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March 2003


Women First

By C.A. Wolski


Angela Allen, PT, explains examination chair positioning to an Access WOW patient.
The general health issues of patients with disabilities are often neglected by rehab personnel because of diminishing reimbursement and the seriousness of their injuries and conditions. This is particularly the case for women whose annual examinations—including mammograms, PAP smears, and bone density evaluations—are either deemphasized or forgotten while health care providers focus on their life-altering medical issues. But SSM Rehab, a nonprofit Catholic hospital in St Louis, is changing this emphasis with its Access Women’s Outpatient Wellness (WOW) center. Opened in July 2002, the program has been an immediate hit with both staff and patients.

Focusing on wellness is more important for this group of patients than the general population. “Disabled women need wellness more than anyone because, since they’ve only got a little bit of wellness to grasp onto, we’d better make sure it’s there and it gets expanded,” says Randy Tobler, MD, a women’s health specialist at SSM Rehab. “A lot of people in the community ignore the sexuality of these women, the urologic issues that affect them, and they are asked to endure hardship that your ambulatory patient wouldn’t put up with for a minute.” The brainchild of Angela Allen, PT, manager of Women’s Services at SSM Rehab, Access WOW is designed to emphasize the patient’s femininity in spite of her disability. “We are treating women here,” she says. “We have women who are sexually active and who are having reproductive changes, but are being seen as the quadriplegic and the paraplegic and the MS patient; they’re not being seen as women. That creates a lot of problems, because there are very gender-specific things that they need to take care of.”

Allen adds that the program’s motivation is mission-driven. “This is not a program where we’re looking to make a lot of money,” she says. “SSM Rehab is an organization that wants to make its community better—that’s the goal.”

A FEMALE-FRIENDLY ENVIRONMENT

To assess the need for the center and the size of its potential patient base, Allen sent out a survey to 1,100 former patients. Those who responded and fit the center’s proposed patient criteria—not being able to position themselves on an examination table or stand on their own during a mammogram—were invited to set up appointments. Though the initial group of patients contacted was from SSM Rehab, the current patient base comes from a variety of sources, including referrals from outside providers and self-referrals. The center, located in an SSM Rehab physiatry office, currently operates on Mondays and sees 6 to 8 patients per week.

The need for the center was obvious to Thy Huskey, MD, FAAPMR, medical director of general rehabilitation at SSM Rehab. Wheelchair-bound because of multiple sclerosis, she knows first hand the challenges associated with getting annual wellness examinations, which include having to make detailed preparations ahead of time.

More fundamental, however, is the issue of wellness within the context of the patient’s permanent disability. “This is an important clinic for these women because they are living with their disability, and a lot of the illnesses that cause the disability don’t come with an easy cure,” says Huskey. “We now know through research the type of cancers we can cure if we can detect them early, and I think that excluding this population [from cancer screening procedures because] we can’t make them accessible is no excuse for the health care profession. You have got to cure the things you can. It’s very important, now that preventative medicine is such a big part of modern medicine, that we do not ignore a population that is at the same risk, just because they can’t walk.”

To accommodate disabled patients, modified equipment has been made available to ensure a comfortable, good examination—which is the paramount concern for the Access WOW staff. “Your woman’s health exam should really be a comfortable experience and should address a variety of wellness-related issues,” says Susan Kendig, RNC, MSN, WHCNP, a women’s nurse practitioner contracted by SSM Rehab to perform the wellness examinations. “This allows patients a time to focus on health care issues that are important to all women and are sometimes overlooked because, when a woman with a disability comes in, there may be a tendency to just talk about the disability or treat the disability without looking at the whole person.

“There’s also a big issue simply about accessibility, not only accessibility to the building, but accessibility to equipment that allows the exam to be done in a respectful manner, in a comfortable manner, in a way that meets the woman’s needs.”

And though many of these women are dealing with physically life-altering injuries and conditions, they still have the same desires and issues of the general population. “These women may want to have babies, they experience menopause, they have the same types of health concerns about their bones and their heart, they need breast exams, all of those things that sometimes get lost in the shuffle of focusing on this traumatic injury and the disability,” says Kendig. “I think [Access WOW] not only provides the comfortable equipment, but it provides woman-focused care that addresses them as a whole person, and I think it’s a safe place where they can ask questions that are important to them as women that they may not have been able to ask elsewhere.”

Though they must fit physical criteria, patients span the same demographics as any general practice. For Kendig, whose background is in women’s health, there have been no surprises in dealing with a specifically disabled population. “In my private practice, I have seen women who have had various disabilities, so that part of it wasn’t a surprise. But I think the intensity of having this population all day is very interesting, because while I’m dealing with the women’s health issues, I’ve tried to learn more about rehab, about the physical problems the women are faced with. Because medical conditions and those physical disabilities have a direct impact on the women’s health, they may have a direct impact on some of the women’s health prescriptions I might want to write,” she says. To help her understand the rehab issues of her patients, SSM Rehab has had Kendig attend the classes its rehab personnel attend.

A MATTER OF WELLNESS

In addition to woman-centered health examinations, the patients can also address general health issues. “The beauty of Access WOW being at SSM Rehab is that there’s a whole team of specialists, so I can call the physiatrist and ask for a consult and they’re right there. I can have a physical therapist come in and look at ways to make [a patient’s] wheelchair more adaptable,” says Kendig. “The patients come in for their woman’s health exam…they get a full physical, but if they have problems unrelated to women’s health, I do go through that with them. There’s a lot of case management and education from the health care perspective that goes on. Women’s health is primarily based on wellness, so what we’re looking at is how we can make sure that we catch any illnesses…so all of those things are addressed within the context of their disability.”

This one-stop approach allows women to deal with issues immediately instead of waiting for a referral or seeing their primary care physicians—both of which may occur months after the Access WOW visit. There are other benefits to the patients and their families as well, says Tobler. “I know that with several of our initial patients, the husband or caregiver has been there, and it’s really nice that we can have them,” he says. “You have this extra advocate to absorb the information, take notes, and make sure the follow-up gets done.”

However, says Kendig, the goal of Access WOW is not to replace a patient’s primary care provider. “The goal is…to offer a service that had been very difficult for women to access,” she says.

WORK IN PROGRESS

The involvement of SSM’s rehab staff—who help position patients and make them comfortable during examinations—has been a positive experience for Kendig. “I think the rehab staff has been absolutely wonderful and supportive,” she says. “Everyone seems very committed and tends to be there to provide the linkages in the continuum of care.” Allen adds that positive feedback from the rehab staff is not only confined to the SSM Rehab community. “I’ve actually gotten calls from staff that work at other hospitals,” she says. “Everybody has really bought into the concept, and they’ve been helpful getting the word out there.”

Though the initial response from patients and staff has been positive, Access WOW is still a work in progress that is evolving week to week, says Kendig. And as part of its progress, Access WOW may move beyond its current client base to become more of a family-oriented practice model. In the meantime, a second Access WOW site is scheduled to open in St Charles County, 35 miles northwest of St Louis, in the third quarter of 2003.

C.A. Wolski is associate editor of Rehab Management.

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