Latino health forum 10.12.2017

Applying an Equity Lens
to Health Transformation
Laura Kate Zaichkin, Acting Chief Policy Officer
Washington State Health Care Authority
DATE

• Medicaid program in Washington is called Apple
Health
• Covers 1.9 million individuals
• 600,000 newly eligible adults under Medicaid
expansion
Who Medicaid serves
2 3
• Populations served
include children,
pregnant women,
disabled adults, elderly
persons, and former
foster care adults

Over the five-year Medicaid Transformation
Demonstration, Washington will:
– Integrate physical and behavioral health purchasing and
service delivery
– Convert 90% of Medicaid provider payments to reward
outcomes
– Support provider capacity to adopt new payment and care
models
– Implement population health strategies that improve
health equity
– Provide targeted services that address the needs of our
aging populations and address the key determinants of
health
Medicaid transformation goals
4

• Up to $1.5 billion for a five-year, statewide effort to
show that Washington can deliver better health care
for more people, while spending dollars in a
smarter way for Apple Health (Medicaid)
beneficiaries.
• Three initiatives:
Medicaid Transformation Demonstration
5
Transformation through
Accountable
Communities of Health
Up to $1.1B
Long‐term Services and
Supports
$175M
Foundational Community
Support Services
$200M

Because we know
that health is more
than health care.
A major focus of the Demonstration: Equity
Adapted from: Magnun et al. (2010). Achieving Accountability for Health and
Health Care: A White Paper, State Quality Improvement Institute, Minnesota.

Regional organizations that:
• Address health issues
through local
collaboration on shared
goals.
• Better align resources
and activities that
improve whole person
health and wellness.
• Support local and
statewide initiatives
such as the Medicaid
Transformation
Demonstration, practice
transformation and value-
based purchasing.
What are Accountable Communities
of Health?
7

• Opioid use crisis
• Maternal & child health
• Oral health services
• Chronic disease promotion
Prevention
& Health
Promotion
• Bi-directional integration of care
• Community-based coordination
• Transitional care
• Diversion intervention
Care Delivery Redesign
• Financial stability
through value-based
payment
• Workforce
• Systems for population
health management
Health System & Community
Capacity Building
How the Demonstration is structured

How many projects are there?
Care Delivery Redesign
• Bi‐directional integration of physical & behavioral health through
care transformation
• Community‐based care coordination
• Transitional care
• Diversion interventions
Prevention & Health Promotion
• Addressing the opioid use public health crisis
• Reproductive & maternal/child health
• Access to oral health services
• Chronic disease prevention & control
Required (1)
Required (1)
At least 1
At least 1
Total = at least 4
9

• Definition of health equity in the Demonstration
toolkit:
– Reducing and ultimately eliminating disparities
in health and their determinants that adversely
affect excluded or marginalized groups.*
• Project selection criteria must include:
– The ability to address health equity and social
determinants of health
Demonstration requirement:
Addressing health equity
10
*"What is Health Equity? And What Difference Does a Definition Make?"
May 2017, Robert Wood Johnson Foundation

• Southwest Washington ACH: hired VP of Partnerships, Policy & Equity
– Strong commitment to equity and social justice; works with the
community to ensure authentic community voice.
• North Sound ACH: forming a Regional Health Equity Coalition
– "While committed to delivery system reform, we believe that in
order to achieve improvements in health equity, we must look
downstream, mid-stream, and upstream, and lean into
uncomfortable dialogue about class, privilege and race."
• Olympic Community of Health: applying equity to project selection
– Consider the degree to which the project addresses social
determinants of health and improves health equity
• King County ACH: Community/Consumer Voice Committee
– Informs project planning & selection
ACHs applying an equity lens
Examples from across the state*
*From Accountable Community of Health Phase 2 Certification applications, https://www.hca.wa.gov/about-hca/healthier-
washington/medicaid-transformation-resources

• State level: Measures within the Demonstration
– Diversion intervention
• % homeless
• % arrested
• ACH level: project planning
– Identifying health disparities and social risk factors
– ACES (Adverse Childhood Experiences)
– Identifying and recruiting social service providers
(including long-term services and housing)
– Supporting Community Health Workers
Addressing social determinants
12

• Services designed to delay & divert need for more
intensive interventions
– Medicaid Alternative Care (MAC): A new choice designed to
support unpaid family caregivers
– Tailored Supports for Older Adults (TSOA): A new eligibility
group to support people who need long-term services and
are at risk of spending down to impoverishment
Initiative 2: Long-term services &
supports
13
Transformation
through Accountable
Communities of
Health
Up to $1.1B
Long‐term Services
and Supports
$175M
Foundational
Community Support
Services
$200M

• Supportive housing & supportive employment
– Targeted Medicaid benefits that help eligible
clients with complex health needs obtain and
maintain housing and employment stability
Initiative 3: Foundational Community
Supports
14
Transformation
through Accountable
Communities of
Health
Up to $1.1B
Long‐term Services
and Supports
$175M
Foundational
Community Support
Services
$200M

Five years from now
Current system
• Fragmented care delivery
• Disjointed care transitions
• Disengaged clients
• Capacity limits
• Impoverishment
• Inconsistent measurement
• Volume-based payment
Transformed System
• Integrated, whole-person care
• Coordinated care
• Activated clients
• Access to appropriate services
• Timely supports
• Standardized measurement
• Value-based payment
Lindeblad15

• Health Innovation Leadership Network
– Health Equity Accelerator Committee
• Shared Decision Making
• Whole-person care through integrated physical
& behavioral health
• Addressing access to care
Other Healthier Washington efforts

Join the Healthier
Washington Feedback
Network:
healthierwa@hca.wa.gov
Learn more:
www.hca.wa.gov/hw
17

