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CONTENTS SAN FRANCISCO MEDICINE January/February 2007 Vol. 80, No. 1­ Neighborhood Medicine FEATURE ARTICLES

MONTHLY COLUMNS

10 Curry Senior Center: Personalized Care for Seniors in the Tenderloin Gay Kaplan

4 On Your Behalf

12 Haight Ashbury Free Clinic: Health Care for the Homeless, Addicted, and Mentally Ill John Nienow, MD

7 President’s Message Steve Follansbee, MD

5 SFMS Election Results

13 Native American Health Center: Diabetes, Alcohol, and Depression in a Displaced Community Mark Espinosa 14 Lyon-Martin Women’s Health Services: A Safe Place to Turn Dawn Harbatkin, MD

16 Mission Neighborhood Health Center: Continuous Care From Birth to Death for a Primarily Latino Community Antonia Sachetti, MD 17 San Francisco Free Clinic: Serving Uninsured People from All Walks of Life Richard Gibbs, MD 18 North East Medical Services: Culturally and Linguistically Competent Care Tailored to Chinese Immigrants Linda Bein 19 South of Market Health Center: Innovative Health Care for a Diverse Population Peter Berman, MD, MPH 21 San Francisco Community Clinic Consortium: Providing Advocacy for All Underserved Neighborhoods John W. Gressman, MSW, MA

www.sfms.org

24 Public Health Update: HPV and Cervical Cancer Carol A. Lee, Esq. 25 Hospital News

15 Bayview Hunters Point: Illness and Cure Amidst the Violence Mitchell Katz, MD

23 Universal Health Access: A True “San Francisco Value”? Steve Heilig, MPH, and Gordon Fung, MD

9 Editorial Mike Denney, MD, PhD

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue Please contact Amanda Denz for subscriptions, adenz@sfms.org or (415) 561-0850 ext. 261 Advertising: Information is available on our website, www.sfms.org, or can be sent upon request. Please contact Galen Foster, foster@sfms.org or (415) 561-0850 ext. 240 Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605

january/february 2006 San Francisco Medicine 


January/February 2007 Volume 80, Number 1

ON YOUR BEHALF A sampling of activities and actions of interest to SFMS members

Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay

Notes from the Membership Department

Cover Artist Nico Johnston Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Arthur Lyons

Toni Brayer

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

Shieva Khayam-Bashi SFMS Officers President Stephen E. Follansbee President-Elect Stephen H. Fugaro Secretary Michael Rokeach Treasurer Charles J. Wibbelsman Editor Mike Denney Immediate Past President Gordon L. Fung SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve L. Heilig Director of Administration Posi Lyon Director of Membership Therese Porter

New Year Notes from the Membership Department In 2007 the Membership Committee plans to expand the number and variety of both social and professional events for the SFMS membership. This year, in addition to the January Tennis Mixer and the Symphony Night in the fall, watch for another Gallery Mixer event. Opera and/or Ballet Nights, a baseball game, wine tasting, lectures and seminars of interest to various sections of SFMS membership, and a golf event are all being explored as possibilities.  As always, the input of our membership is invaluable for inspiration. Contact Therese Porter in the Membership Department (tporter@sfms.org or [415] 561-0850 extension 268) with your suggestions for making membership more fun, interesting, and beneficial. 2007 is going to be a great year to be a member of the San Francisco Medical Society. If your physician peers are not yet members, encourage them to join!

Director of Communications Amanda Denz Board of Directors Term:

Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Donald C. Kitt

Term:

Jordan Shlain

Jan 2005-Dec 2007

Lily M. Tan

Gary L. Chan

Shannon Udovic-

George A. Fouras

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

John W. Pierce

Mei-Ling E. Fong

Daniel M. Raybin

Thomas H. Lee

Michael H. Siu

CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate

Gordon Fung Appointed to California Council on Multicultural Health California Department of Health Services (CDHS) Director Sandra Shewry announced the appointments of twelve new members to the California Council on Multicultural Health, a twenty-four–member statewide group of health policy experts who advise and assist the director and CDHS’ Office of Multicultural Health (OMH). Among those appointed is Gordon Fung, MD, MPH, immediate past president of the San Francisco Medical Society. “The council is an invaluable resource to key programs throughout the department and helped us establish our goal of closing the gaps in health status and access to care among the state’s diverse populations,” said Shewry. “We deeply appreciate the expertise, commitment, and passion of these

 San Francisco Medicine january/february 2006

community leaders to improve the health of all Californians.” OMH was created in 1993 to expand the ability of CDHS, health care providers, and other community partners to eliminate health disparities and improve the quality of life of California’s diverse populations.

It’s Time to Order Flu Vaccine for Next Season Physicians can now order flu vaccine for the 2007–2008 flu season. CMA encourages physicians to place their orders early to guarantee that they will receive their supply in time to vaccinate their high-risk patients in the autumn. Physicians can place orders directly with manufacturers or through their regular pharmaceutical distributor. Some manufacturers sell out quickly, so place your orders as soon as possible. To order the vaccine, contact: • ASD Healthcare at www.asdhealthcare. com or (866) 281-4FLU (4358). • CuraScript (Priority Healthcare) at (877) 599-7748. • Henry Schein, Inc., at www.henryschein. com or (800) 772-4346. • Henry Schein/GIV at www.giv.com or (800) 521-7468. Henry Schein/Caligor at www.caligor.com or (888) 225-4467. • McKesson: The first point of contact is your McKesson Medical-Surgical account manager. If you do not know your representative’s contact information, please call (800) 366-8990.   • FFF Enterprises (Chiron vaccine) at www. fluvaccine.net or (800) 843-7477. • PSS/World Medical at www.pssworldmedical.com or (904) 332-3000. • Sanofi-Pasteur at www.vaccineshoppe. com (online orders receive a 2 percent discount) or (800) 822-2463. • Seacoast Medical at www.seacoastmedical.com or (800) 732-2115. • STAT Pharmaceuticals at www.fluvaccine.com. www.sfms.org


Save the Date: Legislative Leadership Day, April 24, 2007 CMA’s thirty-third annual Legislative Leadership Conference is Tuesday, April 24, in Sacramento. This is the most important day of the year for physician advocates! A revamped schedule will include more time than ever to meet with your elected officials in the State Assembly and Senate. Attendees will receive a CMA health policy briefing and a short course on “Lobbying 101,” which will train them to become strong physician advocates and prepare them for the legislative meetings later in the day. Don’t miss the opportunity to meet one-on-one with your legislators to discuss important health policy issues that affect the practice of medicine in California. For more information, contact Susan Bassett at (916) 444-5532 or sbassett@ cmanet.org.

Resubmission Period for Aetna Modifier 57 Claims Now Open Aetna is now accepting resubmissions of previously denied claims for E&M services provided on the same day as a decision for surgery, with dates of service between January 1, 2005, and February 11, 2006. In 2005, Aetna announced that it would begin reimbursing physicians for E&M services billed with a Modifier 57 and performed on the same day as a decision for major surgery (global, ninety-day procedure). Implementation of this policy change was delayed, and Aetna’s claims processing systems finally began recognizing E&M codes with these modifiers effective February 11, 2006. At that time, Aetna also announced that previously denied claims with dates of service of August 15, 2005, to February 11, 2006, could be resubmitted. This policy change was recommended by Aetna’s Physicians Advisory Board, which was created as part of Aetna’s RICO lawsuit settlement. A recently resolved RICO settlement compliance dispute has increased the number of claims eligible for retroactive reconsideration. Previously denied claims with dates of service back to www.sfms.org

January 1, 2005, can now be resubmitted. The resubmission period is January 1 to April 30, 2007. For more information, contact CMA’s legal information line at (415) 882-5144 or legalinfo@cmanet.org.

Physicians Must Register NPIs with Medi-Cal by March 1 to Prevent Cash Flow Disruption Physicians must register their national provider identifiers (NPIs) with Medi-Cal by March 1 to ensure that their payments are not interrupted when Medi-Cal transitions from its current provider numbering system to the NPI system on May 23. Providers can register their NPIs online at the Medi-Cal website, www.medi-cal. ca.gov, or by mail. To request a paper NPI registration form, call (800) 541-5555 and select option 16, followed by option 18. If you haven’t already applied for your NPI, you should do so immediately. Applying for an NPI is fairly simple. Physicians can apply online at https://nppes.cms.hhs. gov. If you do not have Internet access, call the NPI Enumerator at (800) 465-3203 and request a paper application form. For more information, ontact CMA’s legal information line at (415) 882-5144 or legalinfo@cmanet.org.

SFMS Election Results 2007 Officers (for one-year term): President-Elect: Steven H. Fugaro Secretary: Michael Rokeach Treasurer: Charles J. Wibbelsman Editor: Mike Denney Board of Directors (seven elected for threeyear term): Jordan Shlain Brian T. Andrews Lily M. Tan Lucy S. Crain Jane M. Hightower Shannon UdovicDonald C. Kitt Constant Runners up Corey S. Maas Paul M. Silvestre William A. Miller Nominations Committee (four elected for two-year term): Eileen G. Aicardi Keith E. Loring Mei-Ling E. Fong William A. Miller Solo/Small Group Practice Forum Delegate (two-year term): Eric Tabas Solo/Small Group Practice Forum Alternate (two-year term): Gary L. Chan

ACCMA Annual Dinner SFMS Past-President Dexter Louie, MD, CMA President Anmol Mahal, MD, and SFMS Executive Director Mary Lou Licwinko, JD, MHSA, are pictured below (left to right) at the Alameda-Contra Costa Medical Association’s Annual Dinner in November.

