How One Health Center Treats Patients as Partners

ROBERTA WAITE: Well, this person’s blood sugar might be high, how is it that we’re able to adapt and work with their current living situation, resources that we can support to bring to the table to really move them in a space to where they want to move to have a healthier life. you know, individuals who are diabetics.

There is — they might like eating fried chicken, but what is a way that we can make that chicken healthier, using whole wheat flour, maybe oven-frying it instead of using oil and grease and butter. So there are different adaptations that can be taken to make things healthier versus just cutting it out completely.

SHANOOR SEERVAI: So you’re not going to tell a person who wants to eat fried chicken that they can only eat raw lettuce, but rather you’re going to work with what their life is and their diet is.

ROBERTA WAITE: You’re right, because I think one of the biggest things is oftentimes when people are told or they’re informed that they have diabetes, they immediately get told everything they can’t eat. Literally.

SHANOOR SEERVAI: Yeah.

ROBERTA WAITE: And what do you think that does to a person? I mean, they really shut down and it’s like you’re taking away all the joys. So instead of approaching it in that way, looking at what are those things that you really like to eat and how could we adapt it and work within these parameters.

SHANOOR SEERVAI: Hi everyone, welcome to The Dose. I’m Shanoor Seervai, and you just heard from Roberta Waite, a nurse and researcher at Drexel University. Roberta heads a community health center in North Philadelphia called Stephen and Sandra Sheller 11th Street Family Health Services, operated in partnership with the Family Practice & Counseling Network. My colleagues, Martha Hostetter and Sarah Klein, have written a detailed case study about 11th Street and what makes it really stand out among community health centers across the country. Sarah is going to be joining us on the show as well.

Roberta, I’m going to ask you to transport me to North Philadelphia, to the neighborhood where 11th Street Family Health Services is located.

ROBERTA WAITE: We are situated within a vibrant inner city. It’s densely populated. When you’re looking around at the homes, we’re surrounded by five housing developments, and other row homes. We’re still considered a food desert in the sense that we don’t have major grocery stores that are really flourishing in the area. There are a lot of fast food, you know, type stores and other, smaller corner stores that are in the area, but there is — it’s continuously developing.

SHANOOR SEERVAI: Could you give me some examples of the fast food restaurants?

ROBERTA WAITE: McDonald’s. Subway. Dunkin’ Donuts. Hoagie stores, Popeye’s, probably almost any type of fast food restaurant that you can think of in addition to sort of nontraditional, big-chain type stores. You have even smaller entities that are still fast food pizza places and Chinese food places and things of that nature.

SHANOOR SEERVAI: Got it. Okay, so now tell me about the people who live in this community and this neighborhood.

ROBERTA WAITE: Okay. So historically, our area was predominantly African American. Many of our individuals here have lower-paying jobs or they may have been unemployed.

SHANOOR SEERVAI: Like what kind of jobs?

ROBERTA WAITE: They’re minimum wage jobs. Probably working at many of the fast food restaurants.

SHANOOR SEERVAI: So Sarah, as I understand it, North Philadelphia and the community have changed over time. Could you tell me how?

SARAH KLEIN: Yeah, it’s really an interesting place. It was the site of a really notorious housing project where people lived in just deplorable conditions. There was sewage that would back up into apartments and the electricity went in and out, there was a lot of crime. Fortunately that was torn down and replaced by townhomes for the residents. And what you are starting to see are more expensive homes being built that draw a different demographic, young white people. It is a neighborhood in transition, and a lot of people who have lived there a long time feel that they are losing the community that they had, the sense of camaraderie. And they are made to feel I think in some cases like they are interlopers in their own neighborhood.

SHANOOR SEERVAI: That must be so hard to feel like you are an interloper in what has basically been your home, maybe your family’s home, for generations.

SARAH KLEIN: One of the things that has been special about 11th Street, is that I think they are trying to restore a sense of community, and one that is welcoming to all.

SHANOOR SEERVAI: And so as we think about the community, I wanted to ask you, Roberta, what are the health care needs that the people who live there have?

ROBERTA WAITE: We do have a lot of our population that have high levels of obesity, hypertension, diabetes for, you know, our adults, plus other types of respiratory conditions. Asthma and so forth. There’s a high need for oral health care, so for dental services. And there’s a high need for mental health care, behavioral health services, for some of the challenges with trauma, depression, anxiety, PTSD. Those are common issues.

SHANOOR SEERVAI: When people identified these health needs, how do they go about trying to meet them? What’s different about the way that 11th Street works?

ROBERTA WAITE: Well, I think one difference is that we listen to our community members. We listen to our patients. And we design care in partnership with them.

SHANOOR SEERVAI: Give me an example of what it means to design care in partnership?

ROBERTA WAITE: So I guess more recently, about four years ago, we had an expansion to our center in addition to our original building.

So in working with a lot of different collaborators, including getting insights from our community advisory committee members on the design, the layout, the space, the color, a lot of different things, the building was developed, and it opened in June of 2015. So from a design standpoint, even looking at some of the services that we bring in, the voices of our patients are incredibly important.

