Working to 'break down barriers': Rural health center to reach out to hard-to-reach patients

DOUGLAS -- Connecting with health care providers isn't always easy in Arizona's smaller communities.

A farmworker, for example, might not be able to leave work to go to a doctor's appointment. A busy parent might may miss a child's appointment because of an illness.

Chiricahua Community Health Centers is using a mix of grant funding and its own money in Cochise County to try to raise vaccination rates and improve health outcomes.

The health centers focus on primary medical and dental care and behavioral health needs in the county. 

Now, immunization specialists work in their dental offices to better increase access to vaccines.

“We are working to break down any barriers for patients that may not be able to get vaccines,” said Kelsey Vincent, a vaccine program manager at Chiricahua Community Health Centers.

Vincent piloted this program in August.

The centers' low vaccination numbers reflected the county’s low vaccination rates. According to Chiricahua Community Health Centers, 32% of people with Medicare in Cochise County received an annual flu vaccine, compared with 45% throughout the entire state. 

The low vaccination rates mainly stem from barriers to access among such a rural population, according to Dennis Walto, the chief of external affairs for Chiricahua Community Health Centers.

Among the patients at Chiricahua Community Health Centers, fewer than 41% had received the flu vaccine, and only 33% had finished their COVID-19 series of vaccines.

Placing immunization specialists in dental offices was based on the idea of medical-dental integration, which incorporates dental medicine into primary care, said Dr. Brianna Hillier, director of dental services.

She noted this model is particularly useful in pediatric medical centers when children are going in for their medical check-ups. If they are due for their dental check-up, they can get their dental needs looked at as well.

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“The hygienist can do a quick screening and assessment, place a fluoride varnish, do anything that we've agreed upon,” Hillier said, adding that some of Chiricahua's medical clinics even offer teeth cleaning as they already have all the necessary supplies.

Chiricahua surveyed patients across both medical and dental clinics to find out if they would be amenable to such an approach.

Of the 642 adult patients surveyed, 61.8% said yes. Of the 628 parents and caregivers of pediatric patients surveyed, results showed a 50.2% acceptance rate.

Tanya Garcia, a vaccine program manager, said many of Chiricahua's patients come in for acute visits and will not always return for their vaccination appointments.

If patients have to make a second appointment for or go to a different building for vaccinations, they were less likely to make that appointment, she said.

Chiricahua’s medical providers thought they might ask if patients would be interested in getting vaccinated while at their dental appointment.

 “We've got a nurse on site who can administer the vaccine, and let's see if they want to do a one-stop shop for their vaccinations,” Hillier said.

Garcia said with the increased outreach about the integrated model, patients are asking for vaccinations now.

“Patients love that we are paying attention at our dental visits,” she said about immunizations.

When patients with other medical providers go to Chiricahua for their dental appointments, they also are offered they option to be vaccinated if they have not been already.

The pilot program was funded partly through Chiricahua and partly through two donors, the Halle Foundation and Delta Dental of Arizona, who donated a combined total of $100,000.

Reaching out to their rural patients

Chiricahua is also increasing access to vaccines by adding more walk-in hours at their Pediatric Center of Excellence in Douglas, located in one of the town's first schools, built in 1905.

Margarita Guevara, the health center administrator, said the center expanded walk-in hours from one day a week on Saturdays. Now, the center also is open to walk-ins on Mondays, Wednesdays and Fridays.

Anyone accompanying a child also can be vaccinated at the same time, she said.

During the COVID-19 pandemic, pediatric clinics and others saw fewer in-person patients, while hospitals were full.

With pediatric health providers’ open schedules, they began increasing their outreach, trying to make sure children were coming in for their well-child visits.

“We were very concerned about young children coming in for their well visits because it's a crucial period of development in the brain,” said Dr. Darlene Melk, the organization’s chief medical officer.

“If we miss any nutritional deficiencies or developmental delays and didn't act on them, we knew that that child would be affected forever.”

What they also found was children who attended all their wellness visits, whether at the dental or medical clinic, 96% of them were likely to be up to date on their routine vaccines.

The importance of these well visits meant that while most other patients were seen via telehealth during the pandemic, children continued to be seen in person.

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Providers increased efforts to call families and tell them it was important to come in for their child’s routine vaccinations, even before the COVID-19 vaccination was made available.

During the first year of the pandemic, while childhood vaccination rates plummeted across the country, Chiricahua’s immunization rates for children under five increased by almost 10%, Melk said.

Chiricahua’s strategy centered on using their mobile clinics as clean spaces to bring in patients under 5 years for vaccines, laboratory testing and assessments.

However, as communities have returned to normal and clinics grew full again, they went back to care as usual. And for patients under two years old, Chiricahua saw a drop in immunization rates over the past year.

According to Chiricahua’s data in 2022, full vaccination coverage decreased from 48% to 35% in pediatric patients.

Melk said she is not sure why, noting that there could be issues with the data, or that parents are bringing their children less often to get vaccinated.

She noted vaccine hesitancy varies throughout the county and is higher in Benson compared with Douglas.

Chiricahua goes out to the fields to provide care for farmworkers

On a recent Tuesday afternoon, one of Chiricahua’s mobile clinics was at a cannabis farm in Willcox, a farming town 65 miles northwest of Douglas.

Along the way to Willcox, dairy farms and orchards dot the countryside, and cars can be seen zooming past pecan and pistachio trees.

The farming town of Elfrida sits along that route, halfway between the two towns. With a population of 306 people in 2021, according to the U.S. Census, Elfrida is where the Chiricahua Community Health Centers was founded.

The health provider began in a green metal shed in 1996. It was founded by Ginger Ryan, the first CEO, and rancher Cliff Whetten, who wanted his workers to have better access to care. During that time, Walto said, people would ride their lawnmowers to the clinic.

Since then, the organization has expanded to 10 clinical and dental sites, four pharmacy sites, six mobile medical clinics and two mobile dental clinics. 

On this particularly sunny but frigidly cold Tuesday, a mobile medical unit was parked at The Blossom Farms outside several large commercial cannabis-growing greenhouses. The unit was endearingly named Dardo, Spanish for the word dart.

Erika Vega Castro, a community health worker supervisor, said the center began sending mobile units to farms when staff realized farmworkers were missing medical appointments.

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Castro, a former farmworker herself, said she understood how challenging it was for farmworkers to make their medical appointments because of work hours that could stretch from 5 a.m. to 7 p.m.

Castro also noted that farmworkers are not usually allowed to use their cellphones on the job, so they were not getting their appointment reminder calls.

“Many (farmworkers) have diabetes and high blood pressure they didn’t know about,” said Anayeli Limon-Flores, human resources coordinator for The Blossom Farm, about how the clinic has helped the company’s workers.

She added that before the mobile clinic arrived, many worried about how they would make their doctor’s appointments.

Castro said Chiricahua’s mobile clinics travel to rural businesses including farms, recovery centers, shelters and a clinic that helps children with disabilities.  

The team consists of a nurse practitioner, a medical assistant and numerous community health workers who conduct routine health tests and could connect people to services and information to help them access health insurance.

Nancy Hilburn, 56, was one farmworker at The Blossom Farm who wanted to see the nurse practitioner.

In Spanish, she spoke about how she found out she had high blood sugar levels after being seen by the mobile clinic.

“The truth is I was not taking care of myself. When they came here is when … they checked me,” she said. “What a surprise it was when they found high blood sugar.”

Hilburn said she now has medicine for her health issues and eats healthier food.