Post on 03-Jun-2020
Better Health Through Better Partnerships How Health centers Integrate Their
Knowledge of the Community with the Delivery System
March 19, 2018
Multi-site CE/CME – must sign in Evaluation Electronic Devices
HOUSEKEEPING
All presenters have signed a conflict of interest form and have declared that there is no conflict
of interest and nothing to disclosefor this presentation.
CONFLICTS OF INTEREST
Dr. Robert Moore, MD, MPH, MBAChief Medical OfficerPartnership HealthPlan of California
Welcome and Introductions from Partnership HealthPlan of California
4
Liz Gibboney, MAChief Executive OfficerPartnership HealthPlan of California
Mission:To help our members, and the communities we serve, be healthy.
Vision:To be the most highly regarded managed care plan in California.
About Us
• How Community Partnerships fits into Social Determinants of Health framework
• Spotlight on Tribal Health
Introductory Reflections
• SDH are “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics”
-World Health Organization
Defining Social Determinants of Health
1.) Economic Stability- Poverty, Employment, Food Security, Housing Stability2.) Education- High School Graduation, Enrollment in Higher Education, Language and Literacy, Early Childhood Education and Development3.) Social and Community Context- Social Cohesion, Civic Participation, Discrimination and Inequity, ACEs, Incarceration/ Institutionalization4.) Health and Healthcare- Access to Health Care, Access to Primary Care, Health Literacy5.) Neighborhood and Build Environment- Access to Healthy Foods, Quality of Housing, Crime and Violence, Environmental Conditions
5 Key Areas of SDH
Mechanisms
Chronic Disease
Psychological Distress
Physiological Stress
Depression/Anxiety/Substance
Use Disorder
Social Determinants
Increased Morbidity and Mortality
Interventions for Social Determinants of Health
•Assess individual issues•Address: Navigate, Collaborate, Provide•Track
Individual Interventions
• Community activation, engagement• Collective impact
Community Interventions
• Health in All Policies• Local, State, Federal
Wider, societal Interventions
Tribal Health Centers
The Tribal Health Context
• Many social determinants of health issues• Residual institutional discrimination• Governance • Social compact
• Collaborate in assessing underlying causes of health issues
• Utilize relationships and resources to address underlying causes
• Generalizability?
Honoring Native Land
Jack Potter, Jr.Tribal ChairmanRedding Rancheria
Opening Ceremony
14
Karen McIntireDirector of Human ResourcesSouthcentral Foundation
NUKA System of Care
15
Daniel Hartman, MD, MPHMedical DirectorSouthcentral Foundation
65,000 voices
Southcentral Foundation Overview
Alaska Native People Shaping Health CareKaren McIntire, Director of Human Resources
Dan Hartman, MD, Medical Director
Why listen to our story?
Alaska Native People Shaping Health Care
Prolonged federal domination of Indian Health Service programs has served to retard rather than enhance progress of Indian people and their communities.
Denied an effective voice in the planning and implementation of programs that respond to the true needs of the people.
Indian Self Determination and Education Assistance Act of 1975
Government Recognition If the people receiving the health service are involved in the decision making processes, better yet, if they own their own health care –programs and services have a potential for enhancement and the people and their health statistics will improve.
