An Assessment of Inadequate Primary Care in Bedford-Stuyvesant/Central Brooklyn

Causes and Recommendations

12/20/2012

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Bedford-Stuyvesant and its surrounding neighborhoods that comprise Central Brooklyn are among some of the most medically underserved in New York City and state. My time as an intern at the Coalition for the Improvement of Bedford-Stuyvesant (CIBS) during the summers of 2010 and 2011 helped me see more deeply how Bed-Stuy and Central Brooklyn are underserved. During the summer of 2011, I participated in helping to establish Bed-Stuy as an Aging Improvement District (AID). The idea behind making Bed-Stuy an AID was that the population of older individuals in the neighborhood was growing because people are living longer. As these individuals age, there are certain accommodations that need to be made in order to allow this aging population to navigate the neighborhood. In trying to establish what types of things should be focused on in Bed-Stuy, I interviewed a variety of seniors in the neighborhood. In one interview with an older woman, she mentioned the struggle she goes through in order to go to the doctor for check-ups. She mentioned that her doctor was not in the neighborhood so she had to utilize various means of transportation with her Social Security income to get to her appointments. When I asked her why she did not attend a doctor in the area, she mentioned that she did not feel as if there were enough quality doctors in the area to warrant changing to a new primary care physician. From this conversation, I felt that it was clear that the primary healthcare system in Bed-Stuy had to be lacking not only for the older population but the entire community. As a result, I have developed an interest in the state of healthcare in Bed-Stuy and how CIBSs previous involvement in the neighborhood could help bring about change. I intend to return to CIBS and help in addressing some of these critical healthcare issues. In order to do that, I am using this document to present research on the area dedicated to particular problems in accessing healthcare, what can be done to address these issues, and how CIBS can be involved in this effort.

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Bed-Stuy is often included in the surveys and reports of numerous organizations that look at the nature of inadequate healthcare. These reports and surveys focus on a variety of factors including the limited medical resources (such as few primary care physicians), poverty, lack of medical insurance and more. These issues have existed in Bed-Stuy for many decades, yet changes in healthcare policies have yet to make the type of difference that is necessary for the residents in this area. From this, it is evident that there are larger underlying issues that are keeping the changes from being effective. This is represented by the fact that hospitals and their emergency services are used for medical issues that should typically be addressed by a patients primary care physician. The hospitals in Bed-Stuy that are taking in this population of patients are beginning to suffer in major ways. Hospitals like Woodhull Medical and Mental Health Center and Interfaith Medical Center are struggling with the number of patients they see and the funds they use to operate. Interfaith Medical Center is an example of a hospital that is in desperate need of help as it was operating on a negative 29% profit margin in 2011 (Hartocollis). This clearly affects the quality of care patients receive by reducing it even more than before. When these issues overlap and appear to link to one another, it becomes evident that the problem with medical service in Bed-Stuy results from faults in a larger healthcare delivery system, underlying racial factors, socio-economic status and the presence or lack of health insurance in addition to various political factors (House, 2002). Addressing the issue of inadequate healthcare requires that all of these factors are researched and well understood before policy changes are made. To investigate this issue, I will assess the underlying causes of limited healthcare and why they exist. In 2004, New York Citys Health Department launched an initiative to help NYC neighborhoods improve in ten crucial areas: having a regular doctor, keeping their heart healthy,

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getting checked for cancer, getting the immunizations they need, having a healthy baby, being tobacco free, knowing their HIV status, getting help for depression, living free of drugs and alcohol, and making their home safe and healthy. In a 2006 version of the data provided in the report, Central Brooklyn fell in the bottom ten of all 42 New York City neighborhoods in the first five areas (Olson, et al., 3). This showcases the need for having proper basic healthcare. At the time of this report, nearly 30% of residents did not have a primary care physician, 13% of residents had gone to emergency care facilities while sick, and more than a third of residents were uninsured the year prior and/or were still uninsured by the time the statistics were released (Olson, et al., 5). These statistics of Bed-Stuy and Central Brooklyn show the importance of a solid primary care delivery system. One survey of NYC low-income communities looked at private physicians and institutional providers of primary healthcare. This study chose to look at low-income neighborhoods because they recognized that socio-economic status also weighs heavily on the type of care the residents receive, especially since 31% of Central Brooklyn residents live below the poverty line (Olson, et al., 2). Because so many residents live in poverty, it is impossible to imagine that they can afford to pay the necessary medical fees that come with routine checkups if they are struggling to put food on the table for their families. This in turn leads to more serious illnesses when they do occur. The study on low-income communities and the state of primary care in these areas by Prinz and Soffel is extremely telling about what needs to be changed in neighborhoods like Bed-Stuy. This study came to several main conclusions: 1) although policy emphasizes managed care for primary care delivery, those who are behind the policies know nothing about primary care in these neighborhoods; 2) that hospitals pick up the slack where traditional primary care falls short in these neighborhoods; and 3) the presence of a primary care physician does not equate to accessible healthcare (Prinz and Soffel, 646-47).

