Looking Beyond the Laboratory

Montefiore Medical Center is located in the Bronx, which boasts 1.4 million residents –approximately one-third of whom are immigrants and nearly two-thirds of whom speak a language other than English at home. Most of this population relies on social programs such as Medicare or Medicaid to provide healthcare – and many are entirely uninsured. With such a diverse and underserved population, the providers at Montefiore and at Albert Einstein College of Medicine take it upon themselves to become a part of their community – and to give back in every possible way. We discuss two of their ongoing outreach initiatives with Mark Suhrland (Division Chief, Cytopathology), who directs Montefiore’s See, Test & Treat Program; Amy Fox (Division Chief, Point of Care Testing and Outreach), and Michele St. Louis (Medical Director, Montefiore School Health Program).

How does Montefiore reach out to underserved communities in the Bronx?

Mark Suhrland: When I arrived at Montefiore in 1985, they had already established an extensive network of ambulatory care practices throughout the Bronx and lower Westchester County. Now, we also have a School Health Program that offers diagnostic and preventative care to the school-age population and the free Einstein Community Health Outreach (ECHO) clinic, where Einstein medical students provide care to uninsured patients. We have sidewalk services – literally outside the hospital doors next to the bus stop – where companies offer home health care and provide information on Medicare, Medicaid, and child health plans. And, of course, we have health fairs such as See, Test, and Treat. The purpose of these offerings is to engage the public and help them discover the options and services available to them.

We are often guilty of the assumption that everybody knows about preventative health care and health maintenance – but that’s not always the case, especially with a large population that may not have had access to health education.

Tell us about Montefiore’s outreach programs…

MS: See, Test, & Treat was created by a pathologist, Gene Herbek, who examined Native American homelands throughout the United States and found little or no access to healthcare. He identified two common women’s health issues that would benefit from screening – cervical lesions and breast cancer – and developed mobile units that traveled to these homelands to provide mammograms and Pap tests. Now, the program has spread to all kinds of communities with poor access to healthcare – including inner-city populations like ours.

Montefiore implemented its See, Test, & Treat program eight years ago with a great deal of support from the Department of Pathology, our chairman, and partners in obstetrics and gynecology and radiology. Our key focus was on providing not just testing, but also health education to help people understand the importance of prevention and help them gain regular access to healthcare. We offer mammograms and Pap tests. A key component in patient engagement are the pathology residents and cytology fellows, who show patients what abnormal cervical cells look like under a microscope and discuss the role of the human papillomavirus (HPV) in cervical disease – which leads to a wider conversation about the value of HPV vaccination for patients’ families, especially their children.

We never had any difficulty finding providers – everyone was eager to lend a hand. Our biggest challenges lay in finding a space large enough to run the program as it grew and in encouraging patients to stay and wait for their results. Everyone is busy and some want to leave right after undergoing the test – so it can be a challenge to engage them and make healthcare screening and prevention “real” enough to motivate them to remain, learn a little more, and receive their results.

Michele St. Louis: David Appel created the Montefiore School Health Program to provide comprehensive healthcare – that is, medical, dental, mental health, and now even vision – to as many students in the Bronx as we could. Over the years, our reputation has grown to the point where people reach out to ask us, “Can you open a health center in our school?” Now, the program – led by Rosy Chhabra – is the largest of its kind in the nation, with 32 sites throughout the Bronx and Yonkers serving all age groups.

Amy Fox: When times get tough financially, it’s typically these kinds of programs that are cut first – but I would say that the School Health Program at Montefiore is untouchable due to its vital mission. The Department of Pathology is privileged and honored to partner with the program and provide on-site laboratory services for the students. For us, it’s all about the children. These are children whose parents can’t take time off from work to take them for vaccinations or eye appointments – and who often don’t even know how to navigate our complex healthcare system. Imagine how much those children benefit from having it all right there at school!

There’s something important about knowing that, at the end of the day, you’ve made a difference in a child’s life. That’s why we fight to get the services that Michele needs – and that’s why my extraordinary team is there and dedicated to helping. That’s why, even when the pandemic closed schools, Montefiore leadership kept as many of our centers as possible open to continue providing care (and COVID-19 testing).

How do you publicize your programs?

MS: We have a Facebook page and a Twitter account where we advertise See, Test, & Treat events – but we also try to get out into the community in person. We talk to store owners, put up posters, and advertise in local newspapers and television channels, because we know that not everyone is on social media. We promote the event at the ECHO clinic, reach out to their family and friends, and invite other health and outreach organizations to help us spread the word as well.

We also connect with religious organizations in the community. One of the major lessons we’ve learned since launching the program is that it’s important to be diverse and creative in our outreach. Think about the community infrastructure that already exists – for instance, churches. If we talk to a few people at a church and put a poster up in the foyer, we gain an automatic level of trust within that church community – and people talk to each other and support each other in attending. Another great example is local politicians; we reach out to them and provide posters and, as soon as they promote the event to their constituents, it gains another layer of trust – and we gain another opportunity to provide preventative care where it’s most needed.

Why do you think it’s important to reach out to underserved communities?

MS: Many people in those communities don’t fully understand the importance of screening and prevention – but, if we can detect potential issues before they become major problems, we can save both costs and lives. Hospitals, clinics, insurance – all of this can be quite daunting to people who aren’t well-versed in how the system works. Often, people give up before they even start. We try to simplify things so that patients can just walk in, be entered into the system, and be given a healthcare provider who stays in touch with them to support their health education and maintenance. We model this during our See, Test, & Treat events; each participant has a volunteer “health navigator” who takes them from one station to the next and explains each one to demystify the process. The more comfortable patients become with the system, the more likely they are to continue receiving preventative care.