Alaska Native people chose to assume responsibility
Alaska Health System
We Asked the Community
unfriendly staff long waits no customer input inconsistent treatment
desired their own primary care provider
cleaner and better facilities
People Said…
People Said: Access to own provider culturally appropriate care
People Said: Cleaner and Better Facilities
People shared their top 5 needs
Domestic ViolenceChild Abuse
Child NeglectBehavioral Health
Addictions
Needs
We Changed Everything
Customer-Ownership
Direct Input Into Health Care RedesignCustomer-Owners
Vision A Native Community that enjoys physical, mental, emotional and spiritual wellness
MissionWorking together with the Native Community to
achieve wellness through health and related services
GoalsShared ResponsibilityCommitment to QualityFamily Wellness
Leadership Principles
Operational Principles
Created a NewOrganizational Structure
President & CEO
Vice PresidentExecutive and Tribal Services
Vice PresidentResource and
Development/Chief of Staff
Vice PresidentFinance
Vice PresidentMedical Services
Vice PresidentBehavioral Services
Vice PresidentOrganizational
Development & Innovation
Functional Committee Structure
Core Concepts
Governing Board Advisory Committees Elder Council Annual Gatherings 24-Hour Hotline Personal Interactions
Customer-Owners Satisfaction Surveys and
Comment Cards Employee Survey Employee Interactions
(Over 55% are Customer-Owners)
SCF Continues to Ask the Community
Customer-owner changes We are active We are responsible We seek information We ask questions We seek advice and options We become a partner with the provider
Key Improvement
Health care provider changes No longer gives orders No longer just prescribes meds No longer our hero No longer controls Gives customers options Provides customer with resources Provider becomes our partner
Key Improvement
Providers and Customer-Owners in Shared Responsibility
Same-day access to primary care provider Monitoring for culturally appropriate care Improvements in waiting times
SCF Changed Everything
Behavioral Health RedesignLearning Circles
Integrated Care Teams
Clinical Workload Prior to System Redesign
Empaneled Customer-Owners: Ensures Continuity of Care Builds Relationships Creates Trust Between Customer and Team Progress/Healthy Outcomes Open Access to Integrated Care Team Email, Phone, Talking Rooms
Continuity
Traditional Work Flow
Customer Customer Customer Customer Customer
Customer Customer Customer Customer Customer Customer
Parallel Work Flow Redesign
Case Management Support
RN Case Manager
Dietician
Primary Care Provider
Coverage NP/PA
Certified Medical Assistant
Behavioral Health Consultant
Integrated Care Teams
Talking Room
Is it effective?
SCF Balanced Scorecard
Team Dashboard
Action Lists
(Fictitious Customer-Owners)
Provider Performance Over Time
Comparison Charts to Identify Best Practices
Ensure Successful Relationships: 5 Dynamics Mentor Training Core Concepts Motivational Interviewing Crucial Conversations Team Dynamics
Training and Support
Sustained Improvements
95%Employee Satisfaction
97%Customer Satisfaction
40%Reduction in ER Visits
2000-2017
36%Reduction in Hospital Discharges
2000-2017
907-729-6852 | www.scfnuka.com | SCFEvent@scf.cc | @SCFNuka
Upcoming Nuka Events
Event Name Date
Quality Management Training March 19-23, 2018
Motivational Interviewing March 19-20, 2018
Integrated Care Team Training March 21-23, 2018
Behavioral Health Integration Training March 21-23, 2018
Coaching and Mentoring Program April 23-27, 2018
Nuka System of Care Conference June 18-22, 2018
Háw'aaHaida
Mahsi'Gwich’in Athabascan
IgamsiqanaghalekSiberian Yupik
T’oyaxsmTsimshian
GunalchéeshTlingit
QuyanaYup’ik
Tsin'aenAhtna Athabascan
Chin’anDena’ina Athabascan
QaĝaasakungAleut
QuyanaqInupiaq
Awa'ahdahEyak
QuyanaaAlutiiq
Thank You!
The Circle of Care Model
Sonia Tucker, MD, MBAQuality Improvement DirectorLa Maestra Community Health Centers
65
La Maestra Circle of Care™ Addressing Social Determinants of Health through Outreach &
Integration of Services
Presented by: Sonia Tucker, Chief Quality Officer
About La MaestraOur Mission: “To provide quality healthcare and education, improve the overall well-being of the family, bringing the underserved, ethnically diverse communities into the mainstream of our society, through a caring, effective, culturally and linguistically competent manner, respecting the dignity of all patients.”
History: Clinic formed in 1990 under La Maestra Amnesty Center. The need for culturally competent healthcare was identified by Student Council representing over 12,000 students who participated in legal residency and citizenship programs, ESL, VESL, job training at LMAC.
