Consumer Health Foundation

The Journey Toward Racial Equity: An Internal Path

In November our Board and staff met at Gallaudet University for our annual retreat. This year our retreat focused on furthering the Foundation’s work on racial equity. Its purpose was to directly engage individual Board and staff members in a training and conversation on structural racism and racial equity concepts as they relate to the work of the Foundation, particularly as our work in this area continues to grow. We had 100% attendance, including several past board members.

Our journey to this place began in 2007 when we volunteered to take part in a racial justice grantmaking assessment pilot project. Over the years, our journey has taken us through many processes, including doing an internal assessment looking at all of our practices from a racial equity lens; engaging in several board and staff facilitated discussions on both structural racism and its role in health disparities and inequities; and hosting more annual meetings and convenings on health and racial equity. This process culminated in us laying out for our community the Foundation’s commitment to health justice, which includes tackling issues around structural racism in the context of our work in health care access and the social determinants of health.

The genesis of the retreat came from a series of racial equity trainings that the Foundation sponsored for our advocacy grantee partners in the spring of 2010. After listening to a staff report on these trainings, our Board expressed an interest in doing the same at its annual retreat. At the outset, we enlisted two consultants with extensive backgrounds and expertise in racial equity capacity-building. They helped design and facilitate the training. Prior to the retreat, our consultants administered a comprehensive and confidential survey to current and former CHF Board and staff members. It was agreed that the training needed to be both theoretical and practical. There was a strong educational component as well as time and “space” for board and staff members to engage in personal, thoughtful exercises and deeper conversation. The goal was to further apply and institutionalize racial equity concepts and knowledge within both the internal practices and policies of the Foundation and its external work moving forward.

At its heart, the retreat helped the Board and staff ground our work in the relationships among and between us. The day’s conversation evoked personal stories that revealed commonly held values and intertwined threads of experience. They also revealed the cultural and historical realities of our diverse Board and staff members. For example, the opening exercise – Conocimiento where we described in words and/or drawings our individual Cultural History Charts – allowed everyone to listen to each other’s personal experiences. These experiences helped to inform each individual’s understanding of the world and what they bring to the work. Some of the themes discussed were: the micro-aggressions (also called “a thousand little cuts”) experienced by communities of color as the result of the invisible yet tangible effects of the historic and contemporary patterns of structural racism; the challenges in teaching and explaining issues of race, internalized racism, implicit bias; the ways in which we “otherize” people socially and culturally that intentionally excludes them from the mainstream and maintains inequities; and the ways in which language holds us hostage and limits our ability to have open, honest and accurate conversations on race. These conversations also allowed us to discover that we all shared strong groundings in family, faith, and an ethos of giving back to our community.

The depth of the conversation at our retreat was possible because CHF has cultivated a diverse and inclusive board. The Foundation has done this very intentionally, recognizing that the work that we do requires a Board that is reflective of the rich racial and ethnic diversity of our region, and the diversity of communities served by critical nonprofit organizations. Diversity is a critical lens we use in conjunction with the range of skill sets that we need related to board service. We also work to recruit people for the Foundation’s board by reaching out broadly and by drawing upon a range of networks in our community. CHF puts out an annual “Call for Nominations” asking our community to nominate people for Board service as a way of identifying new voices and perspectives.

Our experience has been that a diverse board generates a higher level of creative and dynamic thinking when the culture is inclusive. Again, CHF has very intentionally sought to bring a range of views and perspectives into the processes, activities and decision-making of the Foundation. This requires a different type of engagement among board members. Deep and very intentional listening is a critical capacity.

According to a 2010 study by the Urban Institute and The Racial Diversity Collaborative, Measuring Racial-Ethnic Diversity in the Baltimore-Washington Region’s Nonprofit Sector, 72.9% of the nonprofit board members in the region were white and 27.1% were people of color. The study indicated that we have made some progress in our region in terms of Board diversity; however, there is still more work to be done. The good news is there are more and more resources to help guide us along this path.

On a Personal Note

CHF’s work around racial equity has been transformative – for both the Foundation and for me. This journey has been very personal and has enabled me to dig deeply into the tough and difficult issues of white privilege, racism, and class. Perhaps of all I have done over the years at CHF, the racial equity work has been the most unsettling, the most challenging, the most elucidating, and the most rewarding.

In closing, I have chosen to quote the thoughtful and resonant words of George Penick, founding president of the Foundation for the Mid South. These are his closing thoughts in an honest and provocative essay he wrote entitled, More Than Words: A Description of the Foundation for the Mid South’s Organizational Transformation Emphasizing Racial, Social, and Economic Equality:

Freedom comes from letting go of control rather than holding onto it. Self-realization comes from both acknowledging and being open to exploring what you do not know. The mountaintop comes from sharing experience and purpose rather than from individual competence. And humility comes from realizing that you can only begin to uncover and understand the most difficult, painful, destructive, and self-defeating of human weaknesses—our failure to love others as we love ourselves.

“Where you live is a proxy for opportunity,” PolicyLink Chief Executive Office Angela Glover Blackwell told close to 200 community advocates, health and social service providers, funders, policymakers and others at the Consumer Health Foundation’s 15th annual meeting in January. “You tell me where you live and not only can I tell you how long you will live … I can tell you the kind of access you have to high quality education, whether you live near a job,” she said, highlighting the fact that inequities are common across the Washington, D.C. region.

The meeting’s theme, Connecting Communities: Advancing Regional Solutions for Health Equity, built on CHF’s 2010 Annual Report and was selected to explore potential solutions to achieving true health and social equity for the metropolitan DC region. Moderated by James Gibson, senior fellow in residence at the Center for the Study of Social Policy, Blackwell’s keynote address inspired more than an hour of questions from audience members.

“We have to understand the power of place – the power of place in terms of the negative impact … and the positive impact. If place is a proxy for opportunity, let’s make sure that every place provides opportunity,” she urged.

Using this emphasis on “place” as the theme of her remarks, Blackwell called upon the audience to recognize the impact of changing demographics on the health and well-being of communities, the importance of reducing inequities in access to opportunity, and the link between equity and economic growth.

Our Future: A 5-Year-Old Latina

Blackwell pointed to the growing proportion of people of color as a reason to act now to ensure equal access to opportunity. Changing demographics, along with disparities in education – both in the DC region and across the country – will have a long-term impact on economic growth and competitiveness, she noted.

"Already the majority of babies and 46.5 percent of all children under 18 in the nation are of color. By the end of this decade, the majority of all children in the U.S. will be of color; by 2030, the majority of the young workforce will be of color; by 2042, the majority of people in the U.S. will be of color,” she said. Of note: the DC region is already ahead of this curve, with more than 60 percent of children under age 18 non-white, according to the Brookings Institution.

But, she warned, racial and ethnic disparities in education are going to harm both our region and the nation down the road – by 2018, 45 percent of all jobs in the U.S. will require at least an Associate’s Degree. Yet today, only 27 percent of African Americans, 26 percent of Latinos and 14 percent of recent Latino immigrants have this level of education. “How are we going to meet the challenge of the future if the people who are going to be the future are being left behind?” she asked.

“We are at a point in which America can see its future and it’s a 5 year old Latina; it’s a 12 year old black boy, it’s a 17-year old Asian girl. It’s also a poor white young man living in a rural community,” she cautioned.

Engaging Others in the Equity Dialogue

Drawing on PolicyLink’s recent report, Equity as the Superior Growth Model, Blackwell talked specifically about our region when explaining how social factors like education – along with access to transportation, affordable housing, healthy food and places to play and exercise – are related to equity. Inequities are not only harming the health of our region’s residents, but also the economy and opportunities for growth, she warned. The fact that the region is comprised of two states and the District of Columbia with different policies, funding streams and leadership, makes it more difficult to look for solutions elsewhere, she acknowledged, but she pointed to other places that can provide lessons to the DC region.

Citing examples from the use of health impact assessments in Minneapolis to learn about the impact of new transit lines, to Seattle, California and other places across the country that have successfully engaged partners from across regions to work together in various ways to improve health, Blackwell cautioned against thinking that increased spending is the answer and instead urged attendees to work across sectors to share resources, make smarter investments and to collaborate.

“We need to acknowledge that at the moment we do not have the political will to spend the dollars that we need to spend in order to solve our problems, one by one, silo by silo,” she said.
Seattle is one example of a community that has successfully coordinated across a region, Blackwell noted, where cross-county collaboration has led to health improvements and more efficient use of government funds.

She also cited California’s success in cross-regional planning and collaboration as the result of a two-year Commission convened by the state government leaders. The Regional Equity Atlas developed by the Coalition for a Livable Future in Portland, Oregon is another example of successful cross-region planning to improve health.

The follow-up discussion was lively and several audience questions focused on how to engage stakeholders from across the region in ways to engage decision-makers in conversations about health, equity and social factors. Blackwell’s advice: invest in building long-term relationships, seek out people with different backgrounds and beliefs than your own, and try to help people see themselves in the work that you are doing.

Moving forwad, Blackwell reminded attendees that equity is not just about improving opportunity for people that are of color, it’s about “making sure that nobody is left behind.” And, in order to make people understand the conversation about equity, “everybody needs to be able to see themselves in it."

Connecting Communties: Advancing Regional Solutions for Health Equity

Nearly one in three black children and one in five Latino children in Virginia live in poverty, compared to one in 10 white children, Voices for Virginia’s Children (VVC) emphasized in its January 2012 report on child poverty. The report – and the stark racial and economic disparities that it presents – received significant media attention both inside the Beltway and across Virginia.

VVC is a statewide, privately funded, advocacy organization working to improve the lives of children through research, coalition building and by advancing policy and legislation.

The report’s inclusion of data on race – and the organization’s increased attention to racial equity – stems in part from facts its staff and board learned through a racial equity training funded last year by CHF. The training consisted of two in-depth webinars for staff and several board members conducted by Open Source Leadership Strategies, which according to Executive Director John Morgan, has helped shaped VVC’s work both internally and externally.

“The training helped us get ready to have meaningful discussions of racial equity and diversity and we are now better prepared to shine a spotlight on these issues,” explains Morgan. Specifically, VVC gained a “shared vocabulary” to talk about racism, a better understanding of the impact of structural racism, and new ideas and strategies for addressing racial disparities in child well-being.

Morgan cites the child poverty report as just one example of how VVC intends to highlight disparities in its data and research efforts; the organization is also planning to get additional outside advice to help incorporate equity perspectives into the organization’s policy work.

Internally, VVC has made it a priority to become more representative of the children and families for whom it advocates. “Our board is increasingly diverse and now has solid minority participation,” says Morgan, “and we have stepped up our efforts to diversify our staff as well.” The most recent position description for a staff vacancy stressed finding a candidate familiar with racial disparities in child well-being – the first time VVC had been so explicit about seeking someone with this qualification.

A priority focus for VVC is addressing shortcomings in Virginia’s child mental health system to make services more available and effective. Morgan sees this as another opportunity to focus on racial equity: “Consider the well-known disparities in health care access and health outcomes for children – these disparities can be even more prominent in the mental health arena. For example, it can be incredibly hard for minority parents to find mental health specialists who can effectively address the particular needs of minority children with mental health problems. These issues need to be addressed in our broader efforts at system reform.”

Morgan admits that VVC hasn’t radically transformed and should not yet be viewed as a “role model” but says the group will continue to become more representative of Virginia’s changing demographics – including its increasing Latino and Asian populations – and will work to better incorporate a focus on equity in its policy work.

“This recent technical assistance has strengthened both our ability and our commitment to address troubling racial disparities in child well-being. We’ve taken the first steps on that journey, with positive results, so we need to keep moving forward.”*

*VVC’s training was provided as a follow-up to the racial equity training CHF offered all of its Advocacy grantees in March 2011.

Reflections On Our First "Learning Journey"

As the complexity of the Consumer Health Foundation’s (CHF) work has grown, our board has expressed a desire to engage more deeply and directly with communities involved in complex social change initiatives.

In response, in mid-October, our board and staff went on its initial “learning journey” to Langley Park, which sits at the Takoma Park crossroads of Prince George’s and Montgomery Counties. Learning journeys differ from site visits, which tend to be more narrowly focused on the work of a single organization or a distinct program or initiative. Our goal was to engage with key stakeholders and, more importantly, with residents whose voices are often not heard in most conversations about social change.

