Guest Post: "The struggle is eternal. The Tribe increase. Somebody else carries on"

Hello what followers there are out there! (sorry about the weird background, not sure why that happened!)

I'm excited to invite a colleague and friend to post a reflection on here. This friend has recently ready Why Are All The Black Kids Sitting Together In The Cafeteria by Dr. Beverly Daniel Tatum. For me this book was the door to a much more meaningful train of thought and I'm happy to share the reflection of Karmen Kurtz (be sure to hit her up with your thoughts below or on twitter at @kreall). Personally, I want to thank Karmen for being so courageous to share this reflection.

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The sentence read: "The contortions a successful African American has to make to fit in but stand out, to be strong but not to intimidate or frighten, to be black enough but no to black". I had never felt such an intense connection to a quote, one that acted as a catalyst for reflection on my life and my identity. The CNN article that it had come from was on black males graduting from University, but for me, it was the begging of my identity development as a young black woman. It was not until a few hours ago that I had a legitimate term to attach to race-related cognitive dissonance. When Dr. Tatum discussed identity development in adolescence I found my self shouting out in affirmation as a read. Over the past six months I have been in constant discord with race and where I stand in my Blackness. I've been pushed to unthinkable lengths when it comes to my personal experiences with mulit-cultural affairs.These experiences of adversity have forced me to reevaluate my existence as not only a black woman, but a black advocate. I am just now beggining to identify my role in this whole thing; I need to to shift my focus from trying to be the paradigm of a black girl who bears the weight of her entire race on her shoulders to the black girl who understands that blackness doesnt look the same,can maintain her own identity, and is courageous enough to bring up racism in her sphere of influence. I may sound like I have it all figured out but honestly, I dont. I have a long way to go before I can really find my truth and be able to articulate my truth even when the circumstances may persuade me to remain silent. So right now I am trying to find security in my racial position.That means teaching myself the things about my ancestors that have been omitted from my history books. That means internalizing the reality that "there is more to Africa than Tarzan movies and that there is more to Black History than victimization". I can't wait. I can't wait to learn more, I can't wait to grow, and I cant wait to teach. I have found out early on that in this self discovery comes a lot of deeply rooted emotion;feelings that have been illegitimized and pushed aside for years are aroused with a sort of gentrified fervor. I paused my reading last night to watch a video clip to which Dr. Tatum referred and I felt an unparalleled connection to the words that the man,Victor, spoke in the clip (see below) . I was moved to tears. Not because the reality of the system of racism is sad but because until the moment that video ended the truth in Ella Baker's quote  "The struggle is eternal. The Tribe increase. Somebody else carries on" hadnt registered to me.

The Color of Fear - The Red Ground Scene

This process will undoubtedly be trying but its something I feel most African American youth go through without the eloquent framing of Dr.Tatum. Ultimately, I have the leg up by having read Why Are all the black Kids sitting together in the Cafeteria?. I have been exposed to the stories and experiences of other just like me and I have been given a guide to finding myself in a racial context. And I understand now, better than ever, why all the black kids are sitting together in the cafeteria and I know that that is ok.


Huge thank you again to Karmen! You inspire me everyday!

Beyond Patients (part 3)

Since the last post some exciting things have happened. Conversations have started with the Robert Wood Johnson Foundation around an interesting idea being called Flipping The Clinic. What I think is exciting about this is that, while this is still a very new idea, much of what I hear is based around changing the culture around the patient-provider experience.

Also, I think that this is starting to put some framework around the work that the youth team and I are doing at Youth Empowered Solutions (YES!). The idea of "Flipping" comes from Salman Khan and the idea of Flipping the Classroom:

The two cornerstone strategies are that 1) the lectures are completed at home and the "homework" is done in the classroom, with the teacher and the other students, not just enhancing the role of the teacher to teach, but enhancing the relationships that are developed between the student and classroom and 2) through the work being done in the classroom the system of educating becomes more individualized, so that students learn a their own relative pace. 

When I think about how this translates into the patient-provider relationship, I think about greater productivity and outcomes, I think the integration into a stakeholder, an owner, and an investor in the care that they receive. As our national health care systems transitions in to v3.0 (see Part 1) it will be essential to leverage the capacity of consumers at a greater level to sustain a high level of patient-centered care. This makes me think of a fantastic workshop I saw in June at the School-Based Health Alliance 2013 National Convention, which was called Youth-Driven Spaces: Creating an Organizational Culture that Supports Youth-Adult Partnerships. It was led by two adults and two youth representing  the Corner Health Center in Ypsilanti, MI. 

