HCHD Sleep Disorders Center serves one of the largest indigent populations in the country.

Nearly 46 million Americans lack health insurance, and an estimated 16 million more are considered “underinsured” because they have high out-of-pocket expenses relative to their incomes. For uninsured, low-income people, a sleep disorder is not only a health concern, it is a potentially life-devastating condition. 

Consider the plight of one Texas school bus driver. He was out of shape and sluggish, but he showed up for work everyday. Though he could barely make ends meet, at least he had a job. One day, he fell asleep at the wheel. Luckily, no one was killed, but he lost his job. Without medical insurance and income, he may very well have had nowhere to turn. Fortunately, the bus driver lived in Harris County, Texas.

At the Harris County Hospital District (HCHD) Sleep Disorders Center, the bus driver was evaluated by a board-certified sleep specialist, underwent a sleep study, and was diagnosed with sleep apnea. The center’s staff fit him with a CPAP unit, which he took home. Weeks later, he was reevaluated. Thanks to the CPAP treatment, he now was energized, his mood had improved, and he had a good chance of reducing his risk of complications, such as cardiovascular disease and diabetes. What is more, physicians and staff at the HCHD Sleep Disorders Center were working fervently on the necessary documentation to get him his job back.

That is just one of hundreds of happy-ending stories HCHD sleep professionals can share since the county-subsidized Sleep Disorders Center opened some 18 months ago. The HCHD Sleep Disorders Center is unique because it serves one of the largest indigent populations in the United States. Moreover, faculty from two medical schools run the program, which trains fellows from both schools. An unyielding commitment and a spirit of cooperation have made the HCHD Sleep Disorders Center a model to emulate when it comes to providing state-of-the-art care in sleep medicine for a needy population.

A Tireless Campaign
The Harris County Hospital District provides hospital care and health services to the indigent citizens of Harris County, which has a population of more than 3 million and includes the city of Houston. The district operates two hospitals: Ben Taub General Hospital and Lyndon B. Johnson General Hospital. Ben Taub is staffed by faculty from the Baylor College of Medicine, and LBJ is staffed by faculty from the University of Texas at Houston Medical School.

The new HCHD Sleep Disorders Center is a team project of both hospitals and both schools. It was the brainchild of Kalpalatha Guntupalli, MD, a professor at the Baylor College of Medicine and chief of pulmonary/critical care and sleep at Ben Taub General Hospital.

“I had been trying to get a sleep lab at the county facilities for over a decade,” Guntupalli says. “So many Harris County citizens are vulnerable to sleep disorders, but they are uninsured or underinsured. I felt that if we did not provide this very important service, we would see adverse consequences, including increased morbidity, mortality, hospitalizations, ICU [intensive care unit] admissions, and increased lengths of stay.”

Guntupalli says she and her team had drafted a proposal for a county-funded sleep laboratory some 10 years ago. However, like most good things, it took time. Over the years, the county started seeing an increasing number of requests for sleep studies, and an overwhelming number of its patients were found to indeed have sleep disorders.

“We began conducting sleep studies on the poor population in private labs,” says Amir Sharafkhaneh, MD, director of the sleep program at the Baylor College of Medicine. “The county was paying the private labs, but we demonstrated how it would be more cost-effective and better coordinated care if we set up in-house clinics and a lab.”

While the administration was cautious at first, it soon realized the wisdom of starting an in-house service for increasing efficiency and reducing expenditures. Indeed, aggressively screening and treating sleep problems is saving the county money in the long run. Left undetected, sleep disorders may lead to a host of problems, including heart attacks and strokes, which would require more of the county’s medical resources.

“We’re very lucky to be in a county that understands how fiscally prudent this approach is,” says Shyam Subramanian, MD, DABSM, medical director of the HCHD Sleep Disorders Center and an assistant professor at the Baylor College of Medicine. “As we continue to grow, we’ll be helping the county by reducing health care utilization.”

Great Treatment, Low Co-pays
Once the county signed on to the proposed plan, it went all out. The HCHD Sleep Disorders Center comprises two clinics—one at Ben Taub Hospital and one at LBJ. In addition, LBJ now has a state-of-the-art sleep laboratory that rivals some of today’s most sophisticated private laboratories.

The center’s sleep medicine team is also top notch. It includes approximately 10 board-certified physicians and senior faculty members from both Baylor and the University of Texas, fellows from both medical schools, and eight board-certified sleep technicians.

At the clinics, sleep physicians see approximately 35 patients per day. There is no charge to the patient for a clinic visit because the clinics are entirely funded by the county. “Approximately 5% to 10% of our patients have Medicare or Medicaid; another 80% to 90% have no insurance at all,” Subramanian says. “Essentially, the county is providing them with free medical care.”

