This podcast and blog post is presented by the National Nurse-led Care Consortium (NNCC) and describes the unique needs of residents of public housing, underserved racial and ethnic communities, and other special and vulnerable populations and the role community health centers can play in addressing healing and trauma recovery. The below blog post will detail the examples presented in the podcast and provide additional resources for health centers.

What is trauma-informed care?

In this episode, our speakers deliver a topical conversation on trauma-informed care, defined here as recognizing and responding to the impact of traumatic stress while treating all patients and providing psychological safety. Though frequently used in the workforce, the psychological safety mentioned in this episode is regarding patient-provider relationships. As a fundamental tool in trauma-informed care, psychological safety aids in building trust between the patient and provider, helping patients feel they can share anything and fully be themselves without fear of being scrutinized or diminished. Cultivating this type of care requires a holistic systems approach to generate patient-provider relationships through a trauma-informed lens. Trauma-informed care often utilizes the trauma-informed approach developed by the Substance and Mental Health Services Administration (SAMHSA) for the best quality care and efficient care planning.

Trauma-informed model in Practice 

Implementing trauma-informed care requires a culture of professionals to understand and recognize the symptoms of trauma. In practice, providers should put the patient at the center of the care team and address the whole person when caring for patients. Whole-person wellness refers to treating not only the patient's symptoms but understanding and considering the impact of non-medical drives of health that may affect the patient. In this episode, Kathleen and Sara share the importance of health professionals developing strong interpersonal skills, including active listening, self-awareness, deepening compassion, and self-regulation for whole-person wellness. 

Why trauma-informed care?

By following the principles of trauma-informed care, both patients and providers can receive benefits. Trauma-informed care allows patients to feel empowered and in control of their health. Following the trauma-informed principles, patient-provider power dynamics are deconstructed,  and a healthier trusting relationship is created. Patients are met with humility and safety, creating a space for more transparency and openness with providers, leading to more collaboration in their care plan and long-term positive health outcomes. 

Health Workforce Impact 

While treating and serving communities heavily impacted by traumatic stress and adverse events, the healthcare workforce and retention can be negatively affected. In this episode, Kathleen shares staff grounding exercises that hold space for office affirmations and check-ins before meetings. In return, these practices and reflections amongst the staff aid in not only mitigating burnout and staff turnover but also helping providers to see patients as they see themselves. 

Meet the speakers

Kathleen Metzker is the Director of Integrative Health and mind-body services at the Stephen and Sandra Sheller 11th Family Health Services at Drexel University in partnership with the Family Practice and Counseling Network, a federally qualified community health center (FQHC) in Philadelphia. This FQHC serves a community populated primarily with Black Americans, people negatively impacted by the social determinants of health (SDOH), including public housing communities. Many children utilizing this health center are at increased risk for adverse childhood experiences that impact their minds and bodies later in life. In this episode, Kathleen shares implementation strategies you can replicate in your health center.

Sara Reid is a health educator, support group facilitator, and consumer board member for Boston Healthcare for the Homeless. Boston Healthcare for the Homeless serves communities facing substance use disorder, asylum seekers, and those seeking gender-affirming care. Sara also trains health professionals to deliver the highest quality of care. In this episode, Sara shares best practices of care planning and treating the “whole person.”

Additional Resources

Click Here for more information on getting your organization coaching on implementing trauma-informed practices in your health center!

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Support for this episode comes from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). It is part of an award totaling $550,000 with zero percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government.

In 1999, President Bill Clinton signed into law one of the most consequential pieces of housing legislation, but unless you’re an urban planner or housing advocate you probably have never heard of the Section 9(g)(3) of the United States Housing Act of 1937, more commonly known as the “Faircloth Amendment.” Named for Senator Lauch Faircloth (R-NC) who inserted the amendment into the law, it was at the time an obscure section in a package of new rules that made accessing public housing more costly and difficult for individuals and communities across the country. The National Low Income Housing Coalition called the Faircloth Amendment, “the most counterproductive part of this troubling public housing law.” 

Simply put, the Faircloth Amendment effectively makes it illegal for the federal government to build or fund the development of more public housing. Because of this law, the number of public housing units cannot increase more than the number that existed on October 1, 1999. It’s an artificial barrier that prevents policymakers from using a major tool to address our nation’s growing housing crisis.

Since the Faircloth Amendment became law nearly 21 years ago, the U.S. population has grown by about 51 million and the inflation-adjusted median cost of buying a home in the U.S. has risen 36.83% from $198,612.11 to $271,768.42. This is all happening while there is a $70 billion backlog in funding for maintenance and repairs to existing public housing stock. With rising population and housing costs, and deteriorating public housing the need has never been greater for secure housing and smart policy solutions. The COVID-19 pandemic makes this crisis even more obvious and urgent.

When America was faced with another housing crisis in the 1930s, the federal government responded by building millions of new homes. Public housing at mid-century was described by the Economic Policy Institute as, “highly-prized treasures, the most desirable housing available, their lucky residents the object of envy.” Public housing was an asset that gave families security and enabled them to build wealth, but these treasured homes were constructed in white neighborhoods for white families. As we have written before, the history of housing policy in the U.S. has always been interconnected with race and racism.

