Ravenswood Family Health Center in East Palo Alto has been awarded a major three-year grant by the Health Resources and Services Administration (HRSA) Bureau of Health Professions, the federal agency charged with improving access to health care.
Ravenswood serves the uninsured and under-insured in south San Mateo County. The center will receive $1,177,881 over three years for its comprehensive disease prevention and navigation services for patients with chronic diseases.
The center was selected from 231 applications. Ravenswood stood out for a number of reasons, according to spokeswoman Kathleen Alexander.
Almost half of the residents living in Ravenswood's primary service area are below 200 percent of the federal poverty level -- despite its proximity to the most affluent Silicon Valley communities. The poorer the population, the higher are risks of chronic diseases.
Area-wide, chronic disease rates for the 11,411 adults below 200-percent federal level are all higher than comparable countywide rates, according to San Mateo County averages. Higher rates include diseases such as diabetes (13.8 percent versus 8.2 percent), hypertension (32.3 percent versus 26.1 percent), heart disease (6.1 percent versus 5.2 percent), asthma (11.1 percent versus 9.7 percent) and overweight/obesity (63.3 percent versus 56.7 percent).
Ravenswood is one of the only community health centers in the country to have a trained team solely dedicated to provide outreach, prevention and patient-centered chronic disease management services, Chronic Disease Manager Will Cerrato said. But staff must handle large caseloads because the need is so great.
Ravenswood has many patients with chronic-disease conditions. In 2009, diabetes, hypertension, asthma and heart disease were the primary diagnoses for 2,351 patients, Alexander said. Focusing on its more than 900 diabetic patients, Ravenswood's "patient navigation" health team was outnumbered 20 to 1.
"Many of our patients face complex chronic conditions exacerbated by poverty, lack of education about health issues, language and cultural barriers.
"Getting patients to understand what the risks are and providing them with tools and the motivation to make healthy choices is where patient 'navigation' comes in. With this grant we can significantly expand our chronic-disease-management program by adding five patient navigators," Cerrato said.
Similar to a fitness trainer, the patient navigators will teach and motivate patients to make incremental steps towards the goal of optimizing their health.
Ravenswood is now able to offer full chronic-disease support services for patients, from one-on-one education and case management to group workshops, cooking demos, self-management training in getting control of diabetes to helping patients to be peer educators for other patients.