A Capitol Endeavor: Low-Income Washingtonians Get One-Stop Clinic
Providence Hospital, the oldest continuously operating hospital in Washington, D.C., opened a primary health care facility in 1998.
The Perry Family Health Center, located in a poor, crime-ridden area just north of the U.S. Capitol building, offers residents a bright, welcoming alternative to a nearby city-owned neighborhood clinic that has long been the subject of complaints.
The staff of the Perry facility links patients with social and educational services offered by other agencies located in the same building, an old school converted into a multipurpose community center.
The project was part of the Robert Wood Johnson Foundation (RWJF) Local Funding Partnerships national program.
- The health center's caseload has grown steadily, reaching 5,170 as of December 2003.
- The overall Perry building also has experienced increasing utilization from an average of 2,500 visits a month in 2001 to more than 4,000 a month iin 2003.
RWJF supported this project with a grant of $425,000 from June 1998 to May 2002.
Ten blocks north of the U.S. Capitol building and a world away is a neighborhood of housing projects known as Northwest Number One. Poverty, crime, drug use, homelessness and teenage pregnancy have long been pervasive in this near-downtown section of the nation's capital. One housing complex named, ironically Sursum Corda, Latin for "Lift up your hearts" is a regular contributor to the city's daily homicide tally.
Mary Chavis, 52, grew up in Northwest Number One and in the 1960s saw its single-family homes bulldozed as urban renewal planners tried their brand of rehabilitation. Today, this mother of three grown daughters and grandmother seven times over still lives in the neighborhood and is all too aware of its ills. But Mary Chavis also sees the fruits of a remarkable effort to lift Northwest Number One out of its bleak existence.
In the late 1990s, a campaign led by neighborhood activists converted an old, vacant school building next to Sursum Corda into a community center that offers residents a wide range of services from day care and job training to family counseling and even dance instruction. Anchoring this facility, both financially and physically, is the Perry Family Health Center a brightly decorated, inviting primary health care facility dedicated to weaving together medical and social services into comprehensive care for low-income parents and their children.
Located in the basement of the old school building, the staff of the Perry health center does not just write prescriptions and make referrals. The doctors, nurses and supporting aides also ensure that patients actually pick up the prescribed medicine and visit the needed specialists, and that often means providing transportation. "In one two-week period we went through 100 bus tokens," says Cherie Sammis, the director.
This center's holistic approach extends to helping patients with counseling, clothes, rent money and just about anything else to help them get through emotional and economic emergencies. Because the converted building was designed as a collaborative venture, much of this assistance is available from other organizations operating under the same roof.
"There's no rocket science going on here," says Sammis, a family nurse practitioner. The health center is providing basic health care but with a patient management philosophy that seeks to meet a wide spectrum of needs, not just immediate health problems.
Mary Chavis, who suffers from chronic high blood pressure, is one of the beneficiaries. She makes the five-minute walk from her home to the health center at least monthly for check-ups, sometimes weekly when her pressure jumps up and her medication needs adjustment. She could just as easily go to the larger city-owned clinic nearby but as neighborhood residents have done for years she complains about the quality of service at that older facility.
"I never feel unwanted around here," Chavis says, gesturing at the freshly painted interior of the Perry center. "Babies, senior citizens, all of them; they never feel unwanted," she says. "Without Perry Family Health Center, I don't know where the people would be."
A major portion of the Perry center's start-up funding came from RWJF through a matching-grant program called the Local Funding Partnerships. In collaboration with community foundations and other local givers, Local Funding Partnerships seeks to stimulate innovative, community-based projects aimed at improving the health and health care of underserved and vulnerable populations.
The story of the Perry Family Health Center shows how collaboration between a national foundation with large resources and local funders with on-the-ground knowledge of community needs can make a significant difference in people's lives even in a desperate urban environment like Northwest Number One.
