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Originally published in Business People-Vermont in 2003.

Practice Makes Perfect

The Community Health Center of Burlington offers bargain prices for the uninsured, superb health care for all.

by Tom Gresham

Joseph Arioli can't help smiling when he gives a tour of the facilities at the Community Health Center of Burlington. He's still a little stunned. Housed in a sparkling and spacious facility on Riverside Avenue in Burlington's Old North End, the health center has come a long way since its inception 31 years ago in an old supermarket. A former meat locker functioned as the first exam room.

Today, 18 comfortable and spotless exam rooms are based around three "pods" stations of care that allow a focus of doctors and support staff in a concentrated area. Space and updated, glimmering equipment are everywhere at the year-old facility.

"It is fantastic," says Arioli. "This is no broken-down place. It's as nice as any other practice around."

Joseph Arioli, a psychotherapist by training, is executive director of Burlington's Community Health Center, a $5 million operation with a staff of 85 whose mission is to provide access to health care for all people, regardless of their ability to pay.

Buoyed by its new space and busied by the ever-growing demand, the Community Health Center will host 30,000 patient visits this year. Business has simply exploded. In 1996, the year Arioli arrived, the health center's staff numbered 25 and the budget totaled $1.3 million.

Today, the staff includes 75 to 80 people and the budget has swollen to $5 million. The health center's mission is to provide access to health care for all people, regardless of their ability to pay. About 15 percent of the center's patients have no insurance. A sliding fee scale makes it affordable for those without insurance to receive quality medical care. Office visit fees for the uninsured start at just $2.

The center's growth has enabled it to serve its patients in a more comprehensive fashion in recent years, turning sporadic visitors into "regulars." For most of its early years, the health center was equipped to provide only episodic care, which allows for periodic visits for specific ailments. Arioli says the shift to continuous care marks an important graduation in the facility's life. The expansion in care has allowed the formation of long-term relationships between patients and the doctors and other staff, thereby promoting an attention to personal health in those who previously avoided medical care and its accompanying bills.

"Really, the most important thing that we can do for the community is to provide a medical home for those people with barriers to care," says Alison Lyndes Calderara, the health center's director of community relations and development. "We want to provide a place where they can stay through the years."

The health center's expansion of services includes a dental program launched in May 2002. The dental clinic, which is located on the first floor of the facility, demonstrates the continuing attempt to put a host of health services into one facility readily accessible to everybody. Expansion, as Arioli points out, is not restricted to serving more people; it also includes serving people more.

"The need is both broad and deep," Arioli says. "You can serve a large number of people who need care and serve this breadth of people at a sort of low level; but if you exhaust the number of people, you can also go several layers deep in terms of the issues that you deal with. In terms of the dental program, that's what we're trying to do. If you're really going to work with people and improve their lives, you can't just put Band-Aids on serious problems that they have. That's why we've tried to do more go deeper. Let's try to solve some of the core problems. If we do that, it helps stabilize their lives, makes them healthy and gives them one less thing that they have to worry about."

It would significantly dull the benefits of low-cost doctor visits if prescription drugs didn't also carry a reduced price tag. The health center hands out over $230,000 worth of free or low-cost prescriptions each year through the drug manufacturer prescription assistance program.

The beginnings of the health center's blossoming can be traced to its 1993 designation as a federally qualified community health center. The designation qualified the center for federal grants and other programs including the funding that makes the sliding fee possible that have been critical to the health center's rapid growth. Calderara has witnessed the complete booming decade. She was one of only 12 employees when she was hired in 1992.

"It's been so wonderful," she says. "It's just been such an incredibly satisfying thing to watch."

Calderara is particularly excited by an outreach-oriented federal grant that the health center recently secured. The grant will allow for the hiring of a full-time outreach coordinator and will finance beefed-up marketing efforts. The robust numbers in patient traffic at the health center may only reflect a portion of the need for low-cost health care in the area. The chief advertising tool for the facility has been word of mouth.

Typically, marketing efforts are focused at those members of society armed with a disposable income. The health center will be treading new ground by marketing itself toward those with less.

"It will be a challenge," Calderara says. "The community outreach worker will work with all kinds of people and businesses to find folks unable to pay for health care. We have big plans to go to businesses. Not all of them are able to pay a full complement of health benefits to their employees. We want them to know about us. It's important to bring people into this care. It's challenging, but it's also exciting for us right now."

The health center's customers present a set of problems much different from those found in the typical middle-class family practice. Health center patients often arrive burdened with non-health issues that can make them very difficult to treat. Many patients of the health center inhabit lives rife with neglect, abuse, violence and substance abuse.

"We're specialists in the sense that we deal with a lot of people who have very complicated lives," Arioli says.

It provides a stiff challenge for the doctors. "People who come here have serious medical and social needs, not hand-holding type needs," says Dr. Michael Sirois, the medical director of the health center. "You begin with some barriers some incredible barriers whether it be language or economics or whatever. It takes a lot of work to get over those barriers and communicate with them, but it's very rewarding when you do."

Arioli says because the Community Health Center serves a population in sometimes desperate need of medical attention, the impacts can be particularly obvious.

People come from all over the state to take advantage of the center's affordable but expert care. Arioli told the story of a man who recently visited the health center after not seeing a health-care provider for 10 to 15 years.

"He'd heard about us from some people," Arioli says. "The doctors here found diabetes and, as a result, a number of other health problems. They got him into care and he's been coming to the health center ever since on a continuing care basis. They essentially saved his life."

In another case, a young, uninsured woman from outside Burlington came for an appointment to the health center with a lump in her breast. The lump was found to be malignant, but doctors were able to get to it in time.

