And though video remote interpreting (VRI) services are widely available at Connecticut hospitals, patients have reported mixed experiences with the technology.

The issues persist more than 30 years after passage of the Americans with Disabilities Act (ADA), which requires interpretation for patients and family members under the “effective communication” section of the law. In the last three years, the U.S. Attorney’s Office has negotiated four settlements with medical facilities in Connecticut for complaints related to communication with deaf patients.

“At one point, ADA and accessibility seemed to be very good,” said Marissa Rivera, an advocate with Disability Rights Connecticut (DRCT). “And now, in 2022, it has completely collapsed.”

The reasons are multiple and complex but often attributed to an ongoing interpreter shortage, which makes it hard to consistently secure in-person interpretation, especially during unplanned emergency room visits.

About 5% of the state’s adults have a hearing disability, a rate that jumps to almost 9% among people older than 60, according to U.S. Census figures. There are currently 497 registered interpreters in the state, though not all have the required certifications to work in medical settings.

C-HIT worked with The Daily Moth, a news organization that provides daily video news updates in American Sign Language, to provide an ASL summary of the story along with video interviews with some of the sources. Click play to see the story summarized by journalist Alex Abenchuchan.

Connecticut hospitals and state lawmakers have been meeting with advocates through a work group of the legislature’s Human Services Committee, which proposed a bill to accept additional interpreter certifications and better organize state services for the Deaf.

“I would say it’s a universal issue, meaning across the state, that we’re trying to address,” said Human Services Committee Chair Rep. Catherine Abercrombie, who serves Meriden and Berlin.

Deaf residents can file complaints with a hospital or through state and federal agencies, so it’s hard to get a complete picture of how many complaints have been filed. But DRCT gets weekly calls related to medical interpreting issues, Rivera said.

DRCT helped Mary Pat Donovan, 60, of Vernon, file a federal complaint after a mental health emergency in 2016 led to a three-day stay at Hartford Hospital’s Institute of Living. Donovan wasn’t provided an interpreter and therefore couldn’t participate in group therapy sessions or understand her care, according to her complaint, which was recently settled.

Donovan said the lack of communication during her stay made an already difficult situation harder and resulted in her getting the wrong medication.

“I felt like my self-esteem was kind of crushed,” Donovan said through an interpreter. “I wasn’t able to say what I wanted to say. I wasn’t able to express myself.”

Assistant U.S. Attorney William Brown, the civil rights coordinator for Connecticut whose office investigates complaints, said, “We want to work collaboratively with the hospitals. I would say, most of the time, they are responsive, and they want to do the right thing.”

“In the end, the goal is to make sure the Deaf community can communicate with their medical providers just like anyone else can,” said Brown.

Though video remote interpreting (VRI) systems are becoming more common and often touted for their quick access, they can leave patients stranded if technology issues occur.

“This sometimes comes down to life or death,” Rivera said. “We’ve had cases like that, where on someone’s deathbed, not having VRI working. It’s terrible.”

Sometimes, it may be hard to understand an interpreter through a screen in a medical situation, said Connecticut Association of the Deaf President Luisa Gasco-Soboleski.

“If I’m in pain or on deep medication, there’s no way that the video would work for me,” Gasco-Soboleski said through an interpreter. “It depends on the severity.”

Still, remote services might be the only option in some cases.

“On the one hand, people are saying we shouldn’t use VRI in the hospital because of the tech issues. But on the other hand, without VRI, we sometimes have no one,” said Doreen Simons, an American Sign Language (ASL) instructor at UConn. “I would rather have VRI than no interpreter.”

Simons has seen the issues from both sides: as a deaf patient and as a certified deaf interpreter helping other patients understand their care.

Simons of Farmington had emergency heart surgery at UConn Health Center in 2015. Her interpreter for the emergency room visit was having trouble hearing and couldn’t properly explain to her what was going on. When she woke up from quintuple bypass surgery, only her sister was available to interpret.

Melanie Stengel Photo.

Hospitals should provide interpreters for patients, Simons said.

“That was not appropriate at all,” Simons said through an interpreter. “They need to provide a certified interpreter. They should not be putting my family members in that situation.”

Her two adult children ended up interpreting several of the follow-up conversations with doctors after her surgery—emotionally processing the information while also serving in the official role of informing their mother.

Though Connecticut has been known as a leader in supporting deaf residents, advocates say services have declined in the last 10 years, contributing to problems in medical settings.

The state launched the Commission for the Deaf and Hearing Impaired in 1974, the first of its kind in the country. But in 2011, the commission was converted to an advisory council.

Amid budget cuts in 2016, the Department of Rehabilitation Services cut its sign language interpreting service. That same year, the state’s Office of Protection and Advocacy for Persons with Disabilities was eliminated, and tasks reassigned to Disability Rights Connecticut and the Department of Aging and Disability Services.

“We were the first in the country, and our services were awesome,” said Gasco-Soboleski. “And right now, we have zero. And I see more problems popping up, more problems appearing because there is no training.”

A 1998 Department of Justice consent decree, which required hospitals to provide an interpreter within an hour of notification for at least 80% of requests, expired. As part of the agreement, Connecticut Hospital Association contracted with sign language interpreters on behalf of all the hospitals. Without the decree in effect, advocates say compliance has lapsed.

A spokesperson for the Connecticut Hospital Association declined to be interviewed or answer specific questions through email but issued a statement noting hospitals’ dedication to patient care and work with advocates to address concerns.

Several hospitals, either proactively or as a result of complaints, are working on plans to improve services.

Stamford Hospital, for example, recently launched a long-term staff training on cultural considerations, working with interpreters, and basic sign language. The hospital has 30 video remote interpreting machines and a contract for translation services 24 hours a day in more than 200 languages, including ASL.  It also has a contract for in-person interpretation and relies on 211 if no interpreter is available when needed.

“We have always had the standard of needing to provide appropriate interpretation services for patients,” said Liz Longmore, the senior vice president of ambulatory services and patient experience at Stamford Hospital. “It has become more of a challenge over time.”

About 13% of Connecticut residents said they did not have enough money to pay for food at least once in the previous year, according to the most recent Community Wellbeing Survey conducted by DataHaven in 2018.

Black and Hispanic residents were more likely to struggle, with 23% and 28%, respectively, reporting food insecurity. In several cities, about a quarter of all residents struggle to pay for food.