Delegates to the CMA House of Delegates (First four are delegates; next four are alternates; Steven H. Fugaro, President-Elect, will serve as the fifth Delegate according to the SFMS Bylaws) all for a two-year term: Delegates Gordon L. Fung Joshua H. Rassen E. Ann Myers H. Hugh Vincent Alternates Shannon UdovicTaissa Cherry * George A. Fouras Constant Thomas H. Lee * Dr. Cherry has resigned from the Delegation due to time constraints. Total number of qualified ballots: 324

january/february 2006 San Francisco Medicine 


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president’s Message Stephen E. Follansbee, MD

It Takes a Village

A

lthough I did not coin this phrase, it feels appropriate, since this is my first message as your president in an issue devoted to neighborhood medicine. It has probably been a while since San Francisco was called a village. But, in some ways, it is. All of us in the San Francisco Medical Society work here. And whether we live in San Francisco or not, I suspect that most of us call this city home. It is in this village that we provide our professional services. For some of us, the San Francisco Medical Society is what provides the professional network that extends beyond our individual practices, our medical groups, or our medical staffs. The San Francisco Medical Society is an important venue in which we can discuss the successes and the challenges that we face as physicians. We are the physician network that provides and oversees professional health care throughout this village. Community health clinics play an integral role in San Francisco’s health care village. This issue covers the spectrum of neighborhood services provided throughout our community. If we were to drive by many of these practices, we might not even notice them. There is no fancy artwork, no modern lobby, no imposing marble-covered façade with large bronze lettering. But if we took the time to walk by these community clinics, we would notice them. We would feel the energy and commitment of the staff. We would note the crowd of people waiting for services. These clinics are an integral part of the fabric of our neighborhoods. For many San Franciscans, these health care centers contribute to their neighborhoods identities. They are not only places to receive care and advice; they have also become community centers. Most of us think that residents of San Francisco access these services because of lack of health care coverage. We see these clinics as part of a safety net for patients when they lose their health care insurance. That is true for some, but not all. What is very impressive, and should not be surprising, is that San Francisco residents often choose to obtain health care in these clinics. In communities where the health care news headlines often focus on the major medical centers and major medical groups, it is these clinics that usually provide the most accessible and specialized services to many citizens. Some clinics are known for their expert care to transgendered persons, who are often uncomfortable in other health care settings. Some clinics provide culturally competent health care in the patient’s native language or dialect—a service that is often www.sfms.org

inconsistently provided in other health care settings—and they do so without requiring proof of citizenship or residence. Other patients may need ongoing services that combine substance-abuse counseling and mental health support in ways that other physicians are ill-equipped to provide. Many people use these clinics for specialized services, such as STD screening, because they fear initiating discussion about sexual practices with their regular providers. Some clinics are supported by the Health Department of San Francisco, whose laboratory and staff have validated STD testing that cannot be provided by other medical centers or reference laboratories. Indeed, these clinics are not just the access of last resort but are in fact quality programs that help provide comprehensive care to San Francisco residents whose needs are not easily met in the larger, more obviously established settings. I suspect that many of us in clinical practice do not realize where our patients receive their health care when they suddenly disappear from our practice. Sometimes we know, because of a phone call or a request for medical records. But a lot of times we do not know until our patients show up again in our offices. This issue of San Francisco Medicine should convince all of us that the care patients receive can be quality care in all respects, regardless of the place of care. This issue should also reinforce our commitment to seeing that culturally appropriate health care is accessible to all, with adequate resources to address the multitude of needs, both simple and complex. Yes, we are a village. And it takes a village. None of us can do it alone. I am pleased to work alongside all physicians, and to learn more about the outstanding work done in all of our neighborhoods. Dr. Follansbee is the 139th President of the SFMS. An infectious disease specialist, he practices with the Permanente Medical Group and as Director of HIV Services and Module Chief, Adult Primary Care, Kaiser San Francisco. He has been Chief of Staff at Davies Medical Center, director of HIV research and treatment there, attending physician at San Francisco General Hospital, Assistant Director, Bay Area Consortium of AIDS Providers, and on the UCSF clinical faculty. He has been an SFMS delegate to the CMA since 2004.

january/february 2006 San Francisco Medicine 


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DEPARTMENT TITLE HERE Editorial Mike Denney, MD, PhD

Healin’ in the ‘Hood

A

few decades ago in a New York neighborhood called the South Bronx, some young people invented a new way to play old 33-1/3 rpm vinyl music records on nearly obsolete turntables. Instead of allowing the record to turn smoothly and the needle to track the groove, these youth would intermittently touch the spinning disc to cause it to stop, reverse, and go, and they would sometimes nudge the tracking arm so that the needle would scratch across the grooves instead of following smoothly. In this way, they created an exciting new sound of intricate staccato rhythms coupled with dissonant musical notes and chords. Then they added rappers who spoke political lyrics, and thus originated a breathtakingly “neighborhood” kind of music. The trend spread rapidly, so that by 2005 musical instrument stores nationwide sold more turntables than guitars. In street language, these young people have come to be known as turntablists, their technique is called scratchin,’ and they refer to the neighborhood as the ’hood. The ’hood has changed over the years. Until the middle of the twentieth century, urban communities in America were defined primarily by nationality, with immigrant populations gathering with their own to form Italian, German, Irish, Greek, Polish, Russian, and other ethnic neighborhoods. And before the civil rights movement, minorities such as African-Americans and Asians were segregated into their own neighborhoods. With the gradual loss of previous national identity, and with laws banning segregation and programs honoring diversity, neighborhoods became more socioeconomically defined as being “rich,” “middle class,” or “poor.” Finally, with empowerment programs, people living in poor neighborhoods realized that the standard system wasn’t working for them, and they began to take action to improve their opportunities, including access to medical care. In his song “The Neighborhood Bully,” America’s troubadour Bob Dylan wryly lauded the neighborhood medical activist with his lyrics: He took the crumbs of the world, And turned it into wealth. Took sickness and disease, And he turned it into health. He’s the neighborhood bully. In this issue of San Francisco Medicine, we discover ways that the standard system of patient-insurer-provider does not work for the health care of people in the some of the neighborhoods of San www.sfms.org

Francisco. We also learn how some dedicated caregivers are taking action to offer better services. In the heart of the Tenderloin neighborhood, for example, the Curry Senior Center focuses upon the elderly, many of whom are housebound, homeless, and uninsured. Reaching far beyond the ordinary model of clinic and hospital, nurse practitioners and social workers of the innovative In-Home Supportive Services walk the streets and visit the living spaces of the neighborhood, offering information, immediate care, and referrals. Each neighborhood clinic of San Francisco finds new and different ways to serve its own particular population. A clinic that serves a primarily Latino/Hispanic population recognizes that a focus on strong family ties within the community demands that medical care include awareness of the use of home remedies and the importance of grandmothers and other healing curanderos. Another neighborhood clinic finds new ways to provide culturally and linguistically competent care for people, 87 percent of whom are monolinguistic Chinese-speaking, and many of whom are undernourished, impoverished, and underinsured immigrants. Still another neighborhood clinic, serving a population composed of a mixture of Asian/Pacific Islanders and African-Americans, uses its Patient Navigator Program in conjunction with San Francisco General Hospital, allowing on-site representatives to help patients find family doctors in their own neighborhoods. It has also formed a Partnership Program with California Pacific Medical Center that expedites such preventative services as colonoscopies, breast screening, and Pap tests. Yes, the work of the neighborhood clinics of San Francisco seems to demonstrate the necessity of turning the tables on a medical system that, by its nature, excludes the poor and most needy. In the words of turntablist and rapper Mike Down: In the ’hood is where we all try, It’s where we do or die, Cause if we sick it’s how we gonna’ survive, The ’hood is everywhere, it’s how we live our lives. And so it is that for medicine in the neighborhoods, you can’t just track smoothly in the traditional groove. Even if it requires some staccato rhythms and dissonant sounds, if you’re gonna do healin’ in the ’hood, you gotta scratch. january/february 2006 San Francisco Medicine 


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Curry Senior Center Personalized Care for Seniors in the Tenderloin Gay Kaplan

I

n the heart of the Tenderloin sits the Curry Senior Center, a multidisciplinary agency that provides medical care and social services for the seniors in the Central City area of San Francisco. The clinic—located at 333 Turk Street and referred to by our patients as “333”—is close to the Federal Building and Union Square hotels and shops, yet at times seems to be a world away from the San Francisco that most people see. The perception of the Tenderloin as a rough and sometimes dangerous area of the city may be accurate. But it is also a vibrant place where there are many familiar faces, and where people might greet you by name as you walk around the neighborhood and into the hotels. There is a strong sense of community among the residents, and Curry Senior Center is there to respond to the needs of the seniors in this community. The agency, formerly known as North of Market Senior Services, began as a storefront clinic in 1972, with one doctor and one public health nurse providing medical care for the seniors in the surrounding neighborhood. Dr. Francis J. Curry, then the Director of the San Francisco Department of Public Health, was aware that a number of older residents were not able to access medical or social service assistance. Isolation, poor nutrition, and substance abuse were all factors that added to the severity of the unaddressed medical problems and limited the ability of these residents to obtain the care they needed. The solution was to establish a nearby location for medical care. However, just treating the health problems was not adequate. The staff added other services to address the psychosocial and economic issues and made efforts to reach out into the community to encourage

patients to engage in medical care. To Dr. Curry, the mission then was to establish an agency that would “provide services to seniors that promote independent living while maintaining their dignity and self-respect.” Inherent in Dr. Curry’s mission, and as demonstrated throughout the thirty-four-year history of the agency, is the provision of culturally and linguistically appropriate health and social services to the seniors of the Central City area. The agency

“The perception of the Tenderloin as a rough and sometimes dangerous area of the city may be accurate. But it is also a vibrant place where there are many familiar faces, and where people might greet you by name as you walk around the neighborhood.” provides a continuum of services, including a primary medical care clinic, case management, outpatient substance abuse treatment, mental health homeless case management, a congregate meal program, community programs, and thirteen units of permanent housing for formerly homeless seniors. The Tenderloin is often the barometer for measuring changes in the San Francisco population. For a long time, the Tenderloin was home to a large number of merchant marines, retired secretaries, construction workers, and sales clerks. Most of them were Caucasian and African-American, and

