Patient dedication

"Patient dedication" Continued...

Issue: "Race to the finish," Nov. 3, 2012

The process of behavioral change can be painfully slow. It requires cultural understanding. Wayne Aoki, mental health director at Los Angeles Christian Health Center, says the responsibility for change belongs to patients, not doctors. Attempts to badger patients into compliance never work: “In some ways it’s like you are laying out a cost-benefit analysis for your patients.”

For many impoverished people, healthcare isn’t a priority. They aren’t in the habit of making and keeping appointments. That can be a problem when specialists agree to see a patient for free. No-shows waste specialists’ time, making the doctors less likely to offer charity care in the future. 

Project Access NW, a program that matches needy patients with specialists in Seattle and its environs, helps people become good patients. “Teaching responsibility is integral to our success,” executive director Sallie Neillie says. Among Medicaid patients, the missed appointment rate is over 30 percent—but at Project Access it is 5 percent, because mentors counsel patients repeatedly before they ever see a doctor. The program kicks out patients who miss more than two appointments: “We want them to make us part of their team. To help them, they have to play by the rules.”

Some patient populations are more difficult to reach and teach. Shelter Health Services, a clinic on the grounds of a Charlotte women’s shelter, deals with many homeless women. One patient, Theresa, came to Shelter Health Services to get a glucose meter to help her manage her diabetes. Lisa Bishop, clinic manager and R.N., warns Theresa that her diabetes demands careful behavior such as not walking around barefoot and having a doctor clip her toenails to prevent infection. 

“Did they go over dietary guidelines with you?” Bishop asks. Theresa shakes her head no, so Bishop proceeds to tell her the foods she needs to avoid. Most people think of cookies and desserts, she says, but watch the potatoes, corn, and bread. Bishop then grabs a meter out of her desk and scoots her chair over until she is inches from Theresa. She counts out test strips, places them in a small black bottle, and says, “This will last you for 10 days. Let me show you how to use it.”

As Theresa watches, Bishop clicks a small needle into the device and demonstrates the process step by step. Then she hands the device to Theresa: “Now you try it.” Theresa holds it tentatively between her fingers. She has a hard time getting the needle to click. “It’s OK,” Bishop says. “It takes practice.” Theresa whispers, “I used to watch my mom do this when I was growing up.” 

About a third of the people staying at the women’s shelter suffer from a chronic disease. Brochures in the diagnostic room cover the most common: diabetes, high blood pressure, HIV-AIDS, and TB. Since the clinic works with such a transient group of patients, staff members focus on education, jumping on teachable moments. “Repetition is the key,” Bishop says.

The clinic hosts biweekly educational workshops and makes sure they are interactive and use familiar terms. “At the end, we offer HIV testing and get the results in 20 minutes,” Bishop explained. At the clinic’s open forums, women sometimes ask questions like, “Why is weed a bad drug?” and “Why do my feet always stink?”

Clinics like Shelter Health Services rely on teachable moments, but others feature a calendar of classes. Charlotte Community Health Clinic (CCHC) has an education room furnished with 15 black chairs facing a whiteboard and television at the front of the room. CCHC offers classes including exercise for people with arthritis, introduction to diabetes, and how to read nutrition labels. Patients with chronic diseases come to the clinic every three months for disease management and lab work—services that emergency rooms can’t provide.

Angela Williams, 50, a heavyset woman dressed in a sparkly purple halter top and black leggings, walks across the grassy area behind CCHC. Peering into the seven raised garden beds, she searches for signs of buds, but the young plants aren’t producing blueberries or peppers yet. Williams first came to the clinic five years ago because she had a cold. She was grieving her mother’s death and handling her grief by eating. 

Nurses at the clinic told her she was at risk of developing diabetes and high blood pressure because of her weight. It took years for Williams to change her behavior: “It’s very hard. … If it weren’t for this program, I could be dead.” 

She finally went to the diabetes class, the hypertension class, the diet class, and the exercise class: “Whatever they had, I would take an early lunch and go!” She lost 85 pounds over the past year and credits the clinic. She learned from a nutritionist the size of a proper portion—and holds up an open hand to demonstrate. As Williams learned about nutrition, her family benefited: “My family knows we are going to have salad three times a week. We have turkey and baked chicken. If we have fried, it will be once a month.” 

With reporting by Tiffany Owens, Christina Darnell, and Kira Clark


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