Developing a Healthcare Workforce that
Addresses Social and Economic Determinants to
Improve Health and Wellness of Latinos
Gabriel Garcia, MD
He / Him / His
William and Dorothy Kaye University Fellow in Undergraduate
Education and Professor of Medicine
Stanford University
ggarcia@stanford.edu

Leading causes of death in US
Number of deaths for leading causes of death:
• Heart disease: 614,348
• Cancer: 591,699
• Chronic lower respiratory diseases: 147,101
• Accidents (unintentional injuries): 136,053
• Stroke (cerebrovascular diseases): 133,103
• Alzheimer's disease: 93,541
• Diabetes: 76,488
• Influenza and Pneumonia: 55,227
• Nephritis, nephrotic syndrome and nephrosis: 48,146
• Intentional self-harm (suicide): 42,773
National Center for Health Statistics, accessed at
http://www.cdc.gov/nchs/fastats/deaths.htm last night

Mokdad AH, Marks JS, Stroup JS, Gerberding JL. 2000. JAMA 2004;291:1238-1245

Attributable Deaths
Adverse social conditions:
• low education = 245,000 deaths
• poverty = 133,000
• segregation = 176,000
AJPH, June 2011

INSTITUTIONAL
POWER
Corporations &
businesses
Government
agencies
Schools
Laws &
regulations
Not-for-profit
organizations
RISK
BEHAVIORS
Risk Behaviors
Smoking
Poor nutrition
Low physical
activity
Violence
Alcohol & other
Drugs
Sexual behavior
LIVING CONDITIONS
Physical environment
Land use
Transportation
Housing
Residential segregation
Exposure to toxins
Social environment
Experience of class,
racism, gender,
immigration
Culture, incl. media
Violence
Economic & Work
Environment
Employment
Income
Retail businesses
Occupational hazards
Service environment
Health care
Education
Social services
DISEASE
& INJURY
Communicable
disease
Chronic
disease
Injury
(intentional &
unintentional)
MORTALITY
Infant mortality
Life expectancy
SOCIAL
INEQUITIES
Class
Race/ethnicity
Immigration
status
Gender
Sexual
orientation
POLICY
A PUBLIC HEALTH FRAMEWORK FOR REDUCING HEALTH INEQUITIES
BAY AREA REGIONAL HEALTH INEQUITIES INITIATIVE

Key Findings for Santa Clara County
• Santa Clara County families have the second highest median
income in the nation

Key Findings for Santa Clara County
• Santa Clara County families have the second highest median
income in the nation, but
• Over one third of families do not earn a living wage,
• 1 in 10 children and 1 in 12 adults live below the FPL
• About 2 in 10 adults do not have health insurance in Santa
Clara County, including 3 in 10 African Americans and 4 in 10
Hispanics.
• About 10% of adults have delayed getting or did not get a
medicine prescribed by a doctor, and more than 3 in 4 say it
was due to cost or lack of insurance.
Santa Clara County Health Profile Report

Key Findings for Santa Clara County (2)
• Only 19 percent of homebuyers are able to purchase a median-
priced home in Santa Clara County
• Nearly 1 in 10 adults (9%) reported that either they or another
adult in the household had obtained food from a food bank,
food pantry, or church in the past 12 months.
• Two in 10 adults and more than 3 in 10 children with one or
more chronic diseases report barriers to the healthcare system.
• People residing in neighborhoods where 20% or more of the
families fall below the Federal Poverty Level live 2.5 fewer
years on average than people in neighborhoods where less
than 5% of families live below the Federal Poverty Level
Santa Clara County Health Profile Report

Life Expectancy for 40-Year-Olds by Household Income

Life and Death on the Titanic
Conditional Distributions
0
100
200
300
400
500
600
700
800
First Second Third Crew
Class
Frequencies
Alive
Dead

How Will the Work of Physicians Change?
1. Demand for health care services will rise
Shortell and Swartzberg JAMA 2008; 24 : 2916-8

Ebell, Future Salary and US Residency Fill Rate Revisited, JAMA 2008

How Will the Work of Physicians Change?
1. Demand for physician services will rise
2. Learn to partner with organizations working
upstream of health care
3. Exert influence and advocate at both the
provider-patient interface (biological and
behavioral determinants of health) and the
legislation and policy level (social and
environmental determinants of health)

INSTITUTIONAL
POWER
Corporations &
businesses
Government
agencies
Schools
Laws &
regulations
Not-for-profit
organizations
RISK
BEHAVIORS
Risk Behaviors
Smoking
Poor nutrition
Low physical
activity
Violence
Alcohol & other
Drugs
Sexual behavior
LIVING CONDITIONS
Physical environment
Land use
Transportation
Housing
Residential segregation
Exposure to toxins
Social environment
Experience of class,
racism, gender,
immigration
Culture, incl. media
Violence
Economic & Work
Environment
Employment
Income
Retail businesses
Occupational hazards
Service environment
Health care
Education
Social services
DISEASE
& INJURY
Communicable
disease
Chronic
disease
Injury
(intentional &
&unintentional)
MORTALITY
Infant
mortality
Life
expectancy
SOCIAL
INEQUITIES
Class
Race/ethnicity
Immigration
status
Gender
Sexual
orientation
UPSTREAM DOWNSTREAM
Community capacity
building
Community organizing
Civic engagement
Strategic
partnerships
Advocacy
Individual health
education
Health care
Emerging Public Health
Practice
Current Public Health
Practice
POLICY
Case
management
A PUBLIC HEALTH FRAMEWORK FOR REDUCING HEALTH INEQUITIES
BAY AREA REGIONAL HEALTH INEQUITIES INITIATIVE

How Should Medical Education Change?
1. Recruit students who come from and/or have
a desire to serve all communities

Jolly, Analysis in Brief, AAMC, January 2008

2. Develop campus community partnerships in
service learning and participatory research
3. Understand and provide solutions to real
problems in real communities
4. Embrace social change: find out who holds
the power to make the change and who must
be mobilized to exert the necessary pressure

2. Develop campus community partnerships in
service learning and participatory research
3. Understand and provide solutions to real
problems in real communities
4. Embrace social change: find out who holds
the power to make the change and who must
be mobilized to exert the necessary pressure
5. START EARLIER!

