Better care for all

Khaibar Sahar Zoy, 31, an SIV (Special Immigrant Visa holder) from Afghanistan, discusses his medical history with Dr. Fern Hauck, director of the International Family Medicine Clinic. Photo: John Robinson Khaibar Sahar Zoy, 31, an SIV (Special Immigrant Visa holder) from Afghanistan, discusses his medical history with Dr. Fern Hauck, director of the International Family Medicine Clinic. Photo: John Robinson

 

Health is vital to well-being, but not everyone gets the care they need. Here’s a look at some local efforts to help underserved populations, from new moms to new arrivals.

BY Brielle Entzminger, Ben Hitchcock, Erika Howsare, Laura Longhine, and Jennifer MacAdam-Miller.


‘A medical home:’ Treating Charlottesville’s refugees

Seven-year-old Aakriti Tamang sits on an exam table, sipping apple juice, while nurse practitioner Becky Compton listens to the girl’s heart, lungs, and stomach with a stethoscope. On the other side of the table, fourth-year UVA medical student Haley Smith smiles warmly at Aakriti, who glances up briefly, shyly, while Smith and Compton take turns asking questions about her general health, habits, school, and social life.

Aakriti’s answers are what you’d expect from a first grader: lots of details about favorite school lunch options (chicken nuggets, corn dogs, mac ‘n’ cheese, and tacos), the class she likes the most (P.E.), and her BFF (a girl named Mikaela). But when Smith or Compton attempt to tease out more information about health matters, Aakriti just shrugs or whispers, “I don’t know.”

Across the room sits her father, Nima. He listens attentively, occasionally asking questions or chiming in to provide details that Aakriti leaves out. He does so with the help of an interpreter on speakerphone, who translates between Nima’s native Nepali and English. Today’s appointment at the International Family Medicine Clinic at UVA is a routine annual check-up, something that most Americans have had access to their entire lives. But for the Tamang family, and many other refugee patients seen at IFMC, this type of medical care represents a huge cultural shift.

Aakriti was born in a refugee camp in Nepal. Her parents were among hundreds of thousands of ethnic Nepalis driven out of Bhutan in the 1990s, many of whom still languish in camps in Nepal after more than two decades. With the help of the International Rescue Committee, the Tamang family arrived in Charlottesville in 2015, when Aakriti was 2—and, after an initial screening by the Virginia Department of Health required for all new arrivals, were referred to the IFMC for the family’s primary medical care.

According to Harriet Kuhr, executive director of the IRC in Charlottesville, that simply doesn’t happen in most cities where refugees are resettled. “We’re incredibly fortunate,” says Kuhr. “In a lot of places, finding and linking the newly arrived refugees to good health care is an issue. It’s not an issue for us here.”

That’s largely thanks  to Dr. Fern Hauck, professor of family medicine and public health sciences at UVA School of Medicine, who is also founder and director of the IFMC. Hauck says her interest in global health and refugee care took root after working with Cambodian refugees in Thailand in the late 1980s.

“When I learned that there were refugees coming to Charlottesville, I was delighted,” Hauck says, though she soon discovered that their access to health care was what she terms haphazard. “Patients would arrive without records for 15-minute appointment slots with no interpreter. It was very difficult. We didn’t have any real relationship with the IRC or the health department in terms of sharing information.”

“The overarching goal was to provide a medical home for new arrivals.“ says Dr. Fern Hauck, the clinic’s founder

Hauck set out to change all of that. And in 2002, with the blessing of her department chair at UVA, she and a couple of doctors and nurses began working with what was, at the time, a relatively small local refugee population. “The overarching goal was to provide a medical home for new arrivals,“ Hauck says, “to make it easier for them to get the care they need to maximize their health and their integration into a good life here in Charlottesville.”

Today, an interdisciplinary team that includes an RN care coordinator, social worker, pharmacist, and psychiatrist work alongside the clinic’s doctors and nurse practitioners. The clinic also coordinates with the IRC, the health department, Community Health Partnership, Legal Aid, local schools, and other community organizations to provide wraparound care.

“We have a specific outreach and process that Dr. Hauck has worked hard to put into place to make sure that we are very integrated into the community,” says Compton. Quarterly meetings with key community partners help with planning for the special needs or known issues of the refugees and special immigrant visa holders whose resettlements are in process. For the most part, communication between IRC’s social workers and IFMC’s care coordinator happens daily.

