The Inspiration and Creation
When discussing the beginnings of Puentes de Salud (Bridges of Health), Dr. Steven Larson, an emergency physician at the University of Pennsylvania, tells the story of treating a 17-year-old gunshot victim in his emergency room. The circumstances leading up to the teenager’s admission into the hospital were largely preventable, with the recognition that positive environments, enriching education, improved self-esteem, and a strong sense of community are essential to achieve true prevention. Operating in a community with so many underserved individuals, he wondered how to fix what had systematically gone wrong. More importantly, what could he, as a medical professional, do to improve the lives of these individuals?
As a young physician who spent time in Central America after medical school, Larson observed local health workers investing their energy in prevention activities, and upon moving to the United States he wondered about the high prevalence of chronic illness in immigrants from these very same countries. While caring for Latino workers in the mushroom fields of Kennett Square in Chester County, Pennsylvania, Larson recognized that Latinos in particular were underserved and often shut out of the mainstream healthcare system. Often living in the shadows and working jobs requiring hard labor, an incapacitating or ill-managed condition could wreak havoc on an entire family -- havoc further compounded by linguistic and cultural barriers, few health benefits, and a lack of culturally-competent care. In order to better serve this community, Larson would have to take a multi-faceted approach and harness their potential.
In 2003, Dr. Steven Larson and colleague Dr. Jack Ludmir organized a series of meetings with local stakeholders to address the healthcare needs of South Philadelphia’s Latino community. In Philadelphia, nearly three out of 10 residents live below the poverty line , and more than half of the visits to the eight city-run health centers are made by people with no health insurance. Demographic shifts have been in motion since the 1990s due to economic instability in Mexico and other surrounding countries, all serving to feed the increased labor demand in the United States. Today, 37,000 Latino immigrants reside in Philadelphia, making up around 19 percent of the City’s foreign-born population.
The needs of the community are complex, and were not being addressed by existing programming at the time. Larson and Ludmir, joined by Dr. Matthew O’Brien, were acutely aware of this fact, and decided to design and build a new immigrant health and wellness center. The center would serve the needs of the City’s Latino population (and other minority groups), with an eye toward addressing the social determinants of health and long-term sustainability.
With this vision, Puentes de Salud was born. It started out, in the words of Larson, as a “shoestring operation,” with the three physicians and support staff seeing patients two nights a week in an office space at the University of Pennsylvania Medical Center. In the fourteen years since its inception, the organization has taken flight, with nearly 6,500 patients receiving care and many more impacted by the organization’s community programming.
A Synergistic Community-Based Model
The organization’s greatest strength in meeting the demands of patients has been its inclusive nature and interest in building diverse community partnerships. By involving medical residents and students, nurse practitioners, promotoras (lay Latino community members who receive specialized training to provide basic health education), graduate students from various fields, and even undergraduate students in providing care and support services, Puentes de Salud has curated a conscious, innovative, and holistic workforce. In return, it provides valuable experience and training for young physicians, nurses, and allied health workers interested in serving diverse populations.
In an effort to design sustainable, long-term strategies for health promotion and disease prevention Puentes de Salud has partnered with local public schools, universities, governmental institutions, nonprofit organizations, small business owners, and community members. Recognizing that long-term benefits to the population can only occur with sustained upstream work that will influence the lives of the city’s youth, the clinic started Puentes Hacia el Futuro (Bridges Toward the Future), an after-school enrichment program for kindergarten and elementary school children. The program is based at Southwark School, a local elementary school where many of the students attend classes. Volunteers from various institutions work to improve the educational achievement of the children through after-school tutoring and mentoring, kindergarten in-class support, adolescent empowerment groups, a coding program (STEM Dragon Coders), art and dance classes, and a summer literacy enrichment camp.
However, the program’s benefits extend far beyond the classroom. It provides youngsters the opportunity to interact with peers who are interested in their development and growth, and educates parents on how to better adapt to the needs of their children. Clinic volunteers will often describe how mothers, fathers, and caregivers coming in for visits express concerns to physicians about their children’s education, including not feeling like they are able to help with homework or participate in their schooling. Puentes de Salud has differentiated itself by encouraging staff to harness the capabilities of parents in its programming. Parents participate by signing up to read aloud to children or teaching them about cultural holidays. Family events are held at least twice a year, in addition to a new workshop series that surveys parents ahead of time on topics they’d like to learn about (health, legal, etc.) which allows families as a whole to benefit from community resources. Addressing the additional needs of the population through a joint effort at the school and in the clinic has allowed Puentes de Salud to empower both parents and children to adapt, understand, and excel.
For the medical community, such interventions are a powerful reminder of the importance of interdisciplinary action. The Philadelphia Latino community stands to benefit most from such an approach, due to the complex range of geopolitical, national, and local factors affecting their allostatic load. A nearly toxic level of stress related to deep poverty, concerns for safety, and a loss of social support affects nearly all who walk through the doors of the clinic. In an effort to encourage universal good health and support patients and families as they navigate difficult situations, Puentes de Salud added a behavioral health consultant to the care team. Present during open clinic hours, the consultant is able to have seamless access to patients in need of services. The consultant plays a vital role in supporting patients and families suffering from trauma experienced in their home countries, here in the United States, or during their migration journeys. Additionally, the consultant guides individuals as they navigate complex family dynamics, marital struggles, and other mental, emotional, and psychological concerns.
