The young, Middle Eastern woman came to Siloam Family Health Center late the day, after being discharged from a nearby hospital’s emergency room. She had been evaluated for a breathing problem, which was thought to have resulted from ingesting some form of chemical.
“It just didn’t add up,” recalls Dr. Jim Henderson, Medical Director. “The ER did a great job and gave all the help they could give, but they wisely said that she should see her primary-care physician. That was us. She got here with a lot of family and friends – a whole, concerned community, really — and two hours later she walked out happy and breathing comfortably.”
Why? Because she told her doctors what was going on in her life, and it was a case of pure anxiety. She was having a panic attack, and because Siloam has pastoral care and behavioral health care, several people who she knew and trusted could have a lengthy talk with her.
“She had a big family, but we also are a big family,” Henderson says. “She left here grinning, and with no medical intervention.”
That sort of thing happens a lot at Siloam, whether it’s someone from Myanmar, Egypt, Pakistan or Berry Hill. Since 1989, the clinic has been taking care of Nashville’s exploding refugee and ethnic immigrant population — one in six Davidson County residents now is foreign-born — even though its initial charge was a bit different.
“Since Siloam was birthed by a group from Belmont Church in 1991, our mission has been to share the love of Christ by serving those in need through health care, “says Dr. Morgan Wills, President and CEO. “Who are ‘those in need’ has changed somewhat. The original focus was on the Edgehill community, but as patients from other communities began coming through our doors, we realized how much Nashville was changing. So, Siloam is still about serving those in need, but in keeping with the Christian tradition of hospitality, we now bring that open relationship-based approach to a much more diverse group of people.”
The small clinic in Edgehill eventually grew to a new, 12,000-square-foot facility near Franklin Road and Thompson Lane, where 36 staff and 300+ volunteers care for roughly 5,000 unique patients each year. “We are very thankful to have a bigger platform for our work, but it also compels us to work hard to sustain our culture of truly whole-person care,” Wills says.
Relationship-based approach is key
A walk through Siloam bears testament to the personal nature of its operations. Sure, there’s the antiseptic smell that any medical facility is going to have, but there’s also a warm, inviting chapel, colorful flags on the walls representing patient homelands, and a smile and friendly face lurks around every corner. This is not a place where patients shuffle from waiting room to exam room, then back out to the waiting room again, with minimal contact. The conversations begin at the front desk and don’t stop until the front door closes at day’s end.
“It has been amazing to watch this great team take a five-year strategic plan and bend it to meet the needs of today,” says Henderson, who arrived in 2008. “Change comes so fast, and we have to be so flexible. How do we define the gaps? If someone is making $40,000 a year and can’t afford a $20,000 procedure, they have a need. But is that what we are called to fix, and are in a position to meet? Our board’s answer is that we are here for people with no other health care options, and no insurance. That’s still a massive amount of people.”
Even if Tennessee’s legislature opted to accept Medicaid expansion under the Affordable Care Act, the nature of a refugee and undocumented population means that many of these people would never find their way onto those rolls. The doctors and staff at Siloam have also perfected a hands-on approach that appeals to the many different cultures that walk through the doors, and to say that patients are loyal is to vastly understate the case.
“They love our distinctives,” Henderson says. “They love our focus on whole-person care, they love that we have a sliding scale that’s very flexible for those who don’t have money … and they love that we get into their lives. Our founders were wise to realize that we can never meet all the needs. Crisis doesn’t always constitute a call, and the crisis of healthcare, the relative heightened awareness of healthcare we have as a country, doesn’t mean we must meet everyone’s health care needs.”
Got falafel? Payments take unusual forms
Indeed, grateful current and former patients are a staple at Siloam. That gratitude takes many forms, as customs overseas are often far, far different than they are in the United States when it comes to expressing gratitude. At Siloam, for example, a small payment on a sliding scale may be supplemented by more unexpected tokens of appreciation.
“Coming as they often do from more communal cultures, our patients often want to reciprocate in some extra way for the care they receive. We’ve been offered everything from eggs to shot glasses, dresses, and baked goods,” says Wills.
“Some of our patients work at restaurants, and so they will show up unexpectedly with lunch for the whole staff,” Barnett says. “That’s a huge sacrifice financially for them, but they show up grinning and very excited to be able to give back.”
With the rise in community gardens, Henderson adds, “We know we’ll be seeing a lot of produce as well, but at least we’ll be eating healthier.”
We’ve learned that it’s more honoring to them to simply receive the gift,” says Wills. “In fact, to use one of the latest health care terms, it’s actually a form of patient-centered care.”
