159 – What is a Medical Home?

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Dr. Sandra Morgan and Dave Stachowiak talk to Dr. Ron Chambers about the importance of teaching physicians proper patient care systems for trafficking victims in order to build better medical homes.

Key Points

  • Few medical students receive human trafficking training.
  • We need to meet the need of the patient population not just in the first days or weeks, but long term.
  • Community agencies are often wary of bringing victims to medical providers because they are afraid the victims will be re-traumatized.
  • Many victims leave safe houses because the environment is so unfamiliar.
  • You need to be able to meet victims where they’re at. Do they need physical help or mental health services? We must be prepared to provide both.
  • Young men and boys are an underserved trafficking victim community.

“The physician education, training, and development of a human trafficking victim medical home developed at the Dignity Health Family Medicine Residency Program has been conceptualized and implemented with incredible success.  We hope to spread the concept to residencies clinics throughout the country and standardize human trafficking victim and survivor care in physician education and training across the country. It is a viable solution with the potential to synergistically provide widespread healthcare that coincides with training the physicians of tomorrow to recognize and treat this vulnerable patient population.”
—Dr. Ron Chambers


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Dave: [00:00:00] You’re listening to the Ending Human Trafficking podcast. This is episode number 159, What is a Medical Home? An interview with Dr. Ron Chambers.

Production Credits: [00:00:10] Produced by Innovate Learning, maximizing human potential.

Dave: [00:00:34] Welcome to the Ending Human Trafficking podcast. My name is Dave Stachowiak.

Sandie: [00:00:39] And my name is Sandie Morgan.

Dave: [00:00:41] And this is the show where we empower you to study the issues, be a voice and make a difference in ending human trafficking. Sandie, each episode we work to bring something that’s most relevant to our listening community or to bring a guest that will really help us to expand our knowledge. And today is no different. I’m excited

Sandie: [00:01:05] I am too, Dr. Ron Chambers is a program director DIO at Family Medicine Residency Program Chair and his work at Mercy Family Health Center and Mercy Human Trafficking Clinic is to me just very cutting edge and it’s emerging best practice. So, we want to welcome Dr. Chambers to Ending Human Trafficking.

Ron: [00:01:30] Well, thank you for having me.

Sandie: [00:01:32] OK so one of the quotes that I have from you that was kind of a catalyst that made me want to go and see what you were doing, so I actually went and visited Dr. Chambers in Sacramento when I was up there for the California Sociological Association conference. And he said, “the physician education, training, and development of a human trafficking victim medical home developed at the Dignity Health Family Medicine Residency program has been conceptualized and implemented with incredible success. We hope to spread the concept to residencies clinics throughout the country and standardize human trafficking victim and survivor care in physician education and training across the country. It is a viable solution with the potential to synergistically provide widespread health care that coincides with training the physicians of tomorrow to recognize and treat this vulnerable patient population.” And so, can you expand on that? That inspired me so much.

Ron: [00:02:47] Oh well thank you, Sandra. I do think the idea is a viable construct for providing care to this patient population. I became involved with work with human trafficking victims and survivors a few years back after Dignity Health the hospital system I worked for launched an initiative to take on the issue of human trafficking. And they have spent millions of dollars and we’ve spent thousands of hours training the workforce throughout the 43 hospitals in our system and creating a system-wide effort where the hospitals and the personnel working within the hospitals have been trained on human trafficking and to have an approach to patient care that is victim-centered and trauma-informed and survivor lead with Holly Gibbs being the program director for the system. I feel very fortunate that we were involved early on in that initiative and helped write the protocols and be a part of the work that was being done. But what was interesting pretty early on is we recognized that when we were identifying patients when we are identifying victims within the hospital setting we were dealing with people that of course had in days, weeks, months, years, even decades of trauma and abuse. And the protocols themselves were very effective at enabling us to help these patients get removed from trafficking situations and connected with the resources, and law enforcement, and safe houses, and case management services. But there really was an ongoing need for longitudinal medical care. And so that’s what we really focused on addressing at least at Mercy Family Health Center And within our residency program was creating a system within the clinic that could meet the needs of this patient population not just in the first 24 hours or first week but over the course of years and their lifetimes. It really has made enormous success for perspective over the last eight to 10 months since the beginning of the new year January 1st. We’ve seen approximately 110 new trafficking victims within our center.

