Building Medical Home Capacity for Pediatric Early Identification & Linkage
Roots was also recently selected as the hub for East Oakland Building Healthy Communities (EOBHC), which supports 40+ organizations whose services extend from community organizing to direct service, further positioning us to leverage our networks and facilitate peer learning and systems change. This work is a complement to our trajectory of expansion and continued focus on growing as an East Oakland anchor organization committed to equity and mitigating root causes of health disparities such as poverty, trauma and racism. We are dedicated to integrating and leveraging networks, findings and best practices and outcomes for a deeper impact among the aligned projects.
ref. Pediatric Capacity RFP Response_FINAL.pdf Building Medical Home Capacity for Pediatric Early Identification and Linkage A STRATEGIC INITIATIVE OF: Roots Community Health Center and Health Leads, June 2018 – Dan Abrahamson
Core Care Model:
Program: Pediatric Capacity
Themes, Keywords & Tags: Partnerships; Health Leads; Early Childhood; Trauma Informed
Building Medical Home Capacity for Pediatric Early Identification & Linkage
The Bay Area—where Health Leads is part of the most dynamic network of social needs innovators in the nation including UCSF-based leaders of the Social Innovation Research and Evaluation Network (SIREN), and the Center for Care Innovations—has been their fastest growing and most innovative service area to date. Philanthropic and health care system partners have pushed Health Leads to learn, innovate, and grow to better serve patients in California and across the country. In 2011, Health Leads began conversations with Kaiser Permanente (KP), Contra Costa Health Services (CCHS), the California Healthcare Foundation (CHCF), and other funders to launch in the region. These partnerships have helped generate regional learning and refine Health Leads’ strategy, leading to diverse programming statewide. Health Leads’ work with KP led to their affirmation of social needs as a standard of quality care, and the co-design of the first ever social needs call center that serves KP’s most vulnerable patients in Southern California. Health Leads is also working with KP nationally to develop the standard for how health systems can address social needs. Their partnership with CCHS launched with (and continues to have) a college advocate desk model and evolved into a regional innovation hub, testing new tools and developing metrics to drive community investment. CCHS is now the first health delivery organization striving for county-wide screening for all. In addition, the visionary leaders at both KP and CCHS have joined Health Leads to speak at the Institute for Healthcare Improvement and other leading healthcare organizations on the importance of and ability to address social needs as a standard of care.
Roots and Health Leads (“the Partners”) propose a phased engagement that assesses existing infrastructure, initiatives, tools and human resources supporting this work, and pursues opportunities for growth, improvement, training and technical assistance to be accomplished in the following four (4) project phases:
ref. Pediatric Capacity RFP Response_FINAL.pdf Building Medical Home Capacity for Pediatric Early Identification and Linkage A STRATEGIC INITIATIVE OF: Roots Community Health Center and Health Leads, June 2018 – Dan Abrahamson
Core Care Model:
Program: Pediatric Capacity
Themes, Keywords & Tags: Partnerships; Health Leads; Early Childhood; Trauma Informed
Building Medical Home Capacity for Pediatric Early Identification & Linkage
To coordinate and facilitate this effort, the Partners will support the creation of a countywide infrastructure that recognizes and responds to early childhood developmental needs in a culturally responsive, trauma informed, and evidence-based manner. The Partners will initiate activities through relationships with physicians, children, youth, and families with a focus on increasing quality of care, timely and appropriate diagnosis, and coordinated referrals in order to decrease health and access disparities for children ages 0-5. The Partners will also coordinate training and routinized screening and engagement with the HMG network at behavioral health and medical homes to serve children and families.
ref. Pediatric Capacity RFP Response_FINAL.pdf Building Medical Home Capacity for Pediatric Early Identification and Linkage A STRATEGIC INITIATIVE OF: Roots Community Health Center and Health Leads, June 2018 – Dan Abrahamson
Core Care Model:
Program: Pediatric Capacity
Themes, Keywords & Tags: Partnerships; Health Leads; Early Childhood; Trauma Informed
Building Medical Home Capacity for Pediatric Early Identification & Linkage
In conjunction with the Alameda County Public Health Department, First 5, and our collaborative partner, Health Leads, Roots Community Health Center (Roots) proposes to build upon existing infrastructure to improve screening, early identification and linkage to care; identify unmet need among children and families; and build the capacity of pediatric medical homes across the county to address social, emotional and developmental needs of children ages 0-5. We propose a phased engagement that assesses existing infrastructure, initiatives, tools and human resources supporting this work, and pursues identified need for growth, improvement, training and technical assistance. We welcome the opportunity to advance the critical work of routinizing early pediatric screening and intervention, and to anchor this work in the community to ensure continued access and long- term impact. PROJECT GOALS The goal of this project is to improve the health status of children 0-5 by improving early identification and linkage to care. The success of this project will be demonstrated through an increase in the number of sites who: a. are screening universally, b. are screening universally at each recommended interval, c. are screening universally at alternative intervals, d. have met their practice goals for number of children screened, number of intervals screened at, number of tools used, barriers resolved, and children referred, and e. have added screening other than developmental practices
ref. Pediatric Capacity RFP Response_FINAL.pdf Building Medical Home Capacity for Pediatric Early Identification and Linkage A STRATEGIC INITIATIVE OF: Roots Community Health Center and Health Leads, June 2018 – Dan Abrahamson
Core Care Model:
Program: Pediatric Capacity
Themes, Keywords & Tags: Partnerships; Health Leads; Early Childhood; Trauma Informed; FIrst5
Building Medical Home Capacity for Pediatric Early Identification & Linkage
Roots enjoys productive relationships in the county with public agencies including the Alameda County Department of Public Health and Alameda County First 5; healthcare providers, healthcare payers, community based organizations and residents. Roots’ CEO regularly meets with leadership of the county’s hospitals and FQHCs via the Alameda County Safety Net Council, and is actively engaged with local medical providers and systems leaders via membership in the Alameda-Contra Costa Medical Association, the Sinkler-Miller Medical Association, and as a newly-appointed member of the Board of Governors of the Alameda Alliance for Health, our county’s local managed Medi-Cal plan.
