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The STEPP Clinic provided the bridge to prenatal care — and peace of mind that Blossom Olmos needed when she first moved to Tennessee. She delivered her son, Aiden Kai, in mid-December, attended by a nurse-midwife at Vanderbilt University Adult Hospital. Photo by Joe Howell.


When 24-year-old Blossom Olmos learned she was pregnant with her first child, her primary care physician referred her to an obstetrician, but there was just one problem. The insurance provided through her employer didn’t cover maternity care and childbirth.

She and her boyfriend, John Haro, were living in California, but they had just decided to buy her parents’ home in Hermitage, Tennessee. As they planned their big move, Olmos worried about the health of her unborn child.

“I think every mother is anxious about problems that might happen,” she said. “I was freaking out because new things were going on with my body, and I had no idea of what to expect.”

DEFINING A NEED

Access to care/ Coordination of care
Does your neighbor have a health care provider? Almost 1 in 4 Americans don’t. Do they have medical insurance? Can they afford co-payments and deductibles? Can they get routine or preventive services that keep them healthy? Do they have health conditions that need multiple medications, services and health care providers? All these factors are challenges when patients don’t have access to health care — or when their needs are complex and involve multiple providers.

Through an internet search for prenatal care options in the Nashville area, she discovered the Shade Tree Early Pregnancy Program (STEPP), a free health clinic jointly operated by the Vanderbilt University School of Nursing (VUSN) and Vanderbilt University School of Medicine (VUSM). STEPP is located at the student-run Shade Tree Clinic in North Nashville, which has provided comprehensive, free medical care to the uninsured since 2004. The STEPP clinic began in 2009 when the clinicians realized there was a growing, unmet need for early pregnancy care for uninsured women.

“Before STEPP, most pregnant women presenting to Shade Tree did not know how to access available insurance plans and did not know who would provide their prenatal care,” said Shade Tree Medical Clinic Director Robert Miller, MD. “STEPP helped them sign up for insurance and made arrangements for them to be seen in established prenatal clinics. The STEPP program was established to put resource with need.”

Now, a STEPP clinic is held one Saturday each month for uninsured women who are pregnant or who believe they might be. The clinic is run by VUSN nurse-midwifery students and VUSM students. It uses a serviced-based, collaborative model in which students work and learn in interprofessional teams while providing evidence-based prenatal care. The students are supervised by certified nurse-midwives who are VUSN faculty. The STEPP clinic is designed to be an access point to care for women, with referrals provided to other Vanderbilt Health providers for continued care beyond the first clinic visit.

Before patients arrive, STEPP clinic volunteers gather for a huddle to go over the day’s plans. Sitting, from left, are Certified Nurse-Midwife Kameron Brainard, MSN’12, nurse-midwifery student Claudia Cornejo and medical student Shilpa Mokshagundam. Standing, from left, are nurse-midwifery students Megan Lewis, Hannah Grogan, Roxanne Crittenden and Mary Flanigan. Photo by Anne Rayner.

“This is an awesome and exceptional program the Medical School and the School of Nursing have undertaken,” said STEPP co-director and nurse-midwifery student Roxanne Crittenden. “Shade Tree is certainly not the only student-run clinic in the country, but I believe we’re the only student-run free clinic that provides prenatal care. All of the students and our attendings volunteer their time on Saturdays so the students can learn and the patients can receive much-needed prenatal care.”

“The stereotype is that the women who come here can’t afford medical care or they are unemployed so they don’t have access to insurance through an employer,” said STEPP co-director Mary Flanigan, a dual nurse-midwifery and family nurse practitioner student. “That is the case sometimes, but we also see many patients who are doing fine financially but for whatever reason don’t have insurance. Many times there’s some loophole, like they have a new job, their insurance doesn’t click in until two months later and they just found out they’re pregnant. It’s people who, for whatever reason, have fallen through the cracks of the main insurance coverage options in our country. It’s nice to be a safety net for these women.”

