Hogg Foundation for Mental Health

A Portrait of Integrated Health Care in El Paso

March 1, 2009

By Elisabeth Kristo

El Paso resident Ester Ramirez came to Project Vida Community Health Clinic for a simple medical check-up and gained a new life in the process.

At the time of her first visit, Ramirez was uninsured, undereducated, afraid and without hope. She also suffered severe, debilitating, undiagnosed depression that was detected with a routine mental health screening as part of a new integrated health care program funded by the Hogg Foundation for Mental Health.

The integrated health care program at her neighborhood clinic enabled her to overcome seemingly insurmountable obstacles. Today she is able to work, participate in her church, care for her family, speak her mind, and, in general, enjoy life. "The clinic opened my eyes to life and helped me become who I am today," said Ramirez.

Project Vida is nestled in a low-income, eastside "barrio," just a stone's throw from the Texas-Mexico border. The modest clinic serves underinsured, uninsured and indigent residents. Yet within its quaint walls are innovative programs that clearly demonstrate the physical and mental health benefits of culturally competent, integrated care.

The clinic added mental health services to its physical care programs after receiving the foundation's three-year grant in 2006. The integration of care at the clinic mirrored the region's blending of nations and cultures, and is reflected in services ranging from childcare and financial planning to medical exams, nutrition, exercise programs and transitional housing.

"We have something very different from any other clinic. We are a team – the medical staff, the community health workers, myself – and any of us are willing to go the extra mile for any patient," said Rachel Quintanilla, care manager at Project Vida. "It's not just about having good programs and a nice building. It requires the right people and dedication."

Different is an understatement. Unlike the sterile, cold images conjured by the word clinic, the rooms of Project Vida overflow with life and laughter. Murals of children's art cover the walls. Women in traditional Mexican dresses who dance to Latino music for exercise share the community room with women and children who knit and paint as part of the arts and crafts therapy.

Doctors glide in and out of medical exam rooms, in between visits by "promotoras," community health workers who also phone clients to ask how they're doing or why they missed their weekly nutrition class. First names are used. Family members are inquired about. The meaning of "cultural competency" becomes apparent here, where staff and medical professionals blend and become one with the largely Mexican-American population they serve.

Like many border clinics, cases of type 2 diabetes have skyrocketed at Project Vida. El Paso alone has more than 85,000 residents diagnosed with diabetes and an estimated 25,000 more who are undiagnosed, adding up to 15 percent of the population. As research continues to find strong links between diabetes and depression, the need to treat both physical and behavioral health together becomes increasingly clear.

Recent studies in medical journals such as Diabetes Care show that the combination of depression and diabetes leads to a downward spiral in physical and mental health that makes it harder for clients to care for themselves and follow their doctor's recommendations. The results can be disastrous when amputation, blindness or kidney failure occurs from what should be a manageable physical disease.

At Project Vida, diabetic patients who exhibit signs of depression are enrolled in a mental health program. Clients with depression who exhibit diabetes symptoms are tested and, if needed, brought into the diabetes education and management program. This coordination in one place among doctors, counselors, psychiatrists and promotoras is vital, clients say, because they would not have the time or money to address both physical and behavioral issues otherwise.

For Ester Ramirez, integrated health care made the difference between life and death. When Ramirez first came to the clinic, she was paralyzed with fear that tragedy would befall her or her husband – an anxiety that controlled her life. She could not read or write and didn't know how to catch a bus or call 911. She didn't go anywhere without her husband.

"If she even heard of an illness, any illness, she would start crying," said Quintanilla. "Even if it was not diagnosed in her husband, the thought of anything that could possibly affect him would upset her. She felt helpless."

Quintanilla and Ramirez connected through the clinic's mental health screening that took place during Ramirez's first visit. They met that very day and together began the long, slow process of recovery and self-empowerment.

Beyond traditional mental health counseling, Quintanilla taught Ramirez how to read and write, use the phone, count money and catch the bus. "It's all part of integrated health, in a way. It's all connected," said Quintanilla. "How could I work with her psychologically, to empower her, if she can't write and read?"

After about a year, Quintanilla noticed signs of diabetes in Ramirez, who was then checked and diagnosed with prediabetes – her worst fear, a chronic illness that jeopardized her and her family's well being. Fortunately, by this point her depression had lifted significantly and she had developed supports at the clinic and trusted the staff to help her learn to manage her disease.

Through the clinic's diabetes program Ramirez has stabilized her blood sugar, reducing the risk of complications such as blindness or amputation that afflict so many in the region, especially those with depression. "If we had not taken care of the depression, the diabetes would have been too much for her to manage, just another impossible obstacle to deal with," said Quintanilla.