F Data-Gathering Activities

Between July and November 2001, representatives of the Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century conducted five site visits to two Turning Point projects and three Community Voices projects around the country. The goals of the site visits were to

  • Collect qualitative and anecdotal information from community-based public health projects regarding lessons learned, best practices demonstrated, major issues and concerns, and input about the local and national governmental public health infrastructure;

  • Witness community partnerships in action and communicate with stakeholders; and

  • Conduct preliminary report dissemination by introducing the committee’s charge and objectives

A timeline of the site visits with a summary of key facts is provided below.



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The Future of the Public’s Health in the 21st Century F Data-Gathering Activities Between July and November 2001, representatives of the Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century conducted five site visits to two Turning Point projects and three Community Voices projects around the country. The goals of the site visits were to Collect qualitative and anecdotal information from community-based public health projects regarding lessons learned, best practices demonstrated, major issues and concerns, and input about the local and national governmental public health infrastructure; Witness community partnerships in action and communicate with stakeholders; and Conduct preliminary report dissemination by introducing the committee’s charge and objectives A timeline of the site visits with a summary of key facts is provided below.

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The Future of the Public’s Health in the 21st Century TABLE F–1 Summary of Site Visits Site Host Organization Focus/Mission, Goals, and Objectives Public Health Department Role Community Role and Level of Involvement Other Partners Community Voices project, Baltimore, MD (July 31, 2001), Sandtown-Winchester community Vision for Health An unincorporated consortium of health care organizations, a health department, a community organization, a funder, and an academic institution Health care access Community health promotion Basic community and individual needs Integral, a primary partner Moderate Health care providers, academia, community organizations, media Turning Point project, New Orleans, LA (August 27, 2001) Healthy New Orleans A coalition consisting of the health department, health care providers, and a range of community representatives Public health system change Community health improvement Integral, a primary partner High County health department Community Organizations Community Voices project, Denver, CO (September 26, 2001) Denver Health An “integrated health delivery system” public–private health organization functioning both as a department of health and a major regional health care provider Health care access Community health promotion Administratively integrated into organization’s functions and activities Low to moderate State and local government Foundations Local community college Local and statewide coalitions

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The Future of the Public’s Health in the 21st Century Community Voices project, Oakland, CA (October 15, 2001) Asian Health Center/La Clinica de la Raza Two federally qualified community health centers Health care access Community health promotion Supporter, partner Moderate County health consortium Health department Community organizations Turning Point project, Franklin, NH, (November 5, 2001) Caring Community Network of Twin Rivers Community health promotion Public health system change Community efforts to perform needed functions in the absence of a traditional health department High Community members with diverse skills NOTE: This is a concise summary of key characteristics and activities identified during site visists.

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The Future of the Public’s Health in the 21st Century BALTIMORE SITE VISIT JULY 2001 About the Vision for Health Consortium The Sandtown-Winchester community of Baltimore, Maryland, is a largely African-American, 72-block urban community of 10,500 people that has experienced significant rates of substance abuse, unemployment, and other problems. The Vision for Health (VFH) Consortium emerged from a “comprehensive neighborhood transformation program” begun in 1990 by the Community Building in Partnership, Inc., a partnership among Sandtown-Winchester residents, the mayor, and the city government, with funding from the Enterprise Foundation and a neighborhood block grant from the city. At the end of a 2-year process of planning, assessing, and discussing community needs, health (particularly substance abuse issues, children’s health, chronic disease, HIV/AIDS, and homicide) emerged as an area of high community priority, second only to education. VFH’s founding partners include Community Building in Partnership, Inc., which is the organizational representative for the citizenry of Sandtown-Winchester, as well as the Baltimore City Health Department, the Bon Secours Baltimore Health System, the Enterprise Foundation, Total Health Care, the University of Maryland Medical System, and the University of Maryland School of Nursing. In addition to these formal partners, VFH has informal partners, such as the Baltimore Times, a local newspaper that has been a supporter and facilitator of the community health improvement initiative from the beginning. Previously, several of these partners had been competitors, providing health care services within the same territory. Coming together, they agreed to collaborate in the creation of an integrated system of care that would reach out to uninsured or underinsured individuals and respond to the community’s need for health improvement. These partners signed a community compact at the beginning of their collaboration, agreeing upon basic principles for their work together. For example, the compact outlined goals and objectives, agreements for financial and administrative collaboration and accountability, and most importantly, reflected commitment to addressing the needs of the community. In 1998, VFH received funding from the W. K. Kellogg Foundation as part of a national initiative at 13 sites, called Community Voices: Health Care for the Underserved. The Community Voices project administered by VFH mainly targets Sandtown-Winchester and some Baltimore residents— including recently released ex-offenders—least likely to be reached by other social services programs. VFH help to maintain its accountability to the community by employing a resident advisor—a community resident who serves as a liaison to