10 San Francisco Medicine january/february 2006

many had been long-term residents of the city. In the late 1970s and early 1980s, the demographics of the area began to change. The single-room occupancy hotels (SROs) and the relatively lower cost of housing in the Tenderloin attracted new arrivals. The influx of Southeast Asians in the 1980s and the arrival of Filipino veterans in the early 1990s created indelible marks on the community. Curry Senior Center has responded to these changing demographics by creating new programs, and the clinic has developed the capacity for providing these new patients with culturally appropriate services. Effects of economic trends and policy decisions have also been apparent in the patients we currently see: The increasing number of uninsured older adults, the challenges in providing care for individuals with severe mental illness who now live independently, and the struggle to find adequate housing for seniors on fixed incomes are such examples. Currently, we serve approximately 2,600 seniors per year. Men outnumber women. White and African-American patients still comprise the majority, but the percentage of Asian and Pacific Islanders has been increasing, with a significant number of the Asian patients requiring interpreter services. Most of our patients have Medicare and/or Medi-Cal, but there is a growing number (approximately 20 percent) of medically uninsured, especially those between fifty-five and sixty-five years of age. Homelessness (or being at risk for homelessness) is still prevalent, with approximately 10 percent of the patients we see falling into that category. Most of our patients live in the Tenderloin or South of Market areas, usually in www.sfms.org


SROs or in apartments. Many live alone and can be quite isolated, but others live with three or four other individuals in a studio or one-bedroom apartment, in order to defray the cost of rent. This latter situation is especially common for the Filipino veterans who have come to the United States. The primary care clinic functions in a fairly typical way. We have scheduled appointments, and most patients have a specific primary care provider—either a doctor or a nurse practitioner. Other services in the clinic include podiatry care, medication management and education (medisets filled by pharmacists or nurses), patient education by nursing staff, and women’s examinations by a nurse practitioner. We also have a close relationship with the older adult mental health clinic in the Central City area; one of our nurse practitioners sees primary care patients at that clinic, and vice versa. As mentioned above, one important aspect of our medical care is the outreach and persistent efforts made to engage patients in care. A fair number of our patients have experienced difficulty accessing services in the medical care system. For some, educational, language, or cultural differences persist. For others, there are psychiatric or memory problems. Case managers, public health nurses, visiting nurses, counselors, and program aides refer patients for primary care and assist them in various ways to keep appointments. In-Home Supportive Service workers also accompany patients to appointments. We have tried to make the clinic (especially the waiting area and exam rooms) a comfortable, quiet, inviting place for seniors. There are times when, despite everyone’s best efforts, a patient can not come to the clinic. At those times, we employ another outreach technique: a home visit by the primary care provider. Home visits have been a standard activity of our agency since its birth in 1972, and all providers are scheduled to do them. There are a variety of patients whom we see regularly on home visits—mainly those who are homebound due to mobility or psychiatric reasons. But we will make a home visit for a variety of other reasons. For example, we may wish to evaluate a problem that is difficult to understand or solve during a routine clinic www.sfms.org

visit, or we may see someone during an acute illness that severely limits that person’s functional abilities. It is amazing what information can be discovered on a home visit—how someone is taking medications, what food (or lack of food) is in the home, how cluttered a room or apartment is, how much someone is drinking, how safe it is in the building, if someone in the home is exploiting or abusing a senior. Home visits give us the opportunity to see firsthand the daily challenges some patients face in order to live independently. Frequently, we receive referrals from hospital staff and home care nurses when recently discharged patients have failed to keep follow-up appointments. In some of the most fascinating cases, we are asked by case managers or Adult Protective Service workers to assess patients who are resistant to medical care (usually refusing to go to a clinic or emergency room) and who, consequently, have not seen a medical provider for years. Medical conditions can be severe and are often complicated by substance abuse and cognitive impairments. The evaluation and treatment of these patients at home takes a team effort, and we work closely with home care and public health nurses, case managers, counselors, and other care providers. There is one final aspect of the home visit that brings us back to the issue mentioned at the start of the article: our connection to the community. There are many times when our medical providers see and greet patients on the street or in the hallways as they make other home visits. The patients seem genuinely pleased that we are out and about in their neighborhood. We meet desk clerks, managers, neighbors, and hotel and apartment owners who are as concerned as we are about the patients we see on home visits. They often express appreciation for our efforts in seeing patients at home, just as we recognize the informal but important support they provide for the frail, homebound senior. Home visits provide more than an opportunity for medical care. Home visits provide an awareness of what goes on in the neighborhood that we might miss while spending time inside the clinic. We enter the buildings and rooms where patients live.

We walk the streets just like they do when they come to the clinic. We see firsthand the challenges of someone living on a fixed income in the inner city. The seniors of the Central City make us proud to be a part of their community. They inspire us with their enjoyment of life, with their hope despite difficult financial and medical circumstances, with their resilience and courage. We are pleased to provide medical care and social support so that they can remain a part of our community, and can do so with health, hope, and dignity. Gay Kaplan is the Executive Director of the Curry Senior Center. To contact the Clinic please call (415) 885-2274.

Send Your Message to 2,500 Health Care Professionals The San Francisco Medical Society offers multiple advertising opportunities ranging from fullpage, 4-color display ads to classified ads with discounted rates for members. Please contact Galen Foster for more information, (415) 561-0850 extension 240 or foster@sfms.org.

For Local Events of Interest, Magazine Archives, and Other Health Care News Please Visit Our Website, www.sfms.org.

january/february 2006 San Francisco Medicine 11


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Haight-Ashbury Free Clinic Health Care for the Homeless, Addicted, and Mentally Ill John Nienow, MD

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erhaps the greatest accomplishment of the Haight Ashbury Free Clinic is that it continues to exist at all. After forty years of uninterrupted service to the community, which will be celebrated in 2007, the clinic continues to do what it has always done: take care of people that the rest of the medical world rejects. It provides that care with minimal fee—or no fee—and does so in an embracing, non judgmental way. It was the legendary vision of Dr. David E. Smith, now recognized as one of the founding members of the entire field of addictionology and true compassionate care, that brought the Haight Ashbury Free Clinic to life on June 7, 1967, on the corner of a city engulfed in the problems and promises of a social revolution. Homelessness, drug dependency, and impaired mental health were some of the conditions brought literally to the steps of the clinic on the corner of Haight and Clayton back in the 1960s. These are the same conditions, now molded by a new medical, political, and social setting, that the clinic attends to today. One patient, a sixty-year-old man from New York named Joseph, is a resident of the Tenderloin’s legendary “crack alley.” He regularly comes to the clinic as his chronic lung disease progresses, and he needs the chronic pain condition he suffers from treated in a way that doesn’t stigmatize him and push him even further down the social ladder. Another regular patient, Christie, a now-alcoholic child of the sixties, weighs whether she has the strength to undergo the rigorous treatment for her chronic hepatitis C, all the while trying to maintain her sobriety. New patients differ in age and illness,

but they represent the same social and medical castoffs that the clinic has always cared for. There is Troy, a 23-year-old homeless man with AIDS and a difficult methamphetamine addiction—the dual diagnosis most often seen at this clinic. There is Larry, with severe mental illness and social

isolation, who comes to the clinic for alternative treatments, including acupuncture and chiropractic, that are modalities still viewed as suspect by conventional providers. And there is Rodrigo, an employed and uninsured taxi driver with crippling cluster headaches, who would normally seek care in the impersonal, expensive, and increasingly congested emergency rooms of the city. The clinic is still operating in the same drafty Victorian walk-up on the same corner of the same forever-transitional neighborhood where it began. So it came as no surprise when Frontline aired its PBS documentary of the twenty-year history of the HIV epidemic, that it featured the Haight Ashbury Free Clinic as the one of the first places where the virus and its complica-

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tions were noticed. The clinic has always been on the “street,” hearing the hoofbeats of whatever social and medical problems arise, and it has often been the first to respond. The clinic continues to maintain a large, comprehensive program for patients infected with HIV, using its resources to provide acupuncture, mental health services, detoxification and rehabilitation services, and case management to the hundreds who would otherwise be passed by. The clinic has now spawned a growing organization based on its model of integrative health care, providing multiple inpatient and outpatient treatment services, jail-site psychiatric services, primary care services, and even the unique RockMed—a service provided at music venues throughout the Bay Area to keep both patrons and performers safe and well. Hillary Rodham Clinton and Ira Magaziner brought the topic of health care reform to the nation at a time when health care costs were climbing. As a result, the plight of the under- and uninsured received notice, and in some cases action. The Haight Ashbury Free Clinic continues to assert that “health care is a right, not a privilege” and acts as an ongoing thorn in the side of those who would believe that medical parity exists in this country. The number of medically uninsured continues to rise (it is now at more that 45 million), and the Clinic shows that their needs can and must be addressed. Should this country find the will to provide excellent care to those that require it, it need look no further than to the forty-year example of the Haight Ashbury Free Clinic. John Nienow, MD, is the Medical Director of the Haigh Ashbury Free Clinic. Visit the clinic online at www.hafci.org. www.sfms.org


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Native American Health Center Diabetes, Alcohol, and Depression in a Displaced Community Mark Espinosa

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uring the 1960s, thousands of Native American families were relocated from reservations to urban areas by the U.S. government’s Federal Relocation Program. These families were moved across the county in the hope that they would assimilate into the general population. As a result of these relocation programs, the Bay Area Native population quickly became one the largest in the country. Upon arrival, many families, who lacked the education or job skills necessary to succeed in urban areas, were left without services that they desperately needed—such as culturally appropriate health care. So in 1972, the San Francisco Native American Health Center (NAHC) was established, with the primary goal of providing services to this population. Today the NAHC continues to provide services to the Native American community of San Francisco, but it also provides services to the general population. Located on Capp Street in the Mission district, the NAHC provides primary medical, dental, pediatric dental, HIV testing and counseling, family and child counseling, substance abuse and mental health counseling, and WIC services to the community. The NAHC is also a proud member of the San Francisco Community Clinic Consortium. The San Francisco NAHC employs forty-one staff members from various ethnicities and backgrounds. Our staff speaks approximately eight different foreign languages and a few Native American languages. Although the NAHC’s primary focus is the Native American population, it is open to any and all residents of San Francisco. Last year the clinic saw 3,313 patients, with a total patient visits at 10,504. Many of the patients are Mission District www.sfms.org

residents, usually below the federal poverty level and in poor health. The clinic also provides health and dental care to the homeless population. The San Francisco NAHC relies on a variety of funding sources, such as the Federal Indian Health Service, state grants, private donations, and patient revenue. The clinic does not receive direct funding