ref. Pediatric Capacity RFP Response_FINAL.pdf Building Medical Home Capacity for Pediatric Early Identification and Linkage A STRATEGIC INITIATIVE OF: Roots Community Health Center and Health Leads, June 2018 – Dan Abrahamson
Core Care Model:
Program: Pediatric Capacity
Themes, Keywords & Tags: Partnerships; Health Leads; Early Childhood; Trauma Informed; FIrst5
Building Medical Home Capacity for Pediatric Early Identification & Linkage
Roots is headquartered in East Oakland, with our pediatric practice located in the Fruitvale neighborhood. Our pediatric leadership and staff are well-versed in administering developmental screenings utilizing the Ages and Stages Questionnaire Third Edition (ASQ-3) and ASQ: Social- Emotional, and the Modified Checklist for Autism in Toddlers (M-CHAT); adept in addressing the physical, behavioral and social needs of children 0-5 and their families; and enjoy ongoing partnership with First 5 Alameda County’s Help Me Grow system. As an independent safety net provider, Roots is uniquely positioned to understand – and help overcome – the challenges of complying with ever-increasing requirements while meeting the immediate health needs of low- resource patients and families. Given our understanding of the overall landscape, our participation in the pediatric system of care, and our credibility among county leaders, providers, and community members alike, Roots is well-positioned to deeply embed a screening and referral intervention within Alameda County.
ref. Pediatric Capacity RFP Response_FINAL.pdf Building Medical Home Capacity for Pediatric Early Identification and Linkage A STRATEGIC INITIATIVE OF: Roots Community Health Center and Health Leads, June 2018 – Dan Abrahamson
Core Care Model:
Program: Pediatric Capacity
Themes, Keywords & Tags: Partnerships; Health Leads; Early Childhood; Trauma Informed; FIrst5
First5
The proposed program utilizes peer support and coaching to increase fathers’ access to education and information about early childhood development, reduce parental stress, learn positive methods of discipline, and increase their sense of competency as parents. Not only is this service a direct need of our patients and community members, but also augments the system of services in our community. The proposed program focuses specifically on African American fathers in our community, many of whom have a history of incarceration, unstable housing, trauma and exposure to violence. Many may also be unemployed or underemployed, have low skill and/or low literacy, and face multiple barriers to employment. With the passage of both AB109 and Proposition 47, increasing numbers of men are being released back to their/our community from incarceration without supportive services. Many have been disconnected from their families and lack confidence as parents. The proposed program will enable access to culturally and situationally relevant services for lowincome African American men and empower them to fulfill their role as a father with confidence. In addition, the proposed program provides for shared learning between parents and health coaches, thereby increasing our capacity as providers to support early childhood wellness.
ref. First 5 Alameda County_ Community Grant Report
Core Care Model: Care
Program: Family Peer Coaching
Themes, Keywords & Tags: Fathers; Peer Support; Family; First5; Early Childhood
First5
Roots Family Peer Coaching Program represents a strategic expansion of our current health coaching program to include high-risk fathers of children ages 0 to 5. Roots currently operates its Health Coaching Program for various sub-groups of patients requiring additional support, either due to their circumstances (e.g., recently released from incarceration) or their diagnosis (e.g., diabetes). Roots Peer Coaches share lived experiences with the participants with whom they work. We will identify a minimum of 15 fathers per quarter to be paired with a Roots Peer Coach who has completed Roots’ Health coaching curriculum, and received additional training on early childhood development and parenting. Roots Peer Coaches are members of the community who have similar background and experiences as the target population. Roots is committed to employing community members and has successfully integrated peer health coaches into our staff. Not only do health coaches learn health-related information from clinical staff, but they also impart knowledge and increase the care team’s awareness regarding issues that impact their clients. Fathers will be referred to Roots Family Peer Coaching Program through existing and potential referral sources including San Quentin State Prison, Santa Rita Jail, and local community physicians with whom we have established relationships and referral mechanisms. The Peer Coaching Program will also be available to Roots Clinic patients and community members.
Roots Family Peer Coaches provide linkages and referrals to needed services, as well as guidance regarding an array of health and social needs. The proposed program will enable the addition of the early childhood development curriculum, as well as a specific focus on fathers of children ages 0-5. Program participants can avail themselves of clinical, social, employment and barrier removal services already available at Roots (not included within the scope/budget of this proposal). High-risk fathers of children ages 0-5 will be prioritized to receive support via the Roots Family Peer Coaching Program.
An integral part of the care team, Peer Coaches have the most intimate relationship with patients. At the initial Participant-Peer meeting, the participant is provided with their Healthy Measures Planner, a resource and activities binder that provides individuals with a structured means of organizing their schedules and curriculum activities. The Planner will be designed to help participants maintain accountability to personal goals, engage in curriculum to support ongoing assessment of barriers and barrier removal activities, manage self-care and track appointments. The Healthy Measures Planner will be divided into sections for parenting materials, barrier removal activities, important contact information, and information about supportive services. Its content will expand as patients move through the program and learn to create personalized systems of organization. Contents will eventually include specific materials and tracking sheets pertaining to their child’s development.
