CASE STUDY PRIMARY CARE FOR LOW-INCOME POPULATIONS APRIL 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services How do you promote health, instead of just treating sickness? Martha Hostetter Sarah Klein Consulting Writer and Editor Consulting Writer and Editor The Commonwealth Fund The Commonwealth Fund PROGRAM AT A GLANCE TOPLINES KEY FEATURE: The federally qualified health center is run by 11th Street Family Health nurses and serves public housing residents and others in North Services found a high rate of trauma among its patients, who Philadelphia, where the poverty rate surpasses 40 percent. are mostly African American TARGET POPULATION: Most of its patients are African American women covered by Medicaid. women covered by Medicaid. Many have chronic medical conditions; a high number have experienced trauma. This Philadelphia community health center has been a pioneer WHY IT’S IMPORTANT: 11th Street Family Health Services has in using creative arts therapies been a pioneer in using creative arts therapies and mind–body and mind–body interventions to interventions along with traditional counseling to help people help people cope with behavioral and physical health problems. cope with behavioral and physical health problems. BENEFITS: Patients have been willing to try nontraditional counseling approaches and also have benefitted from the social support they’ve found in groups. CHALLENGES: The health center depends on grants to fund some of its more innovative services, as its leaders develop the evidence base to make the case for payer reimbursement. Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 2 BACKGROUND This case study is the first in a series profiling Stephen and Sandra Sheller 11th Street Family Health how primary care clinics — federally qualified Services — a federally qualified health center in North health centers, independent clinics, and Philadelphia — sits in a neighborhood in transition. clinics that are part of large health systems — Four public housing developments and a scruffy bodega are meeting the needs of patients with low surround the center, but blocks away are new bars, restaurants, a gin distillery, and rehabbed rowhouses — incomes. An earlier series of case studies all signs of the gentrification taking place in pockets across profiled care models serving frail elders and a city that still ranks as the poorest of America’s major people with disabilities and/or multiple metro areas.1 chronic conditions. We are now focusing on people who may not have such complex The health center grew out of an effort in the late 1990s to health care needs but are at risk of developing serve the neighborhood’s many public housing residents, problems because they lack the resources to whose high rates of diabetes, cardiovascular disease, and stay healthy. This series will profile clinics that other chronic conditions were compounded by poor exhibit some or all of the following attributes: access to primary care. Residents felt like they lived in a world apart, contending with decades-old public housing • medical home capabilities as a foundation with antiquated plumbing that caused raw sewage to back up in sinks and bathtubs, electrical systems • multidisciplinary teams with community that frequently left them in the dark, and drug dealers health workers operating in the maze of courtyards. Acting in partnership with the Philadelphia Housing • integration of primary health care Authority, Patricia Gerrity, R.N., Ph.D., then associate with public health, social services, and dean for community programs at the Medical College of behavioral health Philadelphia/Hahnemann University, began knocking on doors and attending public housing residents’ council • using data to manage and improve patient meetings. It was slow going. “The residents were really not care and clinic performance interested. They were tired of being assessed and surveyed by people like us from universities who only stuck around • geographic empanelment, including until their research ended,” she says. appropriate risk stratification and targeting • proactive patient and family engagement to address physical, social, and cultural barriers to care • leveraging of digital tools to improve health Stephen and Sandra Sheller 11th Street Family Health Services stands out as an exemplar of integrating physical and behavioral health services. 11th Street Family Health Services commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 3 Gerrity and a few other nurses spent years earning people’s trust, mainly by showing up and delivering practical solutions. At community members’ behest, You can easily look at health they began visiting seniors in their homes to help them stats and see what is happening manage chronic conditions. They lobbied the city to place but you need to connect with a stop sign on a dangerous intersection and created an emergency food pantry for people whose grocery money the people. You can’t walk into ran out at the end of the month. When they heard that a community and say, “I know ambulances struggled to find people in the sprawling what your problem is.” public housing complexes — one woman’s son bled to death in her arms — they