An Outside-the-Doctor’s-Office Approach to Health Care

It’s a perfect day in Pensacola, Florida, and the Blue Angels, based at the nearby air station, are doing their weekly exercises over the Gulf. A drive inland along Palafox Street starts at the upscale town square and passes freshly painted colonials, esthetic surgery clinics, boutiques, and banks. But all this changes at Cervantes Avenue: Suddenly the trappings of wealth disappear, replaced by foreclosure signs, dialysis centers, thrift stores, and check-cashing outlets.

This is still Pensacola, but not the one that snowbirds and tourists see. As Sandra Donaldson, a native of this second Pensacola, explains, “There is an invisible divide between here and there.”

Blocks later, I park in front of a professional brick building, not unlike community clinics that I have worked in during my medical career. Inside, I am surprised to find that Chandra Smiley, executive director for the Escambia Community Clinic network, is working right next to the waiting area busy with coughing patients, beeping toys, and CNN blaring on a wall-mounted TV.

“Being this close to the patients helps me understand what’s really going on,” Smiley says. “I don’t want this to be just another community clinic; I want it to be the community’s clinic.” Her emphasis on the possessive might at first pass seem like an unimportant distinction, but, in fact, it represents radical thinking. Traditionally, safety net clinics like Escambia offer medical services to low-income and underserved patients who access their facilities, but Smiley and her team are trying to expand this role by improving the quality of life in the surrounding community. “Our goal,” Smiley says, “is to help fix things that get us sick in the first place, like substandard housing, unhealthy food, and lack of opportunity.” Escambia, along with four other clinic sites that dot the Gulf Coast, is part of a two-year health care experiment called the Community Centered Health Home (CCHH) demonstration project, which is funded through the Deepwater Horizon Medical Benefits Class Action Settlement, a result of the 2010 BP oil spill off the coast of Louisiana. If it succeeds, this experiment could help redefine the role of community clinics in the United States.

The idea that health care can be an engine for community change is not entirely new. In the mid-1960s, physician Jack Geiger opened clinics in the impoverished rural South, with a mission to go beyond treating patients to address the social determinants of health. Instead of simply recommending better diets, he helped his patients obtain tractors, seeds, and farmland so that they could grow healthful food. While Geiger is credited with starting the first community clinics, his more radical idea to use organized medicine to address the root causes of illness never caught on.

Recently, Geiger’s ideas are getting more attention. The Affordable Care Act, also known as Obamacare, has created a series of mandates and incentives to cut health care costs while expanding health care access and improving quality. Since the United States spends more than twice per capita on health care as countries like Germany, France, and Switzerland but lags far behind in health outcomes, most would agree that these are worthy goals. There is less agreement on how to accomplish them.

Initially, programs promoted by the ACA prioritized expanding insurance coverage and retooling medical services, but it has since become evident these efforts are necessary but not sufficient to change health outcomes for vulnerable communities — hence more outside-the-box approaches such as the one being tested by the Escambia Clinic. If Obamacare in its entirety is repealed, these innovative efforts could also fall by the wayside.

Two days before visiting Pensacola, I met Eric Baumgartner at his office in the Louisiana Public Health Institute in New Orleans. Baumgartner, a pediatrician and public health expert, is directing the Gulf Coast CCHH demonstration project.

Early in his pediatric residency, Baumgartner became frustrated by the fact that much of the illness he was seeing in his young patients was a product of their social situation and their physical surroundings.

“I decided that I wanted to understand interaction between biology and nurturing environment,” he says.

He became an early champion of what is sometimes referred to as the ZIP code effect, a reference to a series of studies showing that one’s address has a far greater impact on health and life expectancy than genetic risk or the quality or accessibility of medical treatment. Baumgartner also contends that individual behaviors, such as diet and exercise patterns, are a product of ZIP code rather than willpower, which may explain why most public health education campaigns have little impact on health outcomes.

I asked Baumgartner to describe what takes place in a Community Centered Health Home.

“It’s more a state of mind than a set of activities,” he says. “And the clinic, which is typically a service delivery organization, has a responsibility to use its position of influence within the community to act as partner in improving the social, environmental, and economic conditions that determine health.” He describes clinic patients of a CCHH as not just representing themselves but being “sentinels for the community in which they reside.”