Roots Peer Coaches are available to their clients by phone 24 hours daily. Outreach calls and face-to-face meetings are conducted based on a mutually agreed-upon schedule between client and Peer Coach. The Peer Coach is available to provide emotional support, assist with logistics pertaining to social services, appointments, etc.; begins preliminary barrier assessment and removal planning, and meets regularly with their client to discuss progress, successes and challenges. Participant and Peer may choose to meet at the clinic, at the participant’s home, or at a mutually agreed-upon location. Because Peer Coaches are culturally congruent men from the same community as the participants, home visits are often welcomed and help to further illuminate assets and challenges within the family dynamic. In addition to oneon-one Peer-Participant activities, we will hold quarterly events for participants and their families. These will include food, socializing and outdoor activities for the entire family, and broaden the peer support network for families.
ref. First 5 Alameda County_ Community Grant Report
Core Care Model: Care
Program: Family Peer Coaching
Themes, Keywords & Tags: Fathers; Peer Support; Family; First5; Early Childhood; Coaching
First5
Roots will engage an early childhood development specialist from Children’s Hospital to assist us with our new training module and provide on-site training to our providers. This specialist will be available during our planning phase and on an asneeded basis.
We will receive referrals to our program through existing relationships with San Quentin State Prison and Santa Rita Jail. Through these relationships, inmates make appointments for benefits enrollment and medical care prior to release, so that upon release, they are immediately linked to a culturally competent primary care medical home as they navigate the transition. In addition to referrals from the State Prison and County Jail, Roots will accept referrals from the four Oakland-based pediatric practices in Roots Community Health Alliance, a 501(c)6 professional association of independent medical Safety Net providers. Pediatricians in these practices will identify children 0 to 5 who may benefit from the additional support this program will provide their fathers and families. In turn, Roots will provide summaries of relevant information to support the care of the child, in accordance with HIPAA regulations.
ref. First 5 Alameda County_ Community Grant Report
Core Care Model:
Program: Family Peer Coaching
Themes, Keywords & Tags: Partnerships; Evaluation; Fathers; Childhood
First5
Roots Family Peer Coaches will be culturally congruent men with shared lived experiences to the target population. They will be trained and certified as health coaches through at least one formal training program, which may include (but does not require) the post-prison healthcare worker certification. Three health coaches will be committed at 0.1 FTE each to provide health coaching to a minimum of 5 fathers per quarter with children ages 0-5. Key roles of Peer Coaches include: available by cell phone 24 hours daily; makes regular outreach calls to patients; is available to provide emotional support; assists with logistics pertaining to medical and social services; begins preliminary barrier removal planning; meets weekly with patients to provide information, education, support and co-learning with participants. The Clinical Services Manager will oversee and supervise the Peer Health Coaches in a manner consistent with her current job duties. As such, her salary is not supported with grant funding. Similarly, the Medical Director has ultimate responsibility for overseeing reporting and ensuring that all activities meet acceptable standards of care. Both the Clinical Services Manager and the Medical Director will provide administrative oversight to the program and as such their role is not directly funded by this grant.
ref. First 5 Alameda County_ Community Grant Report
Core Care Model:
Program: Family Peer Coaching
Themes, Keywords & Tags: Coaching; Fathers; Fatherhood; Early Childhood; Peer Health
First5 Emerging Issues
Babies of African Ancestry (A/A) die at more than twice the rate of other infants in their first year of life. One in seven babies of African descent is born too early or too small, and A/A mothers are more likely to die of pregnancy related complications than other women. These sad statistics are experienced in every part of the United States, and unfortunately Santa Clara County is no exception. Tragically, many of the children that do survive experience a myriad of health and social problems such as over-representation in the child welfare system, poverty, higher hospitalization rates, and more frequent visits to the Emergency Department among many other life-altering issues.
Families of African Ancestry face a host of issues that contribute to poor birth outcomes and the unhealthy development of children prenatally through age five. These families have higher infant mortality rates in every age category and maternal characteristic. Factors such as marital or employment status do not alter the disparities, nor do education or income level. In fact, studies show that birth outcomes among highly educated A/A women (with advanced degrees) are comparable to those of White women who dropped out of high school.
Ten percent of A/A babies in Santa Clara County are born premature or preterm compared with 7% overall. Premature infants are those who are born at 37 weeks or less gestation. Preterm birth is linked with low birthweight which often leads to many more health problems and longer hospital stays at birth. According to the March of Dimes, low birth weight is associated with:
Apnea – pause in breathing Respiratory Distress Syndrome Intraventricular
Hemorrhage – brain bleeding
Necrotizing Enterocolitis – intestinal problems
Retinopathy of Prematurity – abnormal growth of blood vessels in the eyes
Jaundice Bronchopulmonary Dysplasia – lung damage Developmental and learning disabilities
Poor school performance
Experts believe that aspects of social disadvantage including poverty, lack of social support, and racial discrimination and the stress associated with these issues are important contributors to the increased risks of poor maternal and infant outcomes among A/A families. Current scientific understanding suggests that experiencing these kinds of stressful conditions not only during pregnancy, but throughout life, can have dramatic adverse effects on a woman’s own health and that of her baby.
