Connecting Childhood Trauma and Diabetes

Research shows that those who experience trauma as a child have a greater likelihood of developing chronic health problems as an adult: diabetes, heart disease, COPD, and more.

Adverse Childhood Experiences – or ACE’s – refer to trauma that happens before the age of eighteen. Since the nervous system, hormonal system, etc. are all in development at these ages, they are more vulnerable to lasting damage from trauma.

As our CEO George Jones explained, “We have long known that early experiences of trauma— whether from physical violence or the complex suffering caused by poverty and racism— negatively impact a person’s whole health.”

TRAUMA-INFORMED PRIMARY CARE INITIATIVEAnd that is why we are proud to be one of fourteen community groups working with The National Council for Behavioral Health on the Trauma-Informed Primary Care Initiative. As part of this initiative, we launched a new trauma-informed care pilot last July to provide behavioral health supports to 50+ patients with uncontrolled diabetes.

The goal after nine months is to screen these patients for early trauma, and provide those who screen positive with case management support and brief, ego supportive therapy that teaches coping skills. The hope is that this trauma-informed behavioral health treatment, along with social services that help patients address their most basic needs, will help patients manage their diabetes. These efforts will also help Bread’s medical clinic explore additional ways that we can integrate a trauma-informed approach throughout the clinic–from front desk staff to doctors. And if it goes well, we will expand the model with a goal of universal screening of all our clients.

And beyond the life-saving care for the patients being treated, there are potentially significant cost savings to the larger health system when appropriate, comprehensive, and accessible care is provided to survivors of trauma. CNBC highlighted these findings in their January 21, 2016 piece, “Can treating past trauma lead to big US health savings?”

Cost savings aside, we are excited for what we are witnessing seven months into this initiative. We have screened and educated more than 50 patients on the impact of childhood trauma, empowering them to begin to heal old wounds that continue to impact them today. We have also redoubled efforts to educate our staff on trauma and on ways to best work with people who have experienced early childhood trauma–including providing appropriate space for reflection and self care to mitigate vicarious traumas’ impact on staff.

You can learn more about our integrated behavioral health model on some past blog posts here and here, and can learn more about the Trauma-Informed Primary Care Initiative, funded by Kaiser Permanente, on The National Council for Behavioral Health’s website.

Our New Eye Doctor is Here!

Hey, look! That's our new eye doctor!

Hey, look! That’s our new eye doctor!

Remember when we asked you to lend your support so that we could hire an eye doctor? Well, you gave and we hired Dr. Choi. Thank you!

Rosan Choi worked at Kaiser for years before learning about Bread for the City and then volunteering here through the Prevention of Blindness Society of Metropolitan Washington.

Since starting a few weeks ago, Dr. Choi has been busy with all the ins and outs of getting a new clinic off the ground. Her goal is to start seeing patients three days a week in November with hopes to grow the clinic from there.

Bread for the City’s medical clinic has experienced exceptional growth over the past few years: We opened a brand new dental clinic, expanded behavioral health services, became a Federally Qualified Health Center, and are now offering vision services for the first time. This growth is only possible because of the generosity of our community– you all are AWESOME!

Check back soon for more updates on Dr. Choi’s work and an invitation for a ribbon cutting. Trust me–this will be a sight to see. (Sorry, I couldn’t help myself.)

Dr. Choi with Board Member Michael Blue

Dr. Choi with Board Member Michael Blue

Bread for the City’s Vision Clinic is made possible by a community of donors, including the Aid Association for the Blind of the District of Columbia, The Morris & Gwendolyn Cafritz Foundation, and CareFirst BlueCross Blue Shield.

This new clinic is possible because of BFC’s 2011 Medical Clinic expansion, which was primarily funded by a generous grant from the District of Columbia Primary Care Association through its Medical Homes DC Capital Projects initiative, which was funded by the DC Government.

Northwest Center Honored at Preservation Awards

The District of Columbia Historic Preservation Office/Office of Planning presented Bread for the City with a Design and Construction Award for our expanded 7th Street Center at the Ninth Annual Awards for Excellence in Historic Preservation on June 21st. Obviously, we didn’t do this alone. Awarded along with us were Weibenson and Dorman Architects PC, S3E Kilngemann, Inc., JGK Structural Engineers, Heller & Metzger, PC, and Turner Construction Company.