Childhood care becomes adult vocation
Travel, for most 11-year-old kids, means a trip to see grandparents, or maybe the beach. It doesn’t mean a trek across two-thirds of the globe. But that’s what Kap Sum and his family did when they left Burma (now Myanmar) to come to the United States.
“My father had been here for about five years, and so my mother was the only parent to six of us for many years,” he says. “We came straight to Nashville, because at that time my father was working as a sushi chef at Wild Oats. So when I got here, it was straight into the 5th grade.”
He eventually went to Hillwood High, and then on to Belmont University for a degree in international politics. A stint at Vanderbilt Divinity School followed, where Kap Sum earned a master’s degree in theological studies. All along the way, he remembered arriving in the United States and being hit with a barrage of new sights, sounds and tastes. There was no assimilation, really; it was straight into the deep end of a foreign culture.
From his earliest days in Nashville, Kap Sum says he benefited from many kindnesses. One frequent destination was the Siloam Family Health Center, where he now works as a Medical Receptionist.
“I didn’t really use Siloam as much as my relatives did, but I was brought here for immunizations, physical exams and other needs when I was younger,” he says. “Even though I did not arrive under refugee status, almost all of my aunts, uncles and cousins did come here as refugees. They came to Siloam very often, anything from seeing about a baby with a fever to an adult who was sick and couldn’t get past the illness.”
As an undergrad, he came with a cousin to Siloam and realized that the facility needed an interpreter for Zomi (or Tedim-Chin), his ethnic language. He volunteered to help out, and quickly became a part of the Siloam family.
Coping with political flashpoints
The difficulties of health care in the United States have dominated the news for years now, as have the issues surrounding immigrant and refugee populations. Those two challenges intersect at Siloam, where a dedicated team sees not only people who have fallen through the cracks, but also those who were never on the road in the first place. The facility does not bill insurance providers, and so relies on the generosity of an ever-expanding base of churches, individuals and foundations as it has grown.
The clinic just needs to continue to deepen its focus on excellence in health care, continue to draw in the best and brightest as consultants, partners and advisors, he adds, and to “start using models that we’ve learned from the developing world in order to deploy community health techniques to extend our reach beyond the patients who actually come to the clinic.”
Getting the whole story
Since its founding, Siloam has been about treating the whole patient. That’s why social workers and other professionals comprise the treatment teams, and it’s also why the clinic has great success against sometimes staggering obstacles. Language barriers, cultural norms and more come into play every day, but by chipping away at a patient’s fears a little a time, and getting him or her to open up, bridges are built and effective and affordable treatment plans are created.
“I have lived abroad in England and India, and so am sensitive to adapting to a new environment,” Henderson says. “I am often moved when I think about how everyone would love to tell their story, but are rarely asked. When we ask someone to tell us about him or herself, we can be clued into so much more of what’s going on, and intuit even more. We are strange people, wearing white coats, and have different ways than where they are from. But when we really talk with our patients, and listen to them, it becomes so much more than just a medical facility.”
Taking that multidisciplinary, whole-person approach is not only cost-effective and successful at the individual level, it also has a ripple effect. People come to Siloam not only because they are physically ill, but also because they are dealing with chronic poverty, unemployment, alienation from their home community, substance abuse and much more.
“Many are just hungry for something to change their lives,” Wills says. “A person may present with symptoms or complications of diabetes, but it’s not just about that condition. It’s about restoring relationships on multiple levels—from the biological to the social, the psychological, and even the spiritual. We just heard a report from one woman, recently released from prison, who was diagnosed with Hepatitis B and living in deep shame. She just informed one of our staff that the grace and care she’s received at Siloam has had a radical ripple effect in her life. She’s reconciled with her family and is moving towards life with gratitude and hope. We see stories like that every day.”
Future growth means out, not up
Siloam’s success has been gratifying to its staff and many community partners, but also has presented challenges. As was discussed when the new facility was in development, how much is too much when it comes to growth? The building size was carefully considered, as were services to be offered. Now the goal is still to propagate Siloam’s mission, but to do it in a more outward direction.
“We are actually thrilled with our current team, as we have been understaffed for several years,” Wills says. “A new physician, Dr. Brent Snader, is returning from India this summer to round out the clinical staff. He’s a former Vanderbilt student, who also worked at Siloam as a medical resident. It’s neat to see that come full circle.”
