The Low Cost Effective Care Unit

//The Low Cost Effective Care Unit

The Low Cost Effective Care Unit

“CMC reaffirms its commitment to the promotion of health and wholeness in individuals and communities and its special concern for the disabled, disadvantaged, marginalized and vulnerable”

-Excerpt from CMC’s Mission Statement

 

Our roots are very old – the arch of the Mary Taber Schell Hospital built in 1902 situated on the Schell campus

 

The Low Cost Effective Care Unit (LCECU) is one of Christian Medical College’s major responses to the poor living in Vellore city and is a testament to CMC’s commitment to the poor, disabled, disadvantaged, marginalised and vulnerable. By providing primary and secondary health care by Family and Community Health Physicians, at low cost to the residents of Vellore and with its direct referral links to the main CMC hospital when required, it is a unique model of true voluntary ‘Corporate Social Responsibility’ that CMC designed in the early 1980s. LCECU is also unique in its ability to do partial justice to holistic health care by intervening at the social level for many patients and their families. Additionally, LCECU is where Family Medicine has been incubated and we are proud that in 2017 the MD in Family Medicine was started in CMC after years of effort by many.

 

The beginnings and early history

The first Vellore Consultation was held in 1979-80, and its report was entitled “Outreach with Renewal”. One of the major recommendations of the Consultation was that CMC should focus on secondary level medical care of the poor in and around Vellore and that “a section of the main hospital should be maintained for the secondary care of poor people with common diseases at costs within realistic community means.” [1] CMC leaders of the day were farsighted to understand that tertiary care while essential, far less people needed it compared to those needing primary and secondary care. They also understood that inappropriate use of specialist care could lead to high costs and inappropriate treatment.

Towards this new CMC initiative, the Low Cost Effective Care facility was started in project mode in 1982 with a “general practitioner type” outpatient clinic in the town and an in-patient facility called Ida Scudder Ward in the main campus. It was named after CMC’s founder as this was something that was close to her heart. [It is said that while Ida Scudder was alive, she did not allow anything to be named after her]. To ensure speedy implementation, the ward was established in the old A ward (where the present Accident and Emergency department is situated) and beds were provided by various clinical departments. Dr Benjamin Pulimood, the senior-most physician at the time, was made the Programme Coordinator. Other senior faculty who were significantly involved in its growth were Dr. LBM Joseph, Rev. AC Oommen and Dr P. Zachariah. The first Chief Medical Officer was Dr. Varadarajalu, followed by Dr. Sarojini Pancharatnam and later, Dr. Sara Bhattacharji.

 

Former Governor of Tamil Nadu and Maharashtra, Mr PC Alexander visiting Ida Scudder Ward; to his right is Dr VI Mathan and Dr Sarojini Pancharatnam

 

In 1994 the ward was shifted to the Schell campus and was built over the site of the old Mary Taber Schell Hospital and LCECU moved from project mode to a Unit of CMC. There were outreach clinics in Ramnayakam Palayam and Srinivas Nagar initially and later in Thottapalayam and Kagithapettrai that were run in collaboration with Community Health Nurses and the Post-Partum Unit. By 1999 these peripheral clinics were consolidated into one main out-patient clinic held at the Red Cross Building.

 

LCECU out-patient services at the old Indian Red Cross building

 

In 2004, the out-patient facility was shifted to the Schell campus and the ward was renovated and expanded, with funding from many people. A major donor was Dr Robert Fish, who is Dr Ida Sophia Scudder’s grand-nephew and Dr Ida Belle Scudder’s nephew. His parents supported Ida B and her mission work in India and so the work of LCECU became close to his heart. The 2 wards were named after Robert’s parents – Charles and Lillian Scudder Fish ward; and aunt – Ida Belle Scudder ward. In 2005, a labour-room was also established in LCECU.