ref. First 5 Emerging Issues Concept Paper Submission Form_FINAL.doc
Core Care Model:
Program: Family 1st
Themes, Keywords & Tags: First5; African Americal; Babies; African Ancestry; A/A; Child Welfare; Infant; Morbidity; Mortality
Medi-Cal & CalFresh Renewal Assistance & CalFresh Enrollment Project
Earlier this year, Roots was approached to acquire Oakland Pediatrics located in the lower Fruitvale. This clinic has a patient base of over 5,000 children, serving 60% Latinos as well as recently immigrated Guatemalans, and Vietnamese and Chinese families. Approximately 35% of the patient population is African American. The previous director remains as a Roots physician, all staff were retained as Roots staff, and the transition has been smooth. This acquisition has added to our reach into the Fruitvale community, and considerably increased our services to children and Latino community members. Although we have only recently begun offering outreach and enrollment activities at the clinic, we will include their site as a renewal/enrollment location for this contract. In the past year, the Pediatric Clinic provided services for 5,595 patients, with 98% on Medi-Cal.
Core Care Model:
Program:
Themes, Keywords & Tags: Pediatric Care
ACVPI
In addition to providing the direct services described above, IMPACT Eastmont empowers clients, families and community to influence the systems and service providers who serve them through innovative multi-disciplinary, cross-agency collaboration/coordination designed to effect systems change Clients and their families, the Licensed Clinician, Family Coaches and the Peer Navigators (the Care Team) will have the opportunity to share coordination and system navigation challenges with the ACVPI Providers Table which will include authorized representatives from key CBOs and county departments who can recommend and implement changes within their respective agencies. The Care Team is best positioned to provide real-time information on barriers within or between systems that decrease efficiencies, access, understanding and compliance, and ultimately reduce the likelihood of success. This team also offers critical insight to systems that enable them to be more responsive, culturally competent, and meet clients “where they are.”
Members of the ACVPI Providers Table, including The Family Coach, and other members of The Care Team as appropriate will then provide timely feedback to the ACVPI Pilot Team who will guide and oversee the process of developing policy recommendations through the synthesis of observations, findings, strategies and outcomes that flow from the work of the ACVPI Providers Table. The ACVPI Pilot Team may establish Ad Hoc Action Teams and will make presentations/recommendations to standing committees – including BOS committees as appropriate (see Figure 7).
ref. ACVPI_Roots_Proposal.pdf, November 2016 – Dan Abrahamson
Core Care Model: Navigation
Program: IMPACT Eastmont; Healthy Measures
Themes, Keywords & Tags: Systems Change; Family Services
ACVPI
Family Coaching Teams are comprised of (1) a Care Team Supervisor – a clinician who supports direct staff who are working with the clients/families; (2) a Family Coach to facilitate cooperation, structure and communication within the family setting, as well as with key institutional and CBO partners and (3) a Navigator, who will be the client/family’s main point of contact, assisting with service navigation and providing critical support. The Family Coach and Navigator will work together to integrate and coordinate service delivery to clients and their families. This structure allows for a comfortable separation between the primary support persons for clients (the Navigator) and their family (the Family Coach), minimizing the appearance or reality of conflicts, safeguarding the comfort and privacy of the client, and supporting/protecting the wellbeing of frontline staff. Family Coaches and Peer Navigators are well-supported in their work – which is especially stressful and triggering for those with shared lived experiences – by the Care Team Supervisor, a clinician trained to recognize and manage PTSD, vicarious trauma, etc. This model leverages peer personnel with lived experience who tend to build trust and rapport more rapidly with clients, and is also cost-effective as it allows each member to work at the “top” of their training, while prioritizing for the clinician difficult cases and staff support. This model is scalable and replicable as each licensed supervisor could supervise up to six paraprofessionals who each have their own caseload. The Care Team Supervisor will oversee the two Family Coaches, two Navigators and their caseload of up to six individuals and families each, respectively, for a total of 10-12 families. A team of service providers coordinated by the Family Coach, will “wrap around” the client, facilitating success and ensuring services provided by participating CBOs and public agencies are coordinated, responsive, and non-duplicative (see Figure 6). The Care Team Supervisor will oversee the two Family Coaches, two Navigators and their caseload of up to six individuals and families each, respectively, for a total of 10-12 families. A team of service providers coordinated by the Family Coach, will “wrap around” the client, facilitating success and ensuring services provided by participating CBOs and public agencies are coordinated, responsive, and non-duplicative (see Figure 6). family are responsible for prioritizing goals and creating a realistic, actionable plan with the Family Coach. The role of the Family Coach is to facilitate engagement in “needed and wanted” services for the client and family, coordinating with various agencies and service providers.
ref. ACVPI_Roots_Proposal.pdf, November 2016 – Dan Abrahamson
Core Care Model: Navigation
Program: IMPACT Eastmont; Healthy Measures
Themes, Keywords & Tags: Family Services; Model
Mental Health Prevention & Early Intervention (PEI) Services in Sobrante Park
Roots’ experience and expertise with vulnerable youth runs deep and are inseparable from Roots’ commitment to whole health. In October 2017, Roots opened our Dream Youth Clinic, serving high-risk youth (primarily homeless and sexually trafficked), ages 14-25. We did so in partnership with DreamCatcher Youth Services. At this drop-in center, we serve clients of Dreamcatcher Youth Shelter and Covenant House (i.e., transitionally sheltered youth), MISSSEY (sexually exploited youth), and our Street Medicine program (unsheltered young adults). At Dream Youth Clinic, adolescents link with Navigators, hang out in a welcoming, youth-friendly space, and address their primary and behavioral health needs.