First Clinic, opened 1990 LEED Certified Gold Health Center, opened 2010
Locations• 7 medical and 10 dental
sites; 4 school-based clinics; Hope Clinic (Access Point for Homeless) in San Diego communities:
• City Heights • El Cajon • National City • Lemon Grove
• Mental health services onsite & via telehealth
• Digital Imaging – mammo, X-ray, ultrasound, dexaand CT scan
• Mobile clinic – medical, dental, optometry, telehealth
• Mobile mammo coach -first in San Diego
Annual Number of Patients & Visits
29,81132,121
35,52437,782
40,288
44,57043,129
40,07441,317
44,661
47,866
0
10,000
20,000
30,000
40,000
50,000
60,000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
60% of Patients indicated best served in a language other than English in 2017
Total Unduplicated Patients
102,843
122,564
138,070
165,872174,430177,432
188,112
218,312
200,307
224,725
187,623
0
50,000
100,000
150,000
200,000
250,000
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Total Visits
69
2017 Patient Demographicso At least 66% of Patients earned at or below 100% Federal Poverty Level
o 21% of Patients Uninsured, 77% have Medicaid or Medicare
o At least 60% of Patients preferred a language other than English
o 60% of patients were Female
o 3.8% of patients (1,866) were Homeless
66%
10%
2%
Income as % of Federal Poverty Level
<100%FPL
101-200%FPL
>200%FPL
21.8%
73.4%
3.2% 1.6%Patient Insurance
Uninsured
Medicaid
Medicare
PrivateInsurance
Serving the Culturally Diverse Communityo One of the most culturally diverse health centers in California – sites
are in refugee resettlement areas and along US-Mexican border.
o 60% of patients prefer communication in language other than English
o Staff come from the cultures served, ensuring cultural and linguistic competency.
o More than 30 languages and dialects spoken by 500+ employees
o Medically Trained Cultural Liaisons provide valuable, ongoing support, education to local residents and identify new needs – two-way communication
Innovative Models at La Maestrao La Maestra Circle of Care™ - All services and programs have
elements focusing on education, case management, social services − Integrated approach
o Medically Trained Cultural Liaison (MTCL) model
o School-Based, Mobile Clinics; Hope Clinic for homeless; eHealth –Alternative Access Points bringing services to where residents live, work, learn, play and worship
o Electronic and Cloud-based Program/Case Management
o Specialty Care in the Medical Home via Telehealth and Partnerships
o Digital Imaging
o Contemporary Management Team Model
La Maestra Circle of Care™
o Obesity and Overweighto Diabetes (high incidence of Type II)o Cardiovascular Disease and Hypertensiono Liver Disease (Hepatitis B and C)o Increased risk of Stroke and Cancer, and Lower
Screening Rates (esp. Breast, Cervical, Colon Cancers)o Tooth Decay and Gum Diseaseo Asthma and Lead Poisoning in Childreno Pulmonary Conditionso Osteoporosis (seniors)o Co-morbidities
Physical Health Issues
Mental/Behavioral Health Issueso Depression and Anxietyo Influence of Chronic Stresso Unemployment/Under-
employment o Lack of Financial Resourceso Overcrowded Households o Living in High Crime
Communitieso Post Traumatic Stress
Disorder o Substance Use
o Isolation o Alzheimer's and Dementiao Caregivers’ Stresso Domestic Violence, Family
Violence (Child and Elder Abuse)
o Victims of Traffickingo Low Self-Esteemo Cultural Diversity Issueso Stigma/Lack of Mental
Health Awareness
o Food deserts - lack of access to affordable nutritious foodo Urban environment and housing with no outdoor spaceo Unhealthy and unsafe living condition (crime, unmaintained
housing)o Stigmas, myths and cultural beliefs about health and
treatmento Lack of healthcare services in country of origin/refugee campso Lack of financial literacy and access to safe credito Changing generational roles/social order in immigrant familieso Grandparents raising grandchildreno Isolation of seniors and people with disabilities
Environmental and Cultural Factors
o High cost of doctor visitso High cost of medication, glucose test strips, etc.o Linguistic and cultural barrierso Lack of health literacy o Lower screening rates o Misunderstanding of health coverage programso Lack of transportationo Managed Care default
Other Barriers to Health and Wellbeing
77
Network goes beyond the field of medicine, bringing greater resources to our patients in the Circle of CareNew Skills, Independence, Self-Esteem, Helping and Teaching
Others, Working in Healing Environments
o Healthy Choices Food Pantry and nutrition education, eligibility assistance for CalFRESH (SNAP), Medi-Cal, energy bill discounts
o Supermarket Challenge
o Urban Community Gardens
o Exercise – Zumba, Yoga, Walking Clubs
Community Garden & Healthy Cooking ClassesFood Pantry
Wellbeing in the Circle of Care
Zumba
Comprando Rico y Sano
o Economic Empowerment:• Microcredit Program for Women • Blossoms - Flower Shop Social Enterprise • LM Printing - Print Shop Social Enterprise • Microenterprise Assistance• Job Skills Training and Placement