Empowered and cared for

Soon after Olmos and Haro moved to Middle Tennessee, the couple met the clinical volunteers at STEPP, including nurse-midwifery student and Valere Blair Potter Scholar Claudia Cornejo and medical student Shilpa Mokshagundam, BS’14, who serves as co-director for the clinic. The Vanderbilt students completed a comprehensive health history for Olmos and established her electronic health record. They completed a physical exam and ran a panel of standard prenatal lab tests that screen for and diagnose any problems that could affect the mother’s or baby’s health. In addition, because Olmos was concerned about some heredity issues that might be passed to her child, additional genetic testing was done.

Cornejo said volunteering at the clinic fits with both her professional and personal goals. She was born in Houston, Texas, to an immigrant mother who did not speak English and who had very little family support nearby. Cornejo speaks Spanish proficiently, and she recognizes a great need to provide access to prenatal care for women just like her own mother.

“There’s still a lot of work to do in this country in terms of reaching the medically, economically and geographically vulnerable,” Cornejo said. “If we take a step back and look at this globally, the health of a community begins with the health of women and children. At STEPP, I saw that those women were walking out feeling empowered, respected and cared for. That has positive consequences that we can’t begin to understand.

Left, medical students Shilpa Mokshagundam
and Joshua Latner and nurse-midwifery student Roxanne Crittenden work on records for the
STEPP clinic. Photo by Anne Rayner.

“Nashville’s growing, and I hope that people who arrive here — whether they’re coming from a different part of the United States or whether they’re coming from another country — know that the community at large cares for them. When we make an investment in them, they likewise will make an investment in the health of Nashville.”

Mokshagundam, whose parents immigrated to America from India, became involved with the Shade Tree Clinic during her first year of medical school. Now, as she’s entering her fourth year with a planned specialty of obstetrics/gynecology, she’s volunteering at the STEPP clinic. In addition to caring for women in need, the teamwork aspect of the clinic’s care model has proven invaluable, she said.

“Medical students work with the nurse-midwifery students, as well as with social work students who volunteer,” Mokshagundam said. “Eventually, we’re all going to be practicing together, but our educational systems are so siloed. The nursing students do such a great job of taking a complete social history and  understanding the supports and barriers for a patient. We’re not trained in that as much in medical school. I’ve loved working with them and seeing how even first-year nursing students are able to open up the conversation so easily.”

Beyond access to care

In 2016, the students created a new position, STEPP outreach coordinator, to better reach both potential patients and volunteers. Future plans include compiling data on outcomes to validate the clinic’s impact on the health of women and their children in the Middle Tennessee area.

“Hearing stories from the women and getting out in the community has really opened my eyes to that fact that giving people access to prenatal care isn’t just about being a care provider,” said STEPP Outreach Coordinator and nurse-midwifery student Piper Hays, BA’17. “There’s so much more than that. As a future provider, I hope to incorporate things I’ve learned here and make sure I fill other needs that women might have that could be obstacles to them getting the prenatal care they need.” Hays, who holds the VUSN La Juan Furgason Memorial Scholarship, says she’s learned that transportation, language barriers and partnership issues can be such obstacles.

After her medical appointment was complete, Olmos met with a social worker who also volunteers at the clinic. Together, they completed the required paperwork for insurance coverage through Medicaid/ TennCare and CoverKids for Olmos and her baby. Then Olmos’ future obstetric visits were scheduled with a Vanderbilt certified nurse-midwife at another clinical location. She delivered a son, Aiden Kai, in mid-December, attended by a nurse-midwife at Vanderbilt University Adult Hospital.

“I hadn’t actually told my parents yet that I didn’t have insurance that would cover my pregnancy,” Olmos said. “After my clinic visit, I called and told them, ‘Don’t worry. I found this awesome place that’s taking care of me!’ I can’t say enough about the clinic. They connected me to so many new resources and got me set up with insurance. They answered all my questions and calmed me down completely.”

by Jill Clendening

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