We could have a lot more traction and our solutions could be more effective, if we actually slowed down and listened to the people we aim to serve.
Mark Thomas, chaplain at Providence Hood River Memorial Hospital
Columbia Gorge Region, Oregon and Washington
2016 RWJF Culture of Health Prize Winner
Hearing From Everyone on Health
With Mount Adams in Washington to the north and Mount Hood in Oregon to the south, the windy Columbia River Gorge boasts ideal conditions for kite surfers and sailors. High-tech companies have moved into new waterfront buildings up and down the river, joining tourism and agriculture as the area’s main economic engines.
But the Columbia Gorge—a vast rural area larger than the state of Connecticut with only 75,000 people—is characterized by extremes. Not far from the coffeehouses and boutiques of Hood River, Ore.; White Salmon, Wash.; and The Dalles, Ore., are remote towns where some residents live in poverty and the nearest doctor’s office may be an hour away. Orchards throughout the region produce a bounty of pears, apples and cherries—but 1 out of 5 people reports running out of food on a regular basis.
To bridge those disparities, the people of the Columbia Gorge region turned an ordinary requirement from Oregon lawmakers into an extraordinary opportunity to improve the health and wellness of all residents.
It started four years ago when the governor of Oregon signed into law a new system for managing federal dollars for the medical needs of low-income residents. The state was divided into 16 regions, called Coordinated Care Organizations (CCO), and each had to assess the well-being of residents and come up with an action plan for improvements.
The Columbia Gorge Region
Residents in this vast rural area reach out across all sectors of the community to tackle disparities.
“We made a big decision,” says Mark Thomas, chaplain at Providence Hood River Memorial Hospital. “We could have a lot more traction and our solutions could be more effective, if we actually slowed down and listened to the people we aim to serve.”
In the Columbia Gorge, that directive became a catalyst for creating a more collaborative approach for shaping policy and improving results. People saw a chance to start a broader, deeper discussion on health, reaching across all sectors of the community.
Thirty-nine organizations participated in the area’s health assessment, sending surveys to residents in three counties in Oregon and two on the opposite side of the Columbia River in Washington. From that outreach, the community lined up around a set of shared priorities, says Kristen Dillon, a family physician and director of the Columbia Gorge CCO. “It continues to knit our community together as one community,” she says.
The RWJF Culture of Health Prize recognizes the spirit of collaboration in the Columbia Gorge. “It’s a wonderful acknowledgement of what the community has been trying to do and continues to try to do,” says David Edwards, chief executive officer of One Community Health, a federally qualified health center.
The community decided on the makeup of the 15-member Community Advisory Council mandated by the change in Oregon’s Medicaid system, and included individuals who rely on Medicaid for their health care, Latino residents and a parent of a child with a developmental disability. Drawing on the health survey and input from medical and social-service professionals, the advisers came up with a set of 10 priorities. At the top were concerns about food, housing, transportation and jobs, followed by the need for better access to dental and mental health services and better coordination between providers of health care and social services.
A sign welcomes residents and visitors to the Hood River, Ore., which is a port on the Columbia River.
Columbia River winds through a beautiful landscape a few miles outside of the town of Hood River.
The council gives voice to the region’s vast Latino population, which had been historically isolated from decision-making on health matters. About a quarter of the population of the Columbia Gorge is Latino, with many families arriving as migrants to work in the orchards. “First we were not heard, then we had to shout to be heard, and now we can talk together in the same room,” says Elizur Bello, a program manager at The Next Door, a social services nonprofit with a large Latino client base.
The action plan for the Columbia Gorge includes expanding the long-standing use of community health workers. For more than 25 years, The Next Door has relied on trusted community members to help Latino clients navigate issues or problems that may arise outside the clinic walls. The goal now is to expand that model; train and certify workers; and utilize them in a broader range of nonprofits, clinics and agencies.
