Volume XVII, Issue 37 # September 10 - September 16, 2009

One Child at a Time

Sandi Shanahan is reforming health care through sheer strength of personality

by Bonnie Lefkowitz

Sandi Shanahan’s medical clinic for uninsured kids came back with a bang after five homeless weeks. On Shanahan’s first day in new quarters, nearly a dozen children waited with their parents in the basement of Mt. Olive AME Church on Hicks Avenue just off Forest Drive in Annapolis. They played with colorful blocks or watched cartoon videos until it was time for their turn in the exam room.

Alma Chavez brought all four of her children. The oldest, Cristina, just graduated high school and will soon begin training as a medical assistant. Luis is entering his teens, Katherine is seven and Stephanie five. Katherine will be back in a couple of weeks. But today’s visit, the Chavez family’s second since learning about the clinic at their church in Glen Burnie, was for the youngest, about to enter kindergarten.

Stephanie winced only a second when Shanahan pricked her finger for the lead poisoning test. It’s part of the required pre-school protocol because without early treatment, lead contamination can cause permanent brain damage and retardation. “I’m the only low-cost provider of lead testing,” Shanahan explains. “It usually costs over $90.”

Filling a Need . . .

Any given Tuesday from now on, you can find pediatric nurse practitioner Shanahan doing routine exams, diagnosing and treating illness and prescribing medications. She logs over 300 visits annually, half with ongoing patients. The children she sees range in age from infancy to 19. Most are Latino, from five or six different countries. Another 10 percent are African American or Asian.

Alma Chavez, back right, learned about the clinic at church and brought her children Luis, Katherine and Stephanie, lower right, who needed a required exam before starting kindergarten.

Shanahan’s patients learn about the clinic from schools, churches or local health departments. They come for annual physicals as well as those mandated for school entry, endemic problems like asthma, seasonal respiratory infections and flu that plague most youngsters and more exotic conditions that arise when a child has never seen a doctor. All lack health coverage, and most would be hard pressed to find regular primary care elsewhere. Their families pay what they can, up to a maximum of $35. “But to tell the truth,” Shanahan says, “a lot of them can’t pay anything.”

Shanahan, 67, says she’s responding to a need. Back in 1994, her naval officer husband retired and they returned to Chesapeake Country after years of assignments around the world, building a home on the South River. Three children and grandkids — now there are nine — were not enough to keep her busy. Having trained as a nurse, she went back to school to earn certification as a pediatric nurse practitioner. At Anne Arundel Medical Center, where she is still affiliated, she saw hundreds of children crowding into the emergency room for primary care.

Her answer to the problems she saw was a one-woman operation, part-time but still offering continuing care. She decided to focus on the neediest children: Those with no health insurance at all. The Shanahan Children’s Clinic opened in October 2005. Her husband passed away the following year, but she kept going. And kept leaping hurdles.

. . . While Leaping Hurdles

Financial support was the first hurdle. Shanahan could support herself by practicing elsewhere and running school tours in Washington, D.C. For the clinic, she thought about applying for a federal grant. However, that kind of program would have required full-time staff serving both kids and adults. She’d also have been burdened with complex billing procedures for patients with Medicaid or private insurance. So private donations were the way to go, but that meant finding space on a very limited budget.

For four years, the Allen Apartments, not far from her current location, hosted the clinic free of charge in the community room one day a week. But in June she was asked to vacate, with little explanation.

“It was upsetting,” Shanahan says. “Things seemed to be going well. Then we had to leave and they wouldn’t even put up a sign directing patients to the new location. Fortunately, Rev. Johnny Calhoun and Mt. Olive Church stepped into the breech. They have been great to us.”

Another hurdle was communicating with her patients, a hard-to-reach population, many of whom do not speak English. Shanahan leapt that one by finding Spanish-speaking volunteers, a few of whom she pays a nominal fee. They assist her on site, greeting patients and their families, organizing records and translating questions and answers. But they also carry mobile phones and are available to patients 24 hours a day, making appointments and contacting Shanahan to deal with medical questions and emergencies.

On opening day in the new quarters, one of the volunteers, Elena Del Campillo, a plant scientist and Shanahan’s neighbor, is fitting a little girl with special glasses for an eye test and helping parents fill out forms. The other volunteer, Edwin Hernandez, an electrical contractor from Odenton, is interviewing patients. He stops for a moment to tell me why he’s here: “A friend told me this was a good way to help the community,” he says. “It’s like a circle, you know, if everybody helps everybody else.”

To assure her patients the services they needed, Shanahan also cultivated a network of medical specialists who provide discounted care. For example, back in the exam room, she’s coaxing a giggle and a smile from Jaylyn Wells of Edgewater, another beginning kindergartner. Some of her questions for Jaylyn and her mother, Mary Elliott, are part of the usual preventive health litany. “How many glasses of milk a day?” she asks. “How are you doing with fresh fruits and vegetables? What kind of car seat are you using? Do you wear a helmet when you ride your bike?”