Reference: 1. Outreach with Renewal. A five-year plan of the Christian Medical College and Hospital, Vellore. [This document was prepared for discussion at a Post-Consultation meeting held in Geneva October 1980, which was sponsored by the Christian Medical Commission of the World Council of Churches, Geneva]

 

Bricks from the original Mary Taber Schell Hospital built in 1902 (right panel) – found while preparing the foundation for the new LCECU building, now placed in the outdoor Chapel of LCECU

 

The Present

LCECU now functions like a ‘small mission hospital’ in Vellore city. LCECU’s ‘unique selling point’ is being managed by Family Physicians and Community Health Physicians who are able to manage the whole spectrum of primary and secondary medical problems, for both genders, throughout their life-cycle – sometimes called “cradle to grave care”! Out-patients are seen on all week-days and about over 250 patients are seen in a day. First time registration costs Rs30/- and subsequent visits are free of charge. All new patients are screened by the Social Workers to ensure they are eligible to have a chart at LCECU. Patients pay what they can for investigations and medications and when large or chronic subsidy is required, Social Workers make home visits and thereby make more realistic socio-economic assessments rather than a ‘visual biopsy’ in the OPD itself. When possible we encourage patients to utilize government medications and facilities. Occasionally patients cannot come to the OPD and in such situations, home visits are made by the doctor and team and care can be provided at home for those who require it.

 

There is no age, gender, organ or system bar to be seen in the LCECU OPD- it is a family medical clinic!

 

Another major advantage for patients is that many specialty departments [see list below] conduct clinics at LCECU – this not only helps them to get much of their treatment done in LCECU itself but also helps them to establish links with doctors who then help them navigate the maze of a tertiary care hospital. Patients are first seen in the general OPD and if needed sent to a specialty clinic in LCECU or main hospital. We estimate that less than 10% of our patients need referral to main CMC departments. For high cost tertiary care, our Social Workers make an assessment and then we write to our colleagues informing them how much the patient can pay. To enable this system, LCECU started a Patient Support Fund that helps cover part of the costs for these patients.

 

First patient to undergo myringotomy in LCECU

 

While all patients are seen on all days, patients with Rheumatic Heart Disease are seen on Tuesdays and the antenatal clinic is held on Thursdays. On Fridays a group visit for patients with diabetes is conducted – apart from routine care, they receive group health education, get a dental check-up and ophthalmic retinopathy screening. The antenatal clinic is busy and is partly nurse managed with supervision by a doctor. Many women prefer to deliver in government facilities to avail of the Muthulakshmi Reddy scheme of Rs18,000/- provided by the Tamil Nadu government.

 

Nurse explaining to expectant mothers what to expect during ANC and labour in LCECU

 

There was a lull in the theatre services when there was a shortage of anaesthetists, however that has resolved and now many surgeries are being conducted by General Surgery units 1 and 4 and Paediatric Surgery. However, the Family Physicians continued to do minor surgical procedures and tubectomies regularly. Dental services started once a week in 2006, increased to twice a week later in the year and in 2010 a daily clinic that was later upgraded into with a full-fledged dental unit with a new chair and digital x-ray was funded by Dr Robert Fish.

 

1.New LCECU dental clinic funded by Dr Robert Fish in memory of his parents. 2The old Dental Clinic in the main OPD section

 

Departments that conduct weekly clinics in LCECU:

  • ENT
  • Paediatric Surgery [they operate once a week with support from Anaesthesia Dept.]
  • General Surgery [they operate once a week with help from Anaesthesia Dept.]
  • Psychiatry

Departments that conduct monthly clinics in LCECU:

  • Endocrinology

Departments that used to conduct clinics in the past:

  • Child and Adolescent Psychiatry
  • Orthopaedics
  • Obstetrics and Gynaecology

In the past consultants from Medicine Unit 1 used to visit when needed and Child Health Unit 2 used to see complicated in-patients on a weekly basis. PMR consultants do home visits with the outreach team for patients unable to come to the unit.

 

 

The in-patient part of LCECU has 46 beds in 2 general wards, a section for isolation and a section for post-natal admissions. Over the years more complicated patients are being managed here and we even receive patients from the main hospital for step down care or continuation of medications. This helps busy departments in the main Hospital by enabling them to admit more sick patients. There is no charge for admission, bed, nursing or physician care. All of this is underwritten by CMC. There are times when patients request admission for social reasons – such as when an older person with a terminal illness does not want to be at home as there is a wedding in the family and that would be considered inauspicious by some or their roof was leaking in the monsoon!