The idea of the learning journey was developed by the Presencing Institute at MIT, which develops tools for social change with the goal of creating societies that are “more sustainable, inclusive, and aware.” Its website is rich with resources, including steps for “Sensing Journeys” like ours, which involve inquiry, deep listening and dialogue with a range of people and organizations. Its curriculum is ideal for learning more about a community, rather than a particular initiative or organization. This is an important perspective for us to gain, given our focus on regionalism and the range of social and economic forces that affect health and racial equity.

Much of Langley Park’s richness is in its diversity: its residents represent more than 40 countries and speak dozens of languages. According to the census, nearly 80 percent of residents are Latino and about one in five residents live below the poverty level. CASA de Maryland, one of our grantee partners, served as the host for our learning journey. CASA has a strong presence in Langley Park through its direct service programs as well as its community organizing and public policy advocacy work in housing, employment, immigration rights, fair development and access to health care. CASA has strong roots in the community through its close work with neighborhood residents and leaders, business owners, landlords and property owners, and policymakers.

CASA arranged for our board and staff to tour the community – both by van and on foot. We talked with residents and community leaders in their homes, places of business, in a parking lot, and on the street. We listened to stories about the challenges they face.

We then walked back to CASA’s Multicultural Center and, over a delicious dinner prepared by a local restaurant owner, had a powerful conversation with various activists, residents of all ages, and business owners about the issues affecting the Langley Park community, as well as opportunities. Speaking with such a broad range of community members provided us with a strong sense of the different perspectives, relationships and connections within the neighborhood, and how they impact advocacy and policy change.

The conversation was unlike many that I’ve experienced as a funder. It was intimate and touched upon the both the personal and policy challenges in the community. It was open and candid. With the help of an interpreter, we listened to stories about tenuous relationships with law enforcement; and the entrepreneurial spirit of the community coupled with the lack of jobs. Fears of displacement were expressed throughout our learning journey, particularly given the planning around the new Purple Line development in the area. We heard stories about racial and ethnic profiling. We experienced deep, personal emotion and fear around immigration issues, including deportation. And, we also talked with young people about the Dream Act recently passed by the State of Maryland.

The learning journey provided us with a clear and strong sense of neighborhood, place and of community. We witnessed an amazing staff whose job has become their life’s work. We witnessed a community of great hope, tenacity, courage, and resilience. We saw firsthand the power of community organizing in some of the successes residents have gained as a result of their efforts to improve their social and economic condition. We learned more about a largely immigrant community, which is working relentlessly to achieve the American Dream.

As I was driving home from our learning journey, I reflected on why it had been such a powerful experience for me. I had several observations. First, the experience blended personal perspectives (through the stories of residents, leaders, and business owners) and the collective through community organizing and advocacy in the policy arena. The nature of the visit elicited among all of the participants a bigger conversation around social justice, equity and civil rights related to the immigration issues of our times.

For the Foundation, the learning journey reinforced the need to work at all of these levels to achieve health and social equity in our regional community. This is a much more complex way of working. It is non-linear, dynamic and very relational. We will likely need to develop and deploy new ways of thinking and operating beyond what we have envisioned.

The learning journey itself is an example of this kind of new approach. Our staff and board are already asking where we will travel on our next journey. We welcome others to join us.

The simple storefront entrance at Greater Baden Medical Center’s Capitol Heights location provides no hint of the vast network of health care and other services available inside. From primary health care, to patient assistance for housing, legal services and literacy programs, Greater Baden has come a long way from the health clinic founded in a former library in rural Prince’s George’s County with one volunteer doctor in the 1960s. Today, it is the only Federally Qualified Health Center (FQHC) in the county, with nearly 15,000 patients and six locations, including a specialized pediatric clinic.

Across the DC region, community health centers – many of which were originally established in church basements or other makeshift spaces and staffed by volunteers – have become sophisticated and comprehensive, providing a vast array of high-quality health care and other services with dozens of permanent staff. Paper files are being packed away as providers increasingly rely on electronic medical records. On-site pharmacies and labs provide one-stop visits for patients whose insurance coverage ranges from private insurance, Medicaid, Medicare, the DC Healthcare Alliance, or often none at all.

Clinic administrators speak proudly of their niche services and talk about “competing for patients,” recognizing that today’s patients often have multiple options for care – options that will only increase when hundreds of thousands of DC-region residents gain health insurance coverage in 2014 under the Affordable Care Act. But while the physical structures of the health centers and the scope of services provided have changed tremendously in the past few decades, one thing remains the same: a fierce commitment to providing high-quality care to every patient who comes in the door.

Bread for the City

In the heart of DC’s Shaw neighborhood near Howard University, Bread for the City’s recently expanded building at 7th and P Streets, NW, is open and sunny, with multiple waiting areas for various services, including a large atrium on the second floor where chairs are moved away three days each week for exercise classes. A corner with child-sized furniture creates a cozy waiting area for younger patients, and parents are encouraged to take the colorful children’s books home with them through the Reach Out and Read program. An expansive rooftop garden, with a stunning view of the city’s skyline, provides fresh produce and a location for nutrition classes for both children and adults.

“Calmer … more privacy … more dignity and respect,” explains Medical Director Dr. Randi Abramson a 20-year Bread for the City veteran, who speaks passionately about the quality of care provided to patients.

Since the expansion was completed late last year, the center has added a full-time dentist, with plans to add another full-time physician and vision clinic in the next year. And, all of this is just the beginning – Executive Director George Jones says he hopes to double the number of clinic patients in the coming years.

“Our clinics are true medical homes. Patients come back for regular check-ups and routine care in addition to the other services we provide,” Jones says.

Bread for the City also provides a food pantry, clothing room, legal clinic, job readiness training, a social services program and advocacy services. The fact that Bread for the City provides such a broad array of services had complicated a recent internal debate: whether to apply for FQHC status. The benefits are potentially huge: increased reimbursements from Medicare and Medicaid, discounted prescription drugs through federal rebate programs and more stable funding. The tradeoffs: requirements to charge patients copayments based on a sliding fee scale and changing the composition of the Board of Directors to include at least 51 percent patients. This part is particularly complex for an organization whose mission reaches far beyond health care.

Yet although the designation is difficult to obtain and the decision was not easy, Bread for the City’s Board voted earlier this year to proceed with the FQHC application. “It’s time to know where our funding will be coming from. We believe that health care is a right, and we need to provide access,” Jones explains.

Whitman-Walker Health

As one of DC’s best known health clinics, Whitman-Walker Health has undergone a significant transformation from its birth out of the social justice movement in the early 1970s. Founded as a gay and lesbian health center in 1978 in response to the AIDS epidemic, it became the region’s largest AIDS service organization during the 1980s and 1990s. Through the contributions of a wide network of volunteers, Whitman-Walker Health initially provided peer support, a food bank, legal services and housing to help people die with dignity when there were no treatments for AIDS, eventually providing direct medical care when medications later became available.

“Frankly, we struggled with our service model in the late 1990s and early 2000s in large part because we did not adapt our programs to the new reality of life-saving medications,” says Executive Director Don Blanchon. “Our programs were built for persons who would die within two to three years of an initial HIV diagnosis. But with the advent of anti-retroviral medications, our patients now could look forward to a much longer and healthier life.” By 2005, Whitman-Walker Health was losing more than $1 million a year. In response, the Board of Directors made the important strategic decision to transform Whitman-Walker Health from an AIDS service organization to a community health center. The transition took nearly four years and represented a significant organizational and cultural change for all of Whitman-Walker’s stakeholders. It was also not without conflict or public scrutiny as it included two round of layoffs, program closings, and other cost reductions to ensure financial viability.

Today, Whitman-Walker Health operates as a federally qualified health center “look alike” – meaning the clinic has some, but not all of the attributes of an FQHC – and is a financially stable, comprehensive primary care center with a full-time pharmacy, mental health, dental care and legal aid services, and a second location in Southeast, DC. It’s also the only health center in the city that participates in clinical trials with the National Institutes of Health, giving its patients access to referrals there for additional care.

Once a clinic that didn’t ask for or accept payments for care, Whitman-Walker Health now receives third-party insurance payments for 90 percent of its nearly 9,000 primary care patients. Patients without health insurance are cared for without regard to their ability to pay, with a sliding fee scale and discounts based on income. Electronic medical records help produce data on quality of care.

A new entrance and waiting room at the Elizabeth Taylor Medical Center on 14th Street, NW are bright and welcoming. And, because it is no longer exclusively a clinic for people with HIV or AIDS, patients are less self-conscious about coming in the door. According to Blanchon, “Our new health center model gives us a competitive edge in this era of health care reform, where we will be held accountable by our patients and our funders for the quality of care we provide.”

“And today our strength lies in the diversity of who we see and what we do,” he concludes.

Community of Hope

As of January 2011, there were 848 known homeless families in the District of Columbia. In a given year, Community of Hope provides housing services to well over 250 of them, including about 400 children, providing temporary, transitional and permanent housing and a range of supportive services including health care. Its Adams Morgan health center, housed in Marie Reed Elementary School, offers primary medical, dental and mental health care to nearly 4,000 patients a year and its Family Health and Birth Center is the only freestanding birthing center in the District.

Last year, in an effort to increase the use of routine primary care, reduce emergency room use, and integrate physical health and wellness into its permanent housing program, a “wellness coordinator” funded by the Consumer Health Foundation met with formerly homeless families to learn more about where they were accessing health care. By the end of the program, 98 percent of adults and 100 percent of young children had seen a physician. Today, the young children who participated show improvements in multiple health related measures and improvements were even more significant for dental services with up to 91 percent of adults visiting a dentist. Participants also reported much higher levels of satisfaction with their experience of health care system.

Community of Hope has big plans for the future and will break ground on a $25 million, 50,000 square foot, four-story health center in Ward 8 in the next year, according to Executive Director Kelly Sweeny McShane.

The center will include 18 exam rooms and 11 dental chairs, in addition to a laboratory and space for educational classes, enrollment in benefits, social services, and individual and group counseling. The building will be LEED-certified (an internationally-recognized green building certification system) and include state-of-the-art equipment including electronic health records to help serve the 8,500 residents of Ward 8.

“Ward 8 has some of the worst health outcomes in the city and the highest number of medically underserved residents,” says McShane. “They will all have insurance under health reform in 2014 and we want to make sure they have access to care,” she explains.

Greater Baden Medical Services

Greater Baden Medical Services (GBMS) recently moved its flagship center built in 1960 from its original rural location in Brandywine, MD, to a new 21,000 square-foot building in a busy urban area. “It’s important that we be near the places our patient go – near transportation and where they shop,” says Justin Britanik, program compliance officer.

GBMS has done more than move, however, growing from one location to six. GBMS can now be found in Brandywine, Nanjemoy, Oxon Hill, Leonardtown, Suitland and Capitol Heights and employs more than a dozen physicians including pediatricians and family practitioners, several nurse practitioners, midwives, a dentist and a pharmacist. Nurses, social workers and the front desk staff help patients access the services they need and determine their ability to pay (as an FQHC, patients are required to make copayments determined by a sliding fee scale based on their ability to pay).

A “typical patient” is working at a low-wage job, and is either underinsured or uninsured because their employer doesn’t offer insurance or they can’t afford insurance that is offered. Many patients just recently became uninsured due to the recession.

The complexity of care has changed “tremendously” over the years, as GBMS has grown, CEO and clinic physician Dr. Sarah Leonhard explains. In earlier days, her time was primarily spent providing routine primary care to patients largely from rural areas. Today’s patients tend to have more complicated needs – often facing multiple chronic diseases like heart disease, high blood pressure and diabetes. With limited incomes and challenging lives, they often wait for care until “something pushes them over the edge.”

Staff are frustrated by lack of access to specialty care for the uninsured since Prince George’s County has only one hospital and therefore fewer specialists than in other parts of the DC region. A person who is lucky enough to get a cast for a broken arm may not be able to get it removed for six months. Patients can wait more than a year for an MRI. Certain medications are difficult to obtain. While the GBMS staff is highly proficient in navigating the prescription assistance programs that pharmaceutical companies offer, the process is time consuming. Funding is also a challenge, with operating costs increasing every year.

Despite these challenges, nurse practitioner Debbie Apperson is emphatic, “We provide very high quality care.”

Others agree. GBMS has been invited to work with the DC HIV Collaborative to improve data collection measures and recently received significant funding from the Susan G. Komen for the Cure Foundation to use patient navigators to facilitate breast screenings. And just last month, the Federal Office of Minority Health recognized GBMS for its bilingual and bicultural efforts to improve access to care for patients who are overweight or obese or living with diabetes or cardiovascular disease. Leonhard sums up her organizations unwavering commitment in a changing industry, “Greater Baden’s efforts to expand access to high quality primary health care will continue despite the challenges faced by our patients and our organization.”