Then an open-ended query: “Is there anything out of the ordinary going on?”

When Jaylyn’s mother answers that her daughter was born with only one kidney, the questions get more specific. “Has she had any urinary tract infections lately? When was the last time she had a urology workup?” Shanahan makes plans to refer the little girl to a urologist she knows from Children’s National Medical Center, where she used to work.

Fitting into the Big Picture

Sandi Shanahan and her clinic are dealing in miniature with some of the thorniest problems under discussion as the nation struggles to make sense of an irrational health care system.

Shanahan opens her door to the uninsured — though to only a tiny fraction of the 46 million of us as counted by the census in 2007, before the economy turned down. Like many of America’s eight million uninsured children, the kids she treats have fallen through the cracks or just don’t meet the patchwork requirements of programs that cover children.

Last year Shanahan’s total costs were $23,000, mostly for payroll and related taxes. The fees her patients paid covered less than a third. The remainder came from donations — notably from Structural Integrity Associates, a global engineering firm, the Rotary of Parole, her local church and private sources.

So you and I don’t pay a cent for the care Shanahan provides to uninsured patients. For millions of other uninsured Americans, we do pay — as much as $1,800 of the average family’s premium — to cover “uncompensated care” shifted by doctors and hospitals to private insurance.

Shanahan also fills another need. Primary care physicians, the updated version of the old family doctor, are in short supply. One reason is that the specialty professions pay better; another is that until recently the federal government had cut back on support for educating and training primary care physicians. There are 6,184 areas in the U.S. with a total population of 64 million designated as having a shortage of primary care providers. Maryland has 51 such areas, encompassing 275,000 people.

Nurse practitioners like Shanahan are one solution to the shortage. They are registered nurses with advanced training in individual clinical practice. Most have master’s degrees and, starting in 2015, all new nurse practitioners will have doctorates. No longer handmaidens to physicians, they are often found in salaried group settings like Owensville Primary Care, where two of five providers are nurse practitioners [www.bayweekly.com/year09/issue_28/lead_1.html]. But, like Shanahan, they may also practice independently. [See story on page 11.]

The Family Doctor Is a Nurse

Shanahan serves as her patients’ family doctor, providing their primary care and coordinating her own services with others that her young charges need.

In doing so, she’s riding a trend. More and more people are getting their ongoing health care from nurse practitioners. Some do so because even Americans who have health insurance may have a hard time finding a primary care doctor. Others simply like going to a caregiver who spends more time with them and is prepared not just to poke and prod but also to talk and listen.

Reducing the amount the U.S. spends on health care is one of the hurdles our nation will have to leap to reform heath care. We spend roughly $7,300 per person each year, at least double the spending of most other developed countries. Yet our results are not nearly as good. Among those same countries we rank 29th in infant mortality and 42nd in life expectancy. Even across America, the amount spent seems unrelated to higher quality care or better results.

Shanahan does her share by keeping her costs low, taking no profit and generating donations of supplies and services as well as money. She says a rough estimate of what a physician’s office might charge insurers and private-pay patients for the first visit is $150 and for a follow-up, $90. The charge for similar services in a hospital emergency room can balloon to $800. Even if you look at Shanahan’s total costs — because her $35 “charge” to patients is so deeply discounted — a visit to her clinic still averages only $77. And in the longer term, her work to provide timely preventive care, to assure continuity of services and to avoid duplication is likely to lower overall health spending.

The Nurse Leads the Way

For Shanahan’s clinic, things look more secure after a rough patch. If the pattern of the first few weeks holds, reclaiming old patients and attracting new ones is not going to be a problem.

But the clinic survives only because of Sandi Shanahan’s enduring commitment to needy children. This year charity is stretched farther than usual, and expenses are up, what with the move and rising costs of tests and supplies. So she’s always on the lookout for benefactors and creative fund-raising ideas.

A couple of years ago, Shanahan, her family and friends cooked hamburgers in front of the old Whole Foods store at Annapolis Harbour Center, netting $1,000 in contributions. More recently, she has been selling $5 Shop for a Cause coupons from Macy’s. The clinic gets the $5, and the purchaser gets a discount from the department store.

Shanahan is one woman with some 400 kids on her books, coaxing time, space and services from a whole range of sources by sheer strength of personality. Knotty as our health care future is, insoluble as it seems, her story of what one determined person can achieve makes a solution seem not simple, but possible.

Get information or give help: www.shanahanchildrensclinic.com.

Bonnie Lefkowitz, of Holland Point, worked with the federal government for 24 years on health reform and care for underserved populations. She is the author of Community Health Centers: A Movement and the People Who Made It Happen (Rutgers University Press). This, her second health care reform story for Bay Weekly, following “Getting Well: In our back yard, a model for health care reform flourishes” (http://www.bayweekly.com/old-site/year09/issue_28/lead_1.html).