Bread for the City moved into 1525 7th Street in 1994. Before then the building was a former lumber warehouse. How cool is that? Quite cool according to the DC Historic Preservation Office who landmarked the building a few years back. This distinction did make expanding the facility by 11,000-square-feet back in 2010 a bit tricky, but apparently the DC Office of Planning liked how it all turned out. We’d have to agree.

We are pleased as punch to receive this award; however, we knew we nailed the project when a client exclaimed: “This new building takes the breath away. Folks always knew that they had a friend in Bread for the City. Now, they have a home.”

View photos of the Ninth Annual Preservation Awards and our new Northwest Center on our flickr feed. Want your own personal tour? Email and we’ll get in on the books.

Bread for the City’s new 7th Street facility was the first major completed project of the DC Primary Care Association’s Medical Homes DC Capital Projects initiative, which is funded by the Government of the District of Columbia through grants from the DC Department of Health (DOH); the DOH grants provided 75% of the financing for the new facility.


One step forward, two steps back: this time healthcare coordination

Disclaimer: This is an acronym-laden zone. Please proceed with care.

Sometimes we aren’t very good about celebrating our successes. That feels especially true right now in the sad story of the DC Regional Health Information Organization, which only just recently launched and is now, suddenly, suspended. (See this reporting in the Washington Business Journal to learn more.)

The DC Primary Care Association’s ambitious plan was to use the DC RHIO to coordinate the provision of health care services across the regional network of hospitals and specialists and community health clinics like Bread for the City. The goal was to achieve — through established channels of shared information — better patient-centered medical care with fewer errors, greater cost-savings, and protection for the most vulnerable people in our community.

It is a beautiful and exciting vision. In our unfortunate current reality, there are many separate data systems across the city, even within a single organization (like a hospital for example), that all track different pieces of care, without the ability to talk to one another. That makes for seeing a whole health picture very difficult. Think of it this way: in the 21st century, we can access all the world’s information from gadgets in our palm, but when we go to a neurologist or the ER, our doctors don’t have access to our primary doctor’s most recent labs and notes. James Turner of the HealthIT Now Coalition draws a parallel, “It’s as if we live in a time when someone with a Verizon phone can’t talk to someone with AT&T service. But this is healthcare!”

Consider the following scenario that our Dr. Randi lays out: “Say a patient of ours had a heart attack or a stroke. They have just been released from the ER, and they are confused and distressed. They might have no idea what doctors they saw, what tests were performed, or even the outcome of the visit. With a Health Information Exchange, we [providers] can look that patient up in the system, see lab results, medications prescribed, pathology reports, discharge summaries, and we can begin to piece the picture together for the patient. When we can help in that way, the patient is relieved and more informed and we can give them better care with less redundancy and run-around.”

And perhaps the best reassurance that we were doing the right thing with the RHIO: patients were behind it. When we would tell Bread for the City patients that we would be sharing their information with other providers in the RHIO, the response was often “Aren’t you doing that already?!” After all, that’s what quality healthcare and meaningful use of technology is all about, right?

While small at first – six early-adopter clinics and a few hospitals – the big vision for the RHIO entailed the interconnection of every point of contact in the whole system of care in the Washington DC for all the city’s patients.

So why then, if the project was underway, did the District halt the development of its Health Information Exchange? I don’t really know for sure, but I think it’s safe to say that it involves politics and money.

If the RHIO is not saved, a considerable amount of investment will go to waste — and the potential value will be lost. The District has announced the pursuit of a bare bones Direct Project model, instead of a more robust HIE – but this feels a little like salt in the wounds. This Direct Project is essentially just a protected email service — while it serves a function that could be integrated into a bigger HIE system, it falls far short of the comprehensive data sharing necessary to improve care.

Now what? Rather than lose years of progress and millions of dollars which put DC at the cutting edge of health information  technology, we think DC should reconsider this new direction. The DC RHIO is an investment worth protecting. Let’s ensure the effective implementation of the health information technology initiatives that we need to modernize our healthcare system. The State Health Information Exchange is really a valuable public utility — so the Mayor and City Council should be committed to identifying budgetary solutions for next year and beyond. We need $3,086,000 to be funded to DCPCA through the Office of the Chief Technology Officer to save DC RHIO. Please contact the Mayor and your Councilmember today and ask them to invest in our city’s health.


Electronic Health Care: Just Doing It.

–by Julia Eddy, Bread for the City’s new medical clinic operations coordinator!

Before Bread for the City started the expansion of our medical clinic, we’d already completed the implementation of an electronic medical records system. And that puts us ahead of the curve! See this article in today’s Washington Postabout how few health practices are adopting electronic medical records (EMR), despite considerable financial incentives offered by the federal government and efficiencies to be gained by the technology.

