Daytrippers from the Bay Area who head out to rural West Marin for hiking, biking and water adventures tend to wax lyrical about the stunning ocean vistas, rolling green hills, and access to farm fresh produce, oysters, wine, and organic beef and dairy. Tourists from around the world also flock to this pastoral Northern California enclave, home to the crowning jewel that is Point Reyes National Seashore.
But there’s another side that co-exists with all this natural beauty and bounty. Beyond the quaint town of Point Reyes Station, with its bakeries and bookstore full of folks who wear Lycra or drive a Tesla, including some Bay Area residents who own a second home in the area, there’s a largely invisible, mostly Latino, low-income labor force. These residents often struggle with food insecurity and affordable housing. Meanwhile, the rental market in the region is increasingly geared towards the high-salary tech set who favor this outwardly remote-but-gentrifying locale not much more than an hour’s drive from San Francisco.
Many of the region’s low-income residents—who work on farms, ranches, dairies, vineyards, and in food service and hospitality among other industries—receive their health care through what used to be called the Coastal Health Alliance, a medical provider that merged with the Petaluma Health Center in July 2020. The health center now includes two small seaside clinics in Bolinas and Point Reyes Station, in addition to its two main facilities, a mobile clinic and five satellite clinics in Sonoma County, where it serves around 40,000 patients a year.
For children and their families, this safety net health center prioritizes trauma-informed care, a framework based on safety, choice, collaboration, trustworthiness, empowerment, and the knowledge of how both trauma and family strengths can shape people’s lives. That’s vital because childhood trauma, without buffering from a caring adult or provider, can undermine physical and mental health throughout a child’s life . At the Petaluma and Rohnert Park Health Center locations, for instance, pediatrics is an integral part of the organization’s family practice model. The center offers families support for children who experience stress or adversity in their life and provides tools to build resilience and minimize the impact of these experiences.
Like many clinics in California, the center conducts screenings in both English and Spanish using a tool called the Pediatrics Adverse Childhood Experiences (ACEs) and Related Life Events Screener, known by the acronym PEARLS. This questionnaire can help determine which patients would benefit from additional assistance. Screening for ACEs and social needs in pediatric clinical settings promotes early intervention for childhood trauma and can serve as an entry point for safety net clinics committed to providing trauma-informed care, especially when these tools are combined with other efforts to promote resilience with patients and families.
“Patients and families are ready to have these ACES screening conversations,” notes the Petaluma Health Center’s Rachel Joseph, a bilingual family nurse practitioner with a master’s in public health, whose clinical practice takes her to the center’s locations in Point Reyes Station and Bolinas. “And now we’re more prepared to meet them with skill and the right linkages to healing.”
Family advocates key to success
As part of CCI’s Resilient Beginnings Network, the Petaluma Health Center is strengthening trauma-informed care at its West Marin locations. Staff have received training from the nonprofit Trauma Transformed on trauma and resilience-informed systems, known by the acronym TRIS, on how to help support well-being in their organizations through those practices. The pandemic was an extra challenge in an area buffeted by hardships, including natural disasters like wildfires and floods. But it did not deter the center from hosting virtual parenting support groups, training providers in the ACEs Aware program, and ensuring that new hires are trained in ACEs and toxic stress as part of onboarding.
“Engaging with patients about ACEs isn’t as scary as it seemed,” according to Jessicca Moore, a Spanish-speaking family nurse practitioner and director of innovation at the Petaluma Health Center. “For some patients, understanding the impact of ACEs can be the missing piece that helps them understand their lives and challenges.”
And that’s not all. The center created a multi-disciplinary team – including Latina family advocates — to reach community members where they are most comfortable and ensure that families at risk get the help they need. Such settings include home visits for new parents, outreach to families at local schools, and community events in the evening designed to foster connection and trust with working patients in isolated areas who may face multiple barriers to accessing medical and behavioral health care.
“There is nobody who knows the lives and experiences of the patient community that we’re so honored to serve like the family advocates,” says Joseph. The clinics’ pediatric population is largely comprised of Latino children with Medi-Cal health insurance. Joseph views primary care as a tool to advance health equity and racial justice and sees patients as powerful drivers for change in the health care system. The advocates “have these rich, deep, long relationships in the county,” explains Joseph, the director of quality improvement for the Petaluma Health Center and the project lead and liaison for RBN, referring to school advocates Glenda Mejia, Cristina Salcedo, and Samantha Gutierrez, Spanish-speaking Latina residents who themselves have children in the local schools.