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Prinz and Soffel explore the primary care structure within these neighborhoods even deeper by determining the accessibility of care offered by private office-based physicians in comparison to institutionally based ambulatory care sites that also offer primary care. In this essay, the term accessibility is not just a matter of physical location. Accessibility is being used to mean that a resource, in this case primary healthcare, is available, easily approached and utilized by a larger population. Prinz and Soffels results showed that neighborhoods with a large safety-net facility, such as a hospital tend to have other primary care choices. In Bed-Stuy, however, Woodhull and Interfaith Medical Centers along with several other community health centers field a great number of patients from the larger Central Brooklyn population of more than 317,300 people (Olson, et al., 2). One thing that this study found particularly striking was that the amount of primary care for women and children was limited as many obstetrician/gynecologists and pediatricians did not exist as much in private practice when compared to institutional primary care facilities. Although these institutional healthcare centers exist to help with these problems, it is likely that the number of Central Brooklyn residents that are facing the same issue is high. When looking at this evidence it is not surprising that Central Brooklyn fell in the bottom ten of all NYC neighborhoods for having a healthy baby and getting the immunizations they need. The women and children cannot get proper care, leading to babies and older children that are clearly unhealthy when compared to their counterparts elsewhere. Prinz and Soffel also explore the idea of access to primary care physicians in addition to their presence because the benefit of having the doctors present is negated if the residents cannot access them. Major issues that were identified as keeping people from accessing the care they needed were their ability to pay the fees, the number of hours the primary care site is open per week and the ability of the physician and the patient to communicate with one another.

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Since many neighborhoods in Central Brooklyn, especially Bed-Stuy are considered lowincome, the ability to pay for medical care may hinder the treatment people receive. In a study done by William Richardson, which included Bed-Stuy and Crown Heights, he identified that the socio-economic status of an individual determines how they seek care. In his survey he identified illness as a disabling condition that prevented the individual from carrying out day to day activities for two consecutive days (Richardson, 139). Richardson found that ones socioeconomic status determined whether a person saw a doctor and how sick they were when they did see a doctor. Poor individuals were often more seriously sick than their higher-income counterparts due to the fact that they were more reluctant to miss work, as missed work often results in less pay (Richardson, 139). By the time these individuals did seek care, their condition was significantly worse than if they had gone to the doctor earlier. Higher-income individuals do not have quite the same worry, nor do they worry to the same extent. This study directly connects with the Prinz and Soffel study as some of the individuals who are more reluctant to seek medical care may not have insurance coverage. This forces them to pay for doctors visits out of pocket and in many cases results in the doctor not wanting to see them. Uninsured patients were sometimes required to pay in full before being seen, sometimes half of the fee before and half later, and few physicians saw patients before collecting their fees (Prinz and Soffel, 644). Another issue that affects these individuals is whether or not a physicians practice will take Medicaid or other similar health insurance programs. Although a large number of physicians may accept Medicaid, those that did not found Medicaid too bothersome and the rates too low (Prinz and Soffel, 644). With these kinds of limitations, patients may only seek medical treatment when it is absolutely necessary and often too late to prevent serious health issues, such as hypertension and diabetes, which could be taken care of with consistent contact with a

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primary healthcare provider. It is clear that the implementation of an equal healthcare system requires tackling these issues. The two remaining factors that I will discuss that influence whether or not healthcare is accessible to residents of Bed-Stuy/Central Brooklyn are the operating hours of physician facilities and communication between the doctor and patient. Frequently, the operating hours of a medical facility may pose an issue for healthcare. Some sites may not have evening hours and/or weekend hours making it difficult for the typical individual to see the doctor at times convenient for them (Prinz and Soffel, 645). If this is a common practice in the neighborhood, it becomes even harder to find medical care. Furthermore, a fair number of physicians offices do not have a back up arrangement for a patient if the office is closed (Prinz and Soffel, 645). Together these can easily increase the number of patients that visit the emergency departments in these areas. The other issue that exists is the effective communication between doctor and patient. Prinz and Soffel looked at private-practice physicians and whether or not they or someone in their office was capable of communicating with a Spanish-speaking patient, as it is the most common foreign language in New York. While their survey showed positive results for Spanish communication, this neglects other individuals who do not speak English. In Central Brooklyn, where 29% of residents were born in a foreign country, other languages may pose issues in accessing care (Olson, et al., 2). While the majority (70%) of immigrants are from Englishspeaking Caribbean countries such as Trinidad and Tobago, Jamaica and Barbados, there are also non-English speaking Caribbean immigrants from countries such as Haiti (Brown et al., 1645). In addition to these Caribbean immigrants, there are also African immigrants, who speak a variety of non-English languages including French, Swahili and dialects common to their home countries. Some of these African immigrants are also part of larger Muslim communities that