Urban residents are also less likely to have access to fresh fruits and vegetables, according to the survey. Statewide, about 72% said they had excellent or good access to produce, while the rates were only 56% in New Haven and 51% in Hartford and Bridgeport.

Studies have linked food insecurity to higher rates of obesity, heart disease and diabetes—as well as higher health care costs.

“There’s endless amounts of data that says exercise and vegetables make you healthy,” said Jacqueline Maisonpierre, the former co-executive director for the newly merged New Haven Land Trust and New Haven Farms. Maisonpierre left the organization in mid-February.

Melanie Stengel Photo.

Eunice Castelan Castelan keeps her eye on the instructor a during an exercise and nutrition class at the Martinez school in New Haven. In the back are Georgina Castelan and Juana Rodriguez.

The group is one of several around the state seeking to connect lower-income residents with produce from urban farms. The group’s Farm-Based Wellness Program uses a diabetes prevention curriculum from the Centers for Disease Control and Prevention (CDC). Participants learn to prepare healthy meals with fruits and vegetables during an intensive 20-week summer program that continues monthly through the winter.

About 96% of families reported improvements in their eating habits, with an average weight loss of 4.29 pounds, and an average increase in exercise of 64 minutes per week, according to the 2019 evaluation report.

“For those that it works for, it really works,” Maisonpierre said. “We’ve had a lot of folks who have had a really significant turnaround in their health.”

Bill Flynn is one. When he joined the Farm-Based Wellness Program in July 2018, he weighed 360 pounds.

“I knew [my weight] was an issue for 10 years,” Flynn said. “It got to a point where I was a size 50 pants. I couldn’t put on my shoes, and I had congestive heart failure.”

By January 2020, he was down to 240 pounds. Now Flynn volunteers to help others in the program, even cooking meals for the winter meetings.

“I can’t say enough about how much this program has done for me,” Flynn said.

Ruth Torres joined the Farm-Based Wellness Program in 2012 when her 18-year-old grandson was diagnosed with pre-diabetes.

“It helped him a lot,” Torres said. “Before a year was up, he had lost 70 pounds.”

Torres stayed involved because she saw her health problems, including arthritis, improve through the program. She later became a Community Health Ambassador and is now the program coordinator. She regularly grows her own fruits and vegetables—something she never imagined doing.

“The program has taught me that food can be used as a medicine,” Torres said.

Cristina Sandolo, the executive director of Green Village Initiative, said groups operating urban farms and community gardens contribute to better health in several ways: They increase access to fresh fruits and vegetables. They educate children and teens about healthy eating. And they help residents make money through urban farming.

Melanie Stengel Photo.

Juan Ortiz (L) gets some help from exercise instructor, Amanda Mia (C) during an exercise and nutrition class at Martinez school. At right is Soyla Aguilar.

“We are providing access to 150 families in Bridgeport who can now grow their food for their dinner tables,” Sandolo said. “We hear that the bulk of their vegetables during the growing season come from their plots.”

In Hartford, a mobile farmers market brings fresh produce into food desert neighborhoods. In Stamford, cooking classes help cancer patients use nutritious food as part of their healing plan. At Naugatuck Valley food pantries, a nutritionist is available to help provide recipes for the fruits and vegetables it distributes. In some cities, FoodCorps members are embedded in public elementary schools.

Still, programs to help those in need often go underused. For example, the federal Farmers Market Nutrition Program gives books of checks to mothers, children and senior citizens to buy produce at participating farmers markets. Each year, WIC participants receive $15 books, and senior citizens receive $18 books.

After federal money is distributed, the state offers a second round of checks with its own funding. Yet, the state money often sits untouched, according to  Jaime Smith, who manages the program for the Department of Agriculture. Only 36% of state funding for WIC participants and 77% of state funding for senior citizens, was used in a recent year.

“That’s a lot of money on the table that could be used to feed people and generate income to the farmers,” Smith said.

Some are unaware of the program, but others can’t find transportation to get back for the second distribution, Smith said. It’s just one example of the layers that contribute to food insecurity.

“We believe that urban agriculture is one part of a much larger puzzle,” Sandolo said. “The food system is complex, poverty is complex, and the systems that prohibit folks from living the lives they would like to live are complex.”

Jodie Mozdzer Gil Photo.

Bill Flynn joined the Farm-Based Wellness Program in 2018 and now volunteers to help others and even cooking meals to serve during wellness events.

Martha Page, the executive director of Hartford Food System, says helping people become self-sufficient is a first step. She noted that a decrease in food insecurity in Hartford, from 33% in 2015 to 23% in 2018 according to the Community Wellbeing Survey, followed decreased unemployment in the city over the same period.

“At the end of the day, the best thing that can be done for most people from a health perspective as it relates to food, is they have to be able to afford the food that will make them healthy,” Page said.

She has hope despite data showing continued lack of access in cities.

“You have a right to access healthy food in your neighborhood or within easy reach,” Page said. “More people are thinking about it, and more people are arriving at the notion of food justice and food democracy. That was not a concept that we even talked about when I started this job. More people know what it means when your community is a food desert. I think that’s progress.”

Doctor shortages and long commutes make it harder for rural residents to get­­ health care. And some officials worry that changes in hospital ownership and the Affordable Care Act could amplify existing problems.

Carl Jordan Castro Photo.

Robert Pope of Sharon, uses the Geer Village Senior Center Dial-A-Ride bus to bring him to a doctor’s appointment. He travels 45 minutes to dialysis three times a week.

“We have excellent medical care as a general rule in the state,” state Rep. Susan Johnson, D-Windham, said. But rural and other high poverty areas, where many residents are on Medicaid rather than private health insurance, remain vulnerable to hospital service reductions and changes in eligibility for health care coverage, she said.

“My battle is to make sure the basic hospital services, like critical care units, are maintained in the small rural hospitals,” Johnson said. “If you take [hospital consolidation] in combination with the proposals to change the Affordable Care Act, that in combination would definitely decimate not just Connecticut, but most places around the country, in terms of access to health care,” Johnson said.

Of Connecticut’s 169 municipalities, 68 are classified as rural, based on population and number of people per square mile. They’re home to about 9 percent of the state’s 3.57 million population, or about 320,000 residents.

