Category Archives: At-Risk/vulnerable people
Kelly Doran, MD, is an emergency physician and a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholar at Yale University. This post is part of the "Health Care in 2013" series.
Around this time of year I think a lot about my friend Hank. He is one of only two people to whom I reliably send a Christmas card each year, and just as reliably I receive a holiday package from him containing thoughtfully chosen gifts.
When I first met Hank he was homeless, living out of a van he parked near Golden Gate Park in San Francisco. Hank had multiple serious chronic medical conditions, and the homelessness certainly did not help any. He was very sick and, sadly, though he was barely 50 years old I thought he had maybe five years left, tops. Well, 10 years have passed and Hank is still ringing in the New Year… in his own apartment. This is no Christmas miracle, but rather a predictable result of supportive housing.
My New Year's resolution for the U.S. health care system and population health is that there is more sustained attention to the fragile economic state of many of America’s families and households, especially as we continue to climb out of this most recent Great Recession. I say this in light of the strong empirical evidence that economic inequality continues to be inextricable linked to health disparities within our country. I also believe it is especially important at this moment in U.S. history, given the increasing calls to balance the federal budget by defunding social safety net programs— in particular those that provide social insurance to America’s most economically vulnerable populations.
A significant portion of the U.S. population is still either unemployed or underemployed. Many Americans remain deeply concerned about health care costs or the threat of financial instability due to health-related problems. The passage and implementation of the Affordable Care Act was a positive step to ensure proper health care coverage for those previously shut out of private health insurance markets, such as young adults and individuals with pre-existing health conditions. It would be naïve, however, to think that just one policy will provide the economic security U.S. households need to be productive workers and active consumers.
Roseanna H. Means, MD, is the founder of Women of Means, which provides free medical care to homeless women in the Boston area, a clinical associate professor at Harvard Medical School, and an internist on the attending staff at Brigham and Women’s Hospital in Boston. She is a 2010 Robert Wood Johnson Foundation Community Health Leader.
The prolonged recession of the last four years has hit many people hard. My work is taking care of homeless women, which I have done for the past 20 years. I lead a team of volunteer physicians and part-time paid nurses who provide free walk-in care to women and children in Boston’s shelters. We fill in the gaps left by larger, more bureaucratically rigid systems that put unrealistic and unattainable expectations on those who are disabled by extreme poverty, mental illness, trauma, and cognitive dysfunction.
I designed a program of “gap” care that brings health care to them. We act as the communication and advocacy bridge between the shelter/street world and the hospitals and health centers. Gap care is part of a continuum that I feel has an important role to play in health care access for vulnerable populations.
Here is a glimpse of our work.
Walking into one of the women’s shelters on a recent morning, I see a woman standing glumly in line for coffee, her hands chapped and shaky, her face pale and dry, a blanket heaped around her shoulder, pouring hot liquid into her body before staking out a cot where she can sleep for a few hours, let her guard down, away from the doorway where she was prey to drunk men who jumped her, raped her and stole her stuff.
She is hungover. She drank to escape the horror of having been attacked. She has been on and off the wagon so many times we have all lost count. She’s also been raped and stabbed more times than any of us can remember. She doesn’t go to the police any more. She’s just one more homeless woman who has been raped, a “nobody”; just more paperwork. I give her a hug and remind her that I love her no matter what. I know that she has a library of negative and self-loathing messages in her head. Mine is the one that can break through that chatter and give her a shred of self-respect.
David Olds, PhD, is founder of the Nurse-Family Partnership, a Robert Wood Johnson Foundation 40th Anniversary Force Multiplier that provides maternal and early childhood health programs for at-risk, first-time mothers. He is a professor of pediatrics at the University of Colorado School of Medicine, where he directs the Prevention Research Center for Family and Child Health.
When I finished my undergraduate degree in Baltimore in 1970, I went to work at an inner-city day care center, hoping that I might help poor preschoolers get off to a great start and have a better chance of succeeding in school and becoming productive, healthy citizens. But I soon realized that for many children in my classroom, it was already too little, too late. One little boy had been exposed to alcohol during pregnancy and was pretty profoundly developmentally compromised—he couldn’t communicate with words. Other children were being abused or neglected, so it was clear to me that parents’ prenatal health and parenting behaviors were part of the solution for low-income children.
I would have been out of touch, however, to think that all that was needed was for parents to do a better job of caring for their children. Our center was in a poor, inner-city neighborhood, where poverty, crime and a lack of adequate housing were undeniable influences for families. It was clear that parents wanted the best for their children, but their own personal histories and the social and material stressors weighing on them often made it really hard for them to protect themselves and their children. And this was happening in countless communities across the country.
Are you signed up to receive Sharing Nursing’s Knowledge? The monthly Robert Wood Johnson Foundation (RWJF) e-newsletter will keep you up to date on the latest nursing news, research and trends. Here are descriptions of some of the stories in the February issue:
As the leading edge of the baby boomers reach retirement age, there aren’t enough nurses with competencies in geriatric care to meet the surging need for their services. One of the key ways to ensure that nurses are able to provide optimal care for the elderly is to include geriatric content in nursing school curricula, experts say, and some efforts are underway to make that happen.