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The Future of the Public’s Health in the 21st Century the community and who is involved in all decision-making and planning processes. VFH’s Mission, Values/Principles, and Goals VFH’s mission is “to work with the neighborhood transformation efforts of Community Building in Partnership, Inc., to create a community-driven health system in Sandtown-Winchester with the goal of improving the community’s overall health status. This will be accomplished by promoting early intervention, prevention, and access to quality health care regardless of ability to pay” (VFH, 1997:9). The project’s values and principles include a focus on quality and service excellence, on being community driven, having respect and compassion for the community, assuring relationships of integrity between and among partner institutions, and promoting innovation as an integral part of the community transformation process. The goals of the Community Building in Partnership, Inc., initiative were to transform a range of community systems that seemed inadequate or ineffective in addressing major community problems such as unemployment, crime, and poor housing. This wide-ranging perspective on community well-being appears to have formed the foundation of the VFH Consortium’s profound understanding of how social and environmental factors can affect health outcomes and the importance of the individual’s and the community’s roles in improving health. Based on priorities identified by the community, the VFH Consortium describes five goals: (1) adult primary care and health promotion, (2) community outreach, (3) school-based children’s health services, (4) substance abuse treatment, and (5) violence prevention. VFH Activities and Accomplishments In keeping with the spirit of the Community Voices, the residents of the Sandtown-Winchester community have always been an integral part of the VFH Consortium and the process of transforming the health and human services systems in the area. Approximately 500 residents were active in the initial planning process, with community members participating on planning work groups and identifying top neighborhood health priorities. In addition to the resident advisor to the VFH Consortium, several community members work as outreach workers in the community, linking people to needed health promotion and health care services. VFH and its partners continue to conduct community forums and gatherings, where residents engage with administrators and providers in dialogue about the community’s health, its needs, and its accomplishments.

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The Future of the Public’s Health in the 21st Century The activities of VFH involve no overhead costs, because consortium members take turns providing administrative and other resources. VFH staff members are employees of Bon Secours health system, whereas Men’s Health Clinic staff are city health department employees. The Enterprise Foundation takes the lead financial role by receiving funding and reimbursing consortium members as appropriate. For instance, the comprehensive services provided by the neighborhood’s elementary school health centers (fine-tuned through meetings between school principals and VFH staff) are a direct response to the community’s expressed needs for child health care that is more than just “Band-Aids and shots.” The University of Maryland School of Nursing manages the school-based clinics that provide comprehensive preventive primary health care as well as mental and oral health care services. Asthma management and mental health services are some of the extras available in school-based clinics. Baltimore Health Department funds for school health centers go to the Enterprise Foundation, which then reimburses the School of Nursing for services rendered. In other areas, partner agencies donate or otherwise contribute certain services to help support the continuum of care envisioned by the collaborative and the community. For instance, men with substance abuse or mental health needs who receive services at the Men’s Health Clinic (discussed below) are referred to Bon Secours for follow-up care or to the University of Maryland medical system for psychiatric urgent care. Research and evaluation are relatively new areas for the VFH Consortium. They received assistance with needs assessment surveys from the Baltimore Health Department and some evaluation support from a local university. In June 2000, VFH opened the Men’s Health Center, the first component of an integrated health care delivery system for uninsured men. The need for a men’s health care center was identified through community assessments which showed that many women in need of health care lacked a medical home, but had some access to the health care safety net through family planning and prenatal (Healthy Start) services. Men, however, had much less access. This problem was compounded by the men’s reported feelings of discomfort with clinical settings that seemed primarily attuned to women’s health care needs and their concerns about not being able to take care of their own health, let alone their families’ health. Acknowledging these issues, as well as the important roles men can play in maintaining healthy families and neighborhoods, VFH sought to use the Men’s Health Center as a way of both providing care and “building families . . . one man at a time.” The Men’s Health Center currently provides quality primary health care, as well as referrals to substance abuse services and dental care. Through the social workers and community outreach workers on staff, men can also access job training and social services, participate in weekly sup