In Connecticut, rural residents were more likely than their city and suburban counterparts to die from four of the top five causes of death: heart disease, cancer, chronic lower respiratory disease and unintentional injury. The state’s findings mirror national trends, according to a 2017 report published by the Centers for Disease Control, which analyzed data across the country from 1999 to 2014. Nationally, rural residents report higher rates of adverse health factors, such as smoking, obesity and lower use of seatbelts.

Connecticut’s death rate from heart disease in 2015 was about 60 per 100,000 people, but in rural areas, the rate was 72 per 100,000. The cancer death rate was roughly 104 per 100,000 statewide but 127 per 100,000 in rural areas.

Rural residents in Connecticut were almost twice as likely to die from chronic lower respiratory disease, which includes asthma, chronic bronchitis and emphysema. And their death rate as a result of unintentional accidents was about 50 per 100,000 compared with a statewide rate of 38.

“The No. 1 issue is transportation,” said Mary Winar, manager of the state Office of Rural Health, which is based at Northwestern Connecticut Community College in Winsted.

Rural areas have fewer doctors, and they are more scattered. With public transportation centered in more urban areas, those living outside of cities often have to fend for themselves to get to appointments.

Robert Pope, 49, of Sharon, uses a Dial-A-Ride service through Geer Village Senior Community in Canaan to get to his doctor appointments. Pope, who lives alone and has no car, has four-hour-long dialysis appointments three times a week in Torrington, 45 minutes away.

“I’ve tried using other [services]. They’re not always reliable or dependable,” said Pope. “Without the Dial-A-Ride service from Geer, I would literally have no dependable way of getting to my dialysis appointments.”

Nancy Heaton, CEO for the Foundation for Community Health in Sharon, said Litchfield County has studied options to improve transportation. Loop transit services aren’t practical in a rural setting, she said, and on-demand services can be costly.

The foundation has given grants to add trips through Geer’s Dial-A-Ride service and others like it. Still, when the foundation surveyed residents in the Connecticut and New York towns surrounding Sharon Hospital, 60 percent said transportation was one of the main barriers to accessing health care.

“People living here aren’t used to public transportation, so it takes a lot for people to get used to thinking about [it],” Heaton said. “They’re getting there through friends, and family, borrowing cars, or they’re just not going.”

The same is true in Windham County. A survey of 750 clients of the Generations Family Health Center found that 35 percent missed at least one health care appointment in 2016 because of transportation issues. About 67 percent reported a lack of reliable transportation, either because they didn’t own a car or couldn’t always afford to use it.

Two Connecticuts

Connecticut is one of the top performers in the country in patient-to-doctor ratios, but its three predominantly rural counties, Windham, Tolland and Litchfield, ranked the lowest in the state in this category, according to 2017 County Health Rankings data published by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

Windham County has 1,950 patients per primary care provider, compared with Hartford County, with 1,070. The state average was 1,180.

Rural areas fare much worse in number of dentists, with Windham County, for example, showing 2,380 patients per dentist, about half the state average of 1,230.

For several years, not one dentist in Litchfield County accepted adults on Medicaid, Heaton said, forcing those patients to travel to UConn Health center in Farmington for dental care. The foundation gave money to help the Community Health and Wellness Center in Torrington add dental services in 2008.

“Why is there a shortage of physicians over here? They don’t want to work over here,” said Arvind Shaw, the CEO of Generations Family Health Center. “That is not acceptable.”

“When you look at all these things, you can see all these anomalies,” Shaw said. “It’s because the state of Connecticut does not have a plan … for health equity. There is not a system that actually maps resources.”

Maurice Maddox, 60, of Canaan, said it took him more than a month to find a doctor who would take Medicaid and help him with depression and suicidal thoughts. He depends on Geer’s Dial-A-Ride and state contractor LogistiCare’s transportation services to travel to psychiatrist appointments at UConn Health center and to his therapist in Salisbury.

“It’s important for me to see them,” Maddox said. “Not being able to talk about it, keeping it bottled up inside, I think it would be pretty bad for me.”

The problems feed on each other. Fewer doctors in remote areas forces residents to drive farther.

“If we could get the providers and specialists here locally, transportation might not be such an issue,” said Joanne Borduas, CEO for the Community Health & Wellness Center of Greater Torrington.

Hospital Changes

Hartford HealthCare has acquired two hospitals that serve largely rural populations: Windham and William W. Backus in Norwich. The system is also working toward affiliating with Charlotte Hungerford Hospital in Torrington.

Carl Jordan Castro Photo.

Maurice Maddox of Canaan, said he had trouble finding a doctor who took Medicaid in rural Litchfield County.

Being part of a larger health network could help rural hospitals attract new doctors, said Shawn Mawhiney, director of communications for Hartford HealthCare.

Recently Windham recruited four new orthopedic surgeons and conducted its first spinal surgery in a decade, Mawhiney said. “That would have been nearly impossible if Windham wasn’t part of the Hartford Healthcare system,” he said.

Others see hospital consolidation as problematic for rural patients.

Two years ago, Hartford HealthCare reduced the number of beds in Windham’s critical care unit, a change that Mawhiney said was based on patient volume. Some worry that fewer beds could lead to patients’ having to be transferred to another hospital for more serious emergencies, but Mawhiney said this was happening even before the change.

“If they’re not admitted and have to go home, it’s that much farther of a distance from Backus back to Willimantic,” Winar, of the state’s Office of Rural Health, said. “What if you don’t drive yourself or don’t have a family member who can easily help you out? If it’s at night, there are no buses running.”

Johnson, the state representative, said the Windham community fought changes to Windham Hospital’s critical care center in 2015, and said many believe the hospital can’t help them as much as it used to.

“It’s sad and devastating,” Johnson said.

But Mawhiney said the goal is to keep the hospital open, which requires being smarter about how to allocate resources. With a higher percentage of Medicaid and Medicare patients in rural areas, the hospitals there don’t always get fully reimbursed for their services, he said.

“It’s not a Windham Hospital issue. It’s a community hospital issue,” Mawhiney said. “There are very few stand-alone community hospitals left, especially in rural areas. Those hospitals are struggling.”

Carl Jordan Castro contributed reporting to this story.

Overall, 58 percent of communities saw a decrease in the age-adjusted rate of emergency room visits, while 63 percent saw a decrease in the rate of hospitalizations for asthma, according to a C-HIT analysis of the data. Some 36 percent saw improvement in both areas. The data compares age-adjusted rates for each town for 2005-2009 and for 2010-2014 per 10,000 people.

