PHOTOGRAPHS BY MATTHEW SEPTIMUS
MARCH 6 WAS THE KIND OF COLD, RAINY SATURDAY MADE FOR sleeping in. But for a group of P&S students and their faculty advisers, it couldn't have been brighter and more inviting. Their nearly four years of planning paid off with the trial opening of a free primary care center in Washington Heights.
The center, organized by the students, treats uninsured patients who can't afford care in other settings. Every Saturday from 9 a.m. to 1 p.m., teams of students from P&S, the Mailman School of Public Health, and the School of Social Work and one attending physician see patients in space donated by UrgiCare, part of New York-Presbyterian Hospital's Emergency Department, at Audubon Avenue and 166th Street. The students named the program the CoSMO for Columbia Student Medical Outreach Primary Care Practice. The three-month trial period expires at the end of May, but the students hope to continue it beyond that.
The goal for the students is to provide neighborhood residents with comprehensive primary care so patients can reduce their reliance on the emergency room. "Primary care can prevent serious long-term health consequences and expensive emergency room care that lacks continuity," says Samantha Cramoy'04, chairwoman of CoSMO. "We don't want people to have to go to the emergency room for manageable health problems such as diabetes, hypertension, and asthma."
Ms. Cramoy and two other fourth-year P&S students, Nelson Jaeggli and Ben Scott, are leading the effort, which they knew from the start would be a challenge. When the students first mentioned their idea to Dr. Linda Lewis, senior associate dean for student affairs, in 2000, she supported their goal but told them two other student groups in previous years had tried but failed.
Undeterred, they became more determined to succeed. They knew that one free student-run center existed at Albert Einstein College of Medicine. (Since then, New York University and Mount Sinai have formed similar centers, Ms. Cramoy says.) During the planning stage, the students met monthly with their faculty advisers, Dr. Walid Michelen, assistant clinical professor of medicine and medical co-director of the center, and Dr. Mary McCord, associate clinical professor of pediatrics at P&S and of population and family health in the Mailman School, to map out and execute a plan. Dr. Elaine Fleck, associate clinical professor of medicine, is also medical co-director of CoSMO.
"My passion is for the uninsured and injustice in health care," says Ms. Cramoy. "I knew that students at other schools had started similar projects and knew that there were tons of uninsured here in our community unable to access health care due to their lack of insurance. It didn't make sense that we at Columbia didn't have one to both serve our community while at the same time teaching students about serving the underserved."
As outlined in their planning, community groups refer patients to CoSMO to be seen by teams of medical, public health, and social work students and the attending physician. A patient entering the center is greeted by a first- or second-year P&S or Mailman student at the front desk and fills out paperwork and a health needs assessment survey. The patient then goes to a waiting room to learn about health topics such as nutrition and exercise from a medical or public health student. Health videos and print materials in English and Spanish are available.
Patients speak with a social work student about housing, employment, job training, domestic violence, substance abuse, and other issues. Eileen Stewart, manager of social work at New York-Presbyterian Hospital, is on call on Saturdays for questions regarding social work services. The CoSMO center always has one or two interpreters available for patients who speak only Spanish.
The patient is initially seen by first- or second-year students who take a medical history and vital signs and pass on their report for review by third- and fourth-year students. These students take a complete history, perform a medical exam, and present a report to the attending physician, who also examines the patient. The students and the physician decide on the needed care plan, prescriptions, and follow-up.
The UrgiCare space is an appropriate setting for this center because UrgiCare treats patients who have needs for urgent, but not , care. CoSMO is using UrgiCare patient exam, laboratory, and waiting rooms during the three-month trial. Columbia's radiology and pathology departments offer free X-rays and Pap tests. The students are working with the hospital to use an established program in which pharmaceutical companies provide free medications to underserved populations, arranging prescription distribution through a neighborhood pharmacy near UrgiCare. The students will contact medical equipment companies for donations of walkers, canes, wheelchairs, and glucose meters.
CoSMO has benefited from the time and effort of many individuals throughout the medical center, particularly Dr. Daniel Hyman, assistant clinical professor of pediatrics and chief medical officer, Ambulatory Care Network at NYPH; Lesmah Fraser, director of the Ambulatory Care Network; Dr. Karen F. Kerner, assistant clinical professor of medicine and medical director at UrgiCare; Mary Sullivan, practice manager at UrgiCare; and Marian Roman, patient representative at UrgiCare. Through Dr. Jay Lefkowitch, professor of clinical pathology, the Department of Pathology offered to donate pathology services.
The students and Drs. Michelen and McCord reached out to Alianza Dominicana to help find patients. They also recognized the need to build the program slowly. "We need to scale up slowly so we can adjust to handling larger numbers of patients," Dr. Michelen says. "On our first Saturday, we saw five patients. A few months from now, we're going to be packed."
Alianza Dominicana will help enroll patients who qualify for public assistance insurance by having a community worker on site every Saturday to screen CoSMO patients for eligibility.
Ms. Cramoy says the center is filling a need for free primary care services in the Washington Heights and Inwood communities that mirrors a national need. The community's uninsured are among 42 million uninsured people in the United States, and more than 30 percent of Latinos in this country are uninsured. The uninsured work for small businesses, are self-employed, or work a number of part-time jobs without benefits. Undocumented immigrants and individuals who qualify for public assistance but have not enrolled are among other groups of uninsured.
The P&S Department of Medicine's Associates in Internal Medicine and New York-Presbyterian's Ambulatory Care Network facilities serve both insured and uninsured patients but they are not free. Uninsured patients treated at those centers are billed according to what they can afford based on their income. Patients often have difficulty paying even reduced fees, Ms. Cramoy says.
"This means that patients are either unable to obtain care at all or they receive endless bills that they are unable to pay," she says. "Additionally, uninsured patients are often unable to fill prescriptions even if they are able to see a physician."
CoSMO has 10 students on site every Saturday. Program leaders hope to have more than 100 students interested and trained by the last month of the trial period. The students will meet with the administration regularly during the trial period to evaluate the effort and make adjustments. By the end of May, everyone should know whether the effort is successful and should continue.
Opening the center has been a powerful learning experience for the students. "We learned how to think something through, starting from zero, and how to be adaptable," says Mr. Jaeggli. He noted that the center is a special opportunity for students, who are used to watching and learning, to make something happen. "We are active participants in the medical care. People wouldn't get health care without this project."
Andrea Sesko'05, who is chair-elect of CoSMO if it continues beyond the trial period, says "having first- and second-year students present to me was a fabulous educational process" and gave her a better understanding of both the physician and student side of the communication. Victoria Banuchi'07, who was a translator on the center's opening day, echoed Mr. Jaeggli's comments about taking an active role. "This type of experience taking care of people so early on in medical school was amazing," Ms. Banuchi says. "This gives me more motivation to go back and study harder."
Carol Kunz, first-year student at the School of Social Work, says the center gives students across the Columbia graduate schools the chance to work together. "It's an opportunity to show other students what social work is and how it fits into health care," she says. "CoSMO is also pursuing a holistic model of health care, treating the whole person."
The students did not know what to expect on opening day, but the launch went smoothly. The center scheduled monthly visits for a woman who has a thyroid condition that needs to be monitored. Dr. Michelen wrote a prescription for a patient with diabetes who could not afford to refill a previous prescription. Through a New York-Presbyterian program and CoSMO funds budgeted for prescription subsidies, she will get her medication at no cost.
"We were able to help people right from the start," Ms. Cramoy says. "In many places, it is almost impossible for the uninsured to receive quality primary care. We want to change that, at least in this community."