 

1.Tubectomy in LCECU, 2.Ida Belle Scudder Ward

 

 

How LCECU provides low-cost care:

  • There is minimal yet essential infrastructure
  • Charts are maintained by patients themselves
  • Family medicine approach and judicious use of investigations
  • Limited yet essential ‘gadgets’ – eg. Ultrasound for antenatal care
  • Staff multi-task
  • Use of generic medicines
  • Easy, free or subsidized access to specialists
  • In-built subsidies for all and especially for those who cannot pay

Patient retained chart.

 

Outreach work – has been an important component of the work of CMC from its beginning. Ida Scudder realised very early on that many really needy patients often did not come to the Hospital and so she started roadside clinics in 1906 which continued into the 1960s. The outreach activities of LCECU are listed below:

Outreach clinics [2007/8 – ongoing]: These clinics were restarted when Occupational Therapy students [during their CBR posting] presented their findings of a study on the elderly to the Old Town community and in the discussion with the community it was decided to start an outreach clinic for the elderly and people with disabilities. Initially these clinics were held once a month. Now we conduct clinics – open to all patients, in 5 slums – Old Town, Muthu Mandapam, Periyar Nagar, RS Nagar and Samiyar Madam. We visit each slum once a week and about 15 to 65 patients are seen in these clinics per day. The Community Health Nurse and Workers go to the clinics in the morning and check fasting and post-prandial sugars for patients with diabetes. The rest of the team of doctors and social worker join them in the afternoon. The Ophthalmology Outreach unit visits each area once a month. Four of these 5 clinics are held in local churches and volunteers from these areas help in the clinics. We are trying to implement Community Oriented Primary Care in these 5 slums and recently the Community Health Workers have shifted from capturing data on paper and books to using a tablet which makes data entry and transfer much easier.

 

1.The first outreach clinic in the Old Town church, 2.Outreach clinic in Periyar Nagar church

 

Community Based Rehabilitation program [2002 – ongoing]: This program was jointly initiated by LCECU and the Physical Medicine Rehabilitation department in 2002 and used an educational model for CBR. Local volunteers were trained mostly in the field and also received training in the institutional based services of PMR. It was funded by the WHO for 2 years and subsequently the work of the volunteers was included in LCECU’s regular outreach activities. This project aimed to address problems of people with disabilities residing in Vellore town area. This was mostly done by providing care in the community through trained lay volunteers, supported by PMR specialists and referral services to the tertiary care based in the PMR department. The project covered about 30,000 population in Vellore town.

Through this project, volunteers were able to network with other like-minded organizations, NGOs and were also able to guide differently abled people to access various government schemes. Volunteers were able to improve mobility, self-care and productivity and enhance interaction with the wider community for persons with disabilities. In 2016 the Ophthalmology Department trained LCECU volunteers in identifying and referring patients with eye problems to Ophthalmology. Apart from referrals for people with disability, the volunteers also refer people with general morbidity.

 

1. Dr. George Tharion (PMR) training CBR volunteers at a patient’s home; 2. Home based CBR.

 

Community Based Psychiatric care for a girl who was locked in a room for 10 years after her parents had tried all other options and failed

 

CBR Tiruvizha [2005 – ongoing]: This is based on the Rehab Mela and conducted annually for people with any kind of disability. During this networking festival people with disabilities spend a day interacting with each other, learning from each other, play games and share their challenges and victories with others. This festival is run by the CBR volunteers. Many youth who have attended the Life Skills Program attend this program as volunteers.

 

Youth volunteers helping people with disability write about their felt needs at a CBR Thiruvizha

 

Life Skills Program [2006/7 – ongoing]: Youth from Old Town approached the local CBR volunteer, when a friend of theirs died with cancer, they were anxious to know more about cancer. This led to interactions with LCECU and the youth initially on cancer, HIV, sex, alcohol, etc. and later led to the creation of a Life Skills Program for youth in Vellore slums. In addition to general life skills, youth are sensitized to the needs of differently abled people and are encouraged to identify ways in which they can help them and their communities. Later, on request from the volunteers, career guidance was added to these sessions.