offered free training in CPR and other lifesaving techniques. Roberta Waite, Ed.D., R.N. Executive Director of 11th Street By 1998, the nurses had opened a free clinic in an unused Family Health Services public housing unit. After a few years, they convened a community planning session to discuss how to build on their efforts; the session lasted 16 hours and drew people 11th Street grew out of community members’ request for a place to go to be healthy, not just a place to go when they’re sick. commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 4 from the public housing developments, local businesses, In this case study, we describe how 11th Street’s leaders, schools, churches, and the public health department. A staff, and patients have hewn to the founding vision of a clear message emerged: “Community members wanted center focused on health, not sickness. some place where they could be healthy, not just a place to go when they were sick,” says Roberta Waite, Ed.D., R.N., BUILDING A CENTER FOR HEALTH 11th Street’s executive director. To promote health in its neighborhood, 11th Street’s founders looked to international models, including the The nurses eventually secured funding from the U.K.’s Peckham Experiment, a 1930s plan to improve Health Resources and Services Administration and the residents’ health in a working-class South London Philadelphia Housing Authority to build a full-scale health neighborhood by offering nutritious food, opportunities center. The 17,000-square-foot space opened in 2002 on to exercise and socialize, a library, day care, and other ground cleared when the city tore down the old public supports. They studied healthy living centers formed housing complexes and built condo-style units. as part of a 1990s initiative to reduce health disparities between low- and high-income Britons. In 2003, Gerrity Since then, 11th Street Family Health Services has been visited a healthy living center catering to Bangladeshi jointly operated by Drexel University’s College of Nursing immigrants, with a kitchen and event space, and another and Health Professions and the Family Practice and where art therapists helped people struggling with alcohol Counseling Network, a nonprofit health and behavioral addiction. These models’ expansive view of health as more services provider that holds the federally qualified health than just medical treatment and their focus on building center (FQHC) license and manages the finances. 2 strong communities became part of 11th Street’s approach. Most patients are residents of local public housing. commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 5 Most of 11th Street’s 6,000 patients live in local public 11 STREET: PATIENTS AND NEIGHBORHOOD TH housing, but some travel to the health center from other parts of the city or nearby suburbs, after having moved out 85% of the population is or been priced out of the neighborhood. Most are African African American American women covered by Medicaid; significant numbers have chronic conditions including hypertension Private Insurance 12% (appearing even among young adults and children), heart Medicare (mostly dually eligible disease, diabetes, depression, and chronic pain. About 15 for Medicaid and Medicare) 12% patients serve on the Community Advisory Committee Uninsured 16% and play an active role in shaping services and building relationships with local schools, churches, and nonprofits. Medicaid 60% The difference from a traditional primary care clinic is noticeable in 11th Street’s lobby, which brims with 2 of 3 are female activity: people hurrying to a yoga class or a support group, or picking up boxes of fresh fruit and vegetables from Lancaster County farms. Elsewhere, men and women join drum circles, work out at the gym, or take 1/3 12% 20% mindfulness training or creative arts therapy. These are are obese have diabetes have depression some of the ways the center has sought to engage people and help them build health and resiliency. Many of these THE POVERTY RATE THE POVERTY RATE services were added in response to evidence that patients in the fifth district of in the part of the district where had experienced traumatic events and were coping with North Philadelphia is the 11th Street health center is located exceeds both mental and physical health problems. Initially, 11th 36% 40% Street’s leaders used grants to pay for these new services. Some were eventually added to the FQHC operating Data: 11th Street Family Health Services; Center City District and Central budget as leaders gathered evidence of their effectiveness, Philadelphia Development Corporation, Philadelphia: An Incomplete and a handful have begun to be reimbursed by payers, as Revival, Jan. 2017. described below. AmeriCorps volunteer Madeline Frank asks patients about their needs and describes the health center’s offerings. commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 6 A Medical Home and Beyond Every six months, patients are asked to answer questions 11th Street is certified by the National Committee for about their mood and childhood experiences. If the Quality Assurance as a Level III Patient-Centered Medical responses suggest problems, patients are