"Just imagine how a family would be eaten up by the cost of treatment and medications," says patient case manager, Alexandra "Andra" Lawson, R.N., as we end the day

with visits to several of her limited-income and uninsured patients.

"Add to that the concern about your illness and trying to get care. It's devastating."

Lawson understands the problem all too well. She is on the frontlines of the growing health care crisis as part of a community health network that seeks to help those without health care benefits or the financial means to access care. Her practice area includes limited-income uninsured patients registered with the Moore Free Care Clinic, or with other physicians' offices, as well as some Medicaid recipients.

She visits patients in their homes to educate them about their chronic health conditions and helps them "deal with a lot of life issues" that are affecting their health situations.

"The world can be very ugly, and for some, its gets a lot worse before it gets any better," she says.

Lawson readily acknowledges that visiting patients at their homes gives her work another dimension -- and sometimes, it is heart-wrenching.

"When you visit at home versus the physician's office you see what their world is like so you are able to better assess their situation and real need," she says.

She says she sees "the real need" too often in Moore County -- a family without running water, electricity, or worse -- without food.

"That's what makes this work so critical," she says. "I see it as a challenge to fix it for them, and I don't let go of the issue until I feel I've done all I can to resolve it."

Problem-Solving Skills Required

Lawson's position is funded as one component of a state grant, HealthNet, acquired and administered through MooreHealth in partnership with Sandhills Community Care Network, FirstHealth of the Carolinas, and the Moore Free Care Clinic. She brings seven years of nursing skills in step-down, critical care, and home health to help her navigate the system.

"This job is not predictable; it's not your usual nursing care -- it involves so much more," she says. "You do not know what will be thrown your way next. But I love problem-solving."

Given the freedom to think outside the box and find solutions for her patients, she is improving not only their health, but also their lives. In addition, she brings her considerable resources, including her "bulldog tenacity" to find the best solutions for each patient.

"Sometimes, it's a health care issue," she says. "I may need to get a consultation with a specialty doctor, or help a patient get enrolled in the Patient Assistance Program, which gets them medications at no cost. Other times, it is a housing or food issue."

Lawson says one of the biggest problems for the clinic's patients is transportation. She spends a lot of time trying to get transportation for her patients to get to their medical appointments.

"It's a very big issue now with the price of gas, and it is so critical that they get to their appointments," she says, making a mental note of yet another community resource to try to "enlist" in the effort. "If they don't get to the free clinic for their checkups or treatment, it can have a long term effect on their overall health. We don't want them to end up in the ER because they can't get here or get their medications."

Sorting Through the Options

Her patients welcome her home visits for not only the health checkup, but also for her guidance and friendship.

Recently, we visited Martha and Ed, a young couple in Aberdeen. Martha has been a patient at the clinic since 2004, and used to work as a hotel housekeeper. She cannot stand on her feet long because of the painful neuropathy in her hands, feet, and legs, caused by diabetes.

Today, she sits in the tidy living room of her trailer smiling as she recalls Lawson's care.

"I am so thankful that the free clinic sent her to me," she says softly. "She may not realize it, but she inspired me. I have a sense that she really cares about her patients."

Ed sits quietly nearby and is happy for Lawson's encouragement, too.

"We've never been ones to ask for help, it's just not our style," he says.

A patient at the free clinic since 2007, Ed has high blood pressure, high cholesterol, sciatic nerve pain, and is borderline diabetic.

Their income is about $1,000 a month and derived from his employment in both a part- and full-time job. Their meager budget does not leave any room for health insurance premiums -- especially when trying to meet household needs and raising their two sons.

Ed's full-time employer laid him off earlier this year, sending their lives into a tailspin. Then his part-time job was cut back, so he is home a lot. Martha's disability claims continue to be denied despite repeated submissions.

Medication Cost 'Devastating'

Most of Moore Free Care Clinic's patients, like Martha and Ed, suffer from multiple chronic diseases, such as diabetes, hypertension, chronic pain, high cholesterol, obesity, depression, and smoking addiction.