The Patient Protection and Affordable Care Act (ACA) has created both opportunities and challenges for health care safety net providers since its passage in March 2010. Safety net providers are health centers and clinics that share a mission and a commitment to delivering health care and supportive services to the uninsured, Medicaid, and other vulnerable patients. One challenge the ACA poses is that many residents of our region are excluded from its benefits: legal immigrants who have lived in the U.S. for less than five years, and undocumented immigrants. Yet, the benefits are tremendous. Many safety net providers in our region – and across the country – are engaged in planning and implementation efforts to ensure that they will be able to take advantage of the new law’s significant opportunities:

Coverage – The ACA will greatly increase insurance coverage for millions of individuals through Medicaid expansion and enrollment through the Health Benefit Exchanges. In 2014, the law expands the Medicaid income eligibility to 133 percent of the federal poverty level which, when fully implemented, would cover 16 million individuals. Uninsured individuals who are not eligible for Medicaid and whose incomes are between 133-400 percent of the federal poverty level would receive subsidies when they enroll in Health Benefit Exchanges. For consumers, this means care will be more affordable. For providers, this means a source of payment to help cover the costs of care.
Delivery of Care – The ACA offers opportunities for demonstration projects and models which provide integrated and coordinated health care services and better quality of care. It will also help address health disparities. Safety net providers have extensive experience providing services to these underserved populations which is an advantage as patients identify the clinic where they can obtain care.

However, there are also growing gaps between different types of safety net providers that pose challenges to their collective ability to serve all residents who need health care, including those who will be newly insured under health reform, and those who will remain uninsured after health reform is implemented. Below is a table that outlines some of the differences between the types of safety net providers in our local community.

FQHCs	FQHC Look-Alikes	Other community health centers/clinics
Receive an increased Medicaid reimbursement rate for patient visits. This rate can be three times greater than what non-FQHCs receive.	Receive an increased Medicaid reimbursement rate for patient visits. This rate can be three times greater than what non-FQHCs receive.	Receive the reimbursement rate set by the state or District of Columbia. These rates have recently been cut during the recent budget crises.
Have access to malpractice insurance through a federal program.	Must access malpractice insurance on their own or in coalition with other clinics.	Must access malpractice insurance on their own or in coalition with other clinics.
Have access to federal funding opportunities and financial incentives to purchase and implement electronic health records, to achieve meaningful use and to attain Patient Centered Medical Home designation.	Have access to federal funding opportunities or financial incentives to purchase and implement electronic health records, to achieve meaningful use and to attain Patient Centered Medical Home designation.	Have access to federal funding opportunities or financial incentives to purchase and implement electronic health records, to achieve meaningful use and to attain Patient Centered Medical Home designation
Have access to federal funding opportunities to support construction and renovation projects.	Do not have access to federal funding opportunities to support construction and renovation projects.	Do not have access to federal funding opportunities to support construction and renovation projects.
Have systems in place to bill for reimbursement.	Have systems in place to bill for reimbursement.	Typically need to implement systems to bill for reimbursement.

If our region’s clinics are to take advantage of opportunities under health reform, we need to grow the capacity of our safety net system to serve both new patients and existing ones. FQHCs, FQHC look-alikes, and other community health centers/clinics all have important roles to play in the system.

Following are some of the roles that health funders can play to help advance this work:

Provide support to safety net health centers that want to advance their practice through the implementation of electronic health records, and work to achieve meaningful use of or attain Patient-Centered Medical Home designation.
Provide support to safety net health centers who need to implement billing systems and/or working with a group of health centers to create a shared back-office billing system.
Support research on the implications of health reform for other community health centers/clinics.
Support policy/advocacy to ensure those individuals and families left out of health reform will have access to high-quality, affordable health care.

Amidst the implementation of health reform, safety net providers will continue to have an important role in providing comprehensive, high-quality, patient-centered and affordable health care to underserved communities and the uninsured. We need to make sure there is sufficient support for both patients who need services, and the clinics that provide those services in this changing environment.

CHF’s Margaret K. O’Bryon wins the Grantmakers In Health (GIH) 2012 Terrance Keenan Award for Health Philanthropy! Margaret will receive her award at GIH’s Annual Meeting in Baltimore in March 2012.

The Consumer Health Foundation is now on Facebook! “Like” our page!

CHF Welcomes two new Board members: Chan Park and Joe Wright. A resident of Montgomery County, Chan’s background includes community advocacy for improving the quality of life for the Asian-Pacific American community. Joe, a pediatrician from Prince George’s County, has a special interest in the areas of population health and the social determinants of health equity.

The Joint Center for Political and Economic Studies Releases Two Reports on Health Equity:
Segregated Spaces, Risky Places: The Effects of Racial Segregation on Health Inequalities -This study looks at the relationship between the level of segregation in metro areas in the U.S. and the health of the people who live in these communities. Metro areas with the highest levels of racial segregation have the largest racial health inequities.
A Lost Decade: Neighborhood Poverty and the Urban Crisis of the 2000s - This report looks at trends in the share of African American, Hispanic and white families in high-poverty neighborhoods since 1970. While there is a smaller share of black, Hispanic and white families living in high-poverty neighborhoods today than in 1970, black and Hispanic families are increasingly more likely than whites to live in high-poverty neighborhoods.

New Census Poverty Measure Shows Medical Expenses Push 10 Million More Americans into Poverty. In a recent blog, The Commonwealth Fund discuses the findings and implications of a new report released by the U.S. Census Bureau which shows that health care is not only the most significant living expense faced by low-income families, but that the growing burden of health care is pushing even more families into poverty.

The National Association of County & City Health Officials just released Roots of Health Inequity: A Web-Based Course for the Public Health Workforce. Using a social justice framework, this online course provides public health practitioners the concepts and tools to effectively tackle the root causes of racial health inequities.

CHF Goes Global! Last month CHF President & CEO Margaret O’Bryon met with a delegation of 18 Chinese leaders working in nonprofits and philanthropy to talk about philanthropy in the U.S. and CHF’s work. The visit, which included trips to Ford, Rockefeller and other national foundations, was organized by the Foundation Center in China.

Grants Update: CHF makes its final grants for 2011 in the areas of Advocacy, Health Care Systems Development, Safety Net, Innovations/Special Projects, Organizational Development and Knowledge Capital. This year, the Foundation has awarded 35 grants totaling $1,055,000.

'E to the x'

Several years back, I was sitting around a nondescript conference table in a similarly nondescript office building with a group of funders. I don’t remember the subject of the meeting; however, I vividly recall an exceptional conversation with one of the participants, a young woman sitting to my left. What attracted me to her was the tattoo on her arm — not only because she was a funder with a tattoo, but because the tattoo had the mathematical symbol for 'E to the x' — E^x — lodged inside a red heart. I racked my brain to try and figure it out. No such luck. As soon as we had our break I turned to her and asked the obvious question. What does it mean?

A very personal story enfolded which has much less to do with math than it does with wisdom and experience.

She told me that she left home in her mid-teens. Living on her own, she struggled a lot. At the age of 25, she enrolled in college. She was passionate about being an economics major; however, to accomplish this she needed to pass calculus. She failed her first test and immediately went to the professor and asked if, statistically, it was possible with the failure to pass the course. He said she could, but that it would be tough. That was all she needed to hear. She partnered with another woman, a friend, who was in the same situation. Her friend gave her a pencil (which she now treasures) and for days they feverishly worked the equations from every angle. At a critical moment, one equation became clear to her: E^x. That knowledge and clarity turned out to be the breakthrough she needed to understand calculus and meet her goal of passing the course. In fact, in her words, “I broke the curve on the last test.”

Her story and metaphor captured my imagination because it made me think about the nature of breakthrough and the forces that support it. For the young woman, they included amazing drive, a partner, support, “space” to work creatively, the willingness to risk failure, and the knowledge that success was, indeed, more than a possibility. Her story also demonstrated how her breakthrough in understanding one equation led to her understanding a whole branch of mathematics, i.e., calculus. Thus, a single breakthrough has the potential to open up all sorts of possibilities.

It’s hard to predict those breakthroughs. It is possible, however, to support innovation and a process that can lead to breakthroughs, whether it be theoretical (like the one in the story), or concrete, like so much of the work in which funders and others are involved.

A core value of philanthropy is to foster and support innovation. This speaks to the willingness to take risks and to putting ourselves “out there” to do so. We all will make mistakes along the way, learn from them, and move forward in a much stronger position. “We will listen and seek wisdom in familiar and unfamiliar places. This orientation enables philanthropy to lead and “push the edges” in advancing equitable social change by aligning with our many partners in their work to improve the health of our communities.

The Consumer Health Foundation has created a new section on our website called Innovation. Through it we will share what we have learned from others designing and doing creative and effective work in the community. We also intend to advance new thoughts, new ideas. We will elicit the help of our multiple partners in bringing this work to us.

Stay tuned and have a wonderful summer.

The District of Columbia’s foster care system is a complex bureaucracy in which foster families, as well as older foster youth and young adults who are about to age out of the system, often face significant challenges in getting the important health and social services they need. Two local organizations, however, have been tireless champions for these families and young adults. Each group advocates for policy changes that not only increases access to these services, but also improves the system in ways that better meet the respective health, social and economic needs of foster families and young adults. And, both employ similar strategies: empowering and training those living in and affected by the foster care system to become strong and effective leaders in advocating for reforms that enhance the health and life outcomes for foster children, older youth and young adults.

For Foster Parents, One Group Goes to Bat

Becoming a foster or adoptive parent presents a complex set of issues: emotional considerations and juggling requirements of courts, social workers, judges, lawyers, and health and social services agencies. And then, of course, there is caring for the children themselves.

A significant challenge is navigating the health care system, which can be particularly daunting. Foster parents may have to track down medical records, a Medicaid card or prescriptions, and often have to piece together an array of primary, mental health and dental care services for a child.

They often need help, and that’s where the Foster & Adoptive Parent Advocacy Center (FAPAC) comes in.

Over the last decade, FAPAC has worked to improve access to health and social services for foster children by identifying problems and improving communications, and simplifying processes within the District’s child welfare system. During this time, FAPAC has helped to organize coalitions and task groups, bring various groups together, and serve as a grassroots advocate for change. It’s the only organization in the District whose primary purpose is to advocate for systemic reform of the child welfare system.

Giving Foster and Adoptive Parents a Voice

Change within a city-run system on this scale may sound daunting, but FAPAC Director Margie Chalofsky believes that the best approach is an obvious but often overlooked one: training foster and adoptive parents to advocate for children. “Their voice is critical and had been missing in the child welfare system,” she says. “I’m proud to see them leading the charge for better health and social services.”

FAPAC Advocates Elaine Farley and Carrie Porter in Peer Advocacy Training on foster care.

With support from the Consumer Health Foundation, FAPAC has helped to make sure foster and adoptive parents have the tools and resources they need: a Medicaid card, medical records or even access to emergency mental health services in the middle of the night.

FAPAC holds trainings for parents to help them navigate D.C. agencies on topics such as, “Accessing Services for Health and Mental Health Needs” and “Understanding DC and MD Medicaid.” Another recent training focused on legal issues in the child welfare system and included individual legal counsel by appointment.

Other trainings, presented by experts in the field, are chosen to address specific issues, such as “Healing the Invisible Wounds: Children’s Exposure to Violence.” Another training for parents and social workers that Chalofsky believes is critically important teaches participants about the lifelong behaviors and characteristics resulting from fetal alcohol syndrome disorders and how to improve health outcomes for children with those disorders.

She is encouraged by the progress she has seen, but admits that finding resources is a constant challenge. For example, Chalofsky would like to hold the training on fetal alcohol syndrome disorders regularly, but lacks the necessary funding to be able to do so.

In addition to lack of funding, another challenge is the inherent contradictions in the system itself.

Chalofsky notes one such Catch 22 for parents: Foster parents cannot rely on the stipends they receive from providing foster care and must have their own income in order to be eligible to become foster parents. At the same time, they are responsible for taking the child to medical appointments, meetings with their birth parents, school and agency meetings, and court hearings during the work day, as well as making sure that even teenagers are not alone in the house after school, when they are suspended, or when they are on school vacations. “How can a foster parent hold down a job and be available to this degree 24-7?” she asks.

Wanted: Advocates for the Whole Family

She would also like to see stronger partnerships among parents and social workers, noting another contradiction in the system: Social workers – who are sometimes closer to the ages of the children than the foster parents – often identify with the child and view themselves exclusively as the advocate for the child.

