Tanya V Marin PC, doing business as Santa Teresa Children’s Day and Night Clinic (STCNC), was founded in May 2015 by a doctoral prepared pediatric nurse practitioner, Dr. Tanya V. Marin.
Located within an opportunity zone of Santa Teresa, the woman owned, woman run clinic provides care for a rural, economically depressed area of Dona Ana County that includes multiple communities in southern New Mexico. The clinic has grown according to the needs of these communities. It now provides pediatric primary care, mental health counseling, dietary counseling, women’s health services and adult primary care. The number of providers has also increased to three nurse practitioners, one pediatrician, one community liaison specialist, one counselor, and one dietitian. Hours of operation have been extended to provide services according to the population’s needs, such as Monday through Friday 8:00 am to 10:00 pm.. Santa Teresa Children’s Day and Night Clinic, the hub, which provides family centered holistic including in house pediatric and adult primary care, women’s health services, mental health counseling and dietary counseling services, is located in Santa Teresa, Dona Ana County, New Mexico.
Service Area
There are five proposed End-user sites all in medically underserved communities. The sites include three elementary schools in towns with a combined census population of under 3,5000. Approximately 14,275 citizens will be impacted by the proposed hub and end-user sites
The northeast corner of New Mexico is one of the sparsest, most remote regions in an already rural state. Limited healthcare resources pose a tremendous barrier to care, resulting in care discontinuity and multiple health disparities. Two locations identified in this area are Alvis Elementary School in Clayton and Des Moines School-Based Health and Wellness Center (DMSBHWC) in Des Moines. Alvis Elementary School is in the town of Clayton, seat in Union County, New Mexico, with a census population is 2,980. Alvis is without a school nurse most days of the week. Plus, many of the students are bussed in from distant ranching areas. Even though Alvis is located near healthcare services, many of the parents are not, meaning they cannot easily pick up their children and take them to the doctor when they are sick.
Des Moines School Based Health and Wellness Center, is in the town Des Moines, seated in Union County, New Mexico, which is home to a K-12 system of public schools and 128 census residents. The campus of the elementary and high school houses the School Based Health and Wellness Center. It is 40 miles, in either direction, away from the closest & consistently available healthcare services.Many of the families in this area live on distant ranches that are up to an hour’s drive away from the school, usually driving on clay ranch roads. The DMSBHWC serves as an intermediate point between these families and the hospitals and clinics in the two county seats. A nurse practitioner visits the DMSBHWC only once per week during the school year, providing services to students, faculty, and community members (including adults and preschool children) in a limited capacity. This center has not been able to obtain a fulltime provider for more than 10 years.
Socorro County Options, Prevention, and Education, (SCOPE), a comprehensive health council, and Socorro Consolidated Schools, which serves 1,463 students within five schools, helped identify two Elementary schools for which telemedicine can be used to address their medical needs. Midway Elementary School and San Antonio Elementary School are located within a socio-economically disadvantaged Socorro County. Both schools serve families that live in an area where the closest medical service is at least 20 miles away. Midway Elementary School is in the primarily a farming community of Polvadera seated in Socorro County, New Mexico. The census population of 414 “residents”, Polvadera is also known for flooding throughout the year and lacking access to healthcare.
Designated as an Opportunity Zone, Truth or Consequences is a small town in Sierra County, southern New Mexico. It has the designation of a medically underserved area. Olive Tree Community Wellness Center is a non-profit Community Action Center in Truth or Consequences, Sierra County, New Mexico, offering services to all 6,475 residents including 1,294 students. The Olive Tree aims to reach and transform the community using mental health interventions and preventions, including reintegration of post-incarcerated individuals and substance misuse education and prevention. It is a faith based, nonprofit, community action wellness center that is dedicated to creating a model of holistic transformation with mental health prevention and intervention classes. The Olive Tree’s mission is to empower and equip individuals, families, and communities to reach their full potential. These services include fitness classes, art classes, mental health prevention and intervention classes, substance misuse and post incarceration support. However, the community has a wide gap of lacking general adult and pediatric health services. Due to overstressed medical facilities, many of the 6,475 residents must travel to Las Cruces, New Mexico, 1hr and a half (76 miles) away, to receive services. The project at Truth or Consequences is being completed with support from the Middle Rio Grande Economic Development Association and in partnership with the Olive Tree Integrated Wellness Center.
Self-assessment through access, quality of care, population health, and patient satisfaction
Access
Rate of completed scheduled visits will be monitored based on population subgroups (i.e. pediatrics, adult, and subspecialty). Reason for not completing or rescheduling their appointments will be requested from patients. The team will hold extended hours to accommodate for hours of work and transportation. Length of visits will be adjusted based on chief complaint and patient needs. Telemedicine visits will be held in a private location through a secure forum, where patient confidentiality will be maintained. Resources will be allocated to provide translators based on patients’ needs. In the event of a power outage or unforeseen circumstance, paper forms and back up files will be available on site to minimize interruption of care.
Quality of care
Formal training will be provided to participating providers based on best practices. Physical exams, particularly details on performing sensitive exams will be discussed with all providers. Skill for performing appropriate exam via telemedicine will be taught and supervised by medical director, until providers successfully perform independently. Clinic settings will be set up with appropriate equipment and will be conducive to learning and mastering skills. Clinical quality will be measured by implementing peer chart reviews. This will be performed by medical director. Suggestions for improvements/modification in care will be discussed with participating providers. Utilization of resources for each visit will be monitored. If the patient requires in depth exam, an in-person visit will be scheduled within 72 hours of telehealth visit. Providers will be scheduled to travel to participating community facility to meet this requirement. Chart audits will be performed on a monthly basis to ensure this follow up is being completed. Visits to urgent care and the emergency room will be tracked in those patients participating in the program. The information will be compiled, and staff member will contact the patient to note reason for their visit rather than scheduling a telehealth appointment.