asked to complete Home. Primary care teams include nurse practitioners, the full PHQ-9 survey, which asks about their mood, sleep registered nurses, medical assistants, social workers, habits, appetite, and day-to-day functioning, and the behavioral health consultants, and a nutritionist. There are adverse childhood experiences (ACE) survey, which covers no staff physicians, making it one of about 250 nurse-led instances of violence or neglect. In addition, an AmeriCorps volunteer greets patients in the lobby and asks them to FQHCs among nearly 1,400 centers nationwide.3 It has complete an “interest form” indicating their health and traditional behavioral health services as well as creative social needs; a staff member follows up to offer services. arts therapies, a dental clinic, laboratory, and a private pharmacy, which makes deliveries throughout the city. It Patients with chronic medical conditions receive also offers same-day and after-hours appointments, free van comprehensive assessments, including home visits. Care rides to appointments, and a nurse triage hotline. teams follow shared plans to manage their conditions. ADDRESSING BASIC NEEDS Well before research on the “social determinants of health” had become mainstream, 11th Street’s leaders recognized that many people get sick because they don’t have the basic resources to stay healthy.4 Nearly all (about 90%) of patients receive help for things other than medical problems: working with a social worker to enroll in health insurance or other benefits, finding educational or job training programs, or creating a budget. Many receive free legal services on issues like eviction, unsafe housing, and domestic abuse. Given that produce at the local grocery store is too expensive for many residents, 11th Street has partnered with the Farm to Families Initiative, which provides weekly deliveries of subsidized fruits and Yael Tacher delivered vegetables to patients eligible for or enrolled in the Supplemental food boxes along with Nutrition Assistance Program (SNAP). Over 300 families participate. recipes to Jennifer Warshaw, M.S., M.P.H., R.D.N., director of nutrition education patients. services, offers recipes, cooking classes, and food demonstrations in the teaching kitchen, as well as counseling and mindfulness training to patients wishing to change their eating habits. Acknowledging that “no one wants to see a nutritionist,” she’s tried to keep things fun by holding Battle of the Chefs–style competitions, or offering “A Taste of African Heritage,” which teaches people how to use the traditional foods of the African diaspora. commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 7 IDENTIFYING AND RESPONDING TO TRAUMA Over the years, 11th Street’s clinicians heard stories THE EFFECTS OF TRAUMA IN FAMILIES AND from patients about domestic violence, rape, or other NEIGHBORHOODS traumatic experiences, or noticed troubling signs of these Since the original ACE study, scientists have identified experiences. Gerrity recalls hearing from a mother whose some of the ways traumatic experiences can have child had suddenly begun wetting the bed after he saw long-term impacts on brain development, physiology, her stab her boyfriend and from a grandmother whose and behavior. These include changes in the way grandson had tried to rob her in order to buy drugs. we perceive pleasure and rewards, changes to the brain and hormonal systems that react to perceived Stories of traumatic experiences also surfaced during a threats, and even genetic changes that can affect the women’s diabetes management group. “The educator was immune system.6 People who experience prolonged great, the reading level of the materials was appropriate, but or repeated adversity may experience “toxic stress” we weren’t getting results,” Gerrity said. When a behavioral that can take a toll on human development and health specialist began meeting with the women, she lead to long-term health problems. Some who’ve experienced trauma turn to coping behaviors, discovered that many had undiagnosed depression — and including unhealthy eating and substance abuse.7 a shared history of childhood and/or ongoing abuse. “Each one thought they were the only ones,” Gerrity said.5 Researchers have begun to look at how trauma not just within families but in schools, streets, and neighborhoods can affect health. In 2012, 11th Street Family Health Services and members of the Philadelphia ACEs Taskforce used an expanded If it wasn’t for this health version of the ACE survey that asked adults whether center, I would never have as children they had: witnessed violence other than known about ACEs. I will a mother being abused, experienced race-based discrimination, felt unsafe in their neighborhood, always remember Patty been bullied, or had been in foster care. [Gerrity’s] words: “When Among 1,784 Philadelphia residents, two of five you see a child acting out, the (40.5%) had witnessed violence while growing up, question isn’t, ‘What’s wrong such as seeing or hearing someone being beaten, with that child?’ It is, ‘What stabbed, or shot. More than a quarter (27%) reported having felt unsafe in their neighborhoods, while has happened to that child? more than a third (34.5%) said they had experienced What has happened to that discrimination based on their race or ethnicity.8 parent? What has happened to To delve into how racism affects their work, 11th that parent’s parent?’” Street’s staff members take part in sessions about the impact of structural racism and discrimination. “We hone in on how race affects what we do and Jacqui Williams how we interact,” says Waite. The health center is Member, 11th Street Community Advisory now launching a series of educational sessions on Committee the intersections of trauma, racism, and health. commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 8 To investigate how common such experiences were, Waite minority patients in primary care — were startling. and Gerrity screened 801 patients (647 women, mostly While 64 percent of the original Kaiser respondents African American; 154 men, mostly African American) (mainly white and middle-class) reported at least one using the ACE survey. This screening tool was developed type of adverse childhood experience, nearly all (94%) in the late 1990s by a Kaiser Permanente physician who of 11th Street’s patients did. While 12.5 percent of Kaiser discovered that many of his obese patients had a shared respondents reported four ACEs, nearly half (49%) of 11th history of childhood sexual abuse; he theorized that Street’s patients did. Confirming prior studies, 11th Street overeating and other unhealthy behaviors might be coping researchers found that patients who had experienced strategies. The survey asks adults whether as children they adversity as children were more likely to be sick, had experienced physical, emotional, or sexual abuse; particularly with diabetes and/or depression. There was a neglect; lived with someone who was abused, mentally ill, cumulative effect: the more types of adverse experiences incarcerated, or struggled with substance abuse; or had they had lived through, the more likely they were to be divorced or separated parents. sick.9 They were galvanized by the findings: “Having the data gave us an obligation to do something,” says Gerrity. The results of 11th Street’s 2009–10 study — one of the first to explore childhood adversity among low-income, Engaging Community Residents in Conversations About Violence, Abuse, and Trauma 11th Street was an early adopter of “trauma informed care,” which focuses on raising awareness of trauma and its effects on health and creating safe clinical environments that are less likely to trigger traumatized patients. Most health care organizations that have adopted trauma-informed approaches screen patients and educate them about the link between trauma and unhealthy behavior and poor health outcomes. They also may enhance access to treatment by streamlining referral pathways to specialty care or embedding behavioral health providers in primary care settings. 11th Street has gone a step further by adding creative arts therapies and other counseling services that target the negative effects of trauma, including stress and distrust.10 In September 2018, 11th Street became the first primary care provider to become a Sanctuary center, a model adopted by mental health providers, juvenile justice programs, homeless shelters, and domestic violence programs to help traumatized patients. 11th Street recognizes that patients who are racial minorities are less likely than others to ask for help when they experience mental health problems and that some (particularly children) may come to regard traumatic 11th Street encourages people to speak up if they’ve been affected by violence, abuse, or other types of trauma. events such as gun violence and crime as normal. To address this, 11th Street’s leaders launched a campaign commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 9 to educate community members.11 In 2012, Gerrity and years to assess family relationships, promote positive members of the Community Advisory Committee took parenting skills, detect emotional and developmental an Institute for Healthcare Improvement course on problems, and offer referrals to early intervention how to lead change and got advice from a University of services. If fathers are present at visits, the coordinator Pennsylvania researcher who studies what makes ideas will emphasize the important role they play; if not, she spread. They used a postcard campaign to educate people will ask about their involvement and encourage them about ACEs — encouraging them to speak up if they or a to attend future visits. This service has reduced the loved one has been affected by violence, abuse, or neglect number of children being referred to medical specialists and let them know healing is possible. for conditions like bedwetting that can have roots in emotional problems.12 Detecting Problems Early The health center’s leaders have sought to prevent The health center has gradually rolled out ACE screening traumatizing childhood experiences by breaking to all adults receiving primary care services as it has added generational cycles of violence or abuse and promoting sufficient resources to respond to identified problems. strong families. They ask all pregnant women to take the ACE