When it came to health care for the city's poor, the Outreach for Wellness in Niagara program used four counselors to help residents find their way through the confusing maze of health insurance and social services for the uninsured, offering the type of attention usually expected only from a family member.
That's a luxury the city will now have to do without.
A lack of federal funding ended the work of the OWN case managers last month and closed their North Main Street office. They have been replaced by laminated, wallet-sized cards with phone numbers for medical, housing and food services in the area.
Niagara Falls Memorial Medical Center and Mount St. Mary's Hospital in nearby Lewiston both offer primary care clinics for the uninsured and underinsured in the most needy parts of the city. Numerous other services are available, including home visits for high-risk pregnant women, a dental clinic for Medicaid patients and emergency prescription coverage.
The question now is whether the process is in place to link residents with those services without the help of the OWN case managers.
"The case manager is the engine that causes the car to roll," said Charles Giles, former OWN director who is manning the Main Street office by himself now to make sure residents know how to reach him once he closes the doors for good. "They are the impetus to get [residents] into a facilitated [insurance] enrollment program."
>Filling the void
Memorial officials said they could not make room in the hospital's budget for the entire $350,000 per year it would take to keep the OWN office open, so they hired Giles to continue his outreach efforts at the hospital, as well as three part-time people at the hospital's Hamilton B. Mizer Primary Health Center formerly paid through the OWN grant.
In place of the case managers, about 3,000 laminated cards, entitled "Health Resource Guide," have been given out, mostly at the emergency room and in public housing. The cards contain about two dozen phone numbers for various social and medical services.
"It's not ideal, but the hospital does have financial constraints to work under," said John C. Drake, executive director of Center City Neighborhood Development Corp., a home ownership agency that works with low-income families. "It's a loss but they are trying to mitigate it. Having case managers is obviously the most effective style. There's a difference between a card and a helpful hand."
Drake was one of several individuals on Main Street who voiced concerns at the beginning of the year, when it became clear Memorial had decided not to fund the office. The Main Street Business Association wrote a letter to Memorial President Joseph Ruffolo expressing its displeasure.
In the wake of the OWN closing, the reality has set in that there isn't enough money to keep the outreach office operating the way it had for the last five years. The hospital and local social service providers are now stepping up their efforts and adjusting their own daily tasks to try to make sure uninsured residents don't fall through the cracks.
For example, Memorial's emergency department used to forward a list of patients with no primary doctor to the Mizer Center so a receptionist could follow up. Without the OWN case manager who had been dedicated to the emergency room, the department has been asked to also forward the names of patients who have no insurance or who have Medicaid for follow-up.
Also, a receptionist calls patients the day before and the morning of an appointment, something that has helped the no-show rate at the center drop from about 40 percent to 22 percent, Giles said.
This type of attention is necessary, according to local health workers, because the range of health services and the information required to get insurance is overwhelming. Many professional health care providers admit that even they find perplexing the Medicaid application, the choice of services, and general paperwork associated with getting covered through various state programs.
"It's very confusing for me, even after a year," said Pam Gatto, director of eligibility at the Niagara County Department of Social Services. She took on the additional task of processing Medicaid applications last year.
"Medicaid is very extensive," Gatto said. "The different kinds of care and the things that are covered, it's confusing for me, and I can understand why it would be for the people out there."
Gatto said the workers at OWN weren't certified by the state to conduct interviews with residents to find out if they were Medicaid-eligible, but her office has several such employees who work throughout the county. Gatto said the OWN workers came in very handy when they conducted preliminary interviews with potentially eligible residents, and helped them get what they would need to finish an application and get connected to Social Services.
"It's unfortunate they lost that grant," Gatto said. "They came to our Medicaid worker training, so they would know what the client would need from us and they did work with the client. That's one of those things that's not mandated by the state."
Before residents usually get to Gatto's office, many without health insurance or a primary doctor often end up at the emergency room when they have a medical issue.
"People will wait, because it's frustrating finding someone who takes the uninsured," said Lynda Mahoney, director of the Mount St. Mary's Hospital Neighborhood Health Center. "We make access easier and help to educate the people to seek the appropriate level of health care. We really try to keep them out of the ER, which can become a habit."
That center is on Ninth Street in Niagara Falls in a densely populated area of the city's North End, across the street from a low-income housing complex and on a bus route. It's two miles from Memorial's Mizer Center at 10th Street and Ferry Avenue. Both centers serve the same kinds of patients.
Mahoney said when she read about Memorial's outreach program on Main Street closing, and the outrage it sparked, she thought to herself, "We do all that. Maybe we need to toot our own horn."
Memorial and St. Mary's both refer patients with no insurance to their health clinics for follow-up care. Memorial tries to get those patients assigned to one of their 12 resident intern doctors at Mizer within three days.
St. Mary's requires all emergency patients to have an appointment with a primary care doctor before they can be released. If they have no doctor, they get an appointment at the Neighborhood Health Clinic, where eight private practice doctors hold office hours.
Mahoney, who gets teary-eyed easily when talking about the needs of patients, has a cramped office almost in the waiting room at the health center. She greets patients by name, and said her philosophy revolves around meeting more than just health care needs.
"A lot of the people have a lot of social issues as well," she said. "They're just hard people to care for. You have to meet those lower level of needs before you can move on."
She said her office has made calls to Florida to get a resident's birth certificate so they can apply for Medicaid, donated turkeys during Thanksgiving and sent nuns to be with their patients when they have surgery.
That type of kindness is what has made Mary Mathis and Margaret Grier, both Niagara Falls residents, believers in maintaining their relationships with a primary care doctor. Both women had no health insurance when they ended up at Mount St. Mary's emergency department and were then referred to the health clinic.
Grier, 55, a former health aide, still has no insurance and isn't eligible for Medicaid. The asthma patient has decided she cannot afford a to buy a nebulizer, which doctors recommended after two asthma attacks landed her in the hospital.
"I procrastinated on getting to the ER last time because I was afraid of getting a bill," she said.
However, she has been able to get free or cheap medication for her asthma, blood pressure and diabetes through the center. She said she qualifies for special aid through the hospital, so she only pays half the cost of a doctor visit.
Mathis, 58, had no insurance for "a long time" because her former employer, a local nonprofit agency, didn't offer coverage, even though she was full time. She found out she was eligible for Medicaid after a visit to the health center, has qualified and said it feels as though a weight has been lifted.
"I feel so good. Relief," Mathis said last week. "When I get sick, I don't have to worry no more how much it will be to see a doctor."
Those successes are what all the workers in the local health community outreach sector want.
Gatto said she believes the ability to link people with services has improved in the last few years in the area.
Memorial officials said agencies have begun to work cohesively so each knows what the others offer, and word-of-mouth has helped spread the message that centers that focus on Medicaid patients are available.
Gary Hill, director of the Mizer Center, said that primary care clinic saw 10,000 patients last year, and the dental clinic treated more than 5,000.
Mahoney estimated Mount St. Mary's clinic treated more than 6,000.
"The only thing we're losing now [due to OWN's closure] is the helping hand in the community," Hill said. "We're not shutting that down completely. We're going to see how the close collaboration works between emergency room and the clinic.
"Our priority is to get everyone insured, and our nurses educate patients every day."