for primary care and dental services for the medically indigent adults from the County of San Francisco. But there is currently a great need for medical and dental supplies and equipment. Something that makes the NAHC unique is that it provides culturally appropriate services to patients that, in many cases, were removed from their traditional homes and families. The staff members represent many tribes throughout the United States. In addition, the clinic hires traditional consultants from various tribes to come to conduct group sessions as well as one-on-one meetings with clients. Understandably, there is still a certain level of distrust among Native Americans when dealing with governmental agencies; therefore it is very important for the community to receive services from an agency

that they can trust. Many of our Native American clients would not seek health care if this clinic were not available to them. Instead, they would wait until it was necessary to seek out acute care in the city’s already overcrowded ERs—a practice that drives up the cost of health care for all. With rates of diabetes, alcoholism, dental decay, and depression higher than those of the general population, it is important that these clients are able to receive medical, dental, and counseling services, especially those of a preventative nature. The clinic’s clients are very comfortable with the NAHC, and some regard it as a community center. Earlier this year, the Bush Administration proposed the elimination of funding for all thirty-eight Native Urban clinics throughout the country. The Administration reasoned that the services that this clinic, and other clinics like it, offer are a duplication of services. The Administration assumed that these patients could easily be folded into other county medical service plans or other community clinics. What they failed to realize is that a Native American-focused clinic offers a cultural component that cannot be duplicated at other community clinics. Most other urban Indian clinics are located in large cities and these cities, like most others, are struggling to provide services to their non-Native populations; in many cases, they could not absorb the additional patients that would seek services from them. Although Congress initially restored funding to the urban Indian clinics, the budget has not been passed and the possibility of funding cuts still looms. Mark Espinosa is President and CEO of the Native American Health Center. Visit the Center online at www.nativehealth.org.

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Lyon-Martin Women’s Health Services A Safe Place to Turn Dawn Harbatkin, MD

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rowing up in Mexico, Alex had been beaten into wearing dresses, the appropriate clothing for girls. Joining the army at eighteen, Alex was discharged after one year for “liking girls.” At twenty, Alex drove from Sunnyvale to start care at LyonMartin. “I’m not really a lesbian,” he explained, “I’m a boy. My friend told me you could help me.” Katie helped her mother move from Hawaii to live with her and her partner. Their business had grown and her mother agreed to help. One night when her mother changed her shirt, Katie saw the large lump above her mother’s left breast. They hadn’t talked about health-related subjects since her father had died. Katie called Lyon-Martin for an appointment, telling her mother it was for a “light physical.” “Lyon-Martin has always been there for me and my friends,” Katie explained. “I knew you could take care of my mom.” Sam finally felt like she had it together. She had been clean and sober for seven years and had gotten out of an abusive relationship by moving in with her brother and his family in Petaluma. He accepted her as transgender, and she’d even started working in his landscaping business. As part of establishing care at Lyon-Martin, Sam was screened for HIV and hepatitis C—and the positive test results came as a shock. When discussing where to establish

care for her HIV, Sam asked to continue at Lyon-Martin. “I know it’s far to travel,” she said, “but I promise I will make it here for all of my appointments. Never before has a clinic treated me with respect.” Laura moved to San Francisco with her girlfriend after graduation. She was bartending a few nights a week but really wanted to go to law school. When her period didn’t come for the sixth month in a row, her girlfriend became worried enough to make her an appointment. Stress could have explained it at first, but now? During the visit, the doctor suggested that Laura also have her first Pap smear. “Can I afford all this?” she asked the doctor. “I don’t have insurance and I don’t have a lot of money.” “Yes,” the doctor told her. “All labs are covered and we treat people regardless of their ability to pay.” The mission of Lyon-Martin Women’s Health Services is to provide personalized health care and support services to women and transgender people who lack access to quality care because of their sexual or gender identity, regardless of their ability to pay. No one is ever turned away because of lack of insurance or funds. Founded in 1979 and named in recognition of LGBTQ civil rights activists Phyllis Lyon and Del Martin, this clinic was created to respond to the gap in sensitive health services available to lesbians. Since 1993, Lyon-Martin also has been the safety-net health care provider

“Lyon-Martin is the place where people go when they don’t know where else to go— when they are afraid for their health, are afraid of how they’ll be treated in other medical settings, or when they can’t afford health care.”

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for very low-income and uninsured women and transgender people in San Francisco. Currently, 84 percent of our patients are uninsured. Lyon-Martin is the place where people go when they don’t know where else to go—when they are afraid for their health and well-being, when they are afraid of how they will be treated in other medical settings, when they are afraid that they can’t afford health care. The clinic staff helps them manage their anxiety, depression, menopause, diabetes, high blood pressure, high cholesterol, and asthma. They test them for HIV and sexually transmitted infections and screen them for cancer. They vaccinate them for hepatitis, tetanus, and the flu. When needed, they find them free mammograms, free laboratory testing, free medications, and links to specialty services. They give them a primary care home that is safe and empowering. In all services, there is a partnership with patients that engages them in an active role in their own care. Patients travel from as far away as Santa Barbara and Chico, and from as near by as across the street, to receive medical care with respect. Lyon-Martin ensures that poverty and prejudice are not barriers to health care. Without its services, 2006 would have seen four more people with cancer continuing to progress, five more people with HIV infection lingering undiagnosed, thirty-five more people with diabetes remaining poorly managed, six hundred more transgender people buying and injecting hormones on the street, 1,500 more people missing cervical cancer screening, and 2,000 more people lacking the valuable information to answer the simple question, “How are you?” Dawn Harbatkin, MD, is Executive Director and Medical Director at Lyon-Martin. See www.lyon-martin.org to learn more. www.sfms.org


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Bayview Hunters Point Illness and Cure Amidst the Violence Mitchell Katz, MD

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ayview Hunters Point (BVHP) is located in the southeast corner of San Francisco, bordering the Bay. Throughout the early 1900’s, the shipping industry constructed dry docks and filled in the Bay with rock carved from the hill in Hunters Point. The U.S. Navy took over the shipyard at the onset of World War II, and throughout the 1940’s and 1950’s the Navy shipyard and the abundant and well-paying work it offered drew African-American workers to the area. The area became one of the only majority African-American neighborhoods in San Francisco, and its residents developed a thriving community, purchasing homes and creating a commercial area along third street. The naval shipyard closed in 1974 and was leased by a private company until the whole area was shut down in 1994. This series of closures left many BVHP residents unemployed. The shipyard that once served as a source of income was designated a Superfund site, and it and many other industrial facilities polluted the air and water of the newly underemployed community. As employment opportunities deteriorated and the cost of living in San Francisco rose, many residents were forced to move out of San Francisco, to the East Bay or elsewhere. As a result, African-Americans no longer form the majority of Bayview residents, with the Asian/Pacific Islander and Latino populations growing. Poverty is a major issue, with 21.7 percent of Bayview Hunters Point’s 33,170 residents below the poverty line in 2001. Poor neighborhoods are more vulnerable to external factors that are detrimental to health; pollution and poor housing can exacerbate many preexisting health problems. www.sfms.org

There are several determinants that ultimately lead to bad health outcomes, and in order to improve the health of a community, these determinants need to be identified and addressed. BVHP experiences a disproportionate number of social determinants with adverse effects on health, ranging from social isolation to institutional and environmental racism to lack of access to healthy food. These social determinants in turn affect the behavior of residents living in the 94124 zip code: Less access to healthy food makes maintaining a good diet and avoiding obesity more difficult, and an atmosphere of violence forces children to stay inside, leaving them more susceptible to poor indoor air quality, asthma triggers, and obesity. In turn, these behaviors create clinical signs, such as hypertension, obesity, and high cholesterol, which can lead to death and disability. BVHP’s disproportionate exposure to the negative social determinants results in negative health outcomes. Bayview Hunters Point residents are hospitalized more than residents of other neighborhoods for almost every disease, including asthma, congestive heart failure, diabetes, and urinary tract infections. More deadly than any of these diseases, however, is violence; BVHP residents lose more years of life due to violence than from any other cause. The San Francisco Department of Public Health (SFDPH) has been working with

residents to begin to identify and remedy the root determinants of bad health in BVHP. Bayview Hunters Point demographics are constantly changing, and the SFDPH’s programs and approaches to health must evolve as the neighborhood does. Currently in Bayview Hunters Point, DPH funds Southeast Health Center’s primary care clinic, twenty-five substance abuse programs, twenty-two mental health programs, and nine HIV/AIDS servicesproviders. Through community-based primary care centers, and care provided at San Francisco General Hospital, the Department serves an average of 12,800 patients from Bayview Hunters Point annually, with an average of more than 31,900 visits each year. Mitchell Katz, MD, is the San Francisco Public Health Director.

“BVHP experiences a disproportionate number of social determinants with adverse effects on health, ranging from social isolation to institutional and environmental racism to lack of access to healthy food.”

Editor’s Note: This article is an excerpt from a September 2006 report from the SFDPH entitled: “Health Programs in Bayview Hunters Point and Recommendations for Improving the Health of Bayview Hunter’s Point Residents.” To find out more details about the specific health concerns in BVHP and the actions being taken by the SFDPH, please see our website, www. sfms.org, to view the full report.