survey to detect instances of childhood trauma, and Creating a Safe, Welcoming Environment connect women who’ve experienced trauma to therapy As part of its efforts to help patients, 11th Street’s leaders or other supports. They also refer first-time mothers to have encouraged staff members to care for themselves. the Nurse Family Partnership, a program in which nurses All are offered mindfulness training to help them cope visit mothers at home during their pregnancies and their with the stress of working in a busy environment and children’s first two years. being exposed to stories of trauma and so they can model An 11th Street social worker, known as a family, child, and mindful practices for patients. Lekisha Parker, C.M.A., support coordinator, meets with families when women lead medical assistant, uses mindfulness techniques with first become pregnant through their children’s teenage patients who feel anxious about their medical visits. Nurses visit first-time moms at home, while clinicians model mindfulness techniques for patients. commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 10 Offering a Range of Therapeutic Approaches Over the past several years, 11th Street has added creative arts therapies as Some patients have been more well as yoga, meditation, and mindfulness training to complement traditional willing to try music counseling options. or art therapy than traditional counseling. Anyone can drop in to take a class or try creative arts therapy. “We had to reconceptualize the definition of a patient,” says Kathleen Metzker, M.P.H., director of integrative health and mind–body services. “Someone can enter the center through any entry point; there is no wrong door.” These nontraditional therapies have encouraged more patients to seek treatment. Some have been willing to try them because they are more convenient, while others see them as less stigmatizing or intimidating than traditional therapy. “We’ve found that some patients need different approaches in order to make sense of their trauma; it’s important to give them choices,” says Gerrity. Some patients start with creative arts therapy or meditation and eventually try traditional counseling; these patients tend to make the most progress. From the beginning, Gerrity emphasized these new therapies were core parts of their clinical approach and not “alternative” services. The mind–body teacher, for example, uses breathing exercises, guided visualizations, and other methods to help people pay attention to their sensations and emotions without interpretation. Such approaches have been shown to reduce anxiety and promote calm responses — helping to counter the instinct toward “flight or fight” that may be triggered by stressful experiences. Music therapists have offered “Power Over Pain” sessions, which involve singing elongated vowels, humming, and deep breathing, as well as group singing and vocal improvisations to help people cope with chronic pain. Lindsay Edwards, M.A., L.P.C., director of creative arts therapies, offers a dance/movement therapy class to support grandparents raising grandchildren. “We notice how we can feel more in control moving at a slower pace, and we notice that we’re not alone in tackling similar hardships,” she says. In treating our patients, what matters is not so much what we do but how we do it. Kathleen Metzker, M.P.H. Director of Integrative Health and Mind–Body Services commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 11 Patients who need medication management (e.g., for post- brief oral health screening to look for signs of periodontal traumatic stress disorder or major depression) are referred disease, decay, or other problems. While this service is to Sarah Thornburg, M.S.N., C.R.N.P., a psychiatric nurse offered to all, the health center has focused on those at practitioner. Thornburg also provides medication-assisted greatest risk: children, pregnant women, and people with treatment to patients with opioid-use disorder. diabetes or hypertension. Moving a dental office to the primary care suite and Integrating Medical and Dental Care tag-teaming visits “increases the chances people will be Many people avoid dentists because they worry about the willing to receive dental services,” says Dana Robinson, costs or pain of treatment; those who’ve experienced trauma R.D.H., P.H.D.H.P., 11th Street’s public health dental may fear an experience of lying prone and being unable to hygiene practitioner. “Some of our patients haven’t seen a speak. For all, the longer they wait, the harder it feels to go. dentist in 10 or 15 years, so we don’t tend to do cleanings To encourage more patients to receive regular dental right away. We do an assessment and take x-rays. I tell services, 11th Street launched a medical–dental them it’s just baby steps.” Robinson also invites Drexel integration program in 2016. Every day, a coordinator runs music therapy students to provide music during visits a report to identify patients coming for a medical visit to help with anxiety. The health center has seen a 25 who haven’t seen a dentist in the past year. After their visit, percent increase in new dental patients this year, which it primary care clinicians