Instead, Chalofsky says, they should be advocates for the entire family. “Children need to be part of the family structure, but the current system polarizes the child and makes it harder for them to be part of the family,” she says.

And exacerbating the conflict, she adds, is the fact that “the system’s instinct is to move them at the first sign of a problem, but with better training and support for parents, that doesn’t have to be the case. In reality, it creates much less trauma to a child to train and support their foster parents than to move them from home to home.”

Change has been slow, but progress steady.

Eight years ago, parents were not receiving basic information on the physical and mental health needs of the children in their care. Through FAPAC’s advocacy, parents now almost always receive placement packets that include a medical history for the child, and parents know where to turn when they are missing a Medicaid card. FAPAC also successfully advocated to get an emergency mobile van that provides mental health services after hours, and is working to establish training guidelines for “therapeutic” foster care providers and to create standard of care for children with significant behavioral or mental health issues.

FAPAC’s success is due in part to significant efforts to gain the trust of everyone involved in a complex system. Having a staff and board comprised of primarily foster and adoptive parents, FAPAC has significant credibility with and the trust of its constituents as well as its partners, in part because “we rarely present a problem without offering a solution,” she explains.
When FAPAC started, Chalofsky says, she was naïve in thinking the ultimate approach to “system change” was advocating for changes in child welfare policies, when, “in reality, the critical step is to change the institutional mindset. But that’s still not enough. Then you need to change what’s expected, and then you need to make sure it’s happening.”

For Youth Aging Out of Foster Care, the Young Women’s Project Helps Young Adults at Risk

At Antoine McPherson’s first meeting to discuss his transition from foster care to living on his own, he was told that none of the eight people around the table could help him with job leads because of the recession. He was also given the name of a homeless shelter as a housing option.

As a young adult in Washington, D.C.’s foster care system, Antoine lives in an apartment with missing doorknobs and a broken lock. He lives in a high-crime area without access to metro buses or trains, or grocery stores. He also has no internet access, which makes job hunting difficult.

Antoine McPherson testifies at a
hearing on foster care.

For older youth in foster care like Antoine – those ages 15 to 21 – these are the everyday realities of the complex child welfare system, with particular challenges for young adults about to age out of care. This year, 170 youth will age out of D.C.’s foster care system. Despite a system that spends up to $100,000 per child per year, foster teens and young adults often lack vocational skills, face bleak job prospects, and have few housing options as they transition out, putting them at risk for poverty and homelessness.

In many cases, these youth don’t get services to which they’re entitled, and many don’t even know they’re entitled to certain services. And allowances for personal expenses don’t cover clothing, transportation and personal supplies. Antoine receives $580 per month, the same amount he has received since 2001, despite the increased cost of living in D.C. He spends $350 per month on transportation, leaving $230 for food, clothing and any other expenses.

To combat these critical issues, the Young Women’s Project (YWP) created its Foster Care Campaign which advocates for older D.C. foster girls and boys and trains 25-35 youth staff each year to be leaders, advocates and peer-to-peer educators. The program is designed to help teens and young adults in foster care to know their rights, how to navigate the bureaucracy of a variety of city agencies, and to be advocates for better services.

Access to health care is a particular challenge, according to YWP Executive Director Nadia Gold-Moritz, noting that while youth in foster care are covered by Medicaid, they don’t always know how to access reproductive health services, mental health services, or routine care such as eye exams and often don’t practice healthy behaviors. One third of girls in foster care become mothers before they age out of the system.

And while the needs of older youth in foster care are great, one thing the system doesn’t need is more money. “There is plenty of money in the system, but it’s not being used effectively,” Gold- Moritz says.

What specific changes would she like to see? Getting foster youth into good schools and keeping them there; college prep starting at age 16 for youth who show college potential; improving support for youth aging out of the system; reducing poverty by increasing subsidies; and better data collection to see how progress is occurring. YWP is empowering foster youth to help ensure these changes happen.

March 23, 2011 marked the one-year anniversary of the Patient Protection and Affordable Care Act, the most significant federal expansion of health care coverage and delivery reform in decades. The law is comprehensive and complex, and cuts across many issue areas: insurance reform, financing and payment systems, workforce development, health information technology and prevention. Millions of federal dollars have come into the region to government and nonprofits as result of this legislation, and significant activity has occurred over the last year to support implementation of health reform at the local level.

Following are some brief updates from our region:

The District of Columbia became an early adopter of the Medicaid expansion under health care reform in 2010 by petitioning the federal government to move all eligible childless adults with incomes up to 200% of the federal poverty level from the DC Alliance to Medicaid. In the transition, roughly 30,000 people were moved into Medicaid and are now able to receive a fuller benefits package that includes mental health services. Yet this shift also resulted in lost revenue for some safety net health and mental health providers, due to concurrent cuts that were made to Medicaid provider rates through the budgetary process. The mayoral transition in D.C. resulted in leadership and staff changes, creating some delays in the implementation process. The District has reconstituted its Health Reform Implementation Committee and established three working groups: Eligibility and Medicaid Expansion; Insurance; and Health Delivery System. It has contracted with Mercer Consulting around the development of the Exchange and is holding several stakeholder meetings to gather input over the summer. There has been some discussion about the creation of a regional exchange with Maryland or Virginia.

Virginia, in spite of its lawsuit contesting the constitutionality of reform, is moving forward with implementation. It has established the Virginia Health Reform Initiative Advisory Council under the Secretary for Health and Human Services. The Council has looked at the potential impact of reform in VA and provided recommendations around implementation in a report released December 2010. Six task forces have been established to discuss key issues related to reform, including: Medicaid Reform, Insurance Reform, Capacity (Workforce), Delivery & Payment Reform, and Technology. In our region, health care consumers in Virginia have the most to gain from reform since the state currently has very limited eligibility for its Medicaid program. Because of its historically low Medicaid coverage rates, Northern Virginia’s primary care capacity is also limited and will require major investments to meet demand.

Maryland has positioned itself as an early adopter in implementing reform. It has developed a Health Reform Coordinating Council with several committees that have engaged in a process to gather community input on reform and develop recommendations for implementation. It is among a handful of states that have already passed health insurance exchange legislation for the state, and the state recently released its list of appointees to the Maryland Health Benefit Exchange board.

It is important that community members and nonprofits serving low-income people get involved in local health reform efforts. What can you do?

Stay informed. In addition to major media sources, you can also get information from nonprofit organizations that are working on health care reform locally and nationally such as Maryland Citizen’s Health Initiative, the Commonwealth Institute in Virginia, and Kaiser Family Foundation.
Join the conversation. Participate in health reform stakeholder meetings and work groups being organized by the D.C., Virginia, or Maryland governments.
Engage your colleagues. Discuss the impact that health reform will have on our region and how we can work together to prepare for implementation.
Advocate. Recommend policies and programs that serve the interests of the consumers.

Last month The National Prevention, Health Promotion, and Public Health Council released the National Prevention Strategy. The National Prevention Council is made up of 17 heads of departments, agencies, and offices across the Federal government who are committed to promoting prevention and wellness. The National Prevention Strategy focuses on four strategic directions and seven priority areas (see diagram below) to achieve the overall goal of increasing the number of Americans who are healthy at every stage of life. The Strategy is momentous due to its recognition that the health and well-being of all people is affected not just by policies focusing on health care, but policies concerning housing, education, transportation, agriculture, labor and the environment. Recognizing that our health is impacted by these social factors is a vital step in improving the health of Americans across the board.

Why We Care

The Strategy validates what Consumer Health Foundation and its grantees have known for a long time: that preventing disease requires more than just providing people with information about healthy choices.

While knowledge is critical, we also need to address the Social Determinants of Health, which include the social and economic conditions that shape the health of a community.
Strong emphasis on the importance of empowerment and equity, particularly underserved and communities of color.

Bringing the National Strategy to the Local Level

For each strategic direction and priority area covered, the National Prevention Strategy includes actions to be taken at all levels of society including the federal government, state governments, insurers, community organizations, individuals and families. Community organizations can utilize the strategy in the following ways:

Inform new projects and strategies based on the evidence-based research and indicators provided.
Validate current projects and leverage support by referencing the goals and priorities of the strategy as well as the comprehensive research cited.
Advocate that local institutions such as employers, healthcare systems, and schools adapt their practices and policies to align with the strategy.

Yanira Cruz has been on the CHF Board of Trustees since 2009 and chairs the Nominations and Governance Committee. Cruz is the President & CEO of the National Hispanic Council on Aging (NHCOA), is on the board of the American Society on Aging, and holds an adjunct faculty appointment at The George Washington University School of Public Health. She has led numerous public health research efforts to establish solutions and best practices on key health inequities, and is the author of Barriers to Controlling Diabetes among Adult Older Latinos. Before joining NHCOA, she served as executive director and chief operating officer of the Hispanic-Serving Health Professions Schools (HSHPS). She joined HSHPS after serving as director of the Institute for Hispanic Health at the National Council of La Raza where she led numerous public health programs to improve the health status of Latinos nationwide. Cruz received her Bachelor of Science in Biology and holds a Master’s degree in Public Health and a Doctorate in Public Health with a specialty in global health from The George Washington University School of Public Health and Health Services. Her primary focus is to increase policy-maker and public understanding of the needs impacting Hispanics and disenfranchised sectors of our society, and to encourage the adoption of programs and policies that equitably serve everyone. In her leisure time, Cruz loves to run, go on long walks with her family’s Siberian husky, and volunteers at Montgomery County Aquatic Activities where her son Alejandro swims.

Naomi Mezey was appointed to the Board of Trustees in 2007 and chaired the Program Committee. Mezey is a law professor at Georgetown University Law Center. She received her J.D. from Stanford Law School where she served as an articles editor for the Stanford Law Review. She also has a Master’s degree in American Studies from the University of Minnesota. Her areas of research are law, culture, and the construction of identity. Mezey served as law clerk for Judge Marilyn Hall Patel of the United States District Court for the Northern District of California and prior to law school worked on Capitol Hill as a Legislative Aide to former Senator Alan Cranston. While Mezey has long had a personal and professional interest in race and inequality, she received a crash course in the inequalities of access, care and health finance when her younger son was terminally ill with acute myeloid leukemia. Mezey lives in the District with her husband Matt, and their two surviving children, Jake and Lucy. For pleasure, Mezey swims, cooks, gardens and does Glee karaoke with her kids. This summer Mezey and her family will be moving to London for a year where she will be directing the Center for Transnational Legal Studies.

CHF Hires New Program Officer: Edna “Ria” Pugeda
Ria Pugeda joined the Consumer Health Foundation staff this month as a program officer. Prior to CHF, Ria was a program officer at Public Welfare, where she focused on their Health Reform Program and their Reproductive and Sexual Health Program. At CHF, she will help manage its grants portfolio which targets advocacy for health care access and health justice. She will additionally be engaged in CHF’s strategic alliances and other work.

CHF Welcomes 2011 MPH Fellow Allison O’Donnell!
Allison attends the University of Michigan, School of Public Health where she is pursuing a master degree in Health Management & Policy. After graduation in April 2012, Allison hopes to continue her studies to earn a doctoral degree in Public Health. She is interested in studying the intersection between the social determinants of health and personal transformation. A former Peace Corps volunteer, Allison practices and teaches yoga and meditation, and loves Latin dancing.

CHF’s New Articles of Amendment
The votes are in and the members of the Consumer Health Foundation (CHF) voted overwhelmingly to amend CHF’s Articles of Amendment, which changes our status as a membership organization to a non-membership organization and, thus, the manner in which it chooses its Board of Trustees. Under the new structure, all Trustees will be elected by the full Board to serve limited terms. The CHF Board also amended the Foundation’s bylaws in order to strengthen our ongoing commitment to community accountability and participation. Most importantly, the amendments include a provision to assure that the community remains involved in the Foundation’s process for appointing Trustees through an annual “Community Call” for nominations. CHF will also continue to operate transparently by publishing its annual report, holding annual meetings that are open to the public, and posting its annual tax return on our website, among other things. Thanks to everyone who participated in our voting process.

Washington Regional Association of Grantmakers’ President Tamara Lucas Copeland writes about being arrested at a recent DC Vote protest on Capitol Hill.

Maryland Passes Two New Laws that will improve and support the health and social well-being of its residents:

The Maryland Alcohol Tax which will raise the revenue needed to fund critical health care and community services, including health care coverage services for people with developmental disabilities and mental health needs; tobacco, drug, and alcohol prevention and treatment; and health care worker training.
The Maryland Dream Act which grants in-state tuition rates to immigrant students, thereby removing financial barriers to accessing higher education for all Marylanders.