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Mission Neighborhood Health Center Continuous Care From Birth to Death for a Primarily Latino Community Antonia Sachetti, MD

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he Mission Neighborhood Health Center (MNHC) was originally created as part of Lyndon Johnson’s Great Society public initiative to attack the root causes of poverty. The center, whose patient population is 90 percent Hispanic, has been operating for thirtyfour years. It was the first federally funded community health center in San Francisco, spurred into existence because of the absence of linguistically appropriate, affordable medical services for the sizable Latino population in the city’s Mission District. Initially housed in trailers, the MNHC has now expanded to four sites, including two comprehensive primary care centers (the Main Site and the Excelsior Clinic), a Homeless Center, and an HIV Prevention Center. San Francisco is internationally recognized as a sanctuary city for the newly arrived among Latino/Hispanic populations from some thirty-five countries in the Americas. Because of its original mission to provide care to this group, the patient population remains 90 percent Latino. In spite of tremendous diversity among the patients from varying countries, some cultural characteristics are commonly held. Strong religious identities; resilient family ties with a focus on the child; and reliance on grandmothers, home remedies, and curanderos, are some characteristics shared by this population, which values a strong patient-doctor relationship. Many health problems in this commu-

nity are influenced by the fact that the majority are the working poor with low wages. They often lack insurance and come home to crowded living conditions. Unfortunately, living environments are often of low quality—sometimes infested with cockroaches and rodents—and in some cases there is a lack of heating and/or a heavy presence of mold. The average patient has less than a ninthgrade education. A clinic survey shows that although 20 percent desire written materials, the majority learn best from nurse and provider teaching. Since its inception, MNHC has become the medical home of first resort, with a focus on the life cycle starting with perinatal care and concluding with seniors who struggle with the medical challenges of the aging process. The main site houses various clinics, including Pediatrics, Women’s, Adult Medicine, and specialties such as HIV Services and the Teen Clinic. Because the population is mainly young adults (twothirds of whom are women), the women’s clinic emphasizes prenatal care and family planning. Many prenatal patients are new immigrants without family support who benefit from our comprehensive program, which emphasizes patient empowerment, acculturation, and peer support. Two chronic pediatric problems include asthma, which is exacerbated by the home environment, and the epidemic problem of obesity. According to a recent audit, 48 percent of our pediatric population

16 San Francisco Medicine january/february 2006

is overweight or obese. Our teen population faces one of the highest rates of pregnancy in San Francisco. MNHC also addresses gang-related activities, which are dealt with through a specialized teen clinic staffed by an adolescent physician and two full-time health educators. The diseases most common among the adult patients are similar to all adult populations: diabetes, hypertension, and hyperlipidemia. The difference is the severity, because many have never received treatment before coming to the clinic, or they have failed to buy a prescription because they could not afford it. It is very common to encounter new patients with blood sugar levels of > 500 who need acute treatment and intensive follow-up by our multidisciplinary diabetic team. In addition, there are a significant number of HIV-positive patients who, for a long time, refused to be tested or to come to regular clinics because of the lack of acceptance. This stigma has now been greatly diminished through patient education and community awareness workshops. Our sensitive staff addresses the needs of some 450 patients, providing a full scope of services. MNHC is committed to compassionate, culturally competent, and comprehensive health care services. This is evidenced by its bilingual, bicultural staff, which mirrors the life experiences of the patient populations. The combined multidisciplinary skill sets and an unwavering staff fidelity to the mission of the Clinic generate a powerful prescription for what ails this community in addressing health care. This is particularly important given that 67 percent of the more than 12,000 persons served annually are uninsured, 65 percent are monolingual

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San Francisco Free Clinic Serving Uninsured People from All Walks of Life Richard Gibbs, MD

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n the day we first opened the San Francisco Free Clinic, we really didn’t know who would come through the door. The only criterion for receiving care was that one have no health insurance. That was thirteen years ago, and estimates were that nearly one out of six San Franciscans was uninsured. The most heartbreakingly visible were the homeless—not surprising in a city with a moderate climate and a nonjudgmental social philosophy. So that is what we envisioned: treating chronic wounds, a lot of gloves and hand-washing, and sharpening our mental health skills. How could we have known that our first patient would be a little girl whose parents had no health insurance? She was one of nearly 30,000 Bay Area children who were behind in their vaccination schedules, undertreated for asthma and chronic illness, and who never saw a doctor unless they were acutely ill. She looked and behaved exactly as my children do. Along with her parents, she represented the vast majority of people we have treated over the years. They have been our neighbors, students in schools and colleges, and families where the parents hold jobs. It is simply that they don’t have access to low-cost group insurance, and they cannot afford the considerable outlay of cash to purchase private insurance. We see very few children today because Healthy Families, a successful federal/state program, has provided Medicare-type insurance for them. Other than this positive note, remarkably little has changed since we opened. There are still more than 82,000 San Franciscans with no health insurance, and the majority of these are reflected in the people who come to the San Francisco Free Clinic. Our population is a snapshot of the uninsured in the Bay Area. Nearly 60 perwww.sfms.org

cent hold jobs, the average wage is less than $20,000 per year, they range in age from 18 to 64, they include both men and women, and none of them qualify for any kind of federal or state program. Although the homeless are the most visible among the uninsured, the greatest number by far are middle class. They live in nearly every neighborhood of the city. They are people whom we all know and interact with daily. Working at the Free Clinic has been a privilege. The rewards are great when no money exchanges hands. Nearly every intervention receives a “thank you” from the patient, instead of blame or the suspicion that we haven’t done enough. We commonly see people who haven’t been to a doctor in years, so they often don’t know they have hypertension, diabetes, or thyroid problems. When they do carry a diagnosis, they have frequently been off their meds from lack of resources. In either case, patients are enormously grateful for the help. They have not had preventative measures such as Pap tests, lipid screenings, flu shots, and smoking cessation counseling, and they are delighted when we provide such things. In doing what every clinician in town is doing—and often we are limited to doing less—we receive the gratitude and the warmth of human feeling that every clinician should be receiving. Yet we do not have the burden of providing medical care in an increasingly complex and legally difficult reimbursement system, as do most

of our colleagues who treat those with insurance. We know how fortunate we are, and we have admiration and the greatest respect for our colleagues in private practice. Perhaps the most rewarding aspect of the Free Clinic is the amount of selfless, good-natured help we receive from medical colleagues. We never tire of telling the story of how much the San Francisco Medical Society helped when the Clinic started. On first approaching various philanthropic organizations with the idea of a clinic that would offer basic primary care to the uninsured, we uniformly received the same response. They required a demonstration of “community support” to consider funding a new project in the nonprofit arena. We were frankly at a loss until we realized that the one group of which we were members and that was broadly integrated into the community consisted of the other physicians in the Medical Society. We even had a mailing list in the form of the membership directory. We hand-addressed an appeal to every doctor in the directory; the response was a tribute to the generosity of physicians in private practice and to the spirit of the medical society itself. We received more than 150 offers of financial help, medicines and supplies, and donated specialty visits. It was the community of medical care providers that became our base of support, and this impressive demonstration lead to enough funding from

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North East Medical Services Culturally and Linguistically Competent Care Tailored to Chinese Immigrants Linda Bien

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orth East Medical Services (NEMS) was founded in 1968 by a group of concerned Chinese Americans who identified the need to provide bilingual, culturally sensitive, affordable health services in San Francisco’s Chinatown. NEMS established its first clinic in 1971 and has grown to become the nation’s largest community health center serving a predominantly Asian population. NEMS has three clinics, which are located in the Chinatown/North Beach, Visitacion Valley/Portola, and Sunset neighborhoods of San Francisco. The health center’s target population consists of the medically underserved, uninsured, or underinsured; the impoverished; and immigrants who have significant language and cultural barriers. Among its current patient population, 87 percent are monolingual Chinesespeaking, 20 percent are age 65 and older, and almost all are uninsured or underinsured and rely on such public health assistance as Medi-Cal and Medicare. In 2005, NEMS served almost 35,000 patients with about 180,000 visits. We estimate that over the past thirty-five years, more than 250,000 different patients have come through NEMS’ doors for health care services, generating close to one million patient visits. The legacy of NEMS is perhaps best summarized by Milton Wong, one of many patients benefiting from NEMS’ services: “Who would ever have thought that a sickly young child coming from an underprivileged family could be where I am today? Because of the programs [NEMS] designed and the services [NEMS] offered my family, I am able to sit at the Harvard Business School today among some of the most talented leaders of the future.… NEMS made a difference

in my life. Without health, everything else is futile.” NEMS’ service delivery philosophy addresses barriers to health care access by focusing on culturally and linguistically

competent treatment and care. NEMS provides high-quality, comprehensive, “onestop” primary and preventative medical, dental, and behavioral health care services, including case management and ancillary services. NEMS currently employs thirty medical providers, eight dentists, and one optometrist, many of whom have been with NEMS for more than ten years. On-site medical specialty services are available to all patients, including allergy, cardiology, otolaryngology, ophthalmology, radiology, gastroenterology, and surgery. Other available health services include optometry, podiatry, laboratory, pharmacy, X ray, health education, nutrition, and social services. NEMS also provides inpatient hospital care management, case management for chronic conditions, and program eligibility counseling and enrollment. NEMS has always found a balance between being a health care provider and a pioneering business entity. In the 1980s,

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NEMS owned and operated the GoldenBay Health Plan, a Knox-Keene–licensed commercial health plan catering to San Francisco’s small businesses. Today, NEMS runs a management services organization (MSO) to manage Medi-Cal patients for its partners, California Pacific Medical Center and the North East Medical Services Medical Group. The MSO manages administrative needs for a network of more than eighty providers in the City. NEMS sees more than 20 percent (about 34,000) of all Chinese residents in San Francisco, a quarter of whom are or will turn sixty-five years old and older in the near future. It is no wonder that one of the top health concerns involves care for elderly adults, who often have several chronic health conditions and need additional assistance in navigating the complexities of Medi-Cal and Medicare health care coverage. One of NEMS’ biggest projects in the last year was to aid elderly patients in Medicare Part D Prescription Drug Benefit enrollment. Physicians, pharmacists, and Member Services staff led a concerted effort to educate and advise patients on their options regarding this program. Hypertension, diabetes, heart disease, and COPD (Chronic Obstructive Pulmonary Disease) round out the most common chronic conditions among adult patients at NEMS, while a high number of pediatric patients have asthma and allergies. Because NEMS’ patient population includes many Asian immigrants, there are also higher incidences of hepatitis B and tuberculosis than are found in the general population. As a response, NEMS has participated in several chronic-care management

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South Of Market Health Center Innovative Health Care for a Diverse Population Peter Berman, MD, MPH

