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Service Delivery Innovation Profile

Multidisciplinary Family Clinic Increases Access to Care for Inner-City Residents, Leading to Improved Outcomes and High Patient Satisfaction


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Snapshot

Summary

To meet the needs of the surrounding community, 11th Street Family Health Services of Drexel University employs a transdisciplinary model of care that combines both medical and behavioral health services. The clinic offers residents a wide variety of health and wellness services, regardless of their ability to pay, including physical examinations, diagnosis and treatment of illness, family planning, health maintenance/disease prevention services, behavioral health services, physical fitness programs, nutrition services, complementary and integrative therapies, and adolescent health initiatives. The number of patient visits to the clinic has steadily increased over time, and the center has achieved significant improvements in several key measures of health outcomes. In addition, community residents are very satisfied with the center's staff and the services provided.

Evidence Rating (What is this?)

Moderate: The evidence consists of the number of patients served over time, pre- and post-implementation measures of key outcomes, and post-implementation patient satisfaction surveys.
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Developing Organizations

11th Street Family Health Services of Drexel University; Family Practice and Counseling Network
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Date First Implemented

2002
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Patient Population

Vulnerable Populations > Impoverished; Racial minorities; Urban populationsend pp

Problem Addressed

Low-income individuals living in inner-city areas often face significant barriers to accessing health care, leading to poor health status and, in some cases, early death.1,2,3 In the North Philadelphia community, a lack of health care providers left many low-income residents with unmet physical and mental health needs.
  • Many low-income residents: Thousands of low-income, medically underserved individuals reside in the North Philadelphia community, which contains four public housing developments. These residents are often exposed to violence, crime, and other traumatic events that can have a negative impact on physical and mental health.
  • Few health care options: Living in a Federally designated medically underserved area, low-income residents in North Philadelphia—especially the 11th Street corridor—had very limited access to primary care providers who were able to meet their medical needs and treat them with dignity and respect.

What They Did

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Description of the Innovative Activity

The 11th Street Family Health Services of Drexel University employs a transdisciplinary model of care that combines both medical and behavioral health services. The clinic offers residents a wide variety of health and wellness services, regardless of their ability to pay, along with referrals for any additional outside services that might be needed. Key elements of the program include the following:
  • Transdisciplinary care teams providing basic prevention, screening, and treatment services: The core care team includes a nurse practitioner, behavioral health specialist, and social worker. This arrangement allows providers to learn from one another and to integrate behavioral health services directly into primary care, reducing the stigma that is often associated with mental health services. The nurse practitioner focuses on health maintenance, disease prevention/screening/treatment, and patient education. The primary behavioral health specialist focuses on mental health issues (including any issue that might affect a patient's health status, e.g., emotional health and quality of life), whereas the social worker identifies any social and support services patients may need. Patients are referred to health educators, nutritionists, physical therapists, and dentists as necessary.
  • Trauma-informed model of care: Recognizing the underlying role of past trauma in patients' health complications, the center uses a trauma-informed model of care in which primary care staff make a point to assess patients for a history of trauma and potential impact on patients and families. In addition, behavioral health staff host trauma recovery groups.
  • No wrong-door policy: The clinic has a "no-wrong door" policy, meaning that every health care provider in the center can assess and direct patients to the services they need, regardless of where they enter the system.
  • Open access scheduling: The center has adopted an open access scheduling process, through which patients can call and make appointments on the day they need to be seen.
  • Wide array of health and wellness services: In addition to basic preventive care, screenings, and treatment services, the center offers a constantly expanding range of chronic disease management, health promotion, and wellness services. These activities often provide patients with opportunities to share health concerns and common life problems. Such activities are developed in consultation with a Community Advisory Board composed of local residents. A separate Youth Advisory Board helps plan and carry out programs targeted toward children and teens. Examples of programs offered are described below:
    • Nutritional support: In response to the lack of a neighborhood grocery store, the center partners with outside organizations to provide free fresh fruit and vegetables to families each week at a local church. In addition, the center generates cooking recipes that are culturally appropriate for African Americans and Latinos. The center teamed up with Teens4Good (an educational program for promising high school students) to institute a garden run by community teenagers (many of whom are clinic patients) and a farmer's market. The produce harvested from the garden is incorporated into the center's cooking classes. Information provided in January 2012 indicates that each week, Farm to Families supplies North Philadelphia families with boxes of produce from local farmers at a cost of only $10 or $15. Boxes are brimming with fresh fruits and vegetables, often valued at double the price. Additional fresh items including eggs, meat, and seafood are also offered at affordable prices. Cash, credit, Supplemental Nutrition Assistance Program (SNAP) benefits and Farmers Market Nutrition Program (FMNP) coupons are all accepted for payment.
    • Care management program: Information provided in January 2012 indicates that an intensive care management program has been established to meet the needs of patients with chronic illnesses that are poorly controlled (leading to hospitalizations, emergency department visits, or exacerbations of their illness). This program includes a detailed assessment, including a home visit, which is then presented to the transdisciplinary team to develop a comprehensive plan of care. This program has been effective in identifying underlying cognitive deficits and social and environmental issues impeding patients' ability to adhere to a plan of care.
    • Prenatal care and parenting support: The center offers a "Centering Pregnancy" program, through which pregnant women can interact with one another and receive group prenatal care. Through the Nurse Family Partnership, registered nurses also conduct an intensive home visitation program for first-time, low-income mothers and their children, starting during pregnancy and continuing every 2 weeks until the baby turns 2 years old. Drexel University public health students also conduct home visits, checking the homes of pregnant women and others for pesticides and potentially harmful cleaning supplies.
    • Literacy improvement efforts: The center participates in the National Reach Out and Read Program to improve literacy, and nurse practitioners encourage parents to read aloud to their children and provide them with appropriate books to read during checkups.
    • Dental services: The center houses a dental facility that is fully equipped for a full range of clinical dental services and for electronic patient records and digital x-rays. Services are provided 5 days a week, and they include examinations, dental cleanings, x-rays, gum treatments, fillings, root canals, crown and bridge work, dentures, and children's dentistry.
    • Free legal services: The center houses a legal clinic in partnership with the Drexel University School of Law to provide legal services (e.g., wills, advance directives, power of attorney) to the community at no cost. Legal services focus on health-related issues and might expand to cover other matters in the future.
    • Other health promotion activities: Health promotion and wellness activities at the clinic rely on the active involvement of nursing students, physical therapy students, mental health students, and others. The clinic houses a fitness center, teaching kitchen, and other common spaces for activities such as line dancing, self-efficacy programs, creative arts therapy, smoking cessation, parent education classes, family fitness programs, and cooking classes. The clinic has expanded its wellness activities to include complementary and integrative therapies, such as yoga, mindfulness meditation, Reiki, Thai massage, reflexology and breathing techniques (updated December 2010). In addition, students provide immunizations, teach patients about diabetes, and organize community health fairs.

