacy are also provided. Most forms of health insurance, including Medicare and Medicaid, are accepted, and there is a sliding fee scale for the uninsured. The HJAHC provides care to around 17,000 individuals annually, generating over 61,000 visits from three Trenton locations.

“Being in the inner city and being a community health center, we see many [people with] social and behavioral problems,” McIntosh says. “There are not enough funds and social services available.”

The ability to find specialty care is also an issue for the demographic group the center serves. McIntosh notes that many people in underserved communities have used the emergency room as “primary care” in the past because they can’t find specialists who will readily see them. At times, HJAHC will try to facilitate access to specialty clinics. The goal, however, is optimal primary care, health, and wellness. “If we get to the patients earlier, hopefully this will prevent them from presenting further progressions with their problems,” McIntosh explains.

Nurses from minority backgrounds should have major roles in community centers, McIntosh says. “We serve a lot of minorities…and minority nurses have the culture and understanding of care,” she explains.

Working in a center that provides such a wide range of services also means nurses there need to be experienced. “You have to know the specifics across the lifespan,” McIntosh says. “You need a variety of nursing skills, and you have to be very caring and understanding.”

McIntosh believes nurses must also acknowledge what impact their background could have on care provided. “You need to recognize your own culture to understand other people’s cultures….I have to know what problems I have when I approach other people,” she explains. “I have to respect their different views, whether they are religious or social issues. We are working cross-culturally.”

Inside the clinic

Certainly, public health comes with its own challenges, but McIntosh says she couldn’t see herself anywhere else. “The rewards are phenomenal. I love it,” she says. “I would not do anything else. The reward is when a stressed-out patient comes in and at the end of their visit, they say, ‘Thank you for taking the time.’ The reward is I helped someone today, that I brought one person into the health care system.”

McIntosh oversees eight RNs and three LPNs, many from minority backgrounds. “Minority nurses do make a difference; that is the community we serve,” says McIntosh, who is African American. “We are qualified health care providers. We are helping people get access to care, enhancing primary care. We are improving and changing the delivery system [of health care services].”

The Brownsville Community Health Center (BCHC), a FQHC in Southern Cameron County, Texas, is also making a difference in a minority community. Brownsville is on the southernmost tip of Texas, and its county population is mainly Hispanic. Originally established in the late 1940s, BCHC opened doors to its newest center in the summer of 2011. Approximately 215 people work for the corporation, including 50 nursing staff personnel.

The vast majority of nurses who work at BCHC are of Hispanic descent, particularly people from Mexico/Mexican Americans, according to Terry Frizzell, R.N., Director of Nursing. “A lot of our nursing staff is from the area. It is important that the people who are hands-on with the patients are from the same culture because they understand the patients and speak the same language,” says Frizzell, a Canadian native who has worked for the Brownville Health Center Corporation for 16 years.

Originally established in the late 1940s, the BCHC Corporation has four fully functional sites (two other smaller sites are pending providers with recent changeover in key positions). The corporation’s newest facility, the New Horizon Medical Center, is a 47,000-sq. ft. building. It offers OB/GYN, pediatrics, internal medicine, behavioral health, dental, and diabetes education, as well as pharmacy, laboratory, podiatry, and radiology services. BCHC accepts Medicaid/CHIP, Medicare, private insurance, and self-pay patients, who are charged on a sliding scale. In 2010, approximately 19,200 patients visited the center and 85,635 encounter visits were recorded.

Carmen Lopez, R.N., is another long-time employee of BCHC, having worked there almost 13 years. Lopez, born and raised in Brownsville, is a clinical resource nurse. She supervises the nursing staff, which includes a large number of medical assistants, for the centers.

“A lot of times when Hispanic people come here, they usually do not come here until they are really very sick,” Lopez says. “Sometimes we get cases where there is nobody else to take care of them or their Medicaid is done. They [may] have cancer and they have all these [other] problems. When they come here, then they do get help. That is one of the things that’s rewarding: to see people getting taken care of who have all these kinds of problems. You see quite a bit of those kinds of people here.”

Frizzell says finances are not the only barrier to care. “In the Hispanic population, especially with males, they to tend to not seek help,” she says. Whether due to male machismo, a desire to stay strong for family and work responsibilities, or an effort to save money, Frizzell says she sees her patients prolonging their avoidance of medical care. “They don’t see care until the point where they cannot go any more and they realize that something is desperately wrong. Then you do have to be very tactful, very convincing,” she says. “We are all part of a team; we try to be the advocate for the patient.”

Lopez agrees; being a team player is very important in this type of setting. “Everybody has to mesh together,” says Lopez, whose job sees her working across the board with doctors and staff from every department, from OB/GYN to geriatrics. Lopez also has significant administrative duties, including doing evaluations for the nursing staff.

Education is a key part of the role the nursing staff provides. Teaching goes beyond the individual patient, Lopez says. Family members must also be educated. In the Hispanic culture, Lopez says, close family friends are also considered part of the family. “I used to do a little teaching for diabetics, and they would ask, ‘Can I bring my mother, father, brother…? I was helping all these people [get educated] because they are people living with the diabetic and they need to get the information as well,” Lopez says. “Sometimes my classes were quite large.”

Being family oriented is inherent in the Hispanic culture, agrees Angela Hernandez, R.N., a native of Brownsville. She has worked for the BCHC Corporation for almost one year. “Family is just very important,” she says. Hernandez works mainly with adult health and geriatric patients, and she points to geriatric patients as one example where family involvement is paramount. It is very difficult to make the decision to put a parent in a nursing home in this community, she says. Instead, many geriatric patients are cared for at home. “We teach family members what to expect, and about being caregivers. We educate them on things like falls and medication,” she says. “You are treating the whole family.”