The Corner Health Center has all of the dynamic components of a dynamic youth empowerment organization: advocating for community change, addressing and dismantling adultism, and maintaining an amazingly active Youth Leadership Councils. The Youth Council researches community health issues, develops multimedia, and (of particular note) advises the "Corner" on policies and services. They have taken the feedback loop and added another dimension to it. They lifting up the role of the patient, building it's capacity, and allowing them to contribute meaningfully to the success of the health center. 

As a result, youth are invested in where they get the care and the provider is better equipped to serve his and her patients. In the presentation the youth and adult team described the "Learning Culture" at the organization as as an iceberg where on the surface you see the formal policies, systems and practices. However, what ensures authenticity and delivery is the informal practices and symbolic actions and the beliefs, values, and attitudes that lie beneath. I can't help but think having an online chat function with the staff and doctors (meeting the youth where they are at) is what you see, when what we don't see is the board meetings, staff meetings, strategic planning sessions, and consulting that the organization engaged those youth in to develop it. 

I even had a chance to connect with Monique who is resident Health Educator and champion of all things Youth Empowerment at the Corner and I was able to pose just one, simple question: "why?"

"The bottom line is, we don’t put resources into increasing youth voice because it is the nice thing to do. We work to increase youth voice because it builds the capacity of our organization to better meet the needs of the population we serve—youth."

I would definitely encourage you to check out the Corner Health Center online, if you are in Michigan and a support of their school-based health centers, get involved, and if you are an adolescent healthy care organization, I'd recommend you explore the capacity you have to take your work to a new dimension. 

The Sum and the Parts are Equally Huge

This year, for my birthday, my wife April aka GlutenHatesMe reached out to a small group of people who were the closest to me and asked them to commit to one random act of kindness. She would then collect them and give them all to me as a gift.

I was not only awe struck by the willingness of so many people to participate, my whole body smiled when I read how willing people were to put themselves into relatively uncomfortable situations JUST to do something kind. To my friends and family, nothing has been more meaningful in my life than this gift, and I want to do my part to show the world (i.e. the roughly 2 people who read this blog) your kindness:

• Adam - flew back to visit his parents and instead of "so many fun things he could've done, he spent the weekend working in the yard, building a rock wall, exterminating a giant hornets nest, doing work that needed to be done before flying home"

• Susan and Family - bought a strangers dinner without asking one evening, and it sounds like made a friend out of it too!

• Bronwyn - stepped in at the grocery store to help someone who didn't have enough money to pay for their groceries.

• Jeanne - wrote a thank you card to 911 workers who were so helpful and have such a tough job. You also paid in advance for a strangers library fines so that they could continue to check out books!
• Lindsay - Aunt of the year for taking two days off of work to step in and help out with babysitting her niece so that her brother and sister didn't have to use sick time. 

• Ben - bought gas for a stranger at the gas station and spent some time with a friend in need. 
• Kat - on a gloomy night, left a waitress and exceptional tip to cheer her up AND made a special call to three of her closest friends to let them know how thankful she was for them.

• Emily - is dog-sitting two needs a week for her brother so that he can go to grad school and even cooks him (the brother) dinner when he gets out of class!

• Aidil - gave a homeless man her favorite water bottle, went out of her way to help a traveler in need in an area that was unfamiliar to her, but made sure she knew where she was going, and paid for a hotel room for some traveling artists in need. 

• Alex - helped a woman at the vet who was carrying her cat in a carrier, a baby in a seat, two bags and her 2 year old!

• Loren - took a day off of work and came and visited ME! Took me out to lunch!

• Mom (below) and Jeff - sent anonymous flowers to her coworker who lost a child in early August to let her know that she has friends who grieve with her and that they haven't forgotten her loss either. And on top of that, donated some money to YES!

• Martha (above) - when passing a person begging for change, this time instead of the usual buck, gave him $20. 
• Karmen - donated blood! What a great idea!

• Greg - while riding your bike home saw a car stalled in traffic, recruited a fellow cyclist and helped him push his car to the side of the road into a parking lot. 

• Zigmas and Vida (and fam) - Flipped over 3 pennies to Heads Up for some passerby to find and be gifted with good luck. You are special people!

• Suzanne - bought supplies that were much needed and wanted for the wonderful woman who cleans houses for a living, whose husband is unemployed and has a sick mother and father. I love that this is an investment that will have a return for them!