Community Health Advocacy Program
• The need among area clinics for reliable,
trained volunteers to enhance patient care
• The demand among students for substantive
clinical and community-based experiences with
underserved populations
• The need to build a diverse and culturally
competent healthcare workforce

Program Components
MED 161
• Weekly 2-hour class to build
knowledge and skills
• Weekly 3-4 hour clinic shift
• Weekly 1-2 page reflection
• Yearlong project addressing
partner need and associated
assignments
• 1 quarter devoted to media and
legislative advocacy

Unique Aspects of the Program
• Longitudinal engagement
• Community responsiveness
• Student leadership

Longitudinal Engagement
• Clinic shifts can
involve screening, taking vitals,
interpretation, health education
and counseling, and resource
referral
• Weekly shifts over 1-4 years have
strengthened:
• Relationships with clinic staff
• Integration of community health
advocate role into the clinic flow
• Students' confidence in community
health advocate role
• Students' understanding of clinic and
patient population

• Weekly 2-hour class meetings
throughout first year serve to:
– Provide students with context
in working within health
care safety net
– Ground clinic experiences and
observations in
theoretical framework
– Train students in pertinent
skills
– Promote cultural humility and
an understanding of structural
vulnerability
Longitudinal Engagement

Community Responsiveness
• Clinic projects
• Designed to meet needs
identified at each service site
• First-year students work on
projects throughout the
school year in concert with
clinic partner
• Culminates in a joint
presentation with the
community mentor in May and
a report for the partner

Examples of Partner Projects
• Evaluating Patient Satisfaction at Arbor Free Clinic
and MayView Community Health Center
• Establishing an Insurance Enrollment Program at
Pacific Free Clinic
• Evaluating a Women’s Health Navigation project at
Ravenswood Family Health Center
• Developing, deploying and evaluating a healthy eating
curriculum at the Boys and Girls Club
• Performing a needs assessment of the health care
needs of agricultural field workers in rural San Mateo
County at Puente de la Costa Sur

Student Leadership
• Clinic Coordinators
– Train and oversee patient
advocates in each clinic
– Offer advice and insight
• Responses to reflection
• Problem solving
sessions
– Facilitate communication
between patient advocates,
clinic staff, and course
directors

Student Leadership
• Course Coordinator helps
to develop syllabus based on
previous experience in the
class and student feedback
• Program Coordinator helps
to oversee clinical
component of program,
including course-clinic
integration and addressing
clinic partner and patient
advocate needs

Media and Legislative Advocacy Training
Learning objectives
Explore the role of the media in
shaping community health
debates
Learn the value of engaging the
news strategically to advance
advocacy goals
Practice examining news
coverage of health and social
issues critically
Understand how to engage the
news media to advance your
advocacy goals
Newspaper Framing Exercise
What problem or issue is
discussed?
Who is affected by the problem?
Who is responsible for solving it?
If you wanted to expand the news
frame to include your policy
goal,
• What information would you
give the reporter?
• Who would you suggest they
interview
• What would you show them
visually?
Sonja Herbert, Berkeley Media Advocacy Group

Strategy for Change
1. What is the problem or issue?
2. What is a solution or policy – the desired
outcome?
3. Who has the power to make the necessary
change?
4. Who must be mobilized to apply the
necessary pressure?
L. Dorfman, Using Media Advocacy to Influence Policy, 2003

Community Responsiveness
• Community Health in
Oaxaca Program
• Immersive training
experience to build cultural
and linguistic skills; another
example of service learning
• Provides foundation for
students to more
confidently
and competently serve
immigrant communities in
California

Oaxaca
• More than 4 million Mexican immigrants live in
California, close to 40% of the national total.
• About 60,000 immigrants from the state of Oaxaca
currently live in the SF Bay Area.
• Oaxacans live in transborder communities that
maintain strong connections with their families and
communities in Mexico
• The health of Mexican immigrants is compromised by
employment in dangerous occupations, low rates of
use of preventive services, and structural and cultural
barriers that result in poor access to and utilization of
regular health care.

Oaxaca – Pre-field Seminar
Mexican Migration as a Multi-ethnic Process
Rebecca Hester, Graduate student
Film: Sueños Binacionales
Stephen, Lynn, 2007. “Mexicans in California and Oregon” in Transborder Lives:
Indigenous Oaxacans in Mexico, California and Oregon. p. 63-94
Jonathan Fox, “Re-framing Mexican Migration as a Multi-Ethnic Process” Latino Studies,
Vol.4, Issue1-2, .Spring 2006. P.
Communities without Borders,
David Bacon, photojournalist
Bacon, D. “Communities Without Borders,” The Nation, October 24, 2005*
Oaxacan Indigenous Migrants in the United States: An Advocate’s Perspective
Rufino Dominguez Santos, Director, Centro Binacional para el Desarrollo Indígena
Oaxaqueño (CBDIO)
Dominguez Santos, Rufino “The FIOB Experience, Internal Crisis and Future
Challenges”*
Health and Health Care In the Oaxacan Community
Bonnie Bade, PhD, Chair of Anthropology at CSU San Marcos
Bade BL. Is There a Doctor in the Field? Underlying Conditions Affecting Access
to Health Care for California Farmworkers and Their Families. California Policy
Research Center Report (1999)*

