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'A Calling' To Care For The Poor At St. Louis' Grace Hill Community Centers

Sep 05, 2013

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ST. LOUIS -- Some children who visit Grace Hill’s dental chairs at the Murphy-O’Fallon Center in north St. Louis arrive in such terrible condition that all their teeth must be pulled.

For young, unemployed men, an appointment at one of Grace Hill’s four neighborhood health centers may be their first doctor’s visit in several years.

Pregnant women receive medical care at Grace Hill and also learn valuable health lessons in group sessions.

Grace Hill Health Centers Inc., a nonprofit charitable organization that relies heavily on the federal government, provides primary health care for the poor and uninsured in the St. Louis area.

Its spacious, well-appointed health centers — each offering a full suite of medical services under one roof — not only relieve pressure on area hospital emergency rooms, but also forge stronger community ties, helping to stabilize crime-ridden neighborhoods.

Community health centers such as Grace Hill are a linchpin of President Barack Obama’s administration’s efforts under the Affordable Care Act to eventually contain the nation’s health care costs by providing cost-effective, primary care to the poor.

But key government funding for Grace Hill and other smaller nonprofit community health centers in St. Louis is in jeopardy, while the number of people in need of free and discounted care continues to rise.

“You can’t provide the same amount of care with dollars being pulled out of the system,” said Robert Fruend, executive director of the St. Louis Regional Health Commission. “These places run lean and tight. There’s no fat in these health centers. So when you cut, you cut bone and actual service. ... Everything’s on the table in D.C. right now.”

At least 17 percent of Grace Hill’s annual budget of $33 million will evaporate unless the federal government decides to extend its “Gateway to Better Health” program, a demonstration project intended to help uninsured residents transition to an expanded Medicaid program.

If the Gateway program funding is eliminated, Fruend said, uninsured patients “will have to figure out where to get care. ... Then, the emergency rooms get more crowded. It starts that vicious cycle all over again that we were able to get away from 10 years ago.”

An additional 33 percent of Grace Hill’s budget is contingent on federal grant programs that also have come under intense scrutiny as part of the nation’s fiscal crisis.

These threatened cuts come as St. Louis ConnectCare, a key provider of specialty medical services to the area’s poor since 1998, is preparing to lay off more than half of its staff.

The Gateway program was designed as a short-term bridge, but with state lawmakers refusing to expand Medicaid, federal health officials are left in a bind.

Why should the average citizen support health care for the poor?

“It’s the right thing to do,” Fruend said. And by providing less expensive primary and preventive care at neighborhood health centers rather than costly emergency care at hospitals, he added, it helps holds down the cost of health insurance for everyone. In serving the uninsured, health systems such as BJC HealthCare and SSM Health Care tend to shift a portion of these higher costs to patients who have private insurance.

Fruend also said that anyone — even full-time employees — may one day fall into circumstances in which they, too, need subsidized health care. Many people these days are living just one paycheck away from charity.

“Healthier citizens over time cost the health care system less,” said Alan Freeman, chief executive of Grace Hill. “An investment in primary care helps to avoid medical crises down the road.”

A Mission

Grace Hill is the St. Louis area’s largest provider of outpatient services to those on Medicaid and also serves a disproportionate amount of the area’s uninsured and underinsured.

Its neighborhood health centers offer primary care, internal medicine, obstetrics and pediatrics as well as pharmacy and dentistry services, a child development center and access to an adult psychiatric clinic.

Men ages 19-64, especially those with chronic illnesses, would be among the first patient groups at Grace Hill to be affected by substantial funding cuts.

Because these patients often suffer from chronic diseases such as asthma, hypertension and diabetes, they rely on frequent doctor’s visits and low-cost medications.

Grace Hill patients pay a sliding scale fee, starting at $10 per prescription, a $20 co-payment for a doctor’s visit, and a $35 co-pay to see a dentist. Patients also enrolled in the Gateway program pay only $1 to $3 for doctor’s visits and $3 or less for prescriptions. As a result, they have much greater adherence rates for taking their medications and showing up at follow-up appointments.

In addition, Grace Hill provides primary care, prevention and maintenance for nearly 3,000 adults who have a serious mental illness, from bipolar disorder to schizophrenia. These patients live and function in the community with the help of outpatient services, but are often stricken with high anxiety and vulnerable to psychiatric crises including extreme depression and psychosis.

“We have to treat the person as a whole,” said Rajeev John, Grace Hill’s manager of clinical social work. “We also try to preserve their general health.”

These mentally ill patients are often taking two or three potent medications, some with strong side effects. They are often homeless, have short life expectancy and are prone to pneumonia, bronchitis, diabetes and sexually transmitted diseases.

Grace Hill has a partnership with Washington University School of Medicine on adult psychiatric care at the BJC Behavioral Health facility on Olive Street.

If Grace Hill’s federal funding is cut, experts say, more patients are likely to show up at emergency rooms suffering from panic attacks and psychosis. Many psychiatrists are unwilling to see mentally ill patients who are uninsured or on Medicaid.

Dr. David Richards, who practices internal medicine at Grace Hill, says that he often sees signs of poverty in his patients and needs to double up as a psychiatric counselor.