o Supportive Housing for those in Recovery /Re-entryo Help with Affordable Housingo Generations - Youth and Intergenerationalo Culture and Healing through Art Program
Microcredit Entrepreneurs – Catering & Handmade Items
Generations
Senior Job Trainees in Blossoms Social Enterprise
Microcredit Weekly Group
Culture and Healing through Art
Wellbeing in the Circle of Care
Legal Advocacy & Social Serviceso Legal Advocacy launched in 2011 to provide assistance and
support to survivors of crimes: Human Trafficking, Domestic Violence, Violent Crime, Political Torture
o National Human Trafficking Victim Assistance Program
o Legal advocates do not act as attorneys, but give information to help patients understand their rights and options
o Assistance with application for Restraining Orders, Safe Housing, Victims Compensation Program, Family Law Forms
o Referrals to Network of Attorneys for Free / Low-Cost Services
o Community Education and Training for Service Providers
o Immigration Law Services added in 2015
La Maestra Circle of Care™
Circle of Careo Listening to the needs of the community:
o La Maestra Amnesty Center (LMAC) student council voiced a need for healthcare and education provided by physicians and support staff who could understand their cultures and complex health and wellbeing issues
o LMAC teachers, volunteer physicians and LMAC students with healthcare experience founded the clinic; many still are staff or board members
o Recognized since day one that wellness is not just a trip to the doctor; need a variety of services with all staff cross-trained to ensure patient’s and family’s needs are recognized and addressed in their health home, where they feel comfortable
Circle of Careo Each time a new cultural group settles in San Diego, La Maestra is
there to provide for their basic needs, bringing services out to the community
o Broad network of collaborative partners built since 1980s, from government or hospitals to ethnic, religious or community based organizations – La Maestra is often called on to help, trusted for its expertise and willingness to help new populations
o Not just refugees and immigrants, also other populations with unique needs: o Victims of Human Trafficking or Domestic Violenceo Those re-entering society after incarceration or addictiono Homelesso Older adultso Youth
Circle of Careo Current staff identify members of the new cultural group or
special population who have healthcare or other service experience, or who have transitioned from surviving to thriving and now want to help others
o La Maestra recruits these community members to identify needs of community, and tailor culturally competent solutions
o Recruit through volunteer opportunities, job training and placement, board or advisory group membership
o If no health certification in US, job training/placement in other roles such as lab, M.A., billing, or social services but can be called on to be interpreters
o 2nd generation are going to college and want to work at La Maestra - combining their cultural competency with the latest education and training
Circle of Careo Identifying and addressing patient’s needs
o Staff cross-trained to listen and recognize issues affecting health and wellbeing
o Concierge in waiting room, cultural liaisons, or staff at outreach events:
o ask patients if they are in need of other services in the Circle of Care while they wait to see doctor
o provide “warm referral” as soon as need is identified, or
o utilize SDH services templates in EHR, to ensure appointment is made
o Case managers and patient navigators follow up with patient and staff to ensure need was addressed
Circle of Careo Adding and expanding services
o To jump start a needed service, La Maestra may use its operational reserves, fundraiser event proceeds or unrestricted donations until outside funding is obtained.
o Start the service within an existing department until it grows and expands to need its own space and staff
o Track visits and outcomes from the beginning, helps evaluate and with obtaining funding support in future from grants
o Build collaborative partnerships with other organizations
Social Determinants of Health
15 Minute Break
88
Local Breakout Discussions
89
Glen HowardRN, BSN, MS-DM
Executive Director Redding Rancheria
Targeting the needs of a local community: Diabetes Prevention and Reduction among Tribal Youth
Valerie Reed
Project ManagerUnited Indian Health Services
Addressing the underlying social and economic factors contributing to the health of your community
Tribal Health Panel
90
Lunch Break
91
Let’s Talk Relational Accountability! Moving Toward More Responsive Community Services
That Promote Wellness
Jamie Jensen, MSW, ABDDirector of the Distributed Learning ProgramsHumboldt University Department of Social Work
92
About Relational AccountabilityMoving toward more responsive community services that promote wellness.
LET’S TALK!
Today’s Agenda
◼ Introduction
◼ A Case Study: Decolonizing Social Work
◼ Connecting lessons learned
◼ Questions
Case Study: Decolonizing social work in tribal communities.
The Challenge: Who is our community and how do we connect?
The Solution: Use technology to bring degree programs to them.
