We server the underserved

“PARTNERS IN HEALTH” by Rick Nahmias

A well-known adage of Ben Weingart’s was “Create new ideas and things. It will make a better world.”

Though he could not have foreseen it, over the last six years Weingart Foundation headed an initiative to do just that. Starting in 2003 and culminating in late 2009, Weingart Foundation sponsored a visionary process that led to the creation of the Center for Community Health (CCH), a state-of-the-art integrated health facility in downtown Los Angeles’ Skid Row District which will serve up to 9,000 people annually.

The Center for Community Health is not just unique for what it represents to its patients – a clean, well-staffed, modern-day facility completely dedicated to serving the comprehensive health needs of the indigent of the area – but it is equally notable to those in the healthcare and philanthropic worlds. Its creation and the long road to opening its doors has become a testament to an historic private-public partnership.

In 2003, Weingart Foundation began the Skid Row Homeless Healthcare Initiative to reduce the suffering of the area’s homeless population by improving their health through increased access to coordinated and integrated services. This initiative was spurred in part by a report entitled “Neglect On The Streets,” assembled by Dr. Michael Cousineau, from work performed by him and his team at The Division of Community Health at USC’s Keck School of Medicine. Their report brought to light just how underserved the homeless of downtown Los Angeles were in all areas of healthcare services.

Photo: Rick Nahmias

This report, also funded by Weingart Foundation, pointed out in painful detail that of LA’s homeless, the largest such population in the Country, thousands of individuals are located in and around Skid Row. Nearly half of these adults are mentally ill and have little to turn to for basic health resources besides hospital emergency rooms, facilities that by law cannot deny them life-saving services.

Most homeless health professionals would agree, the lack of availability of services was a key dilemma facing those on Skid Row, but equally problematic was the fragmentation of the services that were available. There were a number of providers within proximity to each other, but few communicated with one another. Some services were duplicated, and other essential services were nonexistent.

More so, consensus among experts is that without stable functional healthcare, the homeless will remain homeless. According to Jonathan Hunter, from The Corporation of Supportive Housing, “People without services won’t stay housed.”

A dedicated space where an integrated healthcare system offered comprehensive services under one roof was something completely foreign to this community, yet it was something that had been urgently needed for years. Even so, it was an extremely complex undertaking that did not come together swiftly or easily.

Of the partners that traveled the road with Weingart Foundation from the very beginning, the JWCH Institute, a private non-profit health agency with a 25-year history and mission of helping the underserved, was and still remains a key collaborator in the creation and ongoing day-to-day operations of the Center for Community Health.

Photo: Eric Richardson/blogdowntown

“Since 1991 JWCH had been working in Skid Row with homeless patients,” says Al Ballesteros, JWCH’s Executive Director. “Our doctors and medical staff were challenged with having to find resources for very high risk and very sick patients to support their treatment plans and roads back to recovery. This situation was not optimal and did not work. Therefore when the idea of a one-stop, integrated model of healthcare was proposed, we welcomed the idea and the opportunity to take a leadership position in this vision to move CCH forward.”

Dr. Paul Gregerson, Medical Director for the JWCH Institute and the CCH’s Chief Medical Officer points out, “When Weingart Foundation got the results of Michael’s report, they pulled together all the agencies that worked down here and we began brainstorming and pulling together programs and funding for the gaps identified.”

Over time the main goal became clear: co-locating a variety of essential services in one dedicated building. Most of the housing developed for the homeless in LA County is in this five to ten block radius of Skid Row – shelters, transitional housing, and low cost housing all exist side by side. Creating a “one-stop-shop” exclusively for health needs in a well-situated location was bound to have an impact on the individuals living there.

“This was an amazing opportunity to impact the lives of the people we serve,” says Greg Scott, President and CEO of Weingart Center Association. A small primary health clinic run by JWCH had existed in Weingart Center, but the decision to move the space up the block to 522 South San Pedro Street allowed the footprint to more than double, from 9,000 to 21,000 square feet. With the help of Weingart Center Association, the largest health and human services agency in LA for the homeless, the building was donated and a capital campaign started that would eventually raise $6 million.

Another indispensable partner in the process was the Community Clinic Association of LA County, a private trade association for clinics which according to CEO, Gloria Rodriguez, took on a brokering role in “‘running interference’ and overcoming the numerous political roadblocks which arose, while continuing to help in the day-to-day planning for the clinic and coordinating the service providers.”

“Change is never easy,” says Fred Ali, President and CEO of Weingart Foundation. “In the first meeting we had with service providers, we invited about 10 foundations to join us, essentially, we used the power of money to challenge the various providers to come together and look for innovative ways to expand and improve healthcare on skid row – to develop a less fragmented, more coordinated system of care.”

Ali urged this new collaborative to avoid redundant energy, and from this initial gathering and no-nonsense approach came the impetus for the group to begin meeting on a regular basis.

