Exploring and Developing Career Ladders in Manufacturing & STEM for Formerly Incarcerated Women
We will develop a white paper on manufacturing and STEM as potential pipelines for women who are experiencing barriers to employment, describing career ladders and access to those career ladders for formerly incarcerated women. We will also draw from the experiences and lessons learned in order to develop outreach and education strategies for these women, including the challenges and opportunities specific to women participating in the manufacturing workplace.We will conduct industry research, an updated scan of the local landscape, and specific exploration of advanced manufacturing and engineering as viable pipeline opportunities for women with high barriers to entering the workforce. Our curriculum development and evaluation components will be comprised of three focus group of reentry women who have graduated from and/or are participating in workforce and empowerment programming at Roots (OUR Project, Emancipators, Women’s Empowerment Pilot, etc.), with the goals of identifying their unique needs, aspirations, and their views on the ideal components of women’s workforce programming. Subsequent to each apprenticeship cohort, focus groups will assess the impact of exposure to manufacturing, including advanced manufacturing and higher education, including STEM. In addition to our participation in the Innovations in Reentry Learning Conference, we will aim to present our findings in at least one venue to be determined in collaboration with stakeholders as our results are formulated. One example could be presenting findings on these pathways to Probation Officers who work with reentry women, or presenting general information at a public meeting.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
African American Steering Committee for Health and Wellness
Roots prioritizes rigorous research and evaluation, and maintains the technology and staff support needed to collect and analyze data internally and for outside partners and funders. Through its research department, Roots has considerable expertise in data collection, entry and analysis, and Electronic Health Records (EHR) abstraction. Roots Health Navigators enter their encounter notes into our electronic health record, enabling improved care coordination and streamlined data analysis. Our needs and strength-based intake establishes critical baseline information such as recidivism risk, food security, and overall stability. We track Medi-Cal enrollment, referrals to external partners, emergency department and hospital utilization, and recidivism data. Patient demographics, case management notes, behavioral interventions, medical encounters, medication, laboratory and other patient data are contained within the EHR, ensuring our ability to analyze patient specific and population data, correlating our interventions to outcomes.
Core Whole Health Care Area: Navigation
Program: Healthy Measures
Themes, Keywords & Tags: Data; Evaluation; Research
Exploring and Developing Career Ladders in Manufacturing & STEM for Formerly Incarcerated Women
Roots holds current contracts with Alameda County Health Care Services Agency and Alameda County Social Services Agency which require regular reporting using Results Based Accountability standards. Roots staff has extensive experience collecting and reporting quantitative and qualitative data via multiple platforms and systems including Cityspan for our work under the City of Oakland’s Oakland Unite; our annual Office of Statewide Health Planning (OSHPD) report required as a state licensed clinic; as well as data for Healthcare for the Homeless reporting to the Federal Uniform Data Systems (UDS). All Roots staff are trained annually in HIPAA and all of our databases are HIPAA secure. We currently engage in data exchange with Health Care Services Agency including Health Care for the Homeless.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
Bridging the Gap: Reducing Disparities in Diabetes Care
Data collection methods will include: progress reports by partners and lead staff; focus groups with partners, paraprofessionals, and clients; and surveys to determine paraprofessional satisfaction with the training, increase in knowledge of diabetes, and confidence in their ability to influence change. Evaluators will assess the perceived efficacy of each component through client surveys and focus groups with clients. Change in diabetes self-management will be tracked through the American Association of Diabetes Educators’ (AADE) 7-self-care behaviors framework and associated assessment tools.8 Where feasible, data will be collected and analyzed by clinic and ethnicity to explore differences in implementation, as well as any differences in outcomes by geographic location and ethnicity.
Core Whole Health Care Area:
Program: ACCDRI
Themes, Keywords & Tags: Data; Evaluation; Diabetes
Bridging the Gap: Reducing Disparities in Diabetes Care
Clinics will be able to pull reports from their EHRs to collect data on individual clinical measures. In addition, paraprofessionals will record scores on the Every One with Diabetes Counts or a similar pre- and post-test for participants in DSME classes in a customized spreadsheet or simple database. Once they are ADA recognized, ACDDRI partners will be able to use the ADA’s standards-based DSME documentation system, Chronicle Diabetes, which allows health care professionals caring for patients with diabetes to assess, document, and generate reports regarding their medical care, education, and metabolic management. This web-based system provides tools that DSME providers can use to provide a continuum of care. The clinical methodology of Chronicle is based on published ADA standards as well as NCQA requirements. Chronicle provides electronic medical record features including a complete patient manager, clinical data documentation, and full medications list. Additionally a standards-based behavior change objectives component guides educators through the process of establishing, documenting, and reviewing patient’s behavior change objectives. To supplement data collected from the clinics’ EHRs, Chronicles Diabetes, and the EDC database, ACDDRI will also explore ways to collect data on patients’ Healthcare Effectiveness Data and Information Set (HEDIS) outcomes. By the third year of ACDDRI, we will explore with Alameda Alliance for Health as well as the clinic teams whether and how it will be possible to track HEDIS measures for the cohorts of patients participating in ACDDRI. Such measures included Hemoglobin A1c (HbA1c) testing, HbA1c control, performance of retinal exams, medical attention for nephropathy, and blood pressure control (<140/90 mm Hg).
Core Whole Health Care Area:
Program: ACCDRI
Themes, Keywords & Tags: Data; Evaluation; Diabetes
Bridging the Gap: Reducing Disparities in Diabetes Care
The in-house CAPE Unit includes a nationally recognized team of epidemiologists and program evaluators who provide data analyses, data reports, and evaluation services to support in-house programs, as well as multi-partner and national initiatives. CAPE collects community-level data on a wide variety of diabetes and chronic disease outcomes and related social determinants of health such neighborhood poverty level, availability of healthy food, and quality of public schools. CAPE staff are experts in GIS mapping software and have been active collaborators in this grant application and in the ACPHD Chronic Disease programs over the years. CAPE Unit epidemiologists and evaluation specialists frequently support program activities by functioning in a technical assistance capacity. Evaluators assist programs in developing logic models and implementation plans; epidemiologists analyze key indicator data to support program applications for funding and periodic health status reports. Recent CAPE publications include: Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County, 2008; Health of Alameda County Cities and Places 2010; and His Health: Alameda County Male Health Status Report, 2010. The Health Research for Action (HRA) Center at UC Berkeley aims to reduce health and health care disparities and to help create healthier, more empowered communities. Center staff includes researchers, practitioners, and communication and policy experts. HRA uses highly participatory methods to investigate the broad determinants of health and to co-design effective interventions and policies with the intended beneficiaries and stakeholders. Examples of their intervention research include: investigation of health disparities and interventions among Asian populations related to cancer/cancer screening, diabetes, and other topics; the use of social impact bonds to support community health efforts for asthma and other health issues; and research on the impacts of Medicaid program transitions for seniors and persons with disabilities. An article on the effectiveness of health coaches in diabetes care, published in Diabetes Spectrum (2012) HRA faculty, including ACDDRI’s lead qualitative evaluator Winston Tseng, is included in the Appendices.