The Dream Youth Clinic inspired us to implement a “two-generation” program called Teen Success. Teen Success helps teen mothers, ages 14-19 who have not yet completed high school, (1) acquire social and emotional assets, (2) graduate high school, and (3) develop into effective “first teachers” to their children. The goal of Teen Success is to break the cycle of poverty two generations at a time by helping teen mothers take the steps needed to pursue post-secondary education, and to help inculcate the skills needed to nurture their child’s positive development.
Career and employment readiness and exploration. Roots is a nationally recognized leader in addressing entrenched barriers to economic opportunity for East Oakland’s impoverished and hard-to-employ residents. We know how to positively influence behavior. We begin by empowering individuals. We get them to understand that they have choices, and to exercise those choices, including the manner in which they receive health services. And we strengthen partner organizations in this field by providing them with fiscal sponsorship, incubation, technical assistance and capacity building.
More specifically, and by design, Roots’ clinics are training grounds for Oaklanders who aim to serve their home community as health professionals. Roots trains more than 60 individuals annually in healthcare professions ranging from community health outreach worker to nurse to physician. Roots launched its Emancipators Initiative in 2012 to provide on-the-job training in light manufacturing and then link graduates to permanent employment. The success of the Emancipators Initiative (begun as a workforce pilot with Alameda County Social Services Agency for persons on General Assistance) led to the creation of Roots’ social enterprise, Clean360 (www.clean360.org), in which at-risk individuals study and work in our model soap factory, learning how to produce, market, sell and ship small batch, handcrafted soaps, for which they receive stipends, barrier removal assistance, and ongoing support.
Roots also operates an Empowerment Center – a drop-in site where community members receive assistance with resume development, skills trainings, job search and employment. We host hiring and financial literacy events, connect job seekers with our Better Dressed for Success closet and cultivate relationships with a wide array of employers, like Tesla, who are ready to hire our clients.
Core Care Model:
Program: Teen Success Empowerment Center
Themes, Keywords & Tags: Education; Whole Health; Employment; Youth; Dream Youth Clinic; Literacy
Mental Health Prevention & Early Intervention (PEI) Services in Sobrante Park
The need for behavioral health supports for our community has always been high, and continues to rise. Roots will prioritize its proven interventions for those with high need, thereby maximizing our impact. Specifically, Roots will implement our Family 1st family navigation model, which incorporates numerous best practices (detailed below) for individual and family engagement, and links those in need to mental health treatment and other supports. Root’s will utilize our Family Coaching and Navigation model executed by our Whole Health approach and informed by a Strengthening Family Framework. Key to the successful implementation of this strategy are fostering relationships and networks of support for families and providers.
Core Care Model: Navigation
Program: Family 1st
Themes, Keywords & Tags: Mental Health; Family; Whole Health; Strengthening Family Network
Sobrante Park
Roots always has served all age groups with medical and behavioral care. In recent years, Roots has implemented specific programming targeting the special needs of adolescents and young adults – particularly those at highest risk. In 2016, we began harnessing our relationships with the Sobrante Park Leadership Council, the City and County Neighborhood Initiative, the Alameda County Violence Prevention Initiative and Oakland Unite to lay the foundation for implementation of our Care Coaching program, UpLift Initiative, in partnership with the Community Health Services Division of Alameda County Public Health. This Initiative is an outgrowth of our navigation programming, which provides adult coaching and navigation services. UpLift, however, is designed to meet the needs of youth, supplementing our youth-focused clinical and behavioral services with educational coaching. In summer 2017 we piloted a dual Care Coaching and peer academic tutoring strategy at Madison Park Academy to uplift at-risk students with respect to their grades and goal setting. Our Care Coach supported student leaders who served as tutors for the program, hosted group learning and discussion sessions, and provided one-on-one coaching. We continue to work collaboratively with Community Health Services Division to embed the care coaching curriculum into our organizational model and test strategies to attract high-risk youth. Our goal is simple: make college preparation and readiness as tangible for youth in deep East Oakland as it is for the families in the city’s affluent neighborhoods. In this vein, we also engage with students at Dewey Academy through a two-day guest lecture series exploring choices and barriers to success. Lastly, we run health services, including Navigation, at Laney and Berkeley City Colleges, and are in the process of expanding youth career and academic readiness through our relationship with Peralta College District.
Our collaborative partner, Higher Ground, implements after school and workforce development programming on site at seven Oakland schools, including Madison Park Academy. They are based at the school site and have long-standing, productive relationships with the administration, teachers and students of the upper and lower campuses. Higher Ground helps students create individual growth plans, and intends to turn to Roots to help support students and families whose barriers to wellbeing require off-campus resolutions.
ref. RFP#HCSA-900218_Sobrante Park_narrative.pdf, March 2018 – Dan Abrahamson
Core Care Model:
Program: UpLift Initiative
Themes, Keywords & Tags: Youth; Partnerships; Education
Sobrante Park
Roots’ experience and expertise with vulnerable youth runs deep and are inseparable from Roots’ commitment to whole health. In October 2017, Roots opened our Dream Youth Clinic, serving high-risk youth (primarily homeless and sexually trafficked), ages 14-25. We did so in partnership with DreamCatcher Youth Services. At this drop-in center, we serve clients of Dreamcatcher Youth Shelter and Covenant House (i.e., transitionally sheltered youth), MISSSEY (sexually exploited youth), and our Street Medicine program unsheltered young adults). At Dream Youth Clinic, adolescents link with Navigators, hang out in a welcoming, youth-friendly space, and address their primary and behavioral health needs. The Dream Youth Clinic inspired us to implement a “two-generation” program called Teen Success. Teen Success helps teen mothers, ages 14-19 who have not yet completed high school, (1) acquire social and emotional assets, (2) graduate high school, and (3) develop into effective “first teachers” to their children. The goal of Teen Success is to break the cycle of poverty two generations at a time by helping teen mothers take the steps needed to pursue post-secondary education, and to help inculcate the skills needed to nurture their child’s positive development.
