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Iris M. Santiago and Robert Abreu looked over snack food content ingredients at the Holyoke Health Center recently.
Iris M. Santiago and Robert Abreu looked over snack food content ingredients at the Holyoke Health Center recently. (Nancy Palmieri for the Boston Globe)

Health support for poor to take hit

'08 budget cuts care of chronic ills

HOLYOKE -- A program that has improved the health of low-income patients with chronic illnesses faces deep funding cuts in the pending state budget, even though top state officials touted similar disease management strategies just a month ago as a crucial way to improve healthcare quality and cut costs.

The 2008 budget, now being hammered out in a legislative conference committee, is likely to contain less than one-third of the $2.6 million that the statewide CenterCare program received this year to pay for a broad range of health education and support services at community health centers.

In Holyoke, where diabetes strikes hard and often, the program has helped hundreds of patients at a community health center adopt healthier lifestyles and reduce their blood sugar levels, an improvement that could eventually cut their risk of serious complications nearly in half. Diabetics are offered exercise classes, instruction about the disease, home visits by community health workers, one-on-one sessions with a nutritionist, and drop-in sessions that teach healthy eating.

"I lost 63 pounds and I'm controlling my sugar," said Iris M. Santiago, a patient in Holyoke. "They've helped a lot of people's lives."

The proposed funding cuts threaten the Holyoke program, which has been recognized as a national model, as well as similar efforts at 29 other community health centers statewide. CenterCare this year paid for disease management services for only half the low-income patients eligible across the state -- about 5,000 -- according to the Massachusetts League of Community Health Centers. The program helps patients with asthma, cancer, heart disease, and depression, in addition to diabetes.

"We're talking about low-cost interventions," said Jay Breines , executive director of Holyoke Health Center , which is expecting to receive about $69,000 in CenterCare funding this year. "This shouldn't be the stuff that gets cut."

At a healthcare forum in May, both Senate President Therese Murray and Dr. JudyAnn Bigby , the state secretary of Health and Human Services, said Massachusetts needs to expand chronic disease management to help improve care and control spending.

But Governor Deval Patrick's proposed budget included only $400,000 for CenterCare, and it was folded into an account that would allow the administration to use the money for any purpose at community health centers. The House proposed $557,000 specifically for CenterCare. The Senate included $1 million in a catch-all community health center account. Legislators are expected to produce their final budget plan as soon as this week.

Bigby, in an interview, said the seeming contradiction between her statement and the administration's spending plan resulted from the state's tight budget. "While chronic disease management is very important, we were choosing between that and cutting services for substance abuse, [or] for kids with developmental disabilities. It wasn't an easy choice. I hope we can facilitate disease management in other ways."

State Senator Steven C. Panagiotakos , chairman of the Ways and Means Committee, said the Senate reduced funding for CenterCare because "we are able to address many of the preventative care and disease management needs" through the state's health insurance initiative because many of the program's uninsured clients will get coverage.

But community health center officials say their efforts go far beyond that funded by most insurers, because their patients need more support to overcome the additional barriers to good health presented by poverty and low literacy.

CenterCare was established in 1988 as a managed care insurance program for low-income patients but never got off the ground. It then funded care for the uninsured at community health centers, and most recently has been paying for disease management, according to the community health centers league.

Disease management is particularly important for diabetics, because patients must constantly monitor their blood sugar and adjust eating and exercise habits to keep that sugar level within a normal range. Out-of-control diabetes can lead to serious complications, including heart and nerve damage and death.

"The challenge is to really engage people," said Carol Brownson , deputy director of a national project to improve diabetes care, funded by the Robert Wood Johnson Foundation . "Working with a population that is high risk and hard to reach, Holyoke led the way."

Holyoke is home to a large Hispanic population, which suffers disproportionately from diabetes and has a high rate of death from the disease.

The foundation helped Holyoke Health Center establish a diabetes management program and funded it from 2003 through 2006. This year, the effort was supported by CenterCare money.

Last week, at a "snack club" meeting, patients tried healthy snacks, seeing how easily they could be prepared, and learned about portion control and nutrition. Five paid and volunteer staff members circulated among 15 patients, offering support and serving mini pizzas made with whole-wheat English muffins and low-fat cheese. After tasting and liking the unfamiliar snack, patients peppered the staff with questions about the ingredients.

"Now I can make it at home," said Santiago, a 43-year-old Holyoke resident who says the program and her doctor saved her life.

Two years ago, her blood sugar and weight soared so high that she was hospitalized twice with heart trouble. A community health worker visited Santiago at home regularly for two months and finally convinced her to come to the center's programs.

Gradually, Santiago learned how to care for herself. "I used to eat a very big meal, with lots of rice, a big piece of meat and a little salad," she said. "Now, I have a big salad, a small portion of rice and a little piece of meat. You don't need more."

She exercises, too, and the results show. Over 18 months, she lost 63 pounds, and brought her blood sugar to normal levels.

"My energy came back, and my self-esteem," said Santiago, stylishly dressed in a black sweater with gold necklaces. "I hope they keep this program."

Since the program started at the health center in 2003 the average blood sugar levels of diabetic patients -- called hemoglobin A1c -- have dropped from 8.4 to 7.5, according to Dawn Heffernan, who manages Holyoke's program.

Alice Dembner can be reached at