Core Whole Health Care Area:
Program: ACCDRI
Themes, Keywords & Tags: Data; Evaluation; Diabetes
AVCPI
IMPACT Eastmont is designed to pilot direct services to clients and their families that inform systems change through a coordinated approach to continuous problem solving/troubleshooting, data analysis, innovating and testing solutions, and providing continuous feedback to inform strategic program and process revisions. This comprehensive, holistic structure aligns perfectly with Roots’ Whole Health approach, and draws from key areas of knowledge and expertise in the key domains of Care, Navigation and empowerment, making IMPACT Eastmont an ideal Whole Health Initiative
ref. ACVPI_Roots_Proposal.pdf, November 2016 – Dan Abrahamson
Core Whole Health Care Area:
Program: IMPACT Eastmont; Healthy Measures
Themes, Keywords & Tags: Reentry; Incarceration; Mental Health; Data
AVCPI
Roots prioritizes rigorous research and evaluation, and maintains the technology and staff support needed to collect and analyze data internally and for outside partners and funders. Through its research department, Roots has considerable expertise in data collection, entry and analysis, and Electronic Health Records (EHR) abstraction. Roots Health navigators enter their encounter notes into our electronic health record, enabling improved care coordination and streamlined data analysis. Our needs and strength-based intake establishes critical baseline information such as recidivism risk, food security, and overall stability. We track Medi-Cal enrollment, referrals to external partners, emergency department and hospital utilization, and recidivism data. Patient demographics, case management notes, behavioral interventions, medical encounters, medication, laboratory and other patient data are contained within the EHR, ensuring our ability to analyze patient specific and population data, correlating our interventions to outcomes.
The ACVPI Pilot Team – which includes third party researchers and evaluators (Prevention Institute and Urban Strategies) – will guide and oversee the process of developing policy recommendations by: synthesizing observations, findings, strategies and outcomes that flow from the ACVPI Providers Table and the Care Team; establishing Ad Hoc Action Teams as needed; and introducing infrastructure such as shared data systems. This will ensure a protected space for oversight, accountability and evaluation for team problem solving, with a place-based, family-integrated and peer-led approach to violence and recidivism reduction.
A built-in ongoing research agenda and commitment to efficiency in systems will help to facilitate on-the-ground feedback that will drive critical and innovative modifications to programs and services via evaluation and results based accountability. Third party evaluators – particularly those already involved with Eastment ACVPI – would be well-positioned to do this research. Honoring a process that incorporates the input of clients/families, peers, and community-based providers regarding the systems that serve them will build community capacity to respond to and participate in creating more efficient, transparent, and responsive systems. With proactive design, innovation, renovation and collaborative practices, this pilot and sustained program could prove to be a viable placed-based alternative to incarceration.
ref. ACVPI_Roots_Proposal.pdf, November 2016 – Dan Abrahamson
Core Whole Health Care Area:
Program: IMPACT Eastmont; Healthy Measures
Themes, Keywords & Tags: Data; Evaluation; Research
APHA
Independent clinics and private physicians serving significant numbers of Medicaid recipients play an essential role in the Safety Net, and have tremendous impact on the health of their patients through long-standing relationships and a high degree of trust. They also possesses the cultural competency, clinical knowledge, and community-connectedness to inform the need for and design of research and clinical initiatives relevant to their patient populations. However, because these practices are typically under-resourced and lack the administrative infrastructure to plan and undertake such research, they – and therefore their patients – are often left out of investigations that may shape best practices, improve service delivery models, and inform systems change to improve the health status of underserved communities. In response to specific concerns regarding the unknown prevalence of Hepatitis C among low-income African Americans in Oakland and Richmond, California, Roots Community Health Center, acting as a “hub” organization, designed and implemented an initiative to routinize Hepatitis C screening in four independent primary care practices. This coordinated effort has revealed an overwhelmingly high rate of Hepatitis C positive patients on routine screening – over 10 times the average nationwide.
ref. APHA Abstract_accepted.docx, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Research; Evaluation; Data; Hepatitis C
Reentry Engagement Framework Project: Innovations in Reentry
Evaluation is embedded within all project activities – by the Evaluation Team, Program Staff and by REF Project Fellows, who will use assessment, observation and evaluation as they define report outcomes. Success rests on skilled facilitation that builds each individual’s capacity to identify promising practices, analyze access issues, and also evaluate their own and the group’s work over the grant duration. Process evaluation will include assessments about inclusiveness, openness, trust, ability to learn from others, and the impact of participation on reentry success itself. Qualitative data from transcribed focus groups, interviews as well as participant evaluations will be analyzed, the information sorted and labeled, and emergent themes identified. Interpretation of qualitative data will be performed through listing, diagramming, and connecting categories and emergent themes, and highlighting representative or illustrative statements and quotes. The Evaluation Team will compile all qualitative and quantitative data, and summarize findings. The Evaluation Team and formerly incarcerated Program Staff will review these findings and work together to craft the final recommendations. Review of the final product will be conducted by REF Project Fellows who will edit/add and sign off on the report before it is shared.
Core Whole Health Care Area:
Program: Reentry Engagement
Themes, Keywords & Tags: Evaluation; Data; Reentry
Blue Shield of California
Although new initiatives and models of care continue to develop at the community level, the funding required to sustain them is siloed across a network of payers, policymakers, and philanthropic stakeholders. This disconnect creates a healthcare system that is impeded from delivering lasting improvements. Roots has a strong track record of shifting healthcare paradigms and knows first- hand that promising initiatives launched without a long-term investment strategy can undermine healthy outcomes and fray, rather than build, bonds between patients and providers. We hypothesize that convening patients and regional stakeholders to define and co-create measurements that encapsulate whole health through ongoing learning collaboratives will create new, comprehensive measurements to pilot. These tools, in turn, can help (1) de-silo stakeholders, (2) create a replicable model of multi-stream funding for community health, and (3) persuade investors to provide durable support for models and projects that advance overall health.
In collaboration with Health Leads, Roots proposes to build upon existing infrastructure to bring together a diverse set of patients, healthcare leaders, philanthropic organizations, and policymakers to co-create new measurements that account for the physical, social, and mental well-being of individuals and the community. To do this, we propose a phased engagement that builds out stakeholder groups, convenes meetings to define new holistic health indicators, shares learnings and expertise, pilots new measurements in existing programs, and convenes all stakeholders to ratify new measurements. We believe this groundwork will generate pre-implementation buy-in by investors to provide longer-term support for promising interventions. Roots will lead this project by driving design, patient convening, measurement creation, and pilot testing; Health Leads will help build cross-sector stakeholder groups and define social needs evaluation frameworks.
ref. Blue Shield of CA Fnd.pdf, June 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation; Research; Measurement; Stakeholders
Blue Shield of California
By March 30, 2020, design a comprehensive measurement strategy with stakeholder input: without the voice of the community guiding the development of new measurements—speaking to strengths, assets, challenges, and solutions they envision—even the most well intended efforts will miss critical factors that drive community-level change. To ensure a robust measurement framework, we will create input channels and convening bodies to ensure designs will be community-driven: a patient advisory council (PAC), which will identify and define key community health indicators (with support from both Roots and Health Leads) and meet regularly to discuss and refine them, and; a cross-sector stakeholder learning cohort (LC) comprised of representatives from the public, private, and philanthropic sectors. The LC will share learnings and strategies in response to emerging health indicators to break down communication barriers and co-create new strategies for supporting long-term initiatives that develop from this new framework to better leverage existing resources to grow promising strategies for improving community health.