ref. RFP#HCSA-900218_Sobrante Park_narrative.pdf, March 2018 – Dan Abrahamson
Core Care Model:
Program: Dream Youth Clinic
Themes, Keywords & Tags: Youth; Partnerships; Education; Whole Health
Sobrante Park
The need for behavioral health supports for our community has always been high, and continues to rise. Roots will prioritize its proven interventions for those with high need, thereby maximizing our impact. Specifically, Roots will implement our Family 1st family navigation model, which incorporates numerous best practices (detailed below) for individual and family engagement, and links those in need to mental health treatment and other supports. Root’s will utilize our Family Coaching and Navigation model executed by our Whole Health approach and informed by a Strengthening Family Framework. Key to the successful implementation of this strategy are fostering relationships and networks of support for families and providers.
ref. RFP#HCSA-900218_Sobrante Park_narrative.pdf, March 2018 – Dan Abrahamson
Core Care Model: Navigation
Program: Family 1st
Themes, Keywords & Tags: Family; Whole Health; Strengthening Family Frame Work
Mental Health Prevention & Early Intervention (PEI) Services in Sobrante Park
In recent years, Roots has implemented specific programming targeting the special needs of adolescents and young adults – particularly those at highest risk. In 2016, we began harnessing our relationships with the Sobrante Park Leadership Council, the City and County Neighborhood Initiative, the Alameda County Violence Prevention Initiative and Oakland Unite to lay the foundation for implementation of our Care Coaching program, UpLift Initiative, in partnership with the Community Health Services Division of Alameda County Public Health. This Initiative is an outgrowth of our navigation programming, which provides adult coaching and navigation services. UpLift, however, is designed to meet the needs of youth, supplementing our youth-focused clinical and behavioral services with educational coaching. In summer 2017 we piloted a dual Care Coaching and peer academic tutoring strategy at Madison Park Academy to uplift at-risk students with respect to their grades and goal setting. Our Care Coach supported student leaders who served as tutors for the program, hosted group learning and discussion sessions, and provided one-on-one coaching. We continue to work collaboratively with Community Health Services Division to embed the care coaching curriculum into our organizational model and test strategies to attract high-risk youth. Our goal is simple: make college preparation and readiness as tangible for youth in deep East Oakland as it is for the families in the city’s affluent neighborhoods. In this vein, we also engage with students at Dewey Academy through a two-day guest lecture series exploring choices and barriers to success. Lastly, we run health services, including Navigation, at Laney and Berkeley City Colleges, and are in the process of expanding youth career and academic readiness through our relationship with Peralta College District.
Core Care Model: Navigation
Program: Care Coach; UpLift
Themes, Keywords & Tags: Youth; Education; Partnerships
Mental Health Prevention & Early Intervention (PEI) Services in Sobrante Park
Roots’ experience and expertise with vulnerable youth runs deep and are inseparable from Roots’ commitment to whole health. In October 2017, Roots opened our Dream Youth Clinic, serving high-risk youth (primarily homeless and sexually trafficked), ages 14-25. We did so in partnership with DreamCatcher Youth Services. At this drop-in center, we serve clients of Dreamcatcher Youth Shelter and Covenant House (i.e., transitionally sheltered youth), MISSSEY (sexually exploited youth), and our Street Medicine program (unsheltered young adults). At Dream Youth Clinic, adolescents link with Navigators, hang out in a welcoming, youth-friendly space, and address their primary and behavioral health needs.
The Dream Youth Clinic inspired us to implement a “two-generation” program called Teen Success. Teen Success helps teen mothers, ages 14-19 who have not yet completed high school, (1) acquire social and emotional assets, (2) graduate high school, and (3) develop into effective “first teachers” to their children. The goal of Teen Success is to break the cycle of poverty two generations at a time by helping teen mothers take the steps needed to pursue post-secondary education, and to help inculcate the skills needed to nurture their child’s positive development.
Core Care Model:
Program: Dream Youth Clinic; Teen Success
Themes, Keywords & Tags: Youth; Mothers
Mental Health Prevention & Early Intervention (PEI) Services in Sobrante Park
The need for behavioral health supports for our community has always been high, and continues to rise. Roots will prioritize its proven interventions for those with high need, thereby maximizing our impact. Specifically, Roots will implement our Family 1st family navigation model, which incorporates numerous best practices (detailed below) for individual and family engagement, and links those in need to mental health treatment and other supports. Root’s will utilize our Family Coaching and Navigation model executed by our Whole Health approach and informed by a Strengthening Family Framework. Key to the successful implementation of this strategy are fostering relationships and networks of support for families and providers.