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hange is in the wind at South of Market Health Center (SMHC) during these exciting times. We are raising funds for a brand-new health center; a major emphasis on high-quality, patient-centered care is well underway; and we have hired new staff. We are also moving closer to the construction of the first community health center in San Francisco to be built from scratch. Construction of the state-of-the-art facility, to be located not far from the current site, is scheduled to begin in the first quarter of 2008. SMHC was started more than thirty years ago to serve local South of Market residents who were in need of affordable, quality health care. About 65 percent of our patients have no insurance, and most are relatively poor. Approximately one-third are Asian/Pacific Islander, one-third are African American, one-quarter are white, and one-eighth Hispanic. Health care may have a different importance for others than it does for our patients, for whom day-to-day living simply takes priority. Providing high-quality care in this setting is not an easy task, but it is an attainable one—and it is our goal throughout the health center. Our patients not only want it, they deserve it. We offer social and medical case management to address housing and food assistance issues as well as other vital needs. We have made major changes in our clinical care program for managing chronic diseases, such as diabetes and HIV; and our health maintenance program includes mammography, Pap tests, screening for colon cancer, and other preventative services, following age- and sex-related screening recommendations. We have upgraded www.sfms.org

standards of care to ensure the highest quality together with a uniform approach to patient care. We also have an innovative new program, the SMART (South of MARkeT)

Pain Program, funded by Kaiser-Permanente, which provides a focused approach to patients with chronic low back pain who also have a psychiatric illness or substance abuse history. We currently have twelve patients enrolled in the program. They receive a detailed and complete evaluation, case management services, and a care plan whose goal is improving their quality of life. South of Market Health Center also participates with San Francisco General Hospital in an exciting new program to increase access to primary care services for at-risk residents. Our Patient Navigator program links SMHC patients who do not have primary care providers with someone on-site at SFGH who will provide referrals to participating community clinics. Last year California Pacific Medical Center (CPMC) released the first payment in a two-year grant to the SMHC to support access to both primary and specialty care services. One of the initial beneficiaries was

a South of Market Health Center patient who presented with weight loss, lower abdominal pain, blood in the stool, and constipation. The problem was that the patient could not be seen by a GI specialist at our referral hospital for many months. The newly initiated CPMC Partnership for Community Health program had just started and was able to quickly facilitate a timely referral for a colonoscopy. When cancer was diagnosed, the patient was promptly referred to an oncologist. This is a good example of how we at SMHC believe that we are the Personal Care Providers (PCPs) for our patients, and that we truly “own” the responsibility for their care. Peter Berman, MD, MPH, joined South of Market Health Center as Medical Director in 2004. To contact the Center see www. smhcsf.org.

CMA Legislative Leadership Day April 24, 2007 CMA’s thirty-third annual Legislative Leadership Conference is Tuesday, April 24, in Sacramento. This is the most important day of the year for physician advocates! Don’t miss the opportunity to meet one-on-one with your legislators to discuss important health policy issues that affect the practice of medicine in California. For more information, contact Susan Bassett at (916) 444-5532 or sbassett@cmanet.org.

january/february 2006 San Francisco Medicine 19


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Affinity Group Services Hartford Life and Accident Insurance Company, Hartford, CT 06104-2999

The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life and Accident Insurance Company. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. (Policy #AGL-1762)

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Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Putnam Investments, Mercer Human Resource Consulting (including Mercer Health & Benefits, Mercer HR Services, Mercer Investment Consulting, and Mercer Global Investments), and Mercer specialty consulting businesses (including Mercer Management Consulting, Mercer Oliver Wyman, Mercer Delta Organizational Consulting, NERA Economic Consulting, and Lippincott Mercer).


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SFCCC: Providing Advocacy for All Underserved Neighborhoods­ John W. Gressman, MSW, MA

I

n 2007 the San Francisco Community Clinic Consortium (SFCCC) celebrates twenty-five years of service. The SFCCC was originally created by a group of nonprofit health clinics that envisioned it as an instrument to pool their resources, specifically in the areas of group purchasing and local advocacy. The core mission of SFCCC and its partner health clinics is to ensure the provision of quality and affordable health care services to San Francisco’s uninsured and underserved populations. In fulfilling this mission, SFCCC develops and implements programs and supports policies that increase access to community-based care for all San Franciscans. Today SFCCC continues to provide advocacy for its ten partner clinics at the local, state, and national levels, where consortium representatives educate public officials as well as the general public about issues affecting community health clinics and their patients. SFCCC’s partner clinics, eight of which are featured in this issue of SFM, provide primary care services to more than 70,000 uninsured and underserved San Franciscans each year—nearly 10 percent of the city’s total population. The clinics are located strategically in the diverse neighborhoods of San Francisco, and comprehensive primary, preventive, and ambulatory care services are provided by a team of doctors, midlevel clinicians, nurses, dentists, and health practitioners working under the supervision of a medical director. Patients who come to these clinics will see members of their own communities among the doctors, nurses, staff, and volunteers of the clinics. More than twenty languages are spoken, along with multiple dialects. The SFCCC clinics offer a medical home that includes mental health services, www.sfms.org

dental and vision care, health promotion, and disease-prevention education. We could not do this work without our community partners, including the San Francisco Department of Public Health (SFDPH) and San Francisco General Hospital (SFGH). With the SFDPH partnership, we have developed and implemented major health

information technology relationships that enhance our ability to serve our patients. For almost a decade, Kaiser Permanente has provided major funding, consultation and training, and specialty care for our clinic patients. Saint Francis Memorial Hospital is another of our invaluable partners that supports the clinics with funding and specialty care. In 2005 we entered into a partnership with California Pacific Medical Center that has already provided primary and specialty care for more than 10,000 uninsured patients in designated underserved areas of San Francisco. SFCCC provides centralized grants administration of funding for programs such as Health Care for the Homeless; the Ryan White Care Act programs; Street Outreach Services (SOS), our mobile medical van

that provides medical care for homeless people wherever they are on the streets of the city; leadership in the areas of continuous quality improvement (CQI); chronic disease management; health information technology; and health care workforce development, through continuing education for existing staff and through “pipeline” activities that expose youth to career opportunities in community health. The ten community-based, nonprofit partner clinics of SFCCC are cornerstones in San Francisco’s health care delivery system. The partnership consists of three federally funded community health clinics: Mission Neighborhood Health Center, North East Medical Services, and South of Market Health Center. These three clinics were created in the late 1960s and the early 1970s as part of President Johnson’s War on Poverty initiative. They represent an ongoing effort to empower communities through patient-majority governance boards. Comprehensive health services are provided without regard to the patient’s ability to pay, using a sliding-fee scale that provides discounts based on family income. There are also four free clinics: Glide Health Services, Haight Ashbury Free Medical Clinic, St. Anthony Free Medical Clinic, and San Francisco Free Clinic. Established in response to the unmet health care needs of uninsured San Franciscans, these four clinics work to provide the highest quality health care to those who are the most medically needy. And lastly, there are three special-population clinics: Curry Senior Center, LyonMartin Women’s Health Services, and Native American Health Center. These three clinics serve patients who might otherwise

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january/february 2006 San Francisco Medicine 21


SFCCC: Continued From Page 21...

San Francisco Free Clinic: Continued From Page 17...

not seek care, due to specific cultural needs that are often not adequately addressed by the mainstream medical system. The unique needs of women, native Americans, and seniors have historically been neglected throughout our society. These three clinics exist specifically to address those unique needs with cultural competency. For more information about SFCCC, our partner health clinics, or our twentyfifth anniversary celebrations, please visit us at www.sfccc.org. John W. Gressman has been President and CEO of the San Francisco Community Clinic Consortium (SFCCC) since 1991. He is a dedicated health care administrator with more than twenty-five years of service in communitybased care and is nationally recognized for his work in administration, policy, development, advocacy, and community, and governmental relations. Mr. Gressman serves on the Board of Directors of the San Francisco Health Plan and the California Primary Care Association (CPCA) and is also on several committees of the National Association of Community Health Centers (NACHC). He continues to be actively involved in leadership with the Regional Associations of California (RAC) and the work of the national committee of the Health Center-Controlled Network.

foundations and private businesses to open our doors. This group effort from within the medical community is the heart of the San Francisco Free Clinic today. There are more than 135 physicians and practices that help the Free Clinic in one way or another. In addition, hospitals such CPMC, St. Francis, St. Mary’s, and Chinese have all donated services and studies. Currently, CPMC is generously providing X-ray services, and St. Francis donates cardiac and pelvic echograms. And without the backing of a hospital like San Francisco General for severe illnesses, a project like ours would not be possible. As rewarding as the work has been, we have always known that providing free care for those without insurance is only a temporary solution to a problem that must have a permanent fix. In the year we opened the Clinic, there was great enthusiasm nationally for the President Clinton’s plan to address the problems of the uninsured. In 1994, people actually asked us why we were opening the Clinic when “within a year all the uninsured will be covered.” Since then, the number of uninsured has grown by leaps and bounds. Currently, San Francisco is pursuing a plan that has the potential to provide care for the majority

Mission Neighborhood Health Center: Continued From Page 16...

North East Medical Services: Continued From Page 18...

Spanish-speaking, and 75 percent are nonEnglish proficient. Access to health care is complicated by the fact that 84.7 percent are at or below the poverty level. What attracts providers to the health center? There are many reasons; perhaps the greatest attraction is the opportunity to serve those most in need in a welcoming and appreciative population. There is no greater reward than to see the smile on the face of a child who has been relieved of an illness and now has the gift of wellness and good health. Antonia Sachetti, MD, is the Medical Director at Mission Neighborhood Health Center. Visit the Clinic online at www.mnhc.org. ­

projects to learn and explore new ways to care for patients. The projects, funded by various public and private organizations including the U.S. Department of Health and Human Services, Kaiser Permanente, and the California Health Care Foundation, have given NEMS providers new perspectives and approaches to caring for complex conditions. In the near future, NEMS will be building two larger clinics, one in the Portola/Visitacion Valley District and one in the Sunset District, to expand the access provided by our existing at-capacity clinics. Both new clinics will feature more exam rooms and expanded services to meet

22 San Francisco Medicine january/february 2006

of those without health insurance. We support the plan. It will be a happy day when there is no need for a clinic like ours. When Healthy Families evolved, we literally forced all of our uninsured families with children to join the plan. But we have learned over time that no plan will cover everyone. If the plan is successfully implemented, there will always be a fair number of residents who don’t qualify for one reason or another. And there will always be a sizable number who don’t fit into any structured activity in life. They will still need help with their acute and chronic problems, and, most important, they will still need preventative care. We give our sincerest thanks to those of you who help with the Clinic, and our deep gratitude goes to those who have provided goodwill and encouragement. The Clinic demonstrates that charity and caring for others is alive and well in San Francisco. Let us hope that a more universal means can be found to offer good health to all our citizens. But let us also realize that an allencompassing solution is probably far off, and that smaller, more personal efforts will always be needed. Richard Gibbs, MD, is the Executive Director of the San Francisco Free Clinic. Visit the Clinic online at www.sffc.org.

