North County health officials say restrictive guidelines are barring needy residents from participating in a program that provides treatment to poor people with diabetes and high blood pressure.

Narrow citizenship, age and income requirements are keeping thousands of patients from qualifying for the county's Coverage Initiative program, they say.

And those low enrollments are putting the program at risk of losing its funding -- a three-year, $13 million grant.

The program has managed to enroll only 147 people as of May 13, according to the county's Health & Human Services Agency, which runs the program.

That is far short of its goal -- 3,260 people. The county ranked last in enrollment out of the 10 counties that have received similar grants in California.

North County health officials said the low participation rate is largely due to tough admission requirements, which are a combination of federal, state and local rules.

"When the program was announced, we were very excited about it," said Dorothy Lujan, programs director at the Vista Community Clinic in Vista. "We thought, 'Wow. We're going to get all these people covered.' "

But those hopes were dashed when they looked at how many of their patients would not meet the program's criteria.

A problem

County officials said they are working to boost enrollment. A top official at the state Department of Health Care Services, which is overseeing the grant, said he is watching closely to make sure the county meets its goal.

If North County clinics are an indication, that goal may be difficult to achieve under current guidelines. Two of the three largest community clinics in the region have been able to enlist only 74 people in the first seven months of the program.

The third clinic declined to participate in the program, citing the cumbersome application process.

The Vista Community Clinic is one of about 20 clinics and hospitals throughout the county that participate in the program.

Lujan said the Vista clinic's staff started assessing its patients to see how many would be able to qualify for the program. The clinic saw 48,000 patients in 2006 at its five sites in Vista and Oceanside.

Out of all its patients, 2,500 were identified as having diabetes, Lujan said. Of those, about 500 made it through an initial screening process. And of those 500 patients, the clinic was able to complete applications for 46 patients. Twenty-eight of those applications were approved by the county for enrollment, clinic officials said.

Similarly, the Neighborhood Healthcare clinic in Escondido identified 1,000 of its patients as diabetics. Of those patients, the clinic was able to enroll 42 people, said Tracy Ream, the clinic's executive director.

Neighborhood Healthcare is a nonprofit organization that serves about 65,000 patients each year through its network of 10 clinics in North County, East County and Southwest Riverside County.

Losing out

Stan Rosenstein, chief deputy director for the state Department of Health Care Services, said the county is at risk of losing the grant because it's far from reaching its enrollment target.

"So far, they've had very limited enrollment, and what it needs to do is enroll more people in the county," Rosenstein said.

If the county fails to enlist more patients, the state may shift San Diego County's share of the funds to other counties, Rosenstein said. Otherwise, the state would have to return the unused portion to the federal government, he said.

Rosenstein declined to say when the state would make the decision on whether to shift the funds.

San Diego County was one of 10 counties in the state chosen to receive money from the three-year, $180 million federal grant. By comparison, Los Angeles and Orange counties have enrolled 7,994 and 6,997 patients, respectively.

Holly Crawford, a spokeswoman for the county's Health & Human Services Agency, said the reason for the low enrollment numbers may be due to federal requirements that are beyond its control, such as citizenship requirements and proof that patients are ineligible for other state health programs.

Crawford said the county is reviewing its own criteria to make the program more accessible. She said the county is looking at broadening the income guidelines, expanding the program to cover other diseases and streamlining the application process.

"The model is not identifying the number of patients we had anticipated, and we are working with our partners to make the necessary changes," Crawford said.

Strict admission guidelines

One of the problems may be in the clinics' patient demographics, officials said. They are predominantly Latino immigrant families. Though they have among the highest rates of diabetes, most don't qualify for the program.

A 2006 Centers for Disease Control and Prevention study reported that about 10.8 percent of U.S.-born residents of Latino descent are diabetic, compared with 6.1 percent in the entire native-born U.S. population overall.

Latino immigrants' risk of diabetes increases the longer they've been in the country, according to the report.

Despite their high risk of diabetes, much of this population is barred from the program because of immigration status, income and other factors.

To qualify, applicants must be U.S. citizens, ages 21 to 64. Illegal immigrants cannot participate, and legal immigrants must have lived in the country for five years or more, according to the program's guidelines.

Another barrier is the program's strict income requirements, Ream said. About 98 percent of her clinic's patients earn less than the federal poverty level, according to the clinic's Web site.

The Coverage Initiative program requires that patients earn no more than 200 percent of the federal poverty level, or $1,734 a month for a single adult, but not less than 135 percent of the federal poverty level, or $1,171 a month.

For many of the Escondido clinic's patients, "it's not that they earn too much, it's that they earn too little," Ream said.

Many applicants also are eliminated from the pool because they have children. That's because their children may be eligible for Medi-Cal, the state's health insurance for the poor. Those patients must apply for Medi-Cal first and then provide proof they were turned down, a process that can take 45 days, clinic officials said.

A different route

North County Health Services, a community clinic based in San Marcos, chose not to participate in the program because it anticipated many of these problems, said Irma Cota, the clinic's chief executive officer.

"I'm about health care and providing access to health care without having to be in a position to make decisions about those eligibility criteria," Cota said.

The 35-year-old nonprofit clinic provided care to 58,000 patients last year, including 29,000 children.

Another disadvantage in the program is built into the county's health care system for the poor.

Instead of having a network of county-run hospitals and clinics, San Diego County contracts services out to community clinics. That means that there is no centralized database that health officials can tap into to cull information about diabetics.

Ream said the county and its partner clinics and hospitals had to create a new program to accommodate the Coverage Initiative, and it will take time to work out the problems.

"Most counties decided to take their existing programs and expanded them," Ream said. "We went another route and created a slightly different program."

Contact staff writer Edward Sifuentes at (760) 740-3511 or esifuentes@nctimes.com.