Upstreamists in Action: Upstreamists are changemakers pioneering practices that improve health by blending medical and social care. In this series of profiles, HealthBegins highlights some of these bold leaders and their innovations, in settings large and small. Their stories show us that the journey upstream is not only necessary — it’s possible.
Social needs: Housing; Transportation; Integrated behavioral health
Patient population: Nearly 15,000 patients in rural Sonoma County, 85% of them living in poverty
Strategies: A dedicated homeless-services site; a new social-determinants questionnaire for patients; upstream innovation committees that meet regularly; team-based care; robust data collection and monitoring
How it’s paid for: Primarily by prioritizing the FQHC’s regular budget to support this work, such as by hiring community health workers, plus grants to develop the case-management model
Advice for other upstreamists:
“It’s so easy to get discouraged. There has to be a personal connection. I deal with data and staff, and if I’m stuck looking at numbers all day, I have to humanize it somehow for myself. When I display data I try to make sure we humanize it as much as possible — putting a story behind it, using pictures.”
Ms. Valley’s story:
Dana Valley first grasped the idea that housing is health care as a beginning medical assistant at West County Health Centers 13 years ago. During the hot summers in rural Sonoma County’s oak-studded hills and redwood forests, homeless patients would come in reeking so badly that Valley had to wash them down before a provider could see them. There were no public showers nearby. “No human should ever have to walk around like that,” she thought.
Valley remembers filing the notes for one patient in particular and seeing the provider’s notation that the man had a skin condition because he had no access to a shower. “I was 24 years old, and this was the closest to homelessness that I’d ever been, and I’m thinking: Why is this patient coming to see a doctor? He needs a shower,” she recalls. “It clicked in my head that people need their basic needs met.”
In 2006, she had the chance to start building a system to address those needs. As West County Health Centers opened a new clinic in Sebastopol, leaders took it as a chance to reimagine primary care and extend it beyond episodic urgent care. Or, as Chief Medical Officer Jason Cunningham puts it, “unloading the concept that the provider is the driver of everything.”
The new clinic was built on a team-based model, and Valley worked with Cunningham and other colleagues to expand the role of medical assistant. Because team members have more opportunity than solo providers to build a human relationship with patients, they can get at elements of health that reach beyond clinic walls, she says. “It’s the stuff that our staff has wanted permission to address.”
From the Sebastopol experiment sprang countless more innovations in which Valley has had a guiding hand. The health centers built a major data-tracking effort into the team-based model, collecting data on individual patients and populations and putting it at providers’ fingertips.
The health centers’ standard patient questions, which began as mostly clinical and demographic, now encompass food access and housing risk. Providers capture that data in the course of conversation in exam rooms. And, while West County is required to ask about homelessness as a Federally Qualified Health Center, the staff is now updating that information regularly and feeding it into a data dashboard of all homeless patients to guide their work.
It became clear, says Cunningham, that “if we’re going to look at improving health for that community, and we’re not addressing housing risk, then we’re not really doing anything.”
Valley herself has evolved into West County’s chief data wrangler. She’s working to strengthen data display, overlaying information on social determinants of health to provide a bigger picture of why patients are thriving or struggling. Information from public data sets, including statistics on housing and crime, are fed into the data maps, too.
To complete the picture, the health centers have developed a patient questionnaire on social determinants of health that covers housing, transportation, food insecurity, social support, and racism, along with more conventional subjects such as exercise, stress, and domestic violence. Nearly 700 patients have completed the survey so far.
View West County Health Centers’ complete patient questionnaire on the social determinants of health.
One primary care clinic, in the riverside hamlet of Guerneville, has fully woven the questionnaire into its practice. As the tool is implemented across more sites, Valley and her colleagues will use it both to monitor individual patient needs and to plan strategically for improving the health of whole populations.
“We’re really good at using data to show what we have done,” says Valley. “But now to use data to explore and investigate where we should go, that’s really exciting.”
The way in which the new questionnaire was developed reveals how deliberately upstream work is built into West County’s culture. A staff committee called “The Upstream Champions” piloted the survey and identified potential solutions to its challenges: Who asks these questions? When? How? And how do we know what to do with the answers?
“The Upstream Champions” group, which meets quarterly, was inspired by a presentation from HealthBegins’ Rishi Manchanda. It includes community health workers, nurses, an access coordinator, a board member, members of the homelessness and addiction services teams, and representatives from the teen clinic and other sites. Their key tasks are to tackle the logistics of implementation and to cheerlead—to infuse their workplaces with the values of upstream care. A second social-determinants-of-health group, made up of Valley, Cunningham, and other administrators, meets monthly to address the funding and staffing that support that work.
What will West County staff do with all that new patient information? The health centers’ expanding role with the Guerneville homeless community provides a glimpse of the system to come.
A program director, behavioral health specialist, and nurse work out of a trailer beside the Russian River Health Center in Guerneville, providing services for the homeless. The nearby veterans hall opened its showers to the homeless — just the thing that Valley saw they needed so many years ago — so sometimes the health workers walk over to talk with visitors there, checking in on patients, meeting them where they are. The care team also ventures into the literal woods, into the redwood groves where their patients camp, to provide wound care, blood pressure checks, and other basic services.
Up next: transportation. Beset by no-shows, the health centers have secured a HitchHealth grant to experiment with sponsoring Lyft rides for patients who lack reliable transit. If the strategy works, it will help patients receive the consistent care they need and could potentially pay for itself, preventing the health centers from losing money on missed appointments.
In the midst of all the hopeful innovation, challenges remain. “There’s a lot of change fatigue for staff,” Valley says. “There’s also a rub still between volume versus value. We’re still having to meet productivity, and yet while we’re doing that we have to meet high quality and value, and they’re conflicting. … To keep people excited and engaged and willing to stay is hard, because this is hard, hard work. We’re not dealing with health care, we’re dealing with people’s lives.”
The increasing visibility of the homeless in Guerneville also has stirred up public concern. At a recent town hall meeting, some residents strongly objected to a county plan to expand services for the homeless there further.
Yet all around Valley are signs that the work is worth sustaining. There are the showers, at last. There are the patients who see a counselor instantly instead of being given an appointment for a later date when they’ll never manage to return. “At meetings I’m hearing people, for the first time, talking about housing being health care,” she says. And that’s a little revolution.
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