Nurse case manager Nicole Valcour wasn’t hired for her IT skills.
But as is the way at the People’s Health & Wellness Clinic, she’s figured it out: helping homeless patients with a shaky Wi-Fi connection, counseling retired volunteers on an iPad set-up from the vacant Barre office.
In a pinch, Valcour has learned to rely on a classic piece of IT advice: turn it off and turn it back on.
“We’re muddling along,” she said. “Everyone’s good humored about it.”
Plugging away, maintaining equanimity, is all part of the ethos — and necessity — of working at one of the state’s nine clinics that provide free health care services to the uninsured and underinsured.
While the state’s hospitals have struggled financially because of the Covid crisis, scrambling to secure federal relief dollars, the free health clinics have continued on, using the same scrappy approach they had long before the pandemic — working on shoestring budgets, with limited staff, largely made up of volunteer medical professionals.
So far, the free clinics — the last line of defense that often operate outside the expensive, sometimes chaotic American health care system — have been able to weather the crisis, but some worry the economic downturn could lead to a surge in demand.
As hospitals have come to regulators begging for relief, and scrambled for federal relief dollars, the staff at the state’s clinics sought to continue caring for vulnerable patients with a characteristic uncomplaining resolve.
Not that it’s been simple: Even in more prosperous times, they operate on shoestring budgets, limited staff, a shortage of personal protective gear, and volunteer medical professionals.
The demand for their services may soon be higher than ever.
Thousands of Vermonters have lost their jobs or have seen reduced income. Many may lose their health insurance or be unable to afford care through the regular health care system.
The free clinics are vital to their patients, no matter the economic outlook, said Georgia Maheras, vice president of policy and strategy or Bi-State Primary Care Association, of which the clinics are a member. But “in an economic downturn time, that role is really, really significant.”
The clinics have always found ways to make do, said Steve Maier, executive director and sole employee of the umbrella organization Vermont Free and Referral Clinics.
“They’re pretty resourceful,” he said.
Filling the gaps
People’s Health & Wellness Clinic was founded in 1994, and in many ways, still lingers in the previous century.
“Only the people” have changed in the last decade, said Dr. Terry Naumann, who has volunteered over that period.
Their $342,000 budget covers just the basics — salaries of five staff members, rent for their aging building just south of downtown Barre, and little else. There are no electronic records; shelves of paper charts fill one wall. Their only N95 masks are leftover from the ebola crisis years ago. Volunteer doctors take care of the approximately 550 patients who seek care at the clinic in a given year.
Their clientele has slipped through the cracks of Vermont’s health insurance bureaucracy. They make too much for Medicaid or are too young for Medicare. Or they’ve aged out of Dr. Dynasaur, which provides free coverage to kids under 18. Most don’t have insurance at all; the remainder have unaffordable out-of-pocket costs.
The clinics don’t accept insurance, which means they avoid the paperwork and cost involved with billing for each visit. Instead, they’re financed through grants, donations, and state allocations. In some cases, they’re more different than alike, as they’ve each adapted in response to local needs.
The demand for the free clinics reveals the failures of the existing health care system, said Rep. Anne Donahue, R-Northfield, who serves as chair of the House Health Care Committee. “We still have such big gaps, and they help fill some of them anyway.”
Valley Health Connections in Springfield primarily helps people get insurance and provides referrals to other hospitals. Migrant farmworkers make up about half of patient visits to the Open Door Clinic in Middlebury.
Three of the state’s clinics are affiliated with hospitals — Gifford Medical Center in Randolph, Mount Ascutney Hospital in Windsor, and the University of Vermont Medical Center. Those clinics rely on state funding.
When Covid hit, People’s Health & Wellness took care of the homeless who were moved out of shelters into hotels.
Rick DeAngelis, executive director of the Good Samaritan Haven, said he struggled to get Covid tests for residents, and to get information from the Department of Health. The clinic’s medical director, Allan Ramsay, was a key go-between and tracked down health updates on his behalf. He “knows the questions to ask and who to call,” said DeAngelis.
Despite initial concerns, none of the residents put up in hotels tested positive for the virus.
A 24/7 operation
When the Open Door Clinic in Middlebury halted in-person visits due the pandemic, outreach nurse Julia Doucet and other staff started taking home the office cell phone to field patient calls 24/7. Nurses answered questions about Covid, and triaged health concerns: Some were typical — skin rashes and whether to go to a doctor for a patient kicked by a cow. Many of the clients who come to the Middlebury clinic are migrant workers on area farms.
