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Bridges of Health: Puentes de Salud

Penn nurses attend to the physical and mental well-being of Philadelphia’s Latinos. From the greeting at the front desk - Bienvenidos a Puentes de Salud - to the meeting with the enfermero practicante (nurse practitioner), this clinic is all about making the patient sentirse comodo (feel comfortable).

Puentes de Salud is a one-of-a kind, nurse-led clinic for the Latino population, just across the south Street Bridge from Penn Nursing. Established by University of Pennsylvania healthcare professionals in 2003, Puentes cares for Mexican immigrants - many undocumented workers without health insurance. 

It is an ever-growing mission, explained Martin Camacho, GNu’03, MSN, ACNP-BC, a lead health provider at Puentes and director of its nurse practitioner residency program. “Because of the precarious status of undocumented immigrants in this country,” he said, “they often approach healthcare providers with trepidation and are skeptical about whether to receiver services at all.” 

With a bilingual Latino health team, Puentes provides treatment and wellness services ranging from diabetes care and an after-school reading program to dental exams and behavioral health consultations for approximately 100 patients during the clinic’s twice-weekly hours. 

“Puentes is really who I am,” said Mr. Camacho, who was born in Puerto Rico. “Being able to give back to the Latino community has been so important to me. It has helped me maintain my native identity. Becoming Americanized is very subtle - you find yourself dressing differently, eating differently, not speaking in your native dialect as frequently. Through Puentes, [my native identity] has been rekindled, and it brings a different quality to my clinical practice.” 

The Culture of an Office Visit

Hola, coma esta?” Mr. Camacho greets his patient, a Mexican man in a black T-shirt and paint-flecked pants. A longtime patient at Puentes, he has returned for a follow-up visit to discuss his diverticulitis.

Steven Cabrera, Nu'13Steven Cabrera, Nu'13

Mr. Camacho took the lead in the visit, demonstrating physical assessment techniques to Penn Nursing student Steven Cabrera, Nu’13. The camaraderie with the patient is clear. They all converse in Spanish, and Mr. Camacho explains every step of the exam to his patient, looking him squarely in the eye and leaving time for questions. At the end of the visit, Mr. Camacho puts a firm grip on his patient’s shoulder, offers a strong handshake, and coaxes a laugh out of the quiet man with a joke. 

Even among Latino cultures, said Mr. Camacho, “it’s a delicate and careful process to understand another culture and history. I need to take into consideration other traditions and influences, and sometimes subtle differences in language.” 

He also considers health issues in the context of a patient’s customs and traditions to yield better outcomes. “You really have to dive into the culture to learn the flavors, to learn what healthcare really means to this population. Like most thing, it takes time,” said Mr.Camacho. 

Being at Puentes “is like a homecoming,” said Mr. Cabrera. In striking serendipity, his family hails from the same Mexican town as many of his patients. Mr. Cabrera started as a volunteer at Puentes in his freshman year and has become the clinic co-coordinator. He plans to become a nurse practitioner and aspires to open a Puentes-style clinic in Mexico. 

Much of what Mr. Cabrera learns comes from working with Mr. Camacho, who is a lecturer and clinical preceptor at Penn Nursing. He conducts research and serves as a peer reviewer for journals in advanced practice nursing, critical care, and emergency medicines. He received the Penn Alumni Association’s Recent Alumni Award for Clinical Excellence in 2007 and is a member of the Honor Society of Nursing. Before entering nursing. he was a U.S. Navy Corpsman with the Fleet Marine Force, Camp Lejeune, N.C. 

Both Mr. Camacho and Mr. Cabrera are proud of the impact of Puentes in the community and the influence of nursing at the clinic. “We are lending a nursing voice to a truly interprofessional group of healthcare providers with the common goal of delivering quality healthcare to a population in need,” said Mr. Cabrera. 

From Mexico to 9th Street 

Italian Market Section at 9th Street and Washington Avenue.Italian Market Section at 9th Street and Washington Avenue.

The local Mexican population has a large presence in Philadelphia’s Italian Market section at 9th Street and Washington Avenue where the shopping and restaurant district yields employment. 

Since 2000, the U.S. census has found Latinos to be the largest minority group in the United States. Economic instability in Mexico and the U.S. demand for low-wage, unskilled labor have fueled the influx of Mexican immigrants. A high percentage of this populations works in low-paying jobs, lacking insurance and access to healthcare, and facing language and cultural barriers, 

These challenges make the behavioral health component at Puentes particularly important, said Mr. Camacho. “Coming to America takes a substantial physical and mental toll,” he explained. “These men and women are working all kinds of hours, often in physical labor. They are hearty and proud. But the stress and anxiety of the transition to a new country and what it took to get here is still fresh.” 

The Puentes team is alert for signs of depression. They are also attuned to this population’s rates of hypertension and diabetes, which can be attributes to fluctuations between American and Mexican diets. Some Mexican-Americans lean toward a diet high in saturated fats, cholesterol, and salt, with poor intake of fresh fruits, vegetables, and fiber, and those in a low socioeconomic status find easier access to less nutritious options, said Mr. Camacho.

The comprehensive wellness strategy at Puentes reflects the social Determinants of Health outlined by the World Health Organization, which highlights “the profound impact that education, child development, literacy, social inequality, job security, physical and social environments, food security, discrimination, and access to services and social safety nets have on health outcomes.” 

Puentes’ History

Steven C. Larson, MD, Penn Medicine emergency room physicianSteven C. Larson, MD, Penn Medicine emergency room physician

Puentes began with a nurse. Margaret Harris directed Project Salud, launched in 1985 in
Kennett Square, near the migrant farm worker community. As a volunteer there, Penn Medicine emergency room physician Steven C. Larson, MD wanted to bring the nurse-managed practice model to the Latino community in Philadelphia. He teamed with Margaret M. Cotroneo, PhD, APRN, now associate professor emerita, to create a collaborative, interprofessional setting with providers “who have the right tools for the right job.” 

Dr. Larson highlighted that, “The biggest frustration of healthcare is that various health professionals still haven’t learned to play well in the sandbox together. Puentes dismantles the ‘I’m the doctor, you’re the nurse’ model. We are a team. We are about true patient-centered care.”

Shifting the axis of healthcare delivery to this model is a signature facet of Mr. Camacho’s role at Puentes. “We work hard to have an impact on healthcare delivery, not just provide it,” he said. To accomplish this, educational opportunities for healthcare providers are a cornerstone of the program. Nursing students in their third and fourth years have the opportunity to work as triage supervisors. Nursing and medical students from Penn and neighboring universities are volunteers. 

From the start, Puentes intentionally decentralized the role of the physician, creating an interprofessional model in which promotoras (trained, volunteer “health promoters”), nurses, nurse practitioners, students and physicians collaborate as equal partners to care for the community. 

“Puentes can be a voice for the community to get better quality healthcare, become better educated about their health, and advocate for their own well-being,” said Mr. Carbrera. At the end of a Puentes shift, he said he gets more than he gives.

“It’s a place where I can apply what I’m learning in nursing school about leadership and advocacy,” he said. “It’s about being more than proficient, but rather seeking to serve above and beyond.”