“Sometimes we hear about care needs when people are coming here with a very complicated medical history,” Compton says. “So, before they’re even here, we’re starting to work on setting appointments with specialists. These folks have already been waiting for however many years they’ve had this issue. We want to decrease that.”

“Our refugees come from different environments,” explains Hauck. “They’ve left their home country and gone to another country—and sometimes they’ve been to several countries in camps. In those settings, they’re not going to get any primary care.”

What happens in Charlottesville is transformational. “By having a medical home for these patients, we extend our services beyond acute care management, or even disease management like hypertension, to provide colonoscopies and pap smears and mammograms,” says Hauck. “Basically, to get people into the routine kind of health care that we try to provide to all Americans.”

Toward the end of Aakriti’s well-child visit, Compton suggests to Nima that Aakriti should get a flu shot. Through the interpreter, he asks, “Is it necessary? Is it required?” Compton explains that while it’s not mandatory, a flu shot can prevent certain viruses or shorten the severity and duration of illness. Nima seems satisfied by her explanation and agrees to the flu shot.

Compton’s one concern during this visit is the trend she sees on Aakriti’s growth chart. She calls Nima over to the computer to have a look and, through the interpreter, explains what one of the climbing lines might indicate, and how nutrition can play a role. Then she speaks directly to Aakriti. “I know that chicken nuggets and mac ‘n’ cheese taste good, but make sure there’s something green on your plate.” Nima smiles and laughs after the interpreter translates, the way every parent does when someone suggests their child might actually eat a vegetable.

“After living for years in a refugee camp and existing on rations,” Compton explains later, “the American lifestyle can present new health challenges for many of our refugees.” And that will require yet another cultural shift. –JM


Michelle Little’s ACAC physical therapy program focuses on pelvic health for new mothers, who often suffer from incontinence and other debilitating problems. Photo courtesy subject.

Baby steps: PT specialist helps new mothers stay active, safely

Kylie was 28 when her first baby, a daughter, was born. The new mom had always been very active—“running, lifting weights, and playing different sports,” she says. Even during pregnancy, she’d worked out. But after giving birth, she discovered big changes in her body, including the separation of her abdominal muscles down the midline of her belly, a common condition called diastasis recti. “It was hard for me to return to athletics, postpartum,” she says. “Ten months after I had my daughter, I ran the Charlottesville Ten Miler, and I had a lot of hip pain and pelvic pain during my training for that. And there was weakness in my core.”

Her experience is far from unusual, and many postpartum mothers suffer from even more debilitating problems, including incontinence and prolapse of the pelvic organs. According to Michelle Little, a physical therapist specializing in women’s health, one in four women experiences pelvic dysfunction. No wonder, then, that back when Little treated only orthopedic cases—joint pain and the like—her postpartum patients kept telling her about pelvic problems too.

Based, in those days, at UVA, Little wanted to refer these women to a specialist, but many of her patients discovered that it was hard to find a PT locally who would accept their insurance. “I had a lot of patients who reached out saying ‘I can’t afford that; can I come back?’”

Already an orthopedic specialist, Little decided to earn an additional certification in obstetrics and pelvic health, and last summer she started a new program through ACAC Physical Therapy focused entirely on pelvic health. Being based
at ACAC allows her to offer a few key things to patients: she accepts insurance, has a private treatment room, can spend 45 minutes per appointment, and the gym provides child care while women get treatment.

She’s also bringing her previous specialty to the table. “I think pelvic health and orthopedics shouldn’t be separated,” she says. “As an example, I might have a postpartum mom with urinary incontinence or prolapse, and she wants to do a half marathon and has knee or hip pain. That would be a patient who needs to see two or three providers, but because of my specializations in orthopedics and pelvic health, I can do all that in one.”

Kylie, who started with Little as a PT patient, discovered that she needed to relearn how to engage her core before she could effectively go after her exercise goals. “She would watch me squat and really help me with hip position and breathing, and making sure I’m engaging properly,” Kylie says. “She is so knowledgeable. I have definitely gotten back to full lifting and running, everything I was doing before I was pregnant.”

Little says that most women get far too little information about pelvic health throughout the childbearing period. “What’s so confusing,” she says, “is that after you have a baby, you have this six-week period where you are on pelvic rest. You’re not supposed to do exercise [or] lift anything heavy, but you have a newborn and oftentimes already have a toddler. The reality is you’re constantly lifting and carrying.”