"They got it, but if she had not heard about us for another six months or a year, where would she have been?" Arioli says. "We have stories like this from all over the place. People will have just heard of the health center and they come in with some problem they've known about for quite some time, but just didn't know where to turn."

The complex backgrounds of health center patients could potentially interfere with their medical treatment. However, steps are taken to prevent that. For instance, the health center sees a large number of immigrants who speak little English, so the center employs a pair of part-time interpreters (they speak Bosnian and Vietnamese, two of the more common foreign languages spoken in Chittenden County). Arioli says the staff has the wherewithal to communicate with patients in all 26 of the languages spoken in Burlington.

"Our mission is to provide accessible health care," Arioli says, "but our philosophy is to treat patients with dignity and respect. Many of the people that we serve are not always afforded the dignity and respect that they deserve in their health care. While they are here, though, they are no different than the CEO of a big company. The doctors have the same level of interest in their health. And the treatment for everybody here is very good. It says something that 25 to 30 percent of our patients have health insurance and choose to come here. The treatment is equal to or better than any other practice in the state."

Azra Music, seated, a medical assistant from Bosnia and the sister of medical technician Vedad Arapovic, poses for the camera with Megan Callan, a registered nurse.

Considering the frequently complicated lives of the patients, the presence of social workers is vital to the quality of care at the health center. There are five on staff, and the three pods are always manned by one social worker apiece. Two more social workers, whose focus will be one-on-one extended psychotherapy work, will be hired soon. The health center will also share a psychiatrist part-time with Fletcher Allen Health Care.

"The social workers here make life on the clinical level possible," Sirois says. "The complexity of issues is sometimes so great that the doctors wouldn't be able to work with patients at all without their help."

If a patient had diabetes combined with a serious non-medical issue for example, homelessness, depression, substance abuse it would be difficult for a doctor to sufficiently approach the entire case; but if I'm working with a social worker, I can handle the diabetes and the social worker can go and do the other," Sirois says. "The social workers are lifesavers for the doctors." Sirois has served as the health center's medical director for about a year and a half. The center employs six physicians and four mid-level physicians (there are plans to hire a fifth). Three other doctors a cardiologist, a surgeon, a podiatrist volunteer their time every month to provide free specialty care to the uninsured.

The substantial staff size allows the health center to remain open from 8 a.m. to 8 p.m. three days a week, from 8 a.m. to 5 p.m. two days a week and from 9 a.m. to noon Saturdays. A Vermonter since 1989, Siriois was drawn to the health center for its social mission. He saw an opportunity to earn rewards beyond the financial.

"At this point in my career I'm looking at the giving-back aspect of medicine," Sirois says. "If you're a doctor with an economic or entrepeunerial drive then you won't end up at the Community Health Center, because your income here won't support that drive. It's a very different population to work with and the basic practice of medicine is often complicated by social issues. But all that makes it very rewarding, too."

Arioli says most staff members were probably attracted to the health center by the opportunity to stretch their legs professionally while making a contribution to an often overlooked group of society. "People tend to come here because they're really attracted to serving this population," Arioli says. "It's why I'm here. Over the years I think I have gotten much more of out of it than I've put in and I work very hard."

Nonetheless, Arioli says, it is essential that the health center offer competitive pay in order to assemble a talented staff.

"They may have a social mission, but they still need to feed themselves and their families," Arioli says. "It's important to get the best people possible, especially with this group of people that we serve because they don't come with simple problems. You need people who are really good at what they're doing."

The Community Health Center hands out over $230,000 worth of free or low-cost prescriptions each year through the drug manufacturer prescription assistance program. Ellen Watson, RN (left) and medical assistant Susan Whitman compare notes in the supply room.

Arioli says it has been important that the health center view itself as a business. "Even though we're a nonprofit, we still have to be entrepeneurial," Arioli says. "The best nonprofits see themselves as businesses. We are in the business of providing social and medical services. You have to be a well-run business to be in it for the long run."

Arioli is a therapist by training. Years ago, while working in the world of mental health, he saw that people with serious mental illnesses often did not get the health care they needed. Often, physical ailments were simply attributed to their poor mental health. He began to work to prevent their losing out on health care for any reason.

"I started to get drawn more into administrative work," Arioli says. "I liked working with clients individually, but as I saw it, I was having an influence on 20 or 30 people at a time. The job I have

now, I can influence the care for 12,000 people. And these are people who really need help."

While Arioli was still working for a mental health care facility in Springfield, Mass., he traveled with his family to San Francisco over the holidays to visit his in-laws. During his stay, Arioli found an opening for a position running a health care center in the area. He interviewed and snared the job.

Five years later the Ariolis were looking to move someplace quieter than the hectic Bay Area. On a family trip to Vermont over the holidays to visit family, Arioli, who grew up in Montpelier, noticed an ad in a Burlington-area paper for the executive director position at the Community Health Center. He interviewed and within a few days had a new job.

When he made the move, Arioli was concerned about the quality of the care at the health center because of its nonprofit status. However, his questions were quickly answered when doctors there detected a small irregularity in Arioli's wife's pregnancy (the health center does more prenatal care than any other family practice in Chittenden County). It was something doctors in California had not detected.

"That erased any doubts that I had," Arioli says. "My whole family comes here now and you don't do experiments with your family's health care."

Arioli believes that bringing people from different backgrounds and income brackets into a single health care provider can be a powerful way of uniting a community. The health center's diversity of patients, Arioli believes, bears promise for the Burlington area.

"It's quite a good mission, I think, to provide health care for the whole community," Arioli says. "It's important to have this facility where people come in and sit side-by-side and see that they're not that much different from each other. When you are sitting together in the waiting room, it closes the gap between you and 'those people.'"

Originally published in January 2003 Business People-Vermont

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