Siloam also has launched a community health outreach (CHO) program, which will allow it to leverage its resources over a broader population by sending out nurses to work within particularly marginalized communities of newcomers. Those efforts will be anything from specific education and outreach programs to just listening and finding out what underserved communities need right now, and moving to put that assistance into place. As Wills puts it, “the CHO is ultimately about addressing some of the root causes, or ‘upstream’ factors that drive health care utilization in the first place.”
In addition, Wills says, Siloam is working to address a looming “downstream” issue in health care—the small and inadequately prepared primary care work force in our country. A few years ago Siloam created of the Siloam Institute, a program that offers training about the interconnecting domains of faith, health and culture for health professions students and other clinicians who spend time at the clinic.
“The Institute represents a deepening our longstanding commitment to mentorship. We actually have more learners coming through this facility relative to the staff and patient load than just about any clinic in the country. We think of it as ‘Whole-Person Care—Multiplied,” says Wills. “Some Siloam trainees, like Dr. Snader, have gone on to lead other clinics for the underserved, and to work at major hospitals. One is doing health disparities research for the Mayo Clinic, while another works in poverty medicine locally and co-leads Vanderbilt’s Medicine/Pediatrics residency program. We see Siloam Institute trainees as a “glitch in the Matrix” of the broader health care system, influencing change from the inside. It’s a way to multiply our influence through the next generation of health care providers.”
Whether it’s upstream, midstream, or downstream in focus, health care at Siloam is all about wholeness, or connectedness. And sitting right in the middle of it Kap Sum, one of those key front-line staff whom Wills, Henderson and others credit with making patients feel welcome, safe and understood.
“I had made connections when I volunteered here, but working here allows me to really see what Siloam does from a different side,” he says. “Once I was being helped, so being able to help newcomers to Nashville is a great experience for me. I came here at 11. I volunteered here at 22. For a while, I had forgotten how hard those first initial months and years were, and being an interpreter reminds me of those times. I really want to help the immigrants and refugees who arrive here, and I really see that as my vocation. That is why I am at Siloam.”
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Siloam & The ACA:
Even as it works to expand its reach, Siloam’s operators are well aware of all the healthcare-related issues going on in the community and beyond. Of particular interest are the exchanges created by the Affordable Care Act, which will allow some longtime Siloam patients to transition away from the facility.
“Along with several other faith-based clinics, we received a grant from the Baptist Healing Trust and HCA Foundation to support the work of health Assist Specialist from Family and Children’s Service,” Wills says. “That person is now co-located here, and is able to help with the screening and enrollment process. Both our current and prospective new patients are being screened, and we are flagging those who look like they may be eligible.”
So far, roughly 15 percent of Siloam’s patients qualify for subsidies on the exchanges, and over 200 have actually been able to enroll in newly affordable insurance plans. Still, nobody’s being shoved towards the exits. “We function sort of like a medical foster home for the uninsured,” he says.
“We have a staff social worker who is helping those people transition out to find a new medical home,” says Debbie Barnett, Director of Marketing and Communications. “The transitions are gradual, because it’s a tough one for them. But many of our patients, though sad to leave Siloam, appreciate that they have been the recipients of a lot of generosity from the community here. They are happy to move on, to make room for others who need to be cared for as well.”
“It helps that many of our volunteer physicians and others who have worked at Siloam have private practices elsewhere, and they are willing to see these people in their new capacities,” Barnett adds.
“They understand Siloam’s approach to culturally sensitive, whole-person care, so they know what our patients are accustomed to, and expect,” she says. “We always try to hand off to someone we know, because that means so much to the patients.”
The Siloam Institute:
The Siloam Institute is the clinic’s educational initiative, and focuses in three main areas:
Training
Students can serve in a variety of volunteer roles at Siloam, but senior students and residents can participate in Siloam’s Primary Care Preceptorship Program (PCPP) for academic credit. The Community Health Immersion (CHI) program is a summer experience for pre-medical students
Dialogue
Dialogue regarding whole-person care occurs in several formats, including the Institute blog (www.siloaminstitute.org), speaking engagements, and periodic guest lectures, retreats, and workshops. If you would be interested to have Siloam staff or partners to speak at your church, ministry, organization or academic institution, please contact info@siloaminstitute.org.
Research
Siloam partners with local academic institutions to generate knowledge that shapes clinical outcomes, improves quality of care and fosters the formation of whole-person health caregivers. Projects to date have included studies to foster quality improvement in diabetes care, cost-effectiveness of TB testing, and an efficacy study of behavioral health consultant-assisted depression treatment protocols.