Shireen: In today’s episode, we are in conversation with Dr. Donna Persaud who shares how a safety net health system like Parkland Health is thinking about local communities and building an infrastructure that supports their basic needs that can in turn improve health outcomes. Stay tuned.

Dr Persaud  is a pediatrician and medical director of homeless outreach, medical services and community health needs initiative projects for Parkland Health. Her career has been dedicated to improving the quality of health care and outcomes in underserved populations. Welcome, Dr. Persaud. Thank you so much for joining us.

Dr. Persaud: Thank you so much for this opportunity. 

Shireen: Absolutely. Dr. Persaud, kicking things right off, can you talk a little bit about sort of your background and your way into Parkland Health and who Parkland Health really is in the Dallas community?

Dr. Persaud: Well, Parkland Health is regarded as the safety net in the Dallas community and we have an expectation to deliver high quality health care and service to all the residents of the county, regardless of their ability to pay or have health insurance. And as such, we have a commitment to raise the level of health in the Dallas community at large. And how did I get here?

Shireen: Yeah. So what was your journey? 

Dr. Persaud: Well, my journey is I come from a multinational family, my parents, third world and they were both passionate about helping people. They felt that getting a good education was the way that those that were disadvantaged could get an opportunity in society and beyond that, the society would benefit as a whole if those who did not have opportunities could be advantaged.

So my mom was an English teacher, creative English teacher. My dad was a principal in a tiny fishing village high school in the third world rural area. And I watched the two of them invest their time and energy in really reaching out to the families, supporting them with food. My dad would also do classes for the parents after hours and my mom would use the local dialect to help the children to understand how to verbalize Shakespeare.

And over the course of three years, they raised the academic performance of those children to become competitive with the city high schools. And also they went on, many of them, a higher proportion, very high proportion, went on to get professional degrees and careers. 

And putting that together with an experience I had first year intern in residency trying to discharge a young black American little boy home and mom after an ICU visit from the wards and there were problems with his medicaid. So the refills, the medications couldn’t be paid for that day. And also he needed nebulization treatments and the mom was going to get her electricity cut off the next day because they couldn’t pay the electricity bill. 

And this really what came to me in that moment was how policy, health insurance system issues, poverty, lack of education really played into my ability to deliver health care. And I decided at that moment to dedicate my career to serving underserved children and families.

Shireen: What, what just a remarkable journey Dr. Persaud. And I think it’s got to be so rewarding to see that come full circle in your own life and be able to impact the lives of those within Dallas community and I want to talk a little bit more about that. Tell us more about and I know there was a lot of things you mentioned in your bio, help us understand your role a little bit more within Parkland Health and what your role in turn does to serve the Dallas community or the Dallas County community.

Dr. Persaud: Sure, I have two key roles at Parkland. One is I’m the medical director for the homeless outreach medical services. And my role there is to make sure that the health care quality and delivery is the best quality standards handling the schedule. We cover 27 shelters in a two week period with three fixed sites and five mobile units. One of which is a dental mobile unit so involved with delivering that service and additionally, working with other homeless serving agencies in Dallas housing for the House Office of Homeless Solutions. The health department working with them to innovate and provide wrap around services for these individuals so that they can become healthier and their life as a whole and their issue of homelessness can be addressed. 

The other role I have is dedicated as the medical director, expert for a group of population level initiatives, referred to as a community health needs initiatives. The CHNA initiatives that are dedicated to advancing equity in those zip codes that are disadvantaged where there’s socioeconomic disadvantage and those are correlated with poorer health in a number of ways. And then I guess the other would be, of course, continuing to collaborate with other agencies. 

Shireen: Within the community Health Needs Assessment, I would like to peel back a little bit on it. You know, we talk about SDOH and how there are other factors that impact health. Can you shine a little bit more light on that and give us maybe a couple of examples so we can understand how exactly health is impacted by those supporting mechanisms around us.

Dr. Persaud: Sure. And when we look at what we really find in the community health needs assessment is what is termed health and equity or health disparities. And that means that you find differences between populations that are accounted for by socioeconomic disadvantage. So you find differences in disease rates, deaths from cancer, late diagnosis of cancer, poorer outcomes with mortality, hypertension, diabetes.

And when you look at what is happening, there are key things we find: there’s lack of access to insurance and and health care quality. Those are the main ones in the delivery and how services are actually delivered and access. And then we find as well the conditions of the lives don’t allow them to do what you want people to do to be healthier. They don’t have walkable neighborhoods. Their electricity gets shut off. They don’t have access to homes, they don’t have access to food. They live in a food desert, as you say, get fresh food. Their quality of education is not high and you provide to them written information that is in a language and a grade level that is beyond theirs. 

