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Nurses, other 'mid-level' providers: Future of primary care already here in South LA

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It's early in the morning, and Simmi Gandhi – a family nurse practitioner at UMMA Community Clinic – is making a call to one of her patients.

"I'm sorry to wake you up so early this morning again," says Gandhi over the phone. "But I thought that you would want to know what your results are."

It's unlikely the woman will mind the early morning wake-up. That's because it's good news.

In Urdu, Gandhi explains to the woman that her mammogram came back clean: the mass in her breast isn't cancerous.

Gandhi hangs up the phone, but she doesn't miss a beat: time now to read up on her next patient, who's been M.I.A. for months.

"Looks like he has diabetes," she says, reading off a computer screen. "I had asked for him to get an appointment six weeks thereafter. That was back in September. That was cancelled, and then he didn't come back for two appointments that were rescheduled. And now he's finally back."

The role of non-doctor medical staff in community clinics

Gandhi is what's known as a mid-level provider, a category that includes registered nurses, physician assistants and nurse practitioners like her. But at a clinic like UMMA – located just west of the 110 freeway on Florence Avenue – she might as well have the letters "MD" after her name.

Here, it's nurse practitioners like Gandhi who dispense medicine here.

"A community like this has less resources," she said. "A lot of the folks that live here have less education. As I'm sure everybody's aware, our educational system is stressed, so the basic education people get around their bodies – [health literacy] – is low."

That means a lot of patients have chronic conditions – most commonly, diabetes and high blood pressure – but don't know how to deal with them.

They need a doctor's care, but doctors often come at a premium in community clinics, where salaries are lower. That means mid-level providers often shoulder most of the medical workload.

In an exam room, Gandhi is checking in with her M.I.A. patient: Hamdi Badar, 52, a taxi driver who lives in the Valley and hails from Indonesia.

"I just want to remind you that when you have diabetes, sometimes that can mean that you get problems with your heart, right? You remember that?" Gandhi asks Badar. "With your eyes? With your kidneys?"

As she says each body part, she points to it on her own body. She tells Badar that he needs to manage his diabetes. He's had it for a decade-and-a-half and it's now out of control.

"I've had it 15 years, and I didn't realize it was so bad like that," he said. "It affected my kidneys, she said, my eyes – my everything."

By Gandhi's estimate, UMMA sees about 5,000 patients every year. When she's on, she sees up to four patients an hour. Without her and her fellow mid-level providers, UMMA couldn't care for as many people as it does.

"The future is not with physicians"

Five minutes away, at St. John's Well Child and Family Center, family nurse practitioner Alexis Gomez is checking up on 74-year-old Rafael Baez.

"Today the blood sugar was really good," he tells the elderly man. "I'm really happy with that, Rafael."

Baez has high blood pressure, diabetes and history of heart failure – so Gomez peppers him with questions about his diet in Spanish: Have you eaten a lot of tortillas? No, says Baez. How about fruits and vegetables? Yes, says Baez. That's good, says Gomez, because you know how important it is to do that.

Back in Cuba, Gomez was a doctor, so he's in a unique position: He's experienced life as both an M.D. and a mid-level provider. He puts it simply: What if, one day, all of the mid-level staff at St. John's decided to play hooky?

"I think that [would be] a disaster," he says.

Dr. Padra Nourpavar is the lone doctor at that same clinic site for St. John's. He agrees with Gomez, and says there's a major need for more medical staff – especially in his clinic.

"We could always use more primary care providers," said Nourpavar. "There's always a shortage."

But, he says, that doesn't mean mid-level providers can take the place of full-on doctors. He says that'll be true even after the patient load swells next year with people who will gain health insurance under the Affordable Care Act's Medi-Cal expansion.

"You cannot completely substitute physicians because then the quality of the care can go down," said Nourpavar. "You need people with more experience and higher eduction to also be involved, to make sure the quality is not compromised [for the sake] of numbers."

Nourpavar doesn't speak for all of his colleagues, though.

"The future is not with physicians," said Dr. Felix Aguilar, the president and CEO of UMMA. "The future of primary care will be with what we call mid-level providers."

Like the UMMA Clinic's Simmi Gandhi and Alexis Gomez from St. John's – who shape the future of primary care with every patient they check off their schedules.

This story has been changed to clarify the number of patients the UMMA Community Clinic sees annually.

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