Advancing Health Equity in Pediatric Primary Care: The BLOOM Clinic’s Innovative Model for Black Children

Abstract

Health is a fundamental human right and families deserve health equity, a state where all children have the opportunity to reach their full health potential. Black families and children are disproportionately burdened with racial inequities in morbidity and mortality. Although evidence supports racially concordant care and wraparound pediatric primary services to address racial inequities, there remains a significant gap in developing and evaluating such clinics. Here, we introduce an innovative approach to pediatric primary care for Black children in Oakland, California, the Black Love Opportunity and Outcome Improvement in Medicine (BLOOM) clinic. Responsive to contemporary understanding of the racialized harms experienced by Black families, the BLOOM clinic combines racial concordance and culturally responsive care with extensive psychosocial support and resources to address social drivers of health for Black families. In this article, we describe the impetus, vision, mission, and objectives, structure and components, key outcomes, future research evaluation, challenges, and lessons learned from developing and implementing the BLOOM clinic. Key outcomes described include obtaining funding and institutional commitment, developing community partnerships, launching the clinic, implementing and providing services, and reflecting on the initial reception by staff and parents. The primary purpose of this article is to share the process and strategy of building this innovative clinic with others who may be interested in learning from the process in their own paths to advance racial health equity for Black children.

Keywords

African American pediatrics social drivers of health racial concordance primary care

Introduction

Health is a fundamental human right that is deserved by all children. Health equity is achieved when all children have the opportunity to experience their full health potential, and this state has not been realized.¹ Race-associated differences in pediatric health outcomes often arise due to the effects of racism.^2,3 An overarching system of structural racism—manifesting in systematically discriminatory laws, policies, and practices—has resulted in disparate distribution of resources, services, and opportunities for racialized groups, which leads to considerable harms, including health inequities.⁴ Black families have identified mental and physical health as an important component to thriving, in addition to financial security, quality of life, community and connections, safety, and belonging.⁵ Black caregivers have expressed their concerns about systems that contribute to health inequity and have called for interventions to mitigate the effects of structural racism and their impact on pediatric outcomes, such as having providers address social needs or offering racial concordance between medical providers and families.^6–10

Black children are exposed to persistent and pervasive racial inequities that impact their risk of morbidity and mortality across their lifetime, beginning in the perinatal period and childhood. Black infants are more likely to be born preterm, at lower birth weight, have less access to human milk and breastfeeding, and are at higher risk of mortality compared with White infants.^11–13 After hospital discharge, Black preterm infants continue to be at risk for morbidity and mortality.^14–18 Whether considering postoperative surgical complications or medical diagnoses, Black children are disproportionately burdened.^19,20

The hypothesized mechanisms of racial concordance improving health outcomes include culturally responsive care and increased community trust in the medical system that has proven to be untrustworthy.^21–23 Some studies have shown associations between racially concordant medical care and improved health care utilization and patient experience ratings, as well as lower health care expenditures.^24–27 Whereas others have had mixed or null results for satisfaction, partnership building, length of visit, and communication.⁶ Despite mixed findings, families consistently express desire for racially concordant medical services.^8–10 However, a lack of diversity in medical providers results in infrequent spontaneously-occurring racially concordant care, as only 7.4% of pediatricians identify as Black, despite a United States pediatric population representation of 14.4%.^28,29 In response to racialized health crises and community prioritizations, racially concordant health care models in the fields of obstetrics and gynecology and pediatric primary care have been created and are in development and implementation phases, such as the EMBRACE Clinic, Beloved Birth Group Perinatal Care, Black Centering Midwifery Group Care, and The Honeycomb Clinic.^30–32 In alignment, the American Academy of Pediatrics (AAP) states that pediatricians and health care systems must partner with community organizations and provide interventions through a lens of cultural humility.^8,9

Holistic care with wraparound services to address social drivers of health (SDH) has been proposed as a strategy to mitigate the racial health crisis. Given the long-lasting impact of structural racism, Black families are differentially exposed to higher levels of adversities and fewer protective SDH that impact child health.^33,34 In health literature, addressing SDH can improve children’s health outcomes and reduce avoidable health care utilization. The AAP recommends universal screening and SDH interventions to address the deleterious effects of racism on child health.¹⁰ Despite their potential, wraparound pediatric primary care services remain under-studied, including reduced health care utilization.³⁵

We introduce an innovative approach to pediatric primary care for Black children, the Black Love Opportunity and Outcome Improvement in Medicine (BLOOM) clinic.³⁶ Responsive to contemporary understanding of the racialized harms on Black families, the BLOOM clinic combines racial concordance and culturally responsive care with extensive psychosocial wraparound support and resources to address SDH for Black children. Here we describe the impetus, vision, mission, and objectives, structure and components, key outcomes, research evaluation, challenges, and lessons learned from developing the BLOOM clinic. The primary purpose of this article is to share the process and strategy of building this innovative clinic.

