Those who work in clinics who serve low income patients...

[LTCNS]

What do you like about it? Dislike? What is a typical day like? Do you feel you are making a difference? Is there high staff turnover?

I start a new job tomorrow in a clinic who serves majority low income patients and adults and children on medicaid, uninsured and under insured patients. If the patient can't pay they are not asked to, or they charge on a sliding scale based on income.

This is something I have wanted to do for a long time. I have prayed for at least the last three years for a job that would allow me to somehow be involved with/help those in need. I am aware that there will be incredibly stressful, exhausting and challenging days/weeks/months/years, but I honestly feel like I am up to the challenge. If I don't make it, at least I tried right?

[NRSKarenRN, BSN, RN]

Check out what other clinics are doing:

National Nursing Centers Consortium

Philadelphia's Family Practice & Counseling Network has many innovative programs

[starintn]

I've worked with the uninsured for about 3 years, gee, the same length of time I've been a nurse. My experience has been mainly with a free clinic for those with no insurance and meeting our financial limits. Big issues in this environment have been already addressed-failure to return for office visits, inability to contact patients, knowing local resources and patient compliance. Not in any particular order.

At each visit we ask the patients if they have a new phone number-some will give you a new number, some will just say no. Ask if their current number is ….. and repeat the number you have along with the address. We live an area without public transport other than a state funded van system. Often patients don’t have the gas money to make it to appointments.

Local resources-check out every local resource thoroughly! Get qualifiers for food banks such as what the client needs to take for id or proof of income and when they accept new clients, fees and requirements for low cost dental care, clothing closet details-number of visits per month. Many states have state assisted pharmacy programs-LOTS of details on these. Ours is a good program for our state but there are limits. Also, don’t hand a person a list of resources without knowing if they can read! Did that once and was very embarrassed!

Patient compliance is a huge problem. Refusing to take their diuretic because they work and can’t take frequent bathroom breaks. The lowest cost pharmacy is too far for them to walk to-especially in areas without public transportation. They take several meds and can’t remember how to take them-this is sometimes a problem with low comprehension. And some just wanted that pack of cigarettes more than they wanted to buy their medications. Diabetic Grannies who are raising their grandkids and end up eating what the kids want to eat, when the kids need to eat and on the cheap. The list goes on. Something we started a few months ago-we only accept pharmacy refill requests that come via fax. Often patients would call to tell us they were out of meds-either they didn't know they had refills or we find out they did not take the med as prescribed. This has helped a lot! Every now and then I can come up with a solution so I guess that’s a win.

One thing I still have not achieved is getting thru a quick triage. We ask that they bring their meds with them but if they don’t you’re working on memory and there are a number who are taking meds on their own directions. We are often their sounding board-a sympathetic soul that they can talk to that is not a family member or someone they live with. We don’t want doctors waiting for a patient but building the trust involves listening.

A point made by an instructor I had several years ago, at the end of the day, can you walk out and say to yourself that you did everything you could for your patients? Even if that means a short triage but they do get to see a doctor, reviewing how and when to take meds again with the hopes that it will sink in, teaching on making better lifestyle choices. In the end, I try to reach out as much as I can with the time I have and maybe that is the best I can do that day.

Best of luck!

Star

[OldDude]

You do what you can for those you can help, and accept that some people WANT to be sick or are just nasty and irrational. Don't let the latter make you jaded and cynical about the rest!!

trishmsn, I can see you've been riding in this rodeo for a while. I love your last sentence. I've worked part time in a pediatric urgent care clinic for the past 10 years. 95% of our patients are medicaid with 99% of the daily visits being established patients. To say the urgent care clinic is abused by those who don't have to pay for the visit is the understatement of the millenium. You will run across this frequently; where the patient is held to no accountability or responsibility and everything is expected from you while being held to a standard of absolute perfection. These types of people will never be satisfied. trishmsn really put it into perspective. Good luck. Sounds like you'll be a real blessing to your patients.

[Elvish, BSN, DNP, RN, NP]

I worked in a CHC for several years before my current job; the clinic's focus was migrant and seasonal farmworkers, and most of our patients were Spanish speakers even if they weren't farmworkers. Were it not for an overwhelming desire to be at home with my new baby when he was born, I'd still be there. LOVED every second of it. Even on the hard days, the days where I felt like I was banging my head against the wall, I knew it was what I was born to do. I'm starting FNP school this fall to eventually have a chance to go back to it in a slightly different capacity.

There were people who had plenty and abused the system. There were people who literally had nothing and used it appropriately, and everyone in between. We saw lots of domestic violence. Sometimes we were able to help a person get out of the situation, sometimes we weren't. Some days we raided our kitchen's pantry to send someone home with food who hadn't eaten in three days. We were able to help one of our school-age kids get open heart surgery via charity care to fix a defect he'd had since birth that had stunted his growth; his mother was a migrant farmworker who didn't have the intellectual resources to know that the problem needed fixing, nor the financial resources to get it fixed even if she had known. Post-op, he grew like a weed and was a totally different kid behaviorally. We made a difference for that kid. (You know....the story about the kid throwing the starfish back into the ocean.)

We helped people manage their diabetes. A lot more were non-compliant, but I found that phrase to be pejorative and not entirely accurate. It's hard enough to be compliant on a good day, but when your work hours and crewleaders don't allow for snacks and sugar checks, and when you move every few months to follow the work, getting feedback on your condition is hard. And since most farmworkers live well below the poverty line, affording the strips and meds takes a miracle. And when you live in a migrant camp with one central kitchen and the same cook makes food for all 100 folks who live there, meal management may not be as easy as it sounds. It was a real eye-opener for me to see these folks' reality.

