Delivery of Care

How Central Falls is changing the health care landscape

High school health clinic had helped to achieve a phenomenal 55 percent reduction in teenage pregnancy in the last three years, in partnership with Blackstone Valley’s Neighborhood Health Station

Photo by Richard Asinof

Dr. Beata Nelken, pediatric specialist at Blackstone Valley Community Health Care.

By Richard Asinof
Posted 11/24/19
Dr. Beata Nelken, a pediatric specialist with Blackstone Valley Community Health Care, will be receiving the community partner award at the Rhode Island Kids Count annual luncheon on Nov. 22 to celebrate children’s health. Here is a previous interview with her, published earlier this year in ConvergenceRI.
What would it take for the Rhode Island Foundation to invest in making the Central Falls High School health clinic a sustainable enterprise, as a first step in replicating the model? Will the R.I. General Assembly be willing to create similar health clinics in schools across Rhode Island as a way to cut down on unnecessary health care costs? How can the health clinic model be accepted as a best practice for how to deal with behavioral health and mental health issues? Which commercial insurer in Rhode Island will step up to the plate and provide additional investments to the Central Falls High School health clinic to help cover services to uninsured students?
Sexual trafficking and sex slavery have come to the forefront in several recent legal cases: the charge initially brought against New England Patriots owner Bob Kraft for an alleged sexual encounter in Jupiter, Florida, with a prostitute; the charges brought in Chicago against R. Kelly for alleged sexual encounters with underage women; and the findings by a judge that former Labor Secretary Alex Acosta broke the law when he reached a settlement in a case involving Jeffrey Epstein involving underage sex and alleged sex trafficking without notifying the victims. [Acosta resigned, and Epstein was later arrested under charges brought by the Southern District of New York and committed suicide while in jail.]
These cases reveal that there may be a new legal landscape for accountability when it comes to holding men responsible for their actions in pursuing sex with women who are part of sex trafficking exploitation.

Editor’s Note: On Monday, Nov. 25, Dr. Beata Nelken, a pediatric specialist with Blackstone Valley Community Health Care, will be receiving a “Covering Kids Award” at the Rhode Island Kids Count annual celebration of children’s health.

Nelken, along with Aracella Aponte of Thundermist Health Center, are being honored as community leaders and partners for their commitment and dedication to ensuring that children have primary health and dental care.


Others being honored at the luncheon include: Gov. Gina Raimondo, Sen. Jack Reed, Sen. Sheldon Whitehouse, Congressman David Cicilline, Congressman James Langevin, state Sen. Josh Miller, and state Rep. Joseph McNamara [representing the R.I. House].

Here is story written earlier this year in ConvergenceRI, in the Feb. 24, 2019, edition, discussing Nelken’s earlier work with the high school health clinic in Central Falls. She no longer serves as its director.

The story was written on the cusp of the new Neighborhood Health Station being opened in Central Falls, and the difference that the new facility was making in the way that health care was delivered for residents of the city.


What clearly comes through in the story is the passion and commitment that Nelken brings to her work as a pediatric specialist in serving the needs of the community.

CENTRAL FALLS – Here is some good news that has not yet found its way into The Providence Journal, been broadcast over TV on WPRI, WJAR, and WLNE, been heralded by The Public’s Radio or on WPRO, or been mentioned in political columns by Ted Nesi or Ian Donnis: in the last three years, the rate of teenage pregnancy has declined by 55 percent in Central Falls.


Not only that, but in the midst of public health epidemic in the transmission of Chlamydia, a sexually transmitted infection, both in Rhode Island and nationally, the rate of infection in teens in Central Falls has fallen by 28 percent over the last three years.


Why is that? What are the reasons for such successful outcomes?

The answers can be found in part because of the Central Falls High School-based health clinic, a program begun in 2014 and now run in partnership with Blackstone Valley Community Health Care, and since January of 2016, [had been] under the direction of Dr. Beata Nelken, a pediatrician, as part of the health center’s Neighborhood Health Station.