Population health
Promotion and prevention will focus on promoting immunizations based on age and health risks. Screening will be available for sexually transmitted infections, depression, and substance abuse. A partnership will be developed with the Olive Tree Wellness Center, a church-based crisis center, to facilitate counseling and interventions for substance abuse. A crisis management plan will be implemented; patients will be empowered with knowledge on available resources in their location. Crisis support will be provided 24 hours/7 days a week.
Patient satisfaction
Patients’ feedback will be measured through a form provided immediately at the end of the visit. The form will consist of 2-3 points measured on a Likert scale and a section for comments will be included. Negative responses will be addressed if patient agrees to receive a call back, will be shared with participating providers, and will be compiled in an effort to improve further visits. Review of a toolkit “How to Approach Recruiting and Returning Patient Stakeholders: An engagement guide (HARPS)” will be required by all participating providers.
Outcomes
STCNC is hoping that by providing increase access to care to these communities, their overall health will lead a positive improvement to their general wellbeing and socioeconomic status. This program has been initiated in other rural areas around the country. For example, Southwestern Jefferson County Schools has implemented of virtual clinics in some of their schools. Superintendent Jones believes keeping kids in class has been one of the biggest advantages of having a virtual clinic. Mr. Jones also allows teachers and staff to utilize the clinic. “If a kid misses school, they miss their education, and if a teacher misses school, 100 kids could miss out on an education.” “We believe you have to be healthy to learn and healthy to earn,” Jones said. “There’s a correlation between your education and your health” (Gerber, 2017). Since the implementation of the virtual clinic, school absenteeism from both students and teachers has decreased in the school district. One of the providers for the virtual clinic, Ms. Ready, stated, “even a five-mile drive in a rural community can be too far if you don’t have a mode of transportation. Those barriers keep some kiddos from seeing a doctor, and their cases ended up becoming an emergency when they wouldn’t have to be (Gerber 2017).” Overall, the community has noticed fewer child emergency visits since the virtual clinic was opened. “Telehealth is great, but the initial cost of the equipment is too high for most schools to buy,” she said. “It’s something schools definitely would not be able to budget on their own” (Gerber, 2017).
Sustainability
The financial sustainability of the project will lean on STCNC. The clinic has served, and is therefore familiar with, the New Mexico community for six years, increasing revenue approximately 10% year to year. In 2019, the clinic served over 6,000 patients. It is expected that as new patients use the telemedicine system, the Medicare, Medicaid, and insurance payments will make the project feasible and sustainable once the program is launched. Meanwhile, STCNC will sustain the program financially). A Scope of Work explanation has been provided with clear presentation of how the project will be achieved. A written description of the experience that each team member brings to the project has been provided (See Statement of Experience). Members from the STCNC bring the medical experience as well as the project planning and project implementation knowhow. The communities’ leaders bring the community specific knowledge and project management experience.
All required certifications of compliance with federal statutes and documents proving legal eligibility, legal existence, and legal authority to contract with The United States Government have been included in required documents. Since the project is not proposing broadband facilities, the project will not impact the environment. The documentation on the consultation with the USDA State Director for Rural Development is provided. No grant funds for telemedicine capital expense are available through New Mexico State.
Evidence of Local Support
The project at Truth or Consequences is being completed with support from the Middle Rio Grande Economic Development Association in partnership with the Olive Tree Integrated Wellness Center. Sharon Finarelli, Chair of the Middle Rio Grande Economic Development Association’s Healthcare and Social Work Committee has sign on as a partner. She is ecstatic and interested in providing remote educational programs and health care for the community. Ms. Finarelli is hoping that eventually all four counties in the Middle Rio Grande region of New Mexico receive care. Additionally, STCNC has also received support and commitment from The Olive Tree Integrative Wellness Center in Truth or Consequences, a touchpoint of the community. Lisa Daniel, Executive Director, has committed to creating substance misuse educational programs as well as to use telemedicine to support post-incarcerated community members with wellness, healthcare, mental health appointments.
The leadership of Northeast Network of New Mexico (NEN-NM) and Union County Health Council recognize how telemedicine may resolve the access to care issue and are willing to assist in executing a comprehensive healthcare and wellness suite provide by STCNC. Kristen Christy, Executive Director and NEN-NM Coordinator supports and is looking forward to working with STCNC to meet the healthcare needs of the county.
The local government for the main hub, which is in Santa Teresa, Dona Ana County, continues to echo support for this project. Mayor Perea of Sunland Park (and Santa Teresa) welcomed the opportunity to write a letter of support on the project’s behalf. The mayor is a pivotal partner because he represents local government as well as serves on the following regional boards: El Paso Metropolitan Planning Organization, South Central Council of Governments, South Central Regional Transit District, Mesilla Valley Regional Dispatch Authority, New Mexico Municipal League Policy & Resolutions Committee, Camino Real Consortium and the U.S. Conference of Mayors.
At the state level, we are happy to have received support for the project from the New Mexico Department of Health. Kathyleen Kunkel, Cabinet Secretary, expressed interest in the project after recognizing that “community members must travel for miles and up to hours” for quality, consistent healthcare. Eric Vigil, Acting State Director of the USDA Rural Development, and Nicole Comeaux, Director of the Human Services Department, Medical Assistance Division, have both written letters of support for the project.
