As we wrote in the Blueprint for Complex Care, effective complex care must be equitable. This means addressing the consequences of poverty, racism, and other systemic issues by partnering with individuals with complex needs and their communities — both in identifying barriers and in developing solutions.
Two exciting initiatives, one a brand new startup in Seattle and the other housed in a community health center in Oakland, are doing exactly that. Their workforce development programs not only provide opportunity for vulnerable individuals, but also recognize the critical expertise that these individuals bring to the care team. By thinking beyond the traditional healthcare model, they hope to transform not only individuals’ lives, but entire healthcare systems and communities.
New Trails Navigators, the brainchild of software developer-turned-nurse Ramona Ramadas, is a “peer health navigation program that serves the community’s most vulnerable members.” Still in its startup phase, the model envisions training individuals facing vulnerabilities, including those re-entering society from incarceration, to be peer health navigators that are embedded into settings like emergency rooms, health clinics, and drug courts. Navigators and program participants, who often share common backgrounds and life experiences, will work together to identify needs and address them, with the peer navigator becoming the point person and advocate for the participant on the care team.
Roots Community Health Center in Oakland was co-founded by Dr. Noha Aboelata, who started the center as both a healthcare provider for vulnerable individuals as well as a “think tank for how we can best address the needs of the community.” To address high unemployment — a social factor closely associated with a variety of life-shortening conditions — Roots launched the Emancipators Initiative, where individuals with criminal records and other barriers to employment receive job training and support in an unusual setting: a soap factory run by the health center. Participants gain a host of marketable skills, earn a living wage in the program, and 96% move on to stable employment after graduating. A significant number of graduates are hired by Roots as navigators and outreach and enrollment specialists, helping other community members who face many of the same barriers as them.
Creating opportunities for patients to become providers
Inequitable pipelines — like the school-to-prison pipeline — push individuals into cycles of incarceration, poverty, and poor health. New Trails Navigators and Roots are interrupting that cycle by building new pipelines: ones that harness the expertise of vulnerable individuals to strengthen care systems and the communities they serve.
Addressing healthcare shortages with peers: New Trails Navigators
Ramona Ramadas left the software industry for a career in nursing. She fell in love with community health, working in a mobile clinic, in a Housing First program, and as a home visiting nurse, then moved into healthcare IT roles. The healthcare sector, she said, is experiencing shortages that leave many providers struggling to meet the needs of their patients. New Trails Navigators provides opportunity (and avenues to more advanced training) for individuals leaving precarious situations, but she also hopes infusing healthcare systems with peer navigators will ease workforce shortages and reduce burnout among providers.
New Trails Navigators focuses on training people re-entering society from incarceration because “the right care for the right patient at the right time is often that person that’s walked in their shoes.” Formerly incarcerated individuals, said Ramona, include a huge potential population of peers who intimately understand the barriers faced by community members who need better support.
Community members as leaders: Roots Community Health Center
Noha Aboelata was born and raised in Oakland, and decided in medical school to come back and serve her community. What stood out to her and Roots Community Health Center co-founder Ophelia Long, RN, was that the root cause of poor health in the community “had everything to do with poverty itself and lack of opportunity.”
In 2013, Roots launched the Emancipators Initiative to address what they saw as crisis levels of unemployment in their community, with criminal records posing a widespread barrier to employment. One of the first Emancipators was Noha’s own patient at Roots, where as a practicing physician she continues to see patients alongside serving as the center’s CEO. On top of a number of physical and mental health issues, this patient was becoming increasingly discouraged by his lack of employment, so Noha referred him to the Emancipators Initiative. When he graduated from the program, he was hired at Roots and is now a program manager.
Though the Emancipators Initiative trains participants specifically in light manufacturing at the soap factory owned and operated by Roots, the general job training and support they receive prepares graduates for employment in a number of sectors, including healthcare. Noha estimates that 20-30% of graduates are hired by Roots. At Roots, she said, “we have this continuous pipeline of folks who may have begun as patients or clients of Roots who are now staff, and who have input and leadership into how we continue to develop and grow our services.”
Collecting and analyzing data through an equity lens
Along with being equitable, another core tenet of complex care is that it’s data-driven. When it’s not collected and used thoughtfully, though, data can replicate and amplify inequitable outcomes rather than addressing them. As New Trails Navigators and Roots Community Health Center show, It’s important that complex care providers and others who work to address disparities are creative and intentional in how they collect and interpret data.
Whole-person data: New Trails Navigators
For former software program manager Ramona, anything can be a source of data. Data that are currently collected in healthcare and social services settings aren’t telling the whole story, she said, so she designed a unique “whole person intake assessment” for New Trails Navigators. The assessment combines data about social determinants of health, physical health, and behavioral health, allowing peer navigators and the care teams they work with to better understand their participants’ needs.
New Trails Navigators uses a HIPAA-compliant app that can integrate with EHRs and other records to provide seamless data integration. The app supports care planning, facilitates communication between the peer and the participant through text and video calls, and allows peers to easily document what happens at in-person meetings. This, Ramona said, provides a rich support experience for the participant, and keeps the peer close to where a patient lives, works, and plays.
“When I was working as a visiting nurse, as I was walking down the street to patients’ homes, I saw the safety of the building, the availability of healthy food that my patient could walk to: that’s all data,” she said. “I think we’re just now only starting in complex care to understand those sources and figure out ways to capture them.”
Data-driven programming: Roots Community Health Center
Data also underpinned the creation of the Emancipators Initiative at Roots Community Health Center. Confronted by the reality of high unemployment among their patient population, with criminal records featuring as a significant barrier to employment (over 90% of Emancipators have some kind of criminal record), Noha and her staff embarked on a process to figure out which sectors would not only hire those with criminal backgrounds, but were also growing in the region and provided pathways to more advanced work.
“The Emancipators Initiative has probably been one of the most powerful interventions in transforming health for our community, and it wasn’t something that we just came upon,” Noha said. “We did our homework, we understood the data around us as well as our own data, we assessed the landscape. We felt that it wasn’t enough for us just to know what was leading to poor health outcomes, but that to directly address it is our role and responsibility.” Roots’ research pointed to light manufacturing as a sector that could help their clients reach their goals, so following the data, they opened a soap factory.
Advocating for state-level change that advances equitable care
Making structural change that impacts individuals beyond those served by a specific program often involves coalition-building, advocacy, and working with policymakers and legislators to change laws and policies.
Advocating for better opportunity: Roots Community Health Center
While betting on the light manufacturing sector has paid off for Roots and for the Emancipators that have graduated from the program, Noha wants her patients to have even more opportunities for training and employment. Two new apprenticeships — graphic design and sign installation — are underway and they are planning a partnership with the local community college.
Roots has also been partnering with other organizations to advocate for measures that will stop criminal records from being barriers to employment in healthcare. Last fall, Governor Jerry Brown signed into law AB 2138, which makes it easier for individuals with criminal records to get professional and occupational licenses. “We believe fundamentally that we can’t achieve our mission of uplifting communities that have been impacted by systemic inequities without advocacy,” said Noha. “We can’t program and service our way out of disparities.”
As a community-based health center with a wide range of integrated services, Roots is in a position to support staff and participants in becoming effective advocates for their community, as well as to provide support during and after stressful campaigns. “We know that we can help protect people from either becoming tokenized or just used for the short-term win,” Noha said. “Advocating can be difficult work, and can be particularly triggering if you’re bringing your own life story to the forefront.”
Scaling equitable models: New Trails Navigators
Meanwhile, Washington state’s five year Medicaid Transformation Project, launched in 2016 after the state successfully obtained a Medicaid Section 1115 Waiver, has created an opportunity for Ramona and New Trails Navigators to create systems-level change. Earlier this year, New Trails Navigators was selected as a community innovation partner for Healthier Here, King County’s Accountable Community for Health. Healthier Here is one of nine Accountable Communities for Health across the state that bring regional partners together to redesign care delivery and build capacity.
Ramona is excited about the transformative potential of being able to implement a peer navigation model at scale. “If you zoom way, way out, there’s a system change that can take place as we continue to move this work forward and really integrate it and make it standard process and part of the workflow,” she said.
Putting equity into practice
Both Roots Community Health Center and New Trails Navigators started from the idea that vulnerable individuals and communities are the experts in the challenges they face.
Equity, when done right, isn’t just something tacked onto a program at the end to check a box. When workforce development is conceived through an equity lens, it can be about more than providing opportunities for individuals or correcting staffing shortages. Programs like New Trails Navigators and the Emancipators Initiative can have transformative effects on systems and communities, creating more equitable outcomes for all.
“It’s important that when we see disparities that we dig deeper,” Noha said, “that we ask our community to help us contextualize what is going on, and then that we respond in partnership with community. In a lot of ways, equity is about involving the people that are experiencing the disparities in the solution.”
With both New Trails Navigators and the Emancipators Initiative, the lesson is clear: building equity into a program as a goal from the beginning can lead to surprisingly innovative results.