ConvergenceRI recently sat down to talk with Nelken to better understand why the program had been so successful. Nelken explained that before she arrived, doctors had petitioned the school board and asked that Title X services – confidential, family planning services and other preventive health care for all patients at reduced or no cost – be permitted in the school, and the school board said yes.

As a result, Nelken continued, she had been able to provide health services to teens – including family planning services, STI testing, education about abstinence and how to be safe in relationships – all confidential, all free, in a language that works for the students.

“All we had to do was open the doors,” Nelken said, who had begun her work at the high school health clinic in January of 2016.

“I speak Spanish,” she said. “[All of] our staff speak Spanish. We even have a front-desk person who speaks Cape Verdean Creole.”

“We make it comfortable, confidential, personal, and safe,” Nelken continued. “If you have those conditions for teens, you don’t even need to advertise, you just open the doors.”


Sadness, substances and sex
Nelken explained that whenever she saw a student, she always asked about sex. “I made sure that every kid [who comes to the clinic] is asked about sex, whether they have [come in to be seen] for a hangnail, or broken nose, or an eyelid that twitches,” she said.

I tell them, Nelken continued, “I want to know about your sex life. I want to know if you are using substances. I want to know if you are suffering from mental health issues, such as depression and anxiety – sadness, substances and sex.”

Nelken said she asks all the students: Tell me about yourself. “I’m here, it’s confidential, it’s free, and they start talking.”

The game changer
The big game changer was the capability to provide teenage girls with long-term birth control in the form of an implant of Nexplanon, a hormone that prevents ovulation and which lasts for three years, according to Nelken.

“We also [encouraged] the use condoms as well,” Nelken said. “We had a free supply. Once you are a patient of ours, there’s a bucket in the bathroom. You don’t even have to ask. But you have to have at least one visit with me, to talk about abstinence, to talk about including your family in the discussion, to talk about safe sex and avoiding coercion.”


Nelken explained that she was certified to implant Nexplanon two years ago, and since then, has done implants for some 100 young teen girls.


“One hundred teen girls [have come] into our office for a procedure in their arm that takes about 20 minutes. [I tell them:] See you in three years. Use your condoms. Have a good life. It’s a game-changer, especially for girls who are uninsured, and especially for girls who are graduating. It’s my way of sending them off with the best graduation present ever; see you when you are 21.”


The implant, Nelken continued, is a small procedure that is the most effective for pregnancy prevention with the least side effects. “It’s not the whole vaginal invasive thing that girls don’t want to do when they are teenagers, anyway,” she said. “I am not certified to do IUDs; that’s a whole other area of medicine that I don’t think should be happening at school.”


Connecting the dots
Preventing the number of infants born at highest risk – to women who are under age 20, unmarried, and have fewer than 12 years of education – is one of the top priorities for many public health and human services advocates. Such births increase the risk of delayed prenatal care, preterm births, and low birth weight infants, according to a number of studies.

The success of the high school health clinic in Central Falls could serve as a model to be replicated in other schools in Rhode Island, if there was the funding and the leadership at the state level to implement such a strategy.

When asked what she would say to Gov. Gina Raimondo, if Nelken had the opportunity to sit down and talk with her, here is what Nelken said:
Teen health clinics, Nelken explained, at best, only see about 60 percent of teens in Rhode Island.

“If we only saw 60 percent of our babies, and the clinic wasn’t fully funded, and we couldn’t accommodate them in our clinics, and our clinics were only open half the time, and [did not offer] services in the language [spoken by the patients], and the hours were not convenient for them, and we said: ‘Good luck with your breast feeding if it’s not going well,’ how would that go over? There would be an uproar.”

Nelken continued: “We have a whole teenage population that is absolutely out of our health care system. And, it sets the tone for how they navigate the health care systems [in the future] as adults. If they don’t have a good connection and a good experience in their early youth, the only time you will see them is for car accidents and pregnancy tests and for their births. You can’t do any prevention in that system, for everything that costs the [health care delivery] system so much.”