• Kai  - bought food for a homeless man AND his dog. Also helped some of his neighbors who he didn't know move into their apartment. 

• Aaron - will be walking/running for the March of Dimes with little A-cakes!

• Craig - bought a supplement for a friend in need with back problems. 

• Katie  - sent a note to an incredible teacher sharing how much she appreciates her teaching and modeling kindness to the students. 

• Diana and Drew - went up and above for a special customer who was just diagnosed with brain cancer and is having a rough time. They put together a care package with homemade bread, peaches, and books. 

• Amber  - bought a Tidal Creek Cooperative Market ownership for someone to use for a year, get discounts on local and organic food, and be able to receive a share of the Coops profits!

Beyond Patients (Part 2)

"Full participation of every patient in finding and using safe, decent health care is vital to the success of the health care enterprise in improving the health of individuals and the population."

- Center for Advancing Health

I don't think that anyone would necessarily say that an engaged patient-base is a bad thing. However, when it's time to allocate resources and invest in a means, patient-engagement processes often have to compete with the other priority costs. How can having a 15-20 minute conversation with one patient measure up with diagnosing, treating, or providing preventative medicine to another, maybe more than one? It's a tough argument logistically and financially. When and how will you see the return? Like other models of prevention, the earlier in life it happens the greater financial and human capital return you see, but ofcourse, this does not happen over time.

I would like to make a case, though, that the integration of a bilateral system of designing and delivering care will decrease unnecessary expenses having to do missed appointments and follow up. This is of course on top of the expected increase the success of patient health outcomes and level of patient health literacy and decrease of emergency treatment and tertiary care that collectively would increase the overall capacity of the provider.

I also think there is an equity in this authentically engaging patients as stakeholders that doesn't often get measured in ROI calculators or the financial bottom line. While our health care system hasn't exactly been promoting systems of care that focus on those "intrinsic values", I think there are ways to show a correlation between equity, impact, and return. Ofcourse, much of this work centers around the medical home, as opposed to secondary and emergent treatment. This can be seen through the regrowth of the patient-centered medical home (NCQA) and the attempt of providers to provide team-based, whole person care that is continuous and coordinated. A concept that no doubt benefits most people, directly and indirectly, but has the greatest impact on those populations experience disparities in health and health care access. Within those populations, I'd argue that among the most vulnerable to those disparities are youth. Therefore, an equitable system of care, that is patient-centered, is integrated into the environment that young people spend a majority of their time: school.

School-based health centers (SBHC) are increasingly becoming certified as patient-centered medical homes in providing primary care to some of the most vulnerable populations of uninsured and underinsured youth. They are key components to care management entities that keep state medicaid costs down, are beginning to be integrated into accountable care organizations, and, as I see it, are positioned uniquely to excel in taking youth beyond patients, into stakeholders. SBHCs have the capacity to work with their patients to shape their environment, how they delivery care, what care is delivered, and by doing this, build the level of investment their patients have in their infrastructure.

While there is little research around patient-engagment targeted towards youth, there is tons of research (and jargon) around youth development, youth engagement, and youth empowerment. Despite being "The generation we love to dump on" Millennials are proven to be community minded multi-taskers that want to be engaged.

Models of creating "youth-adult partnerships" (Zeldin), meaning the practice of (a)the practice of multiple youth and multiple adults deliberating and acting together, (b) in a collective (democratic) fashion (c) over a sustained period of time, (d) through shared work, (e)intended to promote social justice, strengthen an organization and/or affirmatively address a community issue, have been documented as creating an outcomes-generating connectedness. Centered around age equity, authentic partnership between youth and adults produce an impact to all of the people involved and then systems that they are attached too (health care, education, government, etc.).

Models of "youth empowerment", with engrained methods of developing individual youth capacity, are focused on individual, organizational, and community change outcomes. Empowerment theory has been documented well by Marc Zimmerman and Brian Christens, and go beyond impacting individual behaviors of youth to prepare them to authentically participate in the systems that impact them the most.

Even in models of "youth organizing" (Christens), where youth come together to talk about the most pressing problems in their communities, conduct research on these problems and possible solutions, and follow through with social action to create community-level change, when implemented through a partnership between a young person and their medical home, the potential is a population level change in health disparities.

While these models are traditionally being implemented within youth-serving non profit organizations, programs and groups outside of the health care system, there are those that are finding the crossover innovation and utility of these models. In Part 3 we'll talk about what this looks like in a health care setting, (hopefully) get some highlights of an awesome organization doing this in Michigan and talk about the cost-effectiveness of this work.

