Consumer Health Foundation

As the complexity of the Consumer Health Foundation’s (CHF) work has grown, our board has expressed a desire to engage more deeply and directly with communities involved in complex social change initiatives.

In response, in mid-October, our board and staff went on its initial “learning journey” to Langley Park, which sits at the Takoma Park crossroads of Prince George’s and Montgomery Counties.   Learning journeys differ from site visits, which tend to be more narrowly focused on the work of a single organization or a distinct program or initiative.  Our goal was to engage with key stakeholders and,  more importantly, with residents whose voices are often not heard in most conversations about social change.

The idea of the learning journey was developed by the Presencing Institute at MIT, which develops tools for social change with the goal of creating societies that are “more sustainable, inclusive, and aware.”  Its website is rich with resources, including steps for “Sensing Journeys” like ours, which involve inquiry, deep listening and dialogue with a range of people and organizations.  Its curriculum is ideal for learning more about a community, rather than a particular initiative or organization. This is an important perspective for us to gain, given our focus on regionalism and the range of social and economic forces that affect health and racial equity.

Much of Langley Park’s richness is in its diversity:  its residents represent more than 40 countries and speak dozens of languages. According to the census, nearly 80 percent of residents are Latino and about one in five residents live below the poverty level.  CASA de Maryland, one of our grantee partners, served as the host for our learning journey.  CASA has a strong presence in Langley Park through its direct service programs as well as its community organizing and public policy advocacy work in housing, employment, immigration rights, fair development and access to health care.  CASA has strong roots in the community through its close work with neighborhood residents and leaders, business owners, landlords and property owners, and policymakers.

CASA arranged for our board and staff to tour the community – both by van and on foot.  We talked with residents and community leaders in their homes, places of business, in a parking lot, and on the street.  We listened to stories about the challenges they face.

We then walked back to CASA’s Multicultural Center and, over a delicious dinner prepared by a local restaurant owner, had a powerful conversation with various activists, residents of all ages, and business owners about the issues affecting the Langley Park community, as well as opportunities. Speaking with such a broad range of community members provided us with a strong sense of the different perspectives, relationships and connections within the neighborhood, and how they impact advocacy and policy change.

The conversation was unlike many that I’ve experienced as a funder.  It was intimate and touched upon the both the personal and policy challenges in the community.  It was open and candid.  With the help of an interpreter, we listened to stories about tenuous relationships with law enforcement; and the entrepreneurial spirit of the community coupled with the lack of jobs.  Fears of displacement were expressed throughout our learning journey, particularly given the planning around the new Purple Line development in the area.  We heard stories about racial and ethnic profiling.  We experienced deep, personal emotion and fear around immigration issues, including deportation. And, we also talked with young people about the Dream Act recently passed by the State of Maryland.

The learning journey provided us with a clear and strong sense of neighborhood, place and of community. We witnessed an amazing staff whose job has become their life’s work.  We witnessed a community of great hope, tenacity, courage, and resilience.  We saw firsthand the power of community organizing in some of the successes residents have gained as a result of their efforts to improve their social and economic condition.  We learned more about a largely immigrant community, which is working relentlessly to achieve the American Dream.

As I was driving home from our learning journey, I reflected on why it had been such a powerful experience for me. I had several observations.  First, the experience blended personal perspectives (through the stories of residents, leaders, and business owners) and the collective through community organizing and advocacy in the policy arena.  The nature of the visit elicited among all of the participants a bigger conversation around social justice, equity and civil rights related to the immigration issues of our times.

For the Foundation, the learning journey reinforced the need to work at all of these levels to achieve health and social equity in our regional community. This is a much more complex way of working. It is non-linear, dynamic and very relational.  We will likely need to develop and deploy new ways of thinking and operating beyond what we have envisioned.

The learning journey itself is an example of this kind of new approach. Our staff and board are already asking where we will travel on our next journey. We welcome others to join us.