Of course, we’re still new to the field — and always looking for fresh eyes and friendly advice. So we were delighted to recently receive a visit from Dr. Ted Eytan, whose research focuses on the potential for health information technology to empower healthcare providers and patients alike, especially through preventive practice in communities that suffer from great health disparities.

Ted came by Bread for the City the other week for a tour of our new facility and an opportunity to shadow our Medical Clinic Director, Dr. Randi.

Ted wrote about the visit recently on his blog, and we encourage you to read the whole post. Here’s an excerpt:

It’s kind of amazing to see what modern, HIT-enabled medical care is like. There’s the community feel of the clinician office, with a laptop garden in the center, and clinicians following each other with electronic charts in hand with more knowledge and information about their patients (and more accountability for it) than ever.

Bread for the City is an early adopter of the eClinicalWorks EMR, as part of a District of Columbia program started in 2007. I think this makes these clinicians both more experienced about what an EHR can do, and more aware of what an EHR should and could do. That puts them in a very good position to recommend improvements to the system and I can tell a lot of innovative ideas will come from this practice. …

Indeed, we’re more than two years into our work with Electronic Medical Records — and it still feels like we’ve only just begun to really use this technology. Upon going “live” with our EMR system, we spent the first year grappling with a lot of technical challenges, including performance speed, reporting processes, software bugs, and even the way our small laptops fit physically into our doctors’ practice.

When I shared some of these challenges with Dr. Eytan, during a walking tour of our neighborhood (which he later documented in Flickr), he reassured me in a manner that every doctor knows well: “you’re normal,” he said. During any transition to Electronic Medical Records, there’s a period of challenging development as a clinic adapts to a new way of working. And indeed, now in our third year, we’ve worked through many of the bugs and snags and are starting to see some results — with reliable software performance and reporting capabilities that we never used to have.

So we’re now starting to seriously explore the potential for this health information technology to transform our practice. For one, it enables our providers to have a total picture of our patients’ current medical history (including visitations with specialists and even trips to the hospital), which helps them deliver more appropriate care. And on a higher level, with our new ability to engage deeply with data from across our practice, we will be able spot health trends that are disproportionately affecting our clients — and that, in turn, will help us develop the services that our clinic will offer in the future.

It’s all very exciting. But there are other serious challenges between where we are now and the true potential of this technology — specifically, how can our patients directly benefit from the technology if they are not capable of using it themselves?

For instance, in his post Dr. Eytan references a “Patient Access Portal,” which wouldprovidepatients with online access to their medical records, appointment scheduling, and even electronic communication with doctors. That sounds great — but we have a major amount of work to do before our client community participate in that kind of technological leap forward. And this is where our Health Resource Room and computer literacy classes come in: teaching the computer literacy skills that people need to engage with information technology. With some help from our community and friends like Dr. Eytan, we’re looking forward to a new world of possibilities.

Our New Medical Home

Today, Bread for the City welcomes the community into our expanded Northwest Center for our Grand Opening. (4pm sharp!) In anticipation, we asked our medical clinic director, Dr. Randi, to share her thoughts on the new space. (And if you haven’t already, check out the CNN-produced special report on Dr. Randi and the clinic!)

Dr. Randi writes:

When I started working at Zacchaeus Free Medical Clinic (which eventually merged with its neighbor and partner organization, Bread for the City), we worked out of a basement. And you can say that we “made do” — but of course it wasn’t ideal.

In a community health clinic, space is important. It’s one thing to be able to offer quality consultation and treatment to our clients, but it’s also vitally important to offer it in an environment that is spacious, clean and organized. Such an environment sets a tone of mutual respect, and conveys a sense of responsibility for the health of individuals and community alike.

Our original clinic was welcoming in that it felt a bit like home — it was crowded and it felt productive and high energy, if a little chaotic. Sometimes that heightened energy meant tempers would flare up due to frustration, the worry that you were not going to be heard. Many of our clients already live in overcrowded conditions that are stressful and at times unhealthy; they walk in to our clinic already frustrated, not feeling well, stressed — and they would often stand right by the desk, trying to ensure that no one would forget them. So for a long time, we knew we needed more space — and not just because we were short on exam rooms.

We serve a very heterogeneous population: babies, frail elderly, active children and adults with a vast range of health conditions. Many patients have mental illness. Some people come to us intoxicated or high. Many new immigrants speaking a variety of languages. They all share one waiting room, they all belong to this medical home.