Sandie: [00:05:07] Wow.

Ron: [00:05:07] And I think our average number is average across the board on there is about four to five clinic visits per patient. So that’s four to five hundred office visits within our center. And I really believe that putting this within the residency education makes sense.

Sandie: [00:05:28] When I read that quote the first time I was reading something online, I had just learned about what you were doing. And I come from a medical background although I haven’t been active in acute care, our listeners know I’m a nurse. But I was really excited about the idea of a medical home and it was really embarrassing when I arrived to visit you and realized that I didn’t even understand what a medical home was. And the more I thought about it, after learning so much from you in just that hour that I spent there, the concept of a home of always knowing you can go back there. That’s part of the success with developing relationships with victims and survivors because they can always come back. That you’re now using technical terminology longitudinal care or services and expand on why that home concept is something we need to integrate into our normal everyday health care strategies.

Ron: [00:06:38] Well there’s the terminology that is borrowed from patient-centered medical home, which is a concept that has been pushed in primary care over a number of years, the last decade really. It’s a patient-centered approach to providing care and there are lots of facets that are incorporated into it. I think that the real benefit of having a center where victims and survivors can come, that caseworkers and the different organizations within the community can come to and use as a resource is incredibly important. When we first started doing this and began connecting with the community agencies what we found was that so many of them were lacking the ability to bring people they were working with their victims to a medical provider for fear of re-traumatization, which was kind of the common scenario and story that we heard. And so, by hearing their stories and learning what their needs were, we created an approach where it’s basically everybody from like the janitor through the front desk staff, all of our nurses, medical associates, everybody’s gone through extensive human trafficking training and victim center trauma-informed care. So, we created a different approach and perspective in working with this patient population, we have completely different workflows back lines, different ways that we approach the patient care. And it’s just working so well, the feedback that we consistently get from especially the various community agencies. And there are a million great ones in Sacramento, there’s Communities Against Sexual Harm, City of Refuge, My Sister’s House, Chick’s in Crisis, the list goes on and on.

Ron: [00:08:36] Let me use this analogy. So, I think about patients that come into our clinic. So much of their life has been about abuse and trauma. And I think of it as it’s almost like they’ve lived a life of pedal to the metal, foot on the gas. And you take somebody like that and you get them into a safe house. And now that night you know they’re hearing crickets and e can use medications, we can use some Prazosin and take away their nightmares at night, we might use a little bit of mood stabilizers that are going to help them sleep and take away some of the liability. And what we find is that everybody thinks OK we’re treating STDs or gynecologic problems and that is a small piece of it, but a large component is addressing other needs treating things like this lot of exposure risk for tuberculosis. There’s a lot of lack of immunizations because of the backgrounds of many of these individuals have come from. And so, by addressing the needs of the patient as a whole and especially the psychological needs, we’ve found that we can get them a day into the safe house, and then we can get them two days, and then a week, and then a month. And now the community agencies have a chance to really work with them and provide the trauma therapy, and the case management services, and the parenting classes. You know and the 99.9% of what needs to be done for this patient or this victim, and really turning them into a survivor you know putting them on a road to recovery. So, the medical piece, what I see it as at least, in a longitudinal setting like this is being able to meet these patients with the right perspective where they’re at being able to address their needs long-term and then really collaborating with the community agencies so that we can we can see more and more individuals going on that road of recovery. And that’s the feedback that we’ve gotten over and over as they say you don’t understand this, this is the game-changing piece for us, this allows us to keep people within our facilities. And you know it’s wonderful to hear that stuff but it’s also very frustrating that as a residency program director, I’m an applicant interview season right now. So, all I’m interviewing over the course of the last couple of months are 100 medical students and I always ask them, “Have you had any medical or have you had any human trafficking training within your medical school.” And I’ve had two people so far this year say yes. We’re talking about just a complete lack of knowledge and understanding and education within at least physician workforce on this issue. So really that’s part of what we’re trying to change to is incorporate this into residency education.

