This is the first in a series of articles that will explore the different ways safety-net organizations are listening to their consumers and using their feedback to improve the design and delivery of care. CHCF believes that systems are more effective when they incorporate the perspectives of the people they serve. Learn more about CHCF’s own listening research and other related projects.

It’s just after noon on the third Wednesday of the month, and at the Trust Health Center in downtown Oakland, California, patients are sharing pizza around a conference table. Meet the Trust Partners, the clinic’s patient-based board of advisers. The role of the eight-member board is to provide patient feedback to assure that the clinic stays meaningfully connected to the community it serves.

One of the partners, William Terry, tells the group about the years he was homeless, living in a run-down minivan. The unregistered van was such a wreck that whenever he moved it for street cleaning, it left a trail of oil. In eight and a half years, he never got a ticket. “I should be in the Guinness Book of Records,” he said with a laugh.

Terry can reflect with humor on his time living on the streets because now he has an apartment, thanks largely to the Trust Health Center. This Federally Qualified Health Center (FQHC), which is operated by LifeLong Medical Care, opened in November 2015 to serve adult residents of Alameda County who have no home or who are at risk of losing their home. LifeLong provides primary care services, mental health care, and social services support.

Lifelong has a separate governing board overseeing the entire organization that meets the Health Resources & Services Administration’s requirement that the majority of a health center’s board must be its own patients. By law, patients must hold a majority on Lifelong’s governing board. Trust Partners offers an additional way to obtain specialized input from patients who have lived on the streets.

Paida Ndemera, who manages the Trust Health Center, said it provides care for approximately 2,000 patients each year. Due to the unstable circumstances and schedules of those who are homeless, she estimates that fewer than 1,000 of them are actively engaged, meaning they visit the clinic at least three times in a 12-month period.

The nearby nonprofit Homeless Action Center, which offers free legal assistance to people who are homeless, often refers clients to the clinic. “They’re just a block away,” Ndemera said. “You don’t even need to cross the road.” And yet, because of the complex circumstances of their lives, many of its clients never make it there.

The Trust Partners helped the Homeless Action Center staff understand this challenge by explaining that public spaces can be intimidating and unwelcoming for people who are experiencing homelessness. “When I would go to Alta Bates . . . we would go to a small waiting room, and I would be smelling really bad,” Terry recalled. “And the people in the waiting room, they’re not in my situation, so I would stick out like a sore thumb. So that made it hard to go there. . . . You deal with so much disrespect from the public.”

For people who are homeless, many of whom have had negative health care experiences, it can be hard to trust providers or care delivery systems.

The clinic is a welcoming and caring environment, but for people who are homeless, many of whom have had negative health care experiences, it can be hard to trust providers or care delivery systems. To help would-be clinic patients overcome these barriers, the Trust Partners arranged for someone to go to the Homeless Action Center and accompany clients to the clinic. They know that even a two-minute walk can feel much safer when you are with someone who has had a similar experience and helps ensure you won’t be judged or disrespected.

In Clinic We Trust

Since the beginning, the goal of the Trust Health Center is to be “an intentionally created community where people without their own safe space feel welcomed and accepted.” Its founders knew that patients’ perspectives had to be baked into the clinic’s decisionmaking process and the design of its services. They credit the Center for Care Innovations (a CHCF grantee) for helping them launch Trust Partners as a key part of their patient-engagement strategy.

Isobel Harvey, RN, MSN, was the center manager when the clinic opened, and she worked closely with CCI to develop the Trust Partners. “We were serving a group of people who are some of the most marginalized in our society and very frequently don’t have a voice, don’t have control over their own lives,” she said. “What you think people need or want, versus what they say — there’s always something to learn from your patients.”

It’s very enlightening speaking to them and hearing what really is going on in the clinic.

—Trust Health Center Manager Paida Ndemera

Ndemera succeeded Harvey in 2017, and she attends Trust Partners meetings to listen to their feedback and opinions on proposed changes to the clinic. The meetings are “a space where they feel comfortable talking about anything and everything,” Ndemera said. “It’s very enlightening speaking to them and hearing what really is going on in the clinic.”

Occasionally patients come into the clinic and act aggressively, threatening other patients or staff. The staff contemplated adding security, but some clinic workers worried that having a security guard would make the clinic feel unwelcoming. According to Harvey, some staff felt that “if the clinic is really called Trust, then we need to trust our patients so that they can trust us.”

But when the Partners discussed it, they surprised Harvey by recommending the clinic hire a security guard to keep the peace in the lobby area. In addition to the guard, they posted ground rules at the entrance — including a reminder to treat other patients with respect. The security presence has decreased the number of fights in the waiting room, making it a calmer and safer space for patients who deal with instability on a daily basis.

The Trust Partners also informed the staff that the public restroom in the lobby area was being used for drug deals and drug use. Applying the principle of harm reduction, the clinic installed a sharps disposal container in the bathroom.

Taking It to the Street

The next project the partners plan to tackle is street outreach. Ndemera said 50% to 60% of the clinic’s new patients come through word-of-mouth referral, and the Trust Partners want to visit nearby encampments to educate residents about the clinic’s services. In effect, the Partners would serve as community health workers (CHWs), frontline workers whose experiences help them connect and build trust with the community they serve.

While people who are homeless might be skeptical of medical professionals, they often trust individuals like Jerry Smith, who first came to the clinic after five years on the streets. The clinic helped him get back on his feet, first tending to a leg wound he endured for three years and then providing him with housing assistance.

Smith is a Trust Partner, and he feels a responsibility to help people who are unsheltered get the physical and mental health care they need. When he was living on the streets, he and his best friend, James, did everything together — recycling cans and bottles, building shelters, looking for a place to wash their faces. After Smith went to the clinic, he tried to convince James to go too. He told James how welcoming Trust staff members were, how other patients wouldn’t stare, how the clinic’s services could help him get off the streets for good. “You have to come with me,” Smith begged.

James never made it off the streets. Smith heard from a friend that James took his own life.

“Things could have changed,” Smith said. “Now it makes me want to go and try harder to get people’s attention.”

Xenia Shih Bion

Xenia Shih Bion is a communications officer at CHCF, where she helps to lead communications around the foundation’s work to create health equity. She is the founding author of the “Essential Coverage” column in The CHCF Blog. Read More

More by this Author:

‘You Want Your Immune System Protecting You and Your Baby’, Envisioning a More Just and Inclusive Health Care System, Spreading the Stories of Joyful Black Births