Another successful initiative is the “Veggie Rx” program, in which health care and social service providers can issue individuals a monthly “prescription” for $30 of fresh fruits and vegetables. Sarah Sullivan, executive director of the Gorge Grown Food Network, which administers the project, said the health assessment exposed the extent of food insecurity. The Veggie Rx program “prioritizes food not just theoretically or through nutritional advice, but on the ground by screening patients for their food needs,” she says. Recipients have embraced the idea: At senior centers, the redemption rate has been as high as 98 percent.
The conversation on health in the Columbia Gorge region depends on including all voices and working together as a community. “It’s a willingness to be open and to listen to our end users and what our community actually needs,” says Paul Lindberg, a collective impact health specialist with the United Way, “as well as a willingness to collaborate as community partners to address those needs.”
Veggie Rx: A Fresh Produce Prescription
Bringing Food Security to the Chronically Hungry
To drive through the Hood River Valley is to witness the bounty of the land. Pear and apple orchards, plus vineyards, stretch for miles. But against this cornucopia, there is hunger: A 2015 survey found that 34 percent of people in the region worry about running out of food, and 15 percent actually ran out of food in the previous month.
A coalition of groups—from health care providers to a network of farmers—came up with a way to address the problem. They mapped out “Veggie Rx,” a fruit and vegetable prescription program designed to increase intake of fresh produce.
Clinics and social service agencies screen for candidates who are worried about running out of food, or who actually have gone hungry in the past year. Some people find the screening uncomfortable because hunger remains a taboo subject, but others understand that fresh food is one key to better health.
Participants receive a monthly packet of vouchers worth $30 and can use them at 10 farmers’ markets or 29 grocery stores, but only to buy whole fruits and vegetables. The funds for the vouchers have the added benefit of helping local farmers and grocers by bringing more customers their way.
There's something different about being handed these vouchers by a health care professional who is telling you this is essential for your health and you deserve it.
Sarah Sullivan, executive director of Gorge Grown Food Network
Usage has been high: The redemption rate for the Veggie Rx is 98 percent at senior centers, one of the distribution points for the vouchers. “The seniors say that there's something different about being handed this by a health care professional who is telling them this is essential to your health and you deserve this,” says Sarah Sullivan, executive director of Gorge Grown Food Network, which administers the program.
June Husted, 69, who lives on the Washington side of the Columbia River in a former logging town, calls the vouchers “a godsend.” She picks up packets from her doctor at a clinic 45 minutes away. Husted, who relies on Social Security income and lives with her 73-year-old husband, who has a disability, normally eats canned vegetables because fresh produce is too expensive in her small town of Klickitat, Wash. The cost of housing and utilities are the first bills she pays every month, leaving little room for food. “Fresh fruit and vegetables,” she adds, “are way down at the bottom.”
The program has fed more than 6,500 people in just one year with an emphasis on pregnant mothers, children younger than 10, diabetics and the elderly. Funding support has come from local hospitals and clinics, as well as private sources, with efforts underway to raise additional public and private funds to expand and sustain a larger base of users.
The Veggie Rx program has been a tool for linking farmers with local consumers. Gorge Grown is getting “fruits and vegetables into people's hands who wouldn't normally be able to afford it,” says Randy Kiyokawa, a third-generation fruit farmer. “We're fortunate to be a part of that.”
Many residents of Columbia Gorge qualify for and use the Veggie Rx program, which provides vouchers for free vegetables and fruits from places like farmers markets.
Connecting Dots to Create a Picture of Health
Paul Lindberg’s new job is to connect the dots. Officially, he is a collective impact health specialist for the Columbia Gorge region.
Translation: He encourages groups that may not be used to collaborating to solve problems, together. Then he helps them find funds to support their ideas through grants or other sources.
Many organizations would not have the resources to research funding opportunities or to apply for grants on their own. But collectively, they have found success, securing close to $3 million in public and private grants since 2014.