If we’re to tackle our nation’s housing crisis, especially during a pandemic that requires so many of us to be at home, we need evidence-based policy solutions. “This rule effectively and arbitrarily limits supply while making it difficult to increase the supply of affordable housing in local communities,” testified Anthony Scott, CEO of the Durham Housing Authority to the U.S. House Committee on Appropriations in March 2019. Scott described the Amendment as “unnecessarily” shackling local communities and preventing the development of new affordable housing. He concluded: “Simply put, the Faircloth Amendment needs to go.”

As public health advocates and healthcare providers, we can support legislation proposing to eliminate the Faircloth Amendment, while also championing fair and equitable housing policies.

Housing insecurity is one of many impacts of COVID-19, and one of the many aspects our nation must tackle during this crisis. It's essential to understand public housing infrastructure to build on it and improve this system for the millions of people who rely on local and federal government assistance for stable housing. Health centers serve over 28 million patients across the country from a variety of historically under-resourced populations, including those living in public housing. For healthcare practitioners, understanding the nuances of the housing programs patients and clients utilize can paint a picture of the lived experienced of the communities they serve.

U.S. Department of Housing and Urban Development (HUD) Programs/Services:

1. Housing Choice Voucher (HCV)

The Housing Choice Vouchers (HCV) program (commonly known as the tenant-based arm of the Section 8 program) is designed to provide residents of public housing with increased mobility and choice by enabling them to select housing options from the private market. The HCV program has grown exponentially since its inception in 1974; to date, over 21% of all renters receiving federal assistance are supported through HCVs, making it the largest single program under the public housing umbrella. Individuals apply for HCVs through their local public housing authority (PHA) by meeting eligibility requirements set by the PHA (though generally, individuals are eligible if their income is at or below 50% of the area’s median income). PHAs then determine both the suitability of the resident’s housing selection and their required rent payment. Individuals using HCVs pay 30% of its monthly adjusted gross income for rent and utilities, and if the unit rent is greater than the payment standard the family is required to pay the difference. Due to the volume of applicants for vouchers across the country, many cities have years-long waiting list or have closed their voucher application process indefinitely.

2. Project Based Voucher (PBV)

Like the HCV program, project-based vouchers (PBVs) subsidize rent for individuals and families who qualify for housing based on their income. One key difference between the HCV and PBV programs is the relationship between local housing authorities and private landlords. Under the PBV program, PHAs contract with landlords to designate one or more units for subsidized housing. Landlords then accept PBVs from families deemed eligible by the PHA. The typical criteria for resident eligible is similar to the qualifications needed to obtain HCVs: the majority of PBV recipients have “incomes not exceeding 30 percent of the local median or the poverty line, whichever is higher.” Families usually contribute 30 percent of their income to rent/utilities while HUD (through PHAs) provides the remaining funds for the unit. To increase flexibility within the voucher program, HUD allows PHAs to convert up to 20% of their HCVs to PBVs if necessary, and enables them to combine waiting lists for both voucher programs to streamline assistance.

3. Project-Based Rental Assistance (PBRA)

The Project Based Rental Assistance (PBRA) program operates through HUD’s Office of Multifamily Housing Program, where HUD directly engages in a Housing Assistance Payment (HAP) contract with private owners to provide subsidized units for low-income tenants. This project-based rental assistance is attached to specific units in a housing development/property. Ninety-six percent of residents in this program have incomes that are less than 50% of the area’s median income. In 1983, in an act that still stands today, Congress disallowed the construction of new units built in connection to the PBRA program.  However, funding remains available today for landlords to renew existing HAP contracts as they continue to provide rental units to individuals in need. Recent examples illustrate this fact, as $800 million of CARES Act supplemental appropriations went to roughly 16,500 properties with established PBRA contracts to help “maintain normal operations” during the COVID-19 pandemic.  

4. HUD’s Public Housing Program (i.e. local PHAs)

HUD distributes federal funds to approximately 3,300 housing agencies throughout the country to ensure eligible, low-income renters can live in affordable housing. Currently, approximately 1.2 million households utilize HUD’s Public Housing Program, which encompasses tradition, PHA-run units. Though income limits may vary based on location, these limits set by HUD for the Public Housing program mirror those of other public housing programs (the lower income limit is set at 80% of the area’s median income, with very low-income limits set at 50% of the area’s median income). Once eligible, residents will either be put on a waiting list or offered a lease for a public housing unit. Typically, gross family income determines the amount of rent, or Total Tenant Payment (TTP), to be paid each month. In other cases, housing agencies use a specific formula that assesses additional financial variables to determine the TTP for each family. Public housing through this program should remain available to residents if they adhere to program rules and regulations.