Course Components - Oaxaca
• Student homestays with local families
• Clinical rotations (3-4 times per week) in government
hospitals and community health centers
• Classroom discussions with Oaxaca based faculty
• Spanish language training (6-8 hours per week)
• Weekly cultural lectures
• Group tours to sites of historical and cultural interest
• Readings and critical reflection sessions
• Direct service activities and community-based
participatory research at the request of our partners

Community Asset Map, La Experimental

Community Asset Map, Oaxaca Centro

Other Outcomes
• 89% felt the program increased their capacity
for cultural understanding in the healthcare field
• 89% said that the program had broadened their
view of health and health care
• 67% reported that the program improved their
interpersonal communication skills
• 100% said they would live and/or work
overseas again
• 100% affirmed their commitment to work with
underserved populations

Defining Projects
Definition of research question = collaboration
between CBDIO, UCSC and Stanford
1. Health status of indigenous migrants
2. Level of cultural competence of staff in clinics
frequented by indigenous migrants
3. Availability and use of interpreter services for
indigenous migrants in service environments

Effect on Student Career Choices
Medicine
Public health
Nutrition
Policy
Non-governmental social service agencies
State and local government services

Student Reflections
“More than anything else, I feel that the experience broadened my perspective.
Working in a clinical setting with so few resources and meeting people
who were struggling just to get by made my perspective on medicine and
public health more real.”
“This experience has helped me understand the importance of taking into
consideration all aspects of the patient, including family and
socioeconomic status.”
“I always had this sense that people choose to pursue research or clinical
medicine based on their personalities - some people like labs and rats and
test tubes and Excel, and some people like patients and hospitals and
developing relationships. I like medicine largely because I like people, so
until recently I thought a research career was wrong for me. … Thinking
back I realized that many of the most brilliant researchers I've met at
Stanford and here at Columbia didn't seem antisocial at all - they just
seemed obsessed with their work in an exciting, contagious sort of way
(Sapolsky, the Fernalds, Zimbardo, many others). In this sense, I can
absolutely see myself pursuing research - being taken by something and
just running with it. Part of the reason I can picture that, is that my Patient
Advocacy project allowed me to do it on a small scale.”

Final Reflections
Community engagement and engaged
scholarship are central to the purpose of a
university
Community members are excited to participate in
educational partnerships that honor their
knowledge and their role as co-teachers
Reflective community service can transform the
attitudes and careers of students

Community Health Workers
Potential for improving Health
Outcomes in Latino Communities
Latino Health Forum. Oct 12. Seattle Washington
Claudia Medina, Director
Community Health Worker Initiatives
UNM, HSC Office for Community Health
medinac@salud.unm.edu

THE MANY NAMES…
Shasthyo Sebika
Village Health Workers
Agente Comunitario de
Salud
Saksham Sahaya
Community Health Agents
Agente comunitário de
saúde
Visitador/a
Group Leaders
Maternal Health Worker
Community Nutrition Worker
Anganwadi Workers
Community-based Workers
Community Health Volunteer
Village Malaria Worker
Maternal Child Health
Workers
Voluntary Malaria Workers
Promotores/as de Salud
Community liaison
Community organizer
Community outreach worker
Nutrition Volunteers
Raedat
Accompagnateurs
Community Health
Volunteer
Behvarz
Village Health Guide
Nutrition Worker
Colaborador Voluntario
Community Drug Distributor
Village Health Helper
Posyandu
Village Drug-Kit Manager
Community Reproductive
Health Worker
Mental Health Workers
Postnatal Support Worker
Community Volunteer
Community Health
Advocates
Community Health Aide
Village Health Promoters
Rural Health Worker
Brigadistas
Community-based Skilled
Birth Attendant
Dai
Bidan Kampong
Dayas
Community Volunteers
Facilitator
Change Agents
Doot
Peer Educators
Lay Counselor
Volunteer Counselor
Volunteer Peer Counselor
Peer Support Worker
health ambassador
Patient navigator
Public health aide

History of CHW Programs
• At least a 50 year history.
• Chinese Barefoot Doctors (mid 1950’s).
• Alma Ata Declaration (1978): CHWs are the cornerstone
of Comprehensive Primary Care.
• Village Health Workers in Africa and Promotor@s in
Latin America focus on economic development/health.
• Economic Recession 1980’s. CHW programs decreased.
• Today’s renewal of use of CHWs in poor communities
around the globe.
• In USA: renewed interest on CHWs after the ACA.
3

The ACA and opportunities to
increase CHWs jobs
• Allows reimbursement for Preventative Care Services rendered by non-
licensed providers (CHWs). State Plan Amendments required if a state
wants to do so.
• Allows the creation of Health Homes for beneficiaries living with chronic
diseases. (care-coordination, support, health education).
• Impose fines to hospitals for re-admission of patients for the same
conditions. Hospitals may use CHWs to keep patients healthier.
• Increased significantly the volume of individuals enrolling in Medicaid
and Obamacare. Need more healthcare providers across the board
including CHWs ( NM: 230,000 new Medicaid enrollees x a total
857,500 since the ACA)

HOWMANYARETHERE?
Only rough estimates can be made…
• United States: employed: 51,900 as of 2016
(Bureau of Labor Statistics).
• New Mexico: ~ 400 to 600 (Bureau of Labor Statistics).
• (+ hundreds of volunteer CHS) (Mostly Latinas).