We designed our new clinic with all this in mind. We wanted to convey a certain message about health. Here, the atmosphere is calmer, which encourages patients to think about their own responsibility in their health. The waiting room is always spacious even when each seat is filled. The children have an area that is inviting and safe — separated but at the same time part of the whole. Each exam room provides the privacy that is appropriate. The lab is off to the side. It’s all very quiet. You can see that it is less stressful for patients.

The staff was mostly hoping for updated equipment that works as it’s supposed to. And we got that; everyone is pleased. But the real surprise was the patients’ reaction to the new space.

The patients have been watching construction all through last year, curious about what will be inside. Now that they finally can come in, they typically walk up the stairs with a look of amazement and awe. From the beginning the tone has been set. I’ve noticed that people are markedly calmer and more patient; the space makes people feel good.

“I am 50 years old and you are my first doctor that knows me,” a man told me on the first day we were open. “And to see this beautiful building makes me so happy.” He has been sober for the past 8 months; he says he is tired of feeling sorry for himself and ready to go look for a job. “This is my home and I am so proud of this new space.”

I am too.

—Dr. Randi Abramson

People’s District: Dr. Randi on Finding Balance

This is the second installment in a weeklong series by one of our favorite blogs, the People’s District, an oral history project featuring the people of Washington DC. This week, the People’s District is publishing five stories of people from Bread for the City’s community, in promotion of our Holiday Helpings campaign. Many thanks to Danny Harris for this series.

Today’s story comes from our Dr. Randi!

“For me, medicine has always been a balance between helping people stay healthy and helping others manage chronic disease. I feel lucky that I have the education, skills and knowledge, and I have always wanted to help people who didn’t have those opportunities. After I did my training at Ohio State and my residency at Northwestern, I followed my husband to D.C. and did a fellowship at George Washington. I always knew that I wanted to be at a community clinic, and found Bread for the City through a woman named Eve Bargmann at GW. She brought residents here once a week and convinced me to come along one day. When I came with her, I realized that this was exactly the kind of place I wanted to work at.

“At that time, the city had a hiring freeze, so I wasn’t sure that working in a community clinic was even an option after my fellowship. While there was so much need, no one had any money and these places were struggling. When I finished my fellowship at GW, I asked the staff at Bread where should I apply for work. I knew they had a shoestring budget and probably couldn’t hire me, but thought they might have some ideas. Instead, they asked me how much I would need to make and if I could work part-time. This was back in 1991.

“One of my favorite stories that I like to tell is that they wanted me to make a two year commitment when I first took the job. My whole life had been committed between school, medical school, residency, and fellowship. I didn’t want any more commitment because I didn’t really like D.C. and wanted to be free to leave when I wanted. Well, as you can see, 19 years later, I am still here, and I still love what I do.

“Working here has made me a part of this community. I love walking here from the subway and seeing all of my clients on the street. I think that it is very meaningful to people that I am still here after 19 years and I didn’t give up on them. People constantly say to me, ‘Wow, I can’t believe that you are still here!’ For me, I stay because I love seeing patients. The ability to help people everyday makes all of this worthwhile to me. And working with the students and volunteers helps them put a face on poverty and to the issues that they read about every day.

“The health care that I do here involves a lot of time educating patients on their medical and nutritional choices in a non-judgmental way. It is up to the patient whether they take medicine or not, or if they eat healthy or not, but I want to be supportive and make sure that people have the information they need to make their own decisions. Many people here eat the foods that are easily available, even if it is unhealthy. I also think there is an eating disorder that comes with the stress of poverty, feeding your emotions. When people are stressed and feel like nothing is going their way, they look to things they can control, like eating. You may be poor, but you can still eat a cheeseburger and french fries when you want. Because of these dietary issues, I see lots of cases of depression, hypertension, arthritis, and diabetes with my clients.

“Some of my clients are very concrete. You will tell a diabetic that they should not be eating waffles with syrup and butter every morning. They will come back and say, ‘I didn’t have waffles today because I switched to pancakes with syrup and butter.’ Many of them don’t make the connection that they are the same thing. I think that people are eager to learn though, but making behavior changes remains difficult, especially if people grew up with poor eating habits.