Fellows specializing in pulmonary care and sleep medicine from both the Baylor College of Medicine and the University of Texas are the first point of contact. “We have had a fellowship in sleep medicine for many years,” says Bela Patel, MD, DABSM, codirector of the HCHD Sleep Disorders Center. “The opportunity for fellows to see patients and learn from them in the center is invaluable, and the partnership between the two institutions is a model of collaboration.”

Patel says there is a multidisciplinary approach to the treatment plan. At the clinics, patients are given a questionnaire, interviewed, and shown educational videos on sleep apnea. Fellows gather a detailed patient history and conduct a physical evaluation. If a sleep study is ordered, the patient is responsible for a $50 co-pay.

The four-bed sleep laboratory is open 6 days per week, Sunday through Friday. The center’s professionals conduct more than 1,000 sleep studies annually. Demand is so high that patients must wait approximately 1 month from the time the sleep study is ordered before they are admitted for testing.

The laboratory is equipped with the latest technology. The medical team conducts all of the major tests a private laboratory is equipped to perform. Typical procedures include split-night studies for apnea, daytime sleep studies or multiple sleep latency tests (MSLTs), and sleep studies with seizure montages. Fellows from each school alternate months, interpreting the studies and discussing results with patients.

The county has gone to great lengths to create a patient-friendly environment at the sleep laboratory. “Patients are surprised by the quality of our facility,” Subramanian says. “It looks like hotel rooms; it doesn’t have that clinical or institutional atmosphere.” The center’s sleep laboratory even provides patients with a continental breakfast the morning after the test.

Moreover, the staff is highly sensitive. “When you go to bed somewhere—in an unfamiliar place—you’re vulnerable,” says Mary Mahaffey, BA, RPSGT, the laboratory supervisor. “We try hard to make the patients feel comfortable.”

Indigent Patients Pose Challenges
Approximately one third of the HCHD Sleep Disorders Center’s patients are Caucasian, one third are Hispanic, and one third are African American. About half are male and half are female. They range in age from 20 to 80, with another 10% being children under the age of 16. One thing they have in common: They are all poor.

The HCHD sleep medicine team says that serving inner-city, low-income patients poses a host of unique challenges. For starters, while the mean age of patients is just 45, many already suffer from overall poor health. This is likely due to a variety of factors, including financial hardship, stress, and poor nutrition.

“Our patients have more illnesses and complications than the typical person,” Mahaffey says. “To work here, you really must know a lot about patient care.”

Obesity, hypertension, diabetes, and lung problems are common issues the team encounters on a daily basis. Technicians have to be particularly careful when prepping diabetic patients’ legs so as to avoid infections later. Furthermore, lung problems make CPAP titration a challenge.

“This is a very sick population that needs coordinated care,” Sharafkhaneh says.

Then there is the financial issue of how patients pay for a CPAP unit, something the county does not provide. “These patients have no resources for anything,” Subramanian says. “So we had to find a way to help them pay for their CPAP equipment.”

The center’s sleep team reached out to a number of durable medical equipment (DME) providers and asked for help. Several were willing to provide the center’s patients with a vastly reduced installment payment plan to help them afford the equipment needed for treatment. Under the plan, patients pay $20 to $30 per month—interest-free—for 1 year. Ultimately, they own the equipment for less than 50% of the actual cost.

In addition, respiratory therapists from the DME providers visit patients regularly and offer them free replacement masks. Pharmaceutical companies, too, have been generous. They supply the sleep physicians with free medications—such as certain costly drugs used to treat narcolepsy—for distribution to patients.

Still, there are other financial issues. With many patients living below the poverty level, it is not unusual for them to be without basic amenities like electricity. “We even call and write to electric companies on behalf of our patients asking them not to shut off the electricity,” Subramanian says. “We explain that without electricity, they cannot continue their CPAP treatment.”

And what about compliance? One might think that the struggle to make ends meet could leave this group depressed and distracted, and therefore less compliant than the average patient. But the center’s sleep staff says compliance is not a major issue of concern.

“The vast majority of our patients adhere to treatment,” Subramanian says. “We rarely get a ‘no show’ for follow-up [appointments], because we give them the message that their disease can be treated and that, in turn, can improve their lot in life.”

Even so, keeping track of patients is a challenge. A permanent address is the exception, not the rule. Many move from one low-income housing option to the next. Others reside in shelters, and still others move in with friends or family when they can no longer afford to pay the rent.