CHWROLESinNM
• Cultural mediation between communities and health and social
systems (CHRs/ Promotoras)
• Informal counseling and support
• Provide direct services and referrals
• Provide culturally appropriate health education.
• Advocate for individual and community needs.
• Assure people get the services they need
• Build individual and community capacity

COMMUNITY HEALTH WORKER INITIATIVES- Overview
of Programs
.
1
2. ACEs:
UNMH –Pediatric
Emergency
Department
• 4 FT CHWs & 8 PT
SW student Interns.
6. PATHWAYS:
• CHWs placed in
community based
Organizations.
• 14 agencies.
• 20 CHWs
7. ED Molina:
CHWs connecting
Molina members to
resources & PCP.
1. I-PaCS:
CHWs integrated at
Primary care clinics
(16 UNMH, 2 FCCH
and 1 HMS).
8. AHC (CMS):
CHWs screening
75,000 Medicaid
beneficiaries at ED,
clinics, mental health
facilities,
5. CARE NM:
CHWs connecting Medicaid members,
(high utilizers of ED) with resources,
health education & PCP.
4. NM Rural Hospital Network:
OCH Integrating and training CHWs
and providers from 5 Rural Hospitals.
MCO’s paying the CHWs.
CHWI
3. Inmate Re-
Entry:
CHWs at County Re-
entry Resource
Center and at MDC.
Co-located agencies.

Primary Care Linked Strategy
Medicaid
selected the
clinic
Medicaid
beneficiaries
who self-
selected the
clinic
Primary Care Linked
Strategy
I-PaCS
Services
withinclinic
Member
s
Member
s
Member
s
Screening
Basic Patient
Support
Intensive
Patient
Support
CHW
Provides
Services
Data
collection
disparities
Data
collection
and
analysis
informs
population
health
strategies
to address
disparities
PCMH
Non-
Medicaid
Patients
Population
Health Strategy

Re-Entry Resource Center
Coordinated System to Transition Newly-released-inmates Into Their
Community
the forensic case managers working at.
RRC
Screenin
g
Comprehensive
Support
Intensive
Support
CHWs
RRC
Primary
Health
Behavioral
Health
MDC
Former Inmate
Coordination
Pathway
agencies
Pathways
Navigators
On-site

UNM/Pres Emergency
Departments
Implementati
on
(UNM-OCH-
CHWI)
Interpersonal Violence
Dental
3 FQHCs, 2 UNM, 2 Pres
Clinics
UNM / Pres /community
Behavioral Health facilities
Utilities/Transportation
Food
Housing
Alignment
(BCHC)
Bridge
(Presbyterian)
Accountable Health
Communities Model in
Bernalillo County
Transportation
MOU1

MOU1 Claudia Medina, 9/25/2017

Pathways Components in
Bernalillo Co.
20+ Community
Health Workers
at
14 organizations
HUB
OCH-
Community
Health Worker
Initiatives
Pathways
Community
Advisory
Group
(PCAG)

Partners: NM Rural
Hospitals, NM Hospital
Association and
MCOs
OCH Role:
• Setting criteria to
choose sites for roll
out: (Las Cruces,
Raton Alamogordo,
Espanola, Santa
Fe, Santa Rosa
Tucumcari
Clayton).
• Technical
Assistance to
develop/implement
project.
• Evaluation
• Payment Model

Utilizing CHWs:
Benefits for Managed Care Organizations.
• Cost Benefits (ROI $4 x every $ 1)
 Reduction of Emergency
Department utilization.
 Increase PCP encounters.
• Improves members satisfaction.
• Allows compliance with NM
Medicaid mandate of increasing
CHW utilization.

Utilizing CHWs:
Benefits for Health Care facilities
• Reduce cost of uncompensated care.
• Increases shared savings.
• Reduces penalties for re-admission.
• Improves providers ease of Practice
• Helps with PCMH recertification.
• Improves quality of care
• Improve patient satisfaction
• Improves Health Outcomes

Utilizing CHWs:
Benefits for Non-profits and Government
Cost effectiveness of Pathways’ completion:
• Healthcare Pathway ROI: 3.47
• Housing Pathway ROI: 1.2 to 2.0
• Behavioral Health: Increased employment
and workforce productivity, quality of life,
decrease healthcare cost. Offset cost of
program.
• Medical Debt: close to 2 million in savings.
Offset the cost of the program.

Other Benefits of a CHW
Coordinated System
• Data collection at a central hub:
 Track outcomes
 Identify gaps
• Established network to advocate for
systemic change.
• Cross-training and Cross-referring
• Community engagement
• Aligned social service sector

Cost Benefits: Integrating CHWs vs
PCMH
Maurice Moffett, PhD
Health Economist, Office for Community Health
Mmoffett@salud.unm.edu
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
Year 1 Year 2 Year 3
Comprehensive CHW
Patient Centered
Medical Home

Conclusio
ns
• CHWs have had and
continue have a positive
impact on the health and
well being of community
members.
• Latino communities have
traditionally utilized
Promotoras.
• Latin@s have much to gain
by becoming CHWs and/or
utilizing CHWs in their
communities.
20

Advancing Trauma-Informed Care
for Latino Populations
12th Annual Latino Health Forum
Seattle, Washington
Brent Crandal, PhD
Clinical Psychologist & Principle Investigator
The Chadwick Center at Rady Children’s Hospital
bcrandal@rchsd.org
@drcrandal

Many of our consumers have been impacted by trauma.
Yes
No
CAST YOUR BALLOTS

I feel confident my organization provides trauma-informed care.
Yes
No
CAST YOUR BALLOTS

Health for the Latino Community
& Trauma-Informed Care

SHARED ROLE
• Comfort
• Knowledge
• Skills

Overview
1. Introducing
Trauma
2. Living with Trauma
3. Advancing Trauma-
Informed Care
4. Secondary
Traumatic Stress &
Compassion
Fatigue

What Is Trauma?
• Witnessing or experiencing one or more
events that poses a real or perceived
threat
• The event(s) overwhelms the person’s
ability to cope