“At Bread for the City, we have been working to make proper nutrition an important part of our work. Until a few years ago, we would host food drives and give out anything that people gave us. Even if we received donations of candy and cookies, we would use that to supplement the food bags. After some time and a lot of conversation, we realized that we needed to model good behavior and pass out food that was healthy and made sense. We now have a whole Nutrition Initiative and an adviser to help the food program, and are giving out fresh fruits and vegetables from local farms. While we have made progress in terms of our work and the food we pass out, it is always amazing to me how much work remains to be done.”


Support that work by making a gift to Holiday Helpings today! Just $29 will provide a healthful, plentiful holiday meal to a family of four.


Swine Flu Frenzy?

>This post is authored by Aviva Bellman, Bread for the City’s medical clinic coordinator.

Media reports about the H1N1 vaccination have painted a scary picture. For instance, a recent Washington Post article quoted a doctor describing “an unprecedented amount of verbal abuse” at medical clinics; another indicated that supplies are being underutilized in some parts of the city. Confusion abounds.

Some people are over-eager to get vaccinated, fearful that there isn’t enough to go around. Other people fear that the vaccine may actually be harmful. It isn’t. But this makes for a very stressful and confusing time for both patients and health-care providers.

And yet, I am happy to report that at Bread for the City, things are proceeding relatively well!

To be sure, this season is challenging: we are much busier than usual. H1N1 vaccination has significantly increased the number of walk-in visits, at times with entire families walking in mid-clinic. Vaccinations are eating up break time and sometimes keep the staff working late.

At the same time, we do not have limitless amounts of the vaccine – and according to CDC guidelines, we can only vaccinate people who fit into key vulnerable groups (including young people, ages 6 months to 24 years old; people who have certain chronic illnesses including asthma, diabetes, and HIV; pregnant women; caregivers to infants; and healthcare workers ourselves).

But I have yet to see a patient be upset when informed that he or she cannot get the vaccine. And, though some qualifying patients do end up opting out of the vaccine, we are fairly effective at explaining to at-risk patients that it is not only safe but important to their health.

This level of communication is deliberately fostered through our model as a medical home. Unlike “drive by” medical providers like health fairs and mass vaccination sites, a medical home allows for strong relationships to develop between people and their doctors. Our patients meet with staff members whom they know and trust, and who take the time to explain they people don’t qualify for the vaccine, or why it’s important for them to take it. Generally, our patients trust us in either case.

As a matter of fact, last week we received word that the DC Department of Health (DOH) “will be adjusting its current H1N1 vaccine clinic schedule, by reducing the number of free H1N1 vaccine clinic locations for priority groups in the District and increasing the amount of vaccine available at doctor’s offices and community health centers.” This means, presumably, that medical homes and other community clinics will have more capacity to vaccinate more people. At BFC, we think that is a very good thing indeed.

(For more about Bread for the City’s medical homes model, watch this video below.)

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>Who’s Honoring Dr. Randi Now?


Our Medical Clinic Director, Dr. Randi Abramson, just received the 2009 Public Health Award from the Metropolitan Washington Public Health Association. These awards are given to people who have “advanced the public health field through ongoing dedication and commitment as a public servant.” And, yes, for sure, that describes Dr. Randi. This, however, marks the third such award in about six months, beaten to the punch by the DC Primary Care Association and the American Medical Association.

Here in Bread for the City’s Devo office, we briefly considered launching a new column that would shine a harsh bloglight upon medical associations that have yet to honor Dr. Randi. (Step it up, HIGPA! Jeez.) But if we’re going to actually speak for her, we would have to politely request that all associations momentarily refrain from giving Dr. Randi any more awards this year. Seriously, doc’s got patients to see.


American Medical Association honors Dr. Randi

>Bread for the City’s longtime medical clinic director, Dr. Randi Abramson, is on a roll: last year, she was honored as the DC Primary Care Association’s “Caregiver of the Year,” and this year the American Medical Association presented her with an “Excellence in Medicine” Award for her dedication to community health.

Thanks to the AMA, we can now share the video that was featured at the awards ceremony in March; the clip shares some insight into Randi’s long history here at Bread for the City, and features some pretty adorable old-school pictures. Note the shot of her with a pregnant woman: back in the day when Bread for the City’s clinic was in a basement without, like, actual doors! The distance from those humble beginnings to our in-the-works expanded medical center speaks to a great vision and commitment.

What’s the Oscar for doctors? Whatever it is, one can safely assume she’ll get that next. Though it should be noted that Dr. Randi was unaware that she’d been nominated for any of these awards, and really was only convinced to receive them because these were good opportunities for her to draw attention to the work of Bread for the City itself. Because who has time for awards ceremonies when there are patients to treat?

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