So those are examples of, you know, that’s what we mean by health disparities and what we found in 2019, and then just in 2022, is we have differences. For example, there’s a greater than 20 year life expectation between the most affluent zip code in Dallas and the worst off in the 75216, 7, and 8. And that is attributable to earlier deaths from heart disease and cancer mortality and diabetes. And when we look at those, what we find is, for example, blood pressures are not as well controlled in individuals that are from poorer neighborhoods. 

And we find in the poorer neighborhoods that there’s lack of access to health care, less transport, there’s not coverage with insurance. So there’s lack of coverage. And when you look at the number of doctors and we’re primary care doctors, specialists within transport, accessibility, you find that there are barriers to the access of care because of all of those things they’re not present. They’re not in their neighborhood and they’re not in their culture.

Shireen: That is so fascinating. And you know, you mentioned the homelessness piece just a second ago, what are these barriers and how does something like homelessness really impact our health? Can you help us sort of make that connection?

Dr. Persaud: Sure. So I think to back up a little bit and talk about what causes homelessness. So most people look at the homeless individuals that they see and look at them and say, ok, you seem uneducated, you have been involved with drugs, it looks like you have mental health issues. You’ve been involved with crimes. So these must be the causes of why you’re homeless or it’s your choices, you didn’t do well at school, you didn’t want to go to school. That’s why. 

And when we’ve looked at the research, you find that those things don’t appear to be the biggest predictors. The research has found, for example, Mississippi has way more poverty, more poverty than and mental health, et cetera than say California, but there’s not as much homelessness in Mississippi and compared to California and what that is is what really makes a difference is affordable housing and access to affordable housing. 

Most people who are homeless or house insecure, they couch couch surfing or living in cars or on the streets or in shelters, many people in the shelters have jobs at least part time jobs or they’re working two jobs and they cannot afford a place to live. So there’s something like 30 people competing for one place in Dallas. In New York, it’s worse.

So when you look across the country, you see that affordable housing is really the causal issue and it’s not elastic, it doesn’t keep up with the ability and the populations. And what you’re seeing is individuals who are vulnerable, who have health conditions, mental health conditions, in the justice system. Those are the individuals who are likely to end up, and of course women with domestic violence or some incidents in the house puts a low family quickly in this issue where a job loss or something, a tragedy in the family paying bills, bankruptcy. They end up on the streets. 

Once you’re homeless, then you add that. Once you’re homeless, you don’t have a place for your belongings, you lose your driver’s license, you lose your documents and the same thing with the justice system, you come out and no one will hire you. You can’t get your documents easily, you can’t maintain them. Someone needs to mail something to you. You have no address. We have our patients can’t be easily treated for hepatitis C, for example, because the medicine is very expensive and it has to be shipped to the home or to a mailing box of the individual. 

We’ve developed ways to handle that, but we’re a system that can do these things. So then, and then living on the streets, their feet, they get bitten by things, they get hurt by other people. If you, if they have diabetes, where will they keep their insulin? They’re down their fridges and even in shelters, in shelters, there are rules, the meals are given a certain way. The meds are held in a certain area. So you really add insult to injury if someone is homeless, that itself is being regarded as a clinical condition, you have the clinical condition of homes, that is a risk factor and that will impact your health negatively.

Shireen: Thank you for framing the problem so well. And which leads me to then how does at Parkland, then Dr. Persaud, really be able to address some of these barriers and combat these barriers. So like you mentioned, right? It’s a, you start out from something that there’s there’s core challenges that lead to the homelessness and now that that has happened now it has ripple effects in your health, right? And the more that it’s being delayed, I can only imagine the cycle only worsens from there. 

So how does at Parkland Health help someone overcome these barriers? And also our listeners are all across the United States, how does a health system? Really? And if you can just speak to broad terms as well, how does a health system, especially a safety system like yours help someone overcome that?

Dr. Persaud: So I’m going to talk a little bit about the population that experience homelessness and also how Parkland as a system addresses health inequities as a whole because that is, that is what moves people into homelessness. So we have to deal with that as well. So for the individuals who are homeless, I think the best thing to discuss is the recent successes that we’ve had in Dallas and across the nation with veterans.

And what has been done with veterans. If you look at veterans, they’re regarded as important because they serve the country, that many of them who are homeless are also of color, have been involved with the justice system, have a history of trauma and being violent and having issues with interaction, mental health, drug use, PTSD. And there are improvements with the veterans and what has been done has been to identify the veterans provide and peer counselors and wrap around services. 