White House Supports DC Voting Rights and Home Rule: DC Vote reports that President Barack Obama recently stated his support for DC voting rights and home rule during an NBC interview, and in a release of a Statement of Administrative Policy, which announced White House opposition to House Appropriators effort to restrict DC's local needle exchange and abortion programs.

CHF Releases its 2010 Annual Report, Connections: Building the Case for Regionalism
Our 2010 report features interviews with eight local thought and action leaders in the public, private, and nonprofit sectors on how working together across jurisdictions to address health care, HIV/AIDS, job creation, social services, and transportation benefits our region.

Grants Update: The Consumer Health Foundation makes its second-quarter grants.

To the Heart

Some years ago I had the privilege of studying with Parker Palmer, a thought leader in the field of spiritual leadership. He is, perhaps, most known for his work in education and teaching. One of the things he said, that has stuck with me to this day, is the need to tie a string between your head and your heart. I see the arts as a powerful way to maintain and tighten that connection. Through art, stories are transmitted. They speak to the heart. They allow us to step into someone else’s reality, and connect us to people whose lived experience is entirely different from our own. Through stories we are able to cross time, place, class, race, ethnicity and culture. We can experience empathy and solidarity. Personal connections, truth, and passion emerge. Community is often developed. Shared values are forged. And, in my experience, these are the forces that can lead to great and profound social change.

We have tried to integrate the arts into our work at the Consumer Health Foundation. This edition of Connections features stories that illustrate the various ways that the arts are being used to change our perceptions, our understanding, our work, and ultimately (and hopefully) our policies in ways that improve community health. In January, the Foundation partnered with Arena Stage to underwrite 200 tickets for Anna Deavere Smith’s performance of Let Me Down Easy. It was not only a powerful performance, but also provided the venue for our community to come together and experience together the stories she portrayed on stage. After the play, a woman who had attended several earlier performances, shared her observation that the audience that afternoon seemed “different” and she couldn’t quite put her finger on that. The difference, perhaps, emerged because a majority of the audience that afternoon was comprised of people who share many of the same stories through their work addressing profound health and health care issues in our community. And what she felt, perhaps, was a silent communication stimulated through that shared experience.

It is my belief that expression through the arts draws us closer to the heart, to the soul, and to our humanity. In closing, Parker Palmer writes that, “The arts are a civilizing institution that can help us learn to hold tension in a way that leads to life, not death. A good painting, a good drama, a good novel, and a good musical composition share at least one trait: they are animated by the tension between their elements, a tension that not only attracts the eye, the ear, and the mind, but draws us into the experience art offers, the reality it has to share. Entering into the tension of great art, and allowing that tension to pull our hearts and minds open, is a time-honored way of becoming more human.”

Storytelling is an art, but when done well, it has the power to transport us into another person’s world. In Let Me Down Easy, actress, playwright and author Anna Deavere Smith combines a journalist’s interviewing technique with the ability to tell stories in the voices, dialects and mannerisms of people ranging from Tour de France winner Lance Armstrong to a physician in a New Orleans charity care hospital to an Idaho rodeo bull rider.

The common theme? Their experiences with the health care system.

Never leaving the stage, Smith uses simple costumes and props to bring to life people whose stories embody the inequity of health care in this country such as actress and model Lauren Hutton, who became sick and had instant access to a range of New York specialists courtesy of her employer, Revlon Cosmetics – contrasted with Hazel Merritt, whose daughter left a hospital covered in blood and wrapped in a sheet after an error with her kidney dialysis.

CHF invited more than 200 community members and nonprofit partners to Arena Stage on Sunday, February 6 for the nearly two-hour performance, which tells brief stories from the lives of 20 people from a variety of socioeconomic backgrounds.

The stories illustrated the “stark differences in the experiences of wealthy and privileged consumers of health care and the poor and vulnerable consumers of health care,” said Uma Ahluwlia, head of the Montgomery County Health and Human Services. “Issues of access, appropriateness of care, the positive or negative contact with health professionals and the sense of optimism in both recovery and in death were all highlighted in vivid detail.”

“Many of the things that happen to us in the health care system happen to us before we get there,” summarized guest speaker Vanessa Northington Gamble, M.D., George Washington University Professor of Medical Humanities, who spoke following the performance.

At times, the audience laughed at Deavere Smith’s uncanny imitations, and at other times, was in tears hearing the accounts about the poor treatment of patients and the feelings of helplessness of a nurse at New Orleans Charity Hospital after Hurricane Katrina.

CHF Board Chair Christopher King called the performance “a powerful depiction of the human experience,” noting that Smith “creatively expressed how people's lives and choices are shaped by their own experiences.”

Maria Gomez, executive director at Mary’s Center for Maternal and Child Health, attended the performance with her 15-year-old daughter who, after the show, asked her pointedly how she would make sure she would show her patients compassion and continue to provide quality care despite the fact that the clinic has grown from 250 patients to 23,000 patients over the years.

“We can’t take it for granted that people have the time and resources to figure out the right questions to ask their doctors,” Gomez said. “This is the reason why we – the doctor, the nurse, the nutritionist or whoever makes the most sense – have to spend time with patients.”

CHF’s guests were asked what in the show resonated with them in their everyday lives.

“Money, power and privilege do lead to better care and treatment,” said Ahluwlia when asked how the performance will translate to her own work. “The show validated both the equity work we have committed ourselves to and the importance of creating systems, services and infrastructure that help reduce disparities.”

As with many art forms, storytelling and theatre can bring people together on an issue and inspire action. After the performance, King reflected how the community is evolving in its approach to improving health: “While investing in initiatives that will improve access to care is crucial, it is equally critical that we work with our partners to address social determinants, which are clearly associated with health status. So, we were thrilled to present this opportunity to our grantees – as we believe it will create dialogue and spark creativity in how we continue to use our resources to improve health and quality of life.”

Various forms of visual media have long been used as an effective strategy for social activism. Here are a few examples of the ways documentary film, photography, video, theater and even sculpture have been used to educate and promote understanding, as well as provide social commentary:

Using Documentaries to Raise Awareness and Spark Action: Since its release in 2007, the PBS documentary Unnatural Causes: Is Inequality Making Us Sick? has helped to change people’s perceptions about what actually makes us sick and what makes us healthy by focusing on the social determinants of health. It has been shown to communities, advocates, and policymakers across the country as both an educational and organizing tool for changing health and healthcare policies. Locally, the Takoma Park-based organization CHEER (Community Health Empowerment through Education and Research) recently held a series of community viewings of Unnatural Causes in conjunction with a community health assessment of Takoma Park and Long Branch. Other documentaries that have been used to highlight important health and social issues include: Race: The Power of An Illusion, The Other City, Money Driven Medicine

Capturing Community Conditions with a Camera: Last year Planned Parenthood of Metropolitan Washington, in partnership with the STICC (Sexually Transmitted Infection Community Coalition), held a series of meetings among youth health advocates and adults working on issues of reproductive health. The meetings were held to help youth analyze and understand risky behavior data within the larger context of the ways in which socioeconomic inequity impacts community health. Using the method of PhotoVoice, 40 DC youth took pictures in their communities to highlight issues of poverty and housing, violence, alcohol and drug use, school conditions, teen pregnancy, and nutrition, to raise awareness on the multiple negative conditions that affect their health and lives in hopes of changing the future. The photos were displayed last summer at the Sumner School and at the Wilson Building where youth testified in front of the DC City Council Committee on Health. A video capturing the Sumner School exhibit can be found here.

Producing Videos and Plays That Tell Your Story: Sasha Bruce Youthwork’s Media Corps program allows young people to channel their creativity into developing advocacy campaigns. Through this program, youth have created and produced several videos over the past couple of years that highlight critical social issues affecting them and the lives and health of their community. Topics have included unequal access to Advanced Placement classes for students living East of the River; the availability of safe and accessible green space in Anacostia; and sexual harassment in the schools. Media Corps youth also wrote, produced and staged two original plays that were featured at community events and the Capital Fringe Fest. The plays were based on youth’s personal experiences and focused on issues such as single fatherhood, gentrification and domestic violence.

Shaping Your Vision of a Just Future: Last year during its annual retreat, Consumer Health Foundation staff experimented with using sculpture as a way to generate new ideas and insights about our work. Our sculpting materials included multi-colored clay, pipe cleaners, little toys and feathers. We used an exercise called “Four Direction Reflection” from the Presencing Institute to guide the process. The basic idea is to sculpt the current situation in your community and the future you want to create, and to include yourself and your organization in the model. Sculpting allowed us to see and feel the ongoing divides in our community by geography, race, class, and accessibility to resources. It also helped us think critically about our role in creating more inclusive communities.

Social Presencing Theater: Social Presencing Theater uses performance to collectively engage communities seeking to bring about profound social change. It synthesizes a number of practices, including theatre, creative arts, contemplative practices, and dialogue. It is an innovative, art-based method to communicate the essence of social change projects in a way that increases awareness in the community and leads to a commitment to action. Ultimately, it enables an organization or a community to collectively see itself and its emerging future. More information on the process of Social Presencing Theater can be found here.

By Dr. Gay Hanna

The play Let Me Down Easy, Anna Deavere Smith’s one-person rendition of 20 characters’ experiences of the healthcare system, reminded me of a strong and vibrant trend emerging in contemporary healthcare: person-centered healthcare where the “whole person” is placed at the center of the healing process. Although advanced medical technology and pharmacology play a critical role in curing disease and treating symptoms, what has often been left out of medical care and training is the people who are being treated—who they are as individuals, their personal histories, their relationships, and their cultural background. This is where the humanities and arts are beginning to play significant roles in medical education as well as throughout healthcare systems.

Exactly what do the humanities and arts bring to healthcare specifically? For one, it allows people to express themselves and share who they are through the visual arts, music, dance, drama and writing, including poetry and journaling. Having creative outlets to tell our stories and share our full personhood not only provides insight into the human condition, it also has a profound healing effect on the patient as well as the entire clinical team including providers and caregivers. Ancient as medicine, the arts have been part of the healing process since our tribal roots. Some of the ways in which humanities and the arts are currently being integrated into our healthcare system include:

Medical Education - More medical schools are establishing humanities and arts programs to improve communications between doctors and patients as well as the entire clinical team. Such programs have been cited as building empathy, attentiveness and compassion among healthcare providers, and the personal enrichment derived from these activities also relieves stress. In clinical practice, the medical narrative moves from describing a patient as just a mix of signs, symptoms and a diagnosis, to a fuller story about an individual with strengths and potential. It is these stories along with the caregivers’ that makes the medical interventions successful.

Visual Arts Programs - Hospitals and clinics can look and feel like cold and foreign environments to both patients and visitors alike. Visual arts change the dynamics of a facility by making it more personal and engaging to the patient, visitors and healthcare staff, which can be a touchstone of life beyond illness and treatment. Many hospitals are now commissioning works of art to both improve architecture and interior design as well as to create visual markers and cultural bridges throughout the clinical space. Vanderbilt University’s Medical Center Cultural Enrichment Program and Chicago Children’s Hospital are noted for their vast public art collections. Some hospitals even have “rotating art exhibits” that feature the artwork of local artists and even its healthcare workers. The University of Michigan Health System’s Art Cart rotates throughout the medical center with framed artwork that can be selected by patients to place in their room during their hospital stay. Rotating art exhibits are very popular and is a way of bringing the community into the clinical environment.

Performing Arts Programs - The presence of performance artists from volunteer community groups or professional ensembles can turn a healthcare facility into a cultural center. This transformation certainly happens most often during the holiday season, yet larger healthcare centers have found ways to sustain this important programming yearlong through developing artists-in-residence programs.

Arts Therapy and Medical Care - Bedside arts programs in which artists and arts therapists work with patients have radically shifted the clinical environment. Through artistic self-expression, patients can tell stories about who they are and what they have experienced. Family members can also participate as it allows them to turn their focus away from the constant worries about their loved one’s illness to a time of enjoyment and sharing conversation that is not medical. Arts participation is especially powerful for engaging children and diverting their attention away from medical procedures. The imaging center at St. Peter’s University Hospital in Philadelphia has been transformed into an African safari where children, family and staff follow the tracks of wild animals in ways that keeps the focus on the adventure of the imagination rather than the “scary” medical personnel and X-ray or MRI machines. The arts also has a direct therapeutic effect on patients’ health. Florida State University’s Musical Therapy Department has developed a Surgical Singing Buddies program in which research has shown that patients who listened to the Singing Buddies before surgery and after recovery did better than those who did not have the musical treatment.