In one collaboration, four school districts, a clinic, health officials and private dentists secured a commitment of $290,000—spread over four years—to develop a comprehensive school-based dental program for every 1st and 2nd grader.
In another example of cross-pollination, the health department in The Dalles, Ore., the county seat of Wasco County, is starting walking groups to educate people on health, exercise and nutrition. By design, the routes will run past corner stores that the Gorge Grown Food Network is working to supply with more locally grown produce. The idea is that when walkers get to the stores, they can use Veggie Rx vouchers—another Gorge Grown initiative—to buy snacks. Both the walking groups and the healthy corner stores have received $50,000 apiece from the Knight Cancer Institute.
Lindberg says “the anchor” for his work are the goals set in the community health improvement plan. “That’s the document that we all can point to and say, ‘That’s what our community said we need,’” he explains.
Lindberg works through United Way of the Columbia Gorge, which receives funding for his position via Providence Hood River Memorial Hospital. A former lawyer who moved to Hood River, Ore., in 2000, Lindberg connects with community groups, nonprofit organizations, medical providers, health departments, schools, private practitioners and social service providers.
“It’s a very community-based, very collaborative effort,” Lindberg says, “and that has been one of the key components to our success.”
Mark Thomas, the chaplain at Providence Hood River Memorial Hospital who also works on mission integration, sees Lindberg’s role fostering more eagerness among groups to work together. “The system is strengthening as momentum is building,” he says.
2015 Culture of Health Prize Winner
Collaborating with Unlikely Players
Spartanburg County, S.C., also created partnerships across sectors to build a Culture of Health.
June Husted cooks a healthy meal using fresh food purchased with her Veggie Rx vouchers. The Veggie Rx program is a result of collaboration across many organizations, and is sustained by cross-promotion and integration with other health efforts in the region.
It’s a very community-based, very collaborative effort—and that has been one of the key components to our success.
Paul Lindberg, collective impact health specialist
Fostering Latino Leadership to Drive Change
The Next Door is the largest social agency in the area and has 28 community-based programs with the main focus being children and families.
Two weeks before the Hood River County, Ore., Transportation District held an election for an open seat, Leticia Valle, 33, threw her hat into the race as a write-in candidate. Learning about the opening through word of mouth, she announced her candidacy on Facebook and sent emails to as many people as she knew. She talked up her qualifications on a local radio talk show and wrote a letter to the editor of the local newspaper.
And she won, earning 453 votes, triple the number of her nearest write-in competitor.
“I can make sure they don’t forget about the Latino voice,” says Valle, who was born in Hood River and returned after college to work as a community health worker for the nonprofit social service agency, The Next Door.
Janet Hamada, executive director of The Next Door, encourages all of her staff—particularly younger members—to become involved as board members with local nonprofits and municipal boards. She even lets them use agency time to fulfill duties as directors or to attend meetings.
“This is so important,” Hamada says. “They’re part of a decision-making team, then they learn how to run an agency.”
You’re not going to affect change that really does move the needle on the health of the community without policy change.
Janet Hamada, executive director of The Next Door
The Columbia Gorge region has an expanding Latino population, centered in Oregon’s agriculturally rich Hood River and Wasco counties. The area has a number of undocumented people, who face additional challenges to meet basic needs and to access health care since their immigration status makes them ineligible for federally subsidized programs.
Hamada says the more Latinos become involved in leadership positions around the region, the more effective the community will be at addressing their challenges.
“You’re not going to affect change that really does move the needle on the health of the community without policy change,” she says. “And there will not be changes in policy in the right way without the community driving it.”
The lack of transportation, for instance, was identified as a major challenge in a regional health assessment. There is no public transportation network for the entire Columbia Gorge region, although some local public bus lines do operate. Valle says this is why her role on the board is so important. She says she can articulate the real needs of the Latino community for others in the community, “and not their idea of what the needs are.”
