The Long View: Time to Take Care of Your Eyes

Glaucoma: Take Care of your Eyes

Dr. Vincent Parsons, right, demonstrates a glaucoma screening on Norma Owens. Norma is an optometric assistant at Swope Health.

January is the month designated to raise awareness of glaucoma, one of the leading causes of vision loss and blindness.

Seeing that clean, new calendar makes it a good time to schedule an eye exam and learn more about taking care of your eyes.  At Swope Health, you can call for an appointment with our optical team at 816-923-5800.

Facts About Glaucoma

Vincent Parsons, O.D., Swope Health’s director of optometry, shared some facts about glaucoma:

  • More than 3 million people in the U.S. have glaucoma. Half of the people who have it don’t know they have it.
  • Glaucoma is usually associated with seniors who are age 60 or older, but it can affect anyone at any age.
  • Glaucoma is the leading cause of blindness in African Americans. It’s also prevalent in Hispanic populations.
  • There is no cure for glaucoma, but early identification can slow the progress of the disease.

According to the National Eye Institute, glaucoma actually refers to a group of diseases that affect the optic nerve in the eye. The optic nerve, a bundle of more than a million nerve fibers, connects the retina of the eye with the brain.

“Throughout most of the disease, there are no symptoms and you can’t tell if you have it,” Dr. Parsons said. “That’s why it’s important to have a glaucoma exam.”

The disease is detected through a visual field test, to see if you have lost side vision or peripheral vision. The optometrist also will use a magnifying glass to look for damage to the optic nerve.  Finally, the optometrist will use eye drops to numb your eyes, and perform a test to measure your eye pressure and determine the thickness of your cornea.

Treatment

If you are diagnosed with glaucoma, you may be treated with medicines to lower the pressure in the eyes. These medicines may be in the form of eye drops or pills, and need to be taken regularly to be effective in preventing the disease from progressing. In some cases, surgery is recommended to lower pressure in the eyes.

In advanced or very advanced stages of glaucoma, you gradually lose your peripheral vision – it appears as if you are looking through a tunnel.

The Center for Disease Control and Prevention estimates that the number of blind and visually impaired people in the U.S. will double by 2030 as the population ages. Taking care of vision health with a visit to the optometrist can help reduce that number and improve health, wellness and quality of life.

“Glaucoma can occur at any age,” Dr. Parsons said. “If you haven’t had an exam by age 40, it’s a good time to start.”

Why wait? Start now with an eye exam: call 816-923-5800 to schedule an appointment. 

Raising the Bar for Patient Safety: New Sterile Processing Department

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As part of their training, SHS associates visited the Sterile Processing Department at North Kansas City Hospital. Here they are in the Decontamination Room where full Personal Protective Equipment (called PPE) is required to minimize the risk of exposure to hazards. From left, Debbie Meads, Program Manager; Veronica Sosa, Medical Assistant; Chris Roseberry, Clinic Manager; Sherry Rider, Medical Assistant

Swope Health Services has launched a state-of-the-art sterile processing area at Central and Wyandotte locations.

The new Sterile Processing department is similar to centers housed in large hospitals.

The purpose is to assure patient safety in the decontamination of all reusable instruments used in medical and dental procedures.

“We’re raising the bar for community health centers,” said Debbie Meads, program manager, who directed the construction of the department.

The project involved changes to the Central clinic environment, water and air handling, as well as to the transportation and storage of instruments.

The project also included an education plan for all associates who work with reusable instruments and special training for about 10 associates in proper disinfection and sterilization of reusable instruments.

These associates now serve as sterilization processing technicians.

“Other than handwashing, sterilization is the next most important thing to consider in infection control,” said Kenneth Thomas, M.D., Chief Medical Officer and a practicing pediatrician.

“It is vital to make sure our instruments are sterile, and how we handle and clean contaminated equipment is just as important. It’s important to the safety of our patients, associates and families.”

Prior to the development of the Sterile Processing areas, equipment was sterilized in autoclaves or small steam chambers in various clinics.

The new department creates greater efficiency and assures consistent practice in the decontamination and sterilization of all materials, under the same standards, every day.

“Our program is important in delivering excellent patient care,” said Dr. Thomas. “It demonstrates our commitment to reducing and controlling infection.”