Although only recently dubbed an Action Coalition, the “Texas Team” has been working to increase the capacity of nurse education in the state for years. Now, as they work to advance recommendations in the Institute of Medicine’s Future of Nursing report, they have recruited more than 120 partner organizations from business, health care, academia, and other sectors.
Learn about the Nurse-Family Partnership, which sends nurses into the homes of new teen mothers to provide assistance, guidance and support. This highly successful evidence-based program is improving child health, developmental and maternal outcomes, and increasing the young women’s self-sufficiency. Now operating in 34 states, the Nurse-Family Partnership has touched the lives of more than 140,000 mothers and families since receiving a $10 million grant from RWJF in 1999.
Read a profile of RWJF Nurse Faculty Scholar alumna AkkeNeel Talsma, whose research explores how perioperative practices, processes and staffing policies may contribute to postoperative infections. Talsma and her colleagues are currently collecting data from a network of Michigan hospitals to learn how their nurses prepare patients’ skin for surgery, and linking these processes with patient outcomes. They are sharing the results among participating hospitals to initiate local improvement projects.
By David Krol, M.D., M.P.H., F.A.A.P.
RWJF Human Capital Portfolio Team Director and Senior Program Officer
“Everyone has access to quality oral health care across the life cycle.”
That was the vision formed by a varied group of individuals from dentistry, dental hygiene, medicine, public health, nursing, economics, law, social work and philanthropy as they wrote the second of the Institute of Medicine’s reports on oral health, “Improving Access to Oral Health Care for Vulnerable and Underserved Populations.” I had the privilege of being a member of that committee. Our report was released on July 13th, 2011.
Our task was an expansive one. We were asked to:
- Assess the current U.S. oral health system of care;
- Explore its strengths, weaknesses and future challenges for the delivery of oral health care to vulnerable and underserved populations;
- Describe a desired vision for how oral health care for these populations should be addressed by public and private providers (including innovative programs) with a focus on safety net programs serving populations across the lifecycle and Maternal and Child Health Bureau programs serving vulnerable women and children; and
- Recommend strategies to achieve that vision.
Piece of cake right?!
Well, as you might guess, we found numerous, persistent and systemic barriers and challenges that vulnerable and underserved populations face in accessing oral health care. Those barriers include social, cultural, economic, structural, and geographic factors. We also recognized that these barriers contribute to profound and enduring oral health disparities in the United States. Americans who are poor, minority, or have special health care needs suffer disproportionately from dental disease and receive less care than the general population. It’s a sobering reality in that many of us take oral health care for granted or don’t even think about it at all until we are forced to.
On July 13, the Institute of Medicine released reports calling for expanded access to oral health care. Esther Lopez, D.D.S., a graduate of the Robert Wood Johnson Foundation (RWJF) Dental Pipeline program, gave the following interview to the Human Capital Blog on the reports, as part of our ongoing Voices from the Field series. Lopez is a volunteer dentist and member of the Dental Advisory Committee at Goldie’s Place, a support center for the homeless in Chicago which houses a dental clinic. See all the posts in this series.
Human Capital Blog: The IOM report recommends the integration of oral health care into overall health care by training non-dental health care professionals to screen for oral disease and administer preventive care. What do you think of this approach to reaching underserved populations?
Esther Lopez: I definitely agree with this, mostly for the obvious reason that people who are losing out in dental health care are children and the elderly. Those two populations are the ones that visit primary providers the most – for a simple cold, the flu, a slip and fall accident – so having exposure to primary providers and non-dental health care professionals would be easier and more accessible. In order for this to happen we have to have more training available for these non-dental professionals. I see a lot of patients who come to Goldie’s Place with dental abscesses and things that need to be drained, that could be drained at a hospital. They go to a hospital are told that nothing can be done for them.
The Institute of Medicine (IOM) and the National Research Council released a report Wednesday that makes a compelling and urgent case for expanding access to basic oral health care for vulnerable and underserved populations. Commissioned by the Health Resources and Services Administration and the California HealthCare Foundation, the report assesses the oral health care system and offers recommendations for ways to improve oral health care for children, seniors, minorities and other underserved populations.
Among its recommendations is the integration of oral health care into overall health care, by training non-dental health care professionals to screen for oral disease and administer preventive care. The report also recommends an improved dental education system that includes residencies and clinical experience with vulnerable and underserved populations, and increased recruitment to bring more people from minority, low-income and rural populations into the oral care field.
The Robert Wood Johnson Foundation (RWJF) is working to promote and increase diversity in the dental workforce. Its Summer Medical and Dental Education Program works with college freshmen and sophomores from underrepresented populations to increase the competitiveness of their applications for dental or medical school. The free, six-week summer academic enrichment program operates at 12 sites across the country. RWJF’s Pipeline, Profession & Practice: Community Based Dental Education Program (the Dental Pipeline program) operated until 2010, reaching dental schools all across the country with strategies that increased diversity in the profession and increased access to oral health care among underserved populations.