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The Future of the Public’s Health in the 21st Century port/discussion groups, and even get registered to vote. Additionally, there are plans to develop similar comprehensive, high-quality health care services to uninsured women. Other VFH plans include expanding the activities of Women Against Violence, a community group that is currently exploring the various effects of neighborhood violence on the family structure and considering future opportunities to partner with churches and organizations on issues related to fatherhood. VFH’s outreach component involves creating bridges between community residents and local agencies and services. Outreach is essential to connecting people who mistrust government programs or systems to the services they badly need. The project employs two types of outreach workers: VFH workers, who conduct general community outreach and education about access to services and related matters, and Men’s Clinic workers, who perform the dedicated role of linking uninsured men to health care services, following up with them when needed and referring them to other human services. In addition to activities specific to the Sandtown-Winchester neighborhood, VFH has been a partner in broader community health improvement efforts. For instance, VFH has participated in and contributed funding for the Maryland Citizen’s Health Initiative, a statewide grassroots effort working to attain universal health coverage. VFH has also been involved in Phases I and II of the National Community Care Network Program, which is part of the Maryland Health Improvement Plan 2000–2010. VFH is also a charter sponsor of the Maryland Citizens Health Initiative Education Fund (MCHIEF), which operates under the banner of “Health Care for All.” VFH has further played a convening role, holding a large symposium for outreach workers and emphasizing the importance of outreach (a state bill passed in recent years mandates an outreach component as part of all managed care organizations). As a result of VFH’s efforts, the rate of childhood immunization, which was about 68 percent in 1994, increased to 100 percent and has remained at that level for several years. Site Visit Discussion In July 2001, representatives of the Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century engaged in a daylong dialogue with staff and partners from VFH. VFH approaches community health improvement primarily from a health care emphasis. More specifically, the consensus among community and institutional partners holds that health care is an essential determinant to good individual and community health, and the fact that many people in the community lack access to adequate and high-quality care affects their

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The Future of the Public’s Health in the 21st Century total lives, including their ability to get physicals required for new jobs and to get treatment for health conditions that impair their quality of life and ability to function. The consortium appears to include substantial community input, from assessment to planning to implementation. VFH staff members, many of whom are themselves residents of the Sandtown-Winchester community, reported that members of the community feel that they own the initiative and that they have a part in what gets accomplished. However, this relationship between the “public” and the public health enterprise is fraught with complexity, and VFH partners described some of the challenges they experienced in thinking about and addressing it. The Men’s Health Center is clearly a product of collaboration between the local public health agency and health care expertise and resources, on the one hand, and community members’ cultural knowledge and social experiences, on the other. On an organizational level, the Men’s Health Center is located in a health department facility, yet it is a separate entity. However, there were initial concerns on the part of community clinics that perceived the center as a sign that the health department was overstepping its bounds and expanding its provision of direct services. VFH partners noted that the role of the health department is to facilitate, support, bring resources to the table, and look at the community in a way that affirms assets, motivation and power for change rather than focusing on the “empty half of the glass,” that is, needs and deficiencies. The local newspaper has been a noteworthy informal partner to Sandtown-Winchester’s health improvement efforts. The newspaper is a trusted and respected source of information in the neighborhood, and it was able to successfully organize and publicize community health events such as an annual health walk, a mall-based health fair, and events targeting both women’s and men’s health issues. In addition to creating several forums for community education (including educating local ministers on health issues) and a gateway for people’s management of their own health, the paper also provides regular health education messages, including special health publications. The Baltimore Times has also formed a new alliance with the health department. In the past, the newspaper’s leadership, committed to community empowerment and education, felt compelled to act as a community advocate in light of what it perceived as the health department’s insufficient regard for the community’s awareness of its own health needs as well as its assets and resources. Over time and through ongoing dialogue, the relationship between the newspaper and the health department has become one of mutual support—the health department even provides copy to the newspaper. As different community needs have been identified, new opportunities