Because, Nelken said: “They don’t see doctors as a trusting place to go, or a place to seek care, or a place where they can say, 'I have something going on, and want to talk about it.’ ”

Here is the ConvergenceRI interview with Dr. Beata Nelken, a pediatrician who had directed the Central Falls High School Health Clinic, talking about the reasons why the interventions practiced at her clinic, in partnership with Blackstone Valley Community Health Care and its Neighborhood Health Station in Central Falls, have resulted in a 55 percent drop in teenage pregnancies in the city over the last three years.

ConvergenceRI: When we began our conversation, you called Central Falls the story of a forgotten land in Rhode Island. Why is that?
NELKEN:
I’m in medicine. Central Falls has a population of some 19,000 people. It was, at one point, the most densely populated city in the U.S. It hasn’t thinned out that much, but somewhere else has gotten the number-one prize since then.


There are a huge number of immigrants who live there – from Cape Verde and Central America, Colombia, the Dominican Republic and Puerto Rico.


There is a huge poverty burden; some 70 percent of the residents speak Spanish. To me, it is like going on a brigade every morning.

ConvergenceRI: A brigade? What does that mean?
NELKEN:
A medical brigade, such as we used to do, as part of many clinics. Clinics would organize medical brigades to Honduras or Guatemala. Thundermist used to do it.

 I’ve had professors call me now to ask: Do you want to come on a brigade? I tell them, I’m all set. I’ve got my own medical brigade right here.

Central Falls, in terms of the medical field, we have a community health center. But we have exactly one pediatrician that is in private practice in the town. There are two internists that I found online in Central Falls. That’s it.


There is not much in the way of options; people don’t maneuver out of the city very well. They are not always bus savvy. They don’t always own their own transportation [only some 70 percent own cars.]



Teens are mostly left to drift in Central Falls until they land on their own, much the way that Woonsocket teens are. Many of the residents don’t speak English as their primary language. They don’t have political people up in the State House. They often get short shrift.


ConvergenceRI: As a pediatrician, you [had] directed the Central Falls High School health clinic. The numbers that your shared are rather astonishing – you had been able to lower the rate of teenage pregnancy by 55 percent over the last three years.
NELKEN:
It wasn’t anything special that I did. It was kind of an opportunity that presented itself. Dr. Michael Fine led the way by re-opening the school-based clinic, along with Blackstone Valley Community Health Care and the Central Falls School District, in 2014. It is now part of the Neighborhood Health Station.

Central Falls was willing to try something new, as they have been in many realms, since their renaissance [following the city’s bankruptcy].


Doctors petitioned the school board at that time and asked that Title X services be permitted in the school, and the school board said yes. And that meant that kids, minors, could seek family planning services, STI testing, with everything confidential, with everything free or at a reduced cost. We were able to provide it in a language that works for them. All we had to do was open the doors.
 We just haven’t provided the right conditions for them until now.


ConvergenceRI: What does that mean?
NELKEN
: Rhode Island laws, up until a few months ago, said: 16 and up, you can have sex, but you’ll have to fend for yourself for pregnancy prevention, or STI treatment, or any confidential care. Even though the national law says, you have the right to seek confidential care around these services.

Massachusetts went ahead, Connecticut went ahead, New York went ahead in saying those teens have right to seek confidential care, on their own, statewide. That’s your right.

It was only a few months ago that Rhode Island finally declared, “Oh, yeah, 16 and up, you can seek care for yourself. You can seek emergency care, you can seek prenatal care, you can seek everything including surgical care; you can consent for yourself.

But before a few months ago, there was a kind of silence. And, if you are not a naturalized resident citizen of the United States, if you don’t speak the language, if you’re not savvy about the bus system, which a lot of these kids are not, [what choices in health care do you have?]

They don’t have cash. And, they are expected at home [after school] to take care of the younger generation. Guess what? You’re not leaving home. You’re going to school, then you’re coming home. And that’s your story.

You figure out the rest on your own. You take chances. You do stupid things, the way that all teenagers do, the way that I did as well. And, guess what? That often lands you in [trouble].