RSVP for CHF’s 15th Annual Meeting, Connecting Communities:  Advancing Regional Solutions for Health Equity, January 12, 2012, featuring special keynote speaker, Angela Glover Blackwell of PolicyLink!  Registration deadline is January 6th, 2012.

The simple storefront entrance at Greater Baden Medical Center’s Capitol Heights location provides no hint of the vast network of health care and other services available inside. From primary health care, to patient assistance for housing, legal services and literacy programs, Greater Baden has come a long way from the health clinic founded in a former library in rural Prince’s George’s County with one volunteer doctor in the 1960s. Today, it is the only Federally Qualified Health Center (FQHC) in the county, with nearly 15,000 patients and six locations, including a specialized pediatric clinic.

Across the DC region, community health centers – many of which were originally established in church basements or other makeshift spaces and staffed by volunteers – have become sophisticated and comprehensive, providing a vast array of high-quality health care and other services with dozens of permanent staff. Paper files are being packed away as providers increasingly rely on electronic medical records. On-site pharmacies and labs provide one-stop visits for patients whose insurance coverage ranges from private insurance, Medicaid, Medicare, the DC Healthcare Alliance, or often none at all.

Clinic administrators speak proudly of their niche services and talk about “competing for patients,” recognizing that today’s patients often have multiple options for care – options that will only increase when hundreds of thousands of DC-region residents gain health insurance coverage in 2014 under the Affordable Care Act. But while the physical structures of the health centers and the scope of services provided have changed tremendously in the past few decades, one thing remains the same: a fierce commitment to providing high-quality care to every patient who comes in the door.

Bread for the City

In the heart of DC’s Shaw neighborhood near Howard University, Bread for the City’s recently expanded building at 7th and P Streets, NW, is open and sunny, with multiple waiting areas for various services, including a large atrium on the second floor where chairs are moved away three days each week for exercise classes. A corner with child-sized furniture creates a cozy waiting area for younger patients, and parents are encouraged to take the colorful children’s books home with them through the Reach Out and Read program. An expansive rooftop garden, with a stunning view of the city’s skyline, provides fresh produce and a location for nutrition classes for both children and adults.

“Calmer … more privacy … more dignity and respect,” explains Medical Director Dr. Randi Abramson a 20-year Bread for the City veteran, who speaks passionately about the quality of care provided to patients.

Since the expansion was completed late last year, the center has added a full-time dentist, with plans to add another full-time physician and vision clinic in the next year. And, all of this is just the beginning – Executive Director George Jones says he hopes to double the number of clinic patients in the coming years.

“Our clinics are true medical homes. Patients come back for regular check-ups and routine care in addition to the other services we provide,” Jones says.

Bread for the City also provides a food pantry, clothing room, legal clinic, job readiness training, a social services program and advocacy services. The fact that Bread for the City provides such a broad array of services had complicated a recent internal debate: whether to apply for FQHC status. The benefits are potentially huge: increased reimbursements from Medicare and Medicaid, discounted prescription drugs through federal rebate programs and more stable funding. The tradeoffs: requirements to charge patients copayments based on a sliding fee scale and changing the composition of the Board of Directors to include at least 51 percent patients. This part is particularly complex for an organization whose mission reaches far beyond health care.

Yet although the designation is difficult to obtain and the decision was not easy, Bread for the City’s Board voted earlier this year to proceed with the FQHC application. “It’s time to know where our funding will be coming from. We believe that health care is a right, and we need to provide access,” Jones explains.

Whitman-Walker Health

As one of DC’s best known health clinics, Whitman-Walker Health has undergone a significant transformation from its birth out of the social justice movement in the early 1970s. Founded as a gay and lesbian health center in 1978 in response to the AIDS epidemic, it became the region’s largest AIDS service organization during the 1980s and 1990s. Through the contributions of a wide network of volunteers, Whitman-Walker Health initially provided peer support, a food bank, legal services and housing to help people die with dignity when there were no treatments for AIDS, eventually providing direct medical care when medications later became available.