Jodie Mozdzer Gil Photo

Daun Barrett, center, director of Community Outreach and Parish Nursing at Griffin Hospital, gathers contact information from nurses concerned about asthma. Barrett and other health officials are pushing for more asthma education to help people better manage the disease.

Meanwhile, the state’s overall rate for emergency room visits in 2014 was lower than recent years but still was higher than it was 10 years ago. The 2014 rate was 66.2 visits per 10,000 people, down from a rate of 73 in 2011, according to a state health scorecard.

The rates help state health officials determine how well Connecticut’s 9.2 percent of adults and 10.5 percent of children with asthma manage the disease. The illness cost $135 million in hospital care in 2014, according to Connecticut hospital discharge data, an increase of about $22 million since 2009.

“This is a problem that everyone is looking at,” said Daun Barrett, the director for Community Outreach and Parish Nursing at Griffin Hospital in Derby, which serves the lower Naugatuck Valley.

Asthma Management: Bright Spot

Several towns in the Naugatuck Valley saw some of the biggest improvements in emergency room visit rates, the data show.

The improvements can be attributed to better education, more physician focus on asthma, and Putting on Airs, a state-sponsored home visit program that regional health departments have implemented, Barrett said.

In Derby the emergency room rate decreased from 115.9 visits per 10,000 people to just 78 in the latest data. In Ansonia the decrease was from 120.7 to 94.7. Seymour dropped from 70.7 to 46.2 while Beacon Falls decreased from 46.7 to 24.5.

Still, the emergency room at Griffin averages one patient a day with asthma symptoms, not counting those who end up being admitted, Barrett said.

“We want to see a decrease in emergency room visits,” Barrett said. “When you have to go to the emergency room, it’s a quick fix, not a long-term approach.”

Mixed Results

The state’s cities continue to have high rates of hospitalizations and emergency room visits for asthma. While some of those rates decreased in the most recent data, others saw increases in both measures.

In Hartford, for example, 216.6 people per 10,000 used the emergency room for asthma in 2005-2009. The rate increased to 247.1 in the latest figures, the highest in the state. The rate of those who ended up getting admitted to the hospital increased from 35 to 37.6 during the same time frame.

New Haven had the highest rate statewide of hospitalizations in both 2005-2009 and 2010-2014, although its rate had dropped in the most recent data from 63.4 to 54.6. The city saw a slight decrease in emergency room visits, from 136.6 to 132.8.

Bridgeport had the state’s third highest rate of hospitalizations in 2010-14, at 29 people per 10,000. The rate had increased from 27.5 in 2005-2009. Bridgeport’s emergency room visit rate increased during the same time, from 126.3 to 131.4.

State officials don’t know precisely why the town-by-town numbers fluctuate.

Marie-Christine Bournaki, director of the state Department of Public Health’s asthma program, said the statistics “allow us to identify where the hotspots are, and that’s where, from a program perspective, we strategize intervention in those particular regions.”

Easy Breathing

Easy Breathing, developed in 1998 by Dr. Michelle Cloutier, director of the Asthma Center at Connecticut Children’s Medical Center, helps doctors diagnose asthma and then treat it based on guidelines from the National Asthma Education and Prevention Program.

The program essentially takes research-based best practices in treating asthma, and simplifies them into color-coded charts and one-page questionnaires.

“She did all the work to make it easy,” said Dr. Ronald Angoff, who is with Pediatric and Medical Associates PC in Cheshire and New Haven, which has used the program for about 10 years.

Patients at Pediatric and Medical Associates are now asked four simple questions that could help indicate a case of asthma:

• Has the child had wheezing or whistling in the chest?

• Has the child been awakened by a cough?

• Has a cough or wheezing prevented physical activity?

• Has the child had a lingering cough after a cold?

• The questions help doctors identify children with under-the-radar asthma cases.

“We’ve seen a major decrease in acute asthma attacks,” Angoff said.

Simple laminated guides in the office help doctors quickly find the appropriate treatment depending on the symptoms, including direction on which insurers supply which medications.

“It’s about giving them simple tools that really make it easier to do Easy Breathing than to not do Easy Breathing,” said Jessica Hollenbach, a research associate with the Asthma Center at Connecticut Children’s Medical Center.

Easy Breathing has been introduced to more than 400 pediatric clinicians in more than 100 doctor’s offices around the state, Hollenbach said, and research into the results shows it helps lower hospital use for asthma treatment.

Putting On Airs

Across the state, nurses, asthma educators and respiratory therapists visited the homes of about 938 people with asthma between 2010 and 2014 under the Putting on Airs program.

A 2010 study by researchers at the state Department of Public Health found that participants in Putting on Airs had fewer unscheduled emergency asthma doctor’s visits, fewer days missed from school or work, and fewer times using their rescue inhaler after six months.

“Asthma education is more than providing knowledge,” said Bournaki, the state asthma director. “It’s also helping the person to change their behavior and take control over their asthma. You can imagine it’s very difficult to be teaching in a context where the person is probably exhausted, going to the emergency room and being discharged.”

Bournaki said that during home visits, the asthma educator works with the patient to practice using inhalers, talks about their asthma action plan and assesses the home for environmental triggers for asthma attacks. The program involves three follow-up phone calls to touch base and gather more data.

“A lot of people, their asthma is not controlled because they’re not using the medication properly,” Bournaki said. “It’s very critical to spend time assessing how the person is administering the medication.”

Meanwhile, the Connecticut Hospital Association is working with doctors and emergency rooms across the state to also coordinate asthma education.

The initiative is training hospital workers to help patients with medications and push for more patients to have asthma action plans to keep them out of the hospital.

In 2013, only 32.7 percent of Connecticut residents with asthma had ever received an asthma action plan, shy of the state’s 40 percent goal, the latest data show.

“For the most part, [asthma is] well managed in an outpatient setting, like a community health center or a primary physician’s office,” said Madeleine Biondolillo, vice president of population health for the Connecticut Hospital Association, which launched the Connecticut Asthma Initiative last year.

The practice — which cultivates an awareness of the present moment and an acceptance of the feelings and emotions that come with it — has reached the mainstream and is being adopted by new fields.