At the most recent See, Test, & Treat event, we had a 50-year-old patient come in for her first-ever mammogram and Pap test. We discovered both breast cancer (ductal carcinoma in situ) and a squamous cervical lesion – allowing us to offer treatment, monitoring, and follow-up care. To some, the number of patients we see at these events may seem modest – but, if we identify even one patient who needs our help, the event has done its job. In fact, at our 2021 event, 29 percent of patients had abnormal Pap smears – a significant proportion.

Unfortunately, the pandemic forced us to suspend the event in 2020. Although See, Test, & Treat did return in 2021, patients were reluctant to attend due to anxiety over COVID-19 – even though we had strict safety guidelines (masks, temperature screening, social distancing) and an infectious disease specialist on site to ensure that we were operating as safely as possible. Our attendance level was much lower than in previous years. That’s a challenge we currently face across the healthcare system; patients are reluctant to seek medical care because they fear exposure to COVID-19. In fact, four patients who registered for the 2021 event didn’t show up – so we weren’t able to offer them the care they may need.

MSL: The people in these underserved communities are struggling; they depend on us. We felt an obligation to use the School Health Program to help them understand and navigate the pandemic. We created a new set of questions for telehealth visits: How are you managing during COVID-19? How are you feeling? Have you had any losses? Do you need any concrete services? Have you lost your job? Do you have a place to live?

They might seem like odd or extreme questions, but these were the problems our community members were facing – and we had to be there for them. Thankfully, we also offer mental health services! We’re very excited to have our students back in school, though, because now we can catch up on needs that we would normally have spotted earlier, but didn’t, because we weren’t seeing the kids every day during lockdown.

What happens in communities that don’t have this kind of outreach?

MSL: For many people, we were their only health care option – their neighborhood health centers were either closed or inaccessible to them for socioeconomic reasons. In communities without services like ours, people’s medical needs are often neglected. That can end up costing them their jobs, their families, or even their lives.

AF: There’s also a level of comfort involved in going to a familiar place for care. Children have to feel comfortable talking to their physician and it can take a long time to build that level of trust. If you overlay an unfamiliar healthcare provider onto the existing fear and instability of a pandemic, the stress can become unbearable – especially in an emergency – and people may go without medical care entirely.

What challenges do you face in administering community outreach programs?

AF: Funding is the biggest challenge. An initiative like this requires a lot of staff and supplies – and, although we do bill patients who have insurance for services, we never deny care to patients who can’t pay. That means we have to make up the shortfall somewhere. We have some private and some public funding but, even so, it’s a challenge to keep the service staffed and running.

People are always surprised when they come into the school because they’re expecting to find a school nurse. Instead, they find receptionists, licensed practical nurses who prep patients, providers who take care of them, mental health providers, dentists, optometrists, and community health organizers to help us ensure that we’re meeting the needs of the entire school community. Keeping that large team in place is a challenge, but it’s vital to doing the work our community needs.

How can other institutions follow in your footsteps?

MS: Build a presence in the community. Reach out in different ways to give yourself the best chance of being heard by your target populations. Communicate in different languages; partner with community organizations; and, most importantly, be proactive.

The See, Test, & Treat program is fantastic and I strongly recommend it to anyone who is considering community outreach. The College of American Pathologists oversees the program and offers tremendous resources and support; for example, they hold regular conferences and Zoom calls where people share information about what has and hasn’t worked for them. Different strategies work in different locations and populations – and, once you join a program like See, Test, & Treat, you not only gain access to all the information that has been gathered so far, but also get help with customizing it to your particular setting.

MSL: Make partnerships. You need a champion who knows how important these services are and will push to get the services, funding, and support you need. And it does require fighting for until you’re established and the positive change you’re making becomes obvious. That’s when things flip – suddenly, people are coming to you to grow the program.

AF: Open your eyes and look around you to see where help is needed. And remember that no one person does this themselves. I wouldn’t put the burden of this solely on a healthcare institution that happens to be in an underserved community. It’s a three-way partnership; you need buy-in from your leadership, relevant NGOs, and industry. (Sometimes it’s a four-way partnership that involves government as well.) Don’t leave anyone behind when you implement a culture change.

MSL: The most important thing is to be curious about your community. What do they need and how can you provide it? Montefiore’s situation is not unique – even affluent communities have pockets of extreme need. I guarantee that, if you look for ways to offer help and bring about change, you will find them!

Mark Suhrland is Professor of Pathology at Albert Einstein College of Medicine and Chief of the Cytology Section, Montefiore Einstein Department of Pathology, Montefiore Health System, Bronx, New York, USA.

Michele St. Louis is Clinical Assistant Professor of Family Medicine at Albert Einstein College of Medicine, Medical Director of the Montefiore School Health Program, Montefiore Medical Group, Montefiore Health System, Bronx, New York, USA.

Amy Fox is Professor of Pathology and of Pediatrics at Albert Einstein College of Medicine; Chief of Point of Care Testing and Outreach Laboratories and Vice Chair for Clinical Research and Faculty Development at Montefiore Einstein Department of Pathology, Montefiore Health System, Bronx, New York, USA.