invite these patients to undergo a attributes to the greater comfort and ease of access. POPULATIONS AT RISK FOR ORAL HEALTH PROBLEMS People with Children and Adolescents Chronic Conditions Pregnant Women 95 % 1 of 5 of Americans with diabetes Hormones released children also have periodontal disease, during pregnancy ages 5–11 which can make it harder CAN CAUSE TO CONTROL PERIODONTAL 1 of 7 BLOOD SUGAR DISEASE teens Inflammation caused by periodontal disease may also put people at have at least one INCREASED RISK UNTREATED, FOR DEVELOPING DECAYED HEART DISEASE TOOTH OR EXACERBATE HEART CONDITIONS Data: American Dental Hygienists’ Association, Fact Sheet; American Academy of Periodontology, Gum Disease and Heart Disease; and Centers for Disease Control and Prevention, Children’s Oral Health. Source: American Dental Hygienists’ Association, Fact Sheet; American Academy of Periodontology, Gum Disease and Heart Disease; and Centers for Disease Control and Prevention, Children’s Oral Health. commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 12 ASSESSING IMPACT To measure the impact of their efforts, 11th Street’s leaders 11th Street performs as well as or better than the national mainly use the Short Form Health Survey, which focuses average among FQHCs on nearly all measures of disease on quality of life rather than clinical benchmarks. It asks prevention and control reported in the Uniform Data people to report on their physical and emotional well- Set. In particular, it does better than the national average being using plain language and say whether they’re able among FQHCs in documenting patients’ body mass index to complete day-to-day tasks. “We want to know whether and offering plans to help them achieve healthy weight people’s lives are changing,” says Gerrity. (83% of patients vs. 64% nationally). More 11th Street 11th Street has used this survey to assess the effects of patients have achieved diabetes control (75% of diabetic the mind–body interventions as well as creative arts patients have an HbA1c less than 9% vs. 66% nationally). therapies. In one study, patients who participated in It does less well in controlling blood pressure among four mindfulness sessions experienced decreased hypertensive patients (56% of patients vs. 63% nationally). anxiety and improvements on measures of mental and physical functioning, social functioning, and vitality.15 It has struggled to engage patients in certain screenings; In another, patients with chronic pain who participated in 2017 just 31 percent of children had received in eight music therapy sessions reported somewhat less recommended vaccinations (Rotovirus and influenza) by pain and were much more likely to say they felt able age 2, compared with 40 percent nationally.13 Strategic to work, complete chores, and socialize than a control initiatives to close this gap, including better tracking and group. They also reported greater feelings of motivation, follow-up, led to a 10 percent increase in immunization empowerment, and sense of belonging.16 rates and recognition from the Philadelphia Department of Public Health. LESSONS Additional evidence suggests that 11th Street’s focus on 11th Street Family Health Services offers lessons for other developing strong families through prevention and early primary care clinicians working to promote health and intervention has paid off. The health center has reduced resiliency for low-income patients. preterm births to 2.5 percent among African American women, compared with nearly 16 percent across the city.14 Promoting Health Requires R&D 11th Street has benefitted from having seasoned leaders Jacqui Williams and Diane Monroe, who are both practical and research-driven; they’ve members of the 11th Street’s listened to what people need, responded in creative Community Advisory Committee. ways, and studied the results. “My job essentially was to continue to learn about the community, to look at those who come for care, those who don’t, try to figure out what they need and what’s the best practice that could address those needs — whether insurance paid for it or not — and then try to do it,” says Gerrity. “And then see if it works.” Because 11th Street’s nurse leaders do not control the operating budget (Family and Practice Counseling Network, the FQHC licensee, does), they’ve relied on financial support from Drexel University and private philanthropies to pilot new services that are not reimbursed. Their willingness to experiment has begun commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 13 to pay off; in 2018, a policy change enabled the health Attend to the Role of Trauma in Poor Health center to begin billing Medicaid for the services of licensed professional counselors, including some of the creative While focusing on positive approaches, 11th Street’s arts therapists. Evidence of the effectiveness of the child leaders have been clear-eyed about the damage inflicted and family support coordinator, who had previously been by patients’ traumatic experiences. They’ve emphasized paid through grants, convinced the Family and Practice the need to shed light on problems and continue to offer Counseling Network to pay for some of her