Core Care Model: Navigation
Program: Family 1st
Themes, Keywords & Tags: Behavior; Family; Strengthening Families Framework
Mental Health Prevention & Early Intervention (PEI) Services in Sobrante Park
Roots will provide family navigation services for 24 juniors and seniors involved in Career Pathways (see Category 3, below). These students will be connected to Madison Park Academy, and therefore not only will they engage in career readiness and exploration, they will also be able to access behavioral health and other services. We anticipate the level of need for navigation will be moderate, and that some co-navigation/co-management with Higher Ground, Native American Health Center, Healthy Schools and Communities, and/or other entities providing services to the students on campus, will occur. Thus, one Roots Navigator will be assigned to provide Family Navigation for all 24 youth and families.
Core Care Model:
Program:
Themes, Keywords & Tags: Youth; Family
Mental Health Prevention & Early Intervention (PEI) Services in Sobrante Park
Navigators will conduct outreach and engage in referral processes with our strong and growing network in Sobrante Park. While traditional interventions primarily focus on women and their babies, our experience, as well as research indicates that a better approach is grounded in social determinants of health theory that views parents not as solitary individuals, but as members of families, communities and larger systems and understands that those larger affiliations can have either positive or negative impacts on parents’ psychological and physical states. Sixteen high-risk individuals will be identified through our intake and assessment process delineated below, and will receive intensive case management services in the home, in the community or at Roots’ sites. We anticipate the level of need for navigation within this group will be more intensive; therefore, consistent with the evidence base for violence prevention and mental health early intervention/prevention, we will implement a smaller panel size (1:16) for this group.
Core Care Model:
Program:
Themes, Keywords & Tags: Youth; Family
Mental Health Prevention & Early Intervention (PEI) Services in Sobrante Park
Care plans and client progress are discussed during face-to-face encounters. This process allows for not only the most meaningful communication, but also the most nuanced tailoring of services and supports to achieve and maintain client stability. Adding Family Navigation to our existing array of services in East Oakland carries tremendous potential for improving the stability of high-risk clients. Our comprehensive intake, assessment and case conferencing processes address the holistic needs of individuals and identify and thus prioritize those persons for whom prevention and early intervention family navigation is urgently needed. We welcome the opportunity to collaborate with HCSA/BHCS to meet the Family Coaching needs in Sobrante Park.
Core Care Model: Care; Navigation
Program:
Themes, Keywords & Tags: Care; Stability; Family Navigation
UpLift Initiative Educational Care Coaching
In Summer 2017, after being awarded the Care Coaching contract from the Community Health Services Division of Alameda County Public Health, we piloted a dual Care Coaching and peer academic tutoring strategy to Uplift the at risk students both in their grades and approach to goals and success. Our Care Coach worked with the Executive Director and Founder of Changefor100 and the Aim High Summer School Program to facilitate leadership development with students who participated in the summer school program on campus at Madison Park Academy. Additionally, our Care Coach provided support to student leaders who served as tutors for the program and create a relationship to better serve the shared constituency. The three weeks entailed group learning and discussion and one on one coaching (see outline attached).
Core Care Model: Care
Program: UpLift Initiative
Themes, Keywords & Tags: Sobrante Park; Youth
UpLift Initiative Educational Care Coaching
Teen Success, Inc. a partnership with a Milpitas based non-profit which helps teen mothers 14-19 who have not yet completed high school develop social and emotional assets, finish high school and become effective “first teachers” to their children. Using a positive youth development framework and best practices serving teen mothers living in poverty, the program focuses on members’ strengths works to foster personal resilience and social connections while at the same time acknowledging the importance of reducing risk and increasing the members’ capacity to reach their full potential. The purpose is to break the cycle of poverty two generations at a time by supporting teen mothers in graduating from high school and pursuing post-secondary education, and developing the skills needed to nurture their child’s positive development. Our mission is to help underserved teen mothers and their children become educated, self-sufficient, valued members of society (see recruitment flyer attached).
Core Care Model: Empowerment
Program: UpLift Initiative; Teen Success
Themes, Keywords & Tags: Youth; Family; Motherhood; Empowerment
UpLift Initiative Educational Care Coaching
We aligned the curriculum with the Care Coaching Model Binder to ensure we were providing a robust program and will engage our Teen Success Navigator in Care Coaching Curriculum Training and have scheduled peer learning between the Care Coaches and Teen Success Navigator to make sure services are gender responsive, trauma informed and can serve youth at risk and with lived experience in a variety of barriers.
Core Care Model: Empowerment
Program: UpLift Initiative
Themes, Keywords & Tags: Youth; Care
UpLift Initiative Educational Care Coaching
As an East Oakland anchor organization, we are pleased to be able to utilize this opportunity to help resource and lift up a new, grassroots non-profit, Changefor100, started by a Madison Park Academy student. We are already providing support and technical assistance to this organization, with the understanding that our impact will only be amplified by investing in our community assets such as Changefor100.