And what wrap around services are is you give them the health care that they need, make sure that they’re getting to, they’re covered, they’re getting to health care, they get primary care appointments, specialty appointments in a timely way they get medications and also they get rehabilitation and support the social support.

If they need mental health, they get it. If they need transport. If they’re disabled, they get into services for transport and housing is provided through various means. Investing in the market in dedicated housing, supportive housing is one option, coupons and assistance for a period of time until they are working. And so we’re seeing a decrease in veterans and so it’s the application of those principles to other individuals that are not veterans that we’re looking at.

So the shelter agencies, first of all, we partner with shelter agencies that is where we deliver care. We’re not on the street, taking people off of the street. And the reason is that we’re really collaborating with the shelter services. And we also have, in addition to the traditional medical providers, dentists, we have peer navigators that have had the lived experiences as well and mental health services and they’re coordinating with the case managers around.

When will this individual get housing? Are they getting to mental health? Our social workers know about the system around. How do you get into employment? How do you address legal issues? What are all the supplemental food, housing assistance, employment finance, all the shelters have multiple educations for education, getting your GED, finance, independent. How do you budget all of this together? 

So the approach to individuals is not delivering health care ad nauseam. Well, we are but tracking populations and groups of individuals and seeing that we’re moving them in the right direction. For example, we have a medication assisted treatment program for those experiencing homelessness and our measures of whether we’re doing things. And also it’s a way of measuring ourselves and making sure that what we’re doing is progressive, is looking at their relationships, their employment issues with the law, staying sober, going to support. Those are what we are measuring to see if we’re improving their lives, not just being off of drugs. So that’s the approach. 

For the population at large, we initiated a set of nine plus now projects in certain zip codes where we’re doing three things, our population level, we provide community access points so that individuals can get help with signing up for health insurance and being paid for at Parkland. 

We do health screenings. We train community health workers to help with those individuals. We hire from the community as an equity anchor. We work with agencies that train health care workers to provide internships at Parkland and also in the community. So the community gets invested in. We look at our contracts, are we allowing those individuals the ability to bid? So raising the social environment by investing in it is also a way to improve health because if you do that, you improve health. So there’s access screening investing and then long term sustainability.

Also, we want the community to be empowered, not being acted upon. So we have a patient families advisory group that is participatory in the projects that we’re involved in giving feedback to the community health workers and to Parkland. Is this what you need and really fostering that participation, empowerment, engage, engagement and their own advocacy.

Shireen: And you know, Dr. Persaud, in the last few minutes we have here, how do you see this sort of going, you know, for someone who’s not in the Dallas area? Right. What are those resources that perhaps they have available? How does one even start to work if they’re a caregiver for their audience here? How does one start to understand? What are the resources that are available to me? What is this infrastructure that has been created that I can possibly tap into? Where does one begin?

Dr. Persaud: So there are many online social agency search engines and what is neat and I can’t remember at this moment hours. But one of the things that health care systems are doing is as a standard, all the intake on patients includes an assessment of social drivers of health. What is your home situation house? Are you on food stamps? Do you have transport? What is your support in the home? 

And we at Parkland have an online service where we do referrals and also we are beginning to track screen track referrals to see that agencies are responding for these individuals and helping them so that the factors that are really driving their health, diabetes hypertension are being addressed at the same time.

And so local agencies, the shelters, they all know Parkland that they also use online services that tell them in the community who’s out there doing what, who are all the homeless serving? Who are all the food pantries? The top ones tend to be homes, food pantries and transport. Churches, we do lots of churches, rehabilitation centers, not for profit organizations, there are many. 

And the great thing is that everyone knows we can’t go out there and do one thing. We also can’t boil the ocean, but we’ve got to do more than one thing to handle, you know, three or four critical needs in an individual and community’s lives to get their health to be improved.

Shireen: Thank you so much for sharing and, and doctors at this point, we are toward the end of the episode. At this point, I would love for our listeners to know how they can connect with you and then just learn more about your work.

Dr. Persaud: Sure. Well, of course, you can use the Parkland website where the Parkland is also on it, on Instagram, Facebook and LinkedIn. I have a profile on linkedin. If any professionals want to send me a message, that’s the way that you can get in touch with me. But our website has an email feature, chat feature. It’s easy to get in touch with Parkland. This work, we get lots of queries. So I’m sure they’ll be guided to the correct place.

Shireen: Thank you so much for your time again, Dr. Persaud. It was such a pleasure chatting with you here today.

Dr. Persaud: It was a pleasure as well. I’m so pleased to have had the opportunity to provide this information to your audience.

Connect with Dr. Donna Persaud:

Parkland Health

LinkedIn