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Invest In The Wellbeing of PLWHA To Prev …

Invest In The Wellbeing of PLWHA To Prevent New Transmissions

This is the second in a series of four Q&A posts capturing founder Bruce Richman’s perspectives on our movement to end HIV stigma with U=U, Prevention Access Campaign, and all of us. Recently he talked with us on DAP LIVE.

Question

We don’t talk enough about how stigma can prevent us from getting HIV testing.

If someone who’s HIV positive can access medication, they can live a very long life. But if they don't know that they have HIV and they don't access medication, there can be all kinds of complications.

Tell me about U=U’s role in ending the epidemic. Because if we don't know our status, and if we don't have access to the medication we need, we're not going to end the HIV epidemic. Also, why is stigma still so prevalent?

Answer

Initially I didn't understand that U=U had a role in ending the epidemic in terms of preventing new transmissions. I always really focused on improving the lives of people with HIV and ending the stigma that we have faced for so long. But in terms of ending the epidemic, U=U is essential. Dr. Fauci says, “U=U is the foundation of being able to end the epidemic,” because the more people who are on treatment and undetectable, the fewer new transmissions there'll be.

So in the United States, when you realize half of the people living with HIV are not on treatment and not in care, and they're not getting the treatment and care or the services, they need to stay healthy.

They're also not getting those services that they need to stay un-transmittable. So if we really want to end the epidemic and save lives, we're going to make sure that we invest in the wellbeing of people living with HIV, so they can stay healthy and prevent new transmissions. We need to link investing in the wellbeing of people living with HIV to ending the epidemic. Because when you invest in the wellbeing of people with HIV, you prevent new transmissions. And that's a big deal.

HIV stigma is intertwined with all kinds of stigma. There's sex negativity, homophobia, transphobia, stigma against people who inject drugs and sex workers. And that deep-seated negativity against all kinds of STIs. HIV stigma is particularly embedded in this country because of the last 35 years of mass fear-based messages. And what we remember since the early days of the 1980s.

It’s something that is really hard to unlearn decades of fear of HIV and people living with HIV. It'll take a long time. That's why we have to keep saying it— “U=U.”

People living with HIV cannot pass it on if you make sure that all of us have the treatment and the care that we need to stay healthy. We're not going to pass on HIV. There's no fear. You can have sex,  babies, love—all with no risk.

Question:

When you started this, did you think it would become a global human rights movement?

Answer:

We launched U=U four years ago. No, I didn't think it was going to be like this. I've always been really behind the scenes with my work in the past. I just knew this had to be done. We had targets, we had the CDC, we had UN AIDS, World Health Organization, public health associations, and research associations.

We were very focused in terms of who we needed to move forward and our advocacy. And we had numbers, I think at the end of the first year, we're going to have 75 in the U.S. and we had already had 200 at that point.

This just goes to show the power, the passion and the brilliance of people living with HIV around the world who are standing up to change the narrative about their bodies. And to reclaim our lives from public health systems that are deeply, inherently flawed, racist and paternalist—all those “isms” that prevented this life changing information from getting to us all those years.

It's almost a thousand organizations in 101 countries. Now it's just, it's phenomenal. And so many different languages.

Preventionaccess.org has a lot of information, including social shares that allies can use. It's got tips about the language that we should all be educating ourselves about. It’s science-based, and values fact over fear.

Get Access To the Care You Need

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Callers can access One Call service by calling 760-992-0426, Monday – Friday, 9am – 4pm PDT.

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Get Insurance and Care with DAP — In J …

Get Insurance and Health Care 

One Call is a service that can enroll callers in health insurance or Medi-Cal through Covered California, register them for medical and behavioral healthcare, and schedule their first appointment at DAP — all in approximately 45 minutes. This is a significant reduction in the amount of time this would normally take, thanks to a DAP Healthcare Navigator who will work one-on-one with each caller.

Callers can access One Call service by calling 760-992-0426, Monday – Friday, 9am – 4pm PDT.

The DAP campus is open for in-person visits. Also, many clients have started connecting and accessing care with Virtual Visits, accessed through MyChart with their doctors and therapists as an alternative to coming to DAP in person.

Accessing great care from wherever they are, patients are using this easy tool on smartphones, tablets, PCs and Macs with an Internet connection and a web cam.