Built in 1891, the Perry school was Washington's first school constructed with public funds specifically to educate African Americans. First as a high school and then as an elementary school, the four-story, red-brick Romanesque structure operated as a school until the 1950s, when it was closed as part of the racial integration of the city system. Mary Chavis's father was among the many students who passed through its tall front doorways.
In the 1980s, after saving the building from the wrecker's ball, community activists began promoting a plan to convert the boarded-up structure into a multipurpose service center to help residents break out of their cycle of poverty. "My hope is that the center will turn this community around," Alverta Munlyn, the leader of the effort, told the Washington Post. The services housed in the renovated structure would target residents of Northwest Number One and adjoining areas in nine census tracts a total of about 20,000 people as of the 2000 census.
Munlyn, a Sursum Corda resident, saw a health center as the keystone to the proposed facility and with good reason. In addition to being one of the city's poorest areas, this predominantly African-American section had alarming health indices, including an infant mortality rate of 40 deaths per 1,000 births five times the national average, as cited by the 1996 funding application to Local Funding Partnerships. Single-parent families constituted 85 percent of the households.
Munlyn and her backers won approval from the D.C. school board to use the building and began raising money to pay for its rehabilitation, including securing $1 million in federal funds from Congress. Munlyn also got approval from then-Mayor Marion Barry for the city's participation in what was to be a private-public health center partnership.
Providence Hospital, owned by the Daughters of Charity and located in the city's far northeast, would manage the facility. Georgetown University would provide the doctors. And the city health department would close its own financially strapped clinic in the neighborhood and subsidize the new operation saving money in the process. "A real win-win situation," D.C. Public Health Commissioner Harvey I. Sloane, a physician, called the arrangement.
This city-owned facility the Walker-Jones Health Center was only two blocks from the Perry school. But the city clinic was physically rundown and chronically short of supplies and manpower. In addition to complaints of poor service at Walker-Jones including long waits for appointments the District's precarious finances kept all city clinics under a constant threat of closure.
However, just two weeks after the parties agreed to the private-public arrangement, city officials balked at the deal, at least partially in response to concerns raised by labor unions representing city health workers. "D.C. Neighborhood's Plan for Health Clinic Derailed," said the Washington Post's front-page story July 1 of that year.
That's when RWJF entered the picture. Sister Carol Keehan, Providence Hospital president, told the Post she saw divine intervention at work. Serendipity was the word used by William J. Bierbower, trustee of the Alexander and Margaret Stewart Trust, a local foundation that has long supported Providence Hospital initiatives. Whichever it was, a week after learning of the hospital's interest in running a health center in the Perry school, Bierbower got a flier in the mail about the Local Funding Partnerships.
The result was that with the Stewart Trust as lead local funder, Providence applied to the RWJF program for the maximum $500,000 to help support the first four years of the health facility's operation. The proposal came with written endorsements from city officials, community development groups and several D.C. philanthropies that were already committed to supporting the planned school building renovation. In addition to this strong show of local support, the Local Funding Partnerships national program office staff viewed the following as among the proposal's key strengths:
- The critical need of the service area.
- The building's design as a one-stop center that could provide residents with social services and educational assistance as well as medical treatment.
- The proven management capacity of Providence Hospital, the city's oldest continuously operating hospital.
- The hospital's existing network of specialty referral services.
- A high probability of the health center's sustainability through Medicare and Medicaid reimbursements.
- The training opportunity that the facility would provide new doctors and nurse practitioners.
RWJF awarded the hospital a $425,000, four-year grant starting June 1998. In September of that year, Perry Family Health Center opened its doors, becoming the first tenant of the Perry School Community Services Center. The rest of the building officially opened a year later.
Local Funding Partnerships grants require a one-for-one match and are not renewable conditions designed to encourage the project's long-term sustainability by community resources. In this instance, local funding exceeded the RWJF dollars by a significant amount. In addition to $355,000 from the Stewart Trust, the health center got a total of $476,000 from seven other foundations over the four-year grant period. (For the list of donors, see the Appendix.)
