Preface

This book emerged from my clinical practice as the only full-time healthcare provider in a small clinic for uninsured, mostly immigrant patients. I had worked in community clinics before as well as in private practice, student health, and urgent care. Despite many years of experience as a nurse and a nurse practitioner, I was unprepared for the beyond-clinical aspects of this type of practice.

The case studies within this book focus on the issues faced primarily by patients who are uninsured, self-pay, or are visiting from their home countries. The latter may be insured in their home countries but are not insured in the United States. Patients who have Medicaid or Medicare are also included because they have access to different, not always better, resources than those who are uninsured. Self-pay patients are typically those who make too much money to be eligible for resources available to the uninsured but either do not make enough money to purchase insurance or prefer not to do so.

Each clinic of this type is different depending on their structure and financial support. However, working with the uninsured, particularly immigrants, to provide them timely and high-quality healthcare with minimal resources is consistent across the board.

This book is not intended to be paternalistic or dictate how providers should approach people from other countries, ethnicities, races, or cultures. Rather, the goal is to share strategies that have proved useful and have assisted both patients and providers to have a comfortable, high-quality primary care clinic experience. The names of the home countries from which these patients came to the United States are not provided, partly to protect patient anonymity and partly to preclude the temptation to group all people from one place as looking, acting, or responding in the same way. Patients, regardless of from where they originate or where they live, remain individuals and should always be treated as such without preconceived assumptions. However, it is helpful for the clinician to think in broader terms when treating immigrant and/or uninsured patients beyond how we are taught to approach patients who have been raised in the United States.

I hope this book emphasizes the ongoing disparities in healthcare access for uninsured, especially immigrant, patients and the urgent need to offer high-quality, equitable, affordable care to everyone. This book offers tips for providers to provide quality healthcare within the parameters that currently exist.

While the cases are clinical and take place in a primary care setting, the focus is less on the clinical diagnosis and treatment than on how diagnosis and treatment are achieved for patients with little to no financial resources. Federally Qualified Health Centers (FQHCs) tend to have more resources for patients than do smaller clinics that depend on state or local funding and grants. The patients in these cases are from the latter.

Clinicians working in these clinics are at the heart of patient care. The patients we serve frequently arrive in the United States without previous medical care or with minimal previous healthcare. If they received healthcare, it may be primitive compared to the cutting-edge medical care in the United States. Many patients have never had dental care or vision screening. Both are sources of potential impairments and pain.

The clinic is a lifeline and a conduit to healthcare and resources that may help patients with food, housing, and bill paying. Advocacy is the priority because many of these patients would not otherwise have healthcare unless they went to urgent care clinics or the emergency department for which they would have to pay, even with payment plans, much more than they pay at these clinics.

Deference and respect are important attributes for the clinician working in any health care setting; however, many of these patients have already experienced significant hardship, discrimination, and sometimes torture in their own countries, while traveling to the United States, or once here. Not only can the clinician in this setting set the tone by representing Americans in a good light but they engender patient trust by treating them deferentially and respectfully.

Visits in these clinics require more time than in private clinics. Not only do new patients or patients returning after several years require extensive histories and physical exams because they may not have had any medical care for a long time, if at all, but also because they may have multiple comorbidities, some of which can be very serious.

Patients may return to the clinic only when they are worried or have a new problem because they cannot afford the visit or the time away from work. Many patients work in hourly wage jobs and may lose their jobs if they take time off. Their work is often very physically demanding, such as house cleaning, child care, housekeeping, restaurant kitchen work, landscaping, or various types of construction work. They often present with musculoskeletal complaints or specific concerns arising from their work. Many work in multiple jobs in addition to caring for their children and/or other family members or friends. It is important that the clinician be generous with notes for work that allow a couple of days off to rest or days off from heavy lifting or other physical work. Sometimes, rest is all the patient needs to feel better.

Some patients live in shelters or basements or with their employers. They may be exploited by landlords or employers and are largely unaware of "how things are done" in the United States, expecting to have to bribe officials or wait in long lines for food.

This is healthcare at its most basic and its most complicated. It is basic because sometimes all that is needed is rest and a mild analgesic. It is complicated when the patient needs much more, but rest and an analgesic are all they can access. The clinician is constantly challenged to get patients what they need regardless of the barriers. This requires the clinician to be creative and to develop strong relationships with outside providers and volunteer specialists. "Curbside consultations" are frequently necessary to treat patients who cannot get to or afford specialty care.

Patients may not know the names of their conditions or the medicines they have been given, if they received any in the past. In addition, they may receive medicines from a neighborhood Latin store or from friends or have them sent from their home countries with or without a prescription. The ingredients of the medicine may be unclear or untested. Patients may maintain a televisit relationship with a provider in their home country. Many use herbs, cupping, or other alternative treatments. Patients rarely bring documentation from health visits in their home country or with televisit providers. It is frequently necessary to "start from scratch."

Patients may take their medicines sporadically to save money and frequently think they are done with their medicines when the prescription ends. They do not always know they need to return to the clinic periodically to be rechecked and receive refills. They may not be aware the prescription allows for a refill or how to obtain the refill. If they are aware but don't have the money to pay for the refill, they may wait so long to refill the medication that the prescription has expired. Some patients share their medications with friends or family members who cannot get to the clinic.

Many clinics provide free medications based on evidence showing the patient meets a certain federal poverty level. Medicare, Medicaid, and self-pay patients are not typically eligible for these free medications. Some clinics may be able to afford to give patients some free or low-cost immunizations, but frequently patients must get vaccinations at local pharmacies. Vaccinations can be unaffordable without insurance. Patients may not get blood work or other tests due to financial concerns and may be reluctant to or unaware they can ask for an installment plan.

Volunteers are integral to the clinic. The clinic budget is typically too low to hire as many staff as needed to comfortably run the clinic. Volunteer healthcare providers are especially important because their presence in person or in a televisit increases patient access to specialty care, such as endocrinology, pulmonology, and gastroenterology. Volunteers who help at reception and the front desk can relieve paid staff from answering phones and data entry. Some translators are people who volunteer their time or are premedical or nursing students who want experience in a community clinic.

Translators are necessary in these clinics; in person is preferred. The rapport developed between translator and patient is important to the patient-provider relationship. Patients may tell translators details they do not tell the provider, feeling a greater degree of comfort with someone who speaks their own language. If possible, it is ideal for the provider to speak the patient's language or at least make an effort to do so. However, patients come from all over the world to these clinics. Phone interpreter access can be sporadic and is not as effective as in-person translation. Translators are frequently volunteers without experience in professional translation. Training is necessary because visits can go off course if the translator translates more than the provider has said. Translators may say words differently despite speaking the same language. They should always use the formal version of language rather than the informal...