salary. “We’re “ACEs 101” training for members of the Community an incubator for ideas,” says Waite. Advisory Committee, who give presentations in their churches, schools, and workplaces. They also acknowledge Positive Approaches Are Key to Engagement that the healing process can be long and messy, and have therefore put no parameters or requirements on patients 11th Street clinicians have been able to earn their patients’ receiving services. trust and engage them in treatment because they’ve focused on health, not sickness. This positive approach is evident in the health center’s creative efforts to promote 11TH STREET’S FUTURE IN A CHANGING healthy development, including dance therapy sessions NEIGHBORHOOD that encourage teen girls to develop positive body images. The model of inclusiveness extends to new residents of It’s also part of its approach to therapy. “We’re really quick the rapidly gentrifying area. Members of the Community to say, ‘This is what’s wrong with me,’” says Metzker. “We Advisory Committee recently launched an effort to serve try to say ‘What is right with you, what’s working?’ When as patient ambassadors to make sure all neighborhood we bolster that we can get to problem-solving and let residents know about the health center’s many services. people experience the best parts of themselves.” “Our community is changing. And we want to get the word out that 11th Street is not exclusively for people with low Like many community health centers, 11th Street serves income. It’s for anyone,” says Jacqui Williams, a longtime predominantly women.17 To engage more men in care, in member of the Community Advisory Committee. “This 2016 the health center sought and received funding from center is a beacon here in this community.” AstraZeneca HealthCare Foundation to engage young men at risk for cardiovascular disease. The initiative aims to help increase their understanding of nutrition and cardiovascular disease, in part through a peer learning group. The health center is also launching a music therapy group for adolescent males and hoping to recruit more male clinicians.18 commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 14 NOTES 1. Pew Charitable Trusts, Philadelphia 2018: The State of the City 7. Center for Health Care Strategies, “Trauma-Informed Care (Pew, Apr. 2018). Implementation Resource Center” (CHCS, n.d.). 2. Medical College of Philadelphia/Hahnemann University’s 8. Public Health Management Corporation, Findings from the School of Public Health later became part of Drexel University. Philadelphia Urban ACE Study (Institute for Safe Families, Sept. Family Practice and Counseling Network is part of Resources 2013). for Human Development, a national health services provider. The Family Practice and Counseling Network operates two 9. 11th Street researchers found that for each for each one-point other FQHCs in the Philadelphia region; collectively, its three increase on the cumulative ACE score, patients had a 19 percent Philadelphia clinics serve more than 23,000 patients. greater likelihood of reporting poorer health in adulthood. Roberta Waite, Maureen Davey, and Laura Lynch, “Self-Rated 3. Health Resources and Services Administration, “HRSA Health Health and Association with ACEs,” Journal of Behavioral Health Center Program,” fact sheet, updated Aug. 2018. While the health 2, no. 3 (June 2013): 197–205; Roberta Waite and Patricia Gerrity, center is nurse-led, a Drexel University physician signs off on “Childhood Trauma and Adult Self-Reported Depression,” ABNF certain medical orders that require physician review, such as Journal 23, no. 1 (Winter 2012): 8–13; Laura Lynch, Roberta Waite, for home health care or visiting nurse, and a cardiologist sees and Maureen Davey, “Adverse Childhood Experiences and patients at the center once a month. A recent study found that Diabetes in Adulthood: Support for a Collaborative Approach nurse practitioner make up a growing proportion of primary to Primary Care,” Contemporary Family Therapy 35, no. 4 (Dec. care clinicians serving low-income patients. Ying Xue, Joyce A. 2013): 639–55. Smith, and Joanne Spetz, “Primary Care Nurse Practitioners and Physicians in Low-Income and Rural Areas, 2010–2016,” Journal of 10. 11th Street’s efforts were aided by grant funding that enabled the American Medical Association 321, no.1 (Jan. 1/8, 2019): 102–5. the center to double in size, adding a large, welcoming lobby, new primary care exam rooms, a gym, and creative arts studios. Some 4. Peter J. Cunningham, “Why Even Healthy Low-Income People of the funds came from Stephen and Sandra Sheller; the latter is Have Greater Health Risks Than Higher-Income People,” To the a counselor and a graduate of Drexel University’s Creative Arts Point (blog), Commonwealth Fund, Sept. 27, 2018. Therapies program. 5. To learn more about this group of women, who named 11. In 2012, 11th Street joined with a group of pediatricians who themselves the “Backbones” in reference to their strength, had recently formed the Philadelphia ACEs Taskforce. Lynch, see Center for Health Care Strategies, Building a Culture of Waite, and Davey, “Adverse Childhood Experiences,” 2013; and Mindfulness: 11th Street Family Health Services (CHCS, May 2018). Public Health Management, Findings from the Philadelphia Urban ACE Study, 2013. 