Veterans groups are using mindfulness and yoga as a healing tool. Teachers in some Connecticut elementary schools have incorporated it into their classrooms to help students focus. And universities are offering mindfulness training to help students deal with stress.

Today, about 600 studies on mindfulness are published annually, according to Dr. Judson Brewer, the director of research at the Center for Mindfulness at the University of Massachusetts. The Center for Complementary and Integrative Health at the National Institutes of Health (NIH) awards millions of dollars in grants for mindfulness research. The Center’s total budget has more than doubled, to $124 million, since 1999.

In September, the NIH directed $4.7 million for studies at Brown and Harvard universities and UMass to gauge whether mindfulness interventions improve medical regimen adherence, including regimens for weight loss. Physicians at Yale University are studying the use of mindfulness meditation in chronic widespread pain and fibromyalgia in adolescents.

Researchers analyzing findings of past studies have found small but consistent positive effects from mindfulness, which has its roots in Buddhist philosophy. Two recent meta-analyses—one published in 2013 by researchers in Israel, and one published in 2014 by Johns Hopkins University researchers—found benefits in pain management, anxiety and depression.

“It’s exciting that the science is catching up with all this, because this is the wisdom of the ages,” said Lisa Berzins, a Connecticut Valley Hospital psychologist who uses mindfulness to counsel clients who have been through trauma.

Connecticut has seen the emergence of new mindfulness centers and meditation groups. A group called New Haven Insight offers regular meditation meetings in New Haven and Hamden, and a new mindfulness center, Copper Beech Institute, opened in West Hartford in 2014.

In response to its growing popularity, the Capitol Region Education Council (CREC) and Central Connecticut State University hosted a Mindfulness Conference in December, bringing together more than 165 educators, psychologists, doctors and therapists.

“Mindfulness teaches a lot about attention, curiosity, attentiveness — all those things that are foundations to learning,” said Emily Rosen, an educational technology specialist at CREC who helped organize the conference.

Meditation session at Copper Beech.

The Science

Scientific, peer reviewed studies on mindfulness and its health effects started getting published in the early 1980s.

The continued practice of mindfulness meditation actually changes the parts of the brain that deal with attention, body awareness and emotional responses, according to a meta-analysis published in the journal Perspectives on Psychological Science in 2011. For example, people practicing mindfulness have more activity in an area of the brain associated with positive emotions.

Individual studies and trials on the topic vary. Some, such as one published in the Journal of Consulting and Clinical Psychology in October, found that while mindfulness was helpful at preventing depression relapse in patients, it was no more effective than music therapy, physical activity and nutrition training was for those in a control group.

Brewer, who has been meditating since he started medical school, said he realized during his residency at Yale that mindfulness could help those with addiction.

Brewer developed a smoking cessation app, Craving to Quit, in 2013, while an assistant professor of psychiatry in Yale’s School of Medicine, after his own research found that mindfulness training was more effective than other treatments in helping people overcome cocaine addiction.

“I wanted to see if we could use this to work with the hardest addiction,” Brewer said of his shift in focus from cocaine to cigarettes.

Brewer and other researchers at Yale conducted in-person trials comparing people trying to quit smoking using mindfulness techniques to those who used the standard American Lung Association smoking cessation program. The research, published in 2011 in the journal Drug and Alcohol Dependence, found that those using mindfulness training had a greater rate of reducing smoking, and kept those gains for longer than those in the traditional program.

“It was five times as good as the gold standard a month later,” Brewer said. “That was eye opening to me.”

Craving To Quit app.

Now, Yale’s Student Wellness department is subsidizing the cost of Brewer’s mobile application Craving to Quit for all students looking to quit smoking, as the university transitions to a tobacco free campus. According to Lisa Kimmel, senior wellness manager at Being Well at Yale, 16 students have signed up since the initiative was announced in October.

Mindfulness In Action

Mindfulness can be practiced during everyday scenarios—such as when the Craving to Quit application asks users to mindfully smoke, accompanied by an audio recording guiding the process.

“Feel the texture, the weight of the cigarette,” a female voice says on the recording. “Look closely at the paper, the colors. Smell the cigarette. What does it smell like?”

At the University of Hartford, Peter Oliver, an associate professor of educational psychology, is using mindfulness in his Stress and Stress Management course, hoping to give students the skills of impulse control and the ability to respond appropriately to stress.

In one exercise, Oliver has students pile their cell phones in the center of the room with the volume turned up. Then they focus on their physical and emotional reactions as notifications start to chime without immediate access to check the phone.

“Being stressed is a very different experience than being aware that I’m stressed,” Oliver said. “Then with that awareness, I can begin to generate choices.”

Mindfulness also can be practiced as more formal meditations, as shown by 50 people who gathered for silent mindfulness meditation recently at the Copper Beech Institute.

Michael Riley, 59, of Bloomfield, regularly attends the Copper Beech meditations. An Air Force veteran suffering from Post-Traumatic Stress Disorder, Riley said his life has changed since he started using meditation to cope with the symptoms.

“I was afraid,” Riley said. “I was using my anger to cover my inability to deal with the fear.”

Riley said he is now able to control his impulse to respond to stressful situations with aggression, as he used to do.

“My whole world has changed now,” Riley said.

The Paradox

While the science suggests mindfulness can help with a variety of health issues, proponents say the goal is not to simply meditate away problems.

“What we learn in mindfulness is this paradoxical wisdom,” said Brandon Nappi, the executive director of Copper Beech. “We are much more able to manage our pain when we let go of this agenda of needing to manage this pain.”

Jodie Mozdzer Gil Photo.

Psychologist Lisa Berzins uses mindfulness to counsel clients.

Compassion is key to Berzins’ therapy group at Connecticut Valley Hospital, a state hospital for people with mental illness. Berzins leads a meditation in which clients focus on a situation that caused them distress, then pay close attention to their physical sensations, as well as their breathing.

Berzins then asks them to put their hands over their heart and repeat phrases of self-compassion, such as “May I be kind to myself.”

“It’s sort of instinctive that people want to push bad feelings away,” Berzins said. “Mindfulness and self compassion are sort of the exact opposite. All feelings are welcome, even the ones that really hurt.”

“Pain is inevitable in life,” Berzins said. “But suffering is pain plus resistance to it.”

C-HIT Writer Lisa Chedekel contributed to this report.