Syphilis Rate Rising Significantly in Co …

FOR IMMEDIATE RELEASE
Contact:
Bruce Weiss, Director of Community Health
Desert AIDS Project (D.A.P.)
Tel:  760-323-2118 x455
Email: bweiss@desertaidsproject.org 

Syphilis Rate Rising Significantly in Coachella Valley as STDs Reach All-Time High in U.S.

Desert AIDS Project urges all sexually-active individuals to protect themselves, test routinely, and seek needed treatment. Gay and bisexual men at especially high risk and should test every 3 months.

PALM SPRINGS, CA, (October 20, 2016) –  Newly-released data from the Riverside University Health System (RUHS) shows that the rate of syphilis in the Coachella Valley is rising significantly. The troubling trend mirrors a just-released report from Centers for Disease Control and Prevention (CDC) which shows the number of sexually transmitted disease (STD) cases has hit an all-time high nationally.

Desert AIDS Project and its sexual health clinic, The DOCK, are urging all sexually-active individuals to get tested regularly for STDs, get treatment if needed, and to use condoms to prevent the spread of infections such as syphilis, gonorrhea and chlamydia – particularly if having sex with multiple partners.

Syphilis rates in the Coachella Valley – as high as 192.3 per 100,000 in one zip code – are astronomically and alarmingly higher than the national rate just announced by the CDC as an unprecedented high in the United States:  7.5 per 100,000. The rise of the syphilis rate among local men is of particular local concern. According to the RUHS Public Health report Syphilis Incidence in Coachella Valley, 2015:

  • Syphilis rates more than doubled from 2013 to 2015, from 14.7 to 30.9.per 100,000.
  • Nearly 98% of all cases are among men.
  • The most impacted age group is 40 to 64.
  • In 2013 there were no cases in individuals 65+ old, however, in 2015 there were 6 cases in this age group – potentially signaling a new trend.
  • In 2015, Palm Springs and North Palm Springs continued to have the highest rates by a substantial margin.   Per 100,000 individuals, zip code 92258 had 192.3 reported cases, followed by 92264 with 167.1 cases and 92262 with 165 cases.  These three zip codes also saw large syphilis rate increases from 2013 to 2015.
  • Many Coachella Valley cities saw significant syphilis rate increases between 2013 and 2015.  Exceptions were a drop in cases and rates for Rancho Mirage, and almost all zip codes in Palm Desert, Thousand Palms, Indian Wells and La Quinta.
  • The largest number of cases and increase in rate between 2013 and 2015 were seen among individuals who identified as white, followed by those identifying as Latino/Hispanic.

Based on these findings, gay and bisexual men between 40 to 64 years old who live in Palm Springs or North Palm Springs are at particularly high risk for syphilis and other sexually transmitted infections.

According to Dr. David Morris, Chief Medical Officer for Desert AIDS Project, “The data and trends are troubling.  Syphilis sores increase the risk of spreading HIV. We also know that HIV can speed the progression of syphilis – a disease which can cause permanent physical damage.”

Fortunately, individuals can take effective steps to protect themselves from STDs and their harmful effects.  Stated Bruce Weiss, D.A.P.’s Director of Community Health: “The combination of condom use and STD testing is crucial to protecting yourself and to ending the spread of syphilis in our community.”

“Many people will have no symptoms and may not know they’re infected;” he continued.   “Syphilis symptoms can often look like other illnesses.  That’s why regular testing – every three months if you’re sexually active – is so important.”

For individuals taking pre-exposure prophylaxis (PrEP) medication, “Remember that PrEP does not protect you from STDs, including syphilis.  Routine use of condoms is effective,” Weiss added.

According to the annual Sexually Transmitted Disease Surveillance Report just issued by the CDC on October 19, the reported number of STD cases has reached an unprecedented high in the United States. Chlamydia, gonorrhea and syphilis are the three most commonly reported conditions.

“We have reached a decisive moment for the nation,” said Dr. Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “STD rates are rising, and many of the country’s systems for preventing STDs have eroded. We must mobilize, rebuild and expand services – or the human and economic burden will continue to grow.”