Context of the Innovation

The 11th Street Family Health Services of Drexel University is a comprehensive, nurse-managed health center run by the College of Nursing and Health Professions in collaboration with the Family Practice and Counseling Network. Its vision is to decrease health disparities by providing transdisciplinary clinical services and health promotion programs in partnership with the local community. The roots of the program began in 1996, when Drexel University and the Philadelphia Housing Authority agreed to improve the health status of North Philadelphia's residents. Public health nursing faculty at Drexel asked leaders of the public housing residents' councils how the university could help the community by addressing health-related issues. Faculty also talked to other community leaders, residents, health providers, churches, and schools. These conversations clearly identified the need for a neighborhood health center where residents without insurance could receive quality health care and have their confidentiality respected.

Did It Work?

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Results

The number of patient visits to the clinic has steadily increased, and the center has achieved significant improvements in several key measures of health outcomes. In addition, community residents are very satisfied with the center's staff and the services provided.
  • Steadily increasing patient volumes: Information provided in January 2012 indicates that since the permanent center's opening in September 2002, the number of primary care visits has increased significantly, from 2,200 in 2003 to more than 14,000 in 2011. Behavioral health visits grew from 210 to more than 5,700 over the same time period, whereas dental service visits grew from 944 in 2005 (when the service began) to 5,749 in 2011. By 2011, the program had provided 1,675 home visits to 148 pregnant and/or parenting first-time mothers.
  • Improvements in outcomes: The center has documented improvements in several key health measures, including diabetes management (a 20-percent reduction in blood glucose levels among patients with diabetes), hypertension control (with 68 percent of patients under control), immunization rates (a 14-percent increase), and breast cancer screening rates (30-percent increase). The center has also led to reductions in the number of low birth weight babies and the prevalence of depression in vulnerable adults with chronic illness.
  • High levels of patient satisfaction: In an assessment of client satisfaction conducted in 2007, scores consistently fell in the four to five range (with five being the highest possible score). Surveyed patients highlighted the staff's friendliness (including how they are personally greeted on arrival) and the breadth of programs and services offered.

Evidence Rating (What is this?)

