This January is the one-year anniversary of the closing of Cooper Green Mercy Hospital. And although the team at UAB’s 1917 HIV/AIDS Clinic successfully incorporated more than 800 of Cooper Green’s patients into their care, it’s doubtful they will be celebrating that anniversary.
When Cooper Green closed last year, many of Jefferson County’s indigent patients were left wondering where they might go for care. While county officials and opponents to the plan publicly duked it out over the loss of the hospital, Dr. James Raper was working with the soon-to-be-defunct St. George’s Clinic. At the time, the 1917 Clinic and St. George’s, both recipients of Ryan White Program grants, were the only two major HIV/AIDS care providers in a seven-county region.
As chief operating officer at the 1917 Clinic, Raper was in touch with the Washington-based group who coordinated the Ryan White Program. “Several years ago when the county got in trouble and it hit the Wall Street Journal…the folks in Washington said this is potentially a big problem. We could have several hundred HIV patients with no healthcare provider. So they requested that 1917 leadership meet with the St. George’s leadership to discuss a program.”
That call set in place the preemptive planning that would eventually be necessary for patients to transfer care, though Raper recalls the months before January 2013 as a time of great anxiety for himself and his colleagues.
Jane Mobley, who founded St. George’s Clinic more than two decades ago, called Raper to deliver the news. As he remembers, “A week before Thanksgiving last year, Jane called me and said, ‘Jim, St. George’s Clinic is going to close.’
“‘All the things in the news have said the hospital is closing but the clinics are staying open,’ I said.
“She said, ‘St. George’s Clinic is going to close.’”
St. George’s Clinic was the only medical provider to HIV positive patients who were indigent. According to Raper, these people had nowhere else to go, nowhere but 1917.
“People’s lives were in jeopardy here,” Raper said.
The 1917 Clinic — which was then operating at maximum capacity, serving 2,100 patients — had 90 days to get everything in place and transition 800 people into care, Raper said. “I didn’t know how we were going to do it.”
Mobley said she only thought about how they would make it work. “I never allowed myself to think about what would happen to these patients if we couldn’t transition into 1917.”
Raper is still reluctant to consider any hypothetical, alternative outcome, one in which those 800 people were left without care or left to seek treatment at one of the private providers in the county — a nearly impossible task for the majority of patients who were without insurance.
“I don’t know what would have happened,” he said. “It’s scary to think. It’s scary for them; it’s scary for the county. It’s scary from a public health standpoint, because when patients come off medicines, their viral loads go up, and they become more transmissible,” Raper said.
“It’s scary for me to think right now,” he added, “because I’m writing this grant, and without this grant, we can’t provide these services. We’re talking about $4.5 million on the line in a state where we’re not going to expand Medicaid. If there were doctors who were willing to take them, they can’t get the care anyway. You can’t take care of a patient with what Medicaid pays, particularly for people who need all the support services to keep them engaged in care: keeping them in clinic, making sure they get their medicine, because there is such a high rate of mental illness and substance abuse in this population.”
The services provided by the 1917 Clinic are extensive and inclusive, Raper said, listing “pharmacy, psychiatry, psychology, dentistry. … We have a dietitian because many of the folks coming from poverty are obese. We have an endocrinologist, a neurologist, a pain management specialist, a nephrologist to control hard-to-control hyper-tension patients.”
So the challenges of taking on St. George’s patients were evident, Raper said — to provide these services to all patients with the highest level of continuity of care possible. “The facility wasn’t really equipped. The ER plan was that we would have evening and weekend clinics to absorb these people, and we would onboard as many of their staff as possible. We had just finished a remodeling project at the clinic, giving us six additional exam rooms in October. It was serendipitous that it happened that way.”
Teams of physicians, counselors, nurses and social workers began holding weekly town hall meetings with the patient advisory board of both clinics — to meet with St. George’s patients and calm the fear and anxiety surrounding the transition.
“Patients were really angry and said some negative things on the television — ‘1917 will never be able to do this.’ They were hurt. They were angry,” Raper said. “I think they were afraid because UAB hasn’t always been friendly to in-county indigents. For years, I haven’t allowed in-county indigents to transfer care here because we were at maximum capacity.”
And then there were the relationships. “They’d been going to St. George’s Clinic for 15 or 20 years, to the same woman who had taken them from the jaws of death in the hospital when they were dying from AIDS,” he said.
That initial fear, too, came from losing a home place, losing the familiarity of the hallways and staff, the fellow patients, the routine. Along with other familiar faces, Mobley transferred to 1917 Clinic. “We brought these portraits from St. George’s, too,” Raper said of black-and-white prints now hanging in his clinic’s halls.
Sharon (who, like all the HIV-positive patients in this story, asked to have her last name withheld) was one of the indigent patients facing the challenge of moving to a new clinic after nearly 15 years of care at St. George’s.
“There’s a lot of people who did not feel comfortable about the change,” Sharon said. In addition to the move, Sharon said the public controversy added to patient fear. “But you’ve got to do what you’ve got to do to keep your health up to par. It’s a difference, sure. It’s a change. But I’m used to changing. That’s how I look at it: bigger and brighter things. When you’re living the way I’m living, you expect change.”
Ricky is the leader of the patient advisory board for the 1917 Clinic, and so he was active in the weekly town hall meetings. “It was tough,” he said, “But the people seem happy now.”
Part of the happiness Ricky refers to, Raper believes, comes from the hard work of his team and support from UAB. The university is scheduled to break ground on a new facility for the clinic this year.
As for this month, Raper is not quite ready to celebrate, though he said he’s proud of the work and thankful for his team, he knows what’s on the horizon.
“Right now,” he said, “it’s a matter of maintaining and planning for the future. Now, we are the only HIV provider in a seven-county region. Jefferson County has the most new cases of HIV every year. I can’t say we’re good at 3,000 [patients] because I know by this year, we’ll be at 3,300, because patients aren’t dying — thank God — but people are getting infected, and they have to get care. My energies are focused on getting a new facility. If I can make it another year, I’ll be lucky, adding at least 300 new patients in a year.”