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Agape/Community Care: Concepts and Services

Introduction

Baylor Community Care grew out of a series of discussions among students, faculty, and people in the East Dallas community. We were encouraged to participate in the life of the community and decided to take responsibility for the health of part of East Dallas (bounded by Live Oak, Fitzhugh, Ross, and Haskell). Operational and philosophical concepts supporting Community Care and its partner, the Agape Clinic, include service-learning, community-oriented primary care, district health, and the mission of Baylor University - all applied to a mission setting (see below).

We (one clinical group of eight students and a faculty member) started at 1415 Annex and worked our way door-to-door to 1614 Annex. Those two blocks took a year - many people and many problems. While maintaining our presence on Annex, we expanded to Carroll Street and then up and down San Jacinto. Because we had an ongoing, demonstrable impact on the community's health, other people began working with us. In the mid-1990s Parkland agreed to send a physician to work with us out of the East Dallas Police storefront facility. We thus had medical services, refugee screening through the Dallas County Health Department, and outreach through Baylor students. We initiated relationships with churches and a seminary to develop a parish health program component. We began working with Church Health Ministries (CHM) in the late 1990s and through that relationship, added additional medical services. We moved to a small community church in 1999 and in the spring of 2000 separated from CHM. Community Care moved to Emanuel Lutheran Church for a few months and entered into a partnership with Agape in the fall of 2000. Photo: Prayer in waiting room 9/11/2003

What is a typical week like in Agape/Community Care?

Wednesdays we meet at Zaragoza Elementary School where students or community health workers provide a class for parents (we always sit among the people attending the class to minimize the us & them dynamic). After the class we talk to individual parents, check BPs, etc.; and then go to the East Dallas Police Storefront where we discuss plans for the day. Some students go to the Garden on Fitzhugh where we work with Cambodian refugees assessing, answering questions, and other health-related activities. Other students make home visits in Old East Dallas either to clinic patients with chronic & more complex health problems or to the homes of Zaragoza students who have too many absences or other health-realted problems. We generally meet back at the police for lunch, either to go out to a neighborhood cafe or store, or bring in food, or sometimes go on a picnic. After lunch its more home visits & work on community-oriented care such as a health fair or Zaragoza classes. Finally, we set up the clinic for Thursday, have post-conference, and that is the end of the day.

Thursdays we hit the ground running at Agape Clinic. Two students also spend part of the day with the Zaragoza nurse, making the Zaragoza project happen. Roles at the clinic rotate, so that each student works triage/front, primary patient care, pharmacy, and as manager. We stay very busy on Thursdays, seeing as many as 60+ patients in a day. Students work closely with physicians and nurse practitioners in the primary patient care role and are responsible for HPI, physical exam, decision-making re expanding the exam (or not), and developing informed ideas re the etiology of the problem(s). After the diagnosis and treatment plans are complete, students are responsible for teaching the patient re the problem, plan, medications, self-care, providing spiritual care if indicated, and so on. Almost all the providers are good about teaching students. After clinic, we set up for Friday, have post-conference & fairly frequently, an in-service, and that is the end of the day.

In summary, we practice community health in a service-learning, community-oriented primary care mission.

Within the context of being a student clinical placement and a mission, Agape/Community Care incorporates several closely-related concepts:

Having students as providers of care means that continuity of care between clinical groups, across semesters, and through holidays is a vital issue. I should note here that the continuity issue sometimes raises questions about the efficacy of using students. Look at it this way: The use of students who are available nine months out of twelve means that the cup is 75% full. Filling the other 25% is not an impossible challenge! Collaboration with a large number of providers and disciplines is necessary.

Individual and Family-Oriented Services

Outreach: As noted elsewhere, outreach is door-to-door through the apartments in the district. We carry flyers in English, Khmer, Spanish, and Vietnamese about, for example, our Friday pediatric clinics, but rather than just leave them on doors, we always knock and if anyone is home, inquire about health problems, vaccinations, etc. We talk with people and check blood pressures, vaccination records, medications, and any other health concerns they have. And always, as much as is possible, we stop to solve problems wherever they are found. Picture: Baylor student and Cambodian patient) This community (and like communities) really is not interested in what someone might do next year, or in knowing that sick people can go to Parkland, or that there is a food stamp office nearby. Reasons why this outreach is successful include:

In general, most needed information on health resources is already out there. What we need to be about is connecting people with services and information. We need also to be acutely aware that in poor and under-educated communities, few people depend on printed material as an important source of information. Of course we use flyers and announcements, but always as an adjunct to person-to-person communications and relationships. The focus on person-to-person communications and relations may not be very efficient; but in the final analysis is more efficient and efficacious than printed material alone.

Language is often an issue. The primary languages spoken in this district (in descending order) are Spanish, English, Vietnamese, Khmer, Laotian, Somali, and Arabic. We are acutely aware that there often are breakdowns in communication! We accept that communications are not complete - which is true in all relationships. We operate on the assumption that some communication is usually better than no communication. Although from time-to-time we have Khmer and Vietnamese caseworker/translators working with us (and now have a Spanish translator with us daily), we want to be absolutely clear in saying that had we waited for the right translators, we would have missed thousands of opportunities to serve this community. Depending on the right translators would have meant cancer untreated, hypertension undetected, births without prenatal care, vaccinations undone, food stamps benefits lost, and on and on and on.

Primary Care, Case Management, and Home Health Care: When people are found with health or related problems, nursing students or other persons involved with the program help find appropriate resources, help clients access the services, follow-up on the care given to be sure that clients understand treatments and medications, and finally, provide further follow-up to determine if treatments were effective and if any new problems develop. Currently, Baylor coordinates Agape Clinic care on Thursdays and Fridays; and Saturday is the original Agape crew - and what a crew they are! Picture: Woman in la clinica.

Common individual problems encountered in the community include clients having difficulty obtaining and understanding:

  • Primary care for hypertension, infections, and similar problems,
  • Prenatal care and family planning,
  • Specialty care for cancer, diabetes, and other chronic illnesses,
  • Preventive care such as childhood immunizations; or early disease detection.
    •

    Often nursing students accompany patients to appointments and thus provide essential advocacy and/or teaching services. In all cases, a goal of care is increasing patient independence so that ultimately the patient is registered with a provider such as the East Dallas Health Center, knows how to make appointments, and is able to recognize the need to seek health care. There is also a continuity component built into the care so that different aspects of the care, e.g., hospital and home, are connected; and the care is connected among different students and across different semesters.

    Mrs. C was a 58 year old Cambodian woman who had undetected cervical cancer when we found her in door-to-door outreach. She had an eleven year old son with Down's, a thirteen year old daughter who provided most of Mrs. C's care, and a fifteen year old son who was sent to prison midway through the course of care. Students and faculty were instrumental in the cancer being diagnosed, played a critical role in getting the patient through two courses of treatment (surgery and radiation), and took responsibility for her home care following crises related to very severe complications of disease and treatment (septicemia, stroke, seizures, bowel obstruction, malnutrition, and dehydration). For two years, Mrs. C received at least three home visits each week. She agreed to hospice care about two months before dying. A faculty member was with her when she died at home earlier this year.

    Primary care services are are available Thursday afternoons, Friday mornings, and Saturday mornings at the Grace United Methodist Church Agape/Baylor Outreach site:

    Other providers frequently involved in work with family and individual care include the East Dallas Health Center, Church Health Ministries, University of Texas Southwestern Medical School Women's Clinic, Parkland Memorial Hospital, Children's Medical Center, and private physicians in East Dallas. Care is continuous between students across semesters. Faculty provides care in summers. Top

    Community-Oriented Services

    Community services currently underway include community assessment, immunizations taken into the community, women's health services, parish health, and community development. These are not one-time projects! They are ongoing community care activities that, over time and with reinforcement and repetition, will change lives. Each is summarized below.

    1. Community Assessment: Assessment of the community is services-based. In other words, we assess the community and its resources through the process of delivering services. We also use biostatistical data, but to a lesser degree than direct experience in the community. As noted earlier, this community has had more than enough studying and assessment. For example, we know that nationally, Asian women under-utilize cancer screening. Should we then take a year to determine the degree to which Asian women in this community also do or do not also under-utilize cancer screening? Or, is the community better-served by developing cancer screening programs and through the process of screening determine the degree of utilization or under-utilization? The answer is obvious.

    2. Immunizations: In going door to door in the community, students assess the immunization status of every child encountered. Immunizations are given every Friday at the Police Storefront by staff from the East Dallas Health Center or Dallas County Health Department. Influenza immunizations are given in the fall. In the areas receiving care over the past two years more than 85% of children less than five years of age are current with immunizations.

    3. Women's Health: In addition to the already described outreach and assistance with family planning and prenatal care, students have planned and implemented six cancer screening events in which a portable mammogram unit is set up in the Police storefront and women who otherwise would be highly unlikely to ever receive a mammogram come in for free screening. Along with mammograms, students teach breast self-exam one on one with the women, screen all participants (and anyone else who comes in the door) for other health problems (e.g., diabetes, hypertension, colon cancer, HIV), and provide follow-up care for all problems. Except for operating the mammogram unit and HIV testing, students are responsible for all aspects of the screening. In the fifth event an additional 14 complete physical exams (Pap, CBC, etc.) were provided for high-risk patients. We are currently following up on compliance with BSE.

