RELATED

Low-cost, free health care Free clinics: Virginia Association of Free Clinics: www.vafreeclinics.org/ Community health centers: Virginia Primary Care Association: www.vpca.com Local health departments: See city or county government pages of local telephone directory. Bon Secours Care-A-Van: For a schedule of visits, call 287-7826 or 545-1920 Richmond Enhancing Access to Community Healthcare: www.reachva.org Family Access to Medical Insurance Security Plan: Medicaid and state children's health insurance program: www.famis.org, www.dmas.virginia.gov VCU Health System's indigent-care program or Virginia Coordinated Care program: 628-0600 Hospital charity care: Central Virginia Health Planning Agency keeps a list of charity-care commitments for hospitals in the Richmond region. www.cvhpa.org/PDF_Files/Charity_Care_10_20_05.pdf Uninsured Medical Catastrophe Fund: www.dmas.virginia.gov/rcp-uninsured_medical_catastrophe.htm

Two years ago, hospitals in the Richmond area were struggling to cope with a growing number of pregnant women, usually Hispanic immigrants, arriving to give birth with no history of prenatal care.

Health-care workers said the pregnant women sometimes waited in cars in hospital parking lots until they were well into labor. They'd then go to the emergency room knowing they were too far along to be turned away.

During a period of months, public and private providers, committed to taking care of low-income, uninsured and vulnerable populations, stepped in and patched together a solution.

"This has been one of the greatest success stories, when you talk about collaboration in a safety net," said Sheryl Garland, vice president of community outreach for the Virginia Commonwealth University Health System.

To help these women, Cross Over Ministry, which has several free clinics in the area, started offering obstetrical services at its Nancy Gilliam Memorial Clinic in South Richmond, where many of the women lived. Volunteer physicians and nurse-midwives see patients at half-day clinics during the week.

"I saw one woman today at 19 weeks," nurse-midwife Sandra K. Voll said last week, between patient appointments. "That's better than no prenatal care."

In the Richmond area, the health-care safety net is made up of community-supported free clinics like Cross Over and Fan Free Clinic; federally qualified health centers such as Vernon J. Harris; doctors in private practice; free prescription-drug programs; VCU's indigent-care program; hospital charity-care missions and mandates; and others -- advocacy groups that do health fairs, Planned Parenthood, Medicaid, VCU's Virginia Coordinated Care program and school-based clinics.

It is a broad, disjointed network that is complex and sometimes hard for patients to navigate, yet flexible enough to quickly respond to new or changing needs.

Even with all that safety-net providers do, they don't fill all the gaps.

"A major one is mental health," said Garland. "There is just not enough capacity to support the population that needs care. . . . The other is access to low-cost prescriptions drugs. It is very, very difficult to try to help a person get well if they don't have access to medication."

A community pharmacy is in planning stages. For now, there is RxPartnership, a public-private effort formed last year. The partnership works to get big drug companies to donate bulk quantities of prescription medications. Since October 2004, drugs with an estimated retail value of $3.8 million have been distributed to 20 affiliated clinics and health centers across the state.

Locally, efforts are under way to foster similar collaboration, partly as a way to make it easier for patients to find services but also to increase individual provider efficiency.

An Institute of Medicine report published in 2000 described the health-care safety net as "intact but endangered." The report said threats to safety-net providers include increased demand for services, eroding subsidies and Medicaid changes.

"Some organizations are better off than others," said Denise Daly, executive director of Richmond Enhancing Access to Community Healthcare, the organization orchestrating much of the collaboration.

"Some have been around for 30 years, others five years. . . . One of the reasons REACH is doing what it is doing is to ultimately strengthen those pieces. We hope to be able to leverage more local dollars and money outside the community."

Safety-net providers say most people find them by word-of-mouth or referrals. Most don't advertise because they don't have the money for it or don't need to.

"We are getting more requests," said Robert LeDoyen, executive director of Irvin Gammon Craig Health Center in northern Henrico County. The center charges people based on ability to pay and accepts insurance. The center is on the campus of St. Joseph's Villa, which provides services for troubled, homeless and disabled children and adults.

"St. Joseph's Villa realized many of the people they cared for had health problems," said LeDoyen. "They were not in the primary-care business. They realized they needed to have a source close by. They talked with VCU, Bon Secours, HCA and other community partners."

The health center opened in 1997, he said.

"I think we are finding it harder and harder to meet the needs," LeDoyen said. New patients may have to wait a month or more for an appointment.

"That is not what we want to do, and [their medical concern] is not going to wait," LeDoyen said. "Typically, they will end up in the emergency room."

Daly, of REACH, said estimates put the number of uninsured in the greater Richmond area at about 103,000 people. Safety-net providers collectively take care of about 50,000 to 60,000 people, she said.

"I think the most vulnerable are the uninsured workers with chronic illness," said Stephen Horan, executive director of the Community Health Resource Center, a nonprofit that provides research and technical assistance. "They tend to be in the 40-to-64 age group where they are not yet eligible for Medicare."

He describes the uninsured-patient experience as "patient pinball." They bounce back and forth between clinics, hospitals and others places for care.

"The challenge from the safety-net standpoint is how to provide coordinated care for people with chronic illness," Horan said.

The prenatal-care project in place in South Richmond shows what can be done through collaboration.

Imaging and laboratory services are donated. Trained volunteers serve as translators and teach prenatal classes.

Staff from REACH help women apply for emergency Medicaid to cover childbirth. A Richmond Health Department worker helps families sign up for the Women, Infants and Children supplemental nutrition program. The women give birth at VCU Medical Center.

Since the program started in March 2004, more than 200 babies have been born to women cared for in the program.

"This allows for screening to prevent problems, so they are not coming at the end with no prenatal care and a whole bunch of problems that can train-wreck," said Charleen Huguet, women's health coordinator for Cross Over Ministry's clinics.

"We are borderline maxing out," Huguet said. We have another nurse-midwife who is interested in volunteering. We could open up another half day. There is always a shortage, but God provides. It always just works out somehow."