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The Future of the Public’s Health in the 21st Century for partnership have emerged. For example, the correctional system is often the only link to primary care for adult men who had not previously qualified for or accessed other health care and social services. The VFH Consortium recently started a collaboration with the local police department to help newly released former inmates returning to their community make the links to care that may include sexually transmitted disease/HIV prevention and treatment, substance abuse treatment, counseling, and mental health care services. For more information about the Vision for Health Consortium, visit www.communityvoices.org/LL-Baltimore.asp. DENVER SITE VISIT NOVEMBER 2001 About Denver Health and Its Community Voices Project Denver Health is both a nonprofit health care system that integrates safety net services and a public-private public health enterprise. Denver Health received funding from the W. K. Kellogg Foundation to establish a Community Voices: Healthcare for the Underserved community outreach program in 1998. Denver Health has five goals that provide for a unique integration of personal health care and public health services and “take care of the special needs of all populations and the needs of special populations” (Gabow, 2001). These goals include: Provide access to quality preventive, acute, and chronic health care for all citizens in Denver regardless of ability to pay. Provide expert emergency medical services to Denver and the Rocky Mountain. Fulfill public health functions as dictated by the charter and the needs of citizens. Conduct health education of patients and education of health care professionals. Conduct research that addresses patient needs as well as the educational needs of health care professionals in training. The position of Denver Health in the local public health system is unique. The organization performs some of the functions of a governmental public health agency, but others, such as environmental health, are under the purview of the local county/city government’s Environmental Health agency.

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The Future of the Public’s Health in the 21st Century Denver Health Community Voices Mission and Goals The 5-year Community Voices initiative has two goals, namely (1) “to improve the health of Denver’s medically underserved through innovations in community outreach, enrollment in publicly funded health insurance and small employment health plans, and intensive community-based case management” and (2) “to change public policy at the state and federal level for health program funding and reduce barriers to enrollment in publicly funded health insurance.” Program Activities and Accomplishments The Community Voices initiative fits smoothly into the operations of Denver Health. Its main activities include: community outreach to enhance access to health care, provide health education and health promotion services, and engage communities in health improvement; facilitating enrollment to link eligible individuals to publicly sponsored health insurance programs; and case management, providing personalized care and services to vulnerable patients. In conformity with the initiative name, Denver Health Community Voices involves community perspectives and partners in health improvement. The initiative’s community outreach component is guided by a multicultural steering committee and includes community health advisors who are staff members drawn from the community and community partners that include schools, local businesses, organizations, religious congregations, and neighborhood groups. Community partners help publicize information about Denver Health and access to health care, and provide opportunities and/or support for community health promotion events. Community health advisors facilitate communication between Denver health and the community about community needs, and help to reduce the impact of cultural and other barriers to access. The advisors also provide health promotion and disease prevention education and some informal counseling and support to individuals and groups in the community. At the state level, Denver Health is involved with the Colorado Coalition for the Medically Underserved and Colorado Access, a safety-net health maintenance organization and Medicaid managed care entity for the Denver area that also includes two local hospitals (one children’s), a physicians’ group, and the network of federally qualified health centers. More information about Denver Health Community Voices is available at http://www.communityvoices.org/LL-Denver.asp. More information about Denver Health is available online at http://www.denverhealth.org/.

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The Future of the Public’s Health in the 21st Century NEW HAMPSHIRE SITE VISIT NOVEMBER 2001 About Caring Community Network of the Twin Rivers Caring Community Network of the Twin Rivers (CCNTR) is a nonprofit organization established in 1996. The Network is active in a tricounty area that includes 12 towns in central New Hampshire. CCNTR member agencies include a wide range of local social services organizations (ranging from shelters, to elder care, drug abuse, and the Women with Infants and Children Program), a regional hospital, the chamber of commerce, a regional nursing association, a mental health service provider, schools, an affordable housing provider, a visiting nurse association, and a clergy association. The CCNTR board consists of 24 members; half of the members are community representatives, and the remainder represent different agencies. CCNTR’s Mission, Goals, and Objectives CCNTR has been a participant in the Turning Point Program, which is funded by the W. K. Kellogg and Robert Wood Johnson Foundations, and directed by the National Association of County and City Health Officials with assistance from the University of Washington School of Public Health. CCNTR is one of three Turning Point project sites in the state of New Hampshire, but it is somewhat unique compared with the other projects in the state and projects in other states, as it works on the creation of local public health capacity in an area with limited public health staffing and infrastructure. CCNTR has six main objectives, including: (1) improving access to health and mental health care; (2) establishing programs to lower youth risk behaviors related to substance abuse and other issues; (3) health promotion and disease prevention; (4) community/public health improvement; (5) increasing social capital, engagement in community health, and development; and (6) supporting the basic needs of individuals and families. There has been some progress in both planning and implementing activities in most areas. In 1998, for instance, CCNTR conducted a large-scale community needs assessment that revealed youth risk behaviors as a major issue, especially because teens do not have many available activities or opportunities for after-school and extracurricular entertainment. As a result, the community and CCNTR developed three strategies for addressing risk behaviors. The first two, which have already been funded and initiated in several communities, include school-based prevention curricula and structured after-school (3:00 to 7:00 p.m.) programs. The third strategy, not yet funded at the time of the site visit, is the alignment of community attitudes

