Small Towns, Large Integration

CUTLER–A silver water tower looms over the local middle school just down Main Street from the Family Education Center, two of only a handful of buildings in this tiny community. Downtown Cutler is merely a blip on the radar to anyone driving through California farm country.

Few visitors to this nondescript burg would imagine it as home to one in a series of cutting-edge health clinics that raise the bar on low-cost, community-based healthcare with a sophisticated set of integrated services spanning primary care to alternative medicine and social outreach.

The Family HealthCare Network includes 11 clinics dotting rural Tulare and Kings counties, both agricultural economies in the heart of the central San Joaquin Valley populated heavily by undocumented workers.

A leading state rural health executive says the clinics push the envelope of low-cost care into the future where poor patients are treated holistically.

“There’s an old adage that 80% of a person’s health has nothing to do with the healthcare they receive,” says Steve Barrow, executive director of the California State Rural Health Association. He praises the Family HealthCare Network clinics: “They get it.”

Fiercely devoted to their motto “We provide quality healthcare to everyone in the communities we serve,” the clinics provide essential medical services to the farm laborers who are the backbone of California’s rich agricultural economy. Staff members including “promotoras,” or health advocates, also reach deeply into the community to assist with mental health, child care, housing, employment, education, teenage counseling, even relationship issues.

“Using a pure medical model isn’t going to get you very far,” says Harry Foster, president and CEO of the network, headquartered in Visalia. “Health has a lot to do with the spiritual, mental, and body that (create) a healthy organism.”

In rural Cutler, many undocumented farm workers once lived in shacks with dirt floors until the network partnered with local enterprises to build a farm worker housing facility right next to the health clinic.

“Moving them in to that kind of housing dramatically improved their health just in and of itself,” says Foster, who left hospital administration to work for the network the last 29 years.

In the midst of underserved communities, the clinics provide traditional medical services including primary care, pediatrics, and obstetrics/gynecology.

But it is the additional services that set the rural clinics apart: mental health, chiropractic care, alternative medicine. nutritional advice, reproductive counseling, and a wide variety of other services.

“It’s all related to health,” says Lupe Vasquez, clinic manager of the Cutler site, which also serves neighboring Orosi. “If you need help, we’re here.”

Sheryl Jones is typical of patients who visit the clinics. In the past 10 years she has used a vast array of services including pediatrics, dentistry, psychology, stress management, weight management, nutritional counseling, even homeopathy (which employs highly diluted tinctures as cures).

The mother of five adopted boys with special needs, Jones says it would be impossible to take care of her family otherwise.

“It would be awful,” she says. “I usually see someone there about once a week for some sort of service, whether it’s a class or the counseling or the dentistry, something.”

In 2010, the 11 clinics served more than 100,000 different patients with over half a million appointments. About 95% are Latino; most are undocumented farm workers or their family members.

The network employs nearly 700 people. Most of its clinical workers are bilingual.

First established with a single clinic in 1976, the network’s model is to knock down barriers to health access, including transportation.

“The individuals who live in those communities walk everywhere,” said Janet Paine, director of marketing and grants development.

In response, the networks share four vans to help transport patients to clinics or between clinics.

Money is often a huge obstacle.

“Our capitalistic system doesn’t work for people in Mexico – or most people in Latin America – because they have a hard time trying to ‘buy the idea’ of paying for healthcare,” says Foster.

The clinics operate on a sliding scale for those with no healthcare coverage. Many patients will pay $20 a visit. Some of them will pay nothing.

Tulare county trumpets itself as the second-highest grossing agricultural county in the United States – with over $5 billion in production last year – but it is also home to the some of the highest rates of poverty among seasonal Latino farm workers, most of them undocumented Mexican immigrants.

One Latina in her 50’s (who preferred anonymity) has visited the Cutler clinic over 100 times in the past five years with her husband and four children. She suffers from diabetes, while her husband is also being treated for high cholesterol and high blood pressure. Her children have visited frequently for colds and flus, also receiving vaccinations. The family depends on the shuttles provided for transportation.

Each facility has a staff member dedicated solely to its Patient Assistance Program; in Cutler this is administrator Elizabeth Flores.

Flores estimates that about three-quarters of Cutler’s patients use the assistance program, particularly for diabetes and hypertension.

“I’ll do my research until they get the medicine they need,” smiles Flores, who spends her day sourcing free of low-cost medicines and products, including nebulizers, inhalers or prescription drugs – using in particular the website “When somebody tells me no, it makes it exciting for me.”

Flores’ biggest success story was helping a pregnant 39 year-old woman who had insurance that wouldn’t cover the needed prescription ursodiol. Flores fought with the insurance plan. The patient got her medicine.

Barrow says the clinics overcome a common complaint: low-cost rural or urban community clinics are typically outdated, dreary, and depressing.

“Their clinics offer state-of-the-art, culturally sensitive, quality care,” says Barrow. “From what I have seen around the state in other rural areas they match up well to even more well-financed clinical settings in more affluent areas of rural California.”

“We strongly believe that having a nice place to go contributes to people feeling better,” agrees Foster.

The network has applied for federal status as an accredited “Patient-Centered Medical Home” – an innovative concept that uses a holistic, culturally appropriate model.

Adam Marks, a physicians assistant in Cutler, says the network is already a long way down the road toward the designation.

“Our organization is providing a lot of the services that make a medical home successful,” says Marks. “Now it’s about coordinating those services in the best way to keep our patients healthy.”

Foster says becoming an official medical home will help speed adoption of electronic resources that allow patients to access their records online and track custom programs for diabetes, weight loss, cholesterol and other conditions.

Already designated a federally qualified health center (FQHC) in 1989 – which pockets the network 8% of their budget in federal funds – the medical home designation will help the network serve patients with more electronic resources, including telehealth – providing health services electronically.

In March, the clinics implemented electronic health records (EHRs) which allow the clinics to share health records.

With millions of California’s 7 million uninsured expected to get some form of insurance in 2014 under the federal Affordable Care Act, the network is already positioning itself for further growth. By June of 2013 they will have a new dental facility and four new clinical settings in the two counties. Urgent care centers are currently being considered.

What can healthcare reformers learn from the low-cost Family HealthCare Network model?

“Where they’re going is the traditional American way,” says Foster, “which is just going to leave a lot of people out, and drive costs up. There is a much more cost-effective way of proving quality healthcare.”

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