East Palo Alto, California - It is lunchtime, and Nunia Ikavuka, 14, waits with her mother in the shade of a tree outside the entrance to the Ravenswood Family Health Clinic here for a tuberculosis (TB) skin test.
For a copayment of just $10, she can have the test done, plus have some other checkups on this visit, said her mother, Lin Ikavuka, who is herself uninsured and relying on her luck to avoid getting any major illness.
On this day, patients pack the clinic’s waiting room—a common enough scene every day, given that the ratio of primary care physicians to patients is 1 per 9,000 in South San Mateo County. The Ravenswood clinic also has a small satellite campus in the Menlo Park neighborhood of Bell Haven.
Pray, Drink Tea and Hope
An estimated 13,000 people in South San Mateo County have no primary health care provider either because “they haven’t signed up in a health care plan or there’s no capacity to take them,” said Ravenswood’s Chief Executive Officer Luisa Buada.
A nurse by training, Buada, who is part Filipina, has been passionate about helping underserved people during 30 years working at community health care centers in California. She has been with Ravenswood since it opened 10 years ago and is the driving force behind many of its programs.
“Before Ravenswood, we didn’t have access to health care,” said its board member and uninsured patient, Carlota Flores. “So when we were sick, we would pray, drink a lot of tea, use home remedies and hope that it would go away.”
Ravenswood provides a primary-care safety net for people in the underserved area of East Palo Alto, population 30,000. This Silicon Valley community still has areas where there are no sidewalks, and it has one of the highest rates of violent crime in California. East Palo Alto’s residents have only one major supermarket, which opened in 2009.
Patients range in age from the very old to the very young and are largely Latinos or Pacific Islanders, reflecting the area’s demographics. Nearly all of them are either on MediCal, are underinsured or have no insurance at all.
Some patients are enrolled in Access to Care for Everyone (ACE), a San Mateo County program that provides discounted reimbursements. Individuals—documented or otherwise—have only to pass a so-called “asset test,” proof they have very low incomes, to qualify.
Young patients like Nunia, who is of Tongan ancestry, are largely on Healthy Families, a state-sponsored, low-cost insurance program for children and teens. But not many clinics accept the program because of its low reimbursement rates.
90 Percent Below Poverty
At Ravenswood, people with incomes up to 200 percent of the federal poverty level pay on a sliding scale. About 90 percent of Ravenswood’s patients live at 100 percent of the federal poverty level ($22,350 for a family of four in 2011). For them, treatment is free, Buada said.
Nearly all of its 126 employees, including those contracted from Stanford University’s School of Medicine, speak at least one other language besides English.
“We make it a point to hire bilingual staff,” Buada said.
“Patient navigators” on the clinic’s staff help clients enroll in health care programs they are eligible for at the local, county and state levels.
Homeless health navigator Tayischa Deldridge seeks out homeless people in the area. She encourages them to get their health care needs met at the clinic, places them in neighborhood shelters and even helps some find public housing.
“The number of homeless in the area is growing because of foreclosures,” she observed.
Larnie Holmes, 67, was one of those who benefited from Deldridge’s tireless persuasion. Homeless for nine years and directionless, Holmes neglected himself until his teeth began rotting and his “mouth looked raggedy,” as he put it. Deldridge got him on MediCal and Supplemental Security Income. Ravenswood’s dentistry unit fitted him with dentures that he constantly flashes at anyone who catches his eye.
“I feel so good about myself now,” Holmes said.
The scant mental health care programs in its service area prompted Ravenswood to offer early mental health intervention through its Integrated Behavioral Health Services, a program started four years ago. Primary health care providers, who detect signs of mental illness in their patients, refer them immediately to an onsite behavioral health counselor and help avert full-blown crises.
“We save the county money by not sending patients to its mental health clinics,” said Dr. Daryn Reicherter, assistant clinical professor of psychiatry and behavioral science at Stanford medical school.
In 2010, with a $1.5 million grant from the David and Lucile Packard Foundation and financial support from other foundations and the California Dental Association, the clinic added a dentistry unit to its services, filling a vacuum in the community.
Up until then, the ratio of low-income population to dentists in South San Mateo County was 81,521 to 1, compared with the national average of 3,000 to 1.
Patient Load Quadrupled
Since its inception in 2001, the number of patients has quadrupled at Ravenswood overall. Last year, the clinic provided 50,200 health care visits to nearly 9,000 patients.
With its annual operating budget of $13.5 million, patient fees cover about half its costs. The federal government provides 23 percent of the clinic’s budget, 50 percent comes from such third-party reimbursements as MediCal and Healthy Families, and the rest, 27 percent, from philanthropy and health care partners.
Recent job losses and the tanking economy are stoking demands for community health care clinics. Not surprisingly, Ravenswood has seen a steep increase in demand for services in recent years, Buada said.
The clinic has outgrown its current 7,800 sq. ft. modular facility in East Palo Alto. Plans are afoot to include mammography, X-rays, a full-blown laboratory and twice as many examination rooms by 2012.
Nationally, community health care clinics serve an estimated 20 million people every year. That number is expected to double by 2015, thanks to an $11 billion infusion from the health care overhaul and $2 billion in federal stimulus funds.
“Community health centers are essential to the implementation of the Affordable Care Act” in 2014, Buada said, referring to the new federal health care reform program.
Pediatric dental care director Yogita Thakur said Ravenswood is the kind of place she has been wanting to work at ever since she graduated from dental school in India. Social dentistry is what motivates her and her colleagues to work at the clinic, she said—not the bottom line. Thakur emphasized, “It’s a humbling experience.”
Luciano Perez watched as his son, Evan, age 6, was having his teeth X-rayed by Hilda Quintero, a registered dental assistant, after Perez signed the intake form with his thumb impression. Evan’s brother, Brian, 9, sat nearby, awaiting his turn in the dentist’s chair.
“But for this place, I would have had to go to El Camino Hospital” in Mountain View, Calif., Perez said in Spanish through an interpreter.
“Our Medical Home”
The new health care law has no dental provisions, but it is full of incentives to encourage doctors to provide so-called “medical homes” for their patients, with coordinated care and close patient monitoring to stay on top of necessary preventive services.
“This is our medical home,” Buada said.
As the US economy continues to reel, Ravenswood is bracing for a 5 to 10 percent cut in government funding, she said.
Meanwhile, Buada is doing everything she can to ensure that no one will be turned away from Ravenswood, even as its patient volume grows.
Aside from being an almost one-stop primary health care facility, patients appreciate both the affordability and dignity of the care at the clinic.
“They have really caring doctors who offer good service,” said Nunia Ikavuka as she waited for her TB test. “This clinic has always accommodated our needs.”