Impetus

The Federally Qualified Health Center (FQHC) in which the BLOOM clinic operates, UCSF Benioff Children’s Hospital Oakland Primary Care Clinic, provides a medical home for 36,000 patient visits per year. The clinic serves a diverse and predominantly under-resourced patient population in Oakland, California. Nearly 90% of the patients served are eligible for Medi-Cal insurance (California’s version of Medicaid), over 90% of families that the FQHC serves are families of color, and of those 40% identify as Black. Within the clinic, Black families have a higher risk of positive adverse childhood experiences screening and higher rates of unmet social needs.³⁷ Despite serving a racially diverse community, only 3.6% of UCSF faculty identify as Black.³⁸ The two founders of the BLOOM clinic, Dr. Dayna Long (Director) and Dr. Javay Ross (Medical Director), have served as pediatricians at the FQHC for 17 years (2007) and 11 years (2013), respectively. Dr. Long co-founded the Center for Child Community Health in 2013 and was co-PI of the PEARLS (Pediatrics Adverse Childhood Experiences and Related Life Events Screener) study in 2016. Dr. Ross has served as the Medical Director of the Alameda County Juvenile Justice Center since 2020. Both founders witnessed the impact of structural racism that families face firsthand as practicing pediatricians in the city of Oakland. Remarkably, both maintained patient panels with over 90% of Black-identifying families, which they have attributed to family requests and appreciation of their shared lived experiences that nurtures deep physician-family relationships and healing. Although the families in their specific patient panels were experiencing racially concordant care, there were still gaps identified. Drs. Long and Ross identified their goal of providing primary, preventative, multidisciplinary, and trauma-informed care as opposed to secondary recognition and intervention of social and health care needs. Early visions of this type of health care model included providing an in-clinic lactation consultation, nutritional support, and mental health support services to all clinic patients. The central framework for the development of the program was rooted in cultural humility and accessing the community and cultural wisdom of health care providers working alongside the community for decades. This team-based care model of wraparound support is consistent with the socioecological framework of providing support at different levels including individual, interpersonal, community, and organizational levels.^39,40 Patient-centered care and trauma-informed care models are also central to BLOOM clinic (see Structure and Components of the BLOOM Clinic section for incorporation of both).^41,42 Together, they presented the concept of the clinic over numerous meetings to administrative leadership, in the wake of the national racial justice movement paralleled by the global COVID-19 pandemic. After 3 years of fundraising, obtaining institutional buy-in, and planning, the BLOOM clinic launched in July 2023 (Fig. 1).

FIG. 1.

Timeline of BLOOM clinic key outcomes.

Vision, Mission, and Objectives

Recognizing the demonstrated needs of the local community, the following vision, mission, and objectives were agreed upon by BLOOM clinic leadership with the conception of the clinic: “We envision a space where Black children have the resources and support to flourish. The mission of the BLOOM clinic is to transform the standard for high-quality care that is timely, equitable, patient-centered, safe and effective for Black children in Oakland, California.” Two key objectives were identified in creating the BLOOM clinic: (1) To dismantle structural racism in pediatric primary care settings in order to deliver better quality care to Black children early in their development and (2) to address existing care gaps for Black children through holistic services delivered by racially concordant providers.

Structure and Components of the BLOOM Clinic

The BLOOM clinic is a novel health care delivery model offering racially concordant pediatricians and wraparound pediatric primary care services (addressing medical and nonmedical SDH) for Black families or families of other backgrounds desiring care from a team of Black providers. The comprehensive components of wraparound services supported by trauma-informed, racially concordant personnel are detailed on Table 1. The BLOOM clinic has five clinical components: (1) racially concordant pediatric primary care services; (2) primary prevention mental health care and response; (3) lactation, perinatal nutrition, and infant feeding support; (4) screening and addressing social needs and childhood adversity; and (5) peer support groups. Typical BLOOM clinic workflow for any given patient and their family is described in Figure 2. The BLOOM clinic is located within the FQHC and follows the usual referral mechanisms for pediatric patient families to the FQHC. Upon contacting the FQHC to request care for their child, or if already a patient at the FQHC, the BLOOM clinic is presented as an option for families who desire this unique care model, and if it is desired by the family, they are scheduled into the available BLOOM clinic sessions. Families are recruited into the BLOOM clinic if they are assigned to the clinic at the time of birth, if they have a sibling who is already seen in BLOOM clinic, from newborn clinic, or referred by a provider from another clinical service in the FQHC.