Palliative care - The benefits of humanities and the arts is especially important in end-of-life and palliative care. More emphasis is being placed on the importance of providing creative activities for older people that encourages them to reflect, reminisce, and share their lives in order to find meaning and purpose at the end of life. The humanities and the arts allows the elderly to continue living through finding satisfaction in the creative arts, either through personal self-expression or as a viewer, listener or reader. Favorite songs, films, books and poems bring meaning to a time in later life where finding meaning is integral to finding life satisfaction.

Overall, the humanities and arts in healthcare gives hope and encourages recovery among patients while strengthening the caregivers, be they family members or the professional medical staff. It makes the person central in their own healing process and is a natural, productive and cost-efficient way to provide care. Let Me Down Easy is a display of narratives echoing the millions of narratives happening around the world today as humanity struggles to improve quality of life for people in times of illness and care-giving. Let us continue to improve healthcare by continuously illuminating the human condition and sharing it to make all of lives healthier and more meaningful to each other, our families and communities – we are our stories!

For further information contact the Society for Arts in Healthcare and the National Center for Creative Aging. For a list of the National Endowment for the Arts’ Arts in Healthcare Best Practices please visit http://www.nea.gov/resources/accessibility/artsnhealth_top.html.

Gay Hanna, PhD, MFA is the Executive Director of the National Center for Creative Aging whose mission is dedicated to fostering an understanding of the vital relationship between creative expression and the quality of life of older people.

Capacity Building in a New Age

As I reflect back over the Consumer Health Foundation’s work in 2010, I am struck by how the breadth and depth of our advocacy and policy grant making has moved us into a new domain – a domain of complex problems and challenges, new networks and alignments within and across jurisdictions, a national health reform policy and big local policy goals (where, by the way, there has been significant success).

As I think about this shift, it is clear to me that the capacity to operate in extremely complex environments with complex agendas may require an additional set of skills beyond more traditional competencies.

Traditionally, foundations’ capacity building efforts have focused on nonprofits, and the technical competencies they need to function as high performing organizations. While this work is critical and must continue, we also need to think about capacity building in a new age, and the new skills that need to be developed to thrive in our current environment. These include sharp critical thinking skills; the ability to navigate complex relationships; the ability to move freely between loosely-held networks; and the ability to align funds and priorities in an extremely tough economic environment, particularly with government cutbacks.

I’d like to focus in on one of these competencies: critical thinking. During our conversation with Dr. Tony Iton at a small dinner before our annual meeting, he stressed the importance of critical thinking as a necessity in advancing a complex, interdisciplinary agenda, like the place-based work he is leading at the California Endowment.

In this context, critical thinking is not a process of disapproval or negativity. It is a discernment process that in its broadest sense has been described as "purposeful reflective judgment concerning what to believe or what to do." Much of the work in this domain comes from the field of education.

In doing a little research, I came across a piece that presented the qualities of a “well cultivated critical thinker”:

raises important questions and problems, formulating them clearly and precisely;
gathers and assesses relevant information, using abstract ideas to interpret it effectively;
comes to well-reasoned conclusions and solutions, testing them against relevant criteria and standards;
thinks open-mindedly within alternative systems of thought, recognizing and assessing, as need be, their assumptions, implications, and practical consequences; and
communicates effectively with others in figuring out solutions to complex problems; without being unduly influenced by others' thinking on the topic.

Intentional focus on supporting the development and application of sharp critical thinking skills (both for the foundation and our partners) may be an area that may be worth pursuing in the new year as we continue to operate in a complicated, complex, and often overwhelming environment. We welcome your input into this exploration and will keep you posted as we advance in our thinking.

As director of the D.C. Department of Health Care Finance (DHCF), Julie Hudman, PhD, has shown herself to be deeply committed to serving and improving the health of the residents of Washington, D.C. Hudman, a political appointee who will leave DHCF in January when the administration changes hands, lives in the city with her husband and two young children, who attend their local public charter school. She says they love to travel as a family, especially to India, where her husband is from, but feel that D.C.’s vibrancy and diversity is a wonderful place to live and raise a family. Hudman grew up and went to college in Oklahoma, and attended graduate school at both Georgetown University and Johns Hopkins. Connections spoke to Hudman in early December about her work over the last few years and the challenges that lie ahead.

Connections: Tell us a little bit about you, your department, and what you’ve tried to accomplish in your role as director.

Julie Hudman: The Department of Health Care Finance is the city’s Medicaid agency. We’re responsible for paying the bills incurred under our public health insurance programs, including Medicaid and the State Children’s Health Insurance program (SCHIP). Mayor Adrian Fenty hired me in 2007 as a health care advisor in his office and the DHCF didn’t exist yet. At that time, it was the Medical Assistance Administration and was part of the D.C. Department of Health.

But, in 2008, the D.C. City Council passed a bill creating a new cabinet-level agency, the DHCF, which the Mayor asked me to head. It was a much-needed change: DHCF is a $2 billion agency that provides health insurance coverage to more than one-third of all D.C. residents—and as such it should be accountable directly to the mayor and, by extension, to the city’s residents. The change not only brought more direct accountability to the agency, but it allowed us to focus our mission more precisely on serving the city’s residents and improving health outcomes.

Connections: What do you mean the agency focused its mission on serving residents and improving their health—wasn’t that the focus before the restructuring?

Julie Hudman: Yes, it was, but those bigger, people-centric goals seemed lost in the all the financial paperwork and bill paying, which is understandable given that we don’t provide services or run programs, we pay nursing homes, hospitals, and providers. With the creation of the new DHCF, we articulated a new mission to improve health outcomes by providing access to comprehensive, cost-effective, and quality healthcare services for residents of the District of Columbia. Our slogan is “investing in your health.”

It seems like a relatively simple change, but it heralded a major realignment that refocused and reenergized the agency and filtered into everything we do. We brought in Medicaid beneficiaries, for example, and talked to them about their experiences with Medicaid and SCHIP and made changes accordingly. We created an ombudsman’s office—the Office of the Health Care Ombudsman and Bill of Rights—to work with individual beneficiaries, helping them to navigate the system and resolve issues. We also started investing our public funds more wisely by asking questions about what we were getting for our dollars. Now we’re creating a perinatal outcomes collaborative to begin measuring quality—we pay for prenatal care, for visiting nurses, but are our babies healthier as a result? Is the infant mortality rate improving? Our managed care providers are now measuring these things and trying to get a handle on what works and what doesn’t. We have plans to do the same thing with chronic disease prevention. It’s long-term work, but it’s so important.

Connections: With health care reform now underway, how does health care access in D.C. stack up against the rest of the nation?

Julie Hudman: The District is very fortunate that we were already ahead in terms of health insurance coverage before the Patient Protection and Affordable Care Act became law. That’s because our Medicaid program already covered a higher proportion of residents than any other state. And, together with coverage provided under the D.C. Alliance for Health Care, any D.C. resident of modest income could obtain health insurance.

That’s still true now—in fact, only 6.2 percent of our residents are now uninsured, the second lowest rate in the nation next to Massachusetts—but the Affordable Care Act (ACA) can help with some of the budgetary issues we’ve started having due to the economy. By opting for early implementation of the ACA’s required Medicaid expansions, for example, we were able to move approximately 32,000 D.C. Alliance beneficiaries into the Medicaid program. We’re also moving an additional 4,000 residents as part of a waiver we submitted to the federal Department of Health and Human Services. We’re anticipating these moves to save District an estimated $66 million in local dollars over the next four years.

Connections: With coverage already so far along, what are the challenges that DHCF faces going forward as reform is implemented?

Julie Hudman: I see two challenges going forward. The first is budgetary—given the economic climate, the agency will have a challenge maintaining the enrollment levels that we’ve achieved to date while the details of reform are being hashed out. And the second relates to those details: the DCHF will be responsible for setting up an insurance exchange, which for those who don’t know is the ACA’s way to reduce health care costs by bringing private insurers together with government insurance to compete for enrollees. We don’t know yet what the details of that will be, how hard that will be to do in the Washington metropolitan region. There are bound to be a lot of technical challenges. And there’s just a big question mark hanging over everything: how do you implement the most ambitious social program at a time when you’re at your weakest as a government in terms of finances and personnel. I think the District is in the best position it could be at this point.

Connections: Given these challenges, what advice can you give consumer health advocates and funders like CHF? What can we do to further advance health care access and improve health outcomes in the region?

Julie Hudman: I have a few ideas that might be helpful. One is to suggest that Consumer Health continue and expand its regional efforts, and get more funders and organizations focused regionally. The D.C. metro area sees a lot of movement across jurisdictions—residents that move across city, county, and state lines for health care, for employment, for housing. There’s a very important regional convening function that needs to continue to happen and even be stepped up. Those relationships will be particularly important as health reform moves forward.

A second idea is that small, community-based providers—free clinics and others—are doing such phenomenal work but they need help upgrading their technology and their systems. Federally-Qualified Health Centers have to meet certain standards for reimbursement and they have an incentive to continually invest in better and better technology that creates efficiencies. The smaller providers can’t really keep up right now, but they need to be able to operate in that high-tech, data driven environment.

And a third is to help develop a more inclusive consumer advocacy community. The city has a strong health care advocates—they’re very sophisticated in terms of data analysis and synthesis, but they’re also very focused on specific constituencies rather than the whole. There are hard-working groups who represent clinics and community providers, who represent the needs of children, of the elderly, of people with disabilities, etc. But we’re missing a strong umbrella organization that is focused on health care more broadly, that represents and educates healthcare consumers regardless of what segment of the population they’re from. Absent of creating a new organization, Consumer Health and other similarly inclined organizations could begin building the health-focused capacities of existing groups that are more broadly consumer focused.

Connections: What’s next for you?

Julie Hudman: I’m planning to take some time with my family. My kids are young and it’s been an intense few years. And I’ll return to consulting, which is what I was doing before I went to work for Mayor Fenty. It’s an exciting time in health care and I want to be part of it.

Julie Farkas joined the Consumer Health Foundation in 1999 as its first program officer. Today, in her role as senior program officer, she oversees the Foundation’s grant-making programs and is deeply engaged with its non-profit community partners in capacity-building, which she initiated soon after she started at CHF. Julie came to the Foundation from the Arlington-Alexandria Coalition for the Homeless, where she served in a variety of capacities from program management, to fundraising, to working directly with the shelter’s homeless residents. While there, she created the shelter’s first employment and job training program—an effort that continues today.

Julie’s first job out of college—she earned a bachelor’s degree in urban planning from the University of Virginia in 1984—was with Jim Rouse’s Enterprise Foundation, which had just begun its efforts to create decent, affordable housing across the country. While there, she helped launch a national network of employment programs serving low-income and homeless people. Julie also worked on the Dukakis-Bentsen presidential campaign in 1988, and shortly after that, spent a year teaching English in Moscow, living in an apartment close to an infamous Soviet political prison and waiting in lines to buy daily provisions.

Julie, who grew up in Alexandria, Virginia, says she was shaped by her family’s commitment to social justice issues as well as by her own observations of inequities in the schools she attended. Her paternal grandfather—who lost most of his family in the Holocaust—founded an NAACP chapter in the small Pennsylvania town to which he immigrated. As one of the first Jewish residents of that community, he also was the first downtown shopkeeper to hire African Americans, and he raised funds to found a YMCA in town because the only swimming pool in the community was for whites only. “He was a mover and a shaker in a town that didn’t want to be moved or shaken,” says Julie.

In addition to her committed professional career, Julie is a busy mom of three sons, ages 18, 16, and 13. To help her keep up with them, she maintains a serious commitment to cycling. During down time, she says she and her husband, Seth Goldman, enjoy hiking, travelling, and playing games with their boys, getting into some “pretty vicious” Boggle competitions. Julie, who also is a volunteer with her synagogue and at her sons’ schools, says she hopes to find time someday to take up pottery and painting and reconnect with her artistic side.

My Visit to San Quentin State Prison: An Inside Look at Prisoner Re-entry

Since 2004, I have had the privilege of serving as a member of the National Advisory Committee of the Robert Wood Johnson Foundation (RWJF) for its Community Health Leaders Program. This role gives me the opportunity to learn about community health leaders from across the country who are making a difference in their local communities in innovative and unique ways.