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The Future of the Public’s Health in the 21st Century to enable recognition of risk and the involvement of adults in community wide prevention activities. Public Health Infrastructure: Existing and Needed Capacity As in most states, the public health infrastructure in New Hampshire has experienced certain difficulties. In New Hampshire, these stem from fragmentation, a lack of coordination between the state and local levels, limited resources, and other factors (Rhein et al., 2001). This means that effective communication, sharing of information, and the standardization of functions, services, and roles can be difficult to accomplish. Local public health entities function under separate and often dissimilar town ordinances. There is one public health laboratory for the entire state, and surveillance functions are covered by individual hospitals, at least in the Twin Rivers area. Unlike localities where there are health departments, a public health infrastructure, adequate facilities, and many public health workers to help facilitate and support community health improvement efforts, the Twin Rivers area does not have an easily visible public health presence. There is no official agency building, and the health officers (one in each town) are mostly semivolunteers who have other full-time jobs (e.g., a firefighter, a plumber, and a city legislator) in addition to their public health responsibilities. The services provided across the region are thus fragmented and reactive, as well as lacking in uniformity, because of local differences in policies and procedures. The collection of public health information, such as the collection of data by the state, has been recognized as one of the areas in need of improvement. For example, people at the local level have charged that the data collected by the state may skew or entirely miss the needs of small, heterogeneous local communities. CCNTR used the state Turning Point project grant to assist local health officers in ensuring the three core public health functions are performed, and to join existing public health efforts with community resources to accomplish more in improving and assuring the health of the population in the area. CCNTR is working on the development of a public health system of governance that would help to shape local public health policy, interface with the state about policy and service delivery issues, and deliver and assure public health services (such as assessment and surveillance). The Caring Community Network has been conducting assessment of a range of basic health indicators, such as adolescent pregnancy, immunization levels, and school-based administration of Behavioral Risk Factor Surveillance System questionnaires. Furthermore, CCNTR carries out formal and informal community needs assessment activities, identifies local strengths and assets that can be used to respond to the identified needs, and also maintains a “big picture” of state policy and other issues that have impact on the

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The Future of the Public’s Health in the 21st Century local level. CCNTR has also worked with the state to change state policies about data collection (e.g. going beyond county data and collecting data in a way that recognizes the heterogeneity of health data across towns) and means for making data available to local levels (e.g., through the Internet). CCNTR’s mission is to work with communities to plan and develop an integrated health and human service delivery system that optimally addresses regional social and health problems, such as an underfunded and fragmented public health system, barriers to accessing services, high-risk behaviors, and many unmet basic needs (e.g., for shelter, food, and transportation). CCNTR embraces a broad and inclusive definition of public health that includes attention to social issues from a low level of community engagement in collective development and change to the mental health and the social needs of youth. The point, according to a CCNTR partner, is to include “things we all do for work and play” in order to engage “as many people as possible in improving community health.” As a result of a perspective that is expansive, flexible, and truly interested in the community’s expressed needs, CCNTR supported the community’s first area of priority: the development of a multipurpose trails/greenways system that could provide a place for recreational activities and that could provide a safe and environmentally friendly alternative for pedestrian and bike traffic. Being responsive to community needs also ensured the interest and involvement of a wide cross-section of community members who felt that they could rally around an issue critical to them rather than being obliged to accept an issue determined by outside “experts.” Other accomplishments of CCNTR have included the redevelopment of the old city hall/opera house in recognition of the economic and social potential of cultural education and the importance of the arts to nurturing the community and developing creative and artistic skills in young people. An important dimension of CCNTR’s work has been its consistent emphasis on communicating with and providing feedback to the community. Site Visit Discussion Because of the limited nature of the public health infrastructure of the Twin Rivers area, CCNTR, local health officers, and the community have creatively assembled a public health system that draws on the locally available public health expertise that is available but also capitalizes on community resources and skills. The committee heard about the potential implications posed by this specific scenario to national-level attempts to standardize local public health infrastructures and credentialing public health workers. Although the Twin Rivers community leaders present at the site visit expressed a clear vision of quality public health services, they expressed some