The CDC report stresses that an effective response to the STD epidemic requires engagement from many players.  Specifically, they advise:

  • Providers: make STD screening a standard part of medical care, especially in pregnant women. Integrate STD prevention and treatment into prenatal care and other routine visits.
  • Public: talk openly about STDs, get tested regularly, and reduce risk by using condoms or practicing mutual monogamy if sexually active.
  • Parents and providers: offer young people safe, effective ways to access needed information and services.
  • State and local health departments: continue to direct resources to people hardest hit by the STD epidemic and work with community partners to maximize their impact.

For a link to the RUHS Public Health report Syphilis Incidence in Coachella Valley, 2015, visit The DOCK website www.thedockclinic.org   

For more information from CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, visit www.cdc.gov/nchhstp/newsroom.

About Desert AIDS Project

Desert AIDS Project (D.A.P.) is a Federally Qualified Health Center in Palm Springs, CA offering a combination of medical, dental, counseling, social services, support groups, alternative therapies, in-house pharmacy and lab, and other health and wellness services.  D.A.P.’s Get Tested Coachella Valley campaign, the nation’s first region-wide HIV testing and access to care initiative, was recognized by the White House for helping to bring about an AIDS-free future.  D.A.P. is rated a “Top 20 HIV Charity” by About.com. Visit www.desertaidsproject.org, www.TheDOCKclinic.org, and www.gettestedcoachellavalley.org to learn more.

About The DOCK

The DOCK sexual health clinic at Desert AIDS Project provides comprehensive sexual health services, information and support. The clinic’s quick, caring, and confidential services for individuals of all gender identities include: STD testing & treatment, Pre-Exposure Prophylaxis (PrEP) and Post-Exposure Prophylaxis (PEP), and free HIV and HEP-C testing.  For more information, please visit www.TheDOCKclinic.org.

Meet the Provider: Dr. David Hersh – L …

Dr. David Hersh, M.D., Chief Clinical Officer, joined Desert AIDS Project in early 2013 as a staff Psychiatrist and accepted the position of Chief Clinical Officer in January 2016 after serving as Director of Clinical Services for the prior two years.  He continues to manage a patient caseload in addition to his administrative duties.

As Chief Clinical Officer, Dr. Hersh oversees the development, delivery, and integration of all medical, behavioral health, home health, social, and dental services.  He also supervises Informatics & Compliance to include medical records and information technology. His primary duties consist of the development, implementation, and monitoring of policies and procedures, quality improvement, meeting goals of fiscal efficiency through billing and budget management, and leading initiatives to enhance collaboration and communication with internal and external stakeholders.

Dr. Hersh has been practicing medicine for 27 years, becoming a Diplomat of the American Board of Psychiatry and Neurology in 1992.  After graduation from Johns Hopkins University in Baltimore, Dr. Hersh received his medical degree from the University of Medicine & Dentistry of New Jersey – Rutgers Medical School, followed by post-doctoral work in psychiatry at the Yale University School of Medicine in New Haven, Connecticut.

Dr. Hersh has been a professor of psychiatry at the University of Connecticut Health Center, and at University of California – San Francisco. Prior to his work at Desert AIDS Project, Dr. Hersh served as Medical Director of Substance-Use Treatment Services for the San Francisco Department of Public Health.

Meet the Provider: Anthony Velasco – S …

Please join us in welcoming Anthony Velasco to the Desert AIDS Project medical team. Mr. Velasco is an Adult-Gerontology Primary Care Nurse Practitioner and has been working in HIV care since 2010. Prior to joining the Desert AIDS Project, he worked as a clinical nurse supervisor at UC San Diego Health in an acute medicine unit specializing in HIV, tuberculosis, hepatitis, opportunistic infections, and AIDS-related cancers.

Mr. Velasco earned both his undergraduate and graduate degrees from San Diego State University, graduating top of his class. He is trained in two advanced practice nursing roles – Nurse Practitioner and Clinical Nurse Specialist. In addition to being a board-certified Nurse Practitioner through the American Nurses Credentialing Center, Mr. Velasco was also awarded board certification in medical-surgical nursing and AIDS care nursing. In 2014, he was honored with the Academy of Medical-Surgical Nurses Career Mobility award. He belongs to the American Academy of Nurse Practitioners, Association of Nurses in AIDS Care, and Sigma Theta Tau Honor Society of Nursing.