“Maintaining a correct phone number on file is a big issue,” Mahaffey says. “We always ask for a second number so we can track them down if they move on.”

In addition, the center relies on a network of social workers throughout Harris County. This group maintains strong contacts in the community, at local churches, and with other organizations. The social workers help keep the lines of communication open with patients who have no physical address.

With a patient base that is one third Hispanic, the HCHD sleep team has taken measures to address language barriers, too. All medical forms, instructions, and educational information are printed in both English and Spanish. Clinic supervisors at both Ben Taub and LBJ are themselves Hispanic and fluent in Spanish. At the sleep laboratory, one technician and one secretary speak Spanish. Finally, LBJ Hospital has interpreters available 24 hours per day. When necessary, the sleep laboratory calls on them for support.

Spreading the Word
“Our primary goal is to provide a high standard of care in sleep medicine to the indigent population and to thereby improve overall health outcomes,” Sharafkhaneh says. By all accounts, the HCHD Sleep Disorders Center is fulfilling that mission. Outreach efforts have rapidly spread the word, and more and more patients are seeking treatment.

In addition to referrals from satellite clinics, the center’s sleep specialists hold symposiums and make a practice of speaking with the print and broadcast media, including Spanish-language newspapers. But the primary way of spreading the message is word of mouth. Patients simply tell one another about the sleep center. A good number of patients have family members who suffer from similar problems. Once they see how effective the treatment is for a relative, they seek help for themselves.

“Once they get treatment, patients become their own best advocates,” Subramanian says. “They feel better, and instantaneously they see the positive impact on their lives.”

In fact, when the Houston Astrodome housed New Orleans evacuees during Hurr­icane Katrina, word spread quickly about the HCHD’s sleep center. Many of these Katrina victims had lost all their medical records, their CPAP machines, and, of course, their financial resources. Since the hurricane, HCHD Sleep Disorders Center has been treating the transplanted New Orleans patients. Even today, the center’s sleep staff continues to see approximately two evacuees per week.

Training, Research, Expansion
As the center continues its daily work, the sleep team remains focused on long-term objectives. Future outreach initiatives are in the offing. The center plans to launch support groups for CPAP users at one or both of the clinics.

“We have so many walking testimonials from people who were falling asleep at red lights and now they feel alert because treatment has changed their lives,” Mahaffey says. “The goal is to have these folks share their stories so others will be encouraged to try treatment.”

Patel has even grander ambitions. She would like to make the center a leader in sleep research and training for sleep physicians. “We want to make HCHD a center of excellence,” Patel says. “This would include a multidisciplinary approach with nutritionists, psychologists, psychiatrists, neurologists, ENT [ear, nose, and throat specialists], and other health care team members.”  

Indeed, the center already is actively training future sleep physicians and technologists. It is highly unusual for two medical schools to collaborate on a project such as this. The program is successful because there is no competition, but rather a spirit of cooperation. “There is a camaraderie between the two teaching institutions and the fellows involved in the program,” Subramanian says. “It’s a service we are both providing, and we share the workload.”

Moreover, there is a cross-pollination of ideas that fuels the center’s progress. “Each school has a unique education and perspective,” Mahaffey says. “When there are discrepancies on a diagnosis or treatment, there is a great deal of expertise to draw from.”

Finally, with two teaching institutions, the research possibilities are promising. “The faculty at the HCHD Center are very interested in clinical research to improve the understanding of sleep disorders and are in the process of establishing research studies,” Sharafkhaneh says. The center keeps a database of all the patients who have come in for treatment and hopes to utilize it for outcomes research. For example, they are looking at how obesity is connected to sleep disorders.

Guntupalli believes the Center is in a unique position to contribute new insights. “Research questions as they pertain to the underinsured and uninsured, and the African American and Hispanic populations, would be important additions to the literature,” Guntupalli says. “Presently, there is little data available on minority populations and sleep disorders.”

The team’s long-term vision is to make the HCHD Sleep Disorders Center a model of care for health care systems serving inner-city indigent populations. It took nearly a decade to make the center a reality, but soon the team hopes to produce data that demonstrates the positive difference the sleep laboratory has made on overall health care quality for patients while reducing health care utilization costs.

“From the demand for services, I foresee a need to expand the lab,” Guntupalli says. “As we stabilize, streamline, and grow, I hope to see an additional lab on-site at Ben Taub Hospital.”

A second laboratory would mean another important investment decision on the part of the county. But with the success the Sleep Disorders Center has seen so far, chances are the county will not need to sleep on it for long.

Marianne Matthews is a contributing writer for Sleep Review.