Bottom-Up: Residents Have a Healthy Voice
Joel Pelayo has a 26-year-old son with a developmental disability whose medical needs are met by Medicaid. Once a month, Pelayo meets with a diverse group of other Columbia Gorge residents who depend on federally-supported health care.
Their assignment: To inform and guide the people who manage and spend those funds for the region.
When Oregon changed the way it would handle Medicaid spending, it created regional CCOs to manage funds, assess health needs and devise a plan for improving overall health. This revamped structure also mandated the creation of a Community Advisory Council to represent the interests of people directly affected by the services and programs of the CCO.
Columbia Gorge has made its advisory council an authentic voice of the community and not just a rubber stamp of the CCO. By law, half of the seats must be held by Medicaid members. Included in the 15-member council for the Columbia Gorge are three Latino members; three people with disabilities; and a parent of a child with a disability.
The council “sets up the CCO as not merely a health care entity to manage money and pay bills, but really as an organization that’s accountable to the community,” says Kristen Dillon, a family practice physician and director of the Columbia Gorge CCO.
The monthly meetings of the council are also attended by as many as 30 people from community groups, state agencies and service providers who provide input and information. The council has become the primary vehicle for community voice and feedback on a variety of issues and initiatives.
It’s good business to take a customer-centric point of view, says Coco Yackley, an engineer who now consults for the Columbia Gorge Health Council, a nonprofit that manages the Columbia Gorge CCO. The advisers are decision-makers. “They decide what the important things are,” Yackley says.
The community representatives worked in tandem with a panel of health care professionals to arrive at the top 10 priorities for improving the region’s collective well-being.
Pelayo, a community health worker at a Head Start center, says his perspective has made a difference: For a health survey, he suggested more colloquial language in a Spanish translation. He views the council as “a powerful tool,” giving families like his “a unique opportunity to share our experiences.”
The CCO is set up as an organization that's accountable to the community.
Kristen Dillon, director of the Columbia Gorge CCO
The Culture of Health Prize
The Prize honors and elevates U.S. communities working at the forefront of advancing health, opportunity, and equity for all.
Helping People Build Bridges to Good Health
Karen Long often visits clients of the Columbia Gorge Housing Authority in their homes. Her job is helping people to transition to self-sufficiency. She asks about everything from job searches to educational plans, finances and budgets.
But Long will also inquire whether a family has enough food. Have children seen a doctor or dentist recently? Do they need help finding one? Is everyone exercising? Walking?
As a community health worker, Long’s job is to help people connect to services in all aspects of their lives, not just housing. It’s not a new idea—in the Columbia Gorge, the nonprofit agency, The Next Door, has been using such workers for more than 25 years. But the model has been endorsed and expanded under a new plan for improving the well-being of residents.
Groups have raised funds to certify 52 community health workers through the Oregon Health Authority. The workers—who are employed at clinics, schools or government agencies—took a 90-hour training course, devised by the health department of Multnomah County, where Portland, Ore., is located. Health partners in the Columbia Gorge also plan to create a centralized system that coordinates and measures the work of community health workers. The partners would also like to test the model of a service navigator in the field of economic development with small business owners.
Elizur Bello, a program manager at The Next Door who also trains community health workers, says the most effective ones are trusted members of a community. Not only can they connect neighbors to services, they also serve as the eyes and ears of policymakers and report back on problems or trends they observe in the field. “They understand the needs,” Bello says.
Maria Antonia Plascencia de Sanchez has been doing the work of a health navigator since she was a little girl in Mexico, escorting adults by train to the doctor’s office in the city because she could read. Today, Sanchez goes to homes to talk to Latino women about breast cancer awareness. “But when you get to the home, you will be facing or talking about different needs, and you need to be receptive,” Sanchez says. Someone will not hear the message on cancer if they are thinking about food needs or how they’re going to pay rent. “They start talking first and then we need to respect them and give them time,” she says.