the health care needs of patients in those neighborhoods. The lack of specialty care available to uninsured and underinsured patients will be another top issue that NEMS will be addressing in the future. NEMS hopes to work with San Francisco’s many medical specialists to identify opportunities to serve patients who otherwise would not have access to adequate health care. Linda Bien is President and CEO of North East Medical Services. Visit NEMS online at www.nems.org.

www.sfms.org


Health Access Update Steve Heilig, MPH, and Gordon Fung, MD, MPH

Universal Health Access: A True “San Francisco Value”? Panel Explores Effort to Provide Health Care to Every San Franciscan Is the current local, state, and national focus on providing every American some sort of health care access simply a political fashion? If so, it, like many fashionable trends, is a recurring one. There’s no denying there is a need, with more than 45 million Americans (including 6 million Californians and 82,000 San Franciscans) without health insurance. That makes no sense in terms of health or costs, at least in the long term. So what to do? At our November forum on this issue, co-sponsored with the CPMC Program in Medicine and Human Values, San Francisco Director of Public Health Dr. Mitch Katz provided details of the city’s proposed Health Access Plan (HAP), noting that to qualify for this plan one will need to be a city resident. “We want it to be a good plan, but not so good that the 82,000 uninsured number grows as those with the cheapest plans change to our new one,” he cautioned. “We’ll provide preventative care and also try to prevent avoidable use of emergency departments, thus saving more money.” Katz projected that roughly half of the approximately $200 million needed for HAP will come from existing funds spent on providing care for the uninsured. Other funds will come from required contributions of businesses of more than 20 employees, at least some of whom are uninsured. The last time a major overhaul of our health system was achieved was with the 1965 initiation of Medicare and Medicaid. Since then, there’s been relative tinkering, with some successes in expanding coverage but much more talk, authoritative reports, and lamentation—to little end. And the main reason for that, as with many things, is money. “Of the top ten reasons for anyone not having health insurance, the first nine are that it costs too much,” said Mark Smith, MD, CEO of the California Healthcare Foundation and a veteran of efforts ranging from the Clinton plan to the current San Francisco effort. “In San Francisco, the majority of the uninsured are young, healthy, hourly employees ­and it does not make sense for them to pay for insurance to protect assets they don’t have,” he noted. Smith also charged the health care system with being out of date in terms of customer service, noting that other industries have upgraded systems to be more convenient and efficient. On the issue of who pays for access to care, however efficient, www.sfms.org

Steve Falk had a slightly different perspective. As President of the San Francisco Chamber of Commerce, he represents more than 2,000 businesses of all sizes. He noted that a restaurant association has already filed a legal suit to stop the SF HAP from going forward. “The mandate would likely cause a decrease in jobs and real wages, as some small employers will not be able to afford it,” he charged. “The complexity of this would be problematic and it would render some businesses noncompetitive.” Falk did reiterate, though, that the Chamber does support a plan to cover everyone, albeit not with an employee mandate. Subsequent to our forum, however, California’s Governor has also made hints that an employer mandate might be part of a statewide plan, at least for children, and 80 percent of Californians support that as well. Where does all this leave San Francisco, if not the state and nation? Katz held firm that the San Francisco effort will go forward and will be viable. Renowned medical ethicist Dr. Albert Jonsen added some historical perspective in tracing the modern concept of universal health coverage to Chancellor Bismarck of Prussia in the 1800s. “The ‘Iron Chancellor’ was no softhearted liberal,” Jonsen noted. “He realized that the economic health of his rapidly industrializing nation depended on the health of his workers. “But, also he was a devout Lutheran who believed that while humans were not equal in the eyes of the Kaiser, in God’s eyes they were equal in their vulnerability to unexpected illness. Bismarck is not much of a moral hero to us now, but his health insurance program made him a moral innovator. Perhaps San Francisco can be a moral innovator today.” The discussion following the panel presentations was lively. “How long will it be before, as in most other modernized nations, providing health coverage is seen as just another cost of doing business?” asked one attendee. Lacking a crystal ball, nobody hazarded a firm guess in answer to that query. SFMS staff member Heilig and SFMS past-president Dr. Fung both served on the Mayor’s initial Universal Healthcare Council, which developed the draft plans for San Francisco. For more information on the San Francisco plan, see www.sfhp.org/sfhap.

january/february 2006 San Francisco Medicine 23


public health update Carol A. Lee, Esq.

HPV and Cervical Cancer: Making the Connection

D

id you know that January was Cervical Cancer Screening Month? While many patients may be aware that Pap screening is a very important aspect of their gynecological care, they may not be aware of the connection between cervical cancer and HPV, and they may not fully understand the need for continued screening and care. A large percentage of patients do not even know what HPV is or how easily they can contract it. An astounding number, approximately 20 million people, are currently infected with HPV. There are up to 6.2 million new genital HPV infections each year. Four viral types are accountable for 90 percent of genital warts and 70 percent of cervical cancer cases. Sadly, the incidence of cervical cancer among African American and Hispanic women is approximately 1.5 times higher than it is among Caucasian women. In general, women born outside of the United States have much higher mortality rates from cervical cancer than do U.S.-born women. According to the American Cancer Society, there will be nearly 4,000 deaths from cervical cancer this year. Approximately 50 percent of those 4,000 are patients who have never even had one Pap test. Now there is new hope on the forefront of HPV prevention, with the recently available HPV vaccine as well as recently available HPV screening tests. The new HPV vaccine has opened up the door for awareness, education, and discussion between provider

and patient. It is an exciting time in medicine to be able to directly affect patient outcome and quality of life. The time for communication is now. In April 2006, the California Medical Association (CMA) Foundation initiated a statewide awareness program addressing the connection between cervical cancer and the human papillomavirus. With physicians and other health care providers in mind, the CMA Foundation and its advisory committee, comprised of representatives from obstetrics and gynecology, adult medicine, pediatrics, adolescent medicine, family medicine, pharmacy, and public health, have identified a number of excellent resources to assist in locating the most up-to-date and useful resources for patient education, provider information, and continuing medical education. You can now easily compare various new guidelines for Pap and HPV screening and vaccination, patient information in various languages, and links to continuing medical education. Visit our website at www.calmedfoundation.org to access these resources for yourself and your patients. Make the connection every day. Take time to talk. With proper understanding and follow-up care, cervical cancer could eventually become a disease of the past. Carol A. Lee, Esq., is President and CEO CMA Foundation

Upcoming Local Events: March 8–10, 2007­ Sixth Annual Developmental Disabilities Conference: Update for Health Professionals Laurel Heights Conference Center, San Francisco A three-day CME course presented by UCSF School of Medicine. Special presentations on developmental disabilities will include improving access to health care for youth and adults; health promotion and screening; ophthalmologic disorders; how to distinguish between seizure and behavioral/emotional disorders; differential diagnosis of dementia; polypharmacy and drug interactions; maximizing independence; legal and ethical considerations; grief counseling; closure and state of developmental facilities; cognitive behavior therapy; and more. For more information, see the UCSF website at www.cme.ucsf.edu. 24 San Francisco Medicine january/february 2006

April 12–14, 2007­ Thirty-First Annual Symposium of the American Society of Breast Disease­ Hotel Nikko, San Francisco This three-day CME program will provide take-home knowledge and skills that you can apply in your daily clinical practice. Sessions will involve lectures, pro-and-con debates, audience interactive polling, and state-of-the-art presentations focused on subspecialty and interdisciplinary issues. For information, visit the Society’s website at www.asbd.org.  

www.sfms.org


hospital news Chinese

Fred Hom, MD

Chinese Hospital’s two neighborhood clinics are alive and well. The Sunset Clinic is steadily busy, while the new Excelsior Clinic continues to grow. Both offer general and specialty medical services, immunizations, and acupuncture. Wai-Lam Chan, Medical Director, and Jian Zhang, NP, Clinic Coordinator, should be recognized for their leadership. The 2006 Thirty-Third Chinese Hospital Annual Award recipient was Dr. Flossie WongStaal, Professor Emeritus at U.C. San Diego. Dr. Wong-Staal is Chief Scientific Officer and Executive Vice President of Research and Development at Immusol, Inc. She lectured on “Viral Villains: From AIDS to Hepatitis.” Thanks to Dr. Mai-Sie Chan, Chair of the Continuing Medical Education Committee, for helping to organize the event. Congratulations also to the Chinese Community Health Resource Center website for receiving the prestigious Recognizing Innovation in Multicultural Health Care Award. The website, www.cchrchealth.org, includes more than one hundred educational pamphlets that can be downloaded in Chinese and English. The National Committee for Quality Assurance sponsored the award. Finally, after being at the post since March 1993, this is my last column, and I pass the keyboard over to our fine Chief of Staff, Dr. Joseph Woo. Good luck, Joe!

CPMC

Kaiser

Damian Augustyn, MD

Robert Mithun, MD

Dr. Gregory Buncke was recently appointed Chair of the CPMC Department of Plastic Surgery. A graduate of Georgetown University School of Medicine, Dr. Buncke has also served as Chief of the Division of Microsurgery since his appointment to the CPMC Medical Staff in 1998. CPMC, along with just six other hospitals in the Western U.S., recently received a top award for Performance Excellence in Acute Myocardial Infarction (AMI) Care. This recognition comes from VHA, a national organization dedicated to the success of not-for-profit, community-based health care. CPMC won the award based on our improvements in AMI care, specifically those related to “door-to-balloon time.” This refers to the period that begins when a patient comes into the Emergency Department with chest pain and a suspected heart attack and continues through transportation to the Cath Lab, insertion of a cardiac catheter and balloon inflation—all of which must occur within a ninety minute time frame. Decreasing door-to-balloon time has been shown to decrease mortality for affected patients. CPMC has achieved an impressive door-to-balloon time of ninety minutes or less. CPMC also won additional recognition in the Team Collaboration category, for the same quality improvement in AMI care.

