“There are barriers, some of which society created, that stop certain people from getting care,” explains Stuart Fisk, CRNP, and director of the Allegheny Health Network (AHN) Center for Inclusion Health. “Inclusivity is about recognizing those things and incorporating them into our plan of care. It’s also about encouraging providers to be understanding of people they might not have been exposed to. We want to provide good health care for marginalized populations, but also create a better health care system that is equipped to take care of all of us. We all deserve the same standard of care.”
A 2018 Excellence in Nursing award winner, and subject of an inspiring “Care without Judgment” video, Fisk has spent much of his career helping socially and economically marginalized populations. The Center for Inclusion Health programs address several areas of need, but Fisk says that all are about “meeting patients where they are, without agenda or judgment,” and expanding access to high-quality, team-based, personalized care. While commending the impact of philanthropy, he also emphasizes that the Center’s programs should be seen through a clinical lens: the focus is improving outcomes, backed by data, and not charity.
Despite the nationwide opioid crisis, and an increase in hepatitis C cases traced to drug use and needle sharing, Fisk says that few providers in traditional health care settings have asked patients basic questions about drug use: Are you using drugs? Which drugs? How do you take those drugs? Do you want treatment to help you stop using drugs? “Historically, we didn’t deal with addiction systematically,” he says, “and we certainly didn’t embrace a comprehensive behavioral and physical health approach.”
From a lack of screening to people being discharged from care too soon to limited access to medication and treatment, the result has been that people with substance use disorders often don’t get the care that could make a difference in their health or their survival.
The Center for Inclusion Health brings together a range of evidence-based substance use treatments, coordinated team-based care, and extensive ongoing support, and also serves as one of Pennsylvania’s Centers of Excellence for Opioid Use Disorder. Its multidisciplinary specialists help anyone with any kind of substance use disorder get health care, substance use treatment, recovery supports, and assistance to live a healthy life beyond addiction. Just as importantly, they continue to provide services for those who are unable or not interested in quitting use.
As is true throughout AHN, the goal is to help people across their entire health journey, not just at one point of care. For example, when someone is brought to an AHN emergency department because of an overdose, immediate treatment to save their life is just the first step. The Center for Inclusion Health may then be involved in getting that person connected with the care and resources to improve their health far beyond that event.
Fisk and the Center for Inclusion Health are also involved in supporting the Perinatal Hope program, which works with expectant mothers who are struggling with substance use disorders. Here, too, Fisk points out that it’s important to think beyond one segmented care program. To be effective, resources must be available to help women struggling with addiction and care for their children after pregnancy as well.
Similarly, efforts to combat stigma must be ongoing. “People with a substance use disorder face stigma at every stage of illness, recovery, and even long past recovery,” he says.
Plenty of research shows the far-reaching benefits of a healthy diet. But in the U.S., millions of people simply do not have consistent access to healthy food due to poverty, location or lack of transportation. Often referred to as food insecurity, lack of access to nutritious food creates enormous barriers to long-term health, and can worsen chronic conditions like type 2 diabetes.
Addressing food insecurity was an early Center for Inclusion Health project, resulting in the Healthy Food Center at West Penn Hospital. More recently, a second food center opened at Allegheny General Hospital, and a third is on the way at Jefferson Hospital.
The Healthy Food Center model aims to make healthy food a realistic option, regardless of one’s financial situation. The way it works is that AHN primary care and specialty clinic staff screen patients by asking two questions related to having enough food. When a patient screens positive for food insecurity, the provider can refer the person to a Healthy Food Center to receive healthy food for free.
Partnering with the Greater Pittsburgh Food Bank, the Healthy Food Center goes beyond just providing food; among other services, the registered dietitians and staff who run the Healthy Food Centers offer family-friendly recipes, tips on shopping for healthy food on a budget, advice on using less common fruits and vegetables, and general health and weight management counseling.
“As with other programs through the Center for Inclusion Health, we’re interested in fixing problems that may not typically be seen as health problems, but that research tells us are connected to poor health outcomes,” Fisk explains. He adds that the Healthy Food Center is a good investment for the overall health system.
“It’s cheaper to buy healthy food than it is to buy insulin,” he points out. “If we can get people healthy food and that means they aren’t requiring medical services or being admitted to the hospital, then we’re helping to reduce the overall cost of health care.”
On Screen: Colleen Ereditario, manager of the Healthy Food Center and a registered dietitian.
The Allegheny Health Network's primary care physicians are asking two screening questions upon a patient's visit. The screening questions are related to food security and whether or not the patient runs out of food at the end of the month or not.
Once they have the referral, they come to the Healthy Food Center. It's a drop-in service. They are able to get two to three days' worth of food based on their household size. I will shop with them. It's kind of like a healthy grocery store based on their medical needs whether they have diabetes, cardiac disease, or high blood pressure. I will be able to pick out the appropriate foods for their needs.
Patients are also offered nutritional resources such as how to shop on a budget, how to cook healthy, and are also offered healthy recipes.
We stock the Healthy Food Center with fresh fruits and vegetables, whole grains, lean meats, and low fat dairy products.
Being a dietitian in the Healthy Food Center and being able to provide patients and their family members with healthy, nutritious foods is very rewarding. Being able to help them bridge the meal gap and also help them improve their health through nutrition is really great.