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A peek inside the new Sterile Processing Department on the second floor at SHS Central where, from left, Jaleeah Jones and Flora Wooster, Sterile Processing Technicians, are preparing reusable instruments for sterilization. This is a special room with its own heating, cooling and ventilation system. It is pressure-controlled, with special air exchange capability to completely exchange all the air in the room 10 times an hour, 24 hours a day. This secure room with these special capabilities assures that no contamination – pathogens or germs – can enter or escape from the processing units.

Coming to SHS for the first time? Here’s what you need to know.

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Melanie Evans, Director of Assurance, manages the Registration operations at Swope Health Services. Registration is on the first floor at SHS Central, straight ahead as you come in the main entrance.

If you are planning to visit Swope Health Services for the first time, here are a few tips to make your visit as convenient as possible.

  1. Bring registration information.

On your first visit, bring along a government-issued photo identification, like a driver’s license or passport.

Also bring any insurance and proof of income or employment, such as a check stub from an employer or social security or pension, tax record, or unemployment benefit letter.

And plan on filling out several forms with basic information – your date of birth, address, phone numbers, emergency contact information.

Why do we ask? SHS is a federally qualified health center, operating under federal grants, which means we have to provide specific reports to the federal government about the care we provide.

We gather this registration information once a year from all patients to satisfy our operating grant requirements.

We also provide services on a sliding-fee scale. We look at several factors, including income, to determine if your fees could be reduced or waived. If we don’t have that information, you can still get services but you may be 100 percent financially responsible for it. If you forget any of this information, we’ll ask you to provide it within 30 days.

  1. Arrive early.

For your first time here, completing all the registration paperwork usually takes about 25 minutes. If you’ve registered before, it rarely takes more than 10 minutes. On follow-up visits after you register, we verify your address, phone number, insurance and date of birth.

We charge a $25 service fee for medical care, and a $45 service fee for dental care. There’s also a $10 service fee for children’s medical care and a $20 service fee for children’s dental care.

There can be additional charges for other services such as lab work or procedures. We will accept whatever you can pay and will work with you on payment plans.

  1. Bring medical records and medications.
SHS Reg Team

Here are members of the SHS registration team at the Central registration desk standing by to welcome you! From left, Sherron Hubbard, Lena Adams, Chiquata “Gladys” Harris, Debra Law, Jaimela Clemons and Tamika Robinson.

Visiting for the first time means you should be prepared to talk about your health history with the clinical care team.

They will ask about all the medications you take, allergies, illnesses or chronic issues and even your family’s history of diseases. Sometimes it easy to bring your medications along with you.

If you can’t bring them, consider making a list or taking a mobile phone photo of each medication bottle. Be prepared to show these photos to your provider during your visit.

It is also helpful to bring records of any recent hospitalizations or other medical attention. For kids, remember to bring immunization records, too.

  1. Let us know if you can’t make it.

When you register at SHS, we ask you to sign an agreement that you will keep your appointments or provide at least a 24-hour notice when you can’t make an appointment.

If you call to cancel, you can reschedule your appointment or come in for walk-in service.

The SHS Wyandotte Clinic, SHS Central Adult Medicine and Outreach clinics all have “open access” scheduling – which means you can take the next available open appointment whenever you come in. In OBGYN and Pediatrics clinics, some time slots are reserved for walk-ins with acute needs only. Services like physicals and procedures always require scheduled appointments in OBGYN and Pediatrics.

If you miss three appointments in 12 months, you may have to accept service on a walk-in basis only.

We do this to respect our clients and providers. We know that you are busy, and we want to operate as efficiently as possible to be able to provide care to as many people as we can.

Do you have other questions about registering? You can also call us at 816-923-5800 or leave a comment below. We look forward to serving you.       

Meet the Providers: Amy Warren

Amy WarrenAmy Warren is a regular provider on the Swope Health Services Mobile Medical Unit (MMU), which visits shelters and other locations to serve the homeless population of the Kansas City area.

Amy, a nurse practitioner, says it’s important to meet her patients wherever they are.

“There is no excuse to not receive medical care,” she said. “We will come pick you up. We will see you at a mission or shelter. We are here to care for you.”

Firmly, she adds, “I want you to realize that someone DOES care.”

Amy’s focus on providing for the indigent was nurtured during her tenure at Frontier Nursing University, located in rural Hyden, Kentucky.