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The Future of the Public’s Health in the 21st Century concern that credentialing and other efforts to formalize local public health services may impair rather than help local work. Although not having a “real” health department may be perceived as a problem in some ways, one participant in the site visit stated that they consider themselves “lucky” that they have no existing infrastructure to “undo” to make it correspond to actual community needs. Workers and community representatives at the site visit noted that they have a great deal of flexibility and the ability to respond to needs in a manner that is unencumbered by the potential rigidity and resistance to change of more formal, highly bureaucratic structures. CCNTR members further stated that they would prefer something more basic than credentialing to ensure standardization and quality. Having standards for health officers is important, they noted, but a formal credential may not be a good idea given their local situation and the already diverse professional backgrounds of existing health officers. Site visit participants would also like to see continuing education available in areas where the infrastructure is underdeveloped and more focus on Internet-based tools. This highlights the potential of distance education and other emerging technologies for the purpose of continuing education and capacity building. Even so, there are some local limitations in terms of technical capacity (e.g., the low level of availability of T1 or DSL connections to the Internet), as well as logistical issues, such as the absence of a central office where public health officers may check in regularly. For more information about Caring Community Network of Twin Rivers, visit http://www.naccho.org/files/other/nh3.html and http://www.ccntr.org/. NEW ORLEANS SITE VISIT AUGUST 2001 About Healthy New Orleans The Healthy New Orleans (HNO) Partnership was formed in 1997 and received a Turning Point project grant from the Robert Wood Johnson and W. K. Kellogg Foundations. It is one of three local Turning Point project partnerships funded in the state of Louisiana. Like other Turning Point partnerships, HNO, formally known as Healthy New Orleans, the City That Cares, emerged to address problems in the public health system that contributed to poor community health outcomes, as well as fragmented and inadequate services. The total grant funding is $20,000 for 3 years. HNO’s diverse membership includes representatives of local community organizations, the state and local health departments, academia, faith-based organizations, non-profit health care providers, and community residents of various ages and of various backgrounds.

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The Future of the Public’s Health in the 21st Century In August 2001, representatives of the committee participated in a dialogue with some of the membership of HNO about their objectives, accomplishments, and lessons learned. Healthy New Orleans Vision, Mission, Goals, and Objectives HNO developed its vision in partnership with the community through a consensus-seeking process and in answer to the question “What will Healthy New Orleans: the City that Cares have in place by 2050?” The “shared practical vision” that emerged is a complex of nine components needed to achieve community wellness. These components were visually arranged by the groups as a pyramid with the vision of community wellness at its heart and with community involvement at its apex. The components of the vision include state-of-the-art diagnostic approaches, emphasis on prevention, expanded view of public health, an electronically linked delivery system, community-based health centers, comprehensive consumer information, community-driven (public health) governance, protective public health policy, and varied funding. HNO developed six objectives to be accomplished in three phases: (1) partnership development, (2) assessment of resources and needs, (3) development of a public health improvement plan, (4) the availability of communications and information systems to serve the community, (5) broad ownership by expanding the vision to nontraditional stakeholders, and (6) accountability in terms of evaluation and feedback to the community. The first phase of HNO’s work, partnership development, was conducted between January 1998 and March 1999. This phase included work on establishing and deepening partner relationships and interorganizational linkages and, most importantly, on defining a partnership structure and partnership objectives in a manner congruent with the resources and needs identified by community members. During the second phase, HNO conducted a strategic planning process in coordination with the state public health entity, resulting in the development of a Community Public Health System Improvement Plan (considered a road map to influence health outcomes in New Orleans) that includes a conceptual framework centered around achieving community wellness by transforming public systems, personal health, and health systems. The third phase involves implementation of the planning process, with particular attention to 17 recommendations for action developed through community workshops. The recommendations with the highest priority ratings included establishment of the Center for Empowered Decision-Making, development of community health networks, and expansion of the definition of public health to include quality-of-life indicators.