Local doula Zoe Krylova says that emotional wellness can also suffer when a new mother confronts physical changes in her body. “Physically, a mom might experience core muscle weakness,” she explains. “This can lead to self-criticism and shame around issues of physical strength and body image. Sometimes even holding your baby can challenge those weakened muscles, and this can be crushing to a mom.” Little agrees: “Urinary incontinence and back pain increases the risk of postpartum depression and anxiety. It’s all so interconnected.”

After six weeks, Little says, women are usually cleared for exercise but aren’t given a lot of guidance. “If you look at the U.K., Canada, [and] France, most women receive pelvic PT after they have a baby, to assess the musculoskeletal system and help them return to exercise,” she says. “But in our community and across the U.S., women are left with bounce-back programs or weight-loss programs.” These focus on a quick return to exercise but are not necessarily optimal for long-term health.

Little thinks mothers need better education both during and after pregnancy, and through her LLC, Women In Motion Wellness, she offers birth-preparation and postpartum classes at ACAC and Bend yoga on the Downtown Mall. “There’s so much we can do preparing moms to stay active during pregnancy, and have a strong core and a good pelvic floor to prepare for the push phase of labor,” she says.

Kylie acknowledges the realities of the transition to motherhood: “There are changes about my body that will probably be forever,” she says. “But I’ve accomplished my goals [returning to exercise]. You can definitely forget your identity when it comes to taking care of your baby, so having that part of my life was so important to me.”—EH


Trust builders: A clinic for the homeless provides more than medicine

Health care for people experiencing homelessness can often be “quite disjointed,” says UVA physician Ross Buerlein. Simple things like having a safe place to store meds or a way to remember appointments, not to mention navigating byzantine financial aid applications, can be a stumbling block for those in crisis.

Buerlein and his colleagues wanted to help. “I knew that if we could intervene early… help manage their chronic conditions, and help them with navigating the complex web that is our health care system, we could make a really big difference in their lives, with pretty minimal financial expenditures on our end,” he says.

Dr. Ross Buerlein

The team decided to hold a bimonthly medical clinic at downtown day shelter The Haven, instead of requiring patients to come to UVA. They spent roughly two years planning, talking to Haven guests and community leaders, and pulling together funding, people, and supplies.

Finally, in May of last year, they opened their first clinic, in The Haven’s cafeteria. No one came.

“It was a little disheartening,” Buerlein admits. “I was scared that all of our legwork was for nothing.”

Many people who are homeless have had bad experiences with the health care system, says Becca Kowalski, a second-year med student at UVA who was part of the clinic team. “So the first step to improving their health is rebuilding those relationships.”

The group adjusted their approach, making the clinic walk-in instead of appointment-based, and starting with medical care rather than getting the financials sorted first. With the help of Haven director Stephen Hitchcock, as well as several med students who had worked or volunteered at The Haven in the past, they slowly developed trust with guests. By  the second clinic, “I think we saw two patients,” Buerlein recalls. “Now, it’s always a bustling clinic.”

Patients receive care for chronic conditions like diabetes, high blood pressure, and high cholesterol, as well as acute issues like wounds and infections. A psychiatrist helps diagnose and initiate treatment for patients with mental health issues—in terms of resources, just having a diagnosis can open a lot of doors, Buerlein says. And the team has partnered with Region 10 and SOAR to help move their cases along.

“It’s been eye-opening to me to see how challenging it is to get patients who often have pretty severe mental illness…expedited care,” says Buerlein.

In general, the staff spend a lot of time on “health care navigation”—helping patients fill out paperwork, qualify for financial assistance, refill prescriptions, and so on. “That’s been a big role that we’ve been able to fill, much bigger than I was anticipating,” Buerlein says.  There are “all these little hurdles,” he says, “that for most patients aren’t a huge deal, but can be a dealbreaker for homeless folks.”

Partnerships have been essential: a local NAACP chapter helps patients sign up for Medicaid, the health department gives vaccines and HIV and hepatitis screenings, and a local nonprofit called All Blessings Flow provides free medical equipment (like canes and wrist braces), which they deliver to The Haven.   

In addition to the clinic itself, held every other Thursday, volunteers spend time at The Haven on other days to do outreach, remind patients of appointments and help them with related tasks, and generally build relationships. Last fall, Kowalski and fellow med student Jacqueline Carson spent Wednesday evenings at the PACEM men’s shelter, an overnight program that is housed in various local churches throughout the winter.

The clinic, says Carson, has been “the best part of my whole medical experience” and confirmed what she wants to do after graduation–join the burgeoning field of “street medicine.” 

Recalling how she was able to get a raised bed for one recently-hospitalized client, who’d found it painful to get up, Kowalski says, “Even the small things we’re able to do for folks makes a big difference.”—LL


Volunteers and doctors discuss a patient’s chart at the Charlottesville Free Clinic. Photo: John Robinson

Care free: Uninsured patients find help at the Free Clinic

“We’re taking care of the people who take care of Charlottesville,” says Colleen Keller, director of the Charlottesville Free Clinic. Tucked behind a parking lot on Rose Hill Drive, the clinic keeps a low physical profile. Inside, though, the complex is a labyrinth; the facilities contain a dental clinic and full pharmacy.

The Free Clinic provides primary care for people who fall into one of the many gaps in the American health care system: those who make too much money to qualify for Medicaid, but don’t get health insurance from their job, often because they work part-time. In Charlottesville, a town with a booming service industry, that’s a significant portion of the population. In 2018, the clinic saw 1,100 medical patients and 1,400 dental patients.

“We’re their regular doctor,” Keller says. “We provide medical, primary care, basic medical wellness prevention, mental health care.” Most of the clinic’s patients are seeking treatment for chronic illnesses like hypertension and diabetes.

The clinic runs on generosity. The organization receives about $200,000 total from the state and the city, but the rest of its $2 million budget comes from philanthropy. The staff is almost entirely volunteer—700 people contribute 14,000 hours per year, according to Keller. Charlottesville’s two large hospitals mean the town is full of medical professionals ready and willing to lend their time and expertise to the clinic. “It’s somewhat unusual to have such an incredible supply of the same doctors someone insured sees,” Keller says.

“As aspiring medical students, it’s really helpful and beneficial for us to see how doctors work from day to day,” says Tehan Dassanayaka, a master’s student at UVA who volunteers at the clinic. “Everyone who comes in the clinic is just really kind and appreciative of the work we do.”

The clinic doesn’t charge any fees at all, though many patients leave a dollar or two in the donation box after picking up their medication.

“Often the patients get that sort of look on their face of, ‘What is this going to cost me?’” says Dr. David Schmitt, a retired infectious disease specialist who has been working with the clinic since 2012. “When you tell them nothing, it’s so emancipating.”

“Volunteering here is kind of a reminder every week of why we’re doing what we’re doing,” says Sula Farquhar, a UVA post-baccalaureate student. “Selfishly, it’s my favorite part of my week.”

The clinic is well-supplied, but it can’t do everything.

“Oftentimes, we know what the problem is, but it’s just, ‘how are we going to take care of that?’ because these patients don’t have insurance,” says Dr. Alan Binder, a retired cardiologist and regular Free Clinic volunteer. “They may not have access to the medication that they need, or the tests that they need, or the therapy that they need. And that oftentimes becomes a marked difficulty.”

“We can be incredible, but [the Free Clinic] doesn’t help you if you have to go into the ICU for three days,” Keller says.

Charlottesville’s exorbitant housing costs and high proportion of service-industry jobs leaves lots of people in the lurch. “Even though you have a perception of the community being affluent, there’s still a preponderance of people who are uninsured,” Keller says.

“Some of them, it’s the first checkup they’ve ever had,” Farquhar says. Those circumstances mean making patients feel comfortable is more difficult and more important than in a commercial practice.

“Much of medicine is figuring out what the patient isn’t telling you,” Schmitt says. “If they feel that they’re in an atmosphere that is un-pressured, you’re more likely to be able to extract that information and deal with it.”

The clinic has an “open-door policy.” Sometimes just leaving the door open isn’t enough, though. “There’s still a large unserved population here that we’re trying to draw into the clinic,” Schmitt says.

In 2018, 47 percent of the clinic’s medical patients were people of color. “We’re thinking a lot about, ‘does everybody know the door’s open, in every community, all races? Can we do better at that?’” Keller says.

Keller will tell you that in a perfect world, the Free Clinic wouldn’t need to exist. The mission initially was to operate the clinic “only as long as you need it.” And while that need isn’t going away, it may soon be getting smaller. Virginia’s 2018 decision to expand Medicaid means many of the people served by the Free Clinic have recently or will soon become insured.

Charlottesville-Albemarle had 12,000 uninsured adults before the latest round of Medicaid expansion. By the time the expansion is over, later this year, that number should be down to around 5,000. The clinic is actively enrolling its former patients in the newly accessible program.

“Regardless of your politics, it does give people coverage, particularly for hospitalizations,” Kellers says of Medicaid expansion.

“We had a lot of people who were sad to leave,” Keller says. “We talked to them about how this is a step forward. Any way people can get more access and coverage is a better world.”—BH


Executive Director Elizabeth Irvin helps support The Women’s Initiative’s free mental health services. Photo: John Robinson

By women, for women: The Women’s Initiative offers free therapy

In recent years, the topic of mental health has become increasingly prevalent in American media. From popular shows like “13 Reasons Why” to hit songs like Logic’s “1-800-273-8255,” it seems that we, as a society, are more willing to talk about mental health, and provide help to those in need.

Yet mental health care remains unaffordable for many Americans. Therapy can range from $65 to $250 or more per hour, and while insurance (for those who have it) can cover some of the costs, it can be difficult to find a therapist who accepts your plan.

Here in Charlottesville, The Women’s Initiative is working to break down these barriers, offering free and low-cost mental health care to women in need—regardless of their ability to pay.

Founded in 2007 by therapist Bebe Heiner, who saw a profound need for mental health care for underprivileged women in our community, TWI now serves over 4,000 clients a year, employs nearly two dozen staff (all but two are women), and provides a wide range of services.

Three days a week, TWI hosts a free walk-in wellness clinic at its main office, during which adults who identify as women can come in and meet with a counselor.

On Mondays, a clinic is held at City of Promise, in Westhaven, and on Tuesdays there’s a clinic at the Jefferson School.

“That is another way that we try to be available to women where they are,” says Communications and Outreach Director Amanda Korman, “to be accessible and welcoming.”

The walk-in clinic is also a pathway to individual counseling. After going through an eligibility screening, clients are connected with a therapy option that suits their needs.

“If you can afford your co-pay and have insurance, we’re going to help you find care in the private community,” says Executive Director Elizabeth Irvin. “If you’re staying with us [for care], it’s because you have no insurance or your insurance is insufficient, which is unfortunately the case for so many people.”

TWI has a sliding scale for individual counseling, but over 90 percent of its clients receive free counseling, funded in part through a grant for victims of crime.

In addition to therapy, clients can choose from a variety of no-cost mental wellness programs. TWI regularly hosts support groups and workshops, as well as creative arts and mind-body activities.

It also works to provide culturally responsive programs, as “the impact of inequality, discrimination, and events like August 12th [is] a really important part of mental health that need to be addressed in order to provide healing,” says Korman.

Shelly Wood, director of the Sister Circle program

The Sister Circle program is a support group specifically for black women. Then there’s the Chihamba West African dance and drumming class and, at the Jefferson School, a monthly yoga class for all people of color.

“A lot of the women [we serve] feel very isolated…they may be one of a handful of black women at their jobs, or in school, or wherever they are,” says Sister Circle Director Shelly Wood. “Just being able to come and find a group of women that look like them and who are having some similar experiences has been really helpful for them. They find a sense of community.”

Led by Ingrid Ramos, the Bienestar Program offers an array of services in Spanish for Charlottesville’s Latinx community, including a support group for Latinx women and a playgroup and parenting program at Southwood. On Wednesday afternoons, TWI’s walk-in clinic is also available in Spanish.

Ingrid Ramos, director of the Bienestar program

“We see and hear from [Latinx women] that it’s so nice to come to a place where I can receive help in my native language,” says Ramos. “They are feeling seen [and] understood because they know that they have a different cultural reference in life.”

For transgender folks of all ages and identities, the Charlottesville Trans* Peer Group and PFlag  host monthly support sessions at The Women’s Initiative.

“Our idea is to build lots of different entry points,” says Irvin. “Different people [need] something different for healing.”

And in the future, The Women’s Initiative hopes to expand its services and outreach even more, in turn helping to touch more lives.

“The need is greater than what we currently can provide,” says Irvin. “The more that we can grow to meet the needs of our people—that’s our goal.”—BE

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