5. Low Income Tax Housing Credit Program

According to HUD and the Office of Policy Development and Research, the Low-Income Housing Tax Credit (LIHTC) “is the most important resource for creating affordable housing in the United States today.” The LIHTC supports the creation or rehabilitation of roughly 111,000 affordable rental units each year. This is currently the largest federally funded affordable housing creation program, costing approximately $9.5 billion per year. Born out of the Tax Reform Act of 1986, LIHTC facilitates the disbursement of federal income tax credits as an incentive to private developers so they can invest (rehabilitate, acquire, construct, etc.) in low-income rental housing units. State and local housing agencies have the authority to allocate the incentives through a competitive process that, again, focuses on the ability of the developer to create affordable housing. To qualify and receive this credit, developers must agree to a “use restriction” to ensure that the property will have appropriately priced units. Though tenants cannot technically enroll into this program, it is important to note just how integral the LIHTC program can be in housing this vulnerable population.

Healthcare providers are entrusted with the health and wellbeing of those residing in subsidized housing, whether through a voucher or traditional public housing unit. To that end, providers should be equipped to offer resources and assistance to families as they navigate this complex landscape to ensure that housing – a key social determinant of health – is incorporated into a holistic plan of care.

Kevin Leacock contributed to this blog post.

You can’t follow the Stay at Home order if you don’t have a home. As cities across the country plan for the ongoing COVID-19 pandemic and its aftermath, we have a collective responsibility to prioritize keeping families safe and in their homes as the cornerstone of any recovery plan. In Philadelphia, the poorest big city in the country, and the city with the third largest income gap between the wealthy and the poor, the need for emergency housing protections is even more pressing.

Skyrocketing eviction rates and rampant gentrification were already wreaking havoc on low-income communities long before COVID-19 hit. In 2017, 53% of renters in Philadelphia were cost-burdened, meaning they spent more than 30% of their income on rent. Roughly one in every 14 renters in Philadelphia is under threat of eviction each year, and presently there are over 2,000 cases in eviction court waiting to be heard once the Public Health Emergency order is lifted.

I have experienced the affordable housing crisis firsthand. I was raised in the Nicetown neighborhood of Philadelphia, and still live on the same block that I grew up on with my four children. As a young single mother, I paid my way through the Community College of Philadelphia while working as a Nursing Assistant. Later, I began working for Easterseals, where I connected children with disabilities and their families to the programs and resources they needed to thrive.

Then, after 17 years of employment at Easterseals, I was laid off. It was 2011, and former Pennsylvania Governor Tom Corbett had introduced sweeping budget cuts that eliminated critical programs across the state. I was devastated, and had a difficult time finding employment with a comparable salary that would support me and my growing family. From there, my circumstances quickly spiraled. Unexpectedly, I lost my house to a sheriff’s sale. In what felt like overnight, I went from being gainfully-employed to struggling to pay rent in my own home.

My story bears many similarities to what families are currently experiencing across Philadelphia and across the country. In April of 2020, the national unemployment rate hovered at just below 15%, the highest since the Great Depression. Just like the 2008 recession, families are suddenly faced with potentially paralyzing budget cuts and unprecedented job loss. Austerity and years of targeted disinvestment have ravaged the Black community, and further cuts will undoubtedly decimate the already weakened social safety net that thousands of Philadelphians rely on to get by.

Increases in homelessness and displacement will result in a massive wave of COVID-19 infections, and people of color will be the hardest hit. In my neighborhood of Nicetown, which suffers from severe air pollution as a result of SEPTA’s Midvale Bus Depot, we have a childhood asthma rate of 31%, making residents all the more susceptible to COVID-19. It is not the time for us to ask for further sacrifice and resilience from our hardest hit communities. It is time that we stepped up and prioritized them instead.

Keeping families in their homes is not only good public health policy, it is a logical step in aiding economic recovery. As someone who has lived the destabilizing effects of housing insecurity firsthand, I know that keeping families in their homes is the first step in getting them back on their feet. It is difficult to imagine finding a new job, homeschooling your children, and doing the increased domestic labor that is required to maintain a home during a pandemic if you are also facing homelessness. It is on local and state governments to step up to ensure that our most vulnerable populations are not left behind as we begin to pick up the pieces of our post-COVID-19 world.

That is why I worked with my colleagues Councilmembers Helen Gym and Jamie Gauthier at the citywide level to introduce a set of common-sense protections for renters in Philadelphia. The Emergency Housing Protection Act would prohibit large rent increases for a year after the pandemic, waive late payment fees, extend the eviction moratorium, require mediation prior to eviction proceedings, establish rent repayment plans, and allow renters to recover damages after illegal lockouts. These measures will help families stay in their homes and provide them with needed security during this uncertain time.

However, we know that keeping families in their homes is not the end of the solution. We need to be proactive about lasting strategies to address the health issues faced by working families. Longer term economic stimulus plans should address the need for green jobs and infrastructure; affordable housing; access to quality healthcare; and well-funded public education.

The COVID-19 crisis has laid bare many of the inequities of our current system, but it has also presented us with an opportunity for real change. As a city and as a society we should have the urgency to provide much-needed immediate relief and the courage to fight for structural changes that would make Philadelphia a livable, healthy, and safe city for generations to come.