Centro SOL: A Community-Academic Partnership to Care for Undocumented Immigrants in an Emerging Latino Area

Abstract

Problem

From 2000 to 2014, the Latino population in Baltimore city, an emerging Latino settlement area, has experienced rapid growth. Many of these individuals are undocumented and not eligible for coverage. Academic medical centers often lead the way in addressing the health needs of undocumented immigrants, however, examples from emerging immigrant areas are limited.

Approach

In October 2013, Johns Hopkins Medicine clinicians established the Center for Salud/Health and Opportunities for Latinos (Centro SOL) to better address the health needs of Baltimore’s growing Latino community. Centro SOL’s mission focuses on four core activities: clinical services, advocacy and community engagement efforts, pipeline/education opportunities, and research consultations. Progress is measured through a scorecard reviewed annually by Centro SOL leadership.

Outcomes

Centro SOL’s program have expanded health care access for undocumented immigrants, patient safety and quality programs for patients with limited English proficiency, and pipeline opportunities for Latino youth. In 2017, 2,763 uninsured patients received primary or specialty care and 290 people received group therapy to address stress-related conditions. In addition, 49 Latino students (ranging from high school to postgraduate students) received mentorship at Centro SOL.

Next Steps

In the next 5 years, Centro SOL plans to expand the pipeline for Latinos interested in health professions fields and to further improve access to health services for Latino families through both advocacy efforts and enhanced clinical services.

Problem

From 2000 to 2014, the Latino population in Baltimore city grew by 166%, as immigrants from Central America and Mexico fleeing violence or searching for economic opportunities settled in the city.¹ The highest-density Latino neighborhoods are within the catchment areas of the two of Johns Hopkins Medicine (JHM) hospitals. This presents both opportunities and challenges for JHM, whose mission “is to improve the health of the community and the world by setting the standard of excellence in medical education, research and clinical care.”

Furthermore, it is estimated that approximately 27%, or about 250,000, of Maryland’s immigrant population, which includes many Latinos, are undocumented.¹ These individuals are not eligible for coverage under the Affordable Care Act (ACA) and can pose a financial challenge to health care settings, including academic medical centers. There are often other important obstacles to undocumented immigrants accessing care, including language barriers, lack of familiarity with the health care system, discrimination, stigma, and fear of deportation.² Baltimore, like other settlement areas without long-established Latino communities, has a limited infrastructure and workforce for meeting the needs of patients with limited English proficiency (LEP). This can leave both patients and providers dissatisfied.

The ethical obligation of physicians to fulfill a “special obligation to all fellow human beings” is in conflict with exclusionary health care policies. For example, the Physicians’ Charter endorses social justice, stating that “physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”³ Unfortunately, physicians serving undocumented immigrant patients are often caught between a rock and a hard place, as they try to balance professional values and workplace realities.⁴

Academic medical centers often lead the way in addressing the health needs of undocumented immigrants, but examples from emerging immigrant areas are limited.^4–6 This Innovation Report describes how a grassroots effort led by faculty and trainees concerned about access to care for Latino immigrants in Baltimore garnered the institutional support to establish a center for Latino health. This center’s goals are to improve clinical care for Latino immigrants, expand the pipeline of Latino health professionals, and advocate for the Latino community through engagement and policy.

Approach

Grassroots advocacy by junior faculty and trainees

In 2008, a group of JHM clinicians (made up of junior faculty and trainees) from various specialties met to discuss the care of immigrant Latino patients. In addition to health care access, the group identified major hurdles in providing equitable care for patients with LEP and low health literacy. In 2010, the group established the Hopkins Organization for Latino Awareness (HOLA), which was open to anyone interested in Latino health, including faculty, trainees, staff, and hospital administrators. HOLA activities focused on mentoring, community-based research, and innovations in the delivery and financing of care for Latinos. HOLA members participated in various committees (both internal to JHM, such as the Health Equity Committee, the Latino Alliance, and the advisory board for the Urban Health Institute, and external to JHM, such as the Latino Providers Network and the Baltimore City Health Department’s HIV Planning Group and Commission and Teen Pregnancy Prevention initiative). However, increasing demands on the HOLA junior faculty who participated in these committees and planned HOLA activities, which were not compensated, raised concerns that this work was detracting from academic productivity. It became apparent that sustaining these efforts would require institutional support to advocate effectively for system-level change.

