Student Spotlight: Addressing Barriers to Care

Elizabeth Lawton, a nurse practitioner and an online MPH student at Brown, provides care to medically underserved communities in Connecticut.

Elizabeth Lawton is an online MPH student, nurse practitioner and mom of four boys, passionate about reducing barriers to care for vulnerable groups within her community. In this interview, Lawton shares how her drive to provide equitable patient care led her to pursue her master’s in public health at Brown, her passion for providing care to those with substance use disorders and how mobile clinics could be a viable care model to help improve access to care. 

What led you to pursue an education in public health?

I have worked in health care for over 15 years: 10 years as a registered nurse, and now as a family nurse practitioner. I began my career in the hospital setting and later started seeing patients in their homes in suburban and rural areas. While delivering in-home care, I quickly discovered how big of a role an individual’s social determinants of health play in their health outcomes. This inspired me to go back to school to get my master's in nursing to become an Advanced Practice Registered Nurse (APRN) to help better serve my patients. 

Through my work as an APRN, I observed that many barriers to care are systemic. Rather than pursue a doctorate in nursing, I decided the next step was to pursue my master's in public health, to give me the tools to identify opportunities to improve the delivery of vital services and improve population health for vulnerable poses for photo

What did you discover while providing in-home care to patients?

It was eye-opening to go from seeing patients in the hospital environment to providing care in neighboring cities, where many of my patients' basic needs were not met. I discovered that the way we administer care management instructions to patients isn't always how things are interpreted or applied in patients' lives. 

Many patients were trying to manage complex medical needs without access to consistent housing or running water; then they were being penalized by a health care system that is focused on efficiency. Many of these patients were labeled as non-compliant and even discharged from practices for missing appointments. I recognized that the health system often does not take into consideration how transportation, housing insecurity and untreated mental health impact an individual’s ability to seek consistent care. 

How do you address the barriers to care within your community as an APRN? 

I currently work as a family nurse practitioner at Wheeler Health, a Federally Qualified Health Center (FQHC). FQHCs provide primary care services for medically underserved communities, regardless of an individual’s ability to pay. Our organization provides equitable and comprehensive care by utilizing a patient-centered medical home with a multidisciplinary approach. 

At Wheeler Health, we use a model that integrates behavioral health care within primary care because it's hard to separate an individual’s mental health from the rest of their health and well-being. Our clinic has behavioral, mental and dental health clinicians on staff. We see patients across the lifespan. 

In addition to primary care, I provide medication-assisted treatment for people with substance use disorders. It reduces the barriers to care for people who are looking to get treatment for that, as well within our primary care model, which is something I am very passionate about. 

Our clinic takes a harm-reduction approach. We do not penalize patients if they've used or are struggling with relapse. We aim to provide patients with the safest options to assist them—depending on their level of readiness. We offer infectious disease and HIV screenings, provide Narcan instructions for overdose prevention, offer medications like Suboxone to help people who are trying to stop using and connect patients with resources. We also provide fentanyl test strips, because a lot of other drugs are laced with fentanyl. There are many cases where drugs are not what the user may think they are. 

Why are you passionate about providing care to those with substance use disorders? 

I am passionate about promoting harm reduction and substance use treatment partially because I believe in my organization’s mission and because my father struggled with a substance use disorder. My father has since passed away due to complications from his substance use and my experience with him added a bit more of a human aspect to it. I think years of seeing patients in a variety of settings have reinforced that feeling too. When you take the time to connect with somebody, you can see that they are a human, not just their diagnosis or their disease. 

“ People develop mistrust for health care providers and our health care system. I think it's extremely important to provide a place for people to seek care where they feel safe and know they can access care regardless of what's going on. ”

Elizabeth Lawton, APRN, GS

Many people with substance use disorder aren't sure where to go for help. Some local hospitals and walk-in clinics may not be equipped to offer the level of treatment that they need at that time. If someone does not need an acute medically-assisted detox, a hospital may not be able to serve them. They may tell them that they don’t need to be hospitalized; these hospitals may not know where to point them. There's quiet bias and a lot of ways for people to slip through the cracks and for things to get ignored or blamed on substance use. We have a very fragmented care system that puts people's needs in pieces and not the whole picture together. 