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The Future of the Public’s Health in the 21st Century Accomplishments of HNO From the beginning of its work to transform the way in which public health is done in New Orleans, HNO used a broad definition of public health that encompassed social and environmental issues such as poverty, housing, and green spaces. HNO is further distinguished by its attention to the human and social elements involved in making partnerships and coalitions work. Collaborative planning has been the centerpiece of HNO’s activities both in terms of establishing a workable representative coalition that “owns” the process and the products and in terms of planning community health improvement in a detailed and strategic way. HNO recognized the assets and resources that the community and other partners had to contribute. However, the group also identified what it termed “underlying contradictions” or areas of conflict, such as a lack of community empowerment, systemic resistance to change, and other barriers to progress (Healthy New Orleans Partnership, 2001). “The community means everyone,” stated one participant during the site visit, and others commented on the need to end the separation between “public” and “health” in public health. Furthermore, when discussing where the public health enterprise begins and ends, HNO partners emphasized that public health agencies are part of the community and should act as ”amoebas,” adapting to circumstances, being responsive to community needs, and focusing on the psychosocioeconomic determinants of health. Participants also acknowledged a prevalent misconception about public health as being “for the poor” and suggested that public health be equated to community wellness. Subsequently, they noted, public health funding must be aligned with community definitions and needs rather than categorically linked to a predetermined framework. When asked about the role of public health departments, HNO participants remarked on the unique position of public health practitioners as keepers and communicators of data and people who “get” the holistic view of health, unlike some providers and funders. HNO has had some influence on its partners, for instance, helping to facilitate changes in state-level data collection and reporting to increase its usefulness and accessibility to the local level. HNO has also taken steps to implement several of the recommendations that emerged from the community health improvement planning process. For instance, three of eight New Orleans neighborhoods, Carollton, Bienville/Tulane, and St. Bernard/ Gentilly, have received small HNO grants to conduct some collaborative planning activities in their communities. Their visions and goals focused on specifics such as creating a multipurpose community center, improving and developing neighborhoods, and addressing violent crime. A fourth neighborhood is beginning its own process of grassroots collaborative planning. HNO has been involved in a slow, thoughtful process of facilitating

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The Future of the Public’s Health in the 21st Century change; members of the partnership stated that there is no “quick fix,” that achieving something lasting takes time, sensitivity, valuing equity, and civic engagement. There was also agreement that public health education should change to fit the times (that is, there is a need for outreach and community-based public health) and should be extended to the private sector, health care providers, and others. Some attendees expressed concerns about the limitations on funding that addresses the root causes of health problems (e.g., determinants of health), as well as frustration with the dichotomy between community knowledge and scientific expertise. Although HNO participants articulated a desire to evaluate their work in a scientifically valid way, a question lingered: “What will it take before communities can be heard without first having to get the Ivory Tower Seal of Approval?” It is apparent that the community members and organizations involved in HNO have become profoundly engaged in the process of collaborative planning and have begun to achieve objectives on their way to transforming the local public health system. Further efforts to research and evaluate community-level outcomes will help guide the initiative. The ultimate sustainability of the process, although a stated goal of the grant and foremost in the minds of the facilitators of the project, is not clear at this time. For more information about Healthy New Orleans, visit http://www.naccho.org/files/other/la1.html. OAKLAND SITE VISIT OCTOBER 2001 About Asian Health Services and La Clinica de la Raza The committee visited the Oakland Community Voices for Immigrant Health project site in October 2001. The Community Voices project in the city of Oakland, California, is administered by the Asian Health Services and La Clinica de la Raza, two multisite, nonprofit, community-based, federally funded clinics in Oakland. The partnership among these two health care services providers, the Alameda County Health Department, and other community organizations like the Alameda Health Consortium has been fruitful and effective in addressing several of the complex and interrelated issues facing area communities, ranging from a lack of health insurance to tobacco use among minority, disadvantaged populations. Both La Clinica and Asian Health Services have an impressive history of community engagement. La Clinica de la Raza was founded in 1971 by a group of students, health professionals, and community activists and was organized under a board consisting of patients, community members, and professionals elected in annual elections. La Clinica employs approximately 350 staff at four locations in Alameda County and at a medical and dental