Core Care Model: Empowerment
Program: UpLift Initiative
Themes, Keywords & Tags: ChangeFor100; Youth
First5
Roots Family Peer Coaching Program will utilize peer support to increase fathers’ access to education and information about early childhood development, and increase their sense of competency as parents. Our program focuses on, and provides culturally competent services to, low-income African American fathers, prioritizing those recently released from incarceration.
ref. First 5 Alameda County_ Community Grant Report
Core Care Model: Care
Program: Family Peer Coaching
Themes, Keywords & Tags: African American; Fathers; Family; First5
First5 Emerging Issues
Traditional interventions have focused on women and their babies as individuals. Research shows that a better approach is grounded in social determinants of health theory and treats them not as individuals, but as members of families, communities and larger systems that have either positive or negative impacts on their psychological and physical states. Roots proposes Family 1st, an African-centered model for strengthening families. This model case manages A/A families at risk for poor birth outcomes and integrates best practices for improving the health and social well-being of families. This intervention recognizes family as those individuals closely associated with the child 0-5 years of age, including parents, extended family (grandparents, aunts, uncles, etc.), godparents, neighbors and others who directly impact the well-being of the child. This African Centered model recognizes and incorporates these important values:
- The interdependency of the family unit
- Community is valued and participation is expected
- Culture is highly relevant to everyday behavior. Values, shared history, experiences, and language all affect how things are seen and felt, and determines what matters
- Treatment/intervention must include discussion of social context, history, racism, and other relevant issues
- Multigenerational racism and trauma (including post-traumatic slave disorder) must be acknowledged, understood and addressed
ref. First 5 Emerging Issues Concept Paper Submission Form_FINAL.doc
Core Care Model:
Program: Family 1st
Themes, Keywords & Tags: Family; Infant; Babies; Fathers
First5 Emerging Issues
The goals of Family 1st are to:
- Lower risk factors that are associated with poor birth outcomes in the A/A community, thereby reducing infant mortality and morbidity by enrolling women into Covered California and/or Medi-Cal and assisting them with identifying an OB/GYN for prenatal care
- Promote behaviors that contribute to healthy children, i.e. breastfeeding for first six months of child’s life, ensuring children receive timely immunizations, assisting with access, assessing baby’s developmental progress (ASQ 3), providing education on Back to Sleep and eliminating barriers that prevent well-baby checks ups, etc.
- Increase protective factors that contribute to strengthening families, i.e. improving family resilience and family/community relationships, increasing parenting skills and knowledge for the improvement of the child’s development and referring and coordinating access for families to critical support services
- Increase participation of fathers in the lives of their children. Particularly those recently released from incarceration
- Encourage pride and positive cultural identity
The Objectives of Family 1st include:
- Outreach to at least 300 families, enroll and retain75 families in year one, increasing annually to reach 300 families by year three
- Increasing the number of pregnant women who enter prenatal care in their first trimester by 5% above the established baseline
- A minimum of 80% of participating women breastfeed for at least the first 6 months of their infant’s life
- Ensuring 100% of pregnant women enrolled in Family 1st have medical insurance
- Tracking and assessing 100% of participants’ developmental progress as measured by ASQ3 and immunization records
- Increasing parenting skills and knowledge of participants by 25% of baseline as measured by pre/post-test in parenting classes.
- Moving a minimum of 30% of participants from red (critical) phase to yellow (engagement) / yellow to green (stable) as measured by ongoing assessments and case manager notes (see below for a detailed description of these phases).
- Increase participation of fathers in their kids’ lives by 20% as measured by pre/post-test in Fathering classes
ref. First 5 Emerging Issues Concept Paper Submission Form_FINAL.doc
Core Care Model:
Program: Family 1st
Themes, Keywords & Tags: Family; Infant; Babies; Fathers
First5 Emerging Issues
Sustainability is a core Roots value, as we recognize that our services and programs must be ongoing, sustainable and rooted in the community to have the deepest impact. Because we are a licensed Community Health Center, we are able to directly bill for clinical services, as well as some ancillary services (such as smoking cessation counseling) to state Medi-Cal/managed care Medi-Cal. In addition, Roots is working closely with the Santa Clara County Public Health Department regarding Medi-Cal Administrative Activities and Targeted Case Management. While First 5 funding will allow Roots to leverage both MAA and TCM, we anticipate being able to leverage significant resources through the TCM program given the long term, comprehensive nature of the case manager-client relationship and the fact that TCM funding can be leveraged at a higher rate for most of our male clients as they are newly eligible for Medi-Cal under the Affordable Care Act. Specifically, ACA guidance indicates that for the newly-eligible population, Federal Medical Assistance Percentages will be 95% in 2017, as opposed to 50% for other Medi-Cal clients. This represents an excellent opportunity to reinvest into and expand the scope/duration of our case management program.
ref. First 5 Emerging Issues Concept Paper Submission Form_FINAL.doc
Core Care Model:
Program: Family 1st; FIrst5
Themes, Keywords & Tags: Sustainability; Funding
First5 Emerging Issues
The data is clear that children whose fathers are present fare better physically and socially overall in life, highlighting the importance of fathers having tools and methods to confidently engage in their children’s lives. We also know that the myth that the “absentee” A/A father is at the root of problems in the A/A community creates additional stigma which may be a barrier to A/A men seeking to obtain these tools and methods. Despite this myth, evidence has revealed that A/A fathers spend as much – and in many cases more – time with their children than other racial groups. The data also shows that not cohabitating does not equal absenteeism: 67% of A/A fathers that live apart from their children see them at least once a month, compared to 59% and 32% of white and Latino dads, respectively. In other words, A/A fathers, both in and out of the household, are more involved with their children than other racial groups. Our work with fathers has revealed that empowering them with this data, teaching skills that build confidence as a father, and assisting them with overcoming barriers to reunification with their families, brings tremendous benefit to the entire family and community. As partners with the local Public Health Department we look forward to the opportunity to utilize our skills and expertise to fill the current gap in services for A/A families in Santa Clara County, and specifically addressing these issues through a cultural lens
ref. First 5 Emerging Issues Concept Paper Submission Form_FINAL.doc
Core Care Model:
Program: Family 1st
Themes, Keywords & Tags: Fathers; Fatherhood