“We see a lot of very sick people here,” he said, adding that patients in general have high rates of obesity and low rates of health literacy. “The overwhelming majority of my patients have next to no teeth. ... Some people are not able to afford coats in the winter.”

Grace Hill patients also produce about 800 babies a year, most of which are delivered at Barnes-Jewish Hospital and SSM St. Mary’s Health Center. Grace Hill’s “centering pregnancy” sessions are credited with holding down the number of preterm deliveries and babies with low birth weights.

Some young children who receive care at Grace Hill’s Murphy-O’Fallon Clinic show signs of homelessness.

“They move a lot, following their parents,” said Dr. Amal Antoun, a pediatrician at the center. “If I see a kid for a health issue, and I see that they have another health issue, we handle that immediately, because I know that I may not see them again. That’s my chance.”

Many of these children suffer from asthma, which can be triggered by environmental conditions such as second-hand smoking, soiled carpets and roaches. A rising number of children in grade school are obese and diabetic.

“I did my residency at City Hospital and worked with this population,” Antoun said. “I felt I could do something for these kids, make them feel better. I see them growing and some of them going to college, and that makes my day.”

In north St. Louis, Grace Hill also operates the Water Tower Health Center. Its other facilities include the Soulard-Benton Center and Grace Hill South Center on South Broadway, which has a high Latino population.

According to Grace Hill officials, about 95 five percent of Grace Hill’s patients have income below 100 percent of the federal poverty level, and roughly 60 percent are uninsured. About 36 percent of Grace Hill’s patients are on Medicaid or the Children’s Health Insurance Program (CHIP) for children, and 22 percent are homeless or staying in community shelters.

“The majority of our clinicians see this as a mission, and in some respects a ministry,” said Freeman, Grace Hill’s director. “It’s their way to give back, and I have a great respect for them.”

“We place an emphasis on the team environment,” he said, “so we have a number of advanced nurse practitioners work in collaboration with one or more clinicians on staff.”

Grace Hill has 320 employees, including 17 physicians, 10 nurse practitioners and five psychologists. It also employs eight dentists and four dental hygienists. And it plans to operate a large-scale dental clinic near Lafayette Square in St. Louis in conjunction with A.T. Still University in Kirksville.

Grace Hill also provides optometry services in partnership with the University of Missouri at St. Louis; audiology services through the nonprofit Center for Hearing & Speech; and foot care through for-profit Midwest Podiatry Services.

Obese patients receive one-to-one counseling and referrals to the clinic’s dietitians. Group sessions are also held on smoking cessation and diabetes.

“We’re trying to prevent our patients from hitting bottom and keep them as stable as possible,” said Yvonne Buhlinger, Grace Hill’s vice president of community health services. “This is their primary care home.”

The Most Vulnerable

Grace Hill is one of four “federally qualified health centers,” or FQHCs, in the St. Louis area and one of the largest of 23 of these centers statewide. The others in St. Louis are Betty Jean Kerr People’s Health Centers; Family Care Health Centers; and Myrtle Hilliard Davis Comprehensive Health Centers Inc.

Under the law, these community health centers exist mainly to serve vulnerable populations. They are required to provide care to all patients, regardless of their ability to pay, and must offer a sliding fee scale based on income.

FQHCs, which are found in urban and rural areas, must be run as nonprofit entities and governed by community-based boards in which the majority of directors are consumers or patients.

“We can’t just give someone a prescription and quick instructions,” Buhlinger said. “When you become our patient, you don’t just see the doctor. You’re going to be contacted and followed up on.”

She said that many patients needed education, monitoring and scheduling. In some cases, she added, a home visit may be warranted.

Grace Hill’s neighborhood centers handle a total of nearly 47,000 individual patients (adults and children) a year for primary care at its four comprehensive health centers and BJC Behavioral Health, and about 135,000 total patient encounters.

Freeman said that in the past five years Grace Hill had seen an increase of about 11,000 patients.

Grace Hill is trying to alleviate patients’ barriers to care, arranging transportation for some patients and establishing later clinic hours for working people.

“People have the notion that we’re kind of a mom-and-pop shop. We are a state-of-the-art health care facility,” said Veronica Richardson, Grace Hill’s vice president for quality improvement. “We want to be the health provider of choice.”

She said that Grace Hill’s strength was its “sense of community,” a multi-generational presence in north St. Louis for more than a century.

“Here, you see people who you know who live in the neighborhood,” she said. “Sometimes, you go upstairs (to the clinic’s main floor) and it’s just like old home week.”

But it also can be a tough job, with patients sometimes voicing their frustration and anger over their circumstances to Grace Hill’s staff.

“People who work in a community health center have a calling,” Richardson said. “You do it because you want to take care of those who don’t have a voice and need to be heard.”

But with today’s financial uncertainty and increased competition in the health care marketplace, Grace Hill is beginning to focus on how to make its neighborhood centers even more attractive to patients.

“We’re committed to state-of-the-art services for our patients,” Buhlinger said. “We strive to provide the highest quality of care that is the most accessible.”

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