The PAC will be sourced from focus group discussions with participants of Roots’ existing programs and represent a diverse range of ages and experiences. Similarly, the learning cohort (LC) will lend unique insights from a range of interrelated—but historically disconnected—fields to conversations with the PAC. This bi-directional design is crucial for changing investment channels because the co- building process will align diverse stakeholders to health indicators as defined by those whose lives are impacted by them—thereby re-framing a shared definition of health and shifting investment priorities to what the community thinks will have the greatest impact.
ref. Blue Shield of CA Fnd.pdf, June 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation; Research; Measurement; Stakeholders
Blue Shield of California
By June 30, 2020, implement new measurements into existing violence reduction programs as a pilot. To pilot test and refine the new measurements, Roots will integrate the evaluation frameworks into our existing violence reduction programs including (1) a place-based violence prevention program including early intervention on behavioral conditions, education/employment pathways, and neighborhood beautification, (2) a pre-and post-jail release program including service navigation and linkage to care, (3) a two generation group visit and case management program for pregnant teenagers who are homeless sexually trafficked, and/or victims of violence, (4) intensive case management and life coaching for individuals identified as gun/gang involved by Oakland police, (5) a place-based strategy aimed at ensuring children are ready for school, including an assessment of neighborhood risk and resiliency factors. These programs each have a different funding source and unique sets of community based and agency partners.
Over this three-month period, we will work closely with project staff and program participants to refine implementation best practices, hone evaluation strategies to better align with the newly defined measurements, solicit feedback from program participants and staff, and develop a pilot report to share in advance of the cumulative convening. This report will serve as the primary aligning document for the ratifying convening between the PAC and LC, during which we will review pilot results, receive feedback, discuss pathways forward, and align on operational next steps for wider implementation.
ref. Blue Shield of CA Fnd.pdf, June 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation; Research; Measurement; Stakeholders
Blue Shield of California
By September 30, 2020, hold a convening meeting between PAC and LC stakeholders to share and align on final measurement strategy: by the end of the 24-month grant period, we will hold a ratifying convening meeting with the PAC and LC to review pilot results, receive feedback, discuss pathways forward, and align on operational next steps for wider implementation. Completing this objective will represent the successful creation of a new kind of steering committee in community-based healthcare—one that orients funding to community-identified need and community-driven strategy by creating communication channels between patients, providers, and investors that can be engaged well into the future.
Key to this meeting will be the PAC and LC’s development of community health and wellness measurements that reflect a definition of health shared by the PAC and LC. Creating a bi-directional communications channel grounded in dignity and culturally informed discourse will be key to driving toward the ratification meeting and will help ensure that this vital conversation is sustainable long beyond the timeline of this specific scope of work. Similarly, ensuring that measurements reflect the voice and needs of the community as well as the perspectives of the LC stakeholders will help lay the groundwork for ongoing investment opportunities; a common definition of health, a shared vision, and dialogue norms that reinforce the dignity and perspectives of everyone in these groups. This will help reorient regional funding paradigms away from a model that privileges results-only mindsets and instead emphasizes collaborative communal efforts that address barriers to and gaps in care, and support existing community strengths and capacities to reinforce both formal and informal supports that are already having a tremendous impact.
ref. Blue Shield of CA Fnd.pdf, June 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation; Research; Measurement; Stakeholders
Piloting a Flexible Mechanism for Reentry Engagement in Local Public Process
Roots staff has extensive experience collecting and reporting quantitative and qualitative data via multiple platforms and systems including Cityspan for our work under the City of Oakland’s Oakland Unite; our annual Office of Statewide Health Planning (OSHPD) report required as a state licensed clinic; as well as data for Healthcare for the Homeless reporting to the Federal Uniform Data Systems (UDS). We are enthusiastic about the ability to conduct real-time data searches within the County-designated data tracking system, and welcome the opportunity to enter our data in that system as well.
Core Whole Health Care Area:
Program: Reentry Engagement Framework (REF)
Themes, Keywords & Tags: Data; Evaluation
On the Frontlines of Communities in the U.S. (FOCUS)
Data collection will occur at each practice site per HealthSTATS customized workflow, to be delineated during the planning phase. The Project Liaison will be responsible for gathering and inputting the data into the Roots database on-site at each practice on a monthly basis. In practices that have an EHR with a full laboratory interface, lab results will be easily exported from the EHR and uploaded into the Roots HealthSTATS database. This will occur on a monthly basis, as coordinated between the Project Liaison and lead staff person appointed by the physician at each site. For those practices still in a paper environment, “tickler forms” will be placed in a designated location along with the lab results when available. The Project Liaison will gather this information on a monthly basis, entering it manually, directly into Roots’ database. For those who have an EHR that may not be fully integrated, a hybrid model will be utilized, including some data export and some manual entry. The exact method of coordinating with the staff and gathering the data will be customized to each setting so as to minimize disruption to the practices and maximize the use of technology.
Core Whole Health Care Area:
Program: HealthSTATS
Themes, Keywords & Tags: Data; Hepatitis C; HIV
Hepatitis C Screening and Treatment
Data collection to support RFP indicators. Roots prioritizes rigorous community-led research and evaluation; as such, we maintain the technology and staff support needed to collect and analyze data internally as well as for outside partners and funders. Program evaluation provides data-driven feedback on program implementation to continually improve the quality of education, services, and training. Through its community research department, Roots has considerable expertise in data collection (including field data collection), data entry and analysis, Electronic Health Records (EHR) abstraction, as well as data packaging and upload to various partners and funders. We also are accustomed to tracking data using systems provided to us by partners and funders, and to compiling client-level as well as aggregate data as required. For our own research and tracking purposes, we also develop customized databases when needed. In order to report on the outcomes as expected for this project, the majority of data will be abstracted from our electronic health record. This includes results of screening, laboratory test ordering and results, all clinical and RHN visits, referrals, and post-treatment surveillance. Case management notes, prescription and radiology orders and refills, and psychology encounter summaries are also entered into the shared medical record, enabling not only improved coordination of care, but data collection and analysis as well.
Core Whole Health Care Area:
Program: HealthSTATS
Themes, Keywords & Tags: Data; Evaluation; Hepatitis C; HIV
Hepatitis C Screening and Treatment
Root’s Quality Assurance and Improvement (QA/QI) Program is summarized in its policy that was approved by its Board in February 2012. Objectives of Roots’ QA/QI Committee and each of its subcommittees are designed to ensure that the provision of services is consistent with and sets a high benchmark for the standard of care in the community. Quality review activities include ongoing analyses of operational efficiency, policies, patient satisfaction, and data collection and interpretation. Roots’ Patient Experience Subcommittee is responsible for ensuring that satisfaction surveys are properly distributed and collected for the overall organization as well as specific programs such as the program proposed herein. This subcommittee reviews all patient satisfaction surveys to inform continuous quality improvement, and acts upon any issues that arise.
Roots’ Director of Research and Compliance is co-chair of the Data Quality Subcommittee of the QA/QI committee, and is responsible for ensuring data quality and accuracy across all Roots research and evaluation programs and projects. Internal data audits are performed by the Director of Research and Compliance on at least a quarterly basis and results are reported to the Data Quality Subcommittee. For newly-implemented programs, internal audits typically occur on at least a monthly basis until a determination is made that quarterly audits are appropriate. Any issues in data accuracy or quality are addressed immediately to ensure the integrity of the research or evaluation effort. Challenges in field data collection are addressed in team meetings in order to develop and implement strategies to overcome them. Roots internal systems or database-related issues are addressed in real-time and then taken to the Data Quality Subcommittee for discussion and action.
Our data collection will include percentage of Roots patients born 1945-65 who have ever had an HCV Ab test in their record; percentage of patients with chronic hepatitis C who have received lab-based staging tests; percentage of patients with chronic hepatitis C who have received prescriptions for hepatitis C treatment; percentage of patients who initiated HCV treatment that have completed the prescribed course of treatment; and percentage of patients with chronic hepatitis C who have received prescriptions for hepatitis C treatment and have achieved SVR12.