ConvergenceRI: Beyond preventing teenage pregnancies in Central Falls, what are some of the other successes that you have been able to track as a cause and effect for your efforts at the high school health clinic?
NELKEN:
Once they’re sexually active, we test everyone every six months for STIs. We are in the midst of an epidemic in Chlamydia, nationwide and Rhode Island-wide.



In Central Falls, incidences of Chlamydia have actually decreased by 28 percent over three years.
I track the patients. I keep a massive spreadsheet, for some 200 girls I’ve seen in the last three years: who’s on what; when they are due for their next pill, their shot, their implant, when it runs out, if they switch methods; who their boyfriend is; whether they have Chlamydia, when do they need to do the next testing; who is their mom, does their mom know, who’s their pharmacist, what is their insurance, if they have any; when do I need to see them next.

Then we keep to access to their classes at school, so we can call them down.

ConvergenceRI: And, how have the students responded?
NELKEN:
The students love it. We need more hours; we can’t accommodate everyone who wants to be seen.

ConvergenceRI: It sounds as if you’ve created a kind of safe haven at the clinic.
NELKEN:
It’s incredible. I feel so blessed to do what I do, to be inspired by the students' stories and to learn from them.


ConvergenceRI: Would you be willing to take on volunteers to work with you?
NELKEN:
Sure. The greatest need, honestly, is in mental health. What I thought was going to be mostly a pediatrics/birth control clinic has quickly turned into a mental health clinic.

Without the resources to send kids to places that don’t speak English, basically, these kids are coming to see me every week, until they get more annoyed with me than the people in their lives that are disturbing them.

ConvergenceRI: Because?
NELKEN:
They have no insurance; they only speak Spanish. There are no resources to send them to private practitioners.



ConvergenceRI: Even at Blackstone?
NELKEN:
At Blackstone, you need the parent’s consent, you need time out of work, you need to be willing to enter the system, and not all parents are willing or able to do that.


They don’t have free time; they are often working two to three jobs.


And, there is a different culture sometimes about what mental health is. Such as: “Why are you sharing your problems with this random stranger at the school? Just suck it up, kid, and get back to work.”


ConvergenceRI: It sounds like you are changing the culture. And, you’re getting students to talk about things that normally they would have no one to talk with about.
NELKEN:
Shouldn’t that be the norm? Because, teens don’t come to regular clinics, it turns out, at least not the urban clinics that I have worked in over the last 13 years.

[The idea], is at 18, we’re going to hand them off to next wonderful adult medicine doctor, but guess what? They don’t ever show up after 14.

Teens show up inversely proportional to the amount of risk they are taking socially.

The ones that are coming in, that are willing to sit with mom in the waiting room, are not the ones who you are worried about.

It’s the ones who are rebelling, who are not at mom’s side or dad’s side, and who are doing their own thing, and whose parents are mostly saying: “Yeah, you’re on your own, you’re doing great.”

The teens are fending for themselves, and they really do not have a connection with the medical system.

ConvergenceRI: By writing about your work with Nexplanon implants, will I be getting you in trouble, say, with right-to-life advocates?
NELKEN:
I don’t think so. Teens across Rhode Island abort some 40 percent of their pregnancies. We have prevented 50 percent of such pregnancies in Central Falls to begin with. You are looking at a lot of abortions that were not done. We are saving lives; we are saving tax dollars.

These are kids who are off the grid; they will never be insured by Neighborhood [Health Plan of Rhode Island], neither their kids nor themselves. We are saving the tax dollars that would have gone toward what would otherwise be the coverage for a mom and a high-risk baby that will never be needed.

Birth control works. All the birth control that we use works in suppressing the ovulation in the beginning. So, there is no conception, there is no abortion, there’s never any conversation about when that life begins, because the egg never gets to the uterus in the first place.

ConvergenceRI: Can the model of the high school health clinic be replicated?
NELKEN:
Yes and no. It is very expensive to do an uninsured population, or a privately insured population, because the parent organization needs to absorb that cost – for those waived visit costs and all the medication that you need to supply for confidential care.

