Griselda Ruiz is like thousands of seasonal cannery workers in Stanislaus County.
She has employer-provided health insurance when she is sorting vegetables from late August to October, then hopes she doesn't get sick the rest of the year.
The Modesto woman was stricken with diabetes when pregnant with one of her two children, and as often happens with gestational diabetes, the disease came back.
As her diabetes escalated this past year, Ruiz bought medicine during two trips to Mexico. She sought help at the Golden Valley Health Center on Sixth Street in Modesto last summer after the pills ran out.
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At the clinic, a test showed her blood sugar was five times above normal and put her at risk of a stroke or going into a diabetic coma.
Ruiz, 52, told Marlene Perez, the clinic's health educator, that she hadn't come in sooner because she was unaware of the nonprofit clinic's sliding fee scale.
She was put on insulin, and Perez taught her to inject the medication and check her blood sugar at home. Ruiz also was monitored weekly until her blood sugar was under control.
She scrapes up $30 to see a doctor at the clinic, but visits with the educator and lab tests are free, and a 30-day supply of medicine from the Golden Valley pharmacy costs her $16.
The Golden Valley clinic is part of the health "safety net," a loosely connected network of health care districts, county clinics, public hospitals and federally funded health centers.
Golden Valley's more than 20 primary care clinics in Merced and Stanislaus counties are part of the federal health center program, a remnant of President Johnson's War on Poverty, launched in the 1960s.
The safety net providers care for patients who are shut out of a commercial medical system that caters to people with insurance. And their patient load is growing.
The number of Golden Valley patients in Stanislaus County swelled from 27,400 in 2004 to 38,600 in 2006. The number served in Stanislaus and Merced counties rose nearly 30 percent, which is consistent with patient growth nationwide in the federal health center program.
In the valley and nationally, community health centers are dealing with rising costs of providing care and a dramatic increase in patients with chronic diseases -- fully a quarter of patient visits are for treatment of chronic illness, according to the National Association of Community Health Centers.
The Stanislaus County Health Services Agency has served 70,000 to 80,000 patients a year, up to 16 percent of the county population. But annual deficits ranging from $8 million to more than $16 million have cast doubt on the future of the county health system.
The county's efforts to downsize its separate network of clinics have diverted patients to the other community clinics.
"It's a fragile system," said Marc Smith, administrator for five Golden Valley centers in Stanislaus County. "If Golden Valley wasn't able to expand, you would have people with major unmet medical needs."
Doctors' student loans forgiven
Golden Valley began as a migrant health program in 1972 and was expanded to serve not only rural towns but the urban poor in cities such as Modesto and Merced. In addition to primary care, its services include pediatrics, women's health, dental care and mental health counseling.
The patients are not only seasonal agriculture workers, but the unemployed, the working poor, single mothers, the homeless, undocumented immigrants and people with mental disorders.
As federally qualified health centers, the clinics receive enhanced reimbursements for Medi-Cal patients and accept patients regardless of their im- migration status.
Smith said Golden Valley keeps up with the growth by recruiting physicians who have student loans forgiven for serving in poor areas, and through government programs giving visas to doctors trained in other countries. In September, it used grant money to open its latest.
Golden Valley's biggest challenge is keeping the clinics staffed. "There is competition for medical and dental staff," Smith said. "With the Kaiser Modesto hospital opening next year, it creates more need for trained personnel."
The clinics serve an area with high rates of chronic illness such as diabetes and heart disease. Golden Valley has seen 4,500 patients with diabetes in the past 12 months, including nearly a thousand at the west Modesto clinic on Sixth Street.
The staff of doctors, physician assistants and nurses give primary care to the patients and rely on educators such as Perez to help them manage their illness when they leave the clinic.
Some diagnosed after collapse
Perez, the only educator at the Sixth Street clinic, said the center records at least one new case of diabetes every day. Before they came in, many of the diabetics went untreated or didn't realize they had the disease.
"Sometimes, the first time we see them, they are being released from the hospital," Perez said. "It took an emergency, where they collapsed in a coma or semi-coma, and then they were diagnosed."
Some patients have lost normal kidney function, some have foot ulcers and a few are blind or had a limb amputated, Perez said.
She instructs patients to keep a daily log of their blood sugar and make dietary changes, such as eating more green vegetables and reducing carbohydrates and sweets. Patients also need to exercise, keep appointments with their clinic doctor and have blood tests four times a year.
But some patients don't stay with the treatment regimen, Perez said. They simply stop caring or neglect their health as they deal with the harsh circumstances of their lives.
"They are not focusing on the disease if there was a drive-by shooting last night or if they don't know the shelter will have a bed for them tonight," she said.
In serving such a diversity of people, Perez said, she has to tailor maintenance programs to the patient's environment. She advises homeless diabetics to carry a plastic bag, with toast slathered in peanut butter, in case they feel shaky on the streets. The toast gives them protein and a carbohydrate to counteract a severe drop in blood sugar.
Perez said Golden Valley is big on educating staff on the latest protocols of managing chronic conditions such as asthma, heart disease, hypertension and anemia. Other patients who come to her office run the gamut from stroke victims to obese children to cancer patients undergoing chemotherapy.
According to an Institute of Medicine report, low-income patients often don't receive timely health care or are treated in inappropriate settings, such as hospital emergency rooms. But some studies have con- cluded that patients who regularly use community health centers receive equal or better care than patients in health maintenance organizations.
Leslie Miller, 18, spent about six years struggling with asthma before learning more could be done to treat her condition.
When her family lived in Riverbank, there were only two physicians who accepted Medi-Cal patients and the one they chose simply gave her albuterol for her inhaler, her mother said. The physician's office is now closed.
Miller's breathing trouble often kept her awake. She was excused from physical education at school because exertion could set off an asthma attack. She used the inhaler more than three times a day, five or six days a week.
The family moved to Modesto after a fire in their Riverbank apartment, and since January, Miller has been treated at Golden Valley for asthma and other health issues. She takes Singulair and Zyrtec to keep her bronchial passages open and reduce inflammation.
She said she now feels the attacks coming on less often, and also is on a weight-loss program to bring down her cholesterol. She has lost 40 pounds.
"I never knew that asthma could be so hard to keep under control," said Marci Nelson, Leslie's mother. Her daughter's health kick also influenced Nel- son to lose weight, bringing down her cholesterol from dan- gerous levels.
"Everybody working together has made a huge difference," Nelson said.
County cutbacks criticized
Most of the Stanislaus County Health Services clinics recently became federally qualified health centers, which will boost their reimbursements for Medi-Cal and Medicare patient visits.
That development didn't sit well with Golden Valley and other safety net providers, who claim the county is out of step with the federal program.
David Quackenbush, executive director of the Central Valley Health Network, an association of community health clinics, noted that county supervisors approved cuts to ancillary services and urgent care hours soon after the federally qualified health center designation.
"They are cutting services when they are going to get an enhanced rate," he said. "You enter the program to expand services, not to decrease services."
He said the Health Services Agency should look for ways to collaborate with other nonprofit clinics.
Mary Ann Lee, county health services director, countered that the county is cutting services, such as clinical lab and radiology, that are generally not found in federally funded health centers. "We are trying to preserve access to care by maximizing efficiencies," she said.
Bee staff writer Ken Carlson can be reached at firstname.lastname@example.org or 578-2321.