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contain Arabs, Pakistanis, and Indonesians who also speak different languages (Echanove). If there is not someone in the physicians office that can speak these languages, these immigrants end up further subjected to the lack of medical care available to them. In order to address the various factors affecting accessibility to primary healthcare in Bed-Stuy, it is important to look at successful models of treating these issues in other neighborhoods. In Atul Gawandes article The Hot Spotters: Can we lower medical costs by giving the neediest patients better care, he addresses the neighborhood of Camden, New Jersey which was well on its way to becoming one of the poorest, most crime-ridden cities in the nation (Gawande). Gawande examines the dedication and innovation of Jeffrey Brenner, a doctor who recognized that the poverty, crime and poor health of Camden residents were related to one another. Brenner noted that one per cent of patients [accounted] for a third of the citys medical costs (Gawande). Brenner also recognized that the patients that had the highest medical costs generally had the worst healthcare and were constantly in and out of the hospital. To Brenner, this indicated a failure of the healthcare system to provide effective preventative and timely care (Gawande). In an attempt to tackle this problem, Brenner created the Camden Coalition of Healthcare Providers which sought to treat the worst-of-the-worst patients. Part of Brenners approach was to get to know the patients on a somewhat personal level to get a full picture of their individual health problems and determine how their lifestyle influences the health problems they were experiencing. Furthermore, Brenners program approach included a team which consisted of physicians, social workers and other medical staff who check up on the patients to verify they are taking their medications and maintaining their health through home visits (Gawande). Although not all patients are receptive to the help, the individuals this program has helped show a great deal of improvement resulting in less frequent, less serious and shorter

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hospitalizations, and a drastic decrease in medical costs. Similar programs have been replicated in a variety of areas including Atlantic City with equally successful results. Atlantic Citys program, headed by Rushika Fernandopulle, took the form of the Special Care Center (SCC) which addressed the affordability of seeing a primary care physician by introducing a monthly fee for each patient as opposed to a fee-per-visit (Gawande). Although the Atlantic City program is even more unconventional than the program in Camden by using regular people to fulfill the role of health coaches, it established that the systems Brenner and Fernandopulle are operating, are extremely effective and applicable. The idea of using regular people as health coaches verifies that these individuals are interested in the work and that they have the personality and drive to make home visits and encourage patients. This article demonstrates that if such a program can be successful in a hopeless neighborhood like Camden, that the core principles and components could be replicated successfully elsewhere. The ability to replicate Brenner and Fernandopulles programs shows promise in a neighborhood like Bed-Stuy where there are already a number of organizations that provide support to the community. As it stands, CIBS has a social services network that contains organizations which address mental health referrals, quality education and childcare referrals, healthy lifestyle workshop programming and safe environments (CIBS Website). While these services are necessary, there is no specific network geared towards the improvement of healthcare. Although CIBS has a directory with a variety of places where individuals can seek medical attention, it is unclear how accessible this directory is to the people who need it. CIBS is capable of utilizing the general idea of Brenner and Fernandopulles projects and adapting them to best fit Bed-Stuys needs. This would require that CIBS first establishes a healthcare network with primary care providers that are interested in reducing their costs (as an incentive) and

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providing quality care to their patients. This network would include both private practices and institutional ambulatory sites, to allow for a wider reach of patients. The network would require that primary care physicians team up with a group of hand selected, enthusiastic individuals from the neighborhood to practice as health coaches. This would allow for the patients to visit their doctors, as well as have follow-ups at their homes with the health coaches. By doing this, it provides both a medical and somewhat social aspect to the patients health. This approach would help determine whether the social environment of these patients is detrimental to their health and to what extent. Furthermore, the relationships the patients form with the health coaches and the physicians can lead to a more trusting patient and a more enriched program. This enrichment would take the form of partnering with the CIBS social services network to create a referral system where health coaches can suggest programs that may be useful in creating a healthier home environment for patients. Another way in which the healthcare network could be enriched is through local beauty salons and barbershops. Previous studies have shown that these two locales have a unique place in Black communities in the United States. The barber and the hair stylist act as natural helpers that offer advice, support, empathy, and often health information (Brown et al., 1646). This provides the opportunity for these stylists to act as supplementary health coaches and relay critical health information to their clients in a non-medical setting. Other studies have shown that beauty salons and barbershops are successful at promoting various health campaigns such as AIDS awareness, early breast cancer detection and diabetes education (Brown et al., 1646). As a result of this, the Arthur Ashe Institute for Urban Health (AAIUH) has piloted projects targeting both males and females through video, live demonstration or through training stylists to share certain messages and knowledge about risky behavior and risk factors for certain diseases (Brown et al., 1647). The idea of utilizing barbershops and beauty salons to