Later, at C.A. Weis Elementary School in Pensacola’s Pinecrest neighborhood, first-graders stream out the double doors and settle on the brand-new playground structure like a flock of migrating birds. It’s a generic-looking playset, one that could be found in any public school around the country. And yet, as I hear how it came to be, I understand that this plastic-and-metal structure is a catalyst for improving neighborhood health.

When it comes to almost every health indicator, the Englewood area (ZIP code 32505), where many Escambia clinic patients reside, has been dealt a crummy hand. Within the context of greater Pensacola, this zone has unusually high rates of violent crime, unemployment, housing foreclosures, drug abuse, and preterm births. Recently the Urban Institute gave it a high inequity score, meaning that it is a place where the poorest 10 percent and richest 10 percent of Americans live in extreme proximity. Another report identified Pensacola as one of a few cities (along with Tampa and Knoxville, Tennessee) where the life expectancy gap between the richest and poorest has increased in the past decade. When Chandra Smiley learned that her clinic had been chosen to be a part of the CCHH experiment, she felt more anxious than enthusiastic. How could she and her colleagues possibly make a difference in the face of such daunting socioeconomic problems? She shared her misgivings with Baumgartner during a CCHH orientation meeting, and he gave her a strategy that was simple yet actionable.

“This is our serenity prayer,” Smiley recalls him saying. “You don’t have to solve all the problems. You just have to get involved.”

Smiley got involved.

She and Sandra Donaldson, director of special programs in the clinic, attended neighborhood gatherings, met with civic leaders, and asked community members what they wanted.

“We put on our tennis shoes and we went door to door,” Smiley says. Her team avoided the typical health surveys that focus on disease risk and medical conditions such as asthma or diabetes. Instead they invited residents to discuss all the factors that affected their well-being.

A common concern: the 600 children at C.A. Weis Elementary School.

At that time, Weis was faring no better than its surrounding neighborhood. It had few financial resources, low parent participation, and high principal turnover. During the 2015–16 school year, the state gave Weis an “F” for its student test scores on the Florida Standards Assessment. All the students qualified for free or reduced-price lunch, and many were eligible for a program that sends children home on Fridays with a backpack of food to tide them over for the weekend. According to data collected by the Escambia Clinic, Weis students were more likely to start life in the local neonatal intensive care unit than kids in other ZIP codes, and they missed scheduled medical appointments and visited the local urgent care center at disproportionately high rates.

It is not surprising, then, that Escambia Clinic’s first CCHH partnership was with the Weis School. What may be surprising to outsiders, however, is that their first project was a playground. After all, the standard medical response would be to expand clinic services to at-risk families. But Weis did not have a real playground, nor was there one in the surrounding neighborhood, and this was of paramount concern to everyone.

Smiley acknowledges that there are other projects that might have a more immediate impact on health, but the playground was what the community wanted. “After all,” she adds, “I knew that in the end, everything has to do with health.”

The Escambia Clinic, along with the University of West Florida and The Children’s Home Society, partnered with the school’s newly arrived principal, Holly Magee, and a handful of volunteers to apply for a grant from the local chapter of Impact 100, a women’s charity where members pool their money for a worthy cause.

Weis mom Ashley Parish, who had never spoken publicly, stood up in front of an audience of 400 funders and said: “My kids stay inside. We have no safe place to play.”

Impact 100 awarded them $106,000 to build the playground.

Then something happened that Smiley had not anticipated: Even before the ribbon-cutting ceremony a year ago, the playground triggered a series of events.

“We showed we cared, and it was like all the doors suddenly opened, and everyone was asking us how they could partner with us,” Parish recalls.

The school district offered to maintain the playground. The Children’s Home Society asked Smiley to staff a clinic at the school so that children could easily access medical services. The managers of Oakwood Terrace, a federally subsidized housing project and home to many Weis families, partnered with Escambia Clinic on a series of wellness initiatives to improve living conditions, offer job training, and address issues of food insecurity. Escambia is also in the process of becoming a residency site for obstetrics, internal medicine, and pediatrics, which will expose doctors-in-training to the CCHH model. Finally, as the ultimate recognition of its value, the clinic received more than $8 million, from both federal funds and local investment, to build a new clinic as well as a community center, teaching center, and garden in what is now an abandoned elementary school.

Within Weis big changes have begun to take place, and Principal Magee attributes much of it to the clinic’s involvement. She says that when she arrived, there was a sense of hopelessness but now there is a will to succeed. Parents and neighbors are more involved, teachers want to stay, and all of last year’s first-graders passed the standardized benchmark test. Magee has completed her second school year at Weis and has no plans to move on.