    Women Screened in Six Mammogram Events: Ethnic Breakdown

    African-American

    18

    Anglo

    10

    Khmer (Cambodian)

    38

    Hispanic

    45

    Laotian

    25

    Native American

    1

    Vietnamese

    41

     

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    Total

    178

    Sarath was a 15 year old Khmer girl in a dangerously abusive relationship with an older man. After initial failures in intervening, students, police and a child welfare agency were finally able to help her move back to her mother in California. Students first made contact with her when she was helping translate for an older woman at one of the mammogram events.

    In areas receiving care over the past two years than 80% of women desiring birth control have obtained and understood viable means of preventing pregnancy, i.e., these women are compliant with oral contraceptives or other means; and more than 75% of pregnant women have received prenatal care by the second trimester of pregnancy. Cooperating agencies in these women's health efforts include the East Dallas Health Center, UT Southwestern Women's Clinic, American Cancer Society, and St. Paul Medical Center Missions at Your Service.

    4. Spiritual Care and Parish Health: One of the underutilized resources identified in our community work were the churches. (Picture: Class at Brady Center) Students made contact with Pastor David Thorp at Emanuel Lutheran Church and obtained his agreement to work with us one day/week. At the same time this relationship was being established, we initiated contact with Dallas Theological Seminary, a heavily academically-oriented seminary near the community. From the seminary contact, several faculty and student volunteers emerged. Thus we had available sources of spiritual care in a community that in many respects is spiritually bereft. The seminary students and faculty have also been enormously helpful in transportation and related activities. Currently, spiritual care is provided by our Chaplain, Alison White, from Common Grace Ministries.

    As a result of work with David Thorp, we developed a relationship with a group of Hispanic women, the "CoMadres," at one of the elementary schools in the community. With the CoMadres, we developed our first lay health promotion curriculum. The curriculum has been expanded (more needed) and is now being used at the Brady Center, a Catholic Charities community center.

    5. Community development: In all aspects of working in this community, whether with individuals or as part of community care, students affirm and strengthen the community's ability to grow and care for itself. Many referrals to people in need come from people with whom students have worked in the past and who have learned basic health measures from the students. There is a small corps of volunteers and a strong network of concerned individuals whom students helped equip to reach out and more effectively help their neighbors. Rather than depend solely on caseworker/translator services (which sometimes become patronage systems), relatives, neighbors, and friends assist with translation, transportation, and other such services when feasible. Existing community groups are used to assist and promote health as much as possible. For example, the Scouts sponsored by the Dallas Police help publicize and carry out the immense effort necessary for successful mammogram events. We are currently working on developing alliances with community organizations and churches to strengthen this and other aspects of services. Top

    Challenges and Problems

    Follow-up and evaluation is a constant challenge. For example, follow-up and measurement of proficiency and compliance with BSEs shows a low level of compliance. We intend to increase efforts to teach BSE at the initial point of contact (mammogram) and redouble efforts to reteach on scheduled follow-up visits. Despite extensive cultural orientation, it is sometimes difficult for students and clients to reach across vast cultural and experiential differences. The greatest structural problem we face is coverage during summer months when the community health course usually is not offered. Picture: Is this student confused?

    Gregory M. is 41 years of age and has severe congestive heart failure and related complications. When we found him, he had no source of health care and could be classified as a complete cardiac invalid. He is now a patient of the East Dallas Health Center. We see him weekly to monitor his condition and teach self-care. He is able to walk without assistance for increasing distances and is compliant with medications. Diet remains a challenge. All his blood relatives > 30 years of age have hypertension. We are working with the family to make lifestyle changes to decrease their cardiovascular risk. Top

    Summary

    This program was designed and has evolved for the specific purpose of addressing the health care needs and problems of a community that - despite the relatively near presence of several health and social service providers - remained significantly under served. The program is driven and defined by human needs. Through meeting the needs and priorities of the community, we are able to gradually introduce services directed to health promotion and disease prevention and early detection. Rather than students coming into the health care system and working as students (whose work would be done whether the students were there on not), students in this program provide services that would not otherwise be provided. Picture: Kachin woman newly arrived in the U.S.

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    References

    Abramson, J.H. (2002). Cross-sectional studies. In R. Detels, J. McEwen, R. Beaglehole, & H. Tanaka (Eds.), Oxford Textbook of Public Health (pp. 509-528). Oxford: Oxford University Press.

    Anderson, E.T. (1991). A call for transformation. Public Health Nursing. 8, 1.

    Fournier, A.M. (1999). Service learning in a homeless clinic. Journal of General Internal Medicine, 14, 258-259.

    Top Or Back to Refugee Health or Asian Health

    Author: Charles Kemp, FNP-C. From papers presented at the American Public Health Association, Texas' Fifth Minority Health Conference, and Community Partnerships in Health Professions Education: A National Conference on Service-Learning.