Central City Concern

Providing comprehensive solutions to ending homelessness
and achieving self-sufficiency.

CCC Celebrates National Health Center Week 2016!

Aug 08, