¡Salud!
Complex Care Management: Changed Lives, Reduced Medical Costs
“This program
transforms
lives and
benefits the
entire health
care system.”
—Naomi Fuchs
CEO, Santa Rosa
Community
Health Centers
Many of the sickest patients we see at Santa Rosa Community Health Centers have gone in
and out of emergency rooms and hospitals, struggling with serious health issues such as cancer,
kidney disease, and heart failure on top of other chronic conditions such as diabetes. Often
they haven’t seen a doctor in years. Without a personal support network or the means to get
needed medications or ongoing care, they are caught in a cycle of worsening health and
increasing medical intervention at exorbitant expense to our community.
What breaks that cycle and makes all the difference for our patients is having a trusting relationship
with a caring provider who checks in with them regularly and understands not only their health
needs but also their circumstances. This is what SRCHC Nurse Practitioner Cindy Dickinson does
for 50 of our patients through our Complex Care Management program, funded through the Tides
Foundation and Partnership Health Plan as a pilot. The patients were invited to participate in the
program due to the high cost of their health care. Naomi Fuchs, CEO of SRCHC, emphatically notes,
“This program has reduced hospitalizations by 46% and saved $500,000 in the past six months.
This program transforms lives and benefits the entire health care system. Hospitals, emergency
transport services, insurance companies, and those who use these valuable services all benefit.”
“I am able to provide care at transitions, to call after an ER visit and to visit at home after a
hospital stay to prevent hospital re-admissions,” Cindy Dickinson explains. “I ensure regular visits
with their primary care doctors and assist with medications and other aspects of self-care to keep
them moving toward their health goals.”
Cindy has made about 150 home visits in the last nine months, which doesn’t include her patient
meetings at parks, coffee shops, or at the health center as part of their visits. “We know that
this intensive relationship with patients really is more cost effective,” she notes, “because
it also maintains their connection with a primary care doctor and a medical home.”
One of her patients is Ralph, who was admitted to the hospital twice and
visited local emergency rooms four times in 2011 because of frequent
seizures. Since coming into SRCHC’s Complex Care program, he has not
gone to a hospital or ER once. “I was on the street for 22 years so my body
wasn’t in good shape,” says Ralph, whose severe, untreated diabetes led
to foot surgery. “It’s a lot better for me to be at home where a nurse can
come over instead of me coming in. I can tell Cindy what’s wrong with
me, and she takes care of it.”
SRCHC providers would love to work with more of our patients this way,
coaching them outside of medical visits to sustain their health. “There are
over 500 people within our health centers right now and probably as many as
5,000 in Sonoma County who would benefit from these services,” notes Naomi
Fuchs. “We’d like to expand this program to take care of all the people who need
this level of care.”
A newsletter from Santa Rosa Commmunity Health Centers | summer 2013
Patient Spotlight: Harold Sweet
2
Harold Sweet is an Army veteran who went to Germany as a translator
with military intelligence. He retired in 1960 with a rank of Specialist 4th
grade, the equivalent to a corporal. He has a Master of Science from Purdue
University and a PhD from UC Berkeley, both in Entomology. He’s worked
as a county agricultural inspector in Los Angeles and a botany and biology
instructor at the Community College of San Mateo.
Harold has been a patient at Santa Rosa Community Health Centers since
2006, and Dr. Joel Lewis has been his primary care provider for the majority
of that time. Dental care is not included in his veteran benefits, and in recent
years Harold has had difficulty paying the co-pay for dental cleanings. As
a result, he says, “I couldn’t find anybody to clean my teeth.” He is diabetic,
which presents certain possible complications when it comes to oral health.
When one of his teeth started “coming loose in the socket and causing an
extremely painful bite,” he felt he had no other option but to take matters
into his own hands. He made sure everything was as sterile as possible and
got as relaxed as he could, then used needle nose pliers to pull the tooth
out himself. Thankfully, he has suffered no problems or complications.
Vista Family Heath Center patient Harold Sweet
Harold is very much looking forward to the opening SRCHC’S new Dental
Health Center so he can get the kind of dental care he desperately needs.
The new facility will make possible the regular cleanings, fillings, and caps
he needs. He jokes, “I hope no more extractions.” Harold adds a sense of
urgency to his ability to access dental care. He says, “I’m 78, so I can’t be
waiting.” Read more about our dental health center on the back cover.
Patient Spotlight: Marcelina Hernandez
A little over a year ago, 51-year-old Marcelina Hernandez went to a health fair where she learned she had high blood pressure
and high blood sugar. She was also overweight. Two months later, after being pushed hard by her family members, she made
an appointment at Southwest Community Health Center, where she began working with Nurse Practitioner Tiffany Lai. Tiffany
diagnosed Marcelina with diabetes, hypertension, and high cholesterol. Marcelina became depressed by this news.
With Nurse Practitioner Tiffany Lai as her primary care provider, Marcelina has learned about and utilized practically all of our
available resources to her great benefit. She attends depression groups, sees a nutritionist, and does Zumba classes. In particular,
our La Vida Dulce group has made a significant impact in her life (read more about
this great program on page 4). Marcelina
says, “Since I started going to La Vida Dulce
I began eating right and doing exercise.
I’ve lost over 40 pounds!” Marcelina is such
a fan of the program that she encourages
her friends to attend with her. She says, “I’m
telling everyone I know. I invite them to go
to the classes.”
Today, Marcelina’s hypertension and diabetes are under control, and she is no longer
depressed. Marcelina remains motivated
to improve both her health and her quality
of life. She says, “After I did all this now I’m
very patient. I have time for everything,
I’ve lost weight, and I don’t feel strange
anymore. Now I’m more relaxed, I sleep for
seven or eight hours, and do yoga and exercises like Zumba.” Way to go, Marcelina!
Marcelina Hernandez (front and center!) with her care team. From left: Karissa Moreno,
Clinic Manager and Zumba Instructor; Ana Geiger, Medical Assistant and La Vida Dulce
Instructor; Eveline Simard, Nutritionist; Tiffany Lai, Nurse Practitioner; David AngladaFigueroa, Psychologist.
SRCHC Preparing for Affordable Care Act
3
In January 2014, 50,000 people in Sonoma County
will be eligible for low-cost health insurance
through the Affordable Care Act. The majority of
SRCHC’s 10,000 uninsured patients will be eligible
for full health insurance coverage through the
Medi-Cal expansion program. Currently, Medi-Cal
is available only to people with children whose
income is less than the federal poverty level
(FPL*). Beginning January 1, 2014, Medi-Cal will
expand to cover all people up to 138% FPL,
including single adults with no kids. Those whose
incomes are greater than 138% FPL will qualify for
insurance coverage through Covered California.
Unfortunately, this change still does not make
insurance coverage accessible to undocumented
immigrants for whom we will continue to provide
excellent, culturally competent care regardless of
their ability to pay.
To prepare for this influx of newly eligible patients,
SRCHC will be hiring several new Certified
Application Assistors (CAAs), who will work directly
with our patients to support them through the
process of applying for public benefits. Our goal
is to enroll all our eligible patients in Medi-Cal
within one year! We know that insurance coverage increases access to health care and improves
people’s health, so we encourage everyone to
take advantage of this exciting time in health care.
Open enrollment will begin October 1, 2013. Stay
tuned as more information becomes available!
* 100% FPL for a family of four is $23,550 in 2013. 138%
FPL for a family of four will be $32,449.
MyCareOnline
Messages
Appointments
Lab & Test
Results
SRCHC Certified Application Assistants Vanessa Lopez, Jessica Medrano,
and Mariela Martinez bring friendly faces to the Medi-Cal application
process.
SRCHC Provides Online Access for Patients!
Starting in July, we’re rolling out a great new service for our patients:
MyCareOnline, a secure website that allows patients to send messages to
their medical providers, view lab and test results, and track their medications
and records of care they get at our health centers. MyCareOnline is
completely free to our patients and offers more choice and control over
the way they communicate with SRCHC.
We’ve been piloting MyCareOnline since March, and the feedback has been
overwhelmingly positive. Patients appreciate that MyCareOnline is available
24 hours a day and feel like it gives them more direct access to their care
team. “I really love this website. It’s easy to understand and gives us more
power over our own health care,” said patient Judy Salerno.
MyCareOnline will be available for patients at Vista Family Health Center
and Southwest Community Health Center in July, then rolled out to our
other health center sites later this year.
Eating Well, Overcoming Diabetes, Changing Lives
In Sonoma County, 7% of all residents and more than 10% of Latinos are diabetic, making this
disease one of our most pressing health issues. Since diet and lifestyle are major factors,
educating patients and helping them develop healthier habits is crucial to preventing or managing their diabetes and improving their overall health. For Santa Rosa
Community Health Centers that translates into looking at the complete picture
of our patients’ daily lives—what happens between their medical visits.
Because many of our patients struggle with poverty, the ability simply to
feed their families and themselves healthy, fresh food is nothing short of life
changing. “One of the things we talk about with our patients,” says Dr. Patricia
Kulawiak, a family medicine physician at Southwest Community Health Center, “is that
they can choose health for themselves and their children and it all starts at the kitchen
table. We hope the power they find through making this choice will translate into other
areas of their lives.”
La Vida Dulce: The Sweet Life
When Francisca Sharp, an RN at SRCHC’s Southwest Community Health Center, found her
schedule overflowing with too many one-on-one sessions for diabetic management and nutrition
education, she decided to try a group approach. Now more than 50 people come weekly to La Vida
Dulce (“The Sweet Life”) for an informal educational presentation, lots of good, shared food, and group
exercise such as Zumba. Francisca invites participants to share their progress. “I am learning and
changing little by little. I’m eating more vegetables and less meat, and I have lost 40 pounds,” says one
patient. Another shares, “I was alone and depressed. Now I’m walking 20 minutes a day, and I’ve lost 10
pounds.” A third proudly indicates, “I’m making a lot of changes, and my family sees that I look well.”
“The diagnosis of diabetes can be such a depressing thing to hand to someone, it can seem like a
punishment,” says Dr. Kulawiak. “Now we can say, ‘Here’s what you can do about it. Go to this class
where you can learn, have fun, and be supported.’ ”
“I was alone and depressed. Now I’m walking 20 minutes a
day, and I’ve lost 10 pounds.” —La Vida Dolce participant
Doctor’s Orders: ‘Eat Your Veggies’
Last year, pregnant patients of Vista Family Health Center at risk for gestational diabetes started
receiving “prescriptions” for fresh fruits and vegetables. This is much like any other prescription
except that this one includes a voucher to exchange for produce at local farmers markets. Santa
Rosa Family Medicine Residency physicians Wendy Kohatsu, MD, and Rachel Friedman, MD, started
Veggie Rx to educate expectant mothers and remove some common barriers to fresh produce for these
patients: access, cost, and information. From September 2011 to February 2012, 100 pregnant patients
took part in the pilot program, reporting monthly about their shopping and eating habits. About half of
the expectant mothers who received vouchers used them at a farmers market at least once a month.
Partnering for Health
The success of SRCHC’s diabetes wellness efforts hinges on fresh, healthy foods being accessible and affordable to our patients. We are excited to share how several community partners
are working with us to address this critical challenge.
In the fall of 2011, Redwood Empire Food Bank (REFB) received a three-year grant through
Feeding America and the Bristol-Myers Squibb Foundation to establish and pilot a
Diabetes Wellness Project. Nursing staff at Vista Family Health Center refer diabetic
patients to receive monthly food boxes brimming with an assortment of healthy
staple foods and fresh produce along with diabetes self-management materials.
REFB staff members are trained to conduct blood sugar screenings and diabetes
risk assessments with Food Bank recipients throughout Sonoma County,
4
5
Overcoming Diabetes (continued)
making referrals to Vista Family Health Center for those without medical
homes. Since its inception, the partnership has positively impacted the
lives of almost 50 patients at Vista Family Health Center.
Each month Vista and Southwest Health Centers also receive fresh, organic
produce for diabetes patients, grown locally and delivered regularly by
WHOA Farm in Santa Rosa. Owners Eddie Gelsman and Wendy Mardigan
produce about 20,000 pounds of vegetables annually, but you can’t buy
their produce because they give it all away. When Eddie and Wendy met
SRCHC’s Dr. Patricia Kulawiak through their children’s school, they dreamed
up the idea of a Community Supported Agriculture (CSA)-type program to
support low-income people with diabetes and nutritional needs. “We grow
an abundance of vegetables, including kale, bok choy, leafy greens, carrots,
beets, and squash—things that are high in nutrients and low in sugar,” says
Eddie.
Through our range of diabetes management programs, Santa Rosa Community
Health Centers is helping our patients gain more control over their personal
health and transform their lives in ways that will carry into future generations.
We are, as Southwest site director Shari Brenner likes to put it, “working to
break the back of the diabetes epidemic in our community.”
* To read a more in-depth version of this article, please visit
srhealthcenters.org/diabetes
The sign that greets guests at the entry of WHOA Farm.
New sprouts line the shelves in
WHOA Farm’s greenhouse.
Dr. Patricia Kulawiak and
WHOA owner Wendy Mardigan.
WHOA photos by Laurie Lynn Hogan
SRCHC Board Member Spotlight: Bill Schrader
6
Board Member Since: February 2009
Community Involvement: In addition to serving on our Board of Directors,
Bill is a current board member for the YMCA and COTS and a Trustee for the
Hanna Boys Center. Bill is Director of both Exchange Bank and the California
Bankers Association.
SRCHC Involvement: Bill is the current co-chair of our Board, and he serves
on our Executive Committee.
“I am inspired by what
people at SRCHC do
every day. They are
changing the health
and vitality of our
community, making
a difference for people
of all ages. They truly
give from their hearts.”
Bill recalls that in 2009 SRCHC Board Member Bob Benavides, Jr., EdD,
introduced him to Southwest Community Health Center, as it was known
at the time. Bill says, “Bob knew I’d been involved with the National Alliance
on Mental Illness (NAMI) and thought that connecting me with Southwest
would be a good fit. It proved to be just that.” Bill says that health, fitness,
and compassionate care for underserved people in our community have
been longtime passions for him. Early in life, he was taught that giving time,
talent, and treasure are an essential part of life. “If you’ve been fortunate and
healthy,” Bill says, “we were taught to find a way to give those things back.
It’s not a gift, it’s a responsibility.”
When asked why he’s on the Board for SRCHC, Bill has a lot to say: “I’m
inspired by what people at SRCHC do every day. They are changing the
health and vitality of our community, making a difference for people of all
ages. They truly give from their hearts.” From a business perspective, Bill says,
“It has been amazing to see the organization grow and prosper under the
great leadership of Naomi Fuchs and others. It is tremendously rewarding to
see the community benefit from that effort.”
Bill notes that five years ago when he joined the Board SRCHC was providing 75,000 patient visits. This year it will be closer to 190,000 patient visits at
eight health center sites. “The scope and breadth of the advances made are
really making a difference for thousands of lives in our community—and the
quality of care is the best!” Bill adds.
There’s an even larger reason for Bill’s participation on our Board. He says,
“One of my core beliefs is that access to quality health care and affordable
care is a right that every individual should have. We are too powerful a
country with too many resources to think any differently than that.”
Bill concludes with this idea: “I don’t have a
single bit of medical knowledge or talent.
I can barely change a Band Aid! I’m
happy to be part of an organization that’s
doing this much in the way of health
care. The work done by so many great
individuals at SRCHC has been inspiring
and challenging and I’m
delighted to be part of a great team.”
Our heartfelt thanks to the following donors who contributed
to Santa Rosa Community Health Centers July–December 2012!
Accounting on Computers, Inc.
Agilent Technologies Foundation
Robert and Kim Agrella
Edward and Gail Akamine
James and Janet Alfieri
Thomas Allen
American Cancer Society
Norman and Susan Amidon
William and Jan Andrews
William Anklam
Robert Anschicks
Donald C. Appleby
Richard Auger and Mary Radu
Barbara Baer
Steve and Laura Baker
Alicia T. Ballantyne
Sharon Barbee
Dennis Bartolomei
Stephen L. and Terry Beck
Richard and Pamela Beebe
Robert and Irene Benavides, Jr.
Lisa Bernard-Pearl, MD
Fred Bernhart
Stephen Birdlebough and Sally Davis
Bottle Barn
Peter and Sou Fong Brett
Miriam Bruner
Marcia E. Burkart
Sylvia Busch
Lynn Camhi
Brad Carter
Niels Chew
Elisabeth Chicoine and Mark Sloan, MD
Chloe’s French Cafe
R.C. and Phyllis Clement
Joseph and Dianne Clendenin
Copperfield’s Books
George and Alicia Cowell
Ronald and Carol Cox
John and Katharyn Crabbe
Stephen and Karyl Crook
Michael and Lynn Davis
Roger and Jo Ann Delwiche
Edward and Michele Dempsey
Mary E. Denton
Porfirio Diaz
Russell and Judy Dieter
Pamela Domino
Brian Donlon and Deborah Donlon, MD
Kathleen Emery
Jane Engdahl
Mark and Jean Farmer
Wesley J. Farmiloe
Kenneth and Nancy Fedder
Dennis and Sue Flynn
Food Maxx
Robert and Margaret Foulks
Genevieve Navar Franklin
Anne M. French
Christina Fritsch
Philip and Joan Froess
Naomi Fuchs and David Willson
Allen and Yvonne Garayalde
Karen Gelphman
Carol Glover
Daniel and Loie Goldfield
Gracie Barra Rohnert Park
M.A. Granieri
Bo and Daisy Greaves
Donald and Cheryl Green
Gil Haramati
Phyllis Jo Harris
Bob and Carol Hasenick
Sally Heath
Barbara Moulton and Tom Helm
Laurie Lynn Hogan
The Home Depot
Kathleen Horan
Jon and Carolyn Hossli
Ruth Hosty
Mary Ann Huckabay
Cecil and Geraldine Humes
Hyatt Vineyard Creek Hotel & Spa
Grace Imokawa
Roy and Dorothy Ingham
Innovative Business Solutions
Daniel Ius
W.H. and G.E. Jackson
Mary Louise Jaffray
Olga Javoian
Joan Jensen
Stuart and Connie Jensen
Donald and Ann Jereb
Gary Andrew Johanson
Jay P. Judin, PhD, Fund
Don and RJ Kamprath
Marjan Kayedpour
Sharon Anne Keating
Joseph and Carole LaTorre
Sam Leader
Louisa Leavitt
Richard and Ann Levin
Mirin Lew
Leslie and Nancy Lewis
LifeMed ID, Inc.
Diana Lowe
Robin Lowitz
William MacDonald
John and Enid Macken
John Mackie and Kathleen Ecker
David Marcus
Steve Marlowe and Joan Gates
Catherine Martin
Larry Martin
Stephanie A. McGill
Rita McGowan
Wendell and Emily McHenry
Barbara McNally
Maj. Eugene L. Meade (ret.)
Dennis and Lucia Mentelos
Microsoft Community Affairs
Maureen Middlebrook
Claire Miller and David Kerben
Jeff and Phyllis Miller
Kathleen A. Mouat
Michael and Ellen Mundell
Neil and Lorna Myers
Michael and Lynn Nacey
Victoria Nash
Gerald and Naomi Niimi
David Noorthoek
Northwood Golf Club
Marthe Norwick
John O’Brien
James and Barbara O’Donnell
Terry Oden and Margaret Songster
Sarah Olson
Osmosis Day Spa Sanctuary
Pacific Service Enterprises
Ruth Hyde Paine
Thomas and Margaret Miles
Lee Perron and Judy White
Jeffrey and Susan Petersen
Bruce and Cynthia Peterson
Linda A. Phillips
Paul Poirier and Laura Whooley
Brad and Faye Pond
Penelope Porch
Avi and Juliet Porton
Merton F. Preston
Glen Price
Prickett’s Nursery
Fred Ptucha
Barbara Puentes
David Quist
Katherine Radcliffe
Raley’s
Gregory and Gail Ralston
Patrick and Maxine Reagh
Redwood Empire Food Bank
Ken Reeder and Virginia Spencer
Joel Reif and Deana Abramowitz
Robert and Patricia Reynolds
Willard and Nancy Richards
Tom Rivard
Natalie Rogers
William J. Ronchelli
Amanda K. Roze
Karen Russell
John and Ann Ryan
San Francisco 49ers
Scandia Family Fun Center
John and Nancy Schiller
Daniel and Marion Schoenfeld
Bill and Patti Schrader
Barbara Schreffler
Jean F. Schulz
Marie H. Schutz
Joseph and June Schwartz
William and Ann Scott
Dr. Barry Allen Smith
Daphne Smith
Muriel Smith
Steven J. Smith
Kathryn Snyder
Sonoma County Medical
Association Alliance Foundation
Mark Spaulding and Roberta Delgado
Speedway Children’s Charities
David Stallmann
Samuel and Ailene Stokes
David R. Strand and Bridget Duffy, MD
Anthony Streutker
Mark Swedlund and Deborah Dobish
Jack and Marilyn Swire
Pamela Tennant
Laura Tinti
Jeffrey A. Titus
Trader Joe’s
Patricia M. Truxaw
Michael Ulloa
Paul and Rebecca Van Lith
VJB Vineyards & Cellars
Volunteer Center of Sonoma County
Jerome Wagner
Brian Rockwell and Lisa Ward, MD
Susan Wielk
Elaine Young
Jay Zaslow and Samantha Rai
Joy Zindell
Matthew Zwerling and Patresa Rollinger
7
non-profit
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3569 Round Barn Circle
Santa Rosa, CA 95403
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Santa Rosa’s First Dental Health Center Becoming a Reality
Santa Rosa Community Health Centers has purchased a 12,600-square-foot building
to house our new dental health center! It is located at 1110 North Dutton—the former
site of Sutter VNA Hospice. At full capacity, we will be able to serve 6,500 children and
adults with almost 20,000 visits. The dental health center will be staffed by six dentists
and two hygienists.
We have launched a capital campaign to pay for the new building and have raised
$700,000 of our $1.5 million goal so far. We are grateful to have received a $2.78 million
federal grant to renovate, equip, and furnish the dental health center, as well as a
$753,382 First 5 grant to fund services for children ages 0–5. We expect the dental
health center to be fully self-sustaining with revenue from operations within
approximately two years.
The floor plan design for the dental health center is complete, the architect is
working on construction drawings, and we are accepting bids for construction.
All of this means we are on target for opening in December 2013 or January 2014.
The realization of this long-awaited dream is very exciting!
If you would like to be included on one of our hard-hat tours of the
new facility, please contact Laurie Lynn Hogan at 707.303.3617 or
[email protected].
in this issue:
Complex Care Management | Preparing for Affordable Care Act | MyCareOnline
Overcoming Diabetes | Patient and Board Member Spotlights | Dental Care Update