6. Edward L. Machtinger et al., “From Treatment to Healing: The Promise of Trauma-Informed Primary Care,” Women’s 12. AHRQ Health Care Innovations Exchange, Multidisciplinary Health Issues 25, no 3 (May/June 2015): 193–97; Rochelle Oliver, Family Clinic Increases Access to Care for Inner-City Residents, “Traumatic Experiences Weaken Immune-System Gene,” Psych Leading to Improved Outcomes and High Patient Satisfaction Central, May 4, 2010, last updated Aug. 8, 2018; and Vincent J. (Agency for Healthcare Research and Quality, Service Delivery Felitti et al., “Relationship of Childhood Abuse and Household Innovation Profile, last updated Jan. 29, 2014). Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” American 13. All data as reported in the Uniform Data Set for 2017. See Journal of Preventative Medicine 14, no. 4 (May 1998): 245–58. HRSA Health Center Program, “Uniform Data System (UDS) Notably, a recent prospective study found that childhood Resources” (Health Resources and Services Administration, trauma was associated with mental illness, addiction, and other n.d.). problems in adulthood. Unlike most other ACE studies, it did not rely on adults’ recall of childhood experiences but actually 14. AHRQ , Multidisciplinary Family Clinic, 2014. followed children for 22 years, as they aged into adulthood. William E. Copeland, Lilly Shanahan, and Jennifer Hinesley, 15. Brad Smith et al., “Short-Form Mindfulness-Based Stress “Association of Childhood Trauma Exposure with Adult Reduction Reduces Anxiety and Improves Quality of Life in an Psychiatric Disorders and Functional Outcomes,” Journal of the Inner-City Population,” Holistic Nursing Practice 29, no. 2 (Mar./ American Medical Association Network Open 1, no. 7 (Nov. 2018). Apr. 2015): 70–77. commonwealthfund.org Case Study, April 2019 Building Health and Resiliency: Philadelphia’s 11th Street Family Health Services 15 16. Joke Bradt et al., “Vocal Music Therapy for Chronic Pain For more information about this case study, Management in Inner City African Americans: A Mixed Methods please contact: Feasibility Study,” Journal of Music Therapy 53, no. 2 (Summer Martha Hostetter 2016): 178–206. Consulting Writer and Editor 17. Studies have shown that many men don’t go to the doctor The Commonwealth Fund because they say they are too busy or dislike the discomfort mh@cmwf.org of certain procedures, such as prostate exams. Black men are particularly unlikely to go the doctor, many citing lack of trust of medical providers. Eric Klein, “60 Percent of Men Don’t Go to the Doctor: Here’s Why,” Everyday Health, Aug. 17, 2016. 18. John George, “AstraZeneca Awards $1.9 Million in Grants This case study is available on the Commonwealth to Support Innovative Heart Health Programs,” Philadelphia Fund’s website at: https://www.commonwealthfund. Business Journal, Jan. 29, 2016. org/publications/case-study/2019/apr/building-health- resiliency-philadelphia-11th-street. ABOUT THE AUTHORS Martha Hostetter, M.F.A., is a partner in Pear Tree Communications. As a consulting writer and editor for the Commonwealth Fund and a contributing editor to its Commonwealth Fund case studies examine quarterly publication, Transforming Care, she conducts qualitative research on health care delivery system reforms and health care organizations that have achieved high innovations. Ms. Hostetter has an M.F.A. from Yale University performance in a particular area, have undertaken and a B.A. from the University of Pennsylvania. promising innovations, or exemplify attributes that can foster high performance. It is hoped that Sarah Klein is editor of Transforming Care, a quarterly other institutions will be able to draw lessons from publication of the Commonwealth Fund that focuses on innovative efforts to transform health care delivery. She has these cases to inform their own efforts to become written about health care for more than 15 years as a reporter for high performers. Please note that descriptions of publications including Crain’s Chicago Business and American products and services are based on publicly available Medical News. Ms. Klein received a B.A. from Washington information or data provided by the featured case University in St. Louis and attended the Graduate School of study institution(s) and should not be construed as Journalism at the University of California at Berkeley. endorsement by the Commonwealth Fund. Editorial support was provided by Deborah Lorber. ACKNOWLEDGMENTS 11th Street Family Health Services: Senetta Boyd, M.S.W., Tawanna Cooper, R.N., Lindsay Edwards, M.A., L.P.C., Madeline Frank, Patricia Gerrity, R.N., Ph.D., Diana Hartley-Kim, M.S.W., Paula Larson, M.S.N., M.P.H., Kathleen Metzker, M.P.H., Diane Monroe, Lekisha Parker, C.M.A., Dana Robinson, R.D.H., P.H.D.H.P., Lidyvez Sawyer, M.P.H., Yael Tacher, Sarah Thornburg, M.S.N., C.R.N.P., Roberta Waite, Ed.D., R.N., Jennifer Warshaw, M.S., M.P.H., R.D.N., and Jacqui Williams. Commonwealth Fund: Melinda Abrams, M.S., and Yaphet Getachew. commonwealthfund.org Case Study, April 2019 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.