FIG. 2.

Typical BLOOM clinic initial visit workflow. BLOOM, Black Love Opportunity and Outcome Improvement in Medicine.

Table 1.

BLOOM Clinic Personnel^a and Services

Pediatric primary care	Primary preventative mental health care	Lactation and nutrition support	SDH resources	Peer support groups
Personnel
Three pediatricians^b	Social worker/mental health care provider^b	Lactation consultant^b	Family resource navigator	Lactation consultant and breastfeeding peer counselors^b
Medical assistantsLicensed Vocational Nurses
Resident physicians			Social worker	Resiliency clinic personnel^c
Services
Well child and sick visits	Screening for mental health conditions	1:1 Lactation support	Screening, referrals, and follow-through of SDH through FINDConnect^d	Lactation peer support groups (monthly)^b
Health screening: vision, hearing, development	Referral to outpatient therapy as needed	Breast pumping and breastfeeding supplies	PEARLS and referral to Resiliency Clinic^c	Black Joyful Parenting Peer Support Groups through Resiliency Clinic (weekly)^b,c
Vaccinations		On-site food pantry and referral to food bank as needed	Enrollment in 529 college savings account

Staff trained in trauma-informed care and cultural humility.

Racially concordant.

Resiliency Clinic: a culturally affirming, trauma-informed, parenting group focused on managing stress, promoting resilience, and strengthening relationships through mindfulness.

FINDConnect: a cloud platform to screen, refer, and follow up SDH locally.

BLOOM, Black Love Opportunity and Outcome Improvement in Medicine; PEARLS, Pediatrics Adverse Childhood Experiences and Related Life Events Screener; SDH, social drivers of health.

Personnel

Personnel include three primary care pediatricians*, a family resource navigator, a social worker/mental health provider*, a lactation consultant*, medical assistants* and licensed vocational nurses*. The majority of providers are racially concordant (indicated by asterisk). Staff working in the BLOOM clinic completed training in cultural humility and trauma-informed care through the Resilient Beginning Network, Mental Health First Aid, and through private consultation from the founder of the Multicultural Educational Program, Dr. Melanie Tervalon.^43–45 Aligned with the concept that cultural competency can never fully be achieved, but practicing from a lens of cultural humility is a perpetual process, staff are committed to regularly participate in these training sessions.⁴⁶ Delivering health care within the context of trauma-informed care honors individuals, family and community strengths, creates safety, builds trust, operates with transparency, provides peer support, empowers families, and contextualizes care within cultural, historical, and gender identities.⁴²

The clinical leadership also recognized the BLOOM clinic as a unique opportunity for professional development of pediatric residents at UCSF Benioff Children’s Hospital of Oakland. Residents can opt to work in the BLOOM clinic in addition to their primary care clinical home. Additionally, BLOOM provides a foundation for a novel scholarly concentration for residents who want to enhance their training with a focus on community advocacy and wraparound medical care for Black children. In addition, working with racially concordant BLOOM providers is a form of racial affinity group caucusing that provides a distinct mentorship opportunity and a type of antiracist curriculum.⁴⁷

Services

Standard pediatric primary care services are provided in well-child visits, follow-up, and sick visits such as vaccinations, vision, hearing, and developmental screening. In addition to pediatric medical services, families also receive holistic wraparound social services, such as connecting families to appropriate social services, screening for PEARLS, lactation support, postpartum nutrition education, support for educational attainment, financial literacy, and early relational health. All families are screened for social needs, referred to resources, and assisted with accessing resources using FINDconnect, an electronic medical record platform developed by Dr. Long.⁴⁸ One referral mechanism for families who screen positive for PEARLS is Black Joyful Parenting (BJP) which is a culturally affirming, trauma-informed, peer-based parenting group focused on decolonizing Black parenting by acknowledging and addressing parental stressors to encourage parental healing. Adapted from a 6-week Resiliency Clinic curriculum that has shown promise for reductions in toxic stress,^49,50 the BJP group promotes resilience through mindfulness, self-regulation, and co-regulation techniques⁴⁹ and makes space for caregivers to discuss how current and historical issues related to power, privilege, and oppression impact their family, while affirming and celebrating community and cultural parenting wisdom.^49,51,52 In addition, lactation and infant feeding peer support groups provided by the community-based organization, BreastFriends, are available to families⁵³ and are led by Black Doulas and Lactation Support Providers (e.g., lactation consultants and breastfeeding peer counselors). All families also have access to a racially concordant lactation consultant, free breastfeeding supplies, and culturally responsive breastfeeding education. Families who screen positive for food insecurity are referred to local community food bank organizations. Most BLOOM services are available to caregivers in-person or via telehealth in the first 3 years of a child’s life, with the exception of the BJP group that is held virtually.