Core Whole Health Care Area:
Program: HealthSTATS
Themes, Keywords & Tags: Data; Evaluation; Hepatitis C; HIV; Research; Quality Assurance
West Oakland Street Outreach
Data collected in the field is documented in customized notebooks pre-printed with the fields required for data entry. These notebooks are submitted regularly to our data team who input the information into a local database for aggregate analysis. Roots prioritizes rigorous community-led research and evaluation; as such, we maintain the technology and staff support needed to collect and analyze data internally as well as for outside partners and funders. WAFC is accustomed to collecting demographic and sign-in information for their groups and events. Data collection tools will be designed for this project, customized to facilitate the gathering of information critical to achieving our outcomes (e.g., risk factors, life plan, etc.). Through daily check-ins and weekly meetings, the Program Manager will ensure that data collected in the field is gathered, input and analyzed, allowing for feedback and program revisions as needed based on both quantitative and qualitative data.
ref. OU_Narrative_FINAL_1020am.docx West Oakland Street Outreach Proposal, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: West Oakland’s Word Assembly of Churches (WAFC); Healthy Measures
Themes, Keywords & Tags: Data
General
Roots staff has extensive experience collecting and reporting quantitative and qualitative data via multiple platforms and systems including Cityspan for our work under the City of Oakland’s Oakland Unite; our annual Office of Statewide Health Planning (OSHPD) report required as a state licensed clinic; as well as data for healthcare for the homeless reporting to the Federal Uniform Data Systems (UDS). Roots prioritizes collecting data that measures progress towards deliverables, gathering client/patient/participant satisfaction surveys, and facilitating a “360 degree evaluation” that helps shape program revisions. Securing basic needs including food, stable shelter, safe environments, and social connectedness are necessary for effective disease self-management and avoidance of unnecessary health services utilization. Incorporated into our care/case management model are augmented health information systems to routinely screen and monitor higher risk clinic populations for basic needs and for measures of health capacity, engagement and function that depend on these needs. On an individual level, Navigators use results to pro-actively connect patients with community resources. For the target population in this scope of work, we will utilize our data systems to correlate baseline status and interventions with health and housing outcomes.
Data collection and evaluation takes place through our community research department, including field data collection, database design, data entry and analysis, Electronic Health Record abstraction, and rapid-cycle improvement based on data. We are accustomed to third-party evaluation and routinely meet/exceed deliverables. For this scope of work, we will collect patient demographics, engagement, services provided, benefits, employment and housing status, and any other metrics as required. We look forward to receiving training on, and utilizing the Alameda County’s Homeless Management Information System (HMIS) as required.
ref. PATH Narr_7_FINAL.docx, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
STOMP
Over one year we anticipate direct contact with at least 600 homeless individuals, with a minimum of 4,800 duplicated contacts. We will record encounter data as required for this scope of work – including for entry into HMIS – to meet program requirements, inform our own program revision, and for annual reporting to the Office of Statewide Health Planning as required of all CA Department of Healthcare Services licensed clinics.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Data; Evaluation
General
Roots staff has extensive experience collecting and reporting quantitative and qualitative data via multiple platforms and systems including Cityspan for our work under the City of Oakland’s Oakland Unite; our annual Office of Statewide Health Planning (OSHPD) report required as a state licensed clinic; as well as data for healthcare for the homeless reporting to the Federal Uniform Data Systems (UDS). Roots prioritizes collecting data that measures progress towards deliverables, as well as gathering client/patient/participant satisfaction surveys, facilitating a “360 degree evaluation” that helps shape program revisions. Data collection and evaluation takes place through our community research department, including field data collection, database design, data entry and analysis, Electronic Health Record abstraction, and rapid-cycle improvement based on data. We are accustomed to third-party evaluation and routinely meet/exceed deliverables. For this scope of work, we will collect patient demographics, engagement, services provided, supplies distributed, and any other metrics as required.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Data; Evaluation
General
Roots staff has extensive experience collecting and reporting quantitative and qualitative data via multiple platforms and systems including Cityspan for our work under the City of Oakland’s Oakland Unite; our annual Office of Statewide Health Planning (OSHPD) report required as a state licensed clinic; as well as data for Healthcare for the Homeless reporting to the Federal Uniform Data Systems (UDS). We are enthusiastic about the ability to conduct real-time data searches within the County-designated data tracking system, and welcome the opportunity to enter our data there as well.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
General
Roots prioritizes collecting data that measures progress towards deliverables, gathering client/patient/participant satisfaction surveys, and facilitating a “360 degree evaluation” that helps shape program revisions. Data collection and evaluation takes place through our community research department, including field data collection, database design, data entry and analysis, Electronic Health Record abstraction, and rapid-cycle improvement based on data. We are accustomed to third-party evaluation and routinely meet/exceed deliverables. We routinely capture the client information required under this scope of work: contact information, demographic information, unique identification information, justice involvement, mental health/substance use co-occurring disorder/diagnosis, housing status, and housing-related needs. We will continue to use intake and assessment protocols and navigated care plans as a means to track client success out of our East Oakland location – a site well-known to be friendly and efficient at serving this population. We will utilize the shared County-designated database for case notes and reporting in order ensure contract compliance and thoroughly track client outcomes. Additionally, our data mechanisms are nimble and prepared for oversight of the budgeted maximum of $5,000 per client. All of our data systems and processes include HIPAA protections with the ability to share protected health information where needed/permitted.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
Sobrante Park Narrative
We are proficient in adopting and/or creating data collection and program evaluation tools and strategies to match performance measures. We have extensive experience collecting quantitative and qualitative data that measure progress towards deliverables, gathering patient/participant satisfaction surveys, database design, data entry and analysis, Electronic Health Record (EHR) abstraction, and rapid-cycle improvement based on data. We are accustomed to third-party evaluation and routinely meet/exceed deliverables. For this scope of work, we will collect participant demographics and risk factors for developing SMI; evidence standards used; methods for high fidelity to practice; significant challenges, successes, lessons learned and examples. Below are the Process, Quality, and Impact Objectives, Measurements, and Tools we propose for this scope of work. We also appreciate the opportunity to consider additional outcomes and indicators, in collaboration with Health Care Services Agency, for evaluation and reporting.
ref. RFP#HCSA-900218_Sobrante Park_narrative.pdf, March 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
Sobrante Park Narrative
The Transitions Clinic Network (TCN) has a robust evaluation team consisting of researchers from UCSF and Yale University who collect, analyze, and report data on the implementation of medical care for previously incarcerated individuals across 13 clinical sites nationally. Roots hypothesizes that health outcomes, health utilization and cost savings will improve following the implementation of the proposed program. To assess this hypothesis, we proposed ongoing program evaluation in partnership with the Transitions Clinic Network (TCN). The purpose of this evaluation is to provide our clinic data-driven feedback on program implementation to continually improve the quality of care provided to our clients. Our collaboration with TCN will include analysis and reporting of: (1) Access to health care, health promotion and target population well-being, (2) Primary care and behavioral health services (3) Emergency department utilization, hospitalizations, and crisis health care services, (4) Recidivism, (5) Innovations in the care of formerly incarcerated clients, and (6) Financial data related to operations and cost savings. In addition to TCN’s contribution to the evaluation of the program, Roots also recognizes that the relationship with Transitions will support service delivery through continuous quality improvement.