Often they are unable to obtain prescription medications they need to prevent rapid progression of their chronic disease. As a result, many seek crisis intervention care -- usually a visit to the ER, which often results in a hospital admission, for which they are unable to pay.

In Martha and Ed's case, they sought care with a local physician who then referred them to Moore Free Care Clinic, where he also volunteered.

After completing an eligibility review and physical exams, which included lab tests, the clinic's staff enrolled them in the Patient Assistance Program (PAP), a program offered by the pharmaceutical companies, which qualifies them to receive certain medications free each month.

The clinic picks up the tab for medications not covered by the PAP -- Martha's insulin, test strips and lancets, and some of Ed's medications. Those medications are paid for by the clinic's Patient Pharmacy Program, which is funded by the clinic's annual fundraiser, Dining in the Pines.

Their medications, insulin, and testing supplies cost nearly $2,000 a month on the retail market.

"It would break us," says Martha. "There's no way we could pay. I just don't know what we'd do without this care. We are so grateful."

A Community Effort

In addition to providing medications to its patients, Moore Free Care Clinic's integrated care model helps monitor patients for other complications from chronic disease.

With the help of the clinic's staff, Lawson obtained a referral to a physician at the University of North Carolina who tests Martha for nerve damage and to another physician in Durham who treats Martha's diabetes.

Each year Martha also sees Dr. Gregory Mincey, an ophthalmologist from Carolina Eye Associates who provides an eye clinic especially for the clinic's patients suffering from diabetes.

Dr. Phillip Ward, a podiatrist, tends her diabetes-related foot problems. In addition, when she suffered a severe toothache, Dr. Clement Monroe, a dentist and clinic volunteer, pulled the offending tooth.

Martha also credits Lawson for helping her understand, for the first time in her life, the connection between her diabetes and poor diet and lack of exercise.

"I was diagnosed with diabetes in my 20s," she says. " I did not know anything about caring for myself. I ate the wrong things and didn't exercise. She enrolled me in the 'Living a Healthy Life with Chronic Conditions' class [Stanford University Chronic Disease Self Management Program] and it was great. I have goals and I've dropped 20 points off my blood sugar. Now I walk, even if it is painful, just because I know it will help me. I really am very proud of myself."

When her patients make a positive step, even a small one, Lawson loads on the praise.

"They need to know they are achieving a goal, that gives them satisfaction and a certain willingness to stay in line with a program," she says.

Daily Challenges Overwhelming

However, sometimes, it is not the praise but the compassion that makes such a difference.

When Martha started feeling low and isolated herself from family and friends, she got frightened.

"I would stay in bed -- I just couldn't get out," she says. "It was as if I was in a dark pit. Life was too challenging and it was closing in on me."

Susan Craven, the former clinic director, diagnosed Martha's depression, one of the most frequently unrecognized and untreated chronic medical conditions, and obtained a referral to Sandhills Center for Mental Health. Martha has since been referred to a counseling clinic.

"She'd tell me she could hardly move," says Lawson. "She knew she needed to talk to a counselor but she could not summon the strength to make the call. I'd reassure her, check back with her, and make sure that she got to the appointment."

Martha credits Lawson with moving her from this dark time.

"I know I could not have moved out of my depression without her," she says. "The classes made me understand that depression can be a side-effect of chronic disease. Now I know I can't do it all, and I've learned to ask for help."

Despite the family's continuing financial problems, she continues to persevere.

"I have great hope and faith and I am moving forward," says Martha.

Caring Makes a Difference

Lawson is a single mom with three children. Energized by each day's new mission, she says her life experiences, good role models, and understanding the real value of life shape her work.

"It's all about taking care of each other," says Lawson. "It's just what you do. I deal with people who have fallen on hard times, for many reasons. It's important everyone understand how valuable they are, and that they are worth something in this world. If I care about them, then they find it possible to care for themselves. That's when their life turns around."

Donations to Moore Free Care Clinic may be mailed to P.O. Box 161, Pinehurst, NC 28370. For more information about Moore Free Care Clinic, visit www.moorefreecare.org.

Contact Pinehurst writer Claudia Watson at cwatson87@nc.rr.com.