Along with making the health center possible, RWJF's commitment had the side effect of spurring additional support for the building's conversion. Before the RWJF grant was made, the capital campaign was still short of what was needed to finance the school's renovation, which started with a projected price tag of $2.1 million and ended up costing $5.6 million. The assurance of a major tenant and the weight of the RWJF name provided the leverage needed to secure the final funding pieces, project leaders say. Bierbower calls the Local Funding Partnerships grant the catalyst that made the project a reality. Munlyn, the inspiration for it all, agrees. "Without it, we wouldn't have opened the doors."
Walk into the Perry Family Health Center any weekday or Saturday morning and you find a large, bright waiting room bustling with activity and presided over by receptionists sitting behind a long counter. It is a scene you might find at any private clinic or large doctors' office.
Before construction work began, Sammis, a Providence Hospital employee, held formal discussions and informal conversations with neighborhood residents to find out what they wanted in a health center from the kinds of services down to such details as whether the staff should wear lab coats or regular street clothes. (The consensus was pro-lab coat, and indeed a lab coat is what all staff members wear.) Sammis calls her intelligence-gathering effort "legal loitering," and says it included talking to kids at bus stops and stopping people on the sidewalk.
Also guiding the center's development was a commitment to build the center to meet requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an independent organization that sets standards for health care organizations and programs. Indeed, the center won accreditation shortly after opening, Sammis says.
The Perry health center follows a private-practice model, with each family's care coordinated by a single health care professional. The result, says Ashwini Sardana, M.D., an internist and the facility's attending physician, is continuity of quality care for a patient population that might otherwise go without it. "It's entirely rewarding because at the end of the day you have treated people who otherwise would not be getting good care," he says. In addition to Sardana, the staff at the end of the four-year RWJF grant consisted of:
- A second physician specializing in internal medicine.
- A general practice physician covering adult and pediatric patients.
- A Children's Hospital pediatrician with part-time hours at the Perry facility.
- Two family nurse practitioners in addition to Sammis, whose duties include caregiving as well as administration.
- A psychiatric clinical nurse specialist working part-time at Perry.
- Two registered nurses (RNs).
- Certified medical assistants.
- Support personnel including an operations manager, patient service representatives, a community health worker and receptionists.
In addition, a podiatrist, psychiatrist and geriatrician provided services on a part-time basis. A nutritionist worked with patients once a week, and nurse midwives gave weekly instruction in prenatal care and women's health. Also supplementing the staff were medical residents from local hospitals and a volunteer community health worker from the faith-based Vincentian Service Corps.
Then as well as now, the staff included several Spanish speakers. Although predominantly African-American, the area has a fast-growing Hispanic population. On some days, Spanish is the native language of as many as a fourth of the patients at the Perry center.
The health center operates as a department of Providence Hospital. The workers are employees of the hospital and use the hospital's computer system and supplies a big help in keeping costs down, says Sammis.
One external development of importance was the city's decision not to close the Walker-Jones Health Center. Instead, in 2001 Mayor Anthony Williams, Barry's successor, turned the facility's operation over to a private nonprofit group as part of a citywide reorganization of the District's indigent-care system.
Housed in a drab elementary school building in space converted from classrooms years ago, Walker-Jones is no match aesthetically for the Perry facility. Users of the handicapped entrance pass through a metal-mesh doorway into a dingy hall. Mary Chavis comments that the clinic has an equally unwelcoming insistence on processing patients for coverage by DC Healthcare Alliance the District of Columbia's health care program for the uninsured before providing treatment. She, at least, sees no comparison in service and staff spirit between Walker-Jones and the Perry center.
Nevertheless, Walker-Jones offers a full range of outpatient services, and Munlyn says the general view is that the facility has improved under the private operator, Unity Health Care.
"To work here, you really have to want to be part of it, because it's chaotic," says Sammis, who previously ran Providence Hospital's obstetrical/gynecological program for low-income women. "A drug-abus[ing] pregnant woman comes in two days late for her appointment. We say, 'We're so pleased to see you.' We try to flex our system around that patient's chaotic life. You have to."