The school is best known for its focus on midwifery and serving women and children’s healthcare needs in the rural Appalachian foothills.

MMU

Thanks to generous donors, the Mobile Medical Unit is fitted with medical equipment and exam rooms to provide healthcare at any location.

In the early days of the school (1939), the area had the highest infant mortality rate in the nation.

With the school’s midwives, who traveled on horseback to remote hamlets and villages and provided basic primary care, the women and children began to thrive.

The model of taking care to the community has been a hallmark of the school’s programs ever since.

The Swope Health MMU is a little bit like today’s version of the horseback provider, venturing out to places where healthcare is needed but hard to get.

And Amy is convinced the MMU can produce the same kind of impact today in Kansas City as her alma mater did nearly 80 years ago in Kentucky.

“I focus on breaking down barriers to medical care,” she said. “My goal is for every patient to feel that someone cares about their health.”

Amy, with more than 20 years’ experience with Research Medical Center, works Tuesdays on the MMU and the remainder in the Outreach clinic.

This MMU, by the way, is a new addition to the SHS Outreach Services fleet.

Delivered in the summer of 2017, the MMU was funded with the generous support of Gould Charitable Foundation, Hall Family Foundation, John W. and Effie E. Speas Memorial Trust and the Sunderland Foundation.

WOW…She’s Been Helping Women at SHS for 40 Years!

Dr. Dhana Rengachary

Dhana Rengachary, M.D.

With 40 years of service, Dhana Rengachary, M.D., is a fixture in Swope Health Services Women’s Health Care.

While she can’t say how many babies she has delivered or how many women she has cared for, she has patients who have brought daughters and now granddaughters to see her for their obstetric and gynecological care.

“The best part of being in the same community for so long is people know you,” she said. “I am seeing many of the third and even fourth generation of my patients.”

She has tremendous recall of names and faces, which often astonishes her patients when she asks about family members and long-ago connections.

“I really have a good memory about people,” she said. “It surprises them to learn that I remember them. They learn that I am still connected to them. And when they come back for a visit, that connection is there.”

“Connection” is important to Dr. Rengachary. She invests her time and energy in making connections with her patients, in special ways that work for her. She arrives early to review the charts and records of the patients she will see each day. That way, when she is in the exam room, she avoids the distraction of using the computer. Her focus remains on her patient and making sure she is listening – connecting – with each person.

Talking to Dr. Rengachary is a bit like visiting with a friendly grandmother. You feel the focus of her attention, and she is always smiling and happy to see you. She asks questions and listens carefully, then offers her own direct views, often with a story of her own experience. It is her special way of developing a bond with her patients.

These days, she finds herself frequently encouraging patients to make time to take care of themselves. She sees the pattern of women putting a focus on children and family for years, and then caring for their own parents in later years.

“I say, ‘Make time to take care of yourself,’ ” she says. “I see people who are so involved with their children’s lives that they forget to care for themselves. Now is the time to live your life.”

For Dr. Rengachary, her own life is inextricably tied to Swope Health Services. She is proud of the care SHS offers, and she speaks as both a caregiver and a patient. Dr. Rengachary tells her patients she uses SHS for her own medical, dental and optometry care.

When colleagues ask for advice, she says there are three things you need for a good practice: Availability, Amicability and Ability.

  • Availability – “I am always on call for my patients.”
  • Amicability – She is approachable and friendly, showing her patients she cares for them.
  • Ability – She brings her medical training and experience to care for every patient.

But her main philosophy is much simpler and can apply to everyone. “Put your heart into your work,” she said.

“This is service. This is what I love,” she says. “I give the best care I can every day. And I can’t wait until I come back the next day.”

We encourage you to take Dr. Rengachary’s advice and make time to visit your doctor. Call us to schedule an appointment: (816) 923-5800.

It’s Time to Applaud, Appreciate and Thank Our Social Workers

stand upThe National Association of Social Workers has named March as Social Work Month, giving us all a chance to recognize and applaud the services of social work professionals.

Given how broad the term “social work” is, we thought this would be a good time to learn more about the role some social workers play here at SHS.

“It’s such a broad field,” said Kortney Carr, Director of Children’s Services at SHS. “That’s both a blessing and a curse.”