And Then… “the question” came
My Study
● In Depth Interviews● Purposive Sampling, n=5● Indigenous Identity● DL Students -MSW
Question: What are the experiences of students in a distributed learning master’s degree program in social work?
And… how do these experiences reveal issues related to the continued colonization of Indigenous Peoples through higher education systems?
What did I learn?
Trust… and healing
Four major tides of decolonization- survival, recovery, development & self-determinations (Tuhiwai-Smith, 2012)
◼ Survival = recognition of past harm
◼ Recovery = returning of what was lost
◼ Development = integration of new ways
◼ Self-Determination = helper as non-expert
Building Relationship
Accountability
Relational Accountability (Wilson, 2008)- Based in community context and demonstrates respect, reciprocity & responsibility.
Reflexivity- What is this white woman doing talking about the experience of Indigenous Students?
◼ Positionality◼ who am ‘I’ as a provider/helper?
◼ Where do ‘I’ stand in relationship to those
my agency seeks to serve?
Cultural Competence or Cultural Safety?
When possible services are provided by people representative of the population being served.
Cultural Safety means… “An environment, which is safe for people; where there is no assault, challenge or denial of their identity, of who they are and what they need. It is about share respect, shared meaning, shared knowledge and experience, of learning together with dignity, and truly listening (Williams, 1999).”
Assessing Community Responsiveness in your Agency
◼ Demographics of the broader community.◼ Who is/isn’t being
served?◼ Staff knowledge of the
community. ◼ Interaction with under-
represented agencies.◼ Agency practice, policy &
procedures.
◼ Agency facilities- location
and accessibility
◼ Composition of staff &
leadership
◼ Role of agency as
advocate and ally
◼ Organizational culture
◼ Service delivery
Where do you stand?
◼ On a scale of 1-10, 1 being ‘culturally destructive’ and 10 being ‘culturally sustaining’, where do you (individually) stand?
◼ Also consider,◼ Where does your agency stand?
◼ How do you know this? What do you see that demonstrates this?
◼ If you aren’t where you want to be on the spectrum, how can you move closer to your preferred location?
◼ Ask yourself: What is my commitment to this?
QUESTIONS?
ReferencesBloom, S., & Sreedhar, S. (2008). The Sanctuary Model of Trauma-Informed Organizational Change. Reclaiming Children and Youth, 17(3), 48-53.
Brascoupé, S., & Waters, C. (2009). Cultural Safety: Exploring the Applicability of the Concept of Cultural Safety to AboriginalHealth and Community Wellness. Journal of Aboriginal Health, 5(2), 6-41.
Buckmiller, T., & Cramer, R. (2013). A Conceptual Framework for Non-Native Instructors Who Teach Adult Native American Students at the University. Multicultural Learning and Teaching, 8(1), 7-26.
Chilisa, B. (2012). Indigenous Research Methodologies. Thousand Oaks, CA: SAGE Publications, Inc.
Katz, R., & Murphy-Shigamatsu, S. (2012). Synergy, Healing and Empowerment: Insights from Cultural Diversity. Calgary, Alberta, Canada: Brush Education, Inc.
Lindsey, D. B., Jungwirth, L. D., Pahl, J. V. N.C., & Lindsey, R. B. (2009). Culturally Proficient Learning Communities: Confronting inequities through collaborative curiosity. Thousand Oaks, CA: Corwin, A SAGE Co.
Rix, E.F., Barclay, L., & Wilson, S. (2014). Can a white nurse get it? ‘Reflexive practice’ and the non-Indigenous clinician/researcher working with Aboriginal people. Rural and Remote Health (14)2679, 1-13. Available at: http://www.rrh.org.au
Smith, L. (2012). Decolonizing methodologies: Research and Indigenous Peoples (2nd ed.). London : Dunedin, N.Z.: Zed Books ; University of Otago Press.
Spector, R. E. (2004). Cultural Diversity in Health and Illness (6th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Wilson, S. (2008). Research is Ceremony: Indigenous Research Methods. Canada: Fernwood Publishing.
Williams, R. (1999). Cultural safety - what does it mean for our work practice? Australian And New Zealand Journal Of Public Health, 23(2), 213-214.
Contact me at...
Jamie Jensen, MSW
Organizational Consultant, HealingOrgs.Com
Jamie@healingorgs.com
707.499.4757
Local Breakout Discussions &
Closing Remarks
112