Health Care Reform Supports Patient-Centered Care in the Tenderloin

November 2010Diana Austin

San Francisco’s Tenderloin District is a vibrant but gritty tableau of single room occupancy hotels, theaters and convenience stores. It’s also home to a diverse group of people: immigrants and addicts, artists and ex-cons, homeless youths and families, all bound by the common thread of poverty.

Nestled within this bustling neighborhood is another community, centered around the city’s famed Glide Memorial Church and composed of the clients, staff and volunteers of the Glide Foundation, which provides an astonishing array of social services to residents of the Tenderloin. Situated at the heart of this community within a community is the Glide Health Services (GHS) clinic.

At GHS, the UCSF School of Nursing – in partnership with other local and regional organizations such as Catholic Healthcare West, St. Francis Memorial Hospital and the National Nursing Centers Consortium – provides health and wellness services to more than 3,500 people. The majority of these patients have no means to pay for care, and many must cope with complex health challenges such as diabetes, substance abuse or mental health problems.

These patients are served by a team of nurse practitioners, physicians, psychologists and social workers that provides an essential safety net for those with no other access to care. The 20 UCSF nursing students who help staff the clinic are part of that team.

A Huge and Growing Need

Glide Health Services clinic (photos by Elisabeth Fall) Health care reform is expected to extend some form of health coverage to as many as 30 million uninsured and underinsured Americans over the next four years, but the strain it will place on a primary care system already bursting at the seams with too many patients and too few providers ensures that community clinics like GHS will become an even more important resource. As the largest nurse-managed health center on the West Coast, GHS is prepared to rise to the challenges that the next few years may bring.

“From the beginning, we’ve been collecting data with the goal of improving outcomes,” says UCSF’s Patricia Dennehy, associate clinical professor, Community Health Systems, and director of Glide Health Services. The payoff of this approach is evident in the success of GHS’s diabetes management program, which Dennehy and UCSF’s JoAnne Saxe established with the help of a multiyear federal grant intended to address health disparities. A recent study demonstrated that participants in GHS’s program achieved better blood glucose control than did patients served by many academic medical centers.

This is especially remarkable, given the challenges faced by Glide’s client population, 60 percent of whom meet the federal government’s definition of homelessness. “Imagine how hard it is to manage your diabetes when you don’t have access to healthy food, much less a kitchen to cook it in,” says Dennehy.

Another project, one with less direct effect on patients but important ramifications for data collection and quality measures, partners GHS with the Institute for Nursing Centers (INC) and the Alliance of Chicago Community Health Services. Using funding provided through the Agency for Healthcare Research and Quality and the American Recovery and Reinvestment Act, GHS has implemented an electronic health record (EHR) as part of an initiative spearheaded by the alliance.

The EHR is centrally hosted by the alliance, which provides both the technical capacity and the infrastructure for data sharing and integration of quality benchmarks across a network of health clinics that serve more than 250,000 patients. “With the INC’s participation, we’re able to benchmark across clinics and against national performance measures, which gives us a unique opportunity to demonstrate what an effective model of health care nurse-managed clinics can be,” says Dennehy.

Health Care Reform Boosts Efforts

Patricia Dennehy This is especially important as health care reform moves forward. While the legislation authorizes $50 million in new funds for nurse-managed health clinics, there is no guarantee that the full amount will ultimately be appropriated. Demonstrating quality and cost-effectiveness is essential to ensuring that nurse-led clinics have access to maximum funding.

GHS has secured three grants totaling $3.5 million in long-term funding to provide education and services to its clients. Capitalizing on the core strengths nurses can bring to the primary care setting, GHS is using some of the funding to expand a comprehensive wellness center in the heart of a neighborhood where the usual trappings of contemporary wellness tend to be in short supply.

In addition to traditional services, clients can take advantage of complementary modalities like massage and acupuncture. Ongoing renovations will provide expanded space for new fitness activities and chronic disease education programs.

“We really strive to provide a continuum of care,” says Dennehy. “We have young, healthy clients that come to us for preventive care, as well as people with chronic conditions that need more intensive and broad-based services.”

In addition, GHS serves as an urgent care clinic and crisis intervention center. It provides recovery services, including drop-in groups and a 90-day outpatient program. Upwards of 40 percent of the services GHS provides is related to behavioral health.

The Need for Trust

One of the greatest challenges, says Dennehy, is the development of trust within the community; an important aspect of GHS’s success is the diversity of its staff. “The mix is important,” Dennehy asserts. “Our diversity allows us to operate within an atmosphere of cultural sensitivity.”

Another component in establishing trust is listening to clients. GHS has convened focus groups of clients to help develop new programs and improve established ones. In accordance with its data-driven ethos, GHS is tracking interviews with clients and undertaking qualitative as well as quantitative information gathering to plan and refine its ongoing mission.

For example, when a dance class that staff had thought would be a huge success had a disappointing turnout, investigation revealed that would-be participants preferred sex-segregated classes. “We didn’t think about the fact that some clients don’t have regular access to basic grooming facilities,” Dennehy reports. “It was a barrier to participation that was easy to fix, but we wouldn’t have known about it if we hadn’t asked. You find out some really important things when you take the time to listen.”