From time to time, I also get to see this leadership in action through participating in site visits. This work recently took me to San Quentin State Prison in California. Opened in July 1852, it is the oldest prison in the state and is the only death row for male inmates in California, which, incidentally, has the largest number of male death row inmates in the United States. And with a population of over 5,000 – 159% of capacity – it is also overcrowded.

My visit included a tour of the medical facilities and conversations with inmates. The purpose was to learn about the work of a young doctor, Shira Shavit, who directs a prisoner re-entry program called Transitions Clinic. An article in the New York Times, “Clinic Works to Include Ex-Inmates in Health Care’s Embrace,” characterized Transitions as “the first in the country specifically for parolees, combining aggressive outreach — like recruiting prisoners before their release — with a nonjudgmental approach.” The program provides recently released inmates who are chronically ill with a medical home, care management, and referral to social services needed upon their release from prison. The goal is to successfully integrate these individuals into their communities.

At the heart of Transitions’ success is a cadre of trained peer community health workers who also have a history of being incarcerated. Chronically ill inmates are first identified while in prison, then the peer community health workers meet them at parole meetings upon their release. They accompany the patients to their appointments and check in with them by phone. In addition to connecting them to housing, employment, education, and other benefits, peer community health workers also help the patients navigate the complex processes that go along with accessing the benefits of fragmented systems.

During our visit to the community clinic in the Bayview neighborhood of San Francisco which houses the Transitions program, we listened to the peer community health workers and recently released patients talk about how much they appreciate the program and the critical health and social support services it provides. One patient drives several hundred miles round trip just to maintain his relationship with the program, and one of the community health workers is now working to complete her education. We also learned about how the community clinic is working to integrate the Transitions patients into its broader practice.

It also was interesting to learn the other ways in which Transitions’ work extends beyond the clinic’s walls and into the community at large. For example, the clinic is one of three partners participating in the Post Release Wellness Project which focuses on:

Providing culturally competent primary care health services and case management for formerly incarcerated individuals.
Advocating for policies that support equal access to quality health services on the state and local level.
Providing training for front-line providers including community health workers.

Other Project participants include a nonprofit advocacy organization, and the City College of San Francisco’s (CCSF) Health Education Department. CCSF is the home of the nation’s first community health worker certificate program, which led to it becoming the first college-based, vocational education certificate program that trains front-line public health providers to specifically work with formerly incarcerated individuals.

While participating in the site visit, I could not help but relate all of what I had learned in San Francisco to our community and the Foundation’s work “back home.” There were several lessons I took away from the experience:

Peer involvement and empowerment—as educators and navigators—is critical for success.
Listening is a powerful tool for developing and implementing this kind of program. Continuous references to the value of “knowledge as power” and “each one, teach one” kept creeping into many conversations with the patients.
Health care is only one piece of the network of services essential for successful reintegration and that, in fact, housing, employment, and support systems often precede health care in a prioritized list of essential services as articulated by the consumers.
The importance of extending the reach of the program beyond providing critical health care services to establishing partnerships with others who work in multiple arenas, including advocacy, policy, education, and multiple social services.
The value of shared leadership at multiple levels – the medical staff (both inside and outside the prison), the community health workers and peer educators, and the volunteers.
The importance of focusing on outcomes, particularly in an environment where there is demand to replicate a successful program.

According to 2008 report by the Pew Charitable Trusts, more than 1 in 100 American adults are incarcerated. As the report notes, “For some groups, the incarceration numbers are especially startling. While one in 30 men between the ages of 20 and 34 is behind bars, for black males in that age group the figure is one in nine. Gender adds another dimension to the picture. Men still are roughly 10 times more likely to be in jail or prison, but the female population is burgeoning at a far brisker pace. For black women in their mid- to late-30s, the incarceration rate also has hit the 1-in-100 mark. Growing older, meanwhile, continues to have a dramatic chilling effect on criminal behavior. While one in every 53 people in their 20s is behind bars, the rate for those over 55 falls to one in 837.” When their sentences are served and these individuals are released into the community, there are often no community supports or safety net. Health and other needs can go unchecked. These individuals become some of the most marginalized and disenfranchised members of a community.

In the District of Columbia, Unity Health Care and a set of community partners have joined forces to design and deliver a prisoner re-entry program for individuals returning from federal penitentiaries outside of the city. According to the Court Supervision and Services Agency, over 2,000 men and women return to the District each year from federal prisons. This is in addition to the thousands that cycle through our local jail. That program is in its early stages. CHF and other local foundations have provided funding support through a Local Funding Partnership with the Robert Wood Johnson Foundation. The work is complex and very tough. But, it’s an issue that our community cannot afford to neglect. The good news is that there are other communities and models across the country to help guide our way.

Keynote speaker Tony Iton says public health must focus on social policy to achieve health equity

On May 20, the Consumer Health Foundation (CHF) convened more than 200 nonprofit leaders, community advocates, and residents at its 14th annual meeting, Health Equity: From Awareness to Action, at the George Washington University’s Marvin Center in Washington, D.C.

Participants gathered to hear keynote speaker Dr. Anthony B. Iton, senior vice president for the California Endowment’s Healthy Communities, talk about his work using a health equity framework to improve health for communities of color. Previously, Iton directed the Alameda County Public Health Department, which in 2008 produced a report Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County documenting health inequities in the county by neighborhood, income level, and race/ethnicity. It also illustrated the links between health inequity and existing socioeconomic inequity and suggested goals and cross-sector policies to lessen these inequities.

"We now know there are strong connections between environmental and economic factors that affect health,” said CHF President and CEO Margaret O’Bryon in her opening remarks to the meeting. Since 2006, CHF has been committed to taking a broader approach to improving the poor health outcomes of low- and moderate-income and communities of color by addressing long-standing social inequities in income, employment, housing, access to healthy foods, opportunities for physical activities, social support and cohesion, and other socioeconomic factors.

Following O’Bryon’s introductory remarks, Iton began his presentation by telling the audience about the “hot spots” for disease and death in Alameda County. He said that county investigators had mapped the deaths in the county according to U.S. Census Tracts. They found that, on average, African American residents of Alameda County die eight years earlier than whites. They also found that high death zones tracked to the poorest neighborhoods in the county.

The Alameda investigators were able to rule out genetics, homicide, and other factors that are usually associated with high death rates. They finally discovered that blacks and others living in disadvantaged neighborhoods were more likely to die from conditions like heart disease, cancer, and stroke.

“These same conditions are killing everyone else, but they’re killing African Americans faster and making them sicker,” Iton told the audience.

Decades of discriminatory practices, like racial segregation and redlining (denying access to or increasing the cost of services such as banking or lending in mostly minority neighborhoods), have led to run-down urban cores that have difficulty attracting jobs, health care providers, educational opportunities, adequate transportation or even stores that sell affordable, healthy food.

Such conditions make it hard for residents of the neighborhood to stay healthy. And the same conditions cause death hot spots in Cleveland, Baltimore, New York, and other urban areas in the United States, Iton told the audience.

Traditionally, public health officials and doctors have blamed high rates of cardiovascular disease, cancer, and strokes on unhealthy behaviors like being sedentary or eating too much junk food. And, in response, they would hand out educational brochures or advise patients to adopt healthier habits.

“There’s no evidence—none—that that approach eliminates anything,” Iton said, adding that such an approach might help an individual but doesn’t fix the systemic causes of the problem, including structural racism and factors that go far beyond individual control.

He suggests that all levels of government work together to enact policies to help eliminate factors that make a neighborhood unhealthy. For example, lawmakers could pass policies that encourage home ownership, universal pre-school that helps children get a healthy start in life, and adequate transportation funding.

After Iton’s presentation, annual meeting moderator Dr. Brian Smedley, vice president and director of the Health Policy Institute (HPI) at the Joint Center for Political and Economic Studies, briefly responded to Iton’s primary points. Smedley talked about opportunities for addressing health equity in our region, highlighting HPI’s Place Matters Initiative, a nationwide initiative launched in 2005 to support communities in developing strategies to address the social factors that determine health.

Afterward, during a lively audience discussion, Iton and Smedley fielded questions from community advocates, non-profit leaders, physicians, and activists. The spirited conversation touched on discriminatory practices and stressful environmental conditions that make it hard, if not impossible, for poor people and people of color in America to erase health inequities on their own. To fix some of the systemic health injustices will require collective action from government officials to empowered residents to community leaders.

Iton urged everyone in the room to begin tackling health inequities in America because there is a high cost to inaction: “People are dying today,” he said.

To download Dr. Iton's presentation, please click here. (20MB)

Since the passage of the Patient Safety and Affordable Care Act in March, CHF has been actively exploring the various ways we can help implement the historic health reform legislation in our region. In May, we partnered with Washington Grantmakers’ Health Working Group to host a briefing for funders that featured Alan Weil, director of the National Academy for State Health Policy (NASHP). NASHP’s briefing paper, State Policymakers’ Priorities for Successful Implementation of Health Reform, is a great resource on health reform. We also are participating regularly in meetings with our foundation colleagues from across the country to learn how they will support health reform implementation in their respective communities.

As in all of our work, our core values and logic model will guide our strategy around health reform implementation—which will surely include a strong focus on health and racial justice for low-income communities of color, as well as approaches that emphasize consumer empowerment and advocacy. Following are four areas of opportunity we have identified, and in which CHF is already involved in some capacity:

Direct consumer outreach and enrollment
Far too many eligible consumers are not currently enrolled in public health insurance programs, and we know that many more will be eligible for coverage or subsidies under the new legislation. We need to begin planning for more effective outreach and enrollment in these programs. CHF has been investing in resources and tools that could support this work through our Ngozi Project, and we know that some jurisdictions are working to simplify enrollment through technology. Trained community health workers and attention to literacy and language access are also critical to efficient and effective outreach and enrollment.

Capacity building for community-based health centers
The true success of health care reform will be getting consumers access to the care they need. Clinics already providing care to underserved populations will need support in planning and developing the infrastructure that will allow them to deliver high-quality, cost-efficient care to a greater number of consumers. This infrastructure expansion will likely include implementing electronic medical records systems, processes for billing for third-party reimbursement, workforce development and new staffing structures, and other innovative supports.

Consumer advocacy
There are a number of state policy decisions that will impact the way health reform is implemented. Important issues such as eligibility for immigrants, benefits design, the structure of health insurance exchanges, workforce policy/scope of practice, and many other details will be determined through state policy decisions. Advocacy and community organizing efforts are needed to ensure that consumers have a voice in the design and implementation of state policies.

Building regional systems of care
Given that residents in our “tri-state” region are used to moving easily across a variety of city, county, and state lines to both live and work, CHF believes strongly in taking a regional approach to healthcare policy and delivery system reform. Regional solutions—including a regional health insurance exchange; regional workforce development strategies; and regional data collection and tracking by race, ethnicity, and primary language—will strengthen and support implementation of health reform.

In addition, we know many other community-based groups are organizing to respond to reform. Here is a snapshot of some of the state-level activity currently underway:

Several community-based groups in D.C. have joined forces to form The District of Columbia Coalition on Health Care Reform, a coalition of organizations who represent consumers and providers participating in public and private health insurance programs in the District. The group recently developed a set of principles to guide health reform implementation in D.C.
Mayor Fenty also established a Health Reform Implementation Committee, which will be co-chaired by Gennett Purcell, the Insurance Commissioner and Julie Hudman, the Director of the Department of Health Care Finance.
The Maryland Health Care for All! Coalition and the Mid-Atlantic Public Health Training Center hosted a series of free forums in June entitled, What Does Health Reform Mean for You, Your Business, or Nonprofit? to educate the public about the local impact of federal reform in Maryland. Additional forums are being planned for later this year.
Governor Martin O’Malley established a Maryland Health Care Reform Coordinating Council to advise the administration on state health reform implementation. An email distribution list has been developed to keep the public informed on the state’s progress in implementing reform.
The Virginia Health Partners Group (The Commonwealth Institute, Virginia Interfaith Center, Virginia Poverty Law Center, and Virginia Organizing Project) and Healthcare for All Virginians are actively planning for health reform implementation in Virginia. The Commonwealth Institute is also working on a series of policy briefs on key issues related to reform.
The state of Virginia has established the Virginia Health Reform Initiative as part of the Office of the Secretary of Health and Human Resources. Cindi Jones, former deputy director of the Department of Medical Assistance Services, was recently appointed to lead the Initiative.

How is your organization engaged in planning for health reform? What role(s) do you think the Foundation should play in supporting successful implementation of health reform in our region? Email us your thoughts at rwick@consumerhealthfdn.org.