The “blessing” is the wide range of opportunity areas for social work: healthcare, mental health, government, military, schools, universities, social service agencies, community organizations. The “curse” is in that same broad variety of services, making it hard to quickly define the field of social work.

“We’re helpers,” Kortney said. “We’re focused on decreasing symptoms that are causing impairments for our patients. We work directly with clients to help them access the services they need.”

What are those services? It could be therapy and healthcare, housing and transportation resources, training and education. Social workers help people who are experiencing illnesses or mental health crises; suffering abuse, neglect or trauma; or facing poverty and other roadblocks to daily living. Social workers’ services are covered by insurance, Medicaid and state and county programs.

social workersJosette Mitchell, Director of Adult Community Services, notes that a big part of the job is advocacy. That can mean making sure the policies and procedures meet the needs of the clients, including weighing in on state and federal programs and providing feedback to legislators and policy makers.

Other times, advocacy can mean going to bat for a specific client – perhaps seeking appropriate medication or helping gain access to needed services. It can involve teaching, coaching and consultations, to help clients build their own toolbox of skills and resources, added Kortney.

Social workers obtain extensive education and training, Josette notes. They are licensed by the state and credentialed by the National Association of Social Workers Credentialing Center. Social workers are required to participate in 30 hours of continuing education every two years to maintain credentials in Missouri.

There are about 50 social workers at SHS and more than 650,000 across the U.S. By standing up for the vulnerable, social workers play an important role in creating healthy communities.

“Every day, we’ll drop everything to do whatever needs to be done,” Kortney said. “We’re here to help. We’re helpers.”

In this month for recognition of social work, we invite you to join us in applauding, appreciating and thanking social workers. At SHS, our professional social workers support clients in behavioral health, pediatrics, OB/GYN, outreach, homeless outreach, residential services and Imani House departments.

Renovations Continue To Make Swope Health Services Better for You

Debbie Meads

Debbie Meads, SHS Program Manager, checks details on blueprints for the renovations at SHS Central.

Did you notice? Last year was a time of many changes at Swope Health Services, including refreshing many clinic lobbies with paint, flooring and new seating.

And the dust hasn’t quite settled yet! The renovations and changes are part of a two-year plan, launched in 2016, as part of a $1.26 million grant from the U.S. Health Resources and Services Administration.

Debbie Meads, Program Manager at SHS, keeps close tabs on all the moving pieces. At any given time, she’s shifting one department, demolishing another, while renovating elsewhere. She juggles the departments to keep services intact throughout the construction to improve our facilities and capabilities.

Part of the effort involves creative use of limited space, she said. For example, SHS has adopted the practice of using open seating, which allows staff members to use any available workspace. Staff members have private lockers for storing personal items, but are free to use office space or open suites for meetings with patients or colleagues.

Shared space opens up possibilities for more clinic exam rooms and more patient services, she noted. Providers also get new breakrooms and lounges in certain areas.

The most significant changes will be in the OB/Gyn and Pediatrics area, to support patient needs. The SHS Central OB/Gyn department will increase to 25 treatment rooms, from 10 today, she said. Pediatrics will grow to 13 rooms from 11 today. These changes will be complete in 2017.

construction sign -swopeHere’s a summary of the main changes at SHS Central:

  • Outreach, Infection Control, Health Care Home, and the new Smoking Cessation program offices moved to newly renovated offices in Building C and on the second floor.
  • Blue Clinic medical staff will move from their west side offices to newly renovated space on the east side of the clinic.
  • Adult Health Services, formerly identified as Yellow and Green clinics, will be merged into space that’s next up for renovation. The renovation and moves are scheduled to be complete in March.
  • Once that’s complete, the former Green clinic space will be modified into the new OB/Gyn expansion.
  • The renovations also converted a former staff conference and training room into a new Specialty Clinic.

It’s all part of the plan to keep SHS growing to meet your needs.

Watch for new signs and additional changes coming to SHS Central. Despite the changes, we’re open for service as usual. Call 816-923-5800 to schedule your visit.

Get to Know Our Director of Dentistry: Dr. David Moyer

david-moyer-d-d-sDr. David Moyer is the Director of Dentistry for Swope Health Services. A native of St. Joseph, Mo., he received his doctorate of dental surgery degree from the Georgetown University School of Dentistry in Washington, D.C.