Commitment from senior faculty and institutional leadership

In 2013, senior faculty and institutional leadership (pediatric and medicine department chairs and a senior JHM administrative leader) helped the junior faculty to secure external funding and institutional support for HOLA by emphasizing how this work aligned with the JHM priorities of economic impact, public health/community benefit, patient safety, regulatory compliance (i.e., Joint Commission accreditation), and diversity and inclusion. In October 2013, HOLA’s founding members established the Center for Salud/Health and Opportunity for Latinos (Centro SOL, http://jhcentrosol.org/); in doing so, HOLA became part of Centro SOL.

Centro SOL’s mission and programs

Centro SOL’s primary mission is to, hand in hand with our Latino neighbors, create opportunities for wellness and to achieve equity in health for Latinos (List 1). Core activities include clinical services, advocacy and community engagement efforts, pipeline/education opportunities, and research consultations. To ensure that programs are responsive to community needs, priority projects are identified through discussions with patients, the Latino Family Advisory Board (LFAB), and community forums. The Centro SOL Advisory Board includes members from academia, nonprofit organizations, and the public sector.

List 1 Centro SOL’s Vision, Mission, and Goals, Johns Hopkins Medicine, Established in October 2013.

Vision

Health and opportunity for all Latinos

Mission

To, hand in hand with our Latino neighbors, create opportunities for wellness and to achieve equity in health

Goals

• To develop innovative clinical programs that pay tribute to the unique cultural, language, and psychosocial assets of Latino populations

• To promote community engagement and include Latino voices in clinical care, education, scholarship, and advocacy

• To translate research to practice, programs, and policies that improve the lives of Latinos

• To train health professionals to provide care and conduct research that is culturally competent and responds to the needs expressed by the Latino community

• To mentor the next generation of Latino health professionals and instill in them a commitment to the well-being of their community

Abbreviation: Centro SOL indicates Center for Salud/Health and Opportunity for Latinos.

Program evaluations

The Centro SOL leadership developed a goal scorecard with specific objectives and timelines aligned with core activities. The scorecard includes goals related to program development, stakeholder partnership, sustainability (grants), and dissemination (peer-reviewed publications, national and local presentations, and conference organization). Data for the scorecard is compiled by a program administrator quarterly in an Excel sheet that includes the following metrics: grants submitted and awarded; abstracts, presentations, and publications; programs established or expanded; and Centro SOL led trainings, conferences, and community engagement activities (including stakeholder partnerships). The scorecard is reviewed and revised annually at a half day retreat for Centro SOL leadership. Outcome evaluations for specific programs are designed independently by lead faculty members. At an operational level, success is measured by rating objectives as successfully met, in progress, or not achieved. There are other less tangible measures of success, such as awareness of Centro SOL within JHM and the community and Centro SOL’s participation in critical decision making at JHM and externally (e.g., inclusion in conversations about Latino populations with the Baltimore City Mayor’s Office).

Outcomes

Select Centro SOL outcomes in clinical services, advocacy and community engagement efforts, pipeline/education opportunities, and research consultations are shown in Table 1 and discussed below.

Table 1.

Select Centro SOL Programs; Outcomes; Trainees, Providers, and Volunteers Involved; and Funding Sources for Academic Year (AY) 2017, Johns Hopkins Medicine (JHM)