Jodie Mozdzer Gil Photo

Miguelina Matista, right, benefited from early childhood programs for her daughter, Nicaury, and son, Noel. Now she is volunteering to let other Danbury parents know about free programs offered through social services agencies.

The efforts include developmental screenings at child care centers, home visits and information hotlines for parents, better collaboration with pediatricians and more support for preschool staff members dealing with emotional and behavioral issues.

The idea is that if a child’s basic health needs aren’t met, he or she won’t be able to keep up with academic and social expectations in school.

“There’s been a huge interest in addressing early childhood development with the understanding that’s where we get the most bang for the buck,” said Lisa Honigfeld, the vice president for health initiatives at The Child Health and Development Institute of Connecticut.

In the last 10 years, there has been “an explosion” of federal funding for early childhood initiatives to get children on track early and prevent spending on remediation down the road, Honigfeld said. In December, President Barack Obama hosted a White House Summit on Early Education.

In Connecticut in 2014, the legislature approved the Office of Early Childhood, which combines services for children ages birth to eight. The United Way has been running the Child Development Infoline to provide free information to parents and caretakers and private foundations are funding many early childhood health initiatives.

The Problems

Several early childhood initiatives stem from a concern for educational goals, but many have shifted to focus on health needs such as nutrition, dental care, and more frequently, mental health issues.

“This idea of health used to be really around your blood pressure or do you have a fever,” said Hector Glynn, the vice president of programs for The Village for Families and Children, a Hartford agency that has several early childhood and prenatal programs. “Now the concept of health is so much broader.”

A look at children’s health measures – such as obesity levels, asthma rates and birth weight – show that there is room for improvement in Connecticut.

Almost a third of Connecticut students in kindergarten and third grade in 2010-2011 were overweight or obese, according to state Department of Public Health data. Connecticut has a higher childhood asthma rate (11.3 percent) than the national average (9.4 percent), according to a 2012 state report on asthma in Connecticut. DPH stats show 7.9 percent of children born in 2012 were considered low birth weight.

Doctors also report that mental health issues are increasing among young children.

“When I started practicing, I might see a case of some behavioral health problem one time every six weeks,” said Dr. Gerald Calnen, who was a pediatrician in Enfield for 38 years. “By the time I retired, I was seeing two to three cases a day.”

Poor academic performance in children is often linked to health and emotional problems, Honigfeld said. A 20-year study released in July showed connections between positive social development in kindergartners and their likelihood of graduating high school or college and becoming employed as young adults.

“We recognize children arriving at school not ready to learn largely have health problems, largely have social-emotional problems,” Honingfeld said.

Influx of Money

Jodie Mozdzer Gil Photo

Elizabeth Quinonez shows off early childhood developmental charts with parents at the Danbury Farmers’ Market in July. Quinonez, the community coordinator for Danbury’s Promise for Children Partnership, has recruited about 20 parents who speak English and Spanish to spread the word about the programs.

That’s why 14 foundations formed a collaborative in 2011 through the Connecticut Council for Philanthropy to direct money toward a comprehensive early childhood system.

They’ve pooled about $400,000 since 2011, and individual foundations have given $25 million to early childhood causes in the same time period, said Maggie Gunther Osborn, the president of the Connecticut Council for Philanthropy.

The William Caspar Graustein Memorial Fund, a member of the collaborative, has been giving early childhood education grants through its Discovery Communities program since the early 2000s. Last year, 53 communities received an average of $50,000 each, said Nancy Leonard, the public policy program officer for the fund.

In 2009, the fund offered several grants for communities to start focusing on children’s health issues, resulting in long-term plans. Through its plan, Enfield and the Key Initiatives To Early Education (KITE) group hosted a forum for all Enfield pediatricians in 2010.

“We talked to them about developmental screening,” said Calnen, who is a member of KITE. “Turns out, as important as it is, nationwide too many pediatricians aren’t doing it. We wanted to find out why that was and how we could encourage the pediatricians to do them in their office.”

Many doctors, Calnen said, don’t have enough time to complete screenings, which could discover development problems, but add about 30 minutes to check-ups. So KITE started working with child care centers and preschools to encourage them share the results of their screenings.

At Opportunity Knocks, an early childhood coalition in Middletown, nutrition consultant Monica Belyea is working to get local companies to offer space for new mothers to pump breast milk at work, citing studies that breast milk improves infant health.

Her group has also been supporting preschool teachers in an effort to reduce suspensions. Two consultants visit classrooms and give advice on how to address behavioral issues, which Belyea said are increasing every year.

There were 106 children in the preschools identified as at-risk this past year, she said. With the help from the consultants, no students were suspended or put on a reduced schedule, she said.

“Teachers have a lot of skills to support kids with normal, challenging preschool behavior,” Belyea said. “What we’re seeing is more kids coming in with trauma and challenging home situations.”

Danbury’s Promise for Children has recruited parent volunteers to spread the word about free services available in the city. On a recent July afternoon, three women chatted up customers at the Danbury Farmers Market about the services. About 20 parents are part of the group, and many speak English and Spanish to reach more parents, coordinator Elizabeth Quinonez said.

“This kind of program helped me to be a better mom,” said Miguelina Matista, a Danbury resident who began receiving early childhood services seven years ago.

Home Visits, Information Sharing

Home visits are becoming common in many early childhood initiatives. Child First sends counselors into homes to give families trauma therapy. The federal Maternal, Infant and Early Childhood Home Visits program guides families through parenting issues.

“We focus on parenting skills, making them understand what their child development looks like,” said Glynn at The Village, which visits more than 100 families through its programs.

The state Office of Early Childhood is working to organize all home visitation programs. The state has recently set up an Early Childhood Information System to track health and learning data so policy makers and experts can address issues.

Efforts like CHDI’s Early Childhood Data Institute seek to bring more data – once relegated to forms in a file cabinet at day-care centers – into a centralized system.

“A lot of things have gotten in the way of exact children tracking: confidentiality issues, inability of state agencies to share data,” Honigfeld said. “We’re just starting to make some headway on overcoming those barriers.”

The Danbury program is explained in Spanish.

Their problems range from bullying to family issues to anxiety.

As the national post-Newtown conversation about mental health issues and school security continues, advocates are pushing for more early intervention programs, such as the health clinics, inside schools.

“Securing buildings from the outside may keep somebody out, but it’s not helping somebody that is behind those doors,” said Shari Shapiro, the executive director of Kids in Crisis, a Fairfield County nonprofit that has an in-school counseling service called TeenTalk in six schools.

The percentage of teens who said they’ve attempted suicide has ranged between 6.7 and 12 percent for the last decade, according to the state’s bi-annual Youth Risk Behavior Survey. In the most recent survey, 27.2 percent of teens said they felt sad or hopeless everyday for two weeks or more.

“We’re not talking about just kids who are going to go out there and create this horrific situation,” Shapiro said. “We’re talking about kids that are struggling in the simplest ways.”

Several health centers have recently started to screen all patients – whether they are there for a sports physical or a headache – for behavioral health issues, clinic directors said.

The state legislature asked the Department of Children and Families to create a plan to focus on mental health needs of children after the Newtown school shooting. One goal of the Connecticut Children’s Behavioral Health Plan, published in October 2014, was to expand in-school services for mental and behavioral health.

“We are generally as a society, with mental health, completely reactive,” said Erin Patterson Janicek, the director of clinical services for the school-based health center program for the Child & Family Agency of Southeastern CT Inc. “The proactive is how we catch this stuff early.”

There are several established in-school mental health programs in Connecticut, which bring outside staff to schools.

The Connecticut Association of School Based Health Centers says the state Department of Public Health funds 92 clinics with both medical and mental health services in 22 communities in Connecticut, including New Haven, Hartford, Bridgeport, Waterbury, Stamford, New London and Bridgeport. Some have been around for more than 25 years.

Most schools also have school counselors and psychologists on staff. But that’s not enough, experts say.

“There aren’t enough services — before (Newtown) and now,” said Jill Holmes Brown, a licensed clinical social worker who directs the School Based Health Center Program in East Hartford schools, run by Integrated Health Services, Inc.

“There has been a significant increase in the number of students and the severity of what we’re seeing,” Holmes Brown said.

In East Hartford, Holmes Brown said the clinics have seen an increase in the number of behavioral health visits each year — and now the visits make up 57 percent of all cases. The clinics also provide medical and dental services to students.

In the New London area, 48 percent of the visits to the health centers were for mental or behavioral needs in 2013-14, roughly a15 percent increase from previous years, according to JoAnn Eaccarino, associate director of school-based programs for the Child & Family Agency of Southeastern CT Inc., which runs 18 school-based health centers in New London county.

Across the state, other agencies are reporting more need as well. TeenTalk will launch its seventh school program – at a middle school in Greenwich – in the fall, according to Shapiro. TeenTalk saw 630 students in 2,838 individual sessions in 2013-14, according to data from Kids in Crisis. That’s up from 553 students the previous year.

Pam Standfest, a licensed clinical social worker at East Hartford High School, said she has also seen an increase in serious cases that required referrals to hospitals or more intensive treatment. Last year she had about five referrals for self-injurious or suicidal behaviors.

At one New London elementary school, the skills built through counseling helped one student deal with an allergic reaction in school recently, said Patterson Janicek.

“While the EMT was examining her, her heart rate came down, and she was able to calm herself down,” Patterson Janicek said.  “It’s one of those stories of how the medical and mental health pieces interact and how important they are together.”

Patterson Janicek said the stress management also helps children with asthma differentiate between symptoms of an attack and symptoms of anxiety, and work through either type of incident.

Alex Strevel and his sister, Kayla Strevel, attend East Hartford High School and have struggled with family crises and bullying in school. After a falling out with their father and their parents’ divorce, the siblings each had personal distress.

Alex dropped out of school his sophomore year, missing 65 days before he finally returned. Kayla struggled with her body image and bullying throughout middle school and her first two years of high school, and said she contemplated “giving up.”

They each found their way to the school-based health clinics in East Hartford schools. Now each one has weekly appointments with Standfest.

“If it wasn’t for the health center, I probably wouldn’t be here, honestly,” said Alex, 17, who is now looking forward to graduating in June and studying art and music in college.

Kayla has had her own progression to confidence and coping skills. The last time another student made fun of her weight, Kayla said she was able to handle the insult by thinking of her meetings with Standfest.

“I’ve been thinking differently, and thinking better about myself. At first I thought no one could love me,” said Kayla.

Their stories illustrate one of the arguments for mental health services: healthy students are more likely to do well in school and graduate.

“There is growing evidence that students with behavioral health needs have higher rates of academic failure and also are subject to high rates of ‘exclusionary discipline,’ [such as arrest, expulsion, suspension],” the DCF report states.

Holmes Brown said having the mental health services available in schools helps reduce the stigma of seeking help. It also opens more opportunities to students to get help, as they don’t have to leave the building to do so.

“It teaches kids from kindergarten up to advocate for themselves with health care,” Standfest said.

“Through doing that, we have picked up kids you might never pick up before,” Eaccarino said. “They’re sort of doing OK in school, they’re not getting in trouble, but they’re really troubled.

“By catching these kids early and getting them into services early, we feel we’re doing a good thing.”

Ava, 3, of Bridgeport, knows what to expect from a visit with Hen, having dealt with asthma since she was 1. She also spent several nights in the hospital after an attack in 2012. “I had always heard about wheezing, but had never really heard it before that,” her mother, Beverly Passley said.

Jodie M. Gil Photo

Megan Judkins, a nurse, helps Ariana Gomez, 7, test her breathing.

Ava is part of growing number of people in Connecticut who have used the emergency room for asthma symptoms, according to the most recent figures from the state Department of Public Health.

Each year from 2005 to 2009, Connecticut residents with asthma symptoms on average visited the emergency room 22,000 times, and were hospitalized 4,800 times.

The reasons vary: some are new asthma patients, some have new conditions that trigger their asthma, and many just poorly manage their medications, doctors say.

The visits made up 1 percent of total hospital health care charges in Connecticut in 2009, at a cost of $112.8 million. Medicare and Medicaid paid for 73.8 percent of the hospitalizations and 60 percent of the emergency room visits.

The increase is being watched by officials in the state health department, researchers at Connecticut universities and community environmental groups, as they look to help people better manage the disease, while saving money on preventable hospital visits.

And yet, the most recent numbers show that the situation is getting worse — especially for minorities and people living in urban areas.

The Numbers

In 2012, the state DPH published “The Burden of Asthma in Connecticut,” which reviewed data from school asthma tracking programs, death certificates, federal labor reports, Centers for Disease Control and Prevention surveys, state Medicaid data and hospital records.