“Frankly, we struggled with our service model in the late 1990s and early 2000s in large part because we did not adapt our programs to the new reality of life-saving medications,” says Executive Director Don Blanchon. “Our programs were built for persons who would die within two to three years of an initial HIV diagnosis. But with the advent of anti-retroviral medications, our patients now could look forward to a much longer and healthier life.” By 2005, Whitman-Walker Health was losing more than $1 million a year. In response, the Board of Directors made the important strategic decision to transform Whitman-Walker Health from an AIDS service organization to a community health center. The transition took nearly four years and represented a significant organizational and cultural change for all of Whitman-Walker’s stakeholders. It was also not without conflict or public scrutiny as it included two round of layoffs, program closings, and other cost reductions to ensure financial viability.

Today, Whitman-Walker Health operates as a federally qualified health center “look alike” – meaning the clinic has some, but not all of the attributes of an FQHC – and is a financially stable, comprehensive primary care center with a full-time pharmacy, mental health, dental care and legal aid services, and a second location in Southeast, DC. It’s also the only health center in the city that participates in clinical trials with the National Institutes of Health, giving its patients access to referrals there for additional care.

Once a clinic that didn’t ask for or accept payments for care, Whitman-Walker Health now receives third-party insurance payments for 90 percent of its nearly 9,000 primary care patients. Patients without health insurance are cared for without regard to their ability to pay, with a sliding fee scale and discounts based on income. Electronic medical records help produce data on quality of care.

A new entrance and waiting room at the Elizabeth Taylor Medical Center on 14th Street, NW are bright and welcoming. And, because it is no longer exclusively a clinic for people with HIV or AIDS, patients are less self-conscious about coming in the door. According to Blanchon, “Our new health center model gives us a competitive edge in this era of health care reform, where we will be held accountable by our patients and our funders for the quality of care we provide.”

“And today our strength lies in the diversity of who we see and what we do,” he concludes.

Community of Hope

As of January 2011, there were 848 known homeless families in the District of Columbia. In a given year, Community of Hope provides housing services to well over 250 of them, including about 400 children, providing temporary, transitional and permanent housing and a range of supportive services including health care. Its Adams Morgan health center, housed in Marie Reed Elementary School, offers primary medical, dental and mental health care to nearly 4,000 patients a year and its Family Health and Birth Center is the only freestanding birthing center in the District.

Last year, in an effort to increase the use of routine primary care, reduce emergency room use, and integrate physical health and wellness into its permanent housing program, a “wellness coordinator” funded by the Consumer Health Foundation met with formerly homeless families to learn more about where they were accessing health care. By the end of the program, 98 percent of adults and 100 percent of young children had seen a physician. Today, the young children who participated show improvements in multiple health related measures and improvements were even more significant for dental services with up to 91 percent of adults visiting a dentist. Participants also reported much higher levels of satisfaction with their experience of health care system.

Community of Hope has big plans for the future and will break ground on a $25 million, 50,000 square foot, four-story health center in Ward 8 in the next year, according to Executive Director Kelly Sweeny McShane.

The center will include 18 exam rooms and 11 dental chairs, in addition to a laboratory and space for educational classes, enrollment in benefits, social services, and individual and group counseling. The building will be LEED-certified (an internationally-recognized green building certification system) and include state-of-the-art equipment including electronic health records to help serve the 8,500 residents of Ward 8.

“Ward 8 has some of the worst health outcomes in the city and the highest number of medically underserved residents,” says McShane. “They will all have insurance under health reform in 2014 and we want to make sure they have access to care,” she explains.

Greater Baden Medical Services

Greater Baden Medical Services (GBMS) recently moved its flagship center built in 1960 from its original rural location in Brandywine, MD, to a new 21,000 square-foot building in a busy urban area. “It’s important that we be near the places our patient go – near transportation and where they shop,” says Justin Britanik, program compliance officer.