While there is universal consensus among healthcare professionals on the importance of addressing the social determinants of health in communities, few providers are engaged, nimble, and equipped enough to identify stressors in communities and respond adequately. The holistic clinical team at Puentes has positioned itself well to do so. In the fall of 2016 following the presidential election, clinic staff noted that many individuals had questions about the future direction of immigration policies in the United States, and how it may affect them. The Puentes behavioral health team, along with legal partners from Friends of Farmworkers, put together a town hall meeting to allay fears in the community. In order to directly address questions from children and parents, Puentes Hacia el Futuro staff organized meetings at Southwark School to provide further information.
The Puentes model treats education, capacity building, and empowerment as key pieces of the prevention puzzle -- pieces that positively impact health outcomes in the long run. Larson, Ludmir, and O’Brien have a deep recognition that involving various types of professionals in educating patients will serve the community well in the long run. The learnings from these efforts and the creation of strong local partnerships have helped Puentes de Salud become an established leader in the community health landscape of Philadelphia.
Building Up: Puentes de Salud’s Next Chapter
As a leader, Puentes de Salud continues to make strides in building programs, encouraging the next generation of volunteer leaders, and engaging more deeply with organizations in Philadelphia. In April 2015, the clinic moved into a new space, customized to accommodate the high volume of patients and various programs occurring at the organization. Instead of two nights a week, providers are now able to see patients throughout the week. The new environment enhances the ability of Puentes de Salud to function as a true medical home. Recognizing that access to medical care often gets patients through the door, the new site has the capacity to host various learning and education activities such as: yoga and ESL classes, GED certification courses, art classes, and other support and learning groups parents and children can take advantage of.
The solid foundation that Puentes de Salud has built so far -- not only as a source of healthcare but as a community resource -- has allowed the organization to grow into its next iteration. In an effort to actively grow systems and programs, the organization is working to identify gaps in care and communication in order to further enhance prevention activities. Recognizing that less than half of Latino children are enrolled in early learning programs, and Latino families are least likely of all ethnic groups to attend preschool due to limited geographic availability and affordability, Puentes de Salud is working to create an early childhood education program aimed at building strong foundations in literacy prior to enrolling in school. By engaging parents, caregivers, and babies in play with a literacy component in their early years, staff hope that children will be better equipped to begin school in the long run. Combined with parenting classes and health workshops with promotoras, Puentes de Salud hopes to better prepare parents while enhancing family strength and communication.
Another key element of Puentes de Salud’s next chapter includes fostering leadership among young, engaged volunteers. A group of three volunteers studying at the University of Pennsylvania were recently awarded the President’s Engagement Prize, a university award providing them with funding to translate their passions into an impactful project. The three students -- studying neuroscience, nursing, and urban studies -- conceptualized a project called Lanzando Líderes aimed at bringing together high schoolers (who were in elementary school at the inception of Puentes Hacia el Futuro) and equipping them with the necessary support and tools to succeed during and after high school. The program includes academic tutoring, workshops and mentoring on college and/or job preparedness, health and wellness training, guest speakers, and field trips to inspire self-confidence in students and provide encouragement as they navigate adolescence. By building on an existing foundation of programming and remaining aware of the adapting needs of the community it serves, Puentes de Salud remains dedicated to cohesive capacity-building in Philadelphia’s immigrant community.
Looking ahead, Puentes aims to not only strengthen its own core medical, educational, and wellness programming, but also partner with organizations similarly invested in a holistic, interdisciplinary view of community work. In September 2017, Puentes de Salud and the Barnes Foundation will partner to create an arts-based literacy enrichment program for young children called “Puentes a las Artes/Bridges to the Arts.” The Barnes Foundation’s educational mission, outlined by founder Albert C. Barnes, emphasizes that art should be accessible to individuals of all educational levels and cultural backgrounds, and that visual literacy and critical thinking skills are essential to every individual’s ability to being a participating, productive member of society. The new program will help develop cognitive and linguistic skills in children and provide adult caregivers with activities and teaching strategies that will enable them to reinforce and extend learning at home. Additionally, the foundation will facilitate family engagement through monthly museum visits and art based activities, intended to educate youth about observation, reflection, and communication. With the launch of this effort, Puentes de Salud takes another step toward its goal of joining forces with local partners to create innovative programming to enrich the lives of the children and families it serves.
Puentes de Salud was started with a broader vision to break the cycle of poverty and meet the needs of a vulnerable population through customized programming. By providing opportunities for patients and community members to express their needs, and working across sectors to construct a model, Larson, Ludmir, and O’Brien have sought to address the social determinants of health in a way that truly makes a difference. With a vigilant eye, Puentes de Salud continues to expand its medical, educational, and wellness programming in a way that best fits the needs of its patients -- while providing creative opportunities for meaningful enrichment. Having done the legwork to engage community members while building its organizational foundation, Puentes de Salud remains able to respond to the changing needs of the community it serves -- a microcosm of the changing international, political, and local landscape in which we live. The clinic began based on a physician’s moral and ethical responsibility to take care of patients in need; what has occurred since can only be described as taking the fight for better health outcomes beyond the emergency room and into the community.
Bhakthi Sahgal is a Program Associate at the Patient Centered Outcomes Research Institute (PCORI) in Washington, DC. She has engaged in community health initiatives and has worked on health legislation and policy on Capitol Hill, the White House Office of Drug Control Policy, and as an academic researcher. She holds a master’s degree in Public Health from the Milken Institute School of Public Health at GWU, and a B.A. in Political Science from Bryn Mawr College in Pennsylvania.
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