It’s all about building relationships and trust with clients—understanding language, cultural, and economic barriers and being open to conversations around those challenges, the advocates explain in a Zoom conversation on the work they do and the roles they play. The RBN team work closely together to ensure that patients get the help they need in an efficient manner. The family advocates are skilled at providing so-called warm hand-offs: they can call the clinics directly to ensure a patient gets on the schedule without having to go through a call center. In West Marin Elementary School in Point Reyes Station, there is an iPad available for appointments, and parents are encouraged to schedule private behavioral health visits at the school, a familiar, convenient, and safe space for many. “I’ve been asking parents here at school how [it’s working] and I’ve heard nothing but good news,” says Mejia, who works at the West Marin Elementary School and Inverness Elementary School.
The warm handoff — from patient advocate to provider, including behavioral health providers — has been key to the program’s success, say advocates and providers alike.
“The family advocates are really the heart and soul of our RBN partnership,” says Joseph. “They’re an essential part of our team.” The advocate positions are full-time and funded by the county via the school district; the health center also provides the advocates with an honorarium, including gift cards and offers wellness support and holistic health services for these frontline workers, who weather the brunt of the trauma and toxic stress families share and need to take care to protect their own health and well-being.
Identifying children and parents who may be dealing with trauma or toxic stress can be difficult for care team providers, especially those that have experienced their own trauma. Health centers now appreciate that providing trauma-informed care and becoming a trauma-informed center cannot only focus on care of patients; they also must create a supportive environment for team members. This can include team debriefs, opportunities for reflection, leaders modeling self-care and work-life balance, and communicating about and providing access to resources to mental health services, known in healthcare as behavioral health.
The RBN team, which meets consistently every two weeks, strives to foster genuine and authentic relationships within the health-care team. The crew keeps it real: Conversations around structural and interpersonal racism and white supremacy in the community and its impact on health outcomes, access to services for low-income people, and housing, food, and transport insecurity, have all been on the table.
Moving forward, the advocates would like more practical training about how to handle some of the situations they encounter in the schools. Joseph agrees. “What’s needed is for community leaders like the advocates, who are already trusted, experts and doing the work, is to get paid well enough to want to stay in and grow in the work,” she notes. “We also need more advocates and to invest in them both financially and with top-quality mentorship, with a pipeline to train and retain those interested [in working] as mental health clinicians.” This would help with both retention and burnout, she says.
“There’s nothing to me more valuable in this partnership than finding a way to justly compensate people in a material way for their invaluable contribution to their community,” she says. What’s also exciting, she says, is that more health centers are working to invest in community health worker models.
Ongoing success of this work depends on advocates training more advocates, clinicians orienting new clinicians to the processes around the partnerships, and, in an ideal world, a space where the team could meet together regularly and collaborate in perpetuity, adds Joseph. She’d also like to see data-gathering in place through the center’s electronic health records to track how many patients access the clinics’ help through this program and what kind of impact the program has in terms of families accessing services. “We see families go to the greatest lengths to ensure that their children reach their greatest potential,” says Joseph. “As a clinic and community partner, we’re left with the much simpler job of connecting the last dots when families need support.”
Patient navigators crucial for reaching far-flung families
In addition to the family advocates, the team now includes a Latina patient navigator, Judith Bravo, a long-time West Marin resident with a passion for racial and social justice. Bravo pioneered and leads a Loteria event that meets monthly in Point Reyes Station and Bolinas and may soon expand into Tomales. Bravo also assists the team by serving as an intermediary and connects patients and families who screen positive to community resources. The RBN partnership also works with two county-based playgroups that offer developmental support to patients and families with ACEs and children with developmental differences.
Despite its considerable gains, the system still needs improvement. Joseph notes that many children seen by practice leads are still not being routinely screened for ACEs. The health center plans to bring in Latino pediatric behavioral health providers to shadow care teams with the largest patient volumes to understand this challenge more clearly and to offer real-time feedback on screening approaches and technical support.
Meanwhile, the RBN team leads continue to reinforce ACEs screening workflows with clinic medical assistants. They also remind providers what documentation will trigger the recording of ACEs screening and counseling in the center’s electronic medical records.
Joseph says that she anticipates that once the center integrates its community playgroup referral plan into its ACEs screening workflow, screening and referrals to services will markedly increase. The team would also like to conduct informational interviews with families who have been screened for ACEs so the clinic can better understand how to capture ACEs data and how to destigmatize the screening and response experience for families.
The idea is to collect this feedback in the context of a focus group in the team’s existing Loteria groups. (Loteria is a game similar to bingo. This evening event is designed to accommodate working parent families.) There is free food and childcare, and it’s held in a safe, welcoming space. It’s a touchpoint for people in the community, Joseph explains, a way for people to connect, for the health team to establish credibility and trust, and for community members to receive referrals to health care services.
Finally, this RBN team also refers patients to a county-wide service that provides both home visits for the parents of newborn babies and information, support, and referrals to families of infants and young children. Lael Lambert, nursing services manager for Marin County, oversees Healthy Families Marin Home Visiting, a program affiliated with Healthy Families America, which tracks children from birth to age five. Home visits help families build a stronger bond with their child despite challenges such as geographic isolation, low income, single parenthood, and anxiety and depression that can put children at risk for adverse childhood experiences.
The barriers in West Marin are significant – from rural isolation to cell and internet connection problems to travel and transport issues to access health care and social services in the county. Typically, home visitors conduct hour-long weekly visits for the first six months after a child’s birth. During COVID-19, visits were conducted via Zoom. After the initial months, visit frequency is based on families’ needs. The community health workers or home visitors, also known as promotores de salud or simply promotores, are bilingual, bicultural, and experienced in assessing new moms and providing support, education, and resources to high-risk families.
For all these efforts in the community to make a difference in patient care, and prioritize ensuring West Marin families survive and thrive, team members agree success comes down to consistency, authentic honest feedback, a warm relationship between team partners—and continual investment in those on the frontlines doing the work.
As team member Mejia notes, they’ve come a long way. She and her fellow family advocates each started with a tiny square of an office and no training or resources to speak of beyond what they literally brought to the table. She remembers crying the first day on the job—Mejia was overwhelmed: where/how to get started? Then a parent came in and talked for 90 minutes about a host of problems. Mejia started calling clinics and other social services and in the process began putting a resource list together. “If I ever leave or something happens, the person that would [take my place] has everything they need now. I have things in order,” she says. “I do it because I know it’s important for our families.”
Meet patients where they’re at—literally. Some of the most important health care happens outside of the clinic walls. An outward facing lens—particularly in a rural, remote setting where many at-risk patients are geographically isolated, is crucial to reaching patients in need. For health care needs, a mobile clinic has proven popular. Family advocates in the local schools have been vital for connecting patients to care and behavioral health, as has the evening Loteria session for working families. Ditto home visits for new moms and playgroups for parents of young children: There is the possibility of doing more and doing better when you meet patients where they’re at.
Nurture community connections. Family advocates in the schools are frequently parents’ first point of contact on health care matters, including psychosocial concerns. These community peers are approachable and accessible and can help parents efficiently access the care they and their children need in a timely fashion.
Center the wellness and resilience of staff. Clinic burnout, toxic stress, and attrition is real, especially during the pandemic. Ensuring that essential workers are connected and their health a priority allows the staff to have the capacity to assist clients and helps to prevent the re-traumatizing of patients the health center is intending to serve.
Protect team time. Prioritizing a consistent time to check in and investing in staff around ACEs screening, resilience-building training, and other trauma-informed care helps to ensure the long-term sustainability of these efforts. In a multi-disciplinary team doing challenging work, it’s essential to schedule in time to connect to work through kinks, offer support, and tackle issues.
Think beyond Zoom meet-ups. Get to know team members beyond the virtual screen and Brady Bunch-like squares. Attend community events. Visit family advocates in the school. Have community team members come to the clinic, meet the staff, talk to providers, and see the space. Pay a visit to a mobile clinic or stop by a playgroup. These are all potentially informative and powerful ways to make meaningful connections and have an opportunity to understand the strengths and limitations of each setting.
The Petaluma Health Center is part of the Resilient Beginnings Network, a learning program that promotes trauma- and resilience-informed care so that 100,000 young children and their caregivers in the San Francisco Bay Area have the support they need to be well and thrive. The Resilient Beginnings Network is powered by the Center for Health Innovations, an Oakland-based nonprofit that fosters health equity and innovation in the health care safety net, and by Genentech Charitable Giving.
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