I strongly feel that everybody deserves to be treated with integrity and respect. In my many years of health care experience, especially in the hospital setting, sometimes the acuity is high. People develop mistrust for health care providers and our health care system. I think it's extremely important to provide a place for people to seek care where they feel safe and know they can access care regardless of what's going on.

How has your organization improved access to care and provided safe environments for those in underserved communities? 

We have recently introduced a new mobile care model to reduce barriers to care within our local communities, which I am really excited about. We have been working on building partnerships to spread awareness about our RV mobile clinic. So far, we have partnered with a local methadone clinic and are available outside for walk-in access for patients with any medical needs. 

We've been able to draw blood, manage blood pressure, do EKGs, help people discover that they have hepatitis and treat them through our mobile care center. Many of our mobile clinic patients have expressed that it's a very accessible option for them. Especially those who have distrust for the medical field and those who have had trouble accessing care in other settings or hospitals where they feel that they would be judged.

As we expand this model, we are examining the provision of mobile care as a way to help improve access to care for vulnerable groups. We hope to help individuals find a patient-centered medical home where they can receive sustainable care. 

How do you measure the success of mobile care units within your community? 

It can be challenging to measure mobile clinic success if patients are not matriculating into our in-office clinic. This is something that I am interested in exploring further for my MPH Practicum – conducting exploratory data analysis to determine the number of patients who can matriculate into our clinic, and how many patients we can create a medical home for. I’d also like to assess whether it decreases the threshold to obtaining primary care and provides individuals with a sustainable place to receive medical care.

We are still learning how to best serve our community with mobile care. Our goal is to make this sustainable. We do not want to show up and then leave. We want to provide ongoing access to care to people when they need it. 

“ I believe that our mobile clinics can be a way to provide safe and accessible care and can help us earn the trust of patients. We recognize that having a safe place for patients to go in their journey is important to them. ”

Elizabeth Lawton, APRN, GS

Have you had any experiences while providing care in the mobile clinic that have reinforced the importance of the mobile clinic model?

A few months ago, a patient brought us a beautiful letter that detailed their struggles with a substance use disorder. They told us that they were celebrating a milestone in their sobriety and that they knew they could always come back and get trusted advice from us. We have also had many patients say “I'm glad you're here today because I probably wouldn’t have gone to the doctor or received care if you weren't here.” For these patients, it’s mostly because of their mistrust of the medical field and lack of transportation.

These experiences feel like signs that we are on the right track. I believe that our mobile clinics can be a way to provide safe and accessible care and can help us earn the trust of patients. We recognize that having a safe place for patients to go in their journey is important to them. 

What are some of the challenges you face in implementing this new model of care? 

Even though I'm in a position that I love with an organization that supports this type of care for populations in the community – there are still so many systemic factors that make it challenging regardless of whether we’re in our mobile or in-office clinic. These patients still need their basic needs met, like transportation and access to medications and insurance, which are challenges in either setting. This is part of the reason I'm in Brown’s MPH program now.

How has the online MPH program helped you address these challenges?

Brown has helped me look at the bigger picture and take a more creative systems-level approach to addressing barriers to care. I have been able to directly apply what I’m learning to all of the projects I’m currently involved in. I was elected to the Watertown Board of Education during COVID, and I’m currently serving my third term in that position. I think getting my MPH will help me in all of these realms of work.

Through our coursework, I am looking forward to exploring how policies create barriers to care. For example, Medicaid reimbursement rates in Connecticut have been flat for about 20 years now. We have a very vulnerable group of people who are being disserviced by this. Despite the changes in our economy over the past 20 years, insurance and reimbursement rates have remained the same. This makes providing care challenging for places like our clinic, who receive flat reimbursement rates to provide care to patients. 

I don’t think our system is working, whether you’re insured or uninsured. Either you have commercial insurance and you're saddled with thousands of dollars in high deductibles, or you have Medicare and you're at the mercy of their reimbursement rates. Or you have Medicaid which has flat funding that many providers will not accept. There are a lot of patients who have a unique set of needs and may have trouble finding the care that they need because of this. I am excited to explore these issues further in my future coursework. 

Working alongside my classmates at Brown has been a highlight of the program too. The learning environment expands far beyond the classroom. Everyone is motivated, dedicated to learning and supportive of one another. We all come from different backgrounds and have different strengths and weaknesses. It has been great to learn and work together – collaboration is important, especially in public health.