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

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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

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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

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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

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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

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