Program	Outcomes	Johns Hopkins trainees, providers, and volunteers	Funding sources
Clinical services
The Access Partnership (TAP)	916 patients served (95% Latino immigrants): • 156 (17%) ≤ 18 years old • 650 (71%) 19–50 years old • 110 (12%) > 50 years old • 592 (65%) female	Providers from all specialties	JHM Charity Care
Esperanza Center	1,847 Latino patients not eligible for insurance served: • 332 (18%) children (ages ≤ 18 years old) • 1,515 (82%) adults (ages > 18 years old) • 333 (22%) of adult patients diagnosed with hypertension, diabetes, or both	• 1 faculty member • 9 internal medicine and medicine-pediatrics residents • 16 nursing students • 4 undergraduate students	MCHRC grant, JHM, and other foundations
Testimonios (adult mental health support groups)	195 Latino participants in group therapy sessions: • Ages 21–65 • 144 (74%) female	• 4 psychotherapists (3 Latino) • 10 undergraduate student leads (2 Latino) • 2 other volunteers (1 Latina)	Multiple foundations
Teen Testimonios (adolescent mental health group intervention)	95 Latino participants in school-based therapy sessions:  • Ages 12–20  • 57 (60%) female	• 1 faculty member • 3 undergraduate students (2 Latino)	Johns Hopkins Urban Health Institute
Quality of service	Implemented a Spanish-language patient portal in the EMR	N/A	Johns Hopkins Office of Diversity and Inclusion
Advocacy and community engagement efforts
Latino Family Advisory Board	• 9 meetings • 19 members	• 2 faculty members • 1 social worker (Latina) • 1 coordinator (Latina)	Multiple foundations
Embajadores de Salud (health ambassador program)	65 Latino family members participated: • 42 adults (ages 24–62) • 23 children (ages 3–17)	• 1 faculty member • 1 coordinator (Latina) • 31 student and staff volunteers (12 Latino)	Pro bono
Health fairs and community events	• 64 events • 3,300 community member participants • 35 partnering organizations	72 student and staff volunteers (23 Latino)	Multiple foundations
Conferences	Hosted conferences to discuss: • ACA and immigration (2015) • Latino youth opportunities (2016) • DACA and public health (2017)	176 trainees and faculty members	Johns Hopkins Urban Health Institute and other foundations
Media	• 12 Spanish-language newspaper columns • 10 programs on Spanish-language radio station	1 faculty member lead (Latina)	Pro bono
Latino Health Policy Workgroup	• Developed a tool for enrolling children into CHIP • 4 advocacy publications	• 1 dean • 6 faculty members (2 Latina) • 12 trainees (12 Latino)	Pro bono
Pipeline/Education opportunities
Centro SOL Youth Program	26 bilingual Latino high school students (DACA recipients and undocumented youth) participated: • Ages 15–17 years • 19 (74%) female	• 1 faculty advisor (Latina) • 1 undergraduate student (Latino)	YouthWorks and other foundations
Centro SOL mentees	• 10 peer-reviewed publications • 8 abstract presentations • 22 mentees (see next column)	• 6 undergraduate students (4 Latino) • 5 graduate students (2 Latino) • 2 medical students (1 Latino) • 6 postgraduate students (6 Latino) • 3 junior faculty members (3 Latino)	Pro bono
Experiential activities for trainees with LEP Latino populations	106 students (32% Latino) from the JHU Schools of Medicine, Public Health, and Nursing participated (see next column)	• 35 undergraduate students (34% Latino) • 10 medical students students (30% Latino) • 61 graduate students (31%)	Pro bono
Seed grants	5 awarded	• 5 faculty members (3 Latina)	Centro SOL and Johns Hopkins Urban Health Institute
Research consultations
Centro SOL research consultation core	41 consultations provided	2 faculty members	Variousa

Abbreviations: Centro SOL indicates Center for Salud/Health and Opportunity for Latinos; MCHRC, Maryland Community Health Resources Commission; EMR, electronic medical record; N/A, not applicable; ACA, Affordable Care Act; DACA, Deferred Action for Childhood Arrivals; CHIP, Children’s Health Insurance Program; LEP, limited English proficiency.

^aThe various research funding sources include, among others, the National Institutes of Health, the Patient-Centered Outcomes Research Institute, the Robert Wood Johnson Foundation, and intramural funding.

Clinical services

Centro SOL’s top priorities in clinical care include expanding access to patients not eligible for coverage under the ACA, addressing mental health, and improving the quality of services for patients with LEP and low health literacy.

To improve access to health care for patients not covered under the ACA, Centro SOL partnered with the Esperanza Center to expand access to primary care services and with JHM’s The Access Partnership (TAP) to expand access to tertiary care. The Esperanza Center is a community-based organization that provides services to immigrants. In 2016, the Esperanza Center requested help from Centro SOL to revitalize a fledgling clinic that relied on occasional volunteer clinicians. Centro SOL secured funding from JHM to support a Centro SOL faculty member to serve as the medical director of the clinic. In this role, the medical director implemented quality assurance processes with a focus on chronic disease management (especially diabetes and hypertension), expanded clinical opportunities for JHM trainees, and collaborated with Esperanza Center leaders to obtain funding for additional clinicians. In the first 18 months since this partnership was implemented, patient volume has more than tripled (2,504 unique patients and 4,727 visits).