Health services offered by Perry Family Health Center include:
- Pediatrics: newborn care, well-baby checkups and sick-child treatment.
- Adult care: general medical problems, physical exams, geriatrics, and treatment of diabetes, hypertension, asthma and other chronic conditions.
- Women's health: Prenatal care and gynecological services.
- Behavioral health: Counseling and treatment for depression and substance abuse.
Health center personnel screen patients for eligibility for Medicaid and other government insurance programs and assist them in applying for coverage. (For low-income children and their parents, the city provides free insurance through DC Healthy Families under the federal Children's Health Insurance Program. Low-income adult residents of the District who are not eligible for Medicaid get free coverage through DC Healthcare Alliance.) "We work like the dickens to get people covered," says Sammis. A small number of patients 56 percent have private insurance. There is a minimum $2-per-visit charge that Sammis calls "a dignity factor."
However, people receive care whether or not they have money or insurance. That is central to the health center's mission. "If a friend or relative is sick and doesn't have insurance, I bring them over here. She (Sammis) won't turn them down," says Mary Chavis, adding that the center's director even provided her home phone number for off-hours calls. In some months as many as 20 to 30 percent of the treated patients have no coverage, according to Sammis.
In addition, the health center provides many services that are ineligible for reimbursement even under insurance plans. Helping patients apply for insurance coverage; assisting them in applying for free and reduced-price drugs; providing bus tokens; arranging transportation through the Providence Hospital van service; and finding social services to meet specific patient needs those costs cannot be recovered. As a result, says Sammis, the operation will continue to need support by foundations and subsidization by Providence Hospital.
"Basically, I help them get whatever they need," says the center's community health worker, Evelyn Ventura, whose job is to help patients navigate the system. That encompasses the routine, such as escorting a patient to the building's top floor to get shoes and clothing from the Center City Community Corp. If an expectant mother has no crib, Ventura knows where to go outside the building to get one.
But sometimes the need is not so routine. When one patient needed a corneal transplant and could not get insurance, Ventura found a surgeon who agreed to do the procedure for free. "She has moles in the community," Sammis says of Ventura's ability to find resources.
Ventura emigrated from El Salvador a decade ago, when she was 15, pregnant and unable to speak English. It was a trial by fire that she says now helps her develop rapport with people in difficult straits. "I get very attached to the patients because I've been there."
Collaboration Among Building Tenants
The developers of the Perry services center intended that the programs housed in the building be not just co-located but collaborative. The health center is part of this collaboration. For example, the staff may refer a patient who needs work to the building's job training and placement service, or a single parent to the free day care center. At the same time, the day care center, dance program and summer youth camp may refer enrolled children and their parents to the health center for medical attention or counseling.
Perry School Community Services Center the community-based organization that oversaw the building's renovation and now operates the facility runs some of the programs itself. Its array of services includes after-school and summer activities for young people, job training and placement, addiction prevention and family counseling. (The name of the building and the name of its operating organization are the same. To avoid confusion, the latter is generally called Perry Inc. which will be used throughout the rest of this report.)
Other services in the building including the health center, the largest tenant are run by completely separate organizations. The directors of all the programs, however, agree to work together for the good of the community, and once a month they meet to discuss how best to do that.
A large wall mural depicting Martin Luther King Jr. and other famous African-American leaders dominates the building's front entrance hall. The services are laid out so that generally the higher the floor, the older the program's target audience. For example, Bright Beginnings, the day care center, is on the first floor, and Jubilee Jobs, a nonprofit employment agency for entry-level personnel, is on the third. Paul McElligott, executive director of Perry Inc., says the health center is appropriately located in the basement since good health is the foundation for all of life. Some of the building's other tenants and the services they offer are:
- Carver Empowerment College: Education in multimedia computer technology and e-learning center.
- Center City Community Corp.: Employment opportunities, housing assistance and crisis intervention.