According to Ballesteros of JWCH, “From our organization’s work with the homeless, we saw specific areas that needed the greatest focus, and we took pains to make sure they were included.” These ultimately included:

  • Better outreach to help with appointments and general clinic awareness.
  • Educating clients about public benefit eligibility with clinic specialists focusing on enrollment, and providing transportation to and from the clinic.
  • Providing recuperative care: a critical issue due to a rising number of indigent patients who were being discharged from hospitals but not ready for life back on the streets.

Private investments and buy-in based on these directives were impressive. Within a short time the millions of dollars raised caught the attention of the Los Angeles County Department of Health.

Cheri Todoroff, Deputy of Planning and Program Oversight for the LA County Department of Health, another key partner in CCH notes, “We had already collaborated with JWCH in doing work to fight HIV/AIDS at its smaller clinic at the Weingart Center Association, and partnering to create CCH proved to be a natural extension to that.”

In what evolved into a private-public partnership, the County saw the potential for innovation and replication down the road, and wanted to be a part of it.

“Trying to get people comfortable with doing something different was a huge thing to overcome…[But] the center provides a unique approach to healthcare integration in the County,” explains Kathy House, manager of the Service Integration Branch for the County CEO’s Office.

“It was one of the most incredible collaboratives I have ever seen. It is a model that will be replicated and studied all over the country,” adds Jonathan Hunter of the Corporation for Supportive Housing, which has been responsible for developing over 1,000 units of low cost housing in the area. “This creates an essential medical ‘home’ for the people living in the housing we’ve created.

Currently, between case management, nurse, and pharmacy visits, the Center for Community Health receives 120–150 patient visits a day with capacity to see more.

Saul Garcia, a CCH patient, ended up on the street after a catastrophic car accident. He credits the center’s innovative peer-led Diabetic Group and his case manager with helping him get to a point where he is no longer insulin dependent. “I was depressed and on the street, and now I have a steady job, and my diabetes is under control.”

Photo: Rick Nahmias

But of the many innovations the creation of CCH has already engendered, its consolidation of patient health records might be the most impressive. All patients of the clinic will have a single medical record assessed by integrated teams, no matter which or how many services they access.

Three (soon to be four) autonomous teams or “pods” of doctors, nurses and support staff work together and meet regularly to discuss patients. Each pod is comprehensive and has the infrastructure to get the specialty care their individual patients require: be it primary medical care, mental health, chronic disease care, substance abuse, pharmaceutical or other needs.

Jim O’Connell, a nationally respected expert on healthcare for the homeless, described the finished clinic as nothing he had ever seen before in respect to numbers served and sheer complexity of the operation. Dr. Gregerson explains, “The difference between this model and the models in, let’s say, Boston and San Francisco is there the employees are all working for the county. This is a multi-agency multi-disciplinary approach which combines the workforces of several different aspects of homeless healthcare.”

Ballesteros of JWCH adds, “We’ve been around the country looking at different models, and this is completely unique and homegrown for LA… We took what was existing, learned from the investment of the Homeless Healthcare Initiative, and culminated in what we have here.”

Photo: Rick Nahmias

Ben Weingart was a firm believer that “those who would have nothing to do with thorns should never attempt to gather flowers.” All partners in this multi-year effort would probably agree this has been a long, sobering experience, which at times was nothing short of a struggle.

At the clinic’s opening last October, Fred Ali called this “another beginning,” knowing that opening the doors was a large and symbolic step, but by no means the end of the efforts to perfect what the collaborative had built.

Photo: Rick Nahmias

The economic downturn and massive state budget cuts have made getting the facility up and running at full capacity a real challenge. Lack of funding has not just limited the intended number of physician teams to three instead of four, but is also keeping the dental clinic – including its seven brand new chairs – limited to two days of use a week, and an eye clinic still awaiting an opening date.

According to JWCH’s Ballesteros, “Due to state budget cuts at the Governor’s level, a year ago a lot more people would have qualified for dental than today.” (He is quick to point out that there is no sustainable payer source for dental care for poor people in the state of California.)

Additionally, there is only one psychiatrist serving the entire clinic, in contrast to the original vision, which was for each pod to have their own attending psychiatrist. “The limiting step is lack of funding rather than lack of demand,” says Dr. Gregerson. That said, he adds, “I pinch myself everyday that we’ve accomplished what we have.”

Through the creation of the Center for Community Health, Skid Row didn’t only get a new state-of-the-art healthcare facility for thousands of its residents, but additionally it has demonstrated that partners on both sides of the private/public equation can come together and collaborate in a way that can transform inadequate systems and old modes of thinking and bring about concrete change.

To patient Kevin Michael Key the changes couldn’t be clearer, or more appreciated. “This center is modern. People feel like they are in a doctor’s office and are treated like ordinary medical patients. The entire system has been upgraded to work in a more professional way.”

It is healthcare – be it addiction counseling, treatment for chronic disease, or other health needs – which helps people stabilize their lives. As Ali notes, “When you combine good healthcare with other efforts now underway, such as permanent supportive housing, you have the ingredients necessary to get people off the streets and on with their lives.”