Moderate: The evidence consists of the number of patients served over time, pre- and post-implementation measures of key outcomes, and post-implementation patient satisfaction surveys.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Formation of Community Advisory Board: The 1996 conversations with local community leaders led to the formation of a Community Advisory Board made up of local residents and community leaders who provide input on health-related issues facing the community.
  • Temporary community health center: In 1998, the Community Advisory Board arranged for use of a temporary space to provide primary care services, with a focus on health promotion and disease prevention. The center was funded by a Health Resources and Services Administration (HRSA) program grant. Health center staff continued to listen to the needs of the community in shaping the services provided.
  • Permanent clinic space: The program secured a $3.3 million grant from HRSA, in partnership with the Philadelphia Housing Authority, to build a freestanding, 17,000-square-foot, state-of-the-art health center, which opened in September 2002. The new clinic site was designed to be centrally located and accessible to four public housing developments in the 11th Street corridor.
  • Partnership with Federally Qualified Health Center: In June 2002, the center partnered with the Family Practice and Counseling Network. Because the network is a Federally Qualified Health Center, the clinic gained access to cost-based reimbursement and grant funds for the uninsured.
  • Building transdisciplinary linkages: In 2003, the clinic director used a Robert Wood Johnson Executive Nurse Fellows grant to travel to the United Kingdom to observe Healthy Living Centres, clinics that go beyond diagnosis and treatment to offer a holistic approach to health. On her return to Philadelphia, the director began incorporating aspects of the UK-based Healthy Living Centres by building links between primary care, public health, behavior health, creative arts therapy, physical therapy, nutrition education, and physical fitness.

Resources Used and Skills Needed

  • Staffing: Staff members include an associate director, a program administrator, a clinical coordinator, four full-time family nurse practitioners, two primary behavioral health consultants, five medical assistants, three front desk personnel, a health educator/nutritionist, seven behavioral health staff, two psychiatrists, seven dental staff, four nurse family partnership staff, two AmeriCorps staff, two student volunteers, a physical therapist, a fitness trainer, a social worker, a driver, an accounts specialist, and contractors for podiatry, midwifery, housekeeping, and security services. Information provided in January 2012 indicates that staffing now also includes three Drexel University co-op students.
  • Costs: The annual operating budget is approximately $4.5 million.
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Funding Sources

Robert Wood Johnson Foundation; March of Dimes; Campbell-Oxholm Foundation; First Hospital Foundation; Genuardi Family Foundation; Hahnemann University Hospital/Tenent; Independence Foundation; Lincoln Financial Foundation; Pennsylvania State Department of Health; Pew Charitable Trusts; Target; United Way of Southeastern Pennsylvania; Wachovia Foundation; Barra Foundation; National Nursing Centers Consortium; Philadelphia Foundation; Bureau of Health Professions - Health Resources and Services Administration; Bureau of Primary Care - Health Resources and Services Administration
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Adoption Considerations

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Getting Started with This Innovation

  • Establish a partnership with the community: An ongoing partnership will help ensure that services are continually tailored to the unique issues of the community. In the case of the 11th Street program, services were based on the self-defined needs of the residents of the 11th Street corridor. Establishing a community advisory board was the first step in the planning and development process, allowing public health nursing faculty to develop services in consultation with community leaders.
  • Hire dedicated staff: It is crucial to hire dedicated staff who believe in the mission and guiding principles of the clinic, and who continuously strive to improve.

Sustaining This Innovation

  • Integrate behavioral health with primary care: Integrating services is critical to reaching individuals who cannot or will not access care in the specialty mental health setting. Treating individuals with more mild symptoms in the primary care setting can also prevent the development of more disabling mental health disorders.
  • Listen to input from the community: The center would not last if its leaders did not listen to the advice of the Community Advisory Board and shape its activities accordingly.
  • Continuously monitor the program's impact: Staff should continuously track the program's impact on access to care and health outcomes and use these data to drive further improvement.

More Information

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Contact the Innovator

Patricia Gerrity, RN, PhD, FAAN
Associate Dean for Community Programs
Director, Eleventh Street Family Health Services of Drexel University
Philadelphia, PA
Phone: (215) 762-4215 or (215) 769-1105
Fax: (215) 762-4542
E-mail: pg28@drexel.edu

Innovator Disclosures

Dr. Gerrity has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Jones A. Health center becomes refuge in economic slump. The Philadelphia Tribune. August 10, 2009. Available at: http://www.drexel.edu/11thstreet/pdf/Drexel-11thSt.Tribune.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)

11th Street Family Health Services. Innovative Care Delivery Models. Available at: http://www.innovativecaremodels.com/care_models/16/

11th Street Family Health Services of Drexel University. Drexel University College of Nursing and Health Professions. Available at: http://www.drexel.edu/11thstreet/services.asp

The American Academy of Nursing's Raise the Voice video, featuring the 11th Street Family Health Services. Available at:http://www.aannet.org/raise-the-voice-resources

A video profiling the 11th Street Family Health Services, created by the Center to Champion Nursing in America. Available at: http://championnursing.org/Philadelphia-family-health-services

Footnotes

1 National Center for Health Statistics. Health, United States 2009, With Chartbook. 2010. Available at: http://www.cdc.gov/nchs/data/hus/hus09.pdf
2 Agency for Healthcare Research and Quality. National Healthcare Disparities Report 2008. AHRQ Publication No. 09-0002. 2009. Available at: http://www.ahrq.gov/research/findings/nhqrdr/nhdr08/nhdr08.pdf
3 Fiscella K, Williams DR. Health disparities based on socioeconomic inequities: implications for urban health care. Acad Med. 2004;79(12):1139-47. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 10, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 29, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 09, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.