Dr. Moyer was a general dentist with the Missouri Department of Corrections and before that, a Colonel in the U.S. Air Force Reserve, serving with the 442nd Medical-Dental Squadron at Whiteman Air Force Base. He joined Swope Health Services in October 2016.

We caught up with him recently to ask a few questions. Here are his responses:

When did you know that you wanted to be a dentist?
It was in college. Growing up, I thought I wanted to be a physician. When I was 6 years old, my father died of a heart attack, so I was interested in medicine.

But while I was in college working at the teaching hospital at Creighton University in Omaha, Nebraska, I saw a woman who was in a car accident and died – it brought my father’s experience back to me and I realized I didn’t want to do this.

But, a friend’s father was a dentist, and that was interesting to me. There was a lot of close work with your hands, and I liked that since I had played piano all my life. It was interesting.

What led you to join Swope Health Services?
I’m getting a Master’s degree in Healthcare Administration from the University of Maryland. I had taken a course in public health and was learning about Federally Qualified Health Centers and I decided to explore opportunities. SHS had an opening, and I got it.

What are the key things you hope to accomplish in your new role?
I want my group to work together as a team. I want to bring in new patients and help them get their treatment plans completed. I’d like to expand our dental services to additional locations. I’m interested in developing a dental outreach program for the homeless.

What is your favorite characteristic in yourself?
I have a degree in mathematics, so I guess I’m fairly analytical. My leadership qualities tend to come out easily.

Least favorite?
My procrastination.

What book is on your nightstand?
The only book I read at night is the Bible.

What’s the one thing you wish you could change about your patients?
I wish I could change the no-show rate. It’s so inefficient and it hurts our patients. It prevents them from completing their treatment and it hinders us from helping other patients.

What else would you like our readers to know about you?
I have an 11-year-old son. I love animals and sports and music. I still play the piano. I’ve played in bands in college – rock and roll and blues bands. I taught piano and guitar during college and I still get invited to sit in with bands for recordings.

Do you have a question for Dr. Moyer? You can leave your question or comment in the box below. SHS has limited openings for new dental patients but we’re working hard to see all those who need us. If you are open to being seen at our Independence, Northland or Wyandotte County clinics, we may be able to see you sooner, rather than later. Please call 816-923-5800 to explore your options.

Get to Know Our Chief Medical Officer: Dr. Kenneth Thomas

immunizations (1)Dr. Kenneth Thomas is the Chief Medical Officer of Swope Health Services. A native of Kansas City, KS, he received his medical degree from the University of Nebraska Medical Center in Omaha, NE.

He completed a pediatric residency and a pediatric emergency medicine fellowship at Children’s Mercy Hospital in Kansas City.

Board-certified in pediatrics (and for a time, in pediatrics emergency medicine), he has worked in children’s health care in the Kansas City area for more than 20 years.

He joined Swope Health Services in January 2015 as Director of Pediatrics and in April 2016 was named to his current post leading all medical services at SHS.

We caught up with him recently to ask a few questions…

When did you know that you wanted to be a doctor?
I knew as early as high school that I wanted to be a doctor. I was fortunate to participate in programs that gave me a chance to shadow doctors in clinics and confirm that it was right for me.

How did you choose pediatrics as your specialty?
I’ve always been interested in taking care of children. Somewhere during my medical training, it dawned on me that I was happiest on the pediatric rotations. You get to play with kids — who wouldn’t love that? For a while, I thought I might want to be a pediatric surgeon, but I realized I wanted to work in primary care, in family-based preventive care and wellness, not cutting something out of a child’s body.

What led you to join Swope Health Services?
I spent 20-plus years at Children’s Mercy, taking care of special needs patients. I decided I wanted to do pediatrics closer to the community, so I moved to Truman Medical Center-Lakewood. I was working in-patient and out-patient and in the community-based nursery.

In the fall of 2014, I got a call from Swope and I initially said no, but I listened. It was an opportunity for leadership in a community-based pediatrics clinic. That’s where my interests are: providing quality care a needy population and becoming more deeply entrenched in the community, not a hospital. To be able to come here and lead that effort, that attracted me.

What are the key things you hope to accomplish in your new role?
There are a thousand things. I want to make sure that we are providing the highest standards of care to our patients. Too often, our patients get just enough to get by, but not really what’s needed. The disparity is so great. I want to give not just the standards of care, but quality care, as efficiently as we can.

