If health care is a small part of health, how does a safety net hospital adapt?

At one of the busiest public hospitals in the nation, doctors have learned that to heal a patient on the inside, they must understand the patient’s world outside the exam room.

What kind of neighborhood do you live in? Are you buying healthy food? How are you getting to work? The questions are meant to uncover the root causes of what bring men and women into the Adult East Primary Care Clinic at the Los Angeles County-USC Medical Center, just east of downtown L.A. Once that screening takes place and a doctor understands how a patient's health is impacted by homelesses, lack of nutrious food or trauma, a team of providers is ready to help. Nurses, social workers, community advocates, nutritionists, mental health specialists, medical students, and volunteers are ready to link a patient to, say, food stamps or psychological care, said Dr. Jagruti Shukla, director of primary care at LAC+USC.

"One important thing is team-based care. We cannot do this alone,” Shukla told a group of 22 journalists from around the nation. The journalists were touring the clinic as part of the 2018 National Fellowship.

“We see a diverse group of patients with multiple needs and with complex backgrounds,” Shukla said. “No longer can one physician take charge. We liken this model to an orchestra and each person is special in what they do, to care for each person.”

The movement to understand what shapes a patient's well-being outside a medical center isn't new. The concept has gained momentum nationwide as physicians, hospitals and insurers look for efficient ways to save money and improve health outcomes. But it means changing an outdated medical care model, Shukla said. That means instead of waiting for patients to come to hospitals in crisis mode, doctors, social workers and navigators are calling homes or using apps to reach out more. And physicans are being trained to dig deeper into “social determinants” — factors such as a patient's employment status, their housing situation, literacy levels, access to nutritious food, social interaction and quality of health care. Studies have found that social factors are responsible for 60 to 70 percent of health. By comparision, the health care delivered by physicians has only a 10 percent impact on life expenctancy, Shukla said.

It was one of Shukla’s own patients that taught her how powerful life experiences and exposures can be in shaping a person’s health. As a young physician in San Mateo, California, one of Shukla's patient's continually struggle to manage his diabetes. She'd see him every three months, and at each visit, his condition hadn't improved. He wasn’t taking his meds. One day, she had a little extra time, and asked him to tell her a little bit about himself.

He told her he was a survivor of Lebanon's civil war, which stretched from 1975 to 1990. One day he was out with a friends at an outdoor cafe when bombs dropped all around them. He remerged from the rubble to find all his friends dead. He ran home and saw his house destroyed, his wife and children killed. 

“Here was a person whose world view is one of ‘anything can be taken from you at any given time,’” Shukla said. In his mind, he didn't care if his diabetes led to an amputation, because he thought he wouldn't be around much longer anyway, she said. His story was a epiphany about the importance of seeking deeper answers instead of only focusing on the illness, she said.

“I wasn't getting at the root cause,” Shukla added.

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2018 National Fellows hear from Dr. Jagruti Shukla, director of primary care at LAC+USC.

That’s why the adult clinic has adopted universal screening, where every patient gets asked questions related to social and behaivorial health issues. The model was recently expanded to include the hospital’s pediatric and geriatric clinics.

“The areas (of concern) that seem to be rising are in mental health, food and housing insecurity,” said Dr. Monika Alas-Segura, a pediatrician and medical director of the pediatric primary care at LAC+USC.

The recent political climate on immigration has triggerd an escalation of mental health concerns, and the rise of social media has made bullying an even bigger problem.

“We've defintely seen children present with anxiety,” Alas-Segura said. “It can start with: my stomach hurts. But when asked, they'll say ‘my dad just got deported, or my mom is worried about being deported'.”

She said she sees many young patients with asthma, and has had to write countless letters to landlords asking them to change carpets where smokers once lived, or to eradicate roaches from dwellings. Families too poor to move often just endure bad conditions, she added.

A recent survey found that 54 percent of all Los Angeles County residents feel stressed over the high cost of housing.

In addition, almost one million residents remain uninsured in the county. They are mostly  undocumented immigrants who do not qualify for federal or state subsidezed health insurance. Los Angeles County, along with other counties across California, offers some local, subsidized care for them, but not everyone is enrolled. 

One way to help patients connect with services available is through the hospital's Wellness Center. Opened in 2014, the center houses 15 nonprofit organizations, including Alma Family Services for mental health needs, East Los Angeles Women's Center for those victims of domestic violence, and Neighborhood Legal Services of Los Angeles County.

The center is located inside the LAC+USC’s original building, known as General Hospital, which opened in 1923.

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Dr. Janina Morrison directs the Wellness Center at LAC+USC.

“This place is really unique,” said Dr. Janina Morrison, medical director for the Wellness Center. Navigators are placed throughout the hospital — including the emergency department — to steer patients who need more than just medical care to the center.

Each week, for example, the center distributes 2,000 pounds of healthy foods to patients in need. About 500 patients use the center regularly, Morrison added.

“As a physician, it is scary to ask a patient about something I can't do anything about," Morrison said, which is why the services the center provides make it easier for doctors to ask about those deeper issues.

Data collected by the clinics are showing some early results. In one clinic, of the patients who screened positive for food insecurity in the last six months, 18 percent of were enrolled into CalFresh, the state's food stamp program. Another 43 percent were referred to The Wellness Center or food banks. Physicians also saw a decrease in blood pressure rates and better control of diabetes among patients who saw social work or mental health providers, said Dr. Barbara Rubino, assistant primary care director at LAC+USC.

Lidia Cetz, a mother of four, said that despite the distance from her home, she routinely travels with her kids to LAC+USC. Cetz drives more than 70 miles from a rural part of Palmdale. She brings her daughter, Gloria, 8, who requires a special wheelchair, and her son Marco, 18, who also uses a wheelchair, for care. Both children have special needs. The hospital has connected Cetz with key services and allowed her to access different providers all in one place.

“These (children) are like my gum, my chicle,” Cetz said while visting with her children's pediatrician recently. “They have to be with me. I like this place, because I can have everything I need for (Gloria) in this unit.”

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