Dr. Vonda Ware spends most mornings talking about high blood pressure, pregnancy and proper diet, trying to meet the needs of the wide range of patients who walk through the doors.
Many of the women she sees rarely go to a doctor.
Some of them don't speak English.
Most can pay only a small amount for medical services.
For 15 years, Ware worked in private practice, but four months ago, she became director of women's health at Chattanooga's two community health centers, which cater mostly to low-income residents.
"At some point in life you start thinking about what you really want to do, to get back into the community you live in and serve the people that may sometimes be overlooked," Ware said.
Ware was hired as a part of changes being implemented at Chattanooga's Dodson Avenue and Southside community health centers. The aim is to provide more comprehensive care to the communities and make the centers self-sufficient.
Erlanger Health System, which owns the centers, hired Knoxville-based Cherokee Health Systems to manage them in December. Erlanger is paying the private nonprofit $37,123 a month.
The federally qualified centers provide care regardless of a patient's ability to pay. They usually operate at a loss, often running more than $1 million a year in the red despite federal grants and payments from Medicare and Medicaid. In addition, the Southside center operates inside the former Franklin Middle School, a decaying building that community leaders long have said needs to be replaced.
Cherokee, run by Dr. Dennis Freeman, will be paid almost $223,000 over the next six months even as Erlanger is laying off employees and taking other steps to stem multimillion-dollar losses.
The hope is that the contract will more than pay for itself if Cherokee can stanch the losses, as Freeman believes it can.
"We are streamlining things, working on being very efficient," said Freeman, 69. "It's a little early to know specifically what some of those changes will be, but we expect the two ends of the budget to come much closer to meeting in the next year. You just have to live within your means."
At an Erlanger board meeting in January, Freeman said the centers are poor-performing and dysfunctional. Access for new and existing patients is inadequate and staff morale is poor, he said.
While the community health centers are part of Erlanger Health System, they have a separate board of directors.
The centers provide medical and dental care, disease management and wellness promotion, with about 35,000 visits a year. Although patient numbers have not increased drastically in recent years -- going from 32,000 in 2006 to 35,000 last year -- operating expenses have grown from $4.4 million to $6 million.
In 2011, 46 percent of the centers' patients were uninsured, 35 percent were on Medicaid or TennCare and 7 percent were on Medicare. Nearly 13 percent had private insurance.
On Wednesday, Freeman -- who spends two days a week in Chattanooga -- said the community health model always has been his life and his passion.
"There is a lot of need in Chattanooga, a lot of underserved population," said the low-key, soft-spoken Freeman. "We need to be an organization that is welcoming and provides top-notch health care to people who have no other alternative."
Freeman said he has hired a behaviorist, a women's health director and several front office staff. He wants to cut down on wait times and provide a better welcome to patients, he said. He doesn't anticipate layoffs, Freeman said, but the staff must become more efficient.
Bill Hicks, the executive director for six years who resigned when Cherokee was brought in, declined to comment about changes at the centers.
CONTRACT WITH CHEROKEE
The contract with Erlanger gives Cherokee the authority to "provide executive leadership and management to the Health Centers."
A Cherokee leadership team will fill the roles of executive director, chief operating officer and chief financial officer. Cherokee has 43 clinical sites in 12 Tennessee counties and offers primary care, behavioral health and prevention programs and services.
Freeman joined Cherokee in 1978 and, under his management, the system went from about 30 employees to 600.
Cherokee began as a mental health organization but moved into primary care. Its focus, Freeman said, is blending behavioral health into primary care, and he hopes to bring that model to Chattanooga.
"Everybody is beginning to accept the fact, if you really want to do primary care right, you have to have some mental health component," he said. "Managing diseases, anxiety, depression, how you discipline your kids -- most things in primary care can use the skills of a behaviorist."
If everyone's happy, Cherokee may extend its contract for up to three years with a pay rate based on performance criteria. Freeman said he is taking a long-range view.
"We work at the pleasure of the board, but I'm sort of assuming we'll probably be around longer" than six months, he said.
Freeman is quick to stress that the centers' primary mission will not change -- serving needy populations. The centers always will welcome paying customers, he said, but will not necessarily try to bring more privately insured patients through the door.
Instead, they will try to reach out to their core customers, the uninsured, he said.
"We will always be a place where people can get care regardless of their ability to pay," he said.
That assurance is what keeps Angela Tishaw coming back to Southside. On Wednesday, the 48-year-old went to see Ware for a four-month check-up. Tishaw has high blood pressure and needs to monitor her medication closely, she said.
She lives in Dade County, Ga., but began coming to Southside when the Dade health department charged her $50 a visit. Tishaw last worked in 2007 but doesn't receive disability. She doesn't have electricity or running water at her home and pays her bills by selling plasma twice a week.
The health center is her lifeline, she said.
"I try to bring at least $5 when I come in, but if you don't have a penny in your pocket, they will still see you," Tishaw said. "Everyone is so good to me."
That sense of mission drives everyone at the health centers, Ware said.
Freeman's holistic approach to providing medical care is one aspect that attracted her to the centers, Ware said, and she regularly sends her patients to the new behaviorist hired by Freeman.
She said she is excited about expanding the centers, waving her hands toward the empty fields behind the Southside location.
"I know we probably don't even own those fields, but I'd like to see playgrounds back there, other things for the communities," she said. "I know we can make a big difference in the community, really deal with the issues."