Falling through the cracks: Budget cuts leave no safety net for San Francisco’s chronically ill

by Chris Brizzard

Ella-Howell-Felicha-Bell-0308-by-Chris-web, Falling through the cracks: Budget cuts leave no safety net for San Francisco’s chronically ill, Local News & Views San Francisco – It has often been said that prevention is the best medicine. But there are many obstacles in life which prevent this age-old truism from being put into practice – ignorance, laziness and something of an entirely different order – budget cuts.

Last month, Mayor Gavin Newsom announced a slew of mid-year budget cuts affecting services city-wide, including the improvement of Dolores Park playground facilities, the postponement of Chinatown alleyway upgrades and the elimination and/or reduction of numerous programs within the Department of Public Health (DPH).

It can be argued convincingly that all DPH programs provide vital health services for the city. However, a closer look at the proposed DPH “reductions” reveals that the vulnerable will be hit the hardest. Consider, for example, the DPH programs and services affected by the mid-year budget cuts:

  1. Closure of Worker’s Compensation Clinic at San Francisco General Hospital (SFGH);
  2. Reduction in hours of operation of the Oral Surgery Clinic at SFGH;
  3. Eight-hour per day reduction in Operating Room time at SFGH;
  4. Elimination of the Chronic Care Public Health Nursing Program;
  5. Mental Health Clinic Director consolidation;
  6. Closure of Buster’s Place Drop-In Center, the city’s only 24-hour, seven-day per week homeless facility;
  7. Elimination of the Senior Disaster Registry, a list of seniors and disabled who may need additional assistance in a disaster.

This saves the City $1,488,624 for its fiscal year 2007-08 budget. However, this short-term monetary gain will undoubtedly be offset by the long-term problems that will come back to haunt the City after the cuts are made.

A case in point is the Chronic Care Public Health Nursing Program (CCP) slated for closure on April 15. The CCP has 15 nurses who make 6,000 annual home visits to 465 chronically ill adults throughout San Francisco, a third of whom live in the city’s southeastern neighborhoods. “We don’t just see anyone who is chronically ill,” said Stefan Lynch, a nurse in the CCP. “We see folks who aren’t going to appointments, who are showing up at the ER, who have mental and physical barriers to getting to a clinic and so are getting sicker.”

Contrary to what one may think, “chronically ill” does not always mean “old.” “[It] means 18 and older,” said Felicha Bell, a nurse in the program. “It’s not that everyone is elderly. Some are chronically ill or disabled, and that could happen at any age.”

Bell, a registered nurse who grew up in Bayview Hunters Point (BVHP) and has participated in the CCP since its inception three years ago, has a caseload of 32 patients whom she sees on a regular basis. Many of them live in BVHP and Visitacion Valley, areas where chronic diseases like diabetes, heart disease and asthma occur at disproportionately higher rates than in other parts of the city.

Bell says the overall goal of the program is to help patients achieve optimal health and independence and to keep them out of long-term health care facilities like those at Laguna Honda Hospital, which are already under enormous pressure. This is done through a combination of community outreach, case management and client education.

Incomplete referrals

When Bell began her work in the CCP in the fall of 2006, she noticed that the doctor referrals she received for her patients often have minimum information. “The reason for the referral would be something generic,” said Bell. “But you’ll get there and you’re like, ‘Whoa, this referral didn’t say that.’ Then you figure it’s because the doctor had no clue” what was happening at home. “Public health nurses are the eyes and ears for the primary care physicians.”

And how could s/he? A typical doctor’s visit lasts 15-20 minutes and that’s just not enough time to get an overall picture of a patient’s needs. What’s more, some patients may feel uncomfortable in a doctor’s office, making assessment all the more difficult. Having nurses like Bell who make home visits ensures that all of a patient’s medical and psychosocial needs are being addressed properly.

Checking the details

Carol, in her mid-50s, is one of the clients Bell has been working with since winter of 2006 who lives in the Bayview. Over 30 years ago, Carol was diagnosed with lupus, a chronic disease which affects the body’s immune system and attacks the body’s cells and tissue. On a recent visit, Bell noticed that Carol wasn’t taking all of her medications. Of the 12 pills she takes every morning, one was too big and she had stopped taking it because it was hard to swallow. Bell made a call to the doctor to see if she could get smaller pills sent to Carol instead. Bell linked Carol to pre-filled mediset delivery service to minimize medication confusion.

Later that week, Bell visited a patient in his mid-40s living in Hunters Point who recently had an aneurysm. He had accidentally been delivered two sets of medications, and he had been mistakenly taking both. He complained of stomach upset. “If he would have moved the rubber band [on the medication box], he could have seen that it had a different name on it,” said Bell. “This is something that we should all know, but because he’s had this aneurysm, his cognitive abilities aren’t there.” Her visit curtailed what would have been a costly and time-consuming visit to the doctor.