SHANOOR SEERVAI: Okay, I really like that idea that it would actually matter to a patient what the colors of the walls of the health center they’re going to are, and so you should consider their opinion when you paint the walls.

ROBERTA WAITE: Patients were shown the designs of the building, you know, in working with architects and things of that nature, where hand rails went, if the door should open this way, that — I mean, really detailed things. We would be in community advisory committee meetings and it was really important, because things that were brought up by individuals who may have had some different types of ability — physical abilities — differences in how they’re able to move around in a wheelchair or cane or walker.

SHANOOR SEERVAI: And the first time we spoke I remember you said that you really try to meet people where they are. Can you talk more about that?

ROBERTA WAITE: Yeah. Well, I’ll use an example of diabetes because that’s something that’s also quite prevalent. And this is truly a real case, we had a person coming in, they had a high A1c which tells you if you have diabetes or not. And they worked with their primary care provider in first learning about what the A1c is, learning about the medications that they were prescribed, but then also our nutrition educator can come in and work with the client again on food and what they can eat and how they may be able to adapt, and providing some basic information on food and nutrients.

We also connect them with our cooking classes that we have here where they could actually practice real time and execute skills and try out different things here within cooking class, and using foods that we use from our farms to family, which are fresh fruits and vegetables organically that we provide or that are provided here every week.

SHANOOR SEERVAI: Sarah, could you talk a little bit about how 11th Street is really different from other health centers you may have visited or written about?

SARAH KLEIN: You know, it’s not like any other health care institution I’ve visited either as a patient or as a health care researcher and writer.

SHANOOR SEERVAI: Wow, that is a really ringing endorsement.

SARAH KLEIN: You know, I think it is a function of the fact that they put a lot of emphasis on creating a welcoming environment for people. They asked them what is it that you really want, and the overwhelming response was that we want a place that fosters health rather than just treats sickness.

And you can really feel it when you walk in the building. There are signs everywhere for yoga classes and music therapy, there is a kitchen where they teach people about diet. It has a really bright, sunny feel to it. And there is artwork — the artwork that patients have created decorating the place, whether it is pottery or quilting or paintings.

SHANOOR SEERVAI: That sounds lovely. I mean, just thinking about my own experience when I go to the doctor, I definitely don’t feel like I am in a bright, sunny place.

SARAH KLEIN: Yeah, I think oftentimes we feel like we just walked into an assembly line when we go to the doctor.

SHANOOR SEERVAI: And just for some context, 11th Street is a Federally Qualified Health Center. So could you tell me what those are and how many there are in the U.S.?

SARAH KLEIN: Sure. There are about 1,400 across the U.S., and they were really created to ensure that people who were underinsured or uninsured had access to primary care. So they receive prospective payments from the federal and state governments with the understanding that they are going to provide comprehensive care.

So you often see in a federally qualified health center a more diverse array of services. At 11th Street there is primary care, behavioral health services, there is dental care, there is — there is also a pharmacy on site. And you also see a kind of more — as a function of that a more diverse staffing model.

It is not just physicians, it is also nutritionists, and in this case creative art therapists. What is a little different about it is that it is nurse-led. About 250 out of the 1,400 community health centers in the U.S. are run by nurses. So patients here will see a nurse practitioner instead of a physician.

SHANOOR SEERVAI: Roberta, you said a lot of people who live in this community have low-wage jobs, so I imagine that there’s some stress over finding a job, getting a better job, losing your job and then what do you do?

ROBERTA WAITE: Oftentimes people make an assumption that everyone knows how to sort of prep themselves and search for a job and develop a resume and honing in on those interview skills and being able to connect with organizations that help you get attire for when you’re going out for those jobs. Some individuals don’t even have a laptop. So we have laptops here that people can use. You know, who may need it. So some of those basic, fundamental things that we know to be automatic are not necessarily automatic for everyone, and so we’re able to provide some of those things.

SHANOOR SEERVAI: Okay. I want to shift gears a little bit and talk about the adverse childhood experiences study — ACES — that you conducted. Tell me about what you learned through this?

ROBERTA WAITE: What I learned is trauma is all too often — too common. It’s universal.

SHANOOR SEERVAI: So this study was trying to get at trauma?

ROBERTA WAITE: It really looks at how trauma impacts health outcomes. And trying to identify that when people are exposed to trauma. There are interventions that can take place to try and mitigate those adverse health outcomes. And quite often, patients did not reveal traumas to the provider, they weren’t even spoken about, they weren’t made visible, and in many people’s lives, they were normalized, because they happen on a day-to-day basis. And because of our societal structures, it’s largely ignored for a large population of individuals.

SHANOOR SEERVAI: So what are the traumas that your patients are exposed to?

ROBERTA WAITE: They’re all different types of abuse: Sexual, household dysfunction, neglect, you were living with someone who may have had a mental health illness — where your mother was battered. Or someone may have been imprisoned. The expanded ACEs also include environmental violence, bullying, relational aggression, and also discrimination.

SHANOOR SEERVAI: Okay. I’m glad you brought up discrimination. Let’s talk about it.