GBMS has done more than move, however, growing from one location to six. GBMS can now be found in Brandywine, Nanjemoy, Oxon Hill, Leonardtown, Suitland and Capitol Heights and employs more than a dozen physicians including pediatricians and family practitioners, several nurse practitioners, midwives, a dentist and a pharmacist. Nurses, social workers and the front desk staff help patients access the services they need and determine their ability to pay (as an FQHC, patients are required to make copayments determined by a sliding fee scale based on their ability to pay).

A “typical patient” is working at a low-wage job, and is either underinsured or uninsured because their employer doesn’t offer insurance or they can’t afford insurance that is offered. Many patients just recently became uninsured due to the recession.

The complexity of care has changed “tremendously” over the years, as GBMS has grown, CEO and clinic physician Dr. Sarah Leonhard explains. In earlier days, her time was primarily spent providing routine primary care to patients largely from rural areas. Today’s patients tend to have more complicated needs – often facing multiple chronic diseases like heart disease, high blood pressure and diabetes. With limited incomes and challenging lives, they often wait for care until “something pushes them over the edge.”

Staff are frustrated by lack of access to specialty care for the uninsured since Prince George’s County has only one hospital and therefore fewer specialists than in other parts of the DC region. A person who is lucky enough to get a cast for a broken arm may not be able to get it removed for six months. Patients can wait more than a year for an MRI. Certain medications are difficult to obtain. While the GBMS staff is highly proficient in navigating the prescription assistance programs that pharmaceutical companies offer, the process is time consuming. Funding is also a challenge, with operating costs increasing every year.

Despite these challenges, nurse practitioner Debbie Apperson is emphatic, “We provide very high quality care.”

Others agree. GBMS has been invited to work with the DC HIV Collaborative to improve data collection measures and recently received significant funding from the Susan G. Komen for the Cure Foundation to use patient navigators to facilitate breast screenings. And just last month, the Federal Office of Minority Health recognized GBMS for its bilingual and bicultural efforts to improve access to care for patients who are overweight or obese or living with diabetes or cardiovascular disease. Leonhard sums up her organizations unwavering commitment in a changing industry, “Greater Baden’s efforts to expand access to high quality primary health care will continue despite the challenges faced by our patients and our organization.”

The Patient Protection and Affordable Care Act (ACA) has created both opportunities and challenges for health care safety net providers since its passage in March 2010. Safety net providers are health centers and clinics that share a mission and a commitment to delivering health care and supportive services to the uninsured, Medicaid, and other vulnerable patients. One challenge the ACA poses is that many residents of our region are excluded from its benefits:  legal immigrants who have lived in the U.S. for less than five years, and undocumented immigrants.  Yet, the benefits are tremendous.  Many safety net providers in our region – and across the country – are engaged in planning and implementation efforts to ensure that they will be able to take advantage of the new law’s significant opportunities:

• Coverage – The ACA will greatly increase insurance coverage for millions of individuals through Medicaid expansion and enrollment through the Health Benefit Exchanges. In 2014, the law expands the Medicaid income eligibility to 133 percent of the federal poverty level which, when fully implemented, would cover 16 million individuals. Uninsured individuals who are not eligible for Medicaid and whose incomes are between 133-400 percent of the federal poverty level would receive subsidies when they enroll in Health Benefit Exchanges. For consumers, this means care will be more affordable. For providers, this means a source of payment to help cover the costs of care.

• Delivery of Care – The ACA offers opportunities for demonstration projects and models which provide integrated and coordinated health care services and better quality of care. It will also help address health disparities. Safety net providers have extensive experience providing services to these underserved populations which is an advantage as patients identify the clinic where they can obtain care.

However, there are also growing gaps between different types of safety net providers that pose challenges to their collective ability to serve all residents who need health care, including those who will be newly insured under health reform, and those who will remain uninsured after health reform is implemented. Below is a table that outlines some of the differences between the types of safety net providers in our local community.