In each of his academic and professional endeavors, he derives the greatest joy from building relationships with his clients, and from collaborating with all members of the transdisciplinary team to offer caring, comprehensive, and compassionate care.

Mr. Velasco is passionate about global health and HIV/AIDS care and has participated in medical missions to Honduras and Haiti. He recently relocated to Palm Springs, September 2016, with his 20-lb cat, Mochi. Although he misses surfing and paddle boarding, he is very eager to explore the gorgeous hiking trails of the Coachella Valley. He is very excited to be a part of the Desert AIDS Project.

*As a part of our new EPIC E.H.R., patients of D.A.P. can click on the Patient Portal button at the top of the website to be taken to My Chart, an interactive tool for online advice from a provider, as well as access to health information and test results, the ability to make appointments, to request prescription refills, and more. Visit the FAQ page to learn more about My Chart. You can even download the My Chart app for iPhone or Android.

Supporting the transgender community

When it comes to helping transgender individuals on a day-to-day basis … whether that means finding a job or accessing culturally-competent medical and psychological care … it’s all about putting aside the stereotypes and embracing people for who they are.

That was clearly the main message to the crowd of about 60 who gathered for Trans Pride 2016 at the Tolerance and Education Center in Rancho Mirage on June 28. The event was sponsored by D.A.P., using a portion of a grant from Riverside University Health System.

The message was reinforced – with a call to self-empowerment – thrown in by keynote speaker Aydian Dowling, the 27-year-old trans bodybuilder, activist, and vlogger who’s recently appeared on TV’s “Ellen” and has a popular YouTube channel called “ALionsFears.” Though Dowling didn’t win a competition to land the cover of Men’s Health magazine – a 2015 campaign backed by thousands – he was eventually featured on a special edition cover with other men. Little wonder that a recent Gay Times magazine cover featured a photo of his tattooed torso with the headline “What a man! The incredible journey of Aydian Dowling.”

D.A.P. Clinical Psychologist Dr. Parker discussed updates in medical and mental health treatment for the transgender community. Emerging best practice models promise to be less stigmatizing and more inclusive of input from the transgender community. Because transgender health care is an evolving practice, Dr. Parker recently attended a four-day education initiative by WPATH—the World Professional Association for Transgender Health—in Atlanta to sharpen his skill at treating transgender clients.

“Over the last five years there have been major changes in mental health approaches for transgender clients,” Dr. Parker says. “Access to services has grown, in part because of the Affordable Care Act. Clinicians and organizations can get new information and models for best practices that previously were hard to acquire if you didn’t live in a major center for transgender health.”

Examples of the new information includes Injustice at Every Turn, an exhaustive survey of 6,450 subjects documenting “in horrific detail” the discrimination that often befalls transgender people and its effect on their mental health. Significantly, the distress that comes from feeling the gender assigned at birth is wrong for you is now called “gender dysphoria” instead of “gender identity disorder.”

Dr. Parker says he believes those who changed the definition in the manual of mental disorders, DSM-V, listened to the transgender community. The goal was to stop labeling the condition a sickness, while maintaining a diagnosis that allows insurance to cover hormone, surgical and other care that might be needed.

Beyond health care, D.A.P.’s Career Building Coordinator Valerio Iovino – who helps D.A.P. clients find jobs, return to school, or gain valuable volunteer or internship experience – spoke to the crowd about innovations in support for the transgender community. For him, offering support is simple: fight the stigma that the world attaches to transgender job applicants and focus instead on their skills and knowledge.

“We don’t worry about the way people look,” Valerio told the applauding audience. “We focus on what they can do.”

Photo by Luis Alberto Gavela

Women’s Empowerment Day invites sharin …

The female clients of Desert AIDS Project will be front and center, as they receive manicures, massages, and sisterly love during the second annual Women’s Empowerment Day on May 21 … and it’s going to be all about health and wellness for women living with HIV and AIDS.

They’ll learn more about their unique health and emotional issues from leading specialists. A favorite from last year’s event, Dr. Laveeza Bhatti, MD, PhD., Director of the Hep C/HIV Co-Infection Clinic at AIDS Healthcare Foundation in Los Angeles, is returning with more good advice. Dr. Bhatti is an infectious disease specialist, who has worked with female HIV-affected patients for years. Dr. Bhatti will be joined by Jill Gover, PhD., director of Mental Health Services at The LGBT Community Center of the Desert. As a clinical psychologist, Dr. Gover specializes in addiction, anxiety, depression, aging, and LGBT issues.