- College Bound: Mentoring of students for college, including help in math, language arts and problem-solving skills.
- Dance Institute of Washington: Dance instruction designed to build self-esteem among at-risk youth.
- Little Friends of Peace: Education for young children in nonviolent skills.
A board of directors with a majority of neighborhood residents governs Perry Inc. and oversees the private management company hired to run the building. Perry Inc. receives foundation grants and some public money, including federal funds for combating domestic violence. The rent paid by the building's tenants goes to support the building, not Perry Inc.'s own programs, McElligott says.
The Perry Health Center and Perry Inc. have had the following results:
- Initial plans called for the health center to serve as many as 6,700 people a year and have 10,000 patient visits in the first year alone. Although the early experience fell short of those expectations, use has steadily increased:
- In June 1999 at the end of the first RWJF grant year and after nine months of operations the patient roster totaled 1,367 people, and the center recorded a total of 3,053 patient visits, according to Providence Hospital's report to RWJF.
- In the three succeeding grant years, the number of reported patient visits rose to 7,715 in year two, 9,707 in year three and about 11,500 in year four.
- At the end of the four-year grant period, the center reported 3,800 patients, a little more than half the planned capacity.
- Since the RWJF grant, usage of the Perry health center has continued to increase. As of December 2003, the facility had 5,170 patients, and visits were expected to reach 13,000 for the year, according to the operations manager, Sharon Taylor.
- Providence Hospital and Perry center staffs cite the continuing existence of several nearby clinics, including Walker-Jones, as the reason for the gap between projected and actual use of the Perry facility. For the 12 months ending September 2003, Walker-Jones had 22,000 patient visits, according to Libbie Buchele, manager of the facility. "We are pretty much jam-packed all the time," she said in an interview.
- Supporters of the Perry health center say its continued growth is evidence of the need for the Perry facility in addition to the Walker-Jones clinic. "The proof of the pudding is that the Perry center is doing 12,000 to 13,000 visits a year," says Robert Hudson, executive vice president of Providence Health Foundation. Bierbower of the Stewart Trust agrees, saying, "The Perry center is going great guns." Munlyn says population growth in the area including the addition of more subsidized housing makes both Perry and Walker-Jones necessary. "The need in the community is greater than ever."
- Like the health facility, the overall Perry building also has experienced increasing utilization from an average of 2,500 visits a month in 2001 to more than 4,000 a month in 2003, according to McElligott. He points to other positive outcomes, including Perry Inc.'s placement of 212 people in career-level jobs.
- Nevertheless, McElligott considers it is too early to try to measure what impact the building and its services has had on the neighborhood. The area's problems are deeply rooted, and correcting them is a long-term process, he says. "We've come a fair way, but I'm not ready to declare victory."
Neither Providence Hospital nor the health center used paid advertising to promote the center's services. Instead, the staff disseminated informational brochures and got free publicity in publications put out by other community organizations (for example, in the North Capitol Neighborhood News) and engaged in various community outreach efforts. These included public tours of the center and special programs such as a series of free classes on breast and cervical cancer conducted at the center by a George Washington University group.
Also, Providence Hospital put information about the Perry facility on the hospital Web site (www.provhosp.org) and in hospital publications, including Memo and House Calls. The hospital also issued written press releases when the health center opened and again when it had its 13,500th patient visit. The Catholic publications America and Catholic Standard ran articles about the facility as well.
Sammis made presentations on the center to neighborhood groups and Providence Hospital-related organizations. She served on task forces related to restructuring of the District of Columbia's beleaguered health care system and participated in the District of Columbia Primary Care Association, a group formed by local safety-net providers to promote improved care for the local Medicaid and uninsured population. Through separate work as a consultant, Sammis spoke to a Florida foundation about possibly establishing a hospital-sponsored primary care facility in that state. Health officials from several foreign countries, including the United Kingdom and Kazakhstan, visited the center to learn about the operation.