Sandie: [00:11:38] So how many residents do you have every year?

Ron: [00:11:43] 21.

Sandie: [00:11:44] 21. So, when they complete their residency with you, you send them out to 21 different new jobs and they take all of this training and it becomes part of how they serve their patients.

Ron: [00:11:59] Absolutely. So that’s a huge component of it. If you think about the ripple effect of putting this education and training into residency programs, what that means is you create a workforce from the ground up of physicians that have some understanding of the issue I mean my residents, every one of them that graduates have taken care of a number of trafficking victims. They’ve you know been there for them when they’re in labor and delivery, they’ve delivered their babies, they’ve taken care of them in the ICU when they get sick or you know recidivism and they end up beat up. We see them all along the road in their path, and it really does create a sense of awareness. And there is a competency level that at least in my opinion that they’re getting out of this residency with and addressing this patient population.

Sandie: [00:12:55] The parallels for me in higher education is the high value we have for experiential learning. And we try to create those opportunities so going in and doing a two-hour introductory training at a hospital is not going to have a huge impact. So, the potential for significant change nationally is huge with this approach.

Ron: [00:13:21] I completely agree with that. And it’s an interesting thing. You know I have been giving a lot of talks on this around the country and at various medical groups and you know traditionally I’ll have a couple of senior physicians come up and show a lot of interest. But it’s a different beast trying to convince somebody in practice for 25 years that they’ve been missing this and that this is something that we need to take on. It can happen, but again the residents there at the prime time of their career to really determine how their future practice is going to play out. You know we train a resident, now we have somebody in practice for 30 years that’s going to be addressing this issue. And I you know I look across the country at the various organizations working on this and people are doing wonderful work. And it’s you know it’s on inspiring places that are run through huge grant funds and have these dynamic teams working with human trafficking victims and survivors. But I think a lot of them there’s drawbacks right. They may have a very high utilization to create a center like that, they may they be able to do it, but then they’re not really spreading the word or training all the other physicians or medical providers around them.

Sandie: [00:14:43] And when the grant runs out, is that sustainable? No.

Ron: [00:14:47] Right. And so, if you look at just family medicine alone, and you know I think you could potentially through in pediatrics and OBGYN and lots of other primary care specialties, but in family medicine alone we have 537 residency programs in this country. That’s 537 guaranteed clinics that could incorporate this care, this education, and this training. It’s a very small increase in utilization at least from our experience. And if we do it, then concurrently we have a physician educated workforce in the future and people that know how to address this issue. So, it’s a very low utilization viable construct for widespread care that also trains the positions of tomorrow to be able to address it. So, it just makes sense.

Sandie: [00:15:38] And I get so excited, I keep interrupting you. 537. And so one of the things you’ve not only done this, but you’ve created a manual to replicate the model in ten steps. So, talk about what that provides and how to access it.