Core Whole Health Care Area:
Program: Healthy Measures
Themes, Keywords & Tags: Data; Evaluation; Partnerships
Service Area Competition
Our patients comprise a high health needs population, the majority of whom live with chronic illnesses, and Roots ensures a seamless continuum of care by collaborating with local public agencies and community-based organizations, such as substance abuse facilities, homeless shelters, transitional housing, and correctional facilities. Many of our patients and/or their family members have been previously incarcerated, are marginally housed, and have been affected by ongoing violence and unsafe living conditions, challenges that must be addressed to ensure patients identify Roots as their medical home. Our staff and clinicians are trained to provide culturally competent, trauma-informed care and the clinic is designed to create an environment that allows patients to experience healing from the point at which they first make contact with front-end staff and throughout the process by which they can establish an ongoing relationship with a primary care provider. Follow-up calls are made by a case manager following the appointment, and at time intervals established by the provider, and case conferences between medical professionals are held on a regular basis. All of these arrangements ensure a continuum of care for our target population.
Roots patients who require hospitalization are referred to Alameda County Medical Center or Sutter East Bay Hospitals. Upon discharge, staff coordinates with the patients to facilitate their return to Roots for follow-up care, and utilize the transfer/referral forms to ensure patients receive timely follow-up. Roots may also order and refer patients for radiology and laboratory testing to these hospitals which have sites within the clinic service area. Roots maintains a strong working relationship with hospitalist staff for admission and discharge planning.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Tracking; Cultural Competency; Hospitals
AB 109 Reentry and SSI Advocacy Population Case and Care Management Services
Our HealthyMeasures Initiative, based on the EBP of care and case management at the critical transition from incarceration to community, is being implemented with strict fidelity to the program model and close internal and external evaluation. We have obtained Internal Review Board approval from Yale University, and work with a robust evaluation team consisting of researchers from UCSF and Yale University. We collect and enter intake and follow up data into a centralized database for analysis and review. We are also experienced in designing, implementing, testing and evaluating program models when an EBP cannot be identified for a problem we are attempting to address, or an outcome we hope to achieve. In cases where there is no or low-quality data and an inadequate knowledge base in the field, along with a pressing need for an intervention in our community, we have designed and implemented programs that incorporate best practices, while drawing from local landscape analyses, focus groups or preliminary data, and our own expertise. A good example of this approach is our wage subsidy workforce pilot that employs formerly incarcerated individuals and those receiving General Assistance and thus far, has demonstrated improved health outcomes as a result of the intervention. This experience will help us effectively implement the care/case management model described in this proposal, in which pilot methodology based on an already successful case management model will incorporate data collection and data-driven feedback that inform optimum program design over the long term.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
AB 109 Reentry and SSI Advocacy Population Case and Care Management Services
Through its community research department, Roots has considerable expertise in data collection (including field data collection), data entry and analysis, Electronic Health Records (EHR) abstraction, as well as data packaging and upload to various partners and funders. We utilize a web-based EHR system to document all client encounters, and utilize this where possible to abstract diagnosis, demographic, utilization, and encounter data for analysis. We also are accustomed to tracking data using systems provided to us by partners and funders, and to compiling patient-level as well as aggregate data as required. For our own research and tracking purposes, we also develop customized databases when needed, or utilize solutions such as Salesforce and NVivo.
Roots has direct access, granted by Alameda County Social Services Agency (SSA), to the Benefits CalWIN (BCW) system through which we verify eligibility for multiple entitlement programs and submit the Medi-Cal, CalFresh and CalWORKS applications directly. This access was originally granted when Alameda County received funding from the State of California to enroll the remaining uninsured into Medi-Cal. Roots was one of the CBOs selected to reach the reentry and homeless populations to educate, screen for eligibility and enroll into benefits. During the contract period, we were also required to enter data collected in the field into an internal SSA database (CAMOC) and demonstrated a high degree of accuracy and completion. While the State funding has ended, SSA is allowing Roots continued, uninterrupted access to the BCW system, and we look forward to continuing to enroll otherwise hard-to-reach populations into the benefits to which they are entitled.
Although we do not currently utilize BHCS databases, we are confident in the capacity of our provider, managerial and research staff to learn and utilize new databases as needed. We currently upload data on a monthly basis to multiple sources such as the Alameda County Public Health Department, Healthcare for the Homeless, and private funders who require patient-level as well as aggregate data. In particular, we welcome the opportunity to utilize a system that enables tracking of linkage to care, housing, food security and income information. We also look forward to developing formal relationships with legal/SSI advocates to better support clients and track outcomes.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation; Partnership
City County Neighborhood Initiative Sobrante Park Resident Action Council
We hold partners to the same standards and quality outcomes to which we hold ourselves. Roots prioritizes rigorous research and evaluation, and maintains the technology and staff support needed to collect and analyze data internally and for outside partners and funders. Through its research department, Roots has considerable expertise in data collection, entry and analysis, proficiency using data and sound documentation to improve our programs and overall impact. Community indicators drive our efforts to augment programming and redistribute resources where they are most needed. Assessing the quality and efficiency of our services helps us better understand the impact and quality of life improvements resulting from services our clients and communities receive. We look forward to partnering with the County of Alameda and the Sobrante Park Resident Action Council to empower and secure a thriving community in Sobrante Park.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation; Partnerships, Sobrante Park
Roots: Roles Outside of Traditional Systems
DOH data is collected at the first point of contact at any one of these sites in the field, or at the first primary care visit, using a paper survey form which may be self-administered, or administered by a Roots Navigator. This intake questionnaire is composed of adaptations from several sources, including the IOM Committee on Social and Behavioral Determinants in EHRs and the Roots to Health Survey. Where available we have used survey questions that have been used/validated in national statistical surveys. Your funding will help us meet our goal to standardize our SDOH data collection and use across all Roots diverse programs and services, including uniform assessment of SDOH for primary care patients who are not case managed; periodic longitudinal assessment of SDOH of all clients; collecting data electronically (e.g. via the EHR patient portal, tablets, or computer kiosks); and to clearly delineate care team roles regarding assessing and acting upon the SDOH data we collect, with a special focus on the physician.
ref. CCI_ROOTSApplication_FINAL.pdf ROOTS: Roles Outside Of Traditional Systems, June 2017
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Collection; SDOH
Roots: Roles Outside of Traditional Systems
Roots uses SDOH data collected through client intake in multiple ways: on an individual level, at the clinic/organization level, and at the community level. SDOH data is first used to help the patient/client access and navigate connections to social, economic, and behavioral resources and services. Through “360 degree assessments,” the care team is sensitized to social determinants, resource referrals, individualized problem-solving, and follow up monitoring. In addition, SDOH data collection and preliminary analyses have guided Roots’ development of several in-house services to respond to SDOH, including health coaching, social services navigation, education and employment support, legal assistance and counseling. In response to SDOH assessment, Roots Navigators enroll clients into benefits for which they are eligible, remove barriers to employment (including legal barriers), assess for possible SSI-eligibility, and prepare non-disabled clients for employment. Care and case management includes responding to housing, transportation and food needs; assisting clients to comply with conditions of probation/the court; support to achieve educational, employment and other goals set forth in their action plan; and addressing legal barriers to employment, including felony reclassification (through Prop 47/clean slate), DMV holds (via amnesty or appeal to County Collections), arrears in child support, restitution, and outstanding warrants.