Key Outcomes

From 2020 to 2023, the BLOOM clinic was envisioned, built, and launched by the BLOOM clinic team (Fig. 1). Drs. Long and Ross founded and led the BLOOM clinic initially through voluntary efforts, starting with envisioning the clinic and assembling a community-based team. As existing leaders at UCSF Benioff Children’s Hospital Oakland, in the FQHC, and the community, they built a team of staff and community partners with whom they already had long-lasting relationships and recruited additional members to fill gaps in expertise.

Explicit Institutional Commitment and Buy-in

In 2020, the founders hired an external consultant to mediate several conversations with UCSF leadership including the President and CEO of the UCSF Benioff Children’s Hospital and the Chair of the Department of Pediatrics, to advocate for institutional commitment and support. Regular meetings were held with other leaders at UCSF and the FQHC, and FQHC staff to obtain commitment and support. By 2023, the FQHC attendings and staff were committed to supporting the clinic and its services, including shifting existing full-time equivalents, recruiting and referring participants and official agreement was obtained for documented press release.

Funding

External funding was required for sustainability and security of the clinic, mainly salary support of the expanded medical team (e.g., lactation, social work) and research staff, as well as to support community celebration events. Through persistent fundraising efforts over 3 years, generous gifts from private philanthropic donors who have prioritized supporting projects focused on promoting equity were secured, totaling $1 million to support the clinic for the first 3 years. The majority of the funds were secured by December 2022.

Community Partnerships

The community has been integral to the BLOOM clinic’s foundation and development. The Family Accountability Board (FAB) was created in 2022 to advise the founding and implementation of BLOOM clinic and related research. The FAB consists of patient families from the FQHC and is led by a BLOOM Parent Leader. In addition to the FAB regular activities such as contributing to a resident training curriculum, the FAB has been regularly consulted throughout the BLOOM clinic’s development and plays a critical role in providing feedback to the research team. Our FAB leader meets monthly, and the entire FAB meets quarterly, and advises best practices for recruiting parents in the BLOOM study and provides consultation on recruitment materials and study design. In addition, community-based organizations and public health partnerships have been developed and continue to be cultivated.

Launch, Provision of Services, and Reception by Staff and Parents

In July 2023, the BLOOM clinic officially launched at a community-wide party and the first weekly clinic visits began. Through steady recruitment, referrals, and enrollment, over 800 visits occurred with 219 patients in the first 2 years. Even after increasing provider capacity from 2 to 3 attending pediatricians, the clinic continues to maintain a full schedule booking out at least 3 months, suggesting strong demand for the program.

In the initial months since clinic launch, parents have anecdotally described positive experiences and their preference for this clinic due to high quality of care, efficiency, resources, and provider compassion. Specifically, parents described their level of comfort and trust in providers, a sense of urgency and excitement to get into BLOOM clinic, a feeling of relief and safety and expectation that their child’s care will be different than the previous care they have experienced, and a general feeling of being on the right track toward positive health and healing.

Initiated Research

The BLOOM Study

An independent evaluation team was assembled to develop and launch the BLOOM Study, designed to understand the longitudinal experiences of Black families with children 0–3 years old in primary care generally and specifically within the BLOOM clinic. Proctor’s framework was utilized to organize implementation, service, and client outcome metrics for our pre–post study design with non-randomized comparison groups.⁵⁴ Our approach to evaluation was also informed by collaboration with family partners, consultation with the clinical team, and decades of experience in clinical intervention research informed by a range of theories. The research study will quantitatively describe Black families’ perceptions of the medical system broadly, their experiences in pediatric primary care, and their preference for racially concordant health care. The study team will explore how those factors are interrelated and how they relate to families’ engagement with primary care and emergency services, as well as caregiver and child health and wellbeing outcomes. In addition, the research study will examine if receiving care in the BLOOM clinic compared to care as usual is associated with improvements in trust of health care systems; fewer experiences of perceived racism and greater patient-centered care within the medical context; greater engagement with preventative health care and health behaviors (e.g., well-child visits, vaccinations, breastmilk feeding); and better social, physical, and mental health and well-being of patients and their families, such as child illness and caregivers’ experiences of social support, symptoms of depression, and hope for their child’s future. More details on the study aims and design can be found within our preregistration.⁵⁵ The research study plans to follow 200 families over 1 year in the FQHC using caregiver surveys and child electronic medical records data. The study began enrolling families in March 2024 and is ongoing.