We’ve managed by grants, and Blackstone’s generosity in paying for medications, and waiving visit costs. They are just absorbing that. 

Title X pays for some of it, but nearly for the number of visits that we’ve generated.

If you have a RIte Care population, replication would be really easy. Because Neighborhood [Health Plan of RI] and United [Healthcare] RIte Care plans will pay for the medications and never send an explanation of benefits to the home; everything is confidential, and free of cost to the patient. And, the clinic gets paid. It is sustainable.


When you’re dealing with private insurance, they send an explanation of benefits to the home, so you have to absorb that cost for confidential visits.

So if you can do it through RIte Care, Woonsocket could be covered. Providence could be covered, except for about 11 percent of their population. And Pawtucket has probably between 11-20 percent uninsured, as a very rough estimate. Central Falls is more like 30 percent uninsured.

ConvergenceRI: How are the issues around mental health informed by anger, and in particularly, trauma?
NELKEN:
I see a lot more violence and anger and rage in the male population. But the girls, it is much more depression and anxiety, especially depression and suicide ideation.

Thanks to Dr. Fine, he gathered a roundtable and was able to find money through the help of Jeff HIll and the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals to secure a grant for a bilingual social worker working in the clinic now to specifically address the uninsured kids.

ConvergenceRI: How do we change the conversation? How do we change the narrative around health care that never seems to get told?
NELKEN:
Especially for minorities; especially about poverty; especially for immigrants; especially for women’s reproductive anything.


The way to change the conversation is to make clinics such as the Central Falls High School health clinic the gold standard in our state, to have such clinics in every school.

Because that is actually where kids will go, as opposed to our standard clinics where we never see teens come through.

It has to happen at the state level, both through funding and legislation, because school boards tend to be very conservative and won’t allow the Title X services.

ConvergenceRI: Do you think there is an opportunity to work with coaches, such as football coaches about male sex education, because the tendency is to think that all we have to do is teach women? Shouldn’t there be a whole male component to this work?
NELKEN:
[laughter] It is at least 50 percent of all pregnancies, last time I checked. The R.I. Department of Education has a beautiful sex ed curriculum, but they have no teeth to enforce it, and we can only make a suggestion that they look at it.

Schools are stretched for time and resources and budgets. And everybody is going charter schools.



At Central Falls High School, 30 percent of the kids don’t go there anymore because they are at charter schools. So, you are supposed to deal with 70 percent of your budget, have the same number of classes, and then accommodate all the new immigrants and everything else to run a school that’s at fult-tilt boogie, and good luck, ready set go. How do you do that?

As for the boys, they come through our clinic as well. We screen them, test them, and educate them about safe relationships, safe sex, abstinence and family involvement. We offer condoms to those that need them and always encourage good communication with their partners.

ConvergenceRI: The new Neighborhood Health Station, how is this approach fundamentally changing health care in Central Falls?
NELKEN:
You have one building where you go for everything. It’s dental, it’s medical, it’s ob-gyn, it’s adult care, labs, X-rays, pharmacy. You don’t have to shuffle around.

Many of our families walk; they don’t want to go across town only to find out that a script wasn’t called into a pharmacy. They give up, and they’ll never tell you, and you think they are taking their medications, and they’re not. There’s so much room for things falling apart. There are incredible potholes that people fall into all the time. But not with the Neighborhood Health Station; it is comprehensive care under one roof.


ConvergenceRI: Are you now in the new facility at 1000 Broad St.?
NELKEN:
I am. And it is fabulous. I love being there. I look forward to going to work. I love every minute I’m there. The families love it. It’s a tremendous, beautiful facility. It’s stunning. It’s a whole makeover.


ConvergenceRI: So, the parents and the patients have been very responsive?
NELKEN:
They love it. They love it. And, they are thrilled to come there. They are thrilled to have everything so convenient. They are overwhelmed with joy. It’s so easy; it makes so much sense.

It should have been done a long time ago. It’s phenomenal what Blackstone has accomplished in this Neighborhood Health Station, it will become the model for what communities can do.

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