“The Women’s Empowerment Day is important because we want our female clients to know we’re here to support their needs, just as we do their male counterparts,” says Brett Klein, Events and Retail Marketing Manager, who, along with Denise Marvel, Human Resources Coordinator, is organizing the day. Brett noted he and Denise want to introduce women to the many workshops, support groups, and alternative therapies offered at D.A.P.

Janine Bell, Substance Abuse Specialist who leads our Women’s Empowerment Group, explains that reaching women, who comprise about 5% of D.A.P.’s client base, is difficult because they’re not as “out” about their HIV-positive status as gay men. Many of them are low-income single mothers who don’t hang out around D.A.P.’s campus and mingle. “After completing their medical, dental or case management appointments, they bolt,” Janine observes.

That’s why Brett feels it’s important for D.A.P. to extend a special invitation to women to let them know that D.A.P. is here for them, too.

“We learned at our first empowerment day that women experience the disease and its medications differently than men,” Brett says. “And there are very few outlets for them to learn about HIV the way they know it and share that knowledge with others who are going through the same thing.”

Last year, Dr. Bhatti explained HIV from a woman’s perspective and fielded questions that were both illuminating and touching. There were tears and reassurance among the audience of about 18 women, who shared their experiences. Dr. Bhatti applauded the size of the crowd saying it was unusually large for an event held by an AIDS service organization for women.

The second annual Women’s Empowerment Day will be held from 9:30 AM to 4 PM. on May 21 at D.A.P.’s main campus. The “safe space” day will include a session on building confidence and coping skills, a back-to-work career building seminar, breakfast, lunch, manicures, and massages.  Childcare services are available on request.

If you’d like to attend, please RSVP on or before May 11 by calling 760.992.0419.

Revivals Palm Desert soon to be “El Pa …

“Location, location, location” might be a realtor’s cliché but it still drives every retailer’s decisions about where to place their new store.

Location – to the third power — has driven Revivals Palm Desert to move from its location just off I-10, at 72-750 Dinah Shore Drive near Costco, and relocate seven miles south down Monterey Avenue to 72-885 Highway 111 near El Paseo. Still in Palm Desert, the new store will have the Westfield mall across the street and the posh El Paseo shopping district behind it. This popular corner at 111 and Monterey is awash in traffic that promises to drive Revivals sales skyward, according to Dane Koch, our Director of Retail.

“The move is all about location,” Dane says. “The store near Costco was so hard to find because we had no visibility from Dinah Shore.” With such heavy reliance on Costco shoppers, to sustain our business, the location offered little ability to grow. Expanding is essential for Revivals to continue its important contribution to D.A.P.’s diversified revenue stream to provide patient and client services.

“The new location on 111 offers great visibility. We believe we’ll retain our current shoppers while gaining new ones,” Dane smiled. “Being located in a strip mall with other successful retailers will greatly increase our traffic and sales. I believe we’ll see a corresponding improvement in the store’s profit. And every one of our 55 volunteers and six paid staff are committed to help us do that in support of D.A.P.’s mission.”

While he declined to elaborate, Dane hinted that this new location will have a closer affiliation with D.A.P.’s 100 Women annual giving program. Watch for details in future issues of DOSE

Foot and vehicle traffic abound at the new location in the shopping center that’s anchored by Staples office supply center and Rite Aid pharmacy. At 15,000 square feet, the new store will be a bit smaller while still retaining the mod-meets-vintage flavor of Revivals, which sells new Mode furniture, along with gently used clothing, housewares, appliances and more.

While a formal Grand Opening date is still pending, the new location will have a “soft opening” on Saturday, May 28, offering a $25 coupon on every purchase of $50 or more. The coupons will be good for the entire month of June. The old location will remain open until very close to that date.

 

D.A.P.’s nutritionist prescribes good …

The health care world, including Desert AIDS Project, looks at nutrition as a key part of good health. That’s why Gustavo Wong, registered dietitian and certified exercise physiologist, joined us about eight months ago as yet another facet of D.A.P.’s holistic approach to the care of our patients and clients.