Christopher J. King was elected to the CHF Board of Trustees in 2008, and currently serves as Vice Chair/Assistant Secretary. As Assistant Vice President of Community Health for MedStar Health, King is responsible for assessing community health needs and determining key priorities, as well as guiding MedStar's community relations and community benefit programs. He also is a lecturer at the University of Maryland School of Public Health.

As a public health professional and educator with interests in management and leadership, King has taught in public schools, managed an assortment of private and federal community health programs, and written more than $15M in successful grant applications for multiple health services organizations. He also has published papers on healthcare philanthropy, health disparities, HIV epidemiology, and primary healthcare access. He currently serves on several nonprofit boards in the region—each with a mission to improve access and quality of care for vulnerable populations.

As a doctoral student in health services administration at the University of Maryland, King is investigating how non-traditional chronic disease management programs can decrease healthcare costs and improve the overall health status of minorities. Other research interests include leadership in health care, health information technology, and healthcare workforce development for minority populations. King received his undergraduate degree in community health from East Carolina University and a master of health science from Towson University. In his free time, King enjoys working out, traveling, biking, and hanging out with his best canine friend, Bailey!

David Rose was elected to the CHF Board of Trustees in 2008, and is currently a member of the Program and Finance Committees. A board-certified pediatrician for more than 17 years, Rose served as assistant commissioner for preventive medicine and epidemiology for the Baltimore City Health Department, where he was responsible for addressing the combined HIV/AIDS and syphilis crises in the late 1990s. In his roles as vice president for medical affairs at Mary’s Center for Maternal and Child Care, Inc., and later, as senior deputy director for primary care and prevention administration of the D.C Department of Health, Rose helped to implement Medical Homes D.C., a public-private partnership dedicated to improving and expanding care for the underserved.

While providing patient care in a number of underserved and minority communities in several large urban areas, his most cherished work has been in the small victories that parents and children achieve when given support and trust to openly communicate. He says, “It has been my experience that all families want and will pursue the best for themselves and their community if they are given reasons to believe that they are heard and respected. It has been my career goal to offer those reasons in all that I do.”

Rose received a B.S. in biological sciences from the University of Pittsburgh, an M.D. from the Howard University College of Medicine, and completed his residency in pediatrics at Emory University in Atlanta. He also received graduate certificates in public health management and the business of health care from the Johns Hopkins University. He enjoys reading, particularly non-fiction and the works of Walter Mosley, traveling, and riding roller coasters with his children.

After 23 years of service, this spring Dick Davis retired as the Executive Director of the McClendon Center, which provides mental health services to adults diagnosed with mental illness. McClendon Center has been a long-time partner of the Consumer Health Foundation and we are grateful to Dick for his leadership and his deep commitment to empowering their clients in becoming proactive in their wellness and recovery. Following is an interview with Dick excerpted from Images of Best Health, a newsletter produced by McClendon’s Best Health Project. Many thanks to Nathaniel Stanley for allowing us to publish it here. We also welcome Dennis Hobb as McClendon’s new Executive Director!

Two consumer members, Chu Cooper and Romilio Novoa, interviewed Dick Davis by phone on June 9 with questions and answers compiled by Patrick Lynch, a group facilitator. Here is the interview:

BEST HEALTH: What motivated you to work initially in social work and mental health years ago?

DICK: Personal. Professional. I have had mental illness in my family and “could see it” before a diagnosis came. I also saw the negativity go up and the services go down for someone with depression and with low-vision or blindness.

BEST HEALTH: What goals did you have for your leadership at McClendon Center when you first became Director? Did you achieve them?

DICK: When I started, the center was fairly informal. I was already with the New York Avenue Presbyterian Church and inherited this small program. I wanted to expand services here at the center which was first a church mission. At first, we had two full-time staff one person who worked 10 hours a week. I wanted to bring in more professionals and consumers to run the groups, to expand the numbers. We started with 16 consumers, 10 to 12 of whom came regularly. I also didn’t know much about DC mental health at first.

BEST HEALTH: How has McClendon Center changed during your tenure as Director?

DICK: McClendon Center has changed tremendously, and, again, was a church mission at first that reported to the deacon and pastor. I wanted to make it into a 501 (c) (3) non-profit and to add new fringe benefits. I added a psychiatrist, nurse and dietician. (There were also hot meals.) I wanted to make the staff more professional. We also got accredited in 1999 through the Accreditation of Healthcare Organizations. We still needed to become affiliated with the hospital (St. Elizabeth’s), acquire a certification of needs, and sign up with Medicaid (which we do now). We also became affiliated with the graduate schools and psychiatric cores of George Washington University and George Mason University. One would not have recognized the original working space and program.

BEST HEALTH: Tell us about the Best Health Program at McClendon Center and the role of advocacy in mental health.

DICK: Ask Patrick, Nathaniel and Jakki. I wrote a proposal to the Consumer Health Foundation 6-7 years ago to have consumers run this program and to empower consumers, somewhat for political purposes and somewhat to make consumers more assertive. I believe in both the personal and professional and am proud of the Best Health Project. Best Health has been funded by a grant from the foundation.

BEST HEALTH: What was your greatest challenge as Director at McClendon Center?

DICK: A series of things. The city’s mental health system was under judicial control or receivership a few years ago. St. Elizabeth’s Hospital lost its JACHO accreditation and had to learn to function under this control. There were other challenges too.

BEST HEALTH: How has mental health improved in Washington? What role has the Dixon Plan had for you and for McClendon Center in the last few years?

DICK: The current director (of the Department of Mental Health or DMH), Steve Baron, is a smart man. DMH has been improving in a tough environment. He has made improvements himself which, in turn, have automatically improved things for McClendon Center. DMH has gotten better but does have a long ways to go. Steve has been trying to get DMH out from under foot of control. We have a good new St. Elizabeth’s Hospital. Regarding the Dixon Plan, he has gone through it one item at a time. Yet, I do fear that if the court no longer monitors the enforcement of the Dixon Plan, services will go down...and not personal to Mr. Baron. The system is still a bit dysfunctional and we may not be able just to let the city run it; we may need to include outside involvement like more advocates.

BEST HEALTH: Tell us about McClendon’s Center role in the local mental health community, including St. Elizabeth’s Hospital and Department of Mental Health.

DICK: The center started small but has become a major player and has expanded. There are now 50-60 consumers a day. There are more different programs. Particularly with the DC Behavioral Mental Health Association, we have lobbied the city to improve the mental health system. Steve Baron listens to (and respects) the McClendon Center staff. Our board has gotten more involved in local mental health issues and we attend monthly CDL-CFO meetings. We have worked closely with the consumer-run Consumer Leadership Forum (CLF) and have taken them into our office. We are glad to host CLF and also have acted as their fiscal agent.

BEST HEALTH: What are you most proud of in your career in social work and mental health, and specifically at McClendon Center?

DICK: Not just one thing. Building the McClendon Center program, from a church mission to a 501 (c) (3), with two sites now; with an increase in staffing, programs and services; a certification of needs, Medicaid funding, a joint commission, a strong relationship with consumers, and associations with educational agencies.

BEST HEALTH: Finally, what will you do in retirement? Any continued work in mental health?

DICK: Right now, I am adjusting to retirement, catching up on doctors and getting used to a new lifestyle-not getting up early every day. I travel to Boston to see my daughter. I reflect on how lucky I was a year and a half ago when I was hit by a car. I will consult with McClendon Center or some other organization not competing with McClendon Center.

Welcome to the first issue of our now electronic newsletter. While it is bittersweet to leave our beloved printed newsletter behind, we believe that to advance our work and engage the community more fully in it, we need to take better advantage of technology. With this newsletter also comes the launch of our revamped Website. When fully realized, the CHF Website will provide new ways for us to share information and engage in online conversations with our community.

We are excited that this first electronic edition highlights some of our new and emerging work in the area of health equity, which will also be the focus of our next annual report. Last year, our Board updated our strategic plan. This work included the adoption of the belief that community health requires a dual focus: 1) assuring that all residents in our region have equal access to quality health care, and 2) addressing the social and economic conditions that shape the health of our communities. Deeply embedded in our work is an understanding that structural racism and inequities in employment, housing, education, and health care contribute to poorer health outcomes among all people of color, and particularly among those with low and moderate incomes. We have heard this over and over again from our community, and it is a reality that continues to be affirmed through a growing body of public health research.

In addition to refining our strategic plan, last year the Foundation also looked very hard at the external forces affecting our work and the work of our nonprofit partners. In countless conversations we heard about the devastating effects funding cuts were having on nonprofits’ abilities to do the work needed by the community. Many nonprofit leaders have indicated that 2011 may even be harder financially, particularly given current indications around government funding. In many shapes and forms, the current financial pressure experienced by our grantees has given our staff a tremendous sense of urgency to help meet the needs of our community. This includes the deployment of our own resources as well as actively helping our grantee partners secure additional funding from other sources. For example, CHF’s Board decided not to cut our grantmaking budget, thus increasing the percentage of our funds dedicated to grants and program spending in 2010. In addition, we are thrilled by our new programmatic partnership with the Meyer Foundation that involves managing the application and grant review process for Meyer's health and mental health grants.

These efforts, combined with our new mission and its social justice lens, reflect our belief that these are not only times of great need, but also times of great opportunity. A recent Chronicle of Philanthropy article, titled Philanthropy Grant Makers Should Take Risks to Build a Better Society, asserts: “We are in the midst of historic opportunities to transform our society to be more equitable, just, and sustainable by enacting new policies on health care, education, green energy, labor standards, immigration, scientific research, criminal justice, and a range of other issues that directly benefit the communities that philanthropy supports.”

Philanthropy is in a position to take risks, to respond quickly to shifting external forces, and to boldly take advantage of the opportunities created by the current environment to shape a better future. For example, many opportunities—and challenges—will be generated by national health reform and its implementation at the local level. This is new terrain. As it is traversed, we are committed to assist in whatever way it can to facilitate our region’s understanding and response to these reforms.

Once again, welcome to the inaugural edition of our electronic newsletter, Connections. We welcome your thoughts or comments.

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Connections March 2012

President’s Corner

Angela Glover Blackwell Speaks On Solutions For Regional Equity

Our Future: A 5-Year-Old Latina

Engaging Others in the Equity Dialogue

Special Video: CHF’s 15th Annual Meeting

Voices For Virginia’s Children Brings Attention to Racial Equity

CHF Bids Fond Farewell to Jacquelyn Brown, Program Officer

News and Notes

Connections Winter 2011

President’s Corner

Register Today for CHF’s Annual Meeting

The Region’s Community Health Clinics Transformed

Bread for the City

Whitman-Walker Health

Community of Hope

Greater Baden Medical Services

Health Reform and Safety Net Providers

CHF Says Goodbye to Julie Farkas, Senior Program Officer

News and Notes

Connections Summer 2011

President’s Corner

Reforming Foster Care to Improve the Health and Lives of Families and Young Adults

For Foster Parents, One Group Goes to Bat

Giving Foster and Adoptive Parents a Voice

Wanted: Advocates for the Whole Family

For Youth Aging Out of Foster Care, the Young Women’s Project Helps Young Adults at Risk

Health Reform Update

The National Prevention Strategy

Why We Care

Bringing the National Strategy to the Local Level

Trustees Spotlight

CHF Offers Racial Equity Training

News & Notes

Connections Spring 2011

President’s Corner

Let Me Down Easy – A One-Woman Play in the Voices of Many

Media Activism: Tools and Techniques

The Role of Humanities and the Arts in Healthcare

News & Notes

Connections Winter 2010

President’s Corner

Q & A with Julie Hudman, Director of D.C.’s Department of Health Care Finance

CHF Staff Profile: Julie Farkas

New Report Makes the Case for Community Organizing

New Report: 2010 Portrait of Women & Girls in Washington

BoardSource on Lack of Diversity and Inclusivity on Nonprofit Boards

Connections: Summer Edition, 2010

President’s Corner

CHF’s Annual Meeting Focuses on Race, Place, and Health

Preparing for Health Care Reform Implementation

Trustees Spotlight

An Interview with Dick Davis of the McClendon Center

CHF Welcomes New Faces

Connections: Spring Edition, 2010

President’s Corner

CHF Updates Strategic Plan to Reflect Focus on Social Justice and Racial Equity

Special Video: The Ruttenberg Youth Health Justice Retreat

Catalytic Change: Lessons Learned from the Racial Justice Grantmaking Assessment

“Changing the Conversation” on HIV/AIDS among Women of Color

Defeat Poverty DC!

SAVE THE DATE! CHF’s 2010 Annual Meeting - Health Equity: From Awareness to Action

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