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For decades, Bread for the City’s medical home has been tweaking its model to better meet the complex needs of clients and reduce health disparities. Today, we are guided by a collaborative, trauma-informed approach that integrates primary care with dentistry, behavioral health, social resources, ophthalmology and wellness programs.

So what’s our vibranium? The glue that sets Bread for the City apart from standard medical approaches to care? I would argue that the spirit of social work is what enables the shared philosophy of collaboration and holistic service. And the spirit sits in each staff member — from medical provider to clinic coordinator, and also in the many social workers who join this collaborative team.

Nearly 5 years ago, Bread for the City imbedded clinical social workers into the standard primary care visit. Today, about 1/3 of all medical patients (600 patients annually) see a social worker or behavioral health specialist as part of their medical check up. Patients have access to a continuum of services— including behavioral health treatment, wellness coaching, support obtaining home health aids, and help accessing public benefits and other social needs.

The social work perspective that you cannot heal without taking into account social reality, lived experiences, and cultural beliefs have always been a part of Bread’s medical clinic’s success. Medical providers at Bread have always tweaked their approaches to meet patient’s choice, social reality, and trust in the process. You can’t treat diabetes with 3 medications when a patient has no access to a kitchen or a bed. You can’t refer a patient to a cancer specialist if they don’t have proof of their identity. You can’t convince a patient to change their diet if they don’t trust you. You can’t treat a patient’s insomnia if they don’t have treatment for the traumatic loss of their son. The list goes on.

From helping clients apply for public benefits to introducing patients to treatment for complex trauma, Bread for the City’s medical clinic has always known that social workers were critical to improving patient health. And so—as we mark a month to honor social work—Bread for the City’s medical home honors social workers and the spirit that imbues its clinic.

For those who want to learn more of the day-to-day work, read a snapshot of one day in my life as a clinical social worker providing behavioral health treatment and social services supports in primary care.