Potentially Traumatizing Events
• Natural disaster
• Fire or explosion
• Transportation accident
• Home, work, or recreational
accident
• Exposure to toxic substance
• Physical assault
• Assault with a weapon
• Sexual assault
• Other unwanted sexual experience
• Combat or war-zone exposure
• Captivity
• Life-threatening illness or injury
• Severe human suffering
• Sudden, violent death
• Sudden, unexpected death of
someone close to you
• Cause serious Injury, harm, or
death to someone else
• Other very stressful event or
experience
Happened to you, witnessed, or learned about:

Different People,
Different Responses
Effects of a potentially traumatic event depend on:
• Way event was perceived, experienced
• Role in the event (witness versus victim)
• Relationship to victim or perpetrator
• Aftermath of the event (environment, safety, support, and
responses of others)
• Age and Developmental Background
• Genetic Makeup
• Self-Concept and Self-Esteem
• Past experience with trauma

Common Effects of a Traumatic Event
•Intrusive Thoughts
•Re-experiencing
•Avoidance
•Hyperarousal
•Negative Thoughts/Mood

Common Effects of Chronic Trauma
• Mood Regulation
• Behavioral Control
• Cognition
• Self-Concept
• Attachment
• Biology
• Dissociation

Obesity & Weight
Loss Program in
San Diego

Adverse Childhood Experiences (ACE) Study

Teen Sexual Behavior
0
5
10
15
20
25
30
35
40
45
0 1 2 3 ≥4
%withHistory
ACE Score
Intercourse by 15
Teen Pregnancy
Teen Paternity
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., ... Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to
many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14, 245‐258.

Injection Drug Use
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
0 1 2 3 ≥4
%withHistoryofInjectionDrugUse
ACE Score

Suicide Attempts
0%
5%
10%
15%
20%
0 1 2 3 ≥4
%withHistoryofSuicideAttempt
ACE Score

ACEs Increase Risk For…
Chronic Lung Disease
Cancer

Nature & Nurture
• Experience  Brain Development
• Brain Development  Behavior
• Behavior  Experiences
– Constantly influencing brain architecture
• New, expanded and closed roads

Nature and Nurture
• Toxic Stress Experiences
• sustained, intense stress
• Constant Fight or Flight
– Changes to Brain Architecture
• Roads become highways
• No Road Closures
– Behaviors to Cope
• Normal responses to abnormal context
– Effective in short run (substances, sexual, obesity)
– Maladaptive in the long run (heart disease, HIV, STDs, ↑risk)

ADVANCING
TRAUMA-
INFORMED CARE

• Understand Trauma
• Understand the Consumer Survivor
– Shift from “How do I understand this problem?” to
“How do I understand this person?”
• Understand Services
– Strengths-based
– Prevention
• Understand the Service Relationship
– Genuine collaboration
Trauma-Informed Systems
Harris & Fallot, 2001

1. Create Safe and Secure Environment
2. Early Screening and Assessment
3. Consumer-Driven Care & Services
4. Educated and Responsive Workforce
5. Offers Trauma-Informed, Evidence-Based
and Emerging Best Practices
6. Engage in Community Outreach and
Partnership Building
7. Ongoing Performance Improvement and
Evaluation
Trauma-Informed Organizations

Compassion Fatigue
The stress resulting from helping or wanting to
help a traumatized or suffering person.
• Connected to Secondary Traumatic Stress
• Nature of the work helping professions
• Having an emotional response is the norm
Figley, C.R. (Ed.) (1995). Compassion Fatigue: Secondary Traumatic Stress Disorders from Treating the Traumatized. New York: Brunner/Mazel

Compassion Fatigue Risk Factors
– High Trauma Caseloads
– High Trauma Frequency
– Personal Trauma History
– Low Work Support
– Low Social Support
• Secondary Trauma, Compassion Fatigue and
Burnout Strongly Tied

What does CF Look Like?
• Avoidance (including of certain clients)
• Preoccupation with clients/client stories
• Intrusive thoughts/nightmares/flashbacks
• Arousal symptoms
• Thoughts of violence/revenge
• Feeling estranged/isolated/having no one to talk to
• Feeling trapped, “infected” by trauma, hopeless, inadequate,
depressed
• Having difficulty separating work from personal life
Killian & Mathieu, 2015

I’ve experience 2+ of signs of secondary traumatic stress.
True
False
CAST YOUR BALLOTS

What Can I Do About STS?
• Debriefing (timely, regular, and quality)
• Supervision (timely, regular, and quality)
• Social Support (at work)
• Rotation of Trauma Caseload
• Training (on trauma-informed practices)
• Control Over One’s Schedule
• Success in One’s Work
Killian & Mathieu, 2015

Compassion Satisfaction
• Tell me about your successes this
month?
• In which ways can you give yourself
credit for the successes?
• What did you do or say that helped
lead to changes?
• What makes you feel proud or
successful in your role?

Questions, Insights, Comments…

Thank you!
Brent Crandal, PhD
bcrandal@rchsd.org
@drcrandal

I have lived here 17 years, I have no family,
money, or an apartment in which to live, I have
nothing, nothing. The only thing I had was my
son, but they [Child Protective Services] took
him.
Moreno, C. L. (2007). The relationship between culture, gender, structural factors, abuse, trauma, and
HIV/AIDS for Latinas. Qualitative health research, 17, 340-352.
Types of Trauma: Chronic

When I was being abused, I thought that was
life; because my mother did it to me, my uncle
and aunts did it to me, so what made me think
that my husband wasn’t going to do it to me?
That was a way of life.
Types of Trauma: Complex

Sometimes to be undocumented mentally kills
a person. The fear of what will happen, that
tomorrow they will take away the help . . . that
the police will come get you, that’s what will
happen.
Types of Trauma: Historical

How Common is Trauma for the
Individuals You Serve?

