Every day, nurse practitioner Maria Medina sees patients who have rarely seen a doctor. Most of them grew up in places where you go to the doctor only when you’re sick.

“Many of our patients who had been diagnosed with a chronic condition and prescribed medication didn’t understand they needed to keep taking the medicine,” said Medina, who works at Care Ring, which delivers medical care to people who often have nowhere else to go in the Charlotte area. “They thought when they felt better, they could stop.”

The clinic is one of several community health organizations supported by Novant Health, which offers Care Ring financial support, volunteer medical staff and an electronic health records system.

If a patient can make lifestyle changes and reverse the effects of diabetes, high blood pressure and other chronic illnesses, he may be able to stop taking meds. That’s what Mario Debernardi, 36, did. When he heard about Care Ring through friends, he wasn’t taking medicine for high blood pressure. Given his family history of type 2 diabetes – and the stress he’s under as the owner of a home repair business – that was a big risk.

His team at Care Ring encouraged him to take charge of his condition. “Mario became very involved in his own care,” Medina said. “He was willing to do everything we asked. He had to go on insulin, but now that he’s lost weight and is exercising, he’s able to manage his diabetes with oral medication and diet alone.”

Debernardi said Medina helped him understand the importance of hitting his health problems head-on.

“In Mexico, we eat a lot of meat and fried food,” Debernardi said. “Now, my wife bakes a lot of our food rather than frying it.” He’s eating more vegetables, too. Fruit elevates his glucose levels, so when he drinks apple juice, it’s diluted with water. He’s cut out soda and checks his blood sugar and blood pressure at home. He’s walking and running regularly.

“Mario has a high degree of literacy about his health now,” Medina said.

The clinic serves about 2,100 low-income patients who are uninsured or underinsured each year, and 53 percent of those have one or more chronic conditions – such as high blood pressure, diabetes, high cholesterol and obesity.

Care Ring’s work with the chronically ill is filling a big void – and it’s in keeping with Novant Health’s mission to care for the community – especially underserved populations – beyond hospital walls.

Novant Health launched new investment priorities this year that focus on health and human services, environment and education, said Betsy Conway, director of social responsibility. “We want to partner with nonprofits doing impact-based, outcome-driven work,” she said. “That’s exactly what Care Ring does, and they have a model that’s been proven effective.” Novant Health donations will total $40,000 over 2018 and 2019.

Novant Health’s investment is paying off at Care Ring, said Executive Director Don Jonas. “In so many ways, we are an extension of Novant Health,” he explained.

While the clinic is staffed by Care Ring’s medical director and three nurse practitioners, more than 450 primary and specialty care physicians from Novant Health have volunteered their time through Physicians Reach Out to provide care to thousands of low-income, uninsured area residents for free. “This kind of additional outreach makes our partnerships even stronger,” Conway said. “It’s a full circle of support.”

And Novant Health’s donation of an electronic health record system means patients’ medical records are readily available. “We’re now in the digital age,” Jonas said. “Almost overnight, we went from a paper-based system to an electronic system. There’s now a wealth of data we can see. Before this gift, if a patient didn’t tell us something, we had no way of knowing. Now, we can verify their medical history, see their prior diagnoses, the medications they’ve been prescribed.”   

‘Very high-touch’

Care Ring’s chronic disease initiative is addressing a public health and a social need, said Kelly Musante, the organization’s development director. “We’re seeing vulnerable patients with multiple chronic conditions that have gone untreated for a year or more. And these are patients whose household income is well below the poverty line.” Average annual income for a Care Ring patient is $16,000.

Part of the clinic’s goal is to keep patients out of the emergency room. It’s working. Each year, the Care Ring clinic says it saves more than $2.6 million in reduced ER visits.  

The staff intends to establish relationships with their patients. “We’re very high-touch,” Musante said. “We offer patients a health coach who will follow up with them to be sure they’re taking their medication as prescribed and eating right.” And, a trilingual staff can communicate with English-, Spanish- and Portuguese-speaking patients.

Plus, it’s a coordinated effort. A doctor and health coach work together to provide the best patient care. Along with them, a case manager, social worker, volunteer mental health provider and volunteer diabetes educator (when needed) all form the core of a patient’s care team.

The clinic is being lauded for its results. The American Heart Association and American Medical Association recognized Care Ring’s clinic as a “gold-level practice” for achieving 70 percent or greater blood pressure control among patients.

It all adds to the personal attention Care Ring offers to patients like Mario Debernardi. “I’m feeling really, really good,” he said. “The people at Care Ring, they take care of me. They are the best.”

Care Ring is at 601 E. Fifth Street, Suite 140, in uptown Charlotte. Learn more at careringnc.com. Interested in volunteering? Contact Carolyn Mullins at [email protected]. Physicians can reach out to Stephanie Cameron at [email protected].