Hernandez says she enjoys the opportunity the clinic setting gives her to forge bonds and follow patients throughout the delivery of care. “Here you get to help people who have nowhere else to go and form relationships with them. I think that is the best part of the job,” she says. “You get them in to see a doctor and get the services they need. It is very rewarding.”

Challenges

As with any specialty, community nursing has its ups and downs. One challenge of this type of nursing is trying to accommodate all patients who seek care. “We do get to see just about everybody, but it doesn’t always happen as quickly as we would like it to happen,” Hernandez says.  “In some cases, you get patients that have never seen a doctor and they wind up in a hospital, and end up with all these chronic conditions and now…they need to see a doctor. There are so many people that come here. That is the frustrating part, the difficult part, getting them in within a reasonable amount of time.”

Another challenge is making sure the patients are compliant with their own care plan, such as taking their medicine as diagnosed. “Many people who come in here have diabetes, hypertension, and COPD. Because of our culture and diet, we have a lot of that here,” Hernandez says. “For hypertension for example, you have to explain that they need to take the medicine daily and they need time to adjust to the medicine.” Getting patients to discuss details of noncompliance, such as side effects bothering the patient to the point where they simply stop taking the medicine, is critical.

Grace Hicks, L.P.N., and Emmanuel Okrah, R.N., M.S.

Being a good listener is another important skill for community health nurses. “The patients have stories,” Hernandez says. “Maybe you cannot do everything for them, but if you listen you have done something for them.”

For Hernandez, the rewards of working in this setting are many. “You get to see the difference you are making in a person,” she says. “You see them and then they come back and tell you [what impact you had]. That is a feeling you cannot describe.”

Lopez advises anyone looking into this career field should take the time to visit a clinic. “You need to have a big heart,” she says. “Your heart has to be in to helping people. It can’t be because of money.”

The Family Health Center of Worcester is a community Federally Qualified Health Center founded in 1970. It is a full-service health facility open to all residents of Worcester, Massachusetts, the second-largest city in New England, and its surrounding areas. Family Health Center of Worcester’s mission is “to improve the health and well-being of traditionally underserved and culturally diverse populations in the greater Worcester area by providing accessible, high-quality, comprehensive primary care, dental care, and social services to individuals and families regardless of their ability to pay.”

While the Family Health Center’s history goes back over four decades, it made a big move in the early 1990s when it rented space on property that once housed Worcester City Hospital. That acute care facility closed its doors in 1991, making services offered by community clinics even more important.

In its quest to fulfill its mission, Family Health Center offers a wide range of services: family medicine, maternal child health, behavioral health, dentistry, nursing, a walk-in center for urgent and primary care same-day visits, pharmacy, lab, radiology, school-based health centers, refugee/immigrant health services, teen health clinic, ADHD clinic, INS clinic, flu vaccine clinics, health education and promotion, HIV counseling and testing, and public health programs for the early detection and prevention of disease. Additionally, Family Health Center administers the Women Infant Children (WIC) nutrition program at four sites in the Greater Worcester area.

Opened in 2010, the Center offers patient support to help its clients fully access necessary health care and other needed benefits. These include medical interpretation in over 30 languages, care coordination for patients with chronic illness, patient advocacy and navigation services, homeless families case management services, Ryan White HIV/AIDS Early Intervention Services, a 24/7 telephone nursing line, financial assistance for prescription drugs, food stamps enrollment assistance, exercise and wellness programs, and community health education. Family Health Center also runs a number of satellite offices, many in the city’s schools. It also offers dental services in the nearby town of Webster in its public schools.

Grace Hicks, L.P.N., has worked for Family Health Center at the main clinic for the past two years. A native of Kenya, she has lived in the United States for the past decade. Daily, she performs a variety of tasks for the patients the Center sees, many of whom are Hispanic. “I do triage, pediatric shots, wound dressing, blood pressures, as well as stitch and staple removal,” she says. “I do pretty much anything that comes in the door that needs to be addressed.”

One attribute Hicks sees as necessary in community nursing is empathy. Nurses act as patient advocates, she says, and sometimes help them find a social or economic link to their health problems. “They may come in not feeling well, but they have other areas that need to be addressed, like their housing [situation] or a lost job,” Hick says. “Sometimes you have to explain that they are depressed and why they are stressed out.”

The center has a rich cultural mix of health care staff on hand as well. “I love it because we get all the different cultural diversity,” Hicks says. “And wherever the patient comes from…they all get taken care of, their needs are met, and they are satisfied with what we did for them.”

The nursing coordinator for infection control and employee health at the center is Emmanuel Okrah, R.N., M.S., who has been installed as a Ghanaian Chief. He notes that the largest concentration per capita of Ghanaians is in New England. They make up part of the population that the Family Health Center serves, Okrah says. The Center also sees many patients with Albanian backgrounds. “It is immigrant populations that are underserved,” he says.

Having a multicultural staff at the Center helps them relate to their clientele. “It is important because as a patient, you feel more comfortable,” he says. “You can open up better to a person you relate to. That is one of the [positive things] I see about minority nurses working in community settings.

“Using my situation as an example, when a medical issue arises with someone from my [native] area, there may be a need for a translator for an English speaking provider. I am a qualified nurse and I can interpret,” he adds. “There is a trust there, and they can feel confident.”

Likewise, cultural barriers can be erected, Okrah says. “If a person doesn’t feel at home or there is a communication issue and that person cannot be able to explain the issue to the provider, then that is a barrier. It is very important to understand the cultural underlining of one’s condition.”

Health care reform has had a positive impact, Okrah says. “It is a big plus for community health centers. In a sense it has allowed our clients, who are underinsured or not insured, to use us as a conduit to meeting their health needs. It is a very important role in providing health care.”