ROBERTA WAITE: Race is a huge discriminatory — actually lemme back up. It’s not actually race. It’s racism. And when I say racism, I don’t mean necessarily — I’m not just talking about a name call or an individual insult, I’m talking about the system of racism that’s embedded within our structures and our policies, and quite often, most times, are rendered invisible and are normalized in such ways that you really have to be so intentional to really sort of pull it out, and really look at it.

SHANOOR SEERVAI: So as we know, systemic racism is a form of trauma, and it has an impact on people’s health. So maybe Sarah, could you tell me a little bit about how 11th Street tries to get at this issue of trauma when they care for people?

SARAH KLEIN: Absolutely. 11th Street has adopted what is known as a trauma-informed approach to care, which is an approach that recognizes that adverse experiences in life, whether that is child abuse or neglect or something that happens in adulthood, say, exposure to violence or a rape, that those incidents have long-lasting impacts on your health.

So I think what the clinic is doing, and what you see in other clinics where they have adopted this approach is to educate patients about it, to let them know that the things they are struggling with are not a character flaw but a function of a physiological experience that they are having as a result of trauma.

SHANOOR SEERVAI: Some of what you are saying is making me think about this book I read a couple of years ago by a Dutch psychiatrist, Bessel van der Kolk. The book is called The Body Keeps The Score, and the argument he makes essentially is that trauma sometimes lodges itself in your body. And so to work through it you may need to do something besides talking about it. And you may need to actually move your body to get that trauma out. And so I know that 11th Street offers different creative arts therapies, there is dance, you’ve mentioned yoga a couple of times. Could you talk about how this philosophy of physically working through trauma comes out in the way that the clinic works?

SARAH KLEIN: Something that is very distinctive about 11th Street is the way in which they have embedded these creative arts therapies into their care model, with the understanding that these aren’t alternative therapies, but actually in some ways the first line of treatment for people who have been traumatized and have, as a coping mechanism, an inability to really talk about it. The brain simply doesn’t allow that as a protective — you know, a protective defense.

So they have just an array of classes that allow people to — to explore these issues through art, through movement, through music.

SHANOOR SEERVAI: So we’ve got these two distinct ways in which 11th Street helps people to get through trauma, really living by and supporting the idea that creative arts therapies can make a difference. And the other is that providers are really sensitive to trauma. So Roberta, maybe you could give me an example of how providers are sensitive.

ROBERTA WAITE: Typically, when somebody gets an exam oftentimes they may be asked to change into a gown. They change into a gown and the provider comes in and oftentimes they’ll, you know, start taking breath sounds, heart sounds, and they start touching them.

Maybe from their perceived perspective in sort of an invasive way. But somebody who’s endured trauma, depending upon the types of trauma, it can be very invasive. And also, you’re not respecting them in the way of sharing, you know, “I’m about to do a physical, this is what I’m going to do, I’m going to have to touch you here, or I’m going to be pulling your gown down a little bit so I can hear your heartbeat, is that okay with you?”

So even that basic communication and respect in that way and the planning to allow that person to say no, I would prefer not to, or if they jump or twinge a little bit, you know, you might know why, and you stop and say is it okay to continue? So, a trauma-informed approach is a way you engage and you build that relationship and you build that trust.

SHANOOR SEERVAI: And what’s the point of using these different modalities, dance therapy or other forms of creative arts therapies to treat trauma?

ROBERTA WAITE: Safety. Everyone doesn’t prefer talk therapy. Sometimes people don’t even have the words for what they’ve experienced. Some people may not feel safe in talking outwardly. Creative arts therapies are extremely important for youth, because many youth don’t have the words to be able to express what’s happened, but they can draw, through pictures, to communicate what they’re thinking and what they’re feeling. So it’s a combination of things.

SHANOOR SEERVAI: And Sarah, what evidence do we have, if at all, that creative arts therapies and the approach that 11th Street takes is effective?

SARAH KLEIN: I think it is really important to 11th Street to demonstrate the impact of these things, and this is work that is under way. They look at the impact of these programs on patients’ quality of life, and I think they see improvements there. They are also looking at the effects on physical symptoms like chronic pain. One of the challenges in health care is that we barely — we barely assess for trauma to begin with, much less the impact of treatment upon it. I think Roberta has a lot of examples though of really its transformative effect on patients.

ROBERTA WAITE: Well, the one I gave you earlier, in reference to the diabetes patient.

It’s really life-changing where his level went from being where it was a high A1c level to the point now of where he’s just diet controlled. He has a totally different lifestyle. Not only did he lose weight, he feels so much better. And so he actually feels like a new person, and he expressed just being so thankful because he was sort of center stage in driving everything, but he had the support that was unwavering and always there. So he holds up his team of — I wanna — they were not just practitioners because it wasn’t just only nurse practitioners, but it was a nutritionist, it was a number of different people that he spoke about that really were integral in sort of his life transformation. And that’s how he sees it, as a transformation for himself.

SHANOOR SEERVAI: He’s doing much better?

ROBERTA WAITE: Absolutely. And that to me tells me more than numbers.

SHANOOR SEERVAI: That’s it for today’s episode. Thank you all for listening and I will see you in two weeks.