 

LSP for youth living in slums of Vellore

 

Youth being sensitized by experiencing disability

 

School Education/SEDU [2007/8 – ongoing]: When the Principal of Uthria Madha School in Old Town came to know about the LSP for youth (as we sometimes used the school premises for larger community meetings), he requested LCECU to run a similar program for 8th standard students. He has noted suicidal threat letters, petty crime and truancy and suggested that LSP in schools could mitigate such issues. We started SEDU in 5 schools, expanded for a few years to 13 schools [based on a request from the Assistant Education Officer who happened to witness one SEDU session] and then reverted back to 5 schools. The sessions include life skills, basic health, violence and injury prevention. Both the LSP for youth and SEDU are run by PMR and LCECU.

 

Teaching road safety to school children

 

CBR training for OT, PT and P&O students [2007/8 – ongoing]: Recognising the CBR program of LCECU-PMR and that CMC’s Occupational Therapy students were only learning institutional based rehabilitation and CBR in theory, the OT department requested a short CBR posting in LCECU for their students to observe the work of the volunteers and to interact closely with them. This was a very popular posting among students and later Physiotherapy students and Prosthetics and Orthotics students also joined the CBR posting in LCECU. In 2017 Optometry students participated for one day. The students get to see the role of volunteers in CBR, different models of rehabilitation, the various Schools and NGOs in and around Vellore that are involved in rehabilitation. Many students are truly inspired by what they have seen and rate this posting as one of their best student postings.

 

OT, PT and P&O students get to visit patients in their homes to understand their lived reality and CBR

 

Listed below are some comments from students.

“A chance to see different types of patients was very exciting. I started to love my OT profession”
“Found fulfilment in my study and not to take chances or advantages of the resources”
“Money is nothing compared to a willing heart; Work not only for money but also for the community’s sake”
“Gave meaning to my profession”
“Eye opener – thought that the therapist is the one who matters in the rehabilitation; now it has changed; have been trained only in IBR; posting has been an eye opener”

Training in CBR and primary care [2002 – onwards]: As LCECU has expanded its training programs, many groups – interns, CMC and overseas medical students, WHO fellows in CBR [PMR is a WHO collaborating centre for disability prevention, capacity building and rehabilitation technology], FOV representatives and a variety of visitors to LCECU have observed first-hand and learnt from the work of the volunteers in LCECU.

A ‘snap-shot’ of the work of LCECU

A time to be grateful

The work of LCECU is an integral part of CMC and is completely underwritten by CMC. We are grateful to the forefathers who conceived the concept and brought LCECU into being. We are thankful for the many supporters within CMC and from the Friends of Vellore organizations abroad and visitors who often become friends of LCECU. We are also grateful to the CMC Administration for very recently sanctioning budgeted posts [in August 2018] for Community Health Workers who function at the grass-roots of our work.

LCECU’s duty is to be a good steward to the investments from CMC and others and to ensure that the poor and marginalised who access us or who we identify in the field are cared and advocated for. LCECU has received significant grants from the FOVs and notably from FOV UK which has supported a couple of projects to expand the work of LCECU for the poor living in the slums of Vellore. We have received a very generous grant from Dr Sulatha Minoson (batch of 1968) to improve care for patients with diabetes and this year we will start a nurse-led program towards this. During the 2018 Ida S. Scudder Humanitarian Oration we learnt of Dr Robert Fish’s continued support and extremely generous matching grant of $50,000/-, and LCECU is extremely grateful for his long-standing support.

LCECU is proud and privileged to be CMC’s urban health centre for the poor and marginalised of Vellore.

“For, the poor you will always have with you in the land. Therefore I command you, you shall open wide your hand to your brother, to the needy and to the poor, in the land’”. [Deut. 15:11]

 

A grateful mother and patient after ear surgery giving thanks at the outdoor Chapel