Trauma-Informed Services &
Health Services
Power and Control
– Management vs. Empowerment
– Problems and Disabilities vs. Strengths
– Symptom Management and Reduction vs. Skill Building
Authority and Responsibly
– Expert Intervention vs. Education
– Allocation of Resources Driven by the System vs. the Consumer
Goals
– Stabilization vs. Growth and Change
Language
– Jargon vs. Everyday Language
Freeman, D. W. (2001). Trauma‐informed services and case management. New directions for mental health services, 2001(89), 75-82.

Advancing Public Policy
for Health Equity and
Prevention
Elva Yañez, MS
Director of Health Equity
Sea Mar Community Health Centers
12th Annual Latino Health Forum

PreventionInstitute.org @preventioninst

4 Prevention Institute
• Meets basic needs of all
• Quality and sustainability of
environment
• Adequate levels of
economic and social
development
• Health and Social Equity
• Social relationships that are
supportive and respectful
Healthy Communities

5
Health equity means that everyone has a fair and just
opportunity to be healthy. This requires removing obstacles
to health such as poverty, discrimination and
their consequences – including powerlessness and lack of
access to good jobs, education, housing, environments and
health care.
Source: Braveman PA, American Public Health Association,
Annual Meeting, November 2, 2016, Denver, CO
Health Equity

• Life expectancy varies by as
much as 12 years
• Watts: 72.8 years
• Bel Air, Brentwood, and
Pacific Palisades: 84.7 years
- Health Atlas For the City of Los Angeles
Life Expectancy in Los Angeles

The Trajectory of Health Inequities
HEALTH
INEQUITIES
Exposures
&
Behaviors
Medical
Care
Unhealthy
community
conditions
Structural
drivers

Health inequity is related both to a legacy of
overt discriminatory actions on the part of
government and the larger society, as well
as to present day practices and policies of
public and private institutions that continue
to perpetuate a system of diminished
opportunity for certain populations
A Time of Opportunity: Local Solutions to Reduce Inequities in
Health and Safety.

Production of Inequities

• Segregation and discrimination
• Biased planning and park making
• Economic restructuring
• Devolution
• Prop 13
• Low priority status of parks
Production of Park Inequities in LA

17
While health inequities have been
created, there is also a pathway to
produce health equity.
The Production of Equity

18
[Policy, systems, and
environmental
improvements] have great
potential to prevent and
reduce health inequities,
affect a large portion of the
population, and can be
leveraged to address root
causes, ensuring the greatest
possible health impact is
achieved over time.
Practitioner’s Guide for Advancing Health Equity, CDC

Spectrum of Prevention
Influencing Policy & Legislation
Changing Organizational Practices
Fostering Coalitions & Networks
Educating Providers
Promoting Community Education
Strengthening Individual Knowledge & Skills

Educating Providers

A formal or informal
agreement on how an
institution, governing
body or community will
address a shared
problem or shared
goals. Any institution
can make a policy.
Source: FoodArc
Policy: A Working Definition

Organizational
•Policy Manual
•Codes of Ethics
•Tenure &
Appointment
Agreements
Regulatory
•Administrative
Rules
•Regulations
•Executive
Orders
Fiscal
•Annual
Budget Acts
&
Regulations
Legislative
•Bills
•Laws/Referenda
•Constitution
Legal
•Court
Decisions
Types of Policy

Source: PolicyLink

• Community need
• Fewer resources required
• Diverse, broad-based coalitions
• Comprehensive solutions
• Accessible elected officials
• Support and participation
• Innovation
• Implementation and compliance
• Potential for replication
• Catalytic
Advantages of Local Policy

1. Assess the policy landscape and define a policy objective
2. Develop policy language that ensure effective
implementation, compliance and enforcement
3. Build and maintain a strong, broad base of support
4. Back up the case in support of the policy
Elements of Local Policy

To assist people in moving themselves:
• From a point of “perceived” powerlessness and
ineffective/non-productive action
• To a point of recognized/realized powerfulness and
effective, constructive action
Source: Anthony Thigpen, AGENDA
Purpose of Organizing

The grassroots approach assumes that the affected
community knows:
• The issues / appropriate actions
• Problems / salient solutions
• Questions / adequate answers
And, that the community has the fundamental right and
inherent capability to define and describe what it knows, and
determine the direction needed to deal with the issues at
hand.
Purpose of Organizing

• Win concrete improvements in people’s lives
• Make people aware of their own power through tangible
victories
• Alter power relationships
Source: Midwest Academy
Principals of Organizing

• Compelling issue
• Sufficient grassroots base of support – organized and
educated
• Strategic coalition building – representative and relevant
• Effective strategy and organizers
• Dynamic campaign
• Ability to effectively counter opposition tactics
Elements of Successful Campaigns

• Well organized base of support
• Authentically diverse coalition
• Clearly articulated strategic goals, objectives & action plan
• Policy goals reflective of community’s level of support
• Policy language that is strong and effective, with coalition
consensus on compromises
• Emphasis on educating the general public, media, business
community, elected officials and health allies
• Ability to effectively counter opposition tactics
Characteristics of Successful Campaigns

City of LA Quimby Reform

LA County’s Measure A

[Policy, systems, and environmental
improvements] have great potential to
prevent and reduce health inequities,
affect a large portion of the population, and
can be leveraged to address root causes,
ensuring the greatest possible health
impact is achieved over time. However,
without careful design and
implementation, such interventions may
inadvertently widen health inequities.
-Practitioner’s Guide for Advancing Health Equity, CDC.