The 166-page report reviewed data from 2000 to 2010. During that time, the rates of people who were hospitalized for asthma increased by 29.2 percent. For those who listed asthma as the secondary reason for hospitalization, the rate jumped by 86.2 percent.

Rates for people living in urban areas were much higher than their suburban and rural counterparts.

In New Haven, Hartford, New London and Bridgeport, residents were hospitalized for asthma symptoms twice as often as in nearby suburbs.

In New Haven, for example, the age-adjusted hospitalization rate  between 2005 and 2009 was 63.4 people per 10,000. In adjacent West Haven it was less than half that, at 31 people per 10,000. East Haven’s rate was even lower, at 23.4 people per 10,000.

In Hartford, the age-adjusted hospitalization rate between 2005 and 2009 was 35 people per 10,000. In adjacent Bloomfield, it was less than half of that, at 13.3 people per 10,000. West Hartford’s rate was even lower, at 7.4 people per 10,000. (Find a town’s rate by clicking on the map.)

At the same time, Hispanic and black asthma patients showed much higher rates of hospitalizations than the overall average, and than subgroups of patients who are white or other races.

In 2009 alone, white asthma patients went to the emergency room at a rate of 34.2 per every 10,000 people. Black and Hispanic patients had rates of 127.3 and 170.5 respectively.

What makes minorities more likely to visit the emergency room?

They start with higher rates of asthma, according to national and state data. Much of that can be attributed to environment.

Cities, which have high minority populations, are filled with various asthma triggers such as air pollution, mold, cigarette smoke and even proximity to rodents.

Veronica Tate, 66, said she developed asthma when she moved to Hartford two years ago.

“Last August, I had this tightening of my chest,” Tate said.

Her doctor thought it was allergies, and prescribed some medicine. But it kept getting worse.

“One night I woke up and I couldn’t breathe,” Tate said. “I couldn’t catch my breath.”

Why The ER?

Many assume people use the emergency room because they lack health insurance. But as more people gain access to insurance, and the numbers of emergency room visits continued to rise, the Connecticut Coalition for Environmental Justice started asking people why they kept going to the emergency room.

“The first focus group really blew me away,” said Sharon Lewis, the executive director of CCEJ. “It (the reason) was not what we would ever think it was.”

The reasons, Lewis said, came down to the quality of health care people said they were getting at community health centers. The main problem, Lewis said, was the lack of comprehensive services at community health centers.

If a patient needed an X-Ray, he or she had to travel to another center where they have the equipment. For someone without much money or a means of travel, the cost of taking public transportation to one, maybe two, maybe three other centers was daunting.

“If you go to the emergency room, it may take 12 hours, but when you leave you’ve got everything done,” Lewis said.

Of the 110 people CCEJ interviewed, only one person said she didn’t have health insurance.

“We need to think of the entire chain of things and how they work before you say people are using the emergency room for the wrong reasons,” Lewis said.

Other researchers have found that a poor relationship with a primary care doctor can lead patients to wait until symptoms are severe before seeking help.

Dr. Kenneth Robinson, the medical director at the emergency department at Hartford Hospital, said he doesn’t ask patients why they opted to come to the hospital.

“Generally in my mind, the complaint of acute shortness of breath is a very appropriate reason to go to an emergency department,” Robinson said.

“I want them to always feel comfortable to come to the emergency department,” Robinson said. “I don’t want to put that thought in their head by asking them why.”

Programs To Help

Hen, the chief of pediatric pulmonology for Bridgeport Hospital, and also affiliated with Yale-New Haven Children’s Hospital, stood in the waiting room of his office recently, waiting for his next appointment — a child in the state HUSKY program being treated for asthma.

The child never showed.

It gets him, because Hen sees the quarterly visits as the way to keep the children out of the emergency room.

“Part of the reason we see asthma kids every three months is to reinforce the education, reinforce the care plan, that you have to stick to your medication,” Hen said.

Some of his patients have ended up in the emergency room. When he looks through their records, Hen said he finds they are the ones who have multiple no-shows, or haven’t scheduled an appointment for eight months.

Jodie M. Gil Photo

Dr. Jacob Hen examines Ava Passley, 3. Ava’s mom, Beverly, looks on.

Hen said that regular treatment of asthma symptoms could prevent about 130 children’s deaths each year nationally.

“I could change those statistics,” Hen said. “Anybody could.”

Hen said community programs are one solution to the problem. If trusted community members can reach families in their churches, at school, then the education might be more likely to resonate, he said.

Several efforts are underway across the state.

Putting on Airs, a statewide program run by regional health districts, sends health inspectors into the homes of asthma patients.

Mary Buckley-Davis runs the Putting on Airs program for the Ledge Light Health District in New London. She said she helps families identify triggers such as mold, scented candles or areas where dust mites can affect a person with asthma.

Sometimes she just goes over the medications patients are using. Some simply mix up their daily medicine with their “rescue” medicine. Some are not filling the prescriptions.

“Many of my clients lead incredibly complicated lives,” Buckley-Davis said. “Truly, they don’t know where their next meal comes from, so asthma gets pushed down the priority list.”

But that extra help can make a big difference. A state review of the program found a decrease in the number of emergency visits to a doctor or hospital for asthma six months after a home visit. A majority of clients said they were missing less work and school because of their symptoms.

Action Plans

Another state program focuses on the need to get asthma patients set up with action plans.

The Easy Breathing Program includes a questionnaire doctors can ask to help determine if patients have asthma, and get them on a treatment plan. The costs include training medical providers.

While prescription costs increased for children in the program, the cost of hospitalizations decreased, especially for chronic asthma sufferers, according to a 2009 study by researchers at the Connecticut Children’s Medical Center in Hartford.

Passley has a color-coded guide to track Ava’s symptoms and respond with the appropriate medicine. On a normal day, when Ava is in the green zone, she’ll take a morning nasal steroid spray and a morning and evening pump of inhaled beclomethasone.

If Ava hits the yellow zone — which can happen as triggers come on, or when she gets a cold or other illness — the doses increase, and she might also need a liquid steroid.

The red zone includes worsening symptoms, and that means it’s time to go to the emergency room.

“It’s really simple,” Hen told Ava. “If you do your stuff every day, you don’t get sick.”    

A website in Spanish on asthma is available here.