Patients of the network of nonprofit community health clinics of Salud Integral de la Montaña (SIM) fail to keep 41% of their medical appointments because they lack transportation.
This is one of the social determinants of health in this central mountainous part of Puerto Rico, where poverty prevails and there is no working transportation system. SIM, which is a Federally Qualified Health Center under section 330 of the Federal Public Health Act, provides primary care and operates emergency room. Nearly nine out of 10 of their patients are on Medicaid (88 percent), 6 are commercial insured or Medicare Advantage, and 4 percent are uninsured.
Because the bulk of their patients are in central mountain in towns such as Barranquitas, Comerío, Corozal, Naranjito, Orocovis and Toa Alta, the experience after the hurricane became terrifying as they realized that patients were unable to reach them because roads were blocked or had been swiped away by landslides. SIM became the front-line of response for primary health services for communities in this region in collaboration with many volunteers including businesses, associations, entities, and universities.
“We stationed our staff in the community,” said Gloria del C. Amador, executive director of SIM. “We worked closely with municipalities and participated in an influenza vaccination campaign with Voces and the Puerto Rico Health Department,” she recalled.
Yet, what they thought was to be a relief effort of a few weeks kept getting longer and longer as the magnitude of the devastation became evident. Before and after the hurricane, SIM staffers had to transfer patients on ventilators from their homes to some of SIM’s facilities and accommodate them, so they could have access to power, water and oxygen tanks.
Puerto Rico suffered one of the longest power outages in recorded time due the havoc caused by Hurricanes Irma and Maria in September of 2017. Although the main power plants did not suffer major damages, the transmission and distribution system were left in tatters. Particularly in the central mountain area, people had to do without power and irregular water service for well over six months. In these conditions, health was a concern. Nearly 3,000 direct and indirect deaths are linked to Hurricane María during the period from September to February, according to a study conducted by the George Washington University Milken Institute School of Public Health.
Mental health also began to take a heavy toll on patients, which led them to organize sessions with SIM mental health professionals, which include psychologists and clinical social workers. Group sessions were also arranged for the staff, who day after day were dealing with very difficult situations in the field.
Alliances are key to extending access
SIM also began to establish alliances with other groups to be more effective in serving patient needs. The Federal Emergency Management Agency (FEMA) and the Health Department, as well as many other organizations, aided with generators, diesel, potable water, vaccines and other necessities throughout this period. “We had 45 employees of a total of 530 who either lost everything or suffered severe property losses, yet they showed up every day to work,” she said.
In April, SIM attended a Health Forum organized by United for Puerto Rico to share learnings from the relief and recovery effort. Gloria shared with the audience lessons from their months in the field. Her concern at the time continued to be how to care for patients who were bedridden and who had difficulty coming to the clinics. Many of these patients lived in rural areas and their families lacked resources to pay for an ambulance or other types of transportation. When she heard that United for Puerto Rico had provided funds for an ambulance for a new community health center that had been established in a part of Utuado that had been cut off from the town, she saw the opportunity to ask if SIM could petition funds for an ambulance designed for the transport bedridden patients.
“As soon as we became aware of their situation, we helped them in designing the proposal, so it would meet their needs,” said Mariely Rivera, executive director of United for Puerto Rico. “As an organization focused on disaster aid, we were particularly concerned about the gaps in care,” said Mariely.
Initially, Gloria said the $169,850 grant proposal focused on a type II ambulance that is built for the specific needs of transporting bedridden patients and to pay for five paramedics. As the custom-built ambulance will not arrive until October or November, she has petitioned to shift the funds for the paramedics to the purchase of two vehicles to transport patients who lack transportation alternatives to reach the clinics.
A year after the hurricane, SIM finds it now has more patients than it did before the hurricane. Prior to the hurricane it serviced 32,169 patients a year. By December 2017, SIM reported servicing 39,002 patients despite all the obstacles. Their outreach has continued to grow. By August 2018, SIM had reached over 45,000 patients and are projecting reaching more than 50,000 patients by ending 2018.
Their reach has been expanding thanks to the support of many organizations, for example the Children’s Health Fund that provided a mobile care unit. The Children’s Health Fund was founded 30 years ago by singer/songwriter Paul Simon, pediatrician and child advocate Dr. Irwin Redlener to provide healthcare to children with the least access. They have also received another mobile unit from Direct Relief, and funds from Banco Popular, and Somos Una Voz, an alliance of singers Marc Anthony, JLO, retired baseball star Alex Rodríguez and the Hispanic Federation.
United for Puerto Rico has distributed approximately 22 percent of the funds to health-related projects. In addition, it distributes funds to four areas of aid for relief and recovery efforts, these are water and food, social wellbeing, economic development and housing. For more information on United for Puerto Rico, visit www.unitedforpuertorico.com. For more information on SIM’s work, please visit www.sim.org or Facebook: Salud Integral en la Montaña – SIM.