ref. CCI_ROOTSApplication_FINAL.pdf ROOTS: Roles Outside Of Traditional Systems, June 2017
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Collection; SDOH
Roots: Roles Outside of Traditional Systems
Routine assessment and maintenance of SDOH status is time-consuming. To be sustainable, data collection practices need to be efficient, utilize patients and non-clinical staff, avoid redundancy, and leverage technology. While efforts to develop nationally standardized tools are emerging, they may not serve population-specific needs and priorities. Roots has laid a solid foundation for the work we are proposing, given our exploration and experimentation in customizing SDOH data collection for the needs of the high risk populations we serve, including ways to optimize collection of SDOH data given constraints such as current EHR technology and HIPAA requirements. While services to our clients are rendered in a variety of settings, we recognize that it is critically important to update and share encounters and information with the care management team in real time. Often, fieldwork at homeless encampments, the streets or jail depend on paper charting as the safest, most expedient, or only option; however, for this project, we have prioritized adapting and scaling our data collection methods and workflows to support utilization of a unified EHR by all members of the care team, maximizing information sharing and wraparound support in real time. Roots would benefit from participating in a learning community as well as from technical expertise in optimizing its approach.
ref. CCI_ROOTSApplication_FINAL.pdf ROOTS: Roles Outside Of Traditional Systems, June 2017
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Collection; SDOH; Assessments, HIPAA
Systems for Action: Systems and Services Research to Build a Culture of Health
This research project will require linkage of data from multiple sources. Roots’ Whole Health Record will be used as a starting point. Roots hasprioritized adapting and scaling data collection methods and workflows to support utilization of a unified electronic health record (EHR) by all members of the care team in real time, despite where care is rendered. Regardless of the services used, Roots conducts a comprehensive medical, social, and behavioral assessment for each new client, which included assessment of social determinants. Data from the intake form are both used to populate the medical, behavioral and social history and create a “social” problem list utilizing ICD-10 codes corresponding to key social determinants (e.g., homelessness, income poverty, social isolation). Raw data from the intake is also retained in a database to establish a baseline and to allow for cross-sectional and prospective analyses.Prospectively, Navigators record periodic problem assessments and plans in a structured but free-text format both in case management forms and additionally document these encounters in the EHR. While these approaches have been adequate for individual care management and for tracking work outputs within distinct programs, they have not allowed thestudy the impacts of our holistic care model as a integrated system.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data
Systems for Action: Systems and Services Research to Build a Culture of Health
We will initially help implement a new database using SQL, which will allow for the collection and monitoring of social determinants of health (SDOH) data that has proven difficult to monitor using the EHR alone. This system will allow community health workers in various areas of the organization (reentry, homeless, employment, education) to input and view data within a unified system. The system will also be designed to pull information on medical and behavioral visits -including diagnoses and medications -allowing for better coordination of care. The new database will be populated at the outset with all of the spreadsheets and flat databases we currently utilize, as well as the electronic health record data we will pull in. Therefore, it will not only serve as the platform for a much-improved workflow, but will also provide the capacity to do robust analysis retrospectively and going forward. Wewill include Alameda Alliance (managed care Medi-Cal payer for the majority of our patients) data (see letters of support) to correlate utilization data with collected data. Ideally we could further incorporate WIC/General Assistance/County hospital (emergency/psych emergency departments) data as well as incarceration data to understand fully the influence of these programs on the utilization of the medical, social services and criminal justice systems. We will use this experience to inform the creation of our database at the Santa Clara site (see LOS)
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Partnerships; SDOH
First5 Emerging Issues
Roots prioritizes rigorous research and evaluation, and maintains the technology and staff support needed to collect and analyze data internally and for outside partners and funders. Through its research department, Roots has considerable expertise in data collection, entry and analysis, and Electronic Health Records (EHR) abstraction. Roots Health Navigators enter their encounter notes into our electronic health record, enabling improved care coordination and streamlined data analysis. Our needs and strength-based intake establishes critical baseline information such as recidivism risk, food security, and overall stability. We track Medi-Cal enrollment, referrals to external partners, emergency department and hospital utilization, and recidivism data. Patient demographics, case management notes, behavioral interventions, medical encounters, medication, laboratory and other patient data are contained within the EHR, ensuring our ability to analyze patient-specific as well as population data, correlating our interventions to outcomes. Related to 0-5 year olds in particular, Roots will track and collect immunization and breastfeeding, length of gestation, birth weight, pregnancy related complications (i.e. diabetes, anemia, and obesity), etc.
All the data will be aggregated on an ongoing basis to create a picture of the population served, and to identify trends and/or issues that may inform program revision or systems change advocacy.
ref. First 5 Emerging Issues Concept Paper Submission Form_FINAL.doc
Core Whole Health Care Area:
Program: Family 1st, First5
Themes, Keywords & Tags: Data; Evaluation; Research
First5 Emerging Issues
Roots Community Health Center currently utilizes an Electronic Health Record to record patient visit information, as well as paper instruments to collect vital data across multiple support service/wraparound programs. Patient Health Navigators and outreach workers collect patient data in the field as well as at the clinic utilizing paper instruments. Data regarding social determinants of health (e.g., food security, housing, etc.) is then manually abstracted and entered utilizing flat files (such as Excel) that limit robust data analysis across programs. In addition, Electronic Health Record data must be downloaded and “bumped” against these files in order to integrate information and learning at the patient level as well as the population level.
Roots Community Health Center seeks the infrastructure for a robust network and centralized, secure, online, shareable, non-corruptible and HIPAA compliant database which will: a. facilitate transparency and real-time sharing of social determinants of health (SDOH) information and responsive actions, reinforcing a team-based approach without relying on/waiting for case conferences b. allow for integration of SDOH, intervention, and outcomes data which will support ongoing evaluation of our team based, multi-disciplinary approach c. integrate clinical and SDOH interventions into care plans to impact health and wellness outcomes in our population d. enable our team to input information accurately and in a timely fashion – avoiding duplications and data entry delays e. provide intra-operability across different sites and across different departments within a given site over a secured network infrastructure f. facilitate ability to extract reports, stats and analytics for internal program revisions as well as data sharing with partners g. enable prompt identification of opportunities to scale up or tailor our operations (adding more navigators, integrating with additional sites, facilities etc.) h. integrate information from our wraparound services/social determinants of health and our EHR software i. consolidate of information into a central, more secure location, thereby decreasing the risk of data breach.
The proposed project would enable us to evaluate and procure the ideal technology for increasing inter- and intra-agency collaboration. Building a customized database (e.g. via Epic build or interoperable SQL database) will allow us to improve communication among patient care teams as well as between participating agencies; assist with population profiling and risk stratification; and enable integrated program evaluation as well as timely program revision.
ref. Funding Request Form TECHNOLOGY AND SERVICE-RELATED FACILITY PROJECT FUNDING REQUEST
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Growth; Funding; Technology; SDOG; Electronic Health Records
General
Roots’ use of data and evaluation as drivers of success. Roots has expertise collecting and reporting quantitative and qualitative data via multiple platforms and systems, including our Electronic Health Record, program-specific databases, and formats required as a state licensed clinic and a Healthcare for the Homeless provider. Roots prioritizes data collection that measures progress towards deliverables, gathering client satisfaction surveys, and facilitating a 360 degree evaluation that helps shape program revisions. Data is regularly reviewed by program and quality improvement staff to continuously “course correct,” accelerating the rate of process and outcome improvement.
ref. GG_accepted
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
General
Dr. Aboelata regards research and evaluation indispensable for shaping services and soliciting resources. Accordingly, she spearheaded the interviews of 33 African American medical practices and collected surveys from 23 additional providers to produce the 2013 report, Realities of Medical Practices: Serving African Americans in East Oakland. The report provides unprecedented information concerning the status of health services as well as the demographics and needs of providers and their patient populations. The report’s findings prompted Dr. Aboelata to found the Community Rooted Provider Coalition, a professional association of 18 health care providers committed to expanding health access for low-income communities of color. The report is available here: http://rootsclinic.org/wp-content/uploads/2014/06/Realities-of-Medical-Practices-Serving-African-Americans-in-East-Oakland.pdf
ref. Irvine Leadership Nomination 2017 – FINAL, 2017
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
MAT Program
Roots will implement an MAT model that will provide medication and psychosocial treatment for patients and clients with OUD and tobacco use. Studies show that MAT in primary care can yield similarly successful results to MAT provided in specialty care settings, and that OUD is a treatable condition that can be managed in an outpatient health care practice with resources and expertise. The data are clear: Many patients who might normally not seek or continue MAT treatment as part of a stand-alone MAT clinic or substance abuse program are more likely to obtain help in the primary care clinic setting because of familiarity, lack of stigma and their ability to simultaneously address other health concerns.