From her experience with the Perry Family Health Center, Sammis offered these lessons:
- Seek synergy with other social service organizations. By working with other agencies housed in the Perry building, the health center avoids unnecessary duplication of services. If a patient needs emergency food assistance, for example, the staff can send him or her to another part of the building to get a voucher. (Project Director)
- When undertaking a new service in a community, build trust among the residents before breaking ground. The extensive effort to find out what kind of health center neighborhood residents wanted helped make the new facility and its staff welcome in the community. (Project Director)
- Keep a close eye on political and governmental developments that affect the project's targeted population. A project director does not have to become a political activist, but he or she should monitor government programs and regulations. Through her membership in the District of Columbia Primary Care Association and local health care task forces, Sammis stayed abreast of Medicare spending, Medicaid restructuring and other issues with a potential impact on the Perry center and its service population. (Project Director)
- Nonprofit organizations should be committed to providing high-quality care even if certain necessary services are not reimbursed and therefore costly. The Perry center maintains this commitment by operating efficiently and maximizing resources down to watching how much is spent on Post-It notes. The center also maximizes reimbursements by providing on-site personnel to help patients apply for Medicaid and follow up on pending applications. In addition, by building the facility to meet JCAHO standards, the center avoided the expense of modifications later to gain accreditation. (Project Director)
- Hospital sponsorship can provide a project with significant economies of scale and support services. The ability to use Providence Hospital resources gave the Perry center access to high-quality support in areas that include billing, personnel management, employee benefits, laundry and linen, medications, medical supplies, sterile processing, risk management and employee education. (Project Director)
- The director of a health facility will benefit by working as a front-line caregiver as well as an administrator. But to play those dual roles, he or she should have an understanding and supportive supervisor. The Perry center director, who is a family nurse practitioner, provided patient services as well as administering the facility. She found that the daily interaction with patients gave her a clearer understanding of their needs than she would have had in a purely management role. But she counts herself fortunate that the leadership of Providence Hospital, for which she worked, understood the competing demands on her time and enthusiastically supported her approach. (Project Director)
AFTER THE GRANT
To supplement its income from government insurance programs, the Perry health center continued to rely on subsidies from Providence Hospital and contributions of money and supplies from outside sources. Among its plans, Providence Hospital was considering the addition of a child literacy program that would use health center visits as an opportunity to provide families with books and encourage adults to read to their children.
One disappointment was the collapse of plans to add dental services to the building. Although not an undertaking of Providence Hospital or the Perry Family Health Center, the long-planned dental facility was viewed as a badly needed complement to the center's efforts to improve the health of area residents. McElligott said the dental facility's third-party developer was unable to secure adequate financing.
GRANT DETAILS & CONTACT INFORMATION
Family-Oriented Primary Health Care Services for Severely Underserved People
Providence Hospital (Washington, DC)
Dates: June 1998 to May 2002
Cherie Sammis, N.P.
Matching Grant Funders - Perry Family Health Center
- Alexander and Margaret Stewart Trust, $355,000
- Arcana Foundation, $100,000
- Cafritz Foundation, $100,000
- Graham Foundation, $100,000
- Meyer Foundation, $100,000
- W. O'Neil Foundation, $50,000
- Abell Foundation, $16,000
- Community Foundation for the National Capital Region, $10,000
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
A Commitment to Excellence and Compassion: A Commitment to the Community. Washington: Providence Health Foundation, 2002.
Blessing and Dedication, Perry Family Health Center (Program). Washington: Providence Hospital, 1998.
Patient/Resident Handbook and Weekly Television Guide. Washington: Providence Hospital, 2001.
Perry Family Health Center (Brochure). Washington: Providence Hospital, 1999.
Providence Hospital Neighborhood Health Centers (Fact Sheet). Washington: Providence Health Foundation, 2001.
World Wide Web Sites
www.provhosp.org. The Web site of Providence Hospital includes a page on the Perry Family Health Center, including hours of operation and a brief description of services.
Report prepared by: Michael H. Brown
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe