Everyone, welcome to Evaluating Best Practices in the Care of Minorities. for this project. Before we begin, I have a few housekeeping items. So disclosure, I, speakers, and moderators do not have any financial interests or relationships to disclose. And then also our CDC disclaimer, the contents are solely the responsibility of the authors and do not necessarily represent the official views nor an endorsement by CDC's, HHS, or the US government. Also, before we get started, we acknowledge that we are all living off the stolen ancestral lands of indigenous peoples for thousands of years. We acknowledge the extraction of brilliance, energy, and life for labor forced upon people of African descent for more than 400 years. We celebrate the resilience and strength that all indigenous people and descendants of Africa have shown in this country. Let's please start and welcome our moderator, Dr. Wilnice Jasmine. Dr. Wilnice Jasmine is Medical Director of Behavioral Health at the Chicago Department of Public Health. She is part of the leadership team responsible for the city's innovations in violence prevention, substance use, recovery, and mental health. She specializes in both family medicine and preventive medicine, public health. She's alumni of John Hopkins Bloomberg School of Public Health and the Cook County Family Medicine Residency Program, where she served as a chief resident during the final year. She also completed the primary care and psychiatry fellowship program at University of California, Irvin. Most importantly, Dr. Jasmine graciously serves as a subject matter expert on this project for our advisory board committee. So, Dr. Jasmine, we're pleased to have you. Thank you. Yes. Good morning, everyone. Good morning. So I want to say that we want to thank and acknowledge our partners, the Centers for Disease Control and Prevention, the American Medical Association Center for Equity, and leaders and advisors from ACPM. Thank you for investing your time to help realize and bring this project to full fruition. So you each should have a printout of today's agenda. And we've carved out time for question and answer at the end of this talk. So ACPM is funded by six grants under the cooperative agreement with the CDC's Center for State, Tribal, Local, and Territorial Support to strengthen public health systems and services through national partnerships to improve and protect the nation's health. This project, Improving Minority Physician Capacity to Address COVID-19 Disparities, is one of the two supplemental awards funded by the COVID-19 Relief and Recovery Fund. And information about other projects is listed on the ACPM website. The purpose of Improving Minority Physician Capacity to Address COVID-19 Disparities is to enhance the capacity of physician-led practices to implement COVID-19 prevention, vaccination, testing, and treatment strategies that improve the health of populations disproportionately impacted by the pandemic, racial injustice, and other forms of oppression. Project strategy centers on equity and document best practices in care coordination for minoritized populations. And in particular, the best practices for care coordination for minoritized communities. Data consistently shows that American Indian, Alaskan Native, Black, Hispanic, Latinx people have experienced disproportionate rates of illness and deaths due to COVID-19. Black, American Indian, and Alaska Native, and other Pacific Islanders in the US had over three times the number of premature excess deaths per 100,000 people in 2020, compared to white or Asian people. Life expectancy decreases were greatest among minoritized men, especially Black and Hispanic men, who experienced decreases in life expectancy at 3.6 and 4.6 years, respectively. South Asian Americans who are already vulnerable, whether due to immigration status, domestic violence, or unsafe working conditions, have most directly been impacted by the pandemic. This pandemic has disproportionately affected people living with disabilities. In early 2020, 18 to 74-year-old with intellectual and developmental disabilities who contracted the virus were twice as likely to die than those without disabilities. LGBTQ plus people had higher rates of self-reported underlying conditions associated with severe COVID-19 outcomes, including asthma, cancer, heart disease. Higher rates of illness and death among people of color reflect increased risk of exposure to the virus due to living working and transportation situations increased risk of experiencing serious illness if infected due to higher rates of underlying health conditions and Increased barriers to testing and treatment due to existing disparities in access to health care Beyond the direct health impacts of the virus The pandemic has taken a disproportionate toll on the financial security mental health and well-being of people of color low income people LGBTQ plus people and under-resourced groups Physicians are grappled with the inadequate resourcing to adapt to the rapidly changing care Landscape and enact comprehensive strategies that address the underlying structural drivers impacting their patients Many small independent rural and safety net providers face financial barriers implementing practice transformation Challenges are felt particularly harshly by small practices facing time and resource constraints and independent practices Minority physician practices have grappled with a lack of adequate equity based strategies and resources While trying to treat and prevent kovat 19 among their patient populations there is a need to understand better and how Minoritized physician practices are linking with their public health partners to use community level data and capture racial ethnic demographic data from their patients Our First speaker miss Maria Regalado health equity project manager at the American Medical Association's Center for equity She provides advanced support coordination guidance and technical assistance opportunities to the 13 physician-led practice award recipients a New York City native Miss Regalado is also a National Diabetes Prevention Program and Self-Management Resource Center lifestyle coach and master trainer Thank You, dr. Jasmine and hello everyone Improving the care of minoritized communities and supporting physicians is key to achieving health equity Health equity means that everyone has a fair and just opportunity to be as healthy as possible This requires removing obstacles to health such as poverty and discrimination including removing their consequences Such as powerlessness and lack of access to good jobs with fair pay quality education and housing safe environments and health care at The American Medical Association Our vision is for all people to live in thriving communities or where resources work. Well Where systems are equitable? Where everyone has the power? resources and opportunities to achieve optimal health that all physicians are equipped with the consciousness and tools and Resources to confront inequities and to dismantle white supremacy racism and other forms of oppression This project aligns with AMA strategic plan and we aim to build alliances and share power Through partnerships and connections with those who have experienced exploitation and injustice across generations We intend to use these partnerships to center the experiences and ideas of those physicians that have been have been minoritized and marginalized Our goal is also to push upstream Where we are focused on the building cap on building the capacity of physicians and trainees and ensure that they're educated Beyond the traditional basic and clinical sciences of medicine to be inclusive of public health structural competency anti-racism and the social sciences With an equity approach in mind ACPM and AMA have funded 15 physician-led practices to implement strategies that center equity To improve the health of populations that have been disproportionately affected by the pandemic racial injustice and other forms of oppression these populations include black indigenous American Indian and Alaskan native Hispanic and Latinx people people that identify as lesbian gay bisexual transgender and queer Asian American Pacific Islanders people with disabilities and other minoritized groups Including populations that have been marginalized based on economic circumstances or other determinants of social inclusion We want to be able to identify track and amplify promising practices and strategies at the intersection of COVID-19 response and equity As we implemented this project we wanted to make sure that equity was at the forefront of all aspects of the project Our Goal is to accelerate the capacity of minoritized and marginalized physicians physician-led practices by increasing information sharing and collaboration among the award recipients identify policies and procedures that address structural drivers of health improving care coordination and Increasing physicians ability to capture representative racial ethnic sexual orientation and gender gender identity data We also focus on facilitating linkages to public health infrastructure to foster sustainability and mitigate inequities Eventually our goal is to disseminate promising practices to inform the feasibility and scalability of equity strategies We plan on sharing key lessons with physicians and systems across the country Going along with a strategy of sharing power Ensuring this was not a top-down approach We wanted to engage with leaders and partners throughout the country to bring together an external Advisory group who could assist us with ensuring equity was centered throughout the RFP and award selection process The advisory board committee's input was invaluable as we developed an RFP process to encourage FQHCs and independent practices to apply for the award We also developed an informed criteria for selecting the demonstration sites The board also provided input on project work plans and deliverables A Ma a CPM and the advisory group agreed that for this effort an equitable RFP process Award selection and financial disbursement plan were equally as important as the end products of the grant We also wanted to maintain a diversity of perspective and experiences And wanted to include at least one pediatric practice At least one practice connected to a preventive medicine residency program We wanted to ensure diversity across geography and population served Practices also needed to demonstrate a need based on the CDC social vulnerability index and COVID-19 prevalence rates With The advisory board committee's guidance We ensure that the scoring rubric favorite organizations whose work plans Serve marginalized and minoritized communities and whose leadership was reflective of the communities that they serve We also wanted to make sure of a participatory award selection process that did not penalize organizations without resources or grant writers Recipients were also able to use more than 50% of their awards towards infrastructure 13 organizations Representing 15 unique sites were awarded Most of the organizations funded were federally qualified health centers or community health centers But we also awarded small independent practices universities physician associations and a farm D family medicine collaborative These practices identify as safety nets within their regions and predominantly focused on marginalized communities In their application responses 11 of the 13 Award recipients responded as having leadership positions held by persons who self identified as being Hispanic Asian gay queer immigrant Indian African-american black and Asian Pacific Islander The 13 grantees across nine states describe the communities that they're serving in Hawaii and Texas We have award recipients serving rural communities with a limited access to transportation services and care Grantees in Florida and at the border in Texas are serving immigrant communities as well as asylum seekers in Chicago Birmingham Atlanta and Boston grant recipients are serving the underinsured those living in housing authorities Those who are food insecure people living with HIV and those who are low-income You may notice there are four grantees in California not because California is our favorite I'm from New York City as you may know already But these four organizations are serving very distinct populations One site is serving Hispanic Latino population who are living at or below the poverty level Another site is serving primarily the LGBTQ plus community many who are living with chronic diseases, including HIV The next site serves patients who are Asian many of whom speak little to no English And the last site is serving persons with disabilities and those with neurodivergence The award recipients are implementing work plans across four domains care coordination addressing structural drivers of health Collaborative data and knowledge management and clinical community linkages and partnerships These domains were chosen by the AMA and ACPM Because they are the most important part of the work plan These domains were chosen by the AMA and ACPM Because they are inclusive Such that an organization who is leading COVID-19 prevention Medication and treatment could benefit from this grant opportunity But also leverage the grant to build upon their existing work to address root causes and advance equity Grantees are implementing different work plans Reflective of the needs of the communities are serving All grantee all the all of the grantees chose care coordination But only three chose data knowledge and management however AMA is providing education and technical assistance to all the grantees For all domains in order to provide capacity building opportunities We acknowledge a collaborative learning model So that the AMA provides space and opportunity for the grantees AMA is leading the evaluation efforts of this grant and the methods are reflective of a very short grant period. So we're utilizing quantitative and qualitative data to tell a story to the CDC through our reporting. We want to ensure that we're documenting and amplifying promising practices and strategies for the care of minoritized communities. I will pass it over to Dr. Jasmine who will introduce our very wonderful next set of speakers. Thank you, Maria. We will now listen to four recipients, award recipients, and learn more about their projects, challenges, and lessons learned. So our next, our first two speakers are both Alabama natives. Dr. Pauline Long and Dr. Jennifer Campbell, co-owners of Principal Consultant Pharmacists of MedPlus Consulting in Alabama. Dr. Long earned her doctor of pharmacy with honors from Samford University's McWhorter School of Pharmacy. Dr. Long serves as an affiliate clinical instructor of pharmacy practice for Samford University and is a member of the Association of Diabetes Care and Education Specialists and the American Society of Consultant Pharmacists. Dr. Campbell earned her doctor of pharmacy with honors from Samford University's McWhorter's School of Pharmacy. Dr. Campbell's certifications include lifestyle coach, diabetes care and education specialist, pharmacogenomics consultant, and medication therapy management. Good morning. I am Jennifer Campbell. And as she stated, we're with MedPlus Consulting. Our goal is to bridge the gap in healthcare. More specifically with this project, we are proud that we were able to bridge the gap of the COVID-19 response in minoritized communities, specifically low income, black, those with language barrier and transportation access. So who are we? As Maria mentioned earlier, we are the one recipient that has the physician PharmD collaborative and our physician, Dr. Marquesha Moore Jarman, she is a private physician. She is double board certified pediatrics and internal medicine, and she has a private practice in Hoover, Alabama. We collaborate with primary care practices. So pre COVID, we were able to provide comprehensive medication review to our patients, diabetes self-management education, and as lifestyle coaches, the diabetes prevention program, as well as others where we saw we needed to fit in. So 2020, we received a call from one of our county commissioners, and there was a need to have more outreach to the communities. Many states, as I'm sure you're aware, had mass clinic drives. Well, those in some communities were unable to drive there to access the care, just was not able to get there. Along with our Jefferson County Health Department, we were able to partner and to begin with Dr. Jarman to provide a lot of those offsite clinics, specifically in churches, et cetera. So that was how we were able to initially address the initial inequitable distribution of the COVID-19 vaccine. We're able to meet the people where they are. We were able to continue to do this in this project, and we were so pleased that we were able to expand upon and have an even greater reach. This allowed us to decrease the barrier to access. And because we were servants in the community, we were a part of the trusted messengers where people were able to come out to be seen, to ask questions. We were able to dispel myths, to have people to have a second opinion upon whether to be vaccinated if they knew someone that had tested positive, what to do. We were able to educate them on different levels as well. So of the communities that we served, two of them were public housing authorities. And we know in housing authorities, they serve low income. The two that we communicated with or that we served, they were 99% black. And one of the other institutions that we reached out to as well was a homeless shelter. So the first one I'm going to talk about is the Housing Authority Birmingham District, and it serves over 10,000 people, 99% of them identify as color, people of color. And there was a 70% percentage of them that were functionally illiterate. The second housing authority community we partnered with was the Fairfield Housing Authority. It serves over 700 people, 99% identify as people of color, and they also had a median income of $18,000 per year. The next is the Jimmy Held Mission. And not only did they serve as a homeless shelter, they also had other facilities throughout the city. One was for women and children. They also help people that were addicted to substances. So they would get them on track with a program to help with the addiction and also to help them to find employment. So we were able to assist them in their needs. And they house up to 160 people across all facilities. And their population makeup was 50% African-American, 48% white, and 2% Hispanic. For our project, the two domains that we focused on was care coordination and clinical community partnerships. My partner, Pauline, she's going to go more in depth on those two and how we strategize. Good morning, everybody. I am Dr. Pauline Long, and I am delighted to be here today to talk about our project. We are very proud of the work that we've been able to do in the city of Birmingham and surrounding areas. I just want to share a little bit of our best practices and things that we've learned as we've continued through. So we selected care coordination as a primary domain to focus on, primarily because we wanted to make sure that the patients that we reached, we were able to close that gap and ensure that they were able to receive their vaccines, they were able to be tested, and if they needed treatment, that we were able to refer them to a site to receive treatment. Primarily our motto at MEDS Plus is that we like to engage and educate. So we used community health workers to go out and engage the community. Before we moved in with the clinic, they would go out to the community, they would hand out flyers, they would answer questions, address concerns of the residents, and be able to just meet with people, meet them where they are, and ensure that all of their questions were addressed. The next phase of the care coordination was to ensure that we had the proper tools to provide testing, as well as the vaccinations and the treatment. So we just wanted to make sure that we had everything that we needed to go into the communities and perform this work. When we selected our immunizers, as well as the community health workers, we were very intentional about who we selected to go out into these communities. Because a lot of these people have mistrust of government, mistrust of healthcare professionals, a lot of them did not regularly see a healthcare professional, we wanted to ensure that the people that were sent out to assist them looked like them. Dr. Jennifer and I are both from the city of Birmingham, so we looked like them. We played where they played, we engaged where they engaged, and that was very important for us to be able to connect with them and become a trusted messenger in these communities. We used materials that featured African-American people so that they would feel comfortable talking with us and receiving the information that we were giving. We used a very simple process to coordinate care. We developed a list of providers who, again, fit the criteria that we look for with the community health workers. We reached out and established partnerships, and that was a simple phone call, email. This is the work as pharmacists that we're doing in the community, once we identify people who may need treatment. And not just for COVID-19, we spoke with people who were non-adherent with their diabetes medication. Dr. Jennifer had a conversation with a patient who was receiving a vaccine, which was amazing, but just speaking with her during the observation period for the vaccine, we noted that she was not taking her diabetes medication properly. She was not actually following the protocol that her doctor had set forth. And so there was a disconnect there, because if you want to protect yourself against COVID, which is amazing, very proud of you for doing that, but you don't want to protect yourself against the complications of diabetes. So it was very important to connect on those levels, have those conversations with people, and be able to refer them to providers who could assist in continuing their care. We created protocols and a referral process, and then we contacted the patients afterwards to close the loop, make sure they were either better, or if needed, be that they sought care after they tested positive for COVID. To dig a little deeper into the care coordination, when we're establishing that provider list, based on previous partnerships, we'd already established relationships with two FQHCs and our private physician, Dr. Jarman, so that if someone tested positive for COVID while we were out in the community, we knew that we could get them treatment if needed. We established a very easy referral process, made sure that we were able to get the patient to the facility if needed. This was very important because in housing communities, many of these people don't have reliable transportation, but the Housing Authority was very accommodating in this respect because they were able to provide transportation if needed, either to the clinics or to the treatment site. And the referral process, again, was very easy. We established a testing protocol where if they tested positive, they were contacted. Within a day, we went through a survey to determine if they should seek treatment. And fortunately, many of these patients did not need treatment out of the ones that tested positive because they were relatively young, they didn't have many chronic health conditions that warranted treatment. But if they needed to, we did have sites available for them to receive treatment. And then again, we wanted to close the loop. We wanted to ensure that if they needed treatment, they received it. If they did not need treatment, that we reached out again to ensure that they were feeling well and that they were able to resume normal activities. If they needed to be tested again, many of these people had jobs where they needed a negative test to return to work. We informed them of other sites where we would be so that they could come and receive another test at no charge. The second domain that we focused on was the clinical community partnerships. And this seemed kind of obvious because of our collaboration with our physician, Dr. Jarman. It seemed kind of obvious that we would choose this domain. But we actually took it a step further and really focused on establishing additional clinical partnerships as well as additional community partnerships and ensuring that we addressed many of the social determinants of health. With the clinical partnerships, we reached out again to other physicians, FQHCs who could see these patients, especially ones that didn't necessarily need COVID treatment, but may have, you know, we may have been talking about a family history of high blood pressure. We had a lot of conversations during the observation period and identified needs beyond COVID and COVID treatment. We established the clinical partnerships again with the community health workers who were able to go out and canvass the communities before the clinics. They were also able to assist patients with the forms at the clinics. As Dr. Jennifer said, 70% of these people are functionally illiterate. So filling out a basic health form proved a challenge for them. So our community health workers were very instrumental in just assisting that we got good information before we either performed a test or administered a vaccine. And then also with our community partnerships, we partnered with organizations such as HICA, which is a Hispanic coalition organization, the National Hispanic Nurses Association. We were able to reach the Hispanic community and just expand our reach. This grant allowed us the opportunity to expand into other communities that we had not had the opportunity to go into prior to receiving this opportunity. That picture on the left is just a picture of us and our community health workers at a clinic. We developed partnerships that helped us enhance our equity strategies. Golden Point Scientific Labs is a local laboratory in Birmingham that allowed us to use their testing protocol and allowed us to use their rapid test to be able to perform the COVID vaccine testing in the communities. Connection Health is the organization that identifies and trains community health workers. Our work would not have been possible without that organization. They were very instrumental in just giving us the capacity to expand our reach and go out into additional communities. And then the Jefferson County Family Resource Center is an amazing organization in Birmingham that provides resources to underserved communities. They do everything from provide healthy, fresh food boxes twice a week to assist family court recipients making sure that they have everything they need to also providing jobs and making sure that people are aware of employment opportunities and education opportunities in the community. We were able to dovetail with a lot of events that they were having to add testing and vaccines in addition to their events. There were also partnerships that assisted us with creating and disseminating information. So when we first completed our proposal, we said that we would create and distribute literature and different flyers and handouts to the communities. But you know, once we got, once we established the partnerships with these organizations, the Alabama Vaccine Confidence Network, the Alabama Department of Public Health, they already had amazing resources that were culturally sensitive. So we, you know, spoke with them, developed that partnership and was able to utilize their information to distribute to the, to the residents. And so we really focused on having clinics that not only allowed us to test and vaccinate, but to also allow us to address other social determinants of health. So there were, like we said, fresh food boxes, there were education and job opportunities for people at the clinics that we, that we served. Throughout the engagement period, from January to April, we offered various COVID services to the residents of the housing authorities. And these just, this just kind of showcases some of the numbers that we were able to do. January, as you can see, was a very busy month for us. Once we established a relationship with the housing authority, the vice president of community affairs gave us a challenge. Omicron was starting to surge and he was like, hey, can y'all go out and hit all of our communities all 14 of our communities in two weeks. And so Jennifer and I kind of looked at each other and we were like, yeah, I guess. So, so yeah, we were able to go out in and we, we hit 14 communities in two weeks and you see the people that we were able to reach. A lot of these, about 10% of these people were first doses, which was amazing in January of 2022. We were very, very proud of that. And just to be able to provide education, we had several people who would come to the clinics and just ask questions, just talk to us because they were unsure. And some of them received the vaccination, some of them didn't, but you could tell people that were just really weighing the decision, whether to get vaccinated or not. And we were happy to entertain their questions and address their concerns. As the month went by the the vaccines kind of, you know, tailed off a little bit, but we were still there. We were still offering. And then starting March and April, the second boosters were starting to come out. And so we had a lot of seniors who were very excited that we were in their communities. They didn't have to make appointments at the pharmacy or try to get to their doctor's office. We were right there in their neighborhood offering vaccines. These are just a few of our partners that we we were able to identify. This is just a few. We have many, many more that we were able to partner with and reach many organizations and communities that at the beginning of this, we really had no idea that we'd be able, that we had the capacity to reach, but the partnerships were really, really key. And the primary partnership that I really want to focus on is the physician pharmacist collaboration. As pharmacists, you know, we often talk that we're sort of underutilized in medicine. You know, we dispense the medications, especially in community pharmacy. We dispense the medication, we answer questions, but we, there's so much more that we have to offer. And so we're very excited about our partnership with Dr. Jarman. We've been able to, as Jennifer said, you know, help her diabetes patients with self-management education. It's allowed us to, her to broaden her reach because her day-to-day practices in her medical practice were undisturbed. She was able to see her patients in her office and we served as her boots on the ground in the communities, reaching patients that she may not have been able to reach without us. So we've been able to optimize those patient outcomes, as well as improve population health. And also just talking a little bit about the benefits of non-traditional clinic settings, by bringing healthcare into the community, we remove those barriers to care. We have many patients, as we stated, who don't use, utilize traditional healthcare systems. They don't go to the doctor on a regular basis. So we were able to reach those patients. We checked blood pressure. We did the CDC pre-diabetes screening test with a lot of these patients and talked about things other than COVID. And so Jennifer's just going to take another minute or so just talking about advocacy and in support of the non-traditional clinical settings. So as you can see, Dr. Pauline and I are very, very passionate about what we do. So as passionate practitioners, the next thing you want to do is to be able to advocate for those things that you can do, that are already in place. And then for those things that you cannot do, that you need to be in place. So right here, we've listed two things. The first one is a House representative bill that's already been introduced, and this is about the equitable community access to pharmacist services. So all of the things that we've been able to do, this would be able to continue on if there's another healthcare crisis, just to continue to help improve all of the outcomes that we all desire of our patients that we see every day. We know that the patient has a story for the doctor, the patient has a story for the pharmacist, the patient has a story for the family member, and it's all up to us to be able to connect that and be able to help where they need that intervention the most. Sometimes it's just one little message that they need to, just to click with them, why it's important, why they need to listen, why they need to do the things they do, why it's so easy to take the first step and we'll help you and guide you along the way. The other one is the Pharmacy Medically Underserved Areas Enhancement Act, and this is the most important one in my site, is that it provides us provider access. So for us to be able to do the things that we do, we still would collaborate with physicians, but then physicians would not need to worry about how are you going to reimburse us, because when we come to physicians, as pharmacists, the first thing you think about is that community pharmacist and what their salary is. This would take care of that. We would still be able to collaborate and be a provider as well and provide those services and see your patients. The other is the Collaborative Practice Act. Some states have provider status, our state, Alabama, unfortunately, does not. What we most recently have is the Collaborative Practice Act that's between our state board of pharmacy and board of medical examiners, and it allows us to practice clinically with physicians based on a protocol. So if we need to change medications, increase, decrease, de-prescribe, that's already set. We are able to access the patient and be able to update the doctor with what's going on, with what's already laid out in the protocol. So we just wanted to make you aware, and when you have that opportunity to advocate, advocate, advocate, to continue these great things that we do. Also if you, in your area, knowing what's available, being able to work with a pharmacist, there's so many different dimensions of pharmacists. You have pharmacists that just want to dispense. We're the pharmacists we want to be able to dispense knowledge, and there are lots of them out there that can help increase the capacity of your practice as well. So this is our contact information. We love to be reached. We love to share best practices. Also we would like to serve as a connector in your city, state, town. If you're trying to find a pharmacist, we have an extensive network that we work with outside of our state, so we will be pleased to connect with you in that way as well. So as you can see, we're just eager. We're ready. We're happy to be here and to be a grant recipient with our physician. It's just been an eye-opening for our previous years behind the counter, in the cage, and to be able to get out, to see people, to be there where we need them. If anything, it has just served the purpose or underscored the importance of us to be able to be in the community because we know we're limited with time, and to be able to access them and have them to freely talk with us has been immeasurable. It has served them well and served us just as well. So thank you very much for your time. Excuse me. Thank you very much for your presentation. As a reminder, please note your questions. There will be time to ask questions at the end, okay? For our next speaker, Ms. Zinnia Dong. She's Immigrant Health Program Associate of Northeast Medical Services, a federally qualified health center serving the medically underserved with a special focus on Asian population in San Francisco Bay Area. Ms. Dong received her BS in Neurobiology, Physiology, and Behavior from the University of California, Davis. And since 2017, she's led multiple organizational improvement projects, such as increasing screening rates for colorectal cancer and depression. Currently, Ms. Dong is involved in Northeast Medical Services COVID-19 response initiatives and expanding preventive health screening efforts for hepatitis B and tuberculosis, disproportionately affecting Asian communities. Good morning, everyone. My name is Zinnia Dong, and I'll be going over some of our best practices at NEMS, Northeast Medical Services. So here's the agenda for my presentation. So just to give a brief background of NEMS, we're a nonprofit community health center in the San Francisco Bay Area, been around since the 1970s, and was recognized as an FQHC in 1992. And today, we serve over 67,000 patients annually. In addition to primary care services, we also offer ancillary services, such as dental, pharmacy, physical therapy, acupuncture. So we call ourselves a one-stop shop because of the comprehensive nature of the services that we offer. And then on the right, you can see the distribution of our sites in the San Francisco Bay Area. We have 13 sites currently. So to give you an idea of our patient demographics, 89% are Asian, 80% are better served in a language other than English, 77% have Medicaid insurance, 7.5% are uninsured, and about a quarter are 65 years and older. Now, with that in mind, when we started looking into the preliminary patient demographic data of our COVID-19 testing, we noticed that the patients who were accessing these services in COVID-19 testing were different than our normal patient demographics. So we saw a 70% Asian compared to 89% Asian, 55% were better served in a language other than English. So the inverse of that would be 45% compared to our normal 20%. We noticed that 14% were newly registered, and of those, 84% were English speaking. So what we hypothesized is that the individuals who are accessing these services, a majority of them at least, were ones who were more tech savvy and knew how to navigate the system. And we were wondering why was it that the people who were accessing these services were so different from our normal population. Maybe our patients just don't know how to access these services or don't know that we are offering them. And so that influenced a lot of the efforts that we implemented moving forward. NEMS, we do have a history of always translating our documents and resources into Chinese since that is a large proportion of our patient population. But what we also did was we put out a lot of educational resources. We translated our education materials in Chinese, Vietnamese, and other languages as well. We set up five COVID-19 drive-through and walk-through testing sites across the San Francisco Bay Area to increase access of testing. And then when the vaccines came out, we produced videos in English, Cantonese, and Mandarin to promote the COVID-19 vaccine since, as many of you are aware, there has been hesitancy in receiving the vaccine. So we really wanted to make sure that our community at least knew that they were safe. So we had provider and patient testimonials for vaccine promotion. And so when Omicron came around, we were doing 600 to 800 tests per week, and we saw 30 to 35% positivity. So this really illustrates the impact of COVID-19 on our patient community. So this brings me forward to our project overview with this grant. These were the three categories that we focused on in our grant. For care coordination, we wanted to focus on reducing disparities and improving rates for COVID-19 testing, vaccination, and treatment among the AAPI community. We also wanted to identify opportunities and barriers to collecting additional patient demographic data. And then lastly, we wanted to strengthen existing partnerships. So for this presentation, I'll be focusing on the first and the third. So as I mentioned with Omicron, we had an increased burden on our lab department for PCR appointment requests. And so what we wanted to do to alleviate some of that burden was to pivot more towards distributing antigen tests if the patient would agree to it. So on the left is just a workflow diagram of something that our call center could use. So a patient calls in asking for a PCR appointment, and the call center staff could actually suggest to the patient, we also have these antigen tests. Would you want to take a few home instead? And it would be up to the patient. If the patient wanted or needed a PCR test specifically, then of course the call center staff can help schedule that. But if not, then they could just schedule them for an antigen test pickup. And so this really helped our lab department who were doing so many PCR tests during the peak of Omicron. And then secondly, what we also did was previously we had a, it was a part of our workflow requirement that if a patient wanted a PCR appointment, they would need to schedule an appointment with their provider. And we decided that what we could do instead to increase the access and also to alleviate some of that provider appointment burden is that the patient could be transferred to nursing. So we created a nursing triage, and then nursing staff could place a standing order if they saw fit to do so. Another approach that we did was to outreaching to our unvaccinated patients. So in California, we do have an online vaccination registry for COVID-19, however, it's not incredibly reliable because most of our patients have Chinese names and in this registry, you need to have the name exactly written the way that, you know, it's inputted. And so sometimes there isn't that 100% match. So what we saw was that we had a large number of patients who were unvaccinated in our medical records and an easy or a more direct way of reaching out to these patients we thought was to do a mass text message campaign. So on the left, you can see the English workflow, and then on the right is the Chinese workflow. And moving forward from this, we also did subsequent text messaging campaigns translated in languages such as Spanish and Vietnamese. And so this kind of created a clear workflow for the patients depending on what they responded to, whether or not they've actually received the vaccine, but just in our records, it shows that they have not yet. And like Dr. Long and Dr. Campbell, we also heavily used, counted on our community health workers. They were a huge part and they actually drove a lot of these outreach efforts to our unvaccinated patients. And so on the left, you can see some of the outcomes from our phone outreach. So over the course of four months, we outreached to over 4,000 people, and of those, 67% were already vaccinated. It takes a lot of time to call these patients, and so 67%, that's a lot of time spent on just finding out that the patient was already vaccinated. And of those, we were able to schedule 20 appointments for a first dose vaccine. Now I want to show you compared to the text messaging campaign, in a course of three weeks, we sent out text messages to 6,800 people. Of those, only 33% responded, and they noted that 84% had already been vaccinated. But in that three weeks, we were able to schedule more people for their first dose vaccine compared to the four months spent on phone outreach. And so next, I want to talk a bit about our partnerships. And so these pictures are pictures of single room occupancy units, which are congregate housing units that are quite common in San Francisco Chinatown. We were reached out to outreach to these residents at SROs because a lot of the residents at SROs also happen to be NEMS patients. These are 8 by 10 square feet rooms, usually housing entire families or elderly couples. They have shared kitchen facilities, shared bathroom facilities. So this is a very high risk environment for COVID-19 transmission. And so how we collaborated to reaching out to these SRO residents in an event of an outbreak, which was defined as three cases or more, was that the local health department gets notice of this outbreak. And they reach out to NECOS, which is a Chinatown community organization connected to a lot of other community organizations in Chinatown. And NECOS will notify NEMS saying that there is this outbreak at this SRO building. Are your community health workers available to do on-site outreach? And so the role for NEMS is we will call all of our patients in that building since we have access to that information, notifying the residents that there was an outbreak in your building. We will be coming to do on-site outreach in the following days. And then when they do on-site outreach, the community health workers will screen for symptoms and they're dressed in full PPE gear, screen for symptoms, door-to-door knocking. And if the resident says, yes, I do have symptoms, then the community health worker gives them like this bright pink paper, which acts as like a fast pass, if any of you are familiar with Disneyland or Disney World, it acts as a fast pass because there is a free community PCR testing service available in Chinatown. And so the community health workers will typically try to schedule it so that the on-site outreach is on the same day as the PCR testing is made available and tell the residents, take this paper with you, go to testing and you don't need to wait. Just take it and you can skip the line essentially. And so this was super effective because this was, this otherwise we wouldn't have been able to reach all of these SRO residents. And the CHW is the community health working team. They're not just reaching out to NEMS patients, they're reaching out to everybody in the SRO building. And they have the language access, which DPH does not. And through the funding of this grant, actually, we were able to provide what we call these survival health kits. And so when the CHW team does door-to-door knocking, they will also provide this kit that has Kleenex, hand sanitizer, antigen test kits, soaps, and they'll be also able to pass this out to help them in whatever way they need if it is helpful. So wrapping up, some key learnings from our time so far is to analyze internal workflows to minimize barriers for patients to access services, just shown by the lab workflow, the nursing triage that we did. Utilize technology to make targeted outreach more efficient and impactful, such as the text messaging campaign. Take advantage of existing partnerships with local community partners to identify new strategies to synergize and fill in service gaps. And the last one is key, build a community health worker team to increase access to more direct on-the-ground and culturally competent services. And I just want to end with some policy and advocacy. As I mentioned, NEMS is an FQHC, so we're always advocating for policies and corresponding funding that will leverage FQHCs to close the health equity gap. For innovation, definitely encourage you, if you are able to, to build a community health worker team and also advocate for additional fundings for these programs across the nation. For workforce, it's very important to supporting policies and programs and funding that will build the infrastructure for a skilled and diverse workforce pipeline for FQHCs. And then lastly, it's just for pandemic preparedness to begin advocating for resources so we are better prepared if another pandemic arises. So this is my contact information if you have any additional questions. Thank you. Thank you for your presentation. Next we have Dr. David Rice, and he's the Interim Chair of Medicine of the University of Texas Health Science Center at Tyler in Texas. Dr. Rice has practiced internal medicine for almost 30 years and has worked in various areas, including group practices, private practices, and inpatient and outpatient settings. And he's also worked as Chief Medical Officer of Mercy Ships, Caribbean Mercy, and Franklin Memorial Hospital. He also serves as Assistant Professor of Medicine and Resident Preceptor at UT Health East Texas's New School of Medicine. Well, hello everyone. Great to be here. I'm new to this type of group as my intro. I'm an internist. I've practiced internal medicine a long time, but I've been privileged to be part of this program that brought together a lot of different elements. And I think that's the biggest point of my whole talk is about the collaboration that we've had with a very diverse group of academics, private practice, federally qualified program, and even our, we have a University of Texas at Tyler and their School of Public Health. We've incorporated them into this process. So I'm going to try to go through that. I'm Dr. Long, these guys, I love to talk as well, and I can get sidetracked. I'll try very hard not to. So let me back up here. So we're doing collaborations to improve the social determinants of health and then with assessments and referrals. Like I said, it's really more about the collaborative effort that we put together with a pretty diverse team. Just a little background. So back about three and a half years ago, there was a big practice in East Texas called East Texas Medical System. They went bankrupt and the University of Texas put in an application to buy this place. It's about 11 hospitals, multiple clinics, many clinical practices, and they got permission to do this, but they had to partner with Ardent Health, which is a publicly traded company. So it brings together academics, and then you also have the whole business side of medicine that is very, very prevalent in what we do. So we have academics, product sector, community assets, UT Health East Texas Internal Medicine Residency Program was a big part of what we brought together this grant with. We have a federally qualified health system that I'll tell you more about, but we brought our Internal Medicine Residency Clinic into this federally qualified program called Family Circle of Care. And we have 60 internal medicine residents, and they have to have a continuity clinic, and this is where it is. And so we're serving a part of our community that is medically underserved, economically disadvantaged, and I am thrilled that we were able to get that in place. That's just started within the last year, and I think it's just going to be a great collaboration. We also have a medical school that's starting, and it'll be our first class next year. One of my colleagues is here, Dr. Paul McGehee. He is the Chair of Community and Rural Health. He's also our Smith County Health Authority, and he pointed out that between the residency and the medical school, we just have to have a way of educating our students and residents about preventative health. This is a great link to it. It's a great way to incorporate them into the process. They're seeing it. They're living it. They're having to practice it, and so we're very excited about that. We also have a preventative medicine residency starting next year, and that's another element to all this. Dr. Peter Pendergrass is here. He is our newly hired director for the program, and again, I'll tell you a little bit more about how we want to incorporate that. And then finally, we have the University of Texas in Tyler. They have about 10,000 students there. They also have a school of nursing as well as a school of public health, and we've also incorporated them into our program to try to utilize the skills that they can bring. A little bit about where we are. The clinic that we work with is in a socially depressed area of our community. They have a social vulnerability index, which was calculated several years ago. It's moderate to high, and I'll just show another slide about that that kind of points it out a little bit more, but the biggest element is language. In our community, it's mainly a Hispanic community. Language barrier is really large, even though in our clinic, the family circle of care has been great about their patient front people. Everybody's bilingual, but the providers, the residents, all the other folks that are involved in this process are not. We have translation services and all the usual type of things, but that's a challenge. Like a lot of places, a high burden of hypertension, diabetes. The work that you guys are doing with pharmacy I just think is wonderful. We have diabetic educators in our system, but they're not pharmacists. I like that idea. This is just a little bit more detail about this index that we used. You can see that they measure socioeconomic. I'm sorry, zero is really good, one is bad, but socioeconomic status and then household composition and disability, minority status and language, and then housing type and transportation just gives a little input about some of the demographics of where we are. Tyler Family Circle of Care, I'll say that wrong every time. I've called them FCC forever and ever, but they are just a great partner. They represent so much of what I've heard from all the other speakers here about what we're trying to do. They are fully committed to serving everyone, regardless of income, insurance status, ability to pay, race, anything. Anybody that walks in the door gets to see somebody, and that's where having something like a resident clinic is really, really good. Like I said, we have 60 residents and they have to see a lot of patients, and so we'll see anybody. And I love it because, you know, this is internal medicine, we deal not with pediatrics and that type of thing, but we see everybody from the 18-year-old asking for STD treatment to the 80-year-old that was sent home from the emergency room because they had heart failure. So it's a really, really good training program. They offer everything there, like I said, we do internal medicine, but there's family medicine, pediatrics, women's health, behavioral health. It's a nice clinic. So, the two parts of our project, we wanted to gather meaningful data for social determinants of health. This is part of trying to pull all this together. We want something that records what we're doing, records what the demographics are, so that we can take this forward and keep the process going. I'll say the word epic in our medical record system. Some people in here may cringe, other people may not. That's the system that we use, and it actually has, in our platform anyway, it has a social determinants of health part to it, and it's really going to be helpful, I think, because it will allow us to track and follow in a very well-defined metric way that we can pull back and take data from. We're looking forward to incorporating our preventative medicine residency program into this process. That's a big part of what we want to do moving it forward. We're looking forward, I think Dr. Pendergrass and Dr. McGehee pointed out that educating and having this element of training to link to this patient demographic and help educate our residents, help educate our other staff, and our community is going to be very, very helpful. I mentioned Dr. McGehee's here with the Smith County Local Health Authority. They really work a lot with us. I haven't talked a lot about COVID in particular. For us, in our community, when we first applied for this grant, we were just like everybody else. We were testing as many people as we could, we were trying to vaccinate, and by the time it all kind of came and went, we really weren't seeing a lot in our clinic. That element of our services was just a little bit less than where we had been, but having Dr. McGehee so involved with us, we can use our community health to help identify other areas of the community, but we can delegate different services. We have a mobile health van that we can send out to different areas, and that's been very, very popular. And then last on this part, we have this University of Texas Graduate Education Programs, and they have a school of public health, and we've been able, through this grant, to hire two graduate research assistants who will be working very, very closely with us. They have two main jobs. One is to help obtain our demographics so that when patients come to the clinic, they can meet them, greet them, and grab as much information as they can. And then the other part I'll talk about here in just a minute is our community outreach part, but we've been able to hire them through this. So on the care coordination part, that's the other side of the project that we're doing. What we noticed when we started putting all this together was that we had a very fragmented system for looking for any type of referral to a wide range of community services that we had. I actually noticed it from the residents. They would come in, they'd say, I have this patient, they don't have a place to live, they're living on the street, they have diabetes, they can't get their medicines. What can I do for them? We didn't really have a place in process to say, well, you can send them here and do this and call these people. And so a lot of what this grant is doing is we are reassessing all the things in our community. I mean, we're making phone calls. Are you open? What's the good phone number? Who do we talk to? How do we get these patients to you? And then we want to track it. We want to follow up on it. So in four or five days, we want to call, make sure that happened, talk to the patient, make sure they got it done. I think it'll be a great tool. It's going to take a while, but I think that'll be an important part of where we go with all this. And we want to structure it in a way that can be monitored, adjusted, transformed as we develop more sophisticated process and partnerships, as all this starts to settle and coalesce together, we want to make sure this tool is there to keep it going. So what's worked? We've created this setup between all these multiple entities. We've got a federally qualified health center, we've got an academic teaching center, we've got an internal medicine program, a preventative medicine program, school of public health, and we're all in the same building. We're there, we're talking, I've told the graduate assistants, you know, when you see something that doesn't work, just tell me. We'll fix it. We'll change it. Because I know there'll be things that won't work. We've implemented Epic, basically. Right now, it's still just paper because of the language barrier. A lot of times we'll give things out in Spanish, we'll ask people to fill them out and give them back to us, and then we'll enter them in. It's hard to do it in real time with folks who don't have a strong language linkage there. We've hired a graduate assistant, and then we're working on getting these community and institutional resources flagged. Some of the challenges, the COVID resources and needs have changed dramatically since the beginning. It's kind of the moving target right now, so we're still trying to see where we want to go with that and how we want to utilize our resources there. The staffing and coordination of different human resources departments, HIPAA, IRBs, that's just, it's just a logistic nightmare. If there's anything we can do to change that, and I know that's not for this discussion, but it's really difficult. We hire somebody at UT, then they have to be approved for the Family Circle of Care, and they have to be credentialed through them, and just one thing after another. I have a few other things to go through, but I want to take just a second to talk about this community trust. I think we've heard it in some other talks. This is a big deal. Our community is used to not being cared for as well as they should be. They don't expect a lot, but they deserve much, much more. The part, you know, we're in Texas, and there's a lot of political and a lot of other elements that come into this, and when these patients come into the clinic, they don't always want to talk. They don't always want to give you information, especially personal information or cell phone information, or how can we contact you? And so, that part about somebody, I think it was you guys that had it on your thing about, you know, people that look like and talk like and, you know, have the same experiences. I think that's a key element that I took from your presentation, that we need to get that type of thing into our clinic because it's a barrier for us. And then the longitudinal follow-up, we talked about the pandemic restrictions. I think the restriction part I put on there just because all of these programs that we're trying to connect with for services Many of them have been closed Defunded don't you know can't work because they use volunteers and they don't have volunteers anymore So a lot of the things that we thought were out there really aren't right now And then last part here just to kind of tie things together the fun part. We're getting these things together. It's coming by opportunities for improvement and expansion over the years. Work toward care delivery truly changes the needs to meet the needs of our clientele in a preventative fashion. And then regardless of COVID-19, identifying the social, emotional and long term impacts that seem to be coming with that. I think that's where we're gonna go with COVID. I don't think it's gonna be as much about the testing and vaccines and that part in our community. I think it's gonna So I was asked to say, you know, promising practices for us. We can do it with multiple organizations. It's a challenge, but they all have their strengths. They all have their challenges to them. But when you bring in, you know, people like Dr. McGee and Dr. Pendergrass, they bring the preventive medicine side. You bring the academics to it. It adds something to the practice. Not everything that has it doesn't have to be the practice, but it brings something to it. And then, you know, each part of it, the graduate education. The politics and policies I'm not really going to get into, that's just part of the lay of the land in language. I don't know where you get to it other than just trying to get more and more people that can be recognized as friends, who are recognized as people who are there to help, not necessarily trying to get anything else out of it. And so just a big thank you. We have a great team. Dr. Elliott and Dr. Escorino, couldn't it be here. Dr. McGehee is here, Dr. Pendergrass is here, and then Dr. Jeff Godfather-Levine. Jeff is kind of retired now. He's still working quite a bit. Big preventive medicine. He has been such a help to me. He's just guided me through this process quite a bit, so I had to mention him. But thank you very much. Thank you. Our next and final speaker, Dr. Emily Hotez is a developmental psychologist, researcher, and assistant professor of medicine at the David. The research program focuses on autism. to think about your lunches and all of that. So I'm going to do my best to keep. talk more about and when the RFP I my team and I really had a unique vantage point that we were operating from I'm a developmental I should say before I get started, here are the others who are on my team. I am alone here, but certainly this was a team effort, and I have on my leadership team preventive medicine physicians, Dr. Nathan Samras and Dr. Candice Gargnani, and they really work with me, since I'm a researcher, I don't work with patients, they really make sure that our quality improvement initiative and our strategies that we're implementing are really going to effectively speak to the needs of the patients they serve on the ground, as well as integrate effectively into clinic workflow, and also operate within the resources and constraints that are available to them and to their patients. I also work with several clinic champions. Our project is unique in that we are working with two clinics here at UCLA serving distinct populations, and in order to make sure that our initiatives are really speaking to those on the ground needs in the clinic and meeting the needs of our particular target populations, it's essential that I'm So UCLA serves an incredibly diverse patient pool, as you all can imagine, and the patient population really has experienced disproportionate negative impacts from the COVID-19 pandemic. So there were many target populations that probably could have been addressed in our project because we do see such a diverse patient population. As a developmental psychologist and an autism researcher, as well as the sister of an autistic adult, my work primarily focuses on neurodivergent and disability populations. So that was a population that I was really tuned into. I am working in my own research and consistently. on this population. And when I'm using the term neurodivergent individuals, I'm generally referring to. So although I am grouping them into one group, they all, within this population, there are distinct needs and disparities that also need to be addressed. So as I was... and I have here, we know that having an IDD was one of the strongest predictors of contracting and dying. case fatality rates of the general population, and that's obviously only speaking to the direct health effects of the pandemic on this population. They also experienced really profound social isolation and other psychological impacts. So as I was reviewing this research and also conducting my own research with this population, I was really attuned to the fact that those with other marginalized statuses were similarly negatively affected. team, it became apparent that we also really needed to focus on gender diverse populations as part of our grant. I'm generally referring to lesbian, gay, bisexual, transgender, and queer questioning individuals within that umbrella. We know that this population before the pandemic experienced pronounced minority stress, and they also experience compounded, this minority stress is compounded by poor access to health care and services and low access to resources, significant levels of stigma and marginalization across interpersonal, economic, educational, financial sectors and systems. So before the pandemic, this support, but during the pandemic we also saw disproportionate impacts. We saw that gender diverse individuals were two times as likely to experience intimate partner violence relative to the general population. This was worsened by disproportionate psychological distress during the pandemic and barriers to receiving support for intimate partner violence. So these populations obviously are high need populations. In our particular project, the broader context is Los Angeles County, which has an extremely high proportion of individuals who are living in poverty, individuals with disabilities, individuals without health insurance. LA County is really racially and ethnic diverse, so that's kind of the general context. So for this project, we're focusing on two specific clinics within UCLA Health. The first clinic is UC LEND, and UC LEND is a collaborative and interdisciplinary program of health professionals, as well as those training to serve individuals with disabilities. And the focus of UC LEND is to support those with neurodevelopmental disabilities and their families. And there are LEND clinics all across the country. So UC LEND is an example of one of those clinics. So the primary focus of UC LEND is to improve the care and outcomes for these individuals over the lifespan. So as you can imagine, this clinic does focus on neurodevelopmental disabilities, but because of the heterogeneity across the lifespan and also the heterogeneity within the category of neurodevelopmental disabilities, there are a lot of different needs within their patient population. But generally speaking, they provide diagnostic clarity, care coordination, educational advocacy, healthcare transition support, and parental support to this population. Another clinic within UCLA that we are focusing on is the Gender Health Clinic, and this is a clinic that strives to offer comprehensive medical and surgical care to LGBTQ plus populations in LA and also has a presence nationwide. It brings together experts from medical and surgical disciplines to deliver a broad array of services and has been recognized by the Human Rights Campaign Foundation as a leader in LGBTQ plus equity. It offers primary care services and a range of others for gender diverse individuals, including hormone therapy, facial reconstruction and body modification, obstetrics, reproductive health. So within UC LEND, similar to the other grantees, we've got a focus on care coordination, so we're really focusing on identifying promising health equity practices for reducing disparities. We are embarking on collaborative data and knowledge management work, which continues to be among the most challenging activities that we are doing because UCLA Health is such a large and complex network of care. And we are also striving to forge clinical and community partnerships. So as part of our initiatives, our primary work is focused on disseminating an emergency preparedness guide to all patients. And I'm sure we've all seen many pandemic and emergency preparedness guides circulating or being under development during the pandemic, but none are really specific to the IDD community who has distinct needs that can be supported through such a guide. And we're particularly proud about the way in which we developed the emergency preparedness. As an autism researcher, my primary lens that I use when I develop research studies is to develop research questions and research materials in collaboration with the community that I seek to serve. So it was really important that when developing the emergency preparedness guide, we solicited feedback from families about the priority resources that they would like to receive. And this was solicited through a survey effort run by Dr. Denise Nunez, who's also here at this conference. And the resulting English and Spanish guide is available online. And we also created a corresponding video walkthrough to make sure that the guide was accessible to our patients. So the guide provides educational and also local specific resources to help families and that's really critical because we wanted to make sure that we were speaking to resources that families could actually access on the ground within their communities. And the goal of the resource is really to help them navigate the COVID related impacts on services and health care and prepare for future emergencies. So we're hopeful that this guide can be further adapted and continuously refined to help families beyond the pandemic as well. And you can see the the guide in the link that I provided in in the slides. We're also identifying opportunities to enhance data collection within the clinic. Prior to the pandemic, UC Lend was a relatively new Lend clinic. So as I mentioned there are many Lend clinics but UC Lend was only established in 2016. So it's a relatively new clinic and data capacity is something that the clinic is working towards but hasn't quite achieved yet. But we recognize the critical importance of collecting data and tracking data to mitigate against health disparities within the clinic and in UCLA more generally. So a lot of our work in this area has been trying to trying to bring in all of the different social determinants of health and equity efforts that are ongoing within UCLA and try to join forces and create a really robust SDOH screening effort within UC Lend but hopefully after this project to scale it beyond other UCLA clinics. And finally we are conducting outreach to UCLA preventive medicine residency programs as well. Within gender health we have the same three general goals but obviously different activities that are really speaking to the needs of our target population. So we are actually developing a strategy for implementing and responding to the IPVT which is an intimate partner violence screener that has been specifically adapted for gender diverse populations. Historically the most efforts to address IPV have been in heterosexual couples and there's been limited attention on gender diverse populations and individuals. And this is particularly concerning because we know that intimate partner violence often takes on unique dimensions when directed against gender diverse, particularly transgender individuals. And the standard IPV measurement tools really don't adequately assess IPV against transgender individuals. So the most valuable piece of this activity has been forging a collaboration with the LA LGBT Center who focuses on this particular population so that we can pilot test the IPVT within our clinic and also train gender health faculty to respond to positive IPVT screeners. UCLA health is as I mentioned very massive but still under resourced and overburdened in many ways. And we in thinking through implementing the IPVT the concern was well we we need a response to positive IPVT screeners. We need to make sure that when we're implementing this we have a comprehensive and effective way to respond to individuals who need help. And the LA LGBT Center has been really instrumental in that and they're going to serve as the point of referral for for positive screens. And just as context the IPVT has four questions that assess the specific ways in which IPV often surfaces in gender diverse or transgender populations. So it asks about being forced to conform to an undesired gender presentation or to stop pursuing gender transition. It asks about being pressured to remain in a relationship by being told no one would date a transgender person. It assesses being outed as a form of blackness. So, as you can see, this is a really targeted screener to the needs of our population. We are also trying to bring in, bring gender health into the fold, into ongoing UCLA social determinants of health screening efforts and enhance equity through, through collaborating with those initiatives. And similarly, engaging UCLA's preventive medicine residency program in, in these efforts. We're really proud of some of our grant successes that we've had across our two clinics. For UC LEND, the emergency preparedness guide was really developed to have high utility for families and local communities. And we did that through a participatory approach to developing the guide through continuous and iterative surveys and focus groups and really working with families on the ground. The resource was also developed with diversity and accessibility in mind. It goes without saying that in LA County, the, the guide certainly had to be translated into Spanish, but also bringing in principles of accessibility and universal design and presenting information in multiple formats to really make sure that we are speaking to the needs of individuals with diverse experiences and preferences. The guide is available for caregivers and families, but as I mentioned, UC LEND serves individuals across the lifespan. So we wanted it to also speak to young and emerging adults who may also be patients in UC LEND and who may find it valuable to use this guide. In gender health, support from the IPVT developers for education and training. We've engaged with the developers of the measure who can support our efforts as we pilot test. Also support from the LA LGBT Center, who are going to, who already have been training our physicians and are instrumental in our referral efforts. And what's been really helpful across both clinics has been a really strong buy-in and working relationships from clinicians, researchers, and community members. As a researcher, it is, I, this is, this is my first ACPM conference and it has been incredibly valuable to be able to collaborate with physicians who are working at UCLA health who I may not have otherwise been collaborating with. It sounds silly because we're all in the medical school together, but there really are these silos between researchers and clinicians. And I am hopeful that the clinicians have also found it valuable because they always want some number crunchers on their side. And I, the specific skillset and lens that a researcher brings to their work can help make sure that it's scalable and sustainable and producing the effects that they'd like. Across both clinics, we've also identified mechanisms for dissemination and scaling. So although we are really honed in on these target populations and these target clinics, it's always in the back of our mind to think, how can we bring this to all of UCLA health? So we don't want to begin a piece of work that we think can only have impacts on this ACPM grant. We want it to be scalable and sustainable. And as I mentioned, the researcher practitioner partnerships to promote translation. So so often I do lots of research on health equity, but that's where it stops and I want to make sure that my work gets translated on the ground. In terms of next steps and future goals, I hope to continue to identify opportunities for scaling as well as continuous and iterative improvements to data capacity. The red tape with the medical charts and all of the bureaucratic things that you all know about, these are all challenges that we're continuously facing. And so there's continued efforts to work towards heightened data capacity and more coordination. And we'll continue to conduct ongoing community and stakeholder outreach as well. Please reach out with any questions or ideas in the future or in this conference. I am all ears and thank you very much. Before we move on to the second part of our presentation, I just want everyone to take a 30 second pause. We're going to do a breathing exercise just to get everyone refocused. So first, you can stay seated. Just, I'll ask you to take, to breathe in on a count of four, to hold your breath on a count of four, breathe out for a count of four, and then hold your breath again for a count of four. And we'll do two rounds of that. So first, breathe in. Thank you. So now we're going to bring back Ms. Maria Regalado who will summarize the challenges and lessons learned so far. So, I just want to, sorry, I wanted to summarize some of the challenges and emerging themes that we have witnessed throughout the grant period. So through our technical assistance and evaluation methods, we're gathering barriers, obstacles that the award recipients are facing, but also gathering the innovative ways that they're responding to COVID-19 related challenges. The grantees have faced policy barriers such as the lack of Medicaid expansion in states like Texas, Florida, and Georgia. They've also expressed challenges in staff having limited capacity to address clinical needs, but also address patient social needs. Fifteen out of the 15 award recipients, all of them have community health workers as the central tenet of assessing and addressing social needs. And engaging community members more broadly. However, many practices depend on grants and supplemental funds to support community health worker programs and community health worker program models. And they have challenges finding sustainable funding and streams of income to support this. Practices have also demonstrated that so far, in order to sustain adequate resourcing to address the needs of minoritized communities, there needs to be an increased reimbursement for screening and referral services that address structural and social drivers of health, as well as increased reimbursement for telemedicine services. What has been reiterated throughout this project is that to be an ally to minoritized physicians and patients, it's important to provide increased education and advocacy regarding the needs of safety net institutions or marginalized communities. The need for expansion of a telehealth policy with increased reimbursement rates, with attention specifically to multicultural able-bodied accessibility. It's also important to understand and advocate for community health worker models of care. It's also important to ensure that organizations have the funding and infrastructure as well as the knowledge to collect SOGI race and ethnicity data. It's important to review regulatory restrictions on mobile service delivery in communities. Also really important to advocate for formal position on ICD coding in support of increased reimbursement for screening and referral of social needs. And also for advocacy for Medicaid expansion across states. So this is, you know, the grant period isn't over yet. We're still gathering data and collecting stories. We felt that this was really important to elevate. was about, well I'll step back. So I'm the Deputy Public Health Officer for Riverside County and I'm overseeing our Division of Infectious Diseases, Community Health Planning, and Equity and serving as a medical advisor for our COVID response and I've been working very closely on the side of therapeutics and when I first came in we did some, collected some data looking at race, gender, ethnicity, and our therapeutics and what we found is that there was large disparities as you can imagine and who was getting the treatments and so we put a lot of effort into trying to shape our program around equity. With that said, we've still found a number of barriers and we continue to find that our numbers aren't where we would like them in terms of expanding access and so my question was about anything that you found that has worked or helped in terms of the, you know, we have the vaccine, we have the testing, but then that transition over to treatment, our test-to-treat programs, the federal ones through the pharmacies, we find are not necessarily working it to get in the patient groups that really need to be seen. We've created our own sites, have been partnering with community health workers, but we still see that lag behind. So my question is about the therapeutics. If you have any comments around Evusheld where we also see a lot of disparities and then down the line also long COVID, we continue to see disparities. So if anything that you've seen that's worked in any of those three areas I would really appreciate it. As far as access to therapeutics, within the patient population that we served, we did not have many patients that needed to receive therapeutics because they were otherwise healthy when we did our screening. But we just ensured before we started the project that we had access at several clinics, so our two FQHCs as well as our physician's office. And we just made sure that they knew we were going to go through this screening process with you, and then if you need treatment, we will find a way to get you there and make sure you receive the treatment. So it was really just the process of ensuring that they were aware that the treatment options were available and that they could receive it if they needed it. As far as expanding those other options, we didn't really have a lot of experience with that, but our thing is a lot of those patients weren't aware, the people that we saw weren't aware of what was available to them, and so that was a big part of what we did is just engage awareness. Not sure if that really answered the question, but we didn't have a lot of experience with therapeutics because many of them just did not, you know, pass the screening. All of these other things, there's expanded access for equity-related issues for therapeutics. And so, yeah, I guess I was wondering if you had any. Okay, another part of your question, I think, just so I make sure I'm understanding correctly, is there a lack of people coming to get the treatment? And you're saying that you were asking for how to educate on that? We either educate or help bring down barriers. There's probably a number of issues across multiple domains that we're trying to work through one by one. But if you had anything in terms of best practice that worked either for that or around education around long COVID. Okay, and you're Riverside, California? Okay, one thing that I would always say when it comes to the community is looking for a trusted partner. Because as Dr. Long just mentioned, a lot of people do not know that they're aware of, they do not know what's available as we do, regardless of what's being broadcast on the news, what may be on other platforms. So a lot of times getting to those trusted messengers, whether it is a community center, senior center, churches, schools, we also partner with our Birmingham City School System, which is an inner city school. They had COVID conversations. They had it where it could be with the parents. They brought in local pediatricians as the vaccine for ages five to 11 became available. That was one way to get them in to dispel some myths. They also had it where they could do it with the school age children. And they selected the people in high school that you kind of look up to. Whether they were cheerleaders, football players. So they were very methodical in who they chose to kind of lead those conversations and talk to the children to make sure that the information was put out there. As Dr. Pauley mentioned, when we collected the screening, not the screening forms, the health education forms from the other partners we had, you'd be amazed at people as they were reading it and being enlightened on the information that was shared. Simple information, the difference between quarantine and isolation. We just did a Zoom talk with the housing authority because they're having summer camp. And the camp counselors were on the Zoom call and we were giving them a COVID talk. And we were talking about testing, when to test, timing the test. And oh, by the way, did you know that there's treatment available in the form of a pill? So it really sparked conversation. But you have to insert yourself in those places of the people that are noticing that demographic that is not knowledgeable because they're not gonna come to you for it. I can just add something maybe from the community health center perspective. What we did was we actually, any kind of communication about a positive test result, we made sure to update it and say that we have, there are treatment options available, but you do need to contact your PCP immediately. So we had to revise a bunch of our, even for the antigen test kit FAQs that we created, we modified it so that it says, what happens if you test positive, well, you know, you do X, Y, and Z, also notify your PCP immediately, you may be eligible for treatment. So that's something that we. We partnered with the Jefferson County Area Agency on Aging. And as a result of that partnership, it wasn't specifically related to this grant, but as a result of that partnership, we were able to visit, they have about 17 to 20 senior centers in Birmingham proper. So we were able to visit several of their senior centers and offer vaccines to those seniors. And the area agency actually secured grant funding to provide incentives for the seniors to get vaccinated. So we were able to partner with several organizations that allowed us to reach senior centers. And again, this is a place where they congregate. Many of the centers had activities for seniors from like 9 a.m. to one. And so we would come in with vaccines during that time because they were already there. And again, it improved access because they didn't have to make the appointment. homebound patients. And I'll never forget, we were at a clinic and the news was there and Dr. Pauline told them, hey, yes, we do do homebound vaccinations because at the time our large healthcare system there, they had a radius and they needed help beyond that radius. So, one actually home healthcare nurse reached out to us and needed vaccines for some of her patients that were outside of that radius. So, we were able to accommodate with that. So, with the seniors in the senior centers, those that are mobile that can get out, then you have your nursing homes, but you also have your homebound patients as well Hi, thank you all for the presentation. Such thoughtful and passionate presentations. My question is, among the vaccine hesitant in your respective groups, what were the major categories of concern that fueled that hesitancy? I heard lack of knowledge, but I was just curious among these different groups what the concerns were. Okay, so in the city of Birmingham, at least once a year, they would have an event called Rocket Docket, and it was where they would meet at the auditorium downtown, and for misdemeanor tickets, you could come in, settle, that type of thing. We had already been partners with the Birmingham Municipal Court, so the representative there called us and said, hey, we're going to have hundreds of people down there. I'm pretty sure most of them need to be vaccinated. These are the dates. Let me know when you can come. We went. It was in the summer. It was during a surge, and actually CNN was there, so it was pretty interesting. It started maybe 8 or 9 a.m., but there were hundreds of people lined up before they started letting people come into the auditorium, so we did our interview with CNN, and Dr. Long and I decided, well, why don't we just walk down the line and ask people have they been vaccinated, and if they haven't, then we'll insert some information if they allow. We heard everything from the zombie apocalypse to the microchip to, no, I'm good, or, you know, I have an appointment next week with my doctor, and I can tell you the majority of people that we spoke with were under the age of 40, and they were African American, and the sense that I got from them is they feel like they're relatively healthy. They're out of that range where your parents took you to the doctor every year for annual, or you played sports and you had to get a physical, or they didn't have insurance, so they weren't seen by healthcare, or they haven't had an illness, so therefore they assume they are healthy. I would say that is one of the biggest misnomers because as we tried to, after we asked permission if we could provide some information about the vaccine, and they felt that they would get sick, and then they heard information from non-healthcare professional that clouded their judgment as well. Out of that time, we made, it was under 20 people that we vaccinated out of hundreds of people, and we went there twice, so even though our efforts were pure, they were set with what they felt was going on with themselves, the information on social. to that, you know, we're working with minoritized populations and these populations have historically been exploited in research and medical practice and there's a lot of mistrust of medical establishments and initiatives within these communities. I'm running a concurrent project to understand and address vaccine hesitancy. anecdotally effective when we're speaking with families on the ground is that there is an important combination of medical expertise along with community and kind of relational validation of vaccines. So having kind of that dual perspective has been helpful for some of the families that I'm working with as part of that project in promoting vaccine confidence. But generally speaking a lot of public health efforts really treat a lot of these groups as monolithic and what we've been learning is that as scientists and health professionals and people in the medical community we're now all kind of forced to be effective public health messengers. And based on what I've heard from my colleagues at least, I think when our patients hear from their community members or their friends about the effects of what happens when you get that second dose and how it puts you out for a few days, that's really scary for them. And especially if they have a job that isn't very empathetic towards that even though they should be. So they're worried about. In our community, it was pretty much what you would expect. It was two-sided. One. Thank you all for your really inspirational work and I think you've all addressed really also eloquently the dance that we do between our sort of scientific training and our love of data and our use of data and analytics and then our need to hear stories and build trust and realize that we can be really smart and if somebody doesn't want to talk to us or come see us, it doesn't matter how smart we are. But holding all that, my question kind of comes specifically from a piece of data that came from the work in the Asian community where you presented that one slide that you showed that in three weeks by texting you got 26, whereas 20 in four months. But nonetheless, there were like 10,000 people approached and that ended up with like 46 vaccines. And so I guess my question after all those words is just, the topic of this was elevating best practices and I was just curious, the initial slide said that this was a short evaluation period so you had to pick sort of what you were going to evaluate. But I was curious from your perspective, from all of you, with all of your outreach efforts, what do you think about the people that still didn't come forward, who didn't respond? Like what have you learned about those people and do we just need to keep going with these efforts or have you thought of different strategies? And the other question is, what do you feel? We are still outreaching to those who are unvaccinated. It's very difficult to come across someone who is willing to be vaccinated with their first dose after so much time has passed since they've had so many opportunities, but still doing a lot of phone outreach. I think the nice thing about the text messaging campaign is that it was an easy way to reach thousands of people, even though a good chunk of them did not respond, but we kind of had to deal with what we could get. I think we're still exploring ways that we can reach out to those who are unvaccinated, especially as there are new guidelines. Thank all of you for a really great presentations. I wanted to direct my question to Dr. Long and Campbell. I think what you all demonstrated and pulled together in terms of the collaborations and the partnerships and the referral and the care coordination and all of that, and how it was helpful for COVID, but also all of the other sort of chronic health conditions to me really demonstrate that need that was in the community anyway. And so my question to you all, and perhaps also to the colleagues from Texas, is would this have happened without this grant opportunity? And what's your plan for sustainability given the kinds of results that you all are seeing? many, many times over the last year and a half that we've been doing this work. And of course, the last six months or so that we've been doing it under this grant is how do we sustain this? And we know that particularly pharmacists are, as I stated before, underutilized in public health. And we know that we have a valuable impact on patients' lives. So we definitely want to expand this beyond COVID. Like we said, we'll, during the observation period for the vaccines, we're talking about family history and when was the last time you got your blood pressure checked? And for several clinics, we actually brought out blood pressure monitors and like I said, the CDC pre-diabetes screening. We recently submitted our CLIA waiver so that we could do point of care testing in the communities. So those are initiatives that we are working on so that we can have more of a global impact on their health and not just focus on COVID, but that, I use the term dovetailing with other events. We want to be able to say, okay, we, you know us as we're known literally in Birmingham as the two black women pharmacists who give COVID vaccines. That's what we've become known as, but you know, there's so much more to us. to make sure that our community members remain healthy. As far as sustainability, of course, that kind of keeps us up at night as well. We both have families to support, so how do we keep our business going? And we're just seeking additional grant funding. We're working with other organizations that also. I'll just ask, what's one piece of advice you would give to someone community health worker team that's I would also add collaboration, and I would be remiss if I didn't say specifically with pharmacists. And I understand that there's a burnout effect across all healthcare professionals as it relates to the COVID-19 response, but pharmacists in particular are, as I mentioned, okay. They would love to be able to help you implement, to collaborate, and as you can see, we can work solo. And that's going to enable you to be able to continue your day-to-day for your practice while expanding your reach, expanding your brand. I can't tell you how many referrals we made to Dr. Jarman. She has a nurse practitioner on staff now. She's expanded into other services. So her practice is very good and viable, and she stayed within her practice. We were her boots on the ground. So definitely collaboration, collaboration, collaboration. Ditto. In our particular setting, I think it comes down to education and educating not just, you know, the future providers that are going to be doing all of this, but the whole team from the pharmacist to the social workers to the caregivers to the front desk, because someone mentioned it, meeting these patients where they are is the only way that we're going to be able to impact their life. We can't dictate to them, at least not in our population, they don't take that well. You have to know where you're coming from. They have to understand you, and you have to understand them. Before we close out, I just wanted to encourage you all to go downstairs on the second floor and visit the exhibit hall. We have another project funded through the CDC supplemental project on vaccine confidence. We developed a campaign toolkit to help boost science. of the conference. Thank you.

COVID-19

minoritized communities

care improvement

partnerships

physician-led practices

best practices

low-income communities

black communities

language barrier communities

community engagement

Northeast Medical Services

Asian community

translation of materials

University of Texas Health Science Center

health disparities