If our region’s clinics are to take advantage of opportunities under health reform, we need to grow the capacity of our safety net system to serve both new patients and existing ones. FQHCs, FQHC look-alikes, and other community health centers/clinics all have important roles to play in the system.

Following are some of the roles that health funders can play to help advance this work:

• Provide support to safety net health centers that want to advance their practice through the implementation of electronic health records, and work to achieve meaningful use of or attain Patient-Centered Medical Home designation.

• Provide support to safety net health centers who need to implement billing systems and/or working with a group of health centers to create a shared back-office billing system.

• Support research on the implications of health reform for other community health centers/clinics.

• Support policy/advocacy to ensure those individuals and families left out of health reform will have access to high-quality, affordable health care.

Amidst the implementation of health reform, safety net providers will continue to have an important role in providing comprehensive, high-quality, patient-centered and affordable health care to underserved communities and the uninsured. We need to make sure there is sufficient support for both patients who need services, and the clinics that provide those services in this changing environment.

After 12 wonderful years, Julie Farkas, CHF’s Senior Program Officer, is leaving.  As the Foundation’s first program officer, Julie helped to create and grow our strategic grant making and comprehensive capacity building programs. She managed our annual MPH Fellows summer program, and participated in key collaborative groups over the years, most recently the DC Promise Neighborhood Initiative.  More on Julie’s professional and personal background can be found in her CHF Staff Profile which was featured in our Winter 2010 edition of Connections.

While all of us are sad that Julie is leaving, the legacy of her work at CHF, which has always been characterized by excellence, passion, energy and extreme dedication, will carry on.

CHF’s Margaret K. O’Bryon wins the Grantmakers In Health (GIH) 2012 Terrance Keenan Award for Health Philanthropy!  Margaret will receive her award at GIH’s  Annual Meeting in Baltimore in March 2012.

The Consumer Health Foundation is now on Facebook!  “Like” our page!

CHF Welcomes two new Board members: Chan Park and Joe Wright.  A resident of Montgomery County, Chan’s background includes community advocacy for improving the quality of life for the Asian-Pacific American community.  Joe, a pediatrician from Prince George’s County,  has a special interest in the areas of population health and the social determinants of health equity.

The Joint Center for Political and Economic Studies Releases Two Reports on Health Equity:
Segregated Spaces, Risky Places: The Effects of Racial Segregation on Health Inequalities -This study looks at the relationship between the level of segregation in metro areas in the U.S. and the health of the people who live in these communities. Metro areas with the highest levels of racial segregation have the largest racial health inequities.
A Lost Decade: Neighborhood Poverty and the Urban Crisis of the 2000s - This report looks at trends in the share of African American, Hispanic and white families in high-poverty neighborhoods since 1970. While there is a smaller share of black, Hispanic and white families living in high-poverty neighborhoods today than in 1970, black and Hispanic families are increasingly more likely than whites to live in high-poverty neighborhoods.

New Census Poverty Measure Shows Medical Expenses Push 10 Million More Americans into Poverty.  In a recent blog, The Commonwealth Fund discuses the findings and implications of a new report released by the U.S. Census Bureau which shows that health care is not only the most significant living expense faced by low-income families, but that the growing burden of health care is pushing even more families into poverty. 

The National Association of County & City Health Officials just released Roots of Health Inequity:  A Web-Based Course for the Public Health Workforce. Using a social justice framework, this online course provides public health practitioners the concepts and tools to effectively tackle the root causes of racial health inequities.

CHF Goes Global!  Last month CHF President & CEO Margaret O’Bryon met with a delegation of 18 Chinese leaders working in nonprofits and philanthropy to talk about philanthropy in the U.S. and CHF’s work. The visit, which included trips to Ford, Rockefeller and other national foundations, was organized by the Foundation Center in China.

Grants Update: CHF makes its final grants for 2011 in the areas of Advocacy, Health Care Systems Development, Safety Net, Innovations/Special Projects, Organizational Development and Knowledge Capital.  This year, the Foundation has awarded 35 grants totaling $1,055,000.