Ron: [00:15:56] Sure. If you don’t mind, I’m just going to step back a little bit from that. I do think that it’s really important that if somebody wants to implement this education and training if they want to take on this issue they really need to go into it with a good framework because I think you know the terminology used very often is the rescue fantasy where we want to help somebody. I mean that’s why we went into medicine. But if we don’t have our systems built ahead of time, if we don’t have our protocols in place I think we definitely have the potential to cause more harm than good. So, you know we see somebody and we say well this is an awful story you’re telling me, we want to get you out of this. Well, what if they’re traffickers in the waiting room with a gun you know or what if there’s no safe house and it would if there are no rooms available. You need to know, and problem solves those issues ahead of time, you need to have the relationships identified ahead of time with law enforcement with many agencies. And so I feel very fortunate that at least Dignity Health, the hospital system I worked for, and then Holly Gibbs is the program manager for the human trafficking response program created these wonderful protocols that exist within our hospitals that are free to download. You can google Dignity Health and human trafficking and it will take to the webpage and you can download the Shared Learnings manual, and their protocols that I’ve already worked with hospital systems and I’m working with one in the Bronx and another in Florida just adopted them and they’re very user friendly and hospitals can use them to create this system ahead of time. Then we can take on the patient population. The protocols that I’ve created for the outpatient center are probably easier to apply widespread because they don’t necessitate everything that’s within the inpatient acute care protocols, but they do exist for residency programs as well and that’s what we wrote up. So those combined with this ten-step procedural manual, I think really make it very simple to replicate this care. I would estimate that any program that wanted to take it on if they have an interested party that wants to lead the charge could do this within about a 1 to 3-month timeframe. And it would be very doable. So, these community agencies. You know just change the names on it. So, all of this stuff exists within Word documents so that it’s very easy to modify for different locations to use. And that’s something that I definitely would like to share with other programs.

Sandie: [00:18:58] Well, I’ve already downloaded it and went through it and was ready to leave my job at Vanguard and go find a place where I could just lead the charge on this. And of course, that’s not realistic, but I believe that there will be people who hear your podcast here that will download this and that we’ll see more champions rise to take this on and they’ll have the tools ready to do that. And a big shout out to Holly who was one of the very first people that we interviewed on this podcast and we use her Walking Prey book in our class. And so, it’s kind of fun to go full circle and see how far her work has gone as a survivor leader, so big shout out to Holly. Do you serve minors in this program? That’s always a big question from people.

Ron: [00:19:55] We do, we serve minors, we serve women, we serve men, we serve both sex and labor trafficking. We’re trying to reach out to certain patient populations. Unfortunately, young men and boys tend to be a population that doesn’t have as many community organizations or agencies specifically working with them. We’ve done things like we’ve reached out to the LGBT community center here in Sacramento to try and access that patient population. We can network with them to try and get some of those patients and that I think are otherwise being missed. The labor trafficking is one that we’re growing right now. But if you wouldn’t mind, I would just step back really quick to what we were talking about as far as spreading this. And I do want to mention that Mercy Foundation has been phenomenal as far as supporting us and helping us get the word out and in collaborating with us. And the next step we’re working with Mercy Foundation to do here in Sacramento and actually at the corporate level as well, is I’m in the process of hiring a program manager for this medical safe haven or medical home that we’ve created to replicate it within about ten residency programs within the Dignity Health System over the next 18 months to two years. Now I’ve actually already gone and trained the residents that I think eight of the programs so far up and down California. And it’s amazing. You do a training like we did a training in St. Mary’s a few weeks back and within I think five or six days they identified two victims, they had never identified a victim before and they had two within less than a week just by having the knowledge in place. And again, then the fallback is we also have the protocols built and in place, so those victims have the chance to get recovered from those trafficking situations in a safe way. So, as we’ve gone through and trained these programs now the next step is this position that I’m hiring for, this person is really going to work collaboratively with the community agencies to network them into these different residency programs. The argument that I’m trying to make, and I actually did a study when I trained the residents just a real simple stupid study assessing their skills knowledge and attitude on human trafficking victim and survivor care which obviously increases after you give them a training. Once we’ve gone through and done this training and we show evidence that it improves skills, knowledge, and attitude and then we’ve implemented this type of care in eight or ten medical residency clinics up and down the state of California. Then I think there’s a strong argument to be made that this care could be spread nationwide across residency programs. Now concurrently you know we’re trying to do a lot of other stuff I was trying to get a joint commission to mandate. You know I was working with the work group to try and see if we could get the protocols and different things mandated for hospital systems. There’s a lot of other side projects we’ve been working on, but I really think and I’m passionate about the idea of putting this into primary care medical education and residency training. I think that would really take us a long way in at least addressing the medical needs of this patient population. But that just intertwines with all the other parameters that go into again put in this patient or this person on a path to recovery.