Food is medicine for all of us, particularly for those living with HIV. “As a way of eating to live a healthier life, I recommend less processed food while choosing more natural items from a specific array of food groups,” Wong says. “Those groups are vegetables, fruits, and whole grains as good sources of carbohydrates, along with protein from meats and healthy fats.”

FoodPlate1As a primary guideline to healthier eating, Wong recommends the “plate method.” The basic idea is to have half of the plate devoted to non-starchy vegetables with a quarter for proteins and a quarter for carbs. However, Wong does tailor recommendations to the needs of individual clients. For example, some foods aggravate gastro-intestinal systems of certain patients, announcing their presence in the form of diarrhea, constipation, or nausea.

“Fats generally are the culprits,” Wong says, “so I want to make sure clients don’t have GI problems. If they do, I adjust their diet accordingly.”

The non-starchy veggies on half the plate include salads, asparagus, beets, mushrooms, broccoli, cucumber, and spinach. Denser carbs that make up a smaller part of the plate include beans, lentils, peas, winter squashes, sweet potatoes, bread, pasta, and corn. Red meat, chicken, eggs, fish, nuts and nut butters round out the plate with protein. On colder days, some people prefer to have vegetable soup, as a way of incorporating those all-important vegetables into their diet.

For breakfast, Wong recommends such items as cereal with nuts and fiber, such as flaxseed meal, or by adding some bran. Regardless of which meal, we all still need the foundation of “macronutrients” – carbs, protein, grains, and healthy fats – to help build a strong immune system. And taking a lot of supplements is no substitute for a balanced diet.

Neither is processed food. Wong insists that the nutrients that have often been removed, limited, or destroyed in food processing are essential for all of us.

Click to watch the tasty video 

HIV and its care pose special challenges …

There are some dental health issues pressing on those living with HIV and AIDS that we should illuminate in February, when National Dental Health Month is marked.

Our dentists, Dr. Ryan Yamashiro and Dr. Daniel Jo, both graduates of Loma Linda University School of Dentistry, agree that some of these concerns weigh more heavily on many of our patients than they do on those who are not HIV-positive. The doctors describe those special challenges and what they do to help.

How important is good dental hygiene for those with HIV?

Dr. Jo: In general, it’s really important for any patient to have good oral hygiene. But yes, some of the medications our patients take can create complications of the mouth.  If you don’t have good dental hygiene you can experience more problems such as gum disease and cavities than a person who isn’t HIV positive might face.

What are some of the oral challenges faced by people living with HIV?

Dr. Yamashiro: Some of the patients have candidiasis, (a fungal yeast infection also known as thrush.)  They take a lot of medications so decay can be accelerated with them. Many also suffer from dry mouth due to some of the medications they’re taking and that also can cause decay. They also have problems with dry mouth in general. They just don’t really salivate that much and it can cause a lot of problems. We try to help manage all of that with them.

How much of that do you see here at D.A.P.?

Dr. Jo: It’s a pretty common problem. It can affect their condition in terms of their HIV.  That goes back to oral hygiene. In general, it’s important to have a healthy oral environment by maintaining the teeth they have, avoiding gum disease, and trying to keep them as healthy as possible.

What do you do about dry mouth that’s a function of HIV, or the amount, or type of medications the patient is taking?

Dr. Yamashiro: Sometimes there’s not a lot you can do. We can prescribe Salagen, (which stimulates salivation), to patients. For some it works, for some it does not work. There’s also salivation replacement therapies they can buy at the store: ACT mouth wash and Biotene spray to name a couple. But they’re all quick fixes that don’t last all day. So, for a lot of patients, it’s difficult to take care of the problem 100%. Sometimes they have to work with physicians to get off those meds or change them. But for some that’s just not possible. They have to suffer with the dry mouth that leads to plaque build-up and tooth decay. It’s frustrating to them because they brush and floss and still get decay.  A lot of times it’s emotionally draining, because they say ‘why should I try when I still keep having this problem?’

Are there any changes in the dental clinic that we ought to know about?

Dr. Jo: Now that we’re a full Federally Qualified Health Center, it’s good for our patients and our workflow as well. The biggest change is we’re growing: They brought me in as the second full-time provider; we have another part-time hygienist; we have more assistance at the front desk. It’s good. We’re starting to scale up so we can provide more services to more patients. In terms of that, I think we’re on the right path.

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