Roots will increase the number of participating MDs who obtain the DATA waiver needed to prescribe buprenorphine. Participating staff, including primary care providers (MDs and NPs), nurses (RN), medical assistants, navigators and licensed behaviorists, will receive appropriate training and certification for MAT treatment and counseling, as well as for naloxone use, training and distribution, and rescue breathing. Physicians, nurses and navigators will screen and provide brief intervention for substance use disorders, tobacco use and depression for patients and clients who utilize Roots clinics and other programs. Staff will use appropriate SBIRT tools, including but not limited to the PHQ-9, DAST, and AUDIT. Staff will present patients and clients with recovery options specific to their particular issue. Additionally, all participants will receive health education on OUD, Tobacco, HIV/AIDS, hepatitis, STD prevention and other related topics. Participants will also receive care coordination/navigation services and be provided risk reduction options (e.g., condoms, PrEP/PEP) and psycho-social counseling or psychotherapy. Those testing positive for HIV/AIDS will be referred to our local health departments and partner agencies to ensure they receive Ryan White and other resources available to them. Roots’ facilities are tobacco-free and we partner with local county Tobacco Control Programs, BREATHE California and American Lung Association to offer both staff and clients tobacco education, cessation classes, nicotine patches and gum, to promote tobacco reduction and eventual abstinence. Roots will develop a MOU with these agencies to develop and implement tobacco education and cessation services specific to our OUD patients. Participants with severe mental illness will be referred to Ujima Adult and Family Services for behavioral health services.
Patients and clients who screen positive for OUD will be diagnosed based on DSM-5 diagnostic criteria and offered MAT services. Additionally, OUD patients with co-occurring mental health issues and/or those who screen positive for alcohol or other drug addiction will receive Roots MAT services along with other appropriate services from our partner agencies. Roots will refer all clients seeking recovery who are not eligible for MAT to the appropriate recovery services and will encourage patients eligible for other appropriate health systems and treatment programs (e.g., Veterans Administration or senior services) to avail themselves of those programs.
ref. MAT FOA_07082018, July 2018
Core Whole Health Care Area:
Program: MAT Program
Themes, Keywords & Tags: Data; Opiod, Tobacco, Overdose, Psychosocial
Medi-Cal and CalFresh Renewal Assistance and CalFresh Enrollment Porject
In 2014, Roots Community Health Center contracted with ACSSA to provide Medi-Cal and CalFresh outreach and enrollment specifically to “hard to reach” populations. Roots was selected to reach all three priority groups – the reentry, homeless and LEP populations – to educate, screen for eligibility and enroll into benefits. Roots conducted 249 distinct outreach activities (e.g., health fairs, block parties, resource fairs), and performed routine outreach activities at a total of 119 locations (e.g., neighborhood hangouts, CBOs, local businesses, etc.). During the contract period, Roots was required to enter data collected in the field into an SSA-created database (CAMOC) and consistently demonstrated a high degree of accuracy and completion. In order to fulfill data collection requirements for ACSSA and to facilitate data-driven process improvements, we created tools for real-time collection of relevant information which was entered and analyzed by our data specialist on an ongoing basis. Outcomes were reviewed at weekly team meetings in order to rapidly refine our outreach strategies, resulting in increasingly effective outreach and enrollment activity over the contract period.
Roots demonstrated its commitment to integrating Medi-Cal and CalFresh enrollment into our organization’s daily workflow by training a total of 16 staff members to perform enrollment utilizing Benefits CalWin. As a result, benefits enrollment is performed by “embedded” frontline healthcare workers including Medical Assistants, Medical Receptionists, and Community Health Outreach Workers/Health Navigators, in addition to dedicated Outreach and Enrollment workers. These embedded staff members also integrate outreach strategies into their work in the community and participate in outreach at numerous health fairs and other events.
During the 11-month performance period, Roots screened 3,980 individuals for Medi-Cal / CalFresh eligibility and submitted a total of 749 applications via the Benefits CalWin system. While many of these applications remain pending, currently 474 Medi-Cal applications and 430 CalFresh applications have a legitimate CalWin status. Thus far 306 have been approved for Medi-Cal and 221 have been approved for CalFresh. Although the contract ended 60 days ago, we continue to provide assistance to these individuals to ensure that they receive their benefits. ACSSA’s review of Roots’ satisfaction surveys reveals that 97% of our clients report moderate to high levels of satisfaction with Roots’ application assistance, and 100% report increased knowledge of how to get or maintain benefits.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Medi-Cal; CalFresh; Evaluation; Partnerships
Medi-Cal and CalFresh Renewal Assistance and CalFresh Enrollment Porject
Roots is well positioned to reach proposed target numbers. We exceeded key target outcomes in our MCOE contract with ACSSA last year, and we are building on our expertise developed since our inception in enrolling less accessible individuals through targeted outreach and demonstrated cultural competence by all staff who participate in this effort. We are adept at refining program strategies quickly when unanticipated challenges surface. We have strong working relationships with ACSSA staff and will collaborate to create efficient, workable tools that strengthen data collection and facilitate success in meeting program objectives.
Roots currently carries out multiple contracts in Alameda County that require reporting in accordance with results-based accountability standards. We are proficient in adopting and/or creating data collection and program evaluation tools and strategies to match performance measures. In partnership with ACSSA, Roots will develop specific targeted outcomes in accordance with ACSSA’s performance measures for this project, and will gather the data required to demonstrate our progress towards these targets throughout the contract period.
Roots evaluation tools are developed by the respective program manager in conjunction with the data department, and are reviewed by our Director of Research and Compliance to ensure that they accurately capture the intended information. The Outreach and Enrollment Supervisor will work with ACSSA, Roots data department and staff to define targeted outcomes, and will measure staff performance against the agreed-upon targets, monitoring productivity and outcomes, and addressing variances. Roots will further “drill down” these targets to develop specific goals for each Healthy Connections 2.0 staff member. Healthy Connections 2.0 Eligibility and Enrollment Specialists will be required to maintain logs of their encounters, activities, work production and travel.
Roots employs a HIPAA (Health Information Portability and Accountability Act)-compliant online tracking tool used for surveys and other research and evaluation efforts. The online database and the ability for supervisors to view them on the “back end” in real time, assists in time tracking, monitoring of resources, and ensuring data fidelity. For field data collection, paper tracking tools are also created to facilitate documentation of activities when Wi-Fi or computer access is limited or impractical.