TAP, established in 2009, is housed in the Johns Hopkins Department of Health Care Transformation and Strategic Planning and is led by a founding member of HOLA and Centro SOL. This program provides access to specialty care, including surgery and complex medical care, to uninsured or underinsured patients in the JHM catchment area for a $20 quarterly fee.⁷ Although TAP was established prior to Centro SOL and is not specifically designed to serve the Latino population in Baltimore, its patient demographics shifted dramatically after the implementation of the ACA. Currently, over 95% of TAP patients are Latino immigrants and the close collaboration between the Esperanza Center, TAP, and Centro SOL has increased community referrals to TAP and helped advocate for sustained institutional funding for this program. In 2017, 2,763 uninsured patients received primary care at Esperanza Center (1,847) or specialty care through TAP (916).

Mental health was another critical health concern for Centro SOL. TAP data indicated a high prevalence of post-traumatic stress disorder, adjustment disorders, depression, alcohol abuse, and stress among Latino immigrants. In 2014, Centro SOL established Testimonios, a free weekly mental health support group, moderated by bilingual JHM mental health clinicians, during which foreign-born Latino adults can discuss their experiences with each other and dispel stigmas and misconceptions about mental health.⁸

In 2015, Centro SOL established Teen Testimonios at 11 public schools to alleviate mental health problems in trauma-exposed Latino immigrant teens through group stress-reduction sessions. Participants learn evidence-based skills for coping with stress and develop problem-solving skills, self-awareness skills, and mutual aid strategies to serve as resources for their peers. In 2017, 290 Latino immigrants (190 adults and 95 adolescents) participated in group sessions to address stress-related conditions.

Centro SOL’s initial efforts in 2013 to ensure patient safety and optimal quality of care for LEP patients focused on developing a Spanish-language patient portal in the electronic medical record. In 2017, a Centro SOL faculty member joined the Johns Hopkins Office of Diversity and Inclusion to improve patient safety, data collection, and equity for LEP and low health literacy patients.

Advocacy and community engagement efforts

Centro SOL is rooted in community engagement. The center hosts over 60 health fairs and community events each year; these events engage over 100 volunteers and partnering organizations and serve more than 3,000 community members (e.g., by providing health screenings and education). Centro SOL also runs a program, initially established by HOLA trainees in 2012, to empower participants to develop their own leadership skills as health ambassadors (Embajadores de Salud). In 2011, HOLA faculty established the LFAB, which is made up of immigrant Latino patients of the Bayview pediatric clinic, to help improve services for LEP families.⁹ Since 2013, Centro SOL has contributed to a monthly “Ask the Doctor” health column in a free Spanish-language newspaper and participated in a monthly radio program hosted by the CBS-owned El Zol Spanish-language radio station.

Centro SOL’s community engagement has informed discussions about the impact of local and national policies on the Latino community. Centro SOL has hosted conferences to discuss the implications of the ACA for immigrant communities (2015), Latino youth opportunities (2016), and the impact of rescinding Deferred Action for Childhood Arrivals (DACA) on public health (2017). Established in 2015, the Centro SOL Latino Health Policy Workgroup has partnered with academic, governmental, and community stakeholders to develop legislative strategies to expand health care for undocumented immigrants and to highlight the impact of enhanced immigration enforcement on the well-being of Baltimore’s Latino communities.²

Pipeline/Education opportunities

In 2014, Centro SOL established a pipeline program for Latino students (Centro SOL Youth Program) to help diversify the health care workforce so that it is more representative of the community served. In 2017, as part of this program, 26 bilingual Latino high school students, including DACA recipients and undocumented youth, participated in a paid summer internship at JHM that exposed them to careers in health care and clinical settings that serve LEP Latino patients. All Centro SOL Youth Program students are mentored throughout the year, and offered advice on college applications and funding options, with an emphasis on resources for non-citizen youth. In addition, more than 100 trainees (32% Latino) have participated in Centro SOL–sponsored experiential activities with LEP Latino populations, and five junior faculty members (3 Latino) have received seed funding ($10,000) for research. In 2017, Centro SOL faculty members mentored 19 Johns Hopkins University undergraduates, medical, and graduate students (13 Latino) and 3 Latino junior faculty members; among the mentored trainees, 3 of 4 Latino undergraduate students were accepted to medical schools.