35 Prevention Institute35 Prevention Institute
Too frequently, low and middle income people and people of color
get squeezed out of neighborhood housing and business markets
rather than benefiting from new development and investments.
• Healthy Communities and Displacement

“…occurs when any household is forced to move from its
residence by conditions which affect that dwelling or its
immediate surroundings, and:
Are beyond the household's reasonable ability to control or
prevent;
Occur despite the household’s having met all previously-
imposed conditions of occupancy;
And make continued occupancy by the household
impossible, hazardous, or unaffordable.”
– Grier and Grier, 1978
Displacement

In addition to the public health
impacts of residential
displacement, commercial
displacement is an issue in its
own right. Commercial
displacement often precedes
residential displacement in
neighborhoods and can
jeopardize community
connectedness and stability.
Small Business Displacement

For public health researchers and
practitioners, preventing displacement
may be the single greatest challenge
and the most important task in our
collective efforts to create healthy
communities for all.”
–Dr. Muntu Davis, Health Officer and Public Health Director,
Alameda County

Displacement is
a Public Health
Issue

Quality, Affordable Housing Promotes Health

• Forced relocation disrupts access to jobs, school,
medical care, and social connections
• People may move to places with less access to
walkable streets, parks, public transit, and
culturally relevant goods and services
• Longer commutes mean less time with family or
exercising, and contribute to greenhouse gas
emissions
Access to Resources, Goods, and Services

• Loss of social networks from displacement
associated with increased stress, adverse birth
outcomes
• Residential instability associated with health,
educational, and behavioral issues in youths
• Serial displacement cumulatively increases risk of
illness, injury, and poor mental health
Community Stability and Social Connections

• Geographic adjacency to high-value or
gentrifying neighborhoods
• High proportion of renter-occupied
housing
• Lack of strong tenant protection policies
especially rent control
• Little to no subsidized public housing
stock
• Existing public transit infrastructure
• Public infrastructure developments
• Low density development that could be
made more dense
• Speculative real estate practices
• Selective or spot zoning that grants
zoning exceptions or variances on a
project by project basis
• Real and perceived improvements in
community safety
• Concentration of low income house-holds
and non-white populations
• Low income or rent-burdened
households
• Lack of home/property ownership
• Lack of household wealth
• Low levels of educational attainment
• Unemployment, under-employment, or
barriers to employment
Risk Factors

• Equity as a guiding principle for all land
use decisions
• Meaningful community engagement in
planning and decision-making processes
• Community connectedness and collective
efficacy
• Community organizations that organize
residents, build their capacity and
leadership skills, and produce or preserve
affordable housing
• High proportion of owner-occupied
housing and businesses
• Monitor and enforcement of strong
tenant protection policies
• Opportunities for meaningful community
engagement in policy-making, planning,
and budgeting processes
• Opportunities to strengthen and grow
financial and social capital
• Home/property ownership
• Intergeneration household wealth
• Job/income stability and good paying
wages
Resilience Factors

Educating Providers

Influencing Policy and Legislation
Examples
• Enact a Health in All Policies ordinance/resolution to integrate health
considerations and performance standards into all government
practices
• Establish special districts/zones to create a focal point for healthy,
equitable investments and policies
• Create requirements and/or incentives for affordable housing units as
part of new transit-oriented residential developments
• Establish impact/linkage fees to capture the value generated by new
development, and invest revenue in affordable housing trust funds, or
other health equity promoting resources
• Enact living wage policies with strong monitoring and enforcement
mechanisms to generate higher incomes and local wealth

Examples
• Use impact analysis tools to anticipate the potential
displacement impacts of plans, policies, investments, and projects
• Build health equity and displacement prevention criteria into
project scoring and selection processes
• Adopt inclusive public outreach and engagement standards
• Collect/analyze displacement and health equity data
• Include specific anti-displacement measures in
comprehensive/general plans and community plans
• Expedite development review and permitting for projects that
meet defined displacement prevention and health equity criteria

Inequitable Land
Use System:
Whose Health is
Most At Risk?

• Active transportation, housing, parks, healthy food,
environmental justice, public health, law
• Grassroots organizing, community development,
academic research, strategic policy advocacy
• Joined by a shared vision that healthy, equitable land
use can be intentionally produced through strategic
multi-sector action
Healthy, Equitable, Active Land Use
Network (HEALU Network)

Is one in which “the decisions, policies, practices, and norms
of government, the private sector, and community
stakeholders produce healthy, safe, and resilient built
environments. The system ensures that both the tools of land
use related fields and the process through which their work
occurs increase community access to health promoting
resources—such as jobs, transit, housing, healthy food retail,
and safe places to play—while protecting people from
hazardous and unsafe land uses.”
- Prevention Institute, 2016
A Healthy, Equitable Land Use System

52
Strategy 1: Equitable Investment
Invest in healthy land use policies and projects in
high needs communities first.

53
Strategy 2: Robust Community Engagement
Increase capacity in government, the private sector, and
community based organizations for robust community
engagement in land use planning, policy, and implementation.

54
Strategy 3: Innovative, Scaled Projects
Accelerate land use innovations in low-income
communities of color—and scale up successful pilot
projects to drive policy change.

55
Strategy 4: Collaboration
Public Health
Parks and Rec
Community
Residents
Law
Enforcement
Planning
Transportation
Housing
Schools
Youth
Faith-Based
Organizations
Foster inter-departmental collaboration to embed health and
equity in all land use decisions.

56
Healthy Land Use for All
“By design, we have left whole communities behind.
By design, we can reverse that and reclaim our
nation and all of its people.” — Rachel Davis
Prevention Institute

#HEALU4ALL
Join the conversation on healthy,
equitable, active land use (HEALU):

PreventionInstitute.org @preventioninst
Elva Yañez, MS
Director of Health Equity
323-294-4527
elva@preventioninstitute.org

Latino health forum 10.12.2017

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