Fisk who began his career helping people with HIV/AIDS during the peak of the epidemic co-founded the Positive Health Clinic with Bonnie Doran, CRNP in 2001. At that time, the clinic saw less than 100 patients with HIV, had few staff and little budget. Then, in 2002, the clinic received a grant through the Ryan White Care Act and the Health Resources and Services Administration (HRSA) that allowed it to grow into a clinic with almost 40 staff and 1,000 patients. Now part of the Center for Inclusion Health, the clinic supports people living with HIV through a nurse-centric “one-stop shop” that includes nurse practitioners, physician assistants, physicians, social workers, pharmacists, therapists, and psychiatrists.
Testing positive for HIV brings many new challenges medical, emotional, and social. The Clinic exists so that no one has to face those challenges alone.
“We created a model that has a high proportion of complicated patients, who are often from excluded communities, yet we’ve had some of the best clinical outcomes in the country,” Fisk says.
Another success has been integrating voluntary HIV screening in emergency departments. If a patient wants the test, and tests positive, there is an immediate follow-up from the Positive Health Clinic.
“We have patient navigators who reach out and connect them to care right away,” Fisk says. “The goal is to get the first dose of treatment in their mouth on the same day they’re diagnosed.”
He explains that treatment can yield a 95% to 97% viral suppression rate, meaning that the disease can no longer progress or be transmitted. In most cases, treatment can reduce a patient’s viral load to an undetectable level within weeks, making it all the more tragic if someone is suffering unnecessarily and putting others at risk because they don’t have access to diagnosis and treatment.
The Center for Inclusion Health is also committed to helping people who are experiencing homelessness or living in an unstable housing situation. Fisk says that as housing gets more expensive, people with lower incomes tend to be pushed farther away from core medical services. Instead of waiting for people to get to them, the Center has a Street Medicine Team that often takes care out to where it is needed, including to homeless shelters and on the streets. This team is made up of physicians, a nurse, social worker and community health worker.
The Street Medicine Team works closely with a homeless outreach group called Operation Safety Net, which identifies people who are living outside of shelters and have medical needs. The Center’s health professionals then go to that person to provide treatment, which also gives them an opportunity to suggest other resources that may help someone. This work has continued even during COVID-19. Homeless people who tested positive have been moved to safe, quarantined locations to make sure they get adequate care and to prevent further spread of the virus.
Another way that the Center for Inclusion Health supports people who are homeless involves visits and consultations at AHN hospitals. As an example, Fisk talks about a diabetic man who had been readmitted to the hospital three times in one month. Only after the Center’s health professionals visited did they learn that the man was homeless and had no health insurance.
“Knowing that your diabetic patient is living on the street and doesn’t have food a lot of the time means you need to change the plan of care and how you try to help that patient,” Fisk says. “While a patient is in the hospital, we can help shape the plan of care, and then also connect them with other resources once they’re discharged.”
Immigrants and refugees have unique challenges in navigating a U.S. health system that may operate very differently than the one in their native land. In addition to training physicians and front-desk staff on cultural elements that could impact care, the Center has also worked to ensure language translation and interpretation services are available at every AHN hospital and physician’s office.
Fisk notes that many immigrants and refugees have experienced trauma, and they tend to have higher risk of substance abuse, HIV, hepatitis C, and mental health issues.
“They may have been exposed to certain problems before their arrival,” he says, “and then they experience stigma and isolation in their new home, which only increases trauma. Plus, they’re now living in a culture where there are many factors that increase the risk of diabetes and obesity, and can exacerbate trauma, depression, and mental health issues.”
One success story in this area involved a two-year grant from the Jewish Healthcare Foundation to hire and train doulas from immigrant communities to support immigrant women through pregnancy and birth. The program’s success resulted in six doulas now working with women from African, Bhutanese, Nepalese, Latinx and Arab-speaking communities. Fisk explains that when doulas, and other community health workers, come from similar backgrounds as the patients they serve, it is easier to establish trust and help patients understand and navigate the health system.
“We hope to build a whole layer of community health care workers within AHN,” Fisk says.
“It’s interesting that, personally, most of my primary care providers haven’t known what my sexual or gender identity is,” says Fisk. “And that’s because they never asked, even though those are important to know from a medical standpoint.”
That spotlights a key aspect of the Center for Inclusion Health’s work in transgender health: education and training for providers. Early on, it hired a program manager with expertise in transgender health, and direct experience of the challenges that the health care system can present for someone who is transgender or gender-expansive.
“We send someone who is a non-binary transgender person to train staff and clinicians,” Fisk says. “And they have been received phenomenally. People want the training, even in some of the more conservative practices in rural or suburban areas.”
The Center is also developing a roster of providers who excel at being transgender-friendly and trans-competent. There is also a training program for primary and subspecialty care on how to do hormone therapy. Circling back to the goal of ensuring equal access and quality of care, Fisk adds that integrating transgender health into primary care is especially important.
“We don’t want to create a health clinic that forces transgender patients into a different space for primary care,” he says. “They should be able to go anywhere.”
Beyond its specific programs, the Center for Inclusion Health plays an important role in driving long-term, systemic change. Education is a critical part of its work, including its own residency track. Participating residents spend two years in AHN rotation, with a large part of their program involving the Center.
“As we get a younger generation of residents, the issues we predominantly deal with are more openly acknowledged,” Fisk points out. “We have residents who come in actively wanting to learn about something like transgender health care.” This “attitudinal shift” has a positive impact on older clinicians as well, increasing awareness and support across the broader organizational culture.
“Many people just don’t realize how poorly marginalized groups of people have been treated in the health system throughout time,” he adds. “We want them to realize how easy it can be to fix certain problems with a little knowledge, attention, investment and innovation. That’s really the principle behind the Center for Inclusion Health. We are trying to transform the way we do care so that at-risk populations have access to the same quality care in the same setting as everyone else.”