Education and linking to services

Ella Howell, who retired several years ago, is a long-time resident of Hunters Point. Two years ago, Howell suffered a stroke that left her barely able to walk. When Bell started seeing her in December of 2006, she wasn’t taking her meds properly and her blood pressure was too high.

Bell helped Howell make some dietary changes to help reduce her blood pressure. For example, instead of using ham hocks in her cooking, Bell suggested changing to turkey to help reduce her sodium intake.

Bell also linked Howell to a service that delivers pre-filled medication sets; to Meals on Wheels, the service that delivers food to people at their homes; and to In Home Support Services (IHSS), where patients receive help with cooking, cleaning, self-care, accompaniment to a medical appointment etc. Howell’s daughter now provides IHSS care for her.

What were once twice-weekly visits are now only monthly. “I tell everybody Ella’s my success story,” said Bell. “She’s doing so much better. She’ll probably live to be a hundred.”

If the Chronic Care Program were to continue, Bell would likely take Howell out of it because of her marked improvement. But this isn’t a bad thing – the program’s goals have been achieved and it would allow Bell to take on another patient.

Out of the ER

Cynthia Smothers, in her mid-40s, is also a long-time BVHP resident. Formerly a medical lab technician, she hurt her back on the job, suffering a herniated disk, and has been out of work since. Smothers suffers from several other ailments – diabetes, hereditary kidney problems and high blood pressure. On top of this, she is responsible for taking care of her mother, who has been waiting eight years for a kidney transplant.

“God has given me the strength to keep fighting my health disabilities,” Smothers said. “If I can’t take care of myself, I can’t take care of my family.”

Smothers got into the Chronic Care Program because she went to the ER so many times for her diabetes that the doctor referred her. “With Felicha coming in, it’s insurance that if I’m not going to the doctor or my blood sugar is too high, she can help me learn how to balance it and see what I’m doing that I’m not noticing,” Smothers said. “Since I’ve been under you guys’ care, I haven’t gone [to the ER] … I can’t remember,” she said with a smile.

After learning about the pending program cut, Smothers had several things to say. “You can give money to other countries [for the war], but you can’t take care of home?” she asked in exasperation. “People need to know that without this service, a lot of people will be in trouble. These people [the nurses] are going out there where the police won’t even go,” she said.

Expensive, time-consuming and outdated

In a recent article in the San Francisco Chronicle (“Bracing for deep cuts in health care,” March 3, 2008), Mitch Katz, the DPH’s director, described the program as “expensive, time-consuming and outdated.”

Katz continues: “Modern health care does not endorse chronic care management being done through individual home visits by nurses. It’s not the most current model or the most cost-effective way to do chronic disease management.”

After reading the article, Bell’s frustration spilled over. “We did research,” she said. “We could not find a program comparable to ours,” referring to a time three years ago when the DPH split public health care nurses into chronic care and maternal child health.

“Now he’s saying it’s outdated, and that’s because I think they did not use the foresight to research what type of reimbursement model they would use,” Bell said. The model was designed for social workers and not nurses. “We have to provide care to everyone, whether they’re insured or not. So if we don’t get full reimbursement for those who are uninsured, then it appears that our program isn’t viable.”

Safety net removed

Imagine what would have happened to any one of Bell’s patients had the Chronic Care Program not been in place. The first that comes to mind is more ER and doctor visits, further clogging a system that can service fewer people while simultaneously creating more demand for those services – a classic Catch-22 scenario.

Secondly, the practice of preventive care would take a drastic blow. Educating and linking patients to services that allow them to lead healthier lifestyles, which in turn keeps them out of hospitals and long-term care facilities, would be taken away.

Multiply this by the number of nurses and their patients in the program and the magnitude of the problem sets in. If the program is cut, what happens to the patients? “That’s my question: Who helps them now?” asked Bell. “You [the DPH] created this for them and you didn’t make allowances for them if you cut our program.”

The reality of being stricken with a chronic illness is closer than we’d like to think. “All of us are one illness away,” said Bell. “We never know what could happen that would put us in their position. And if we haven’t prepared for a catastrophic event, we’ll wind up just like them.”

If the Chronic Care Program is cut and the safety nets removed, the number of people in danger of falling through the cracks will only grow larger as the City’s medical bureaucracy trips over its own feet trying to keep up with the increased burden it will soon face.

To express your opposition to any of the proposed DPH cuts, contact the following:

Chris Brizzard is a graduate student in media studies and a writer at the Bay View. Email him at cepheus_1@msn.com.