“All this,” says Smiley after listing off the changes happening around her, “is what I would call a Community Centered Health Home.” She pauses.

“Even if I had to pay cash for that playground, it would have been worth it. After all, look at all that it has given us.”

***

Some 200 miles away, in a baking-hot parking lot in New Orleans, Rosamar Torres opens the side of her mobile vegetable market to display bins of carrots, snap peas, strawberries, and peppers. The market, funded and operated by a nonprofit called Sankofa, makes the rounds of the city and accepts farmers market coupons and cards from nutrition assistance programs such as WIC and SNAP. Seemingly from nowhere, customers, mainly elderly and African American, begin to appear with shopping bags in hand. Soon the truck is mobbed.

Standing nearby are Chenita Le Blanc and Stephenie Marshall, who are spearheading the CCHH project at the Daughters of Charity (DOC) Clinic in New Orleans’ Gentilly neighborhood. Back in the day, Marshall says, when people heard you were from Gentilly they thought you were fancy. That ended with the economic downturn of the 1980s. “My neighborhood began to have the same problems as anywhere,” she said, listing crime, unemployment, and high rates of chronic disease.

When Hurricane Katrina hit more than a decade ago, Gentilly, located next to Lake Pontchartrain, was underwater. The facade of almost every house in the neighborhood is still emblazoned with the iconic Katrina “X code,” a spray-painted marking left by first responders to record the level of destruction and the number of people found alive or dead in that home.

Similar to what is taking place in Pensacola, the CCHH experiment has allowed the DOC clinic to become a key player in improving health conditions in the community. Their partnership with the Sankofa mobile market is a good example.

Initially Sankofa’s vegetables were going to waste because no one knew about the mobile market, but DOC solved this by referring patients to Sankofa and handing out coupons.

“They wanted customers, and we had customers,” said Marshall. “And we wanted free [food] for our patients, and they had free.”

The DOC clinic has piggybacked on the efforts of other community organizations — most notably Dillard University — to address issues as diverse as job retraining, fair wages, blocking predatory businesses, and building parks and exercise paths.

Le Blanc and Marshall feel that their clinic for the first time is actively preventing disease. Patients and community now view them more favorably, and medical providers are more interested in being a part of their organization. (The Louisiana Public Health Institute is in the process of studying these outcomes and will publish the data at the end of the two-year period.)

Despite the enthusiasm, everyone I spoke with at LPHI and in the clinics seemed uncertain about how to finance the CCHH model once the funds for the two-year experiment run out.

“We don’t want to start programs we can’t continue in this community. We have 180 years of doing good work,” Michael Griffin, the CEO of Daughters of Charity, says. He points to the ACA’s Community Benefits program, which requires nonprofit hospitals to spend a percentage of their proceeds on the surrounding community, as a possible source of funding. But with Obamacare now in jeopardy, it is unclear whether this funding source will continue. No insurance, public or private, he adds, has agreed to pay doctors and clinics to keep a community healthy.

Insurers are set up to reimburse for discrete services such as a lab test, a surgery, or a clinic visit. The CCHH model is a complex set of partnerships and activities rather than one defined service and therefore hard to bundle under a single billing code. How does a clinic bill for helping to create jobs, playgrounds, community gardens, or walkable streets? The dollars and lives saved by this new approach might not be measureable for decades and, even then, it will be hard to prove what actually made the difference.

But talk to the researchers, administrators, doctors, and community members affiliated with the Gulf States CCHH project, and they will argue that this approach is critical to curb runaway health care expenditures while improving health outcomes for communities like Englewood and Gentilly. Smiley, Baumgartner, Griffin, and others made it clear that health care must impact conditions outside clinic walls in order to close the survival gap between the richest and poorest.

“Business as usual has not worked for us,” Smiley says. “We have to do this work and take a leap of faith because the return will come.”

Perhaps no one was able to describe this potential return more clearly than Ashley Parish, the parent volunteer at Weis who helped Smiley make the funding pitch for the playground structure.

“It’s important for health care to get involved in all kinds of things,” she says. “We want our children to be happy because when you are sad, you get sick, and your blood pressure goes up, and you get diabetes. One day these babies are going to be adults, and they are going to say, We had that playground.”