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Inside The Safety Net: Volunteers in Medicine fills in the gaps of an ailing health care system 

Class opens with a taste test. "¡Me gusta!" one woman exclaims to another after spearing a bite of vegetables with a fork. A chorus of

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Class opens with a taste test. "¡Me gusta!" one woman exclaims to another after spearing a bite of vegetables with a fork. A chorus of Spanish erupts. It's Tuesday evening and things at Volunteers in Medicine are, literally, heating up.

Wafts of grilled veggies drift throughout the clinic from the conference room where a colorful, party-like scene is unfolding. Translators volley questions back and forth from the dozen Hispanic adults to the class coordinators. The students tonight are VIM clients enrolled in a free series of classes to learn how to manage their diabetes, a condition that frequently brings them into the clinic. A discussion of where to buy vegetables and how to sauté them at home ensues.

Meanwhile, a small cluster of children play with plastic toys on the waiting room floor at the feet of parents. Volunteer Judy Kampman, a woman with snow-colored hair and a long denim skirt, greets the children while making sure each one receives a book to take home, hand-selected by Kampman.
In a small office on the backside of the clinic, Felip Ramos, a physician's assistant student, asks for advice after recounting some puzzling symptoms of a patient waiting in an exam room. Co-medical director Bob Hakala, MD, dressed casually in jeans and a polo shirt, leans back in his chair and suggests further diagnostic questions. Both men conclude that more lab tests are necessary.

Clinic hours run late on Tuesdays so patients can schedule appointments in the evening. Just about every person working in the clinic this evening, as well as on any given day, is a volunteer. It is this donated time, energy, and expertise that keeps this clinic, which serves low-income Deschutes County residents, up and running.

VIM offers primary care to patients, extending free mental health, dental and vision services as well as prescription drug support to its patients. As of its five-year anniversary in April, VIM had treated more than 6,000 people in the community, logging over 31,000 patient visits and 109,000 volunteer hours. The clinic's mission is to provide medical care to the uninsured, a population that represents almost a fifth of all Oregonians. Specifically VIM targets the large group of people who make too much for government insurance programs like Medicaid, but not enough to afford private insurance.

As a safety net for some of Deschutes County's working poor, VIM provides free services to residents who fall between the ever widening cracks in the health care system - services that rely solely on the goodwill of volunteers. And even as Congress debates a plan to overhaul the current system to provide more coverage to all Americans, the ongoing recession has highlighted the need to provide - at least for time being - an alternative to the pay to play system. It's also underscored that the current system isn't working for many Americans who, often through no fault of their own, aren't able to access basic health care. It's a national problem that is playing out in community clinics, hospital emergency rooms, and living rooms all across America.

At least 17.5% of the U.S. population is uninsured, or about 46 million people, and many Oregonians have to just hope that they don't get sick. About 17% of the state's residents are uninsured. The economic recession and rising premiums have also made it difficult for employers to pick up the slack. Just over half of the state's employers extend health care coverage to employees, according to Cover the Uninsured, a project of the Robert Wood Johnson Foundation. At 12.2 percent, Oregon has a higher unemployment rate than the national average of 9.7 percent. Things are even tougher locally with Deschutes County hitting 15.3% unemployment in July, according to the Oregon Employment Department.

"With the economic downturn, VIM was overwhelmed with the number of new people who wanted to become a VIM patient - we actually had a six month waiting period for new eligibility screening," explained Kim Brown, communications coordinator for VIM.

According to a new plan, a person can call on the first of the month to get an eligibility screening appointment on a first-come, first-served basis. If at that point he or she is determined to be eligible, the patient will be able to see a provider.

VIM currently serves 3,000 patients, most of whom work in the hospitality or retail industries, traditionally low-paying sectors with minimal or no benefits. Others are independent contractors and seasonal workers. Dr. Hakala estimates that there are many more people in the county who fit the VIM patient criteria.

"We are really a gatekeeper for the medically indigent of the community," Hakala said. "We make every effort, from the person at the front desk to the clinical side, to see them in a compassionate, caring way."
The ongoing recession and higher-than-average local unemployment numbers means that more and more individuals and local families are facing the prospect of unpaid medical bills - the number one contributor to personal bankruptcy. In that way VIM is helping its clients avoid not only a health crisis, but a potential financial crisis, said executive director Katherine Mastrangelo.

"VIM contributes to a healthier community," she said. "Medically we help our patients with chronic and episodic health care concerns so they can access the care they need."

