The State of Alabama is ranked #49 in health outcomes overall, #47 in diabetes prevalence, #40 in smoking rates, and #46 in obesity.1 These facts are unsurprising to those of us on the front lines of providing health care in Alabama. In our interactions with patients, we often come across educational, socioeconomic, and cultural barriers that prevent us from providing the best possible medical care. We always recommend a healthy diet to a newly diagnosed diabetic patient, but might miss that the patient doesn’t have access to a produce aisle,doesn’t have a refrigerator in which to store produce or is unclear on the nutritional differences between fresh fruits and fruit flavored juices. Similarly, we would never discharge a patient without insulin and prescriptions for diabetic supplies, but don’t ask how the patient plans on paying for their lancets or storing their insulin. Despite these oversights, we find ourselves frustrated when these fragile patients return to the Emergency Department repetitively, or are admitted for DKA multiple times in a month. In fact, it is incumbent upon us as providers to effectively identify and address these barriers as best we can. The Health Disparities Track is one of the opportunities that UAB Internal Medicine residents have to learn about how disparities impact health outcomes and to treat some of Birmingham’s most socially and medically vulnerable patients in a multidisciplinary clinic.
William Curry, MDThe track was established with the vision of Dr. William Curry of the UAB Division of General Internal Medicine and former chief medical resident Ashley Haddad, who identified an increasing interest in addressing the population level issues that affect health outcomes. It has grown from time spent on block month in the MPower clinic to a formalized curriculum with didactic sessions and time spent in the UAB Providing Access to Healthcare (PATH) clinic several months of the year for interested residents. The PATH clinic is intended for diabetes management for patients without insurance. The staff includes nursing, physicians, social work, nutrition, mental health, and optometry among other practitioners. It is entirely free to the patients. A clinic focused on health disparities is not a new operation: from 2012 to 2015, UAB students, residents, and attendings served at a clinic operated by MPower Ministries in Avondale. It was originally an outreach nurse practitioner clinic, but with a Heath Resources and Services Administration grant from the U.S. Department of Health and Human Services it grew into a multidisciplinary effort. In July 2015, the clinic opened at its new location at the Medical Towers building on 11th Avenue.
“The resident PATH Clinic is one of the most satisfying experiences of my professional career,” says Dr. Bill Curry. “Our residents love the hands-on experience of putting together the complicated pieces of a safety net clinic. They get to see the positive difference in the lives of their patients, and they come away with skills they can use for a lifetime.”
The PATH clinic is able to offer insulin, and at times glucometers, lancets, and syringes to patients in addition to diabetes education, wound care, and eye exams. With the help of social work and RN case managers, patients are often able to find affordable sources for their prescriptions, to become recipients of patient assistance programs, or receive donated or sample medications. Although the chief focus is diabetes, many of these patients have comorbidities that the physicians in the PATH clinic help to manage including hypertension, hyperlipidemia, and depression.
Even through its relatively short lifespan, the PATH clinic has demonstrated significant benefit to the patients it serves. “Eventually we figured out that the key to better quality and lower costs was to have effective care coordination,” Dr. Curry recounts. “It sounds simple, but in the busy clinic environment it can be so easy to miss what is important but not so urgent.” Data shows that in the 12 months prior to coming to the PATH clinic, 254 diabetic patients had cost the health system $2.5 million through frequent health care usage. In the subsequent 12 months, that cost fell to $1.0 million. That savings was also associated with a 57% reduction in hospital admissions. As a result of the cost savings to UAB Medicine, the leaders of the project were able to obtain funding from the Health System for the clinic after the HRSA grant ended last summer.
Currently, eighteen residents are involved in the PATH clinic with twenty-six residents participating in the didactic sessions. Interest continues to grow, with eleven new residents planning on participating next year. When asked about his experiences as a member of the HDT, Rajat Kalra (PGY-3) expresses that one thing he enjoyed was “…learning about community resources for indigent patients that I was largely unaware of while in second year. I was able to apply these to the care for other patients later in third year”. Until the time comes when inequities in access to care, education, and finance no longer impact our patients in Birmingham, the HDT will be a valuable resource in providing education to residents as well as the opportunity to work with other specialties to provide comprehensive care to patients with severely limited health care access.
1 United Health Foundation. “2015 Alabama: State Public Health Statistics.”. America’s Health Rankings. Americashealthrankings.org/Al. Accessed Apr 30 2016.