One of my favorite things to do was outreach - actually visiting the migrant labor camps to do screenings, education, and clinic follow-up. It was hands-down the best way to get to know my patients better. Meeting them on their turf and seeing their reality puts their condition in a context that I'd not have had otherwise.

The diversity among employees is something, esp in an area that is not terrible diverse, I still cherish to this day. We had African-American, white, Hispanic, and Asian coworkers and we all benefited from knowing each other's culture a little better.

Again....I can't wait until I can do this again full-time. Sorry for babbling, but CHCs are close to my heart. I hope you enjoy your job as much as I have. Oh, and learn as much as you can about vaccines. You are likely to give a ton of them. To borrow from another organization's slogan, it might be toughest job you'll ever love.

[klone, MSN, RN]

Right, and there are some specific barriers to compliance in the low-income group that is not found in other socioeconomic levels. Specifically, lack of funds for copays for meds, for example.

Agreed that this is not limited to any socioeconomic level....BUT we WERE discussing a low income clinic specifically, correct??? Please don't imply that I was shooting anyone down.

[nursel56]

I found that those who had enough support to become regular customers were more rewarding to work with than those from upscale suburbia. I guess I'm biased in that regard.

[LTCNS, LPN]

Thank you all so much for the great advice, links to resources and for sharing your experience with me!

Today was a busy day but a good one overall. A couple of times I felt my eyes welling up with tears listening to some of the stories and histories. I actually had a few of the patients tell me very personal things and they had just met me. It made me feel good that they trusted me and knew I wouldn't judge in any way.

I saw a few non-compliant diabetics who admitted they know better, but are just negligent in taking care of themselves, then the compliant ones who are doing everything they can to manage their lifestyles.

The patients I encountered today were very diverse and I enjoyed meeting all of them. I know there are going to be some really tough days, maybe a lot of them, but I do think I am going to like it overall. I found out there might be days I might have to work the clinic by myself, but we do what we have to do right? I just hope that doesn't happen until I've been there awhile. I am definitely not ready for that yet!

[klone, MSN, RN]

I have to say, after reading that long thread about Obamacare, I am recommitted to the work I do and the facility I work for. They have an amazing philosophy, and I'm proud to call myself an employee.

[neverbethesame]

A fantastic book about "non-compliance" is "The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures" by Ann Fadiman.

It is one of the best books I've ever read and I'm a big reader. It's really a must read for anyone on healthcare.

[Elvish, BSN, DNP, RN, NP]

A fantastic book about "non-compliance" is "The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures" by Ann Fadiman.

It is one of the best books I've ever read and I'm a big reader. It's really a must read for anyone on healthcare.

I'll second that recommendation. Very eye-opening. I read it about 15 years ago, so probably should give it a re-read.

[LTCNS, LPN]

I really like the job so far, BUT (there's always a but isn't there?) I have literally been on my own since day two on the job. Working up and triaging the patients is the easy part. It's all the other stuff that comes along with it that's taking some time to learn, which brings me to this little vent. Last Friday I was working my legs off running back and forth triaging and rooming patients. The Clinic Manager, who is not a nurse, asked one of the other nurses where I was because a patient went to him complaining about having to wait. At that time I was helping the NP with a procedure. The nurse told him I was there and was busy. It really threw me off the rest of the day and the NP could tell.

Most of the patients know there is likely to be a long wait because of the nature of the clinic, so they don't complain. The ones who have jobs schedule their appts. on their days off because they know they will be there awhile.

It is a large clinic and we desperately need more nurses. The nurses have been begging for help for years. There are days when one nurse has to work the entire clinic alone, and when the lab tech is out, nurses have to do their own labs. In addition, we have to do our own pre-certs, follow up on referrals, make appts., try to find time to return a ton of calls, etc...For instance, tomorrow I have a boat load of calls to return first thing in the morning and 10 referrals to follow up on.

Like I said, I really do like it, but I feel like I am not being given proper training. Like I am expected to figure it out on my own. I have been told over and over not to rush because of the risk for huge mistakes, but I feel like I am being rushed to learn everything in just a few days. I'm just feeling a bit discouraged.

[LadyFree28, BSN, LPN, RN]

I really like the job so far, BUT (there's always a but isn't there?) I have literally been on my own since day two on the job. Working up and triaging the patients is the easy part. It's all the other stuff that comes along with it that's taking some time to learn, which brings me to this little vent. Last Friday I was working my legs off running back and forth triaging and rooming patients. The Clinic Manager, who is not a nurse, asked one of the other nurses where I was because a patient went to him complaining about having to wait. At that time I was helping the NP with a procedure. The nurse told him I was there and was busy. It really threw me off the rest of the day and the NP could tell.

Most of the patients know there is likely to be a long wait because of the nature of the clinic, so they don't complain. The ones who have jobs schedule their appts. on their days off because they know they will be there awhile.

It is a large clinic and we desperately need more nurses. The nurses have been begging for help for years. There are days when one nurse has to work the entire clinic alone, and when the lab tech is out, nurses have to do their own labs. In addition, we have to do our own pre-certs, follow up on referrals, make appts., try to find time to return a ton of calls, etc...For instance, tomorrow I have a boat load of calls to return first thing in the morning and 10 referrals to follow up on.

Like I said, I really do like it, but I feel like I am not being given proper training. Like I am expected to figure it out on my own. I have been told over and over not to rush because of the risk for huge mistakes, but I feel like I am being rushed to learn everything in just a few days. I'm just feeling a bit discouraged.

That's the nature of being a newbie; you are going to feel rushed, as well as the fact that our pts are very complex, even in the community setting.

Breathe, soak everything up; also realize that you are human, and you can't be pulled in many places.