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www.sfms.org

Creating successful partnerships and community benefit programs is central to the mission of the Kaiser Permanente San Francisco. Specifically, we have supported the San Francisco Community Clinic Consortium and the Department of Public Health in several ways, including basic operational needs, funding for public policy work, group purchasing programs, and HealthCorp interns. Additionally, Kaiser Permanente, both locally and regionally, has shared expertise, training, equipment, and funds for new and ongoing projects. Our Community Benefit Advisory Committee addresses such issues as culturally competent care (vital in a city as diverse as San Francisco), chronic condition care, and health education. In conjunction with several other health care organizations and the SFDPH, members of our community outreach program recently helped organize and sponsor a conference entitled Advances in Chronic Care Management: Partnering across Systems. The conference addressed, among other topics, “Beyond Silos: Taking a Community-Based Approach to Chronic Care,” a subject that the providers at Kaiser Permanente San Francisco feel is vital to preventing and treating our most pressing public health conditions. Such conferences are an optimal way to engage and share with the many other public and health care organizations working together in San Francisco. Extending ourselves to neighboring communities, and the populations within them, creates a mutually beneficial relationship for both the Medical Center and those communities. Our partners continually educate us on how best to create systems that base health care on needs, not money. We hope to create a model for community involvement with the efforts and resources we provide to the Community Clinics Consortium and other outreach organizations—organizations that provide necessary services to vulnerable populations.

january/february 2006 San Francisco Medicine 25


hospital news Saint Francis

Guido Gores, MD

Saint Francis Memorial Hospital is very proud of its community involvement. This past year, the hospital contributed more than $30 million in Community Benefit Dollars, including more than $4 million in direct charity-care services. We focus on the following areas: discharge services for homeless, disenfranchised, or elderly patients; enhancing the capacity of programs that care for our community’s chronic public inebriates; exploring ways to improve health care access for uninsured and underinsured patients and enhancing the capacity of programs that currently provide these services; and helping support housing for homeless and disenfranchised individuals. We are particularly proud of our involvement with the Glide Health Clinic, which just celebrated its eighth birthday. SFMH helped found the clinic and continues to support it, helping provide outpatient diagnostic and pharmaceutical services to three thousand patients annually. With our support, the clinic was licensed as a Federally Qualified Health Clinic in 2004. We’re also very proud of our involvement with the Homecoming Services Program, which SFMH also helped establish. The program ensures that seniors without a support network receive needed services during the initial phase of in-home recovery. Other programs the hospital supports include Rally Family Visitation Services, which provides a safe, structured environment for children to visit a court-ordered noncustodial parent; and our Burn Education/Burn Survivor Support Group, run out of our Bothin Burn Center. Recently Saint Francis made a major investment in the community with the completion of our new Emergency Department, where many of the city’s underserved receive medical care. Through the ED, the hospital collaborates with a number of other programs, including the McMillan Stabilization Project, which provides care for the alcohol-dependent homeless. We’re very pleased to be able to do our part.

Seton

Julius Zsigmond, MD

Seton Medical Center’s mission, established more than four centuries ago by the Daughters of Charity, is to care for the sick and the poor with gentleness, respect, kindness, and compassion. This mission lives today through the vibrant participation of our Community Outreach medical staff and associates, all of whom provide high-quality comprehensive health care services to individuals, families, and communities throughout the Bay Area. The Community Outreach Departments at Seton participate in selected community health fairs and local health-related events, targeting a population that lacks access to health care and is at high risk for cardiac disease and/or diabetes. Blood pressure screenings at these health fairs allow each person served an opportunity to talk with a nurse, ask questions, and learn more about heart-healthy lifestyles and healthy nutrition. Our partnership with Daly City ACCESS supports collaboration between medical providers in San Mateo County so that we can, as a group, provide unduplicated, comprehensive health screenings. These include blood pressure screenings, cardiovascular risk assessments, and bone density and cholesterol tests. This collaboration among country groups also promotes community outreach combined with cultural sensitivity and language capacity at local health fairs. Representatives of family service agencies and health care facilities work together to provide language interpretation as needed. In addition, Seton Medical Center has launched a program to provide women with the knowledge and tools they need to take charge of their health. The Women’s Health Services Task Force has been conducting research for more than four years that supports the Healthy Woman Campaign in our community. The staff at Seton Medical Center is continually inspired by the values of St. Vincent de Paul: respect, compassionate service, simplicity, advocacy for the poor, and inventiveness to infinity.

26 San Francisco Medicine january/february 2006

St. Luke’s

Jerome Franz, MD

Since at least 1946, there has been a neighborhood clinic at St. Luke’s Hospital, staffed for many years through the volunteer efforts of the medical staff. It was a small operation, but one of which we were proud. It served several generations of inner Mission families. In the nineties, however, its capacity was dwindling as specialists retired and primary care doctors became less available. In order to handle its large, busy ob-gyn practice, the clinic became the St. Luke’s Health Care Center and hired the doctors who staff what is now our Women’s Center. The Center supports 1,200 deliveries per year, mostly to Medi-Cal patients. We also added pediatricians to meet the demand raised by these births. When orthopedist James Wood left San Francisco for Johns Hopkins, the Health Care Center hired David Atkin to take over his practice. Dave has built a thriving group of five doctors and two physician assistants, while still managing to volunteer time every year for Operation Rainbow—and keep up his surfing. Desiree Arretz joined the clinic seven years ago as an internist and now will be the medical director of its next incarnation as Health First. It represents a new model of comprehensive care for chronic disease, using active case management to prevent complications and hospitalizations. You will hear more about it in the near future.

www.sfms.org


hospital news St. Mary’s

Kenneth Mills, MD

At St. Mary’s, we dedicate our resources toward delivering compassionate, high-quality, affordable health services; serving and advocating for those in our community who are poor and disenfranchised; and partnering with community health organizations to improve the quality of life. Two of the most visible expressions of our commitment to the hospital’s mission are the Sister Mary Philippa Health Center and the SFO Medical Clinic. The Sister Mary Philippa Health Center is at the core of St. Mary’s response to community needs. Approximately 1,700 of the patients seen have no health coverage and receive their care free of charge or at a reduced rate. The Health Center provides a broad spectrum of care to about 5,400 currently registered patients. Services include adult primary care, medical and surgical specialties, HIV care, advice nurses, social services, translation services, patient advocacy, diabetes education, and nutrition and pharmacy services. The Health Center has a dedicated, comprehensive HIV/AIDS clinic. More than five hundred patients receive state-of-the-art care from a core of HIV specialists. This clinic is supported in part by the Ryan White CARE program through the San Francisco Health Department. SFO Medical Clinic and its team of expert St. Mary’s Medical Center physicians are dedicated to providing the best care while offering a wide variety of services, including travel medicine, occupational health, and primary and urgent care. SFO Medical Clinic provides exceptional medical care in internal medicine, family practice medicine, and urgent care. The clinic’s staff is a team of health care providers who specialize in treating injuries with competence and compassion. As part of our mission at St. Mary’s, we place a high priority on taking care of our community through our additional clinics and resources, while always providing outstanding medical care. www.sfms.org

Veterans

UCSF

Diana Nicoll, MD, PhD, MPA

Ronald Miller, MD

The UCSF Spine Center recently acquired a new imaging system that will assist surgeons in navigation techniques and help the Center expand and enhance surgical procedures. The technology is the first of its kind in the Western United States. Called the O-arm Imaging System, the equipment provides complete multidimensional surgical imaging. It gives surgeons real-time, three-dimensional images, as well as multiplane, two-dimensional, and fluoroscopic imaging. Coupled with other computer-assisted navigation equipment, it enables UCSF surgeons to perform procedures with a higher rate of accuracy, potentially allowing them to successfully perform even more difficult and complex surgeries. “Adding the O-arm to the Spine Center allows us to further streamline operating room efficiency and possibly improve patient outcomes,” said Shane Burch, MD, orthopedic surgeon at UCSF Medical Center and Assistant Professor of Orthopedic Surgery at UCSF. In addition to its use on patients with complex spinal anatomy, the imaging system will be used in more routine, minimally invasive surgical procedures, providing for smaller incisions and a reduction in surgery time. The UCSF Spine Center is one of the largest centers of its kind in the country, treating 10,000 patients per year. The center brings together world-renowned specialists in neurosurgery, orthopedic surgery, neurology, psychiatry, and other specialties to design the most effective treatment for patients. The center treats the full spectrum of spinal disorders, from complex and difficult-to-diagnose conditions to those that have failed previous treatment. In addition to caring for patients, experts and researchers are at the forefront of basic scientific research to better understand spinal conditions and to develop and test new technologies and treatments. For more information or to refer a patient, please contact the UCSF Spine Center at (866) 817-7463.

In response to a VA policy of bringing care to veteran patients close to where they live, the San Francisco VA Medical Center operates community-based outpatient clinics throughout northern California, including Eureka, Ukiah, Santa Rosa, San Bruno, and downtown San Francisco. The SFVAMC Downtown Clinic was first established in 1993 at Thirteenth and Mission Streets. A new, larger clinic at Third and Harrison Streets has received more than 11,000 visits since it opened in January 2006. The goal of the Downtown Clinic is to offer continuity of care. As at every outpatient clinic, veterans receive primary medical and mental health care. The Health Care for Homeless Veterans program offers assessment, referral, and links to VA and community resources for at-risk homeless and marginally housed veterans. Showers, laundry, clothing, mailboxes, and lockers are available for veterans who need them. A number of community agencies and organizations also provide services on site, and clinic staff supply referrals to legal and veterans benefits assistance. Other programs include housing, vocational training, and compensated work therapy. The Clinic provides substance-abuse treatment, and a Sobriety Support group meets regularly. The Ukiah Clinic recently moved to a larger location, and there are also plans to move and expand the Santa Rosa clinic to include more diagnostic and specialty services. All SFVAMC outpatient clinics are supported by the VA’s electronic medical records system, which allows quick access to patient records at any site. Telemedicine and teledermatology are also available for appropriate specialty consultation. A VA transportation system, supplemented by veterans service organizations, provides transport between the clinics and SFVAMC. These community clinics are part of the full spectrum of care provided by the VA: home care—including telehealth—and outpatient, tertiary hospital, and nursing home care.

january/february 2006 San Francisco Medicine 27


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