Quantitative data such as number of individuals contacted via outreach, method of communication, location of assistance, and number/type of completed applications, will be collected in “real time” via paper and/or online tracking tools. This data is transmitted to our data specialist who produces internal reports on at least a weekly basis. This data is then (1) discussed in team meetings to drive program/process improvement, and (2) aggregated to report monthly to ACSSA. At team meetings, qualitative aspects of program implementation, including strategies used to contact and connect with individuals on the SSA-provided list, are discussed and recorded to inform both process improvement and the narrative reports that will be provided to ACSSA.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Data; Evaluation
On the Frontlines of Communities in the U.S. (FOCUS)
Roots Clinic leadership provides research and advocacy, are thought leaders in the area of health disparities in communities of color and has built a strong network of physicians, policymakers, academic and research partners to support its ability to translate research into practice and policy change in accordance with our overarching goals. In addition to disseminating our findings to our provider Alliance, including those not directly involved in this study, we plan to publish our findings in a comprehensive report, including recommendations and best practices. This publication will also be widely distributed via our existing relationships with Alameda County Public Health Department and Alameda County Social Services Agency, and we will seek other opportunities to present this material such as national, regional and local conferences and symposia. In addition, Roots will disseminate a press release as well as opinion/editorial pieces as appropriate to the findings of the study.
Core Whole Health Care Area:
Program: HealthSTATS
Themes, Keywords & Tags: Research; HIV; Hepatitis C; Advocacy
Exploring & Developing Career Ladders in Manufacturing & STEM or Formerly Incarcerated Women
We will develop a white paper on manufacturing and STEM as potential pipelines for women who are experiencing barriers to employment, describing career ladders and access to those career ladders for formerly incarcerated women. We will also draw from the experiences and lessons learned in order to develop outreach and education strategies for these women, including the challenges and opportunities specific to women participating in the manufacturing workplace.
We will conduct industry research, an updated scan of the local landscape, and specific exploration of advanced manufacturing and engineering as viable pipeline opportunities for women with high barriers to entering the workforce. Our curriculum development and evaluation components will be comprised of three focus group of reentry women who have graduated from and/or are participating in workforce and empowerment programming at Roots (OUR Project, Emancipators, Women’s Empowerment Pilot, etc.), with the goals of identifying their unique needs, aspirations, and their views on the ideal components of women’s workforce programming. Subsequent to each apprenticeship cohort, focus groups will assess the impact of exposure to manufacturing, including advanced manufacturing and higher education, including STEM.
In addition to our participation in the Innovations in Reentry Learning Conference, we will aim to present our findings in at least one venue to be determined in collaboration with stakeholders as our results are formulated. One example could be presenting findings on these pathways to Probation Officers who work with reentry women, or presenting general information at a public meeting.
Core Whole Health Care Area:
Program:
Themes, Keywords & Tags: Evaluation; Publication
ACOCAP
Roots staff has extensive experience collecting quantitative and qualitative data that measures progress towards deliverables, and gathering client/patient/participant satisfaction surveys, facilitating a “360 degree evaluation” that helps shape program revisions. Through its community research department, Roots has considerable expertise in data collection (including field data collection), database design, data entry and analysis, Electronic Health Record abstraction, and rapid-cycle improvement based on data. We are accustomed to third-party evaluation and routinely meet/exceed deliverables. For this scope of work, we will collect: client demographics, results of screening against HHS federal poverty guidelines; barriers/needs; training milestones; employment data, client satisfaction, number banked, number enrolled in eligible benefits including Medi-Cal, CalFresh, CalWorks, Earned Income Tax Credit (EITC), etc. Ongoing monitoring will be used to evaluate progress regarding barriers removed and long-term employment outcomes. See infographic attached regarding Emancipators program progress to date.
ref. ACOCAP_RFP_Response.pdf, 2017-2019 – Dan Abrahamson
Core Whole Health Care Area: Navigation
Program: Emancipators Initiative
Themes, Keywords & Tags: Evaluation
Piloting a Flexible Mechanism for Reentry Engagement in Local Public Process
Roots implements and continues to refine best practices that are consistent with the evidence base for recidivism prevention and prevention/early intervention of mental illness. Some of these practices include:
- Prosocial Engagement. Roots’ theory of change states that “empowering marginalized individuals with skills that enable them to engage positively with themselves (self-care and self-advocacy) as well as their communities (pro-social participation) in the context of wraparound services delivered in a safe and therapeutic environment will improve morale and self-efficacy, ensure successful integration/reintegration into society, and reduce the risk of recidivism.” Consistent with this belief, we will facilitate pro-social engagement through this scope of work.
- Shared lived experience. Roots navigators and life coaches – the support structure in place for formerly incarcerated individuals in need of services – share similar life experiences and are connected to the same communities as their clients. – Comprehensive Assessment.
- Clients receive a 360-degree assessment of social, economic, behavioral and physical health conditions to proactively identify needs and barriers to receiving services, as well as strengths and protective factors. This assists in determining stage of readiness to embark on civic engagement activities, which is best done when the individual is out of crisis and is secure in most domains of life.
Core Whole Health Care Area:
Program: Reentry Engagement Framework (REF)
Themes, Keywords & Tags: Evaluation; Assessments; Theory of Change
West Oakland Street Outreach
Roots is a member of a nationwide network of clinical sites providing reentry care, which provides a robust evaluation team consisting of researchers from UCSF and Yale who evaluate recidivism risk, client stabilization and other key domains. Early evaluative feedback indicates high levels of client adherence/engagement with our services, despite high recidivism risk. We are accustomed to third-party evaluation and routinely meet/exceed deliverables.
ref. OU_Narrative_FINAL_1020am.docx West Oakland Street Outreach Proposal, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: Healthy Measures; West Oakland’s Word Assembly a Family of Churches (WAFC)
Themes, Keywords & Tags: Evaluation
West Oakland Street Outreach
Through its community research department, Roots has considerable expertise in field data collection, database design, data entry and analysis, EHR abstraction, and rapid-cycle improvement based on data trends. Customized reports based on the needs of Program Directors are produced for review at program staff meetings, helping to inform strategic program revisions and identify needed resources. For example, this manner of data collection and analysis aided in the success of our program enrolling hard to reach (re-entry and homeless) individuals into Medi-Cal. Through outcomes data reviewed at weekly meetings, we revised our strategies for street outreach, doubling enrollment within 3 months to an average of 100 enrollments/month.
ref. OU_Narrative_FINAL_1020am.docx West Oakland Street Outreach Proposal, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: Healthy Measures; West Oakland’s Word Assembly a Family of Churches (WAFC)
Themes, Keywords & Tags: Evaluation
PATH
Roots demonstrated its capacity and expertise in successful street outreach to homeless and reentry individuals in 2014-15 via a partnership with Alameda County Social Services Agency to conduct Medi-Cal and CalFresh enrollment specifically focused on hard to reach populations. Outreach workers intersected with individuals in the streets, encampments and jails, educating and building the value of obtaining Medi-Cal and CalFresh, and processing new applications for these benefits. During an 11-month performance period, Roots screened 3,980 marginalized individuals for Medi-Cal/CalFresh eligibility and submitted a total of 749 applications via the Benefits CalWin system; the majority of these applications were conducted in the streets. ACSSA’s review of Roots’ satisfaction surveys revealed that 97% of our clients report moderate to high levels of satisfaction with Roots’ application assistance, and 100% reported increased knowledge about how to get or maintain benefits. Our ability to engage marginalized individuals with the bureaucratic process related to Medi-Cal/CalFresh reflects the skill of our outreach workers in providing education and building the value of an important basic stabilizer: public benefits.
ref. PATH Strategy 8 Narr_FINAL, April 2018 – Dan Abrahamson
Core Whole Health Care Area:
Program: STOMP
Themes, Keywords & Tags: Evaluation