Beyond Patients (Part 1)

I just returned from the newly branded School-Based Health Alliance (formerly NASBHC) Convention in Washington, DC. New ideas, new people, new projects...as a movement, things are #trending up, nationally. But there is something that continues to exist, and is relatively pervasive: people struggle to think about youth, or adolescents, as something more than patients.

I was fortunate to hear Dr.Neal Halfon talk about the role SBHCs will play in shifting the way health care delivery systems will be delivering health care reform. Particularly, he talked about the evolution of our health care system from a v1.0 model (episodic non-integrated care), to our more recent and current history of a v2.0 model (accountable and coordinated care), and thinking forward to a v3.0 model (community integrated health care). Dr. Halfon estimated that we are currently operating at an around v2.2 model nationally, but moving towards v3.0 which focuses on population centered care, population based reimbursement, and integration between networks and community resources.

Certainly a major part of this will be the rise of Accountable Care Organizations and the regrowth of the patient-centered medical home. These models push us away from "fee for service" models and reward providers for outcomes, rather than services. These are a means to a more effective and hypothetically equitable health care system, assuming active participation.

However, with all of the resources being put into adolescent health care, public and private, we struggle with thinking youth as more than patients, when in a health care setting. A great quick read that I think points in the right direction is from the Center for Advancing Health and is a White Paper called Supporting Patient Engagement in the Patient-Centered Medical Home. There are great points in this, however, there needs to be thought towards evidence-based models of successfully doing this.

While designing a system to of health care delivery, we need adequate investment by consumers, by those utilizing the care the most, and, as this blog is focused on adolescents, well, the youth themselves. Why can youth not actively participate in the design of health care system? What can youth do more to improve your practice, outside of filling out customer satisfaction cards?

Part 2 will explore different models of doing this, what little research there is about youth-adult partnerships, youth empowerment, and youth development, and the plan for Part 3 is a Return on Investment hypothesis.

An Introduction

One year ago today, I was on a plane from New Mexico back to m home in North Carolina. I was sitting next to a man explaining what school-based health centers (SBHC) were, fresh out of the School Based Health Alliance National Convention, looking to spill the brim of everything I had just learned…to test myself maybe, to see what I held on to. I remember giving him the standard first couple of lines…”***SBHCs are essentially doctors offices on the grounds of schools ***they see all students, but primarily serve students who are uninsured and underinsured ***they keep students in their seats longer and learning.”

At this point, I can almost guess the next 2-3 questions…

• What types of services do they provide (code for: are they sex clinics?)?
• Who funds them?
• What about the school nurses?

Having been through this conversation many times over the past 8 years I’ve worked in and around SBHCs, I have developed a pretty consistent response, tailored to fit the tone of the person questioning:

Centers actually provide acute and primary care, core services that the majority of their patients aren’t already receiving, mental and behavioral health, oral and visual health and they have a focus on prevention: immunizations, well child visits, sports physicals, etc. But they also play a key role for students who have chronic illnesses that impact their time in school, like asthma and illnesses related to being overweight or obese. And for folks in North Carolina, it is against the state law to provide contraceptives on the grounds of a school campus, so let’s be clear that is not happening.

Funding collaboratively through billing Medicaid, CHIP or private insurance, private grants and sometimes some state funds, depending on where they are located. In 2010, SBHCs were also authorized underneath the Affordable Care Act and received $200 million for capital costs, though fell short on providing operational funding.

And school nurses are our biggest allies, well, in places where school nurses exist.

I’ve found that an information gap about school nurses has grown, maybe generationally.  Many people think that school nurses are in every school, most if not all days of the week, and are providing counseling, dispensing medicine, and being a catch all for the students. The reality is that, in Wake County, NC, the 4^th largest school district in the country, there is a school nurse to student ratio of 1: 2500 students. That translates into each school nurse spending 1-2 days a week at each school…and because of tightening restrictions within the school system, “we basically just put ice on things and if it is more serious than that, we call their parents” according to school nurse I talked to last. Fortunately all school districts are as strict and, despite being overworked and under resourced school nurses make magic happen.  And when there is a SBHC in that school, they collaborate to keep students in their seats and healthy.

So I looked at this man, having already plotted my next points and he said with equal parts disapproval and disbelief:

“Sounds like socialized medicine to me.”