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The Future of the Public’s Health in the 21st Century clinic in a neighboring county. The services provided include primary medical care; dental, mental, and eye care; clinic- and community-based health education; nutrition services; social services; and off-site inpatient care. Asian Health Services has been serving the community since 1974 at three locations and with 120 staff. Its services include clinical services like maternal and child health; HIV testing, counseling, and care; adolescent, adult, and elderly care; and urgent care. It provides health education services on topics ranging from family planning to disease prevention (cancer and HIV/ AIDS) and women’s health. Mission, Values/Principles, and Goals of the Oakland Community Voices Project In 1998, Oakland became 1 of 13 sites in the nation funded by the W. K. Kellogg Foundation’s Community Voices initiative to address the problem of uninsurance in local communities. The Community Voices project has been advocating on behalf of Alameda County’s 130,000 to 140,000 uninsured individuals and aiming to develop policy, organize the community to support policy change, inform the community about access to health care, and develop a new insurance model. The project’s primary goal is to create “an integrated community health system of care for the working poor and uninsured immigrants.” Its objectives include: educating and informing immigrant communities about insurance and health coverage; expanding immigrants’ eligibility for health programs; facilitating the inclusion of social services in health coverage; developing alternative models for financing affordable health coverage; documenting effective strategies for outreach and health coverage enrollment in immigrant communities; and collecting in-depth information about uninsured immigrants for continuing advocacy. Activities and Accomplishments of Oakland Community Voices Noteworthy features of the project include a profound level of community involvement and representation in the process; a partnership among community clinics, community organizations, and the local health department; and exceptional attentiveness to cultural competency. Providing health promotion and health care services in a culturally and linguistically appropriate manner is a routine part of “doing business” among these Oakland partners rather than a minor “tag-on” to the services that they

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The Future of the Public’s Health in the 21st Century provide. Asian Health Services even includes a Language and Cultural Access Program that provides translation services and interpreter training in a total of seven languages. Another aspect of the relationship with the community is both La Clinica’s and Asian Health Services’ use of community outreach workers as well as promotoras (female health promoters) to serve as links to the community, in addition to conducting community-based health education and health promotion. La Clinica has also developed a curriculum for training promotoras on a range of health topics. The promotoras are paid through stipends and gift certificates. Asian Health Services conducts specialized, strategic outreach to the various populations that it serves, for instance, to Korean groups at churches and to Vietnamese groups at street festivals. Outreach to diverse audiences also implies a need for awareness of and sensitivity to the sociocultural issues of new immigrants and other underserved populations. The County of Alameda Uninsured Survey was conducted by Community Voices in 2000 (Ponce et al., 2001). The random-probability telephone survey of more than 11,000 households resulted in 1,673 core questionnaires completed by adults 18 and older in English and six other languages (over 40 percent of respondents). The main findings were as follows: More than 70 percent of uninsured adults in the county are people of color. More than half of the uninsured adults in the county are immigrants. The county’s uninsured rate of 16 percent is lower than California’s rate of 25 percent. The objectives of the Oakland Community Voices program are implemented in part through the linked enrollment and outreach activities of community health specialists and community outreach workers based at La Clinica and Asian Health Services. In addition to their educational and health promotion activities, these community workers have made it a priority to discuss issues of health access and health insurance with their communities and to help facilitate linkage to medical homes for any families and individuals who lack coverage. Through the efforts of a strategic collaborative, Oakland Community Voices has participated in the creation of a new health insurance product called Family Care, administered by Alameda Alliance for Health, the local nonprofit managed care plan The Alameda County Health Department has transformed its goals and services to become more community based and has increased staff capacity to work with the community. For instance, field staff have been organized into 11 community health teams to strengthen the relationship with the

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The Future of the Public’s Health in the 21st Century public, increase responsiveness and visibility, and decrease duplication of effort through expanded collaboration with community organizations, such as the Asian Health Services. The health department has also developed a 5-year strategic plan based on the 10 essential public health services. The department’s collaborative efforts include sharing the California tobacco settlement money with community partners. REFERENCES Gabow P. 2001. Denver Health: a health system integrating safety net services. Presentation to the IOM Committee on Assuring the Health of the Public in the 21st Century, September 26, 2001. Healthy New Orleans Partnership. 2001. Annual Progress Report. Funded by National Association of County and City Health Officials. Ponce N, Conner T, Barrera BP, Suh D. 2001. Advancing universal health insurance coverage in Alameda County: results of the County of Alameda uninsured survey. UCLA Center for Health Policy Research and Community Voices Project Oakland. Los Angeles: Regents of the University of California. Rhein M, Lafronza V, Bhandari E, Hawes J, Hofrichter R. 2001. Advancing Community Public Health Systems: Emerging Strategies and Innovations from the Turning Point Experience. Washington, DC: National Association of County and City Health Officials. Vision for Health Consortium. 1997. 1994-1996 Annual Report. Baltimore, MD: Vision for Health Consortium