I want to find that sweet spot between quality, efficiency and cost. A point where all three are optimized. I want to find that middle where quality is present, efficiency is present and the cost won’t break the bank. I want our patients to be happy and I want our providers to be happy. I want to be a model for other federally qualified health centers.

What is your favorite characteristic in yourself?
I don’t take myself too seriously.

Least favorite?
I could be more patient at times.

What book is on your nightstand?
I’m mostly reading on this thing (tapping his computer) or other electronics. But I’m more of a classics guy, so if there’s a book on my nightstand, it would be Homer, The Odyssey.

What’s the one thing you wish you could change about your patients?
To understand the importance of keeping appointments for your children. We have so many people who don’t come in for their appointments. People have problems and they don’t come in for care, they just bounce from crisis to crisis.

Things happen, I understand. But you can still call us. Who knows, maybe we can help you keep the appointment. I want to teach our patients to be proactive and preventive. Come in for well-child visits, get vaccinations on time. Respect those appointments.

What else you would like our readers to know about you?
My approach is: I don’t micromanage. I’m looking for leaders here in our departments. I don’t pretend to know everything, but I know we can sit down together, research and definitely figure out a solution. I strive for the best. I don’t want mediocrity. I don’t want anyone to tell me it can’t be done.

Do you have a question for Dr. Thomas? You can leave your question or comment in the box below. Or call 816-923-5800 to schedule a well-child appointment or check-up for your children.  Same day appointments are available, just call!  

Get Ready! It’s Time to Sign up for Health Insurance

The SHS Certified Application Counselors are ready to help with your health care insurance enrollment. From left, Janelle Strozier, Dr. Karimah Baptiste-Edward, and Angela Rogers.

The SHS Certified Application Counselors are ready to help with your health care insurance enrollment. From left, Janelle Strozier, Dr. Karimah Baptiste-Edward, and Angela Rogers.

Open enrollment season is nearly here. That means it’s time for you to examine your health insurance options and make choices about coverage. You can enroll, make updates, or change your plan between November 1, 2016, and January 31, 2017.

SHS is here to help. Dr. Karimah Baptiste-Edward, Manager of SHS Outreach and Enrollment, and her team are ready to help you pick the right plan that meets  your needs.

“There are a lot of moving parts,” she said, noting some insurance providers have pulled out and others have made changes to plans. “If you are re-enrolling, you’ll want to shop for the best deal and update your application.”

Even if your financial or employment status hasn’t changed, Dr. Baptiste-Edward encourages a visit with the Certified Application Counselors at SHS.

“We might see things that you don’t,” she said. “We’re trained and we’re here to help you navigate the system.”

A counselor can also help with the application process for financial assistance, which is based on projected income and family size. In this region, approximately 86 percent of people who got coverage in the health insurance marketplace (HealthCare.gov) qualified for financial assistance to help lower the cost of their health insurance plan..

This year’s enrollment programs include some new “Simple Choice Plans” or standard packages designed to make comparisons easier. The plans are grouped in tiers – Bronze, Silver, Gold and Platinum.

Some common questions our counselors hear:

Why do I need insurance? Just in case! We don’t walk around thinking something catastrophic is going to happen, but if it does, you know you won’t be bankrupt too. Medical bills are the No. 1 cause of bankruptcy and insurance can protect you.

Is it going to be more expensive? There may be a rate increase, but it’s still better than rates before the Affordable Care Act. Also, if you qualify for a subsidy, that can soften the blow.

How long does it take to sign up? The visit time varies, anywhere from 30 minutes to two hours. We suggest you plan on an hour. We’ll take as much time as you need.

What happens in these sessions? We ask you to bring your social security number, an income statement, like a paycheck or unemployment benefit, plus I.D.s and dates of birth for everyone who’ll be covered. We talk about what’s important to you – specific health concerns, medications you’re currently taking, which physicians you want to see. We help figure out what you can afford and show you all the plans. We help you sign up.

Where can I go to meet with a counselor and sign up? Call 816-599-5590 to schedule with our counselors at any of our locations: Central, South, Independence, Hickman Mills, Belton, Northland, Wyandotte and West.

Resources:

Don’t wait till the last minute! Enroll by December 15 and coverage will begin as early as January 1.To be sure you’re covered, call 816-599-5590 to schedule your visit.