Sandie: [00:23:30] And that is our ultimate goal we are victim-centered, patient-centered. And I think one of the things that I heard you say in person and I want to make sure listeners here understand the incredible value of situating this in a residency program is twofold. One, it’s replicating the knowledge base in the profession as a physician and sending it out, instead of training in one spot and keeping it all in one spot. And then secondly, can you speak to the issue of the financial benefits of situating it in a residency?

Ron: [00:24:11] Sure. So almost across the board family medicine and primary care residency programs are going to have medical clinics where the residents trained that are inherently built to treat vulnerable patient populations, so they already have a lot of capabilities to meet the needs of people that are underserved. Most of them are going to be operations that aren’t big for-profit moneymakers for the hospital or the institution they’re working at. They tend to be a community service-oriented part of a hospital or program setting. And so, what you already have is establish clinics taking care of vulnerable patient populations with a very flexible workforce and that can be tailored to the residents’ education to meet the needs of the patient. So, putting this into clinics such as ours quite honestly the biggest thing is we write off a few of the first visits and then we get them enrolled in Medical or Medicaid, and then they just become another patient at our clinic that is not losing us money. But I guess to speak to the financials just bigger picture it’s a very small utilization increase for us. It doesn’t really the biggest hit was when we shut down the clinic for half a day and put all the staff through the training. But after that, there’s not a loss necessarily for us being able to take care of this patient population. We do some things like when we do intakes for new patients we schedule those appointments an hour, sometimes even hour and a half we put them at the end of the day so that they tend to be a little open-ended. But we also put them you know right before lunch, different places so that we can meet the needs of the patient. But that’s no different than if I was putting a cast on someone’s arm or there are certain appointments that take longer. And so, we just put them into our system and the workflow that it is similar to that.

Sandie: [00:26:15] Well Dr. Ron Chambers, you have so much knowledge to share with us. And I know that you have to go to that clinic like right now. But before we hang up I want to invite you back because I have a lot of questions and I’m sure that many of our listeners do so you can send those questions to gcwj@vanguard.edu. And we’ll collect those and invite you back. Will you come back?

Sandie: [00:26:42] Absolutely. And one last thing Sandra, can I just throw out there that we also are advertising right now for a position for a fellowship in human trafficking. And this would be a physician position. So, you would be a medical doctor that will be very involved with taking care of this patient population, incorporating group visits, creating evidence-based practices, and helping us work with the spread of this concept to another residency program. So, I’m hiring for that position as well and I’m excited about that. I don’t know if there’s any other fellowship for physicians that exist in human trafficking as of now, but we definitely have the patient volume and I believe the experience and it would be something that the right person could really, I believe take this to the next level.

Sandie: [00:27:33] Well we will definitely get that out there and share this podcast with lots and lots of our community. Thank you so much for giving us your time this morning. And we look forward to talking to you again.

Ron: [00:27:46] Thank you, Sandra.

Dave: [00:27:49] Sandie, so many exciting things that they are doing in Sacramento on this. Every time we have a guest on this awed by all the different ways we’re addressing this issue. And if you are listening maybe for the first time I hope that you will take a moment to join us on the endinghumantrafficking.org website. It’s a great place to go to get on our e-mail list so we can keep you up to date on what Sandie is doing and also the work of the Global Center for Women and Justice. And don’t forget the Ensure Justice annual conference is coming up March 2nd and 3rd 2018 you can register now by going to ensurejustice.com. And Sandie I’ll see you again in two weeks.

Sandie: [00:28:37] Alright. Thanks, Dave.

Dave: [00:28:39] Take care everyone.

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