The Mirror Study

The Mirror Study is a qualitative study designed to investigate pediatric residents’ experiences with providing racially concordant care and receiving racially concordant mentorship while training at the BLOOM clinic. Interviews and focus groups were conducted with Black-identifying pediatric residents who work in both the primary FQHC clinic and BLOOM clinic to achieve these aims. This study has concluded and findings have been submitted for publication.⁵⁶

Challenges, Lessons Learned, and Looking to the Future

Several notable challenges were experienced by BLOOM clinic leadership and staff including criticism, lack of financial support, and minority tax (i.e. the additional burdens placed on underrepresented faculty to lead diversity-related efforts without adequate recognition or resources). There were challenges and successes while developing, launching, and implementing the BLOOM clinic, particularly how various invested individuals perceived both its necessity and potential impact on the community.

After establishing the clinic, the patient care within the BLOOM clinic itself has been especially demanding, given the high medical and social complexities that are experienced by the patient population served, and the subsequent care coordination required to address them. Black-identifying providers, who have their own lived experiences with these inequities, working closely with families to navigate systemic racism barriers and its downstream consequences additionally compounds on baseline stress and vicarious trauma experienced. As a result, staff experienced increased compassion fatigue while providing medical, social, and emotional care, which improved as the team and reflective supervision practices were developed.⁵⁷ Staff-suggested solutions for sustainability included reduced patient loads per clinic session, increased nursing support, protected time, and financial support for the non-physician workforce including the community health worker and lactation consultant. Additionally, sustaining the clinic will require longitudinal and dedicated funding.

Despite facing challenges, the team continues to be inspired by their patients and committed to building this community in solidarity and cultivating pediatric primary care spaces that empower and support Black children and their families to thrive, in the Bay Area and beyond. Future goals for the BLOOM clinic include home newborn visits, basic financial supplementation, and expansion of services to children >3 years old.

Conclusion

The BLOOM clinic is an innovative care model of racially concordant providers and wraparound pediatric primary care services, created with the vision of a world in which Black children have the opportunity to realize their full potential in health, wellness, longevity, and the pursuit of happiness. The BLOOM clinic was developed with substantial dedication and intentionality and its team has faced significant challenges. BLOOM’s impact on children and their families is being evaluated and results are forthcoming. We provide this description of the process of BLOOM clinic development in hopes that others might utilize this information in their own pursuits so Black children everywhere might BLOOM.

Authors’ Contributions

K.L.K. conceptualized and designed the article as well as initially drafted and revised the article. D.L. and J.R. developed the article, obtained funding for and launched the clinic, and conceptualized, revised, reviewed, and provided supervision for the article. N.R.B. and A.N.-Z. contributed to data curation (BLOOM study activities described within), content, supervision, revision, and review of the article. H.W.-B., A.A., N.F., C.H., J.M., J.W., I.V.A., C.W., and A.Z. substantially contributed to data curation (BLOOM activities described within), as well as content and revision of the article. All the authors approved the final article as submitted and agreed to be accountable for all aspects of the work.

Footnotes

Acknowledgments

First and foremost, we want to thank all of our families who inspire us to BLOOM. We also want to thank Brandi Gates-Burgess, Roberto Mok, Susan Yang, Lourdes Juarez, Alejandra Plata Zungia, Lisette Mazon, Gena Lewis, Pat Chase, Rhonda Burton, Joyclyn Garrette, Nai Pharn, Tina Smith, Lee Atkinson-McEvoy, and George Weiss. Without your help and dedication, we would never have launched.

Author Disclosure Statement

The authors have no personal or financial conflicts of interest to disclose.

Funding Information

The BLOOM Clinic receives financial support from the Lisa Stone Pritzker Family Foundation, the Stupski Foundation, Sunlight Giving, and Genentech, as well as anonymous donors.

Abbreviations

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