Research consultations

The Centro SOL research consultation core facilitates the inclusion of Latinos in research and provides investigators engaging with Latino populations with best practices for recruitment, data collection, ethical conduct of research, document translation, community engagement, and culturally responsive study design. These activities have led to multidisciplinary collaborations, provided research opportunities for trainees, and served to recruit Latino students to get involved in research related to Latino health.

Next Steps

Centro SOL has received funding (ranging from $5,000 to over $100,000) from more than 10 local philanthropic organizations and from JHM, which made a 5-year contribution to establish Centro SOL in 2013. In addition, JHM makes substantial annual community benefits contributions to TAP. Leveraging community partnerships has been critical for sustainability. For example, Teen Testimonios pools resources from Centro SOL and Baltimore city public schools. Expansion of health care services at the Esperanza Center has been supported by Maryland state programs, local nonprofit and philanthropic organizations, Catholic charities, and JHM. These partnerships have helped identify funding opportunities available to academic nonprofit collaborations outside of the traditional academic research grant funding mechanisms (such as the National Institutes of Health).

In the next 5 years, Centro SOL plans to expand the pipeline for Latinos interested in health professions fields and to further improve access to health services for Latino families through both advocacy efforts and enhanced clinical services. An important goal will be to evaluate short- and long-term outcomes and to develop scalable programs that can be adapted to other settings. To support this work, Centro SOL will seek extramural funding from additional sources, such as the National Institutes of Health, the Robert Wood Johnson Foundation, and the Patient-Centered Outcomes Research Institute.

Increasingly, academic health centers are expanding their core missions of education, research, and clinical excellence to include a social mission that promotes health equity, addresses social determinants of health, facilitates community engagement, and fosters diversity.^5,10 Centro SOL’s experience may offer lessons that other academic institutions located in emerging Latino immigrant settlement areas may want to consider and replicate. Several factors helped garner institutional support: senior faculty and institutional leadership buy in, the promise of external funding, drawing attention to patient safety concerns, aligning Centro SOL’s goals with JHM’s mission statement, and partnering with existing JHM initiatives that address health equity.

There were several components that made Centro SOL a respected resource for the community and JHM. The first and most important was developing meaningful relationships with the Latino community. Centro SOL hired community members with untapped leadership qualities who were trusted and skilled in proposing innovative programmatic ideas; this approach is recommended to others.

The second was identifying stakeholders within and outside of JHM with a similar mission of service to undocumented immigrants. This shared sense of purpose led to productive collaborations that leveraged different strengths, shared resources, and coordinated efforts to maximize the yield of limited resources and avoid redundancies.

Third, the flexibility of the initial funding for Centro SOL promoted innovative strategies and facilitated quick response to needs as they arose, especially as the political context changed over time. This nimbleness helped strengthen relationships with partners, build trust, and allay concerns about the slow pace of academic work and the intangible benefits of research.

Fourth, Centro SOL’s programs span the life course and include direct patient care and investments in community wellness. This strategy is reflected in interdepartmental collaborations between the Departments of Medicine, Pediatrics, Obstetrics, Geriatrics, and Psychiatry, and interdisciplinary collaborations between the Schools of Medicine, Public Health, and Nursing.

Finally, Centro SOL leveraged media to communicate a clear and consistent message of support to the community. This is particularly important during times of increased immigration enforcement, uncertainty, and fear. As always, the personal stories and voices of Latino immigrants themselves are the best ways to convey the strength and resilience of this community.

In Centro SOL’s experience, the joint voices and commitment of trainees, community members, and faculty members served as a catalyst to garner support from donors and institutional leaders to address the health needs of Latino immigrants in Baltimore, while also expanding training and research opportunities for JHM. Similar approaches at other academic health centers, tailored to the needs of their own communities, could help alleviate systemic gaps in care for undocumented immigrants.