They also got more calls for anxiety, and related symptoms. Staff members picked up at all hours of the night. “We wanted to be there for them,” Doucet said.
Seven part-time employees worked at the Middlebury clinic, which operates out of a pair of potato-colored double-wides — one for offices, one for administrative staff. Nearby Porter Medical Center has provided the space for free.
The shift online has been a boon for some patients, Doucet said. Patients can call their doctor by phone, or WhatsApp, the app of choice for migrant workers. They no longer have to find rides to get to Middlebury, or ask for time off for an appointment. Early in the pandemic, the clinic fielded more calls than ever before, Doucet said.
They’re used to finding low-cost, atypical approaches to care, said executive director Heidi Sulis. One local diabetic has donated his extra insulin, which health care workers distribute to patients for free.
The clinic runs outdoor activities, like hiking and skiing trips to help develop “a sense of place,” Doucet said. At one July clinic, a doctor saw a patient for nearly an hour — which would never have been possible if they had to bill insurance for every 15-minute period, said Paola Meza, the patient services coordinator. “What other clinic or hospital will a provider see a patient for free, for as long as they need?” she said.
Naumann, the volunteer doctor, held Open Doors’ first in-person clinic in mid-July. To reduce Covid risk, clinic workers set up a massive cobalt tent that more resembled a tarp-covered tractor than a medical facility.
During his afternoon shift, Naumann saw two patients in-person and three by telemedicine. An interpreter tuned in by video via an iPad propped up on a desk. It was a relief to see patients in-person, Naumann said, rather than relying on a blurry photo of a rash or even worse, a phone call, to make a diagnosis.
“Just the emotional and supportive connection you can give to someone in person, it’s really hard to communicate to someone online,” he said. “It just isn’t the same.”
Naumann, a 66-year-old Richmond resident, is furloughed from his part-time job at UVM Medical Center’s outpatient clinic in Hinesburg. He hasn’t worked since March, and so has increased his volunteer time for both the Barre and the Middlebury clinics.
He’s volunteered at both for more than a decade. It brings him back to the basics of medicine, he said. During his day job, his patients will expect him to order “blood tests for esoteric conditions,” he said. When he’s volunteering in the evenings, “it’s someone who’s just trying to get their blood pressure medicine and can’t afford it because it’s $5 a month.” Their gratitude when he finds a solution “is refreshing,” he said.
Preparing for the unknown
Unlike the hospitals, the clinics haven’t seen revenues plummet during Covid. A majority of their budgets come from grants and donations; about a quarter comes from the state. None have leapt into the “feeding frenzy” for the state’s Covid relief funds, Ramsay said. The Middlebury Clinic, which operates on $429,000 a year, received a PPP grant from the federal government, but will likely have to return most of it because of restrictions on how it’s spent, according to Sulis.
Their financial footing isn’t precarious yet, but that may change, Ramsay said. They won’t be able to hold their biggest fundraiser, the annual bowl-a-thon.
Meanwhile, personal protective gear is in short supply. The Barre clinic has a handful of N95 masks and a small supply of gowns and gloves, but no face shields or scrubs, Ramsay said.
Nor does the clinic have space. Leaders at the People’s Health & Wellness have decided it’s not safe enough to provide in-person visits; there’s little ventilation and no room for social distancing in the building’s narrow hallways and small offices.
Central Vermont Medical Center has allowed them to move into an empty office space in downtown Barre until the lease ends in December. After that, they’ll have to find a new location, Ramsey said.
They may also end up with more patients. The economic fallout caused by the pandemic will likely leave people without insurance. A study by the consumer advocacy group Families USA estimated that about 7% of nonelderly Vermonters had lost their insurance.
Nissa James, from the Department of Vermont Health Access, said 8,000 people had signed up for Medicaid — about a 6% increase — since the start of the pandemic. Likely, that means their income decreased enough to qualify for the program.
Currently about 40,000 Vermonters are unemployed, though many employers have continued providing health insurance to those who are laid off.
And the first signs of the squeeze may be showing.
Already, patients are streaming into Valley Health Connections in Springfield, looking for help navigating issues with insurance or job loss, said executive director Lynn Raymond-Empey. “Quite frankly, it’s a bureaucratic nightmare for patients out there.”
In Barre, Valcour said she’d figure that out when it comes. For now, her bigger concern is getting the word out that the clinic’s doors are open.
“I’m afraid that people don’t know we’re here,” she said. “If things get squirrely with their health care or their work or their medicines or something, there’s no reason not to give us a call.”
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