It is difficult to speculate on how many lives VIM affects and how many it has saved. Patient Judy Fox, 60, is one of many.

"I don't honestly think I'd be here without Volunteers in Medicine," she said. "There was no way of getting the medication and treatments I need."
Two years ago, Fox moved with her husband to Oregon leaving behind a "good-paying" job with benefits. After failing to land a job in Central Oregon, Fox experienced what she calls a "bad period" of depression, her health further failing due to diabetes complications. After a referral to VIM from the Department Health Services, Fox was able to qualify and begin seeing a doctor who has become her primary care physician.

Today, through her VIM treatment plan, Fox is able to access her primary care physician and a psychiatrist once a month as well as receive her medications for free. She also enrolled in the diabetes management class and worked with the instructors one-on-one to manage her weight and glucose levels.

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One of the top diagnoses at the clinic is diabetes, a chronic care condition issue that affects 23.6 million people in the U.S. and requires numerous services. Among the 300 volunteers who donate their time to the clinic are Joan Goodwin and Elaine Blyler who started the series of diabetes management classes three years ago, combining both their desire to make a difference in their community with the need for the classes at the clinic.
Each woman brings her expertise to the table: Goodwin has a nursing background and had a private practice in diabetes management and Blyler is a dietician with a Masters in nutrition. In this first bilingual class, the women not only teach their students how to grill vegetables but also coordinate feet and eye examinations and educate patients on glucose levels. The classes encourage patients to make lifestyle changes by empowering them through self-care, according to Goodwin.

"The patient is responsible for 98% of diabetes management," Blyler said. "We are giving them the tools to create a better life." Without the classes, it is difficult to say whether the patient would ever receive this life-changing information.

Being a part of a solution to the health care crisis is attractive to many VIM volunteers as the clinic serves as a training ground for students - like PA student Ramos - who attend Oregon Health & Science University (OHSU) School of Medicine, Oregon State University-Cascades Masters in Counseling program and Central Oregon Community College's Dental Assisting program.
"Patients who walk through the doors need it the most - there is no alternative and nowhere else to go," said a pre-med volunteer. "It is gratifying to know that if you weren't there they would go without."

Without the daily grind of practice and paperwork, VIM becomes a venue where retired doctors and nurses have a place to stay involved in the medical field. The local clinic has the second highest number of retired doctors of any VIM clinic, according to Mastrangelo. She points to providers such as Dr. Hakala, retired from 29 years of service at Bend Memorial Clinic, as an invaluable resource.

"I derive a great deal of satisfaction helping people who have difficulty accessing medical care and receiving treatment," Hakala said. "It is very gratifying at the end of my career to be able to serve in this role."
Hakala sees an important, but yet-to-be-defined, role for VIM to play in the future even if the country moves to a universal health care system. With a continuing nationwide shortage of primary care physicians, he suspects that there will be access issues under a universal system that VIM can locally alleviate. In the meantime, the clinic continues to strive to improve patient access and services with the addition of an acute care clinic staffed by volunteers from Central Oregon Emergency Physicians so patients can be seen on a more urgent and immediate basis.

"VIM has heightened sensitivity to the health care crisis in the community as well as nationally," Hakala said. "It is also a positive reflection of how the medical community at large can pull together to provide a compassionate, caring clinic where people can be seen and taken care of."

Pulling Together
Without its volunteers, the clinic could not operate. But the support of the Central Oregon community expands and enhances the clinic's existing services. Approximately 185 specialty practices, such as Central Oregon Radiology Associates and St. Charles Medical Center, donate their time and services to VIM patients. Even businesses outside of the medical field, like Mrs. Beasley's and Strictly Organic Coffee Co., step up to the plate by donating food or coffee to keep volunteers fueled. Through this extensive network of volunteers, VIM is able to coordinate primary care and specialty care at the average cost of $350 per patient annually, by way of comparison, the average annual premium for individual healthcare coverage was $4,704 in 2008, according to VIM.

Although there are 71 VIMs spread across the country, each clinic operates independently and is fueled by local donors without financial assistance from federal or state subsidies. An estimated $2.5 million worth of medical supplies, pharmaceuticals, volunteer and pro bono services is donated to the Deschutes County VIM per year, according to the clinic. Even funds for the bricks and mortar of the VIM building were anonymously donated in 2002 and St. Charles continues to lease the land to the clinic for $1 per year.


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