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promote messages pertaining to health has been proven successful in Bed-Stuy and in conjunction with a new healthcare delivery system can aid in the effectiveness of this system. Male and female stylists from participating salons and barbershops would be informed of the healthcare network CIBS would be launching so they could share it with their clients. By doing this, patients would be encouraged by people they already trust to go to the doctor and open up to the idea of a multifaceted approach to healthcare. In addition to this, partnerships between salons, barbershops and the healthcare network could allow the health coaches to visit the various establishments on a rotating schedule to follow-up with patients if the patient felt uncomfortable with the health coach coming to their home. This would still facilitate the building of a trusting relationship as the follow-ups would be in a familiar public space with people they trust nearby. In addition to making follow-ups easier on the doctor, it makes accessing healthcare easier as it can help to reduce the transportation costs of the patients. This network of physicians, health coaches, and stylists can provide more access to underserved patients. It would open up the number of hours by which patients can be seen and provide access to a consultation over the phone or in person when physicians offices are closed. This team approach can also help in regards to language barriers as the individuals who are being hired as health coaches would come from a variety of backgrounds represented in the community leading to more opportunities to communicate with non-English speaking patients. Ideally, this setup would allow for the sickest patients to get the care that they need and work on managing their illnesses and preventing others. For patients in decent health, this service would take on a preventative role and reserve hospitals as a safety net. Eventually, this system would allow for patients who visit hospitals frequently, to reduce the number of hospitalizations, in turn reducing the cost of healthcare. These costs would get translated to the patient through the form of a

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sliding scale where lower income individuals would pay less than their higher income counterparts and still receive quality care. The payment system would emulate that of SCC where patients pay a monthly fee for unlimited services rather than a fee-per-service charge. This would benefit both healthcare providers and patients as it would keep track of patients so they return and pay their fee and provide quality care that is more affordable, more flexible and more easily communicable. In all, CIBS has the potential to establish a Brenner/Fernandopulle system of care in Bed-Stuy due to its established relationships with organizations deeply rooted in the neighborhood. CIBS has participated in a number of other initiatives to help the state of health in Bed-Stuy and would be welcomed with open arms with this new project. With the aid of CIBS and my recommendations, Bed-Stuy stands to be a healthier, medically well-served community in both the short term and long term.

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References Bernstein, Nina. "Caring for Poor in Harsh Focus as Hospitals Ail." New York Times 10 Nov. 2011, late ed., sec. A: 1. Web. Bernstein, Nina. "Panel Urges Sharp Change for Hospitals in Brooklyn." New York Times 29 Nov. 2011, late ed., sec. A: 20. Web. Brown, Necole., Naman, Priya., Homel, Peter., Fraser-White, Marilyn., Clare, Richard., and Browne, Ruth. Assessment of Preventative Health Knowledge and Behaviors of African-American and Afro-Caribbean Women in Urban Settings. J Natl Med Assoc; 2006; 98(10): 1644-1651. Echanove, Matias. "Bed-Stuy on the Move: Demographic Trends and Economic Development in the Heart of Brooklyn." Thesis. Columbia University, 2003. Urbanology. Web. 16 Nov. 2012. <http://urbanology.org/bedstuy/>. Gawande, Atul., The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care? The New Yorker. January 24, 2011. Hartocollis, Anemona. "Hospitals in Brooklyn Defended at Hearing." New York Times 29 July 2011, Late-Final ed., sec. A: 23. Web. House, James S. Scientific Foundations of Demand-Side Health Policy I: From Biomedical to Social Determinants of Health in Beyond Health Care Reform: Social Determinants and Disparities in Health and Americas Paradoxical Crisis of Health Care and Health. 2002. Olson EC, Van Wye G, Kerker B, Thorpe L, Frieden TR. Take Care Central Brooklyn. NYC Community Health Profiles, Second Edition; 2006; 10(42):1-16. Prinz, Timothy S. and Soffel, Denise. The Primary Care Delivery System in New Yorks LowIncome Communities: Private Physicians and Institutional Providers in Nine Neighborhoods. J Urban Health; 2003; 80(4): 635-649. Richardson, William C. Measuring the Urban Poors Use of Physicians Services in Response to Illness Episodes. Medical Care; 1970; 8(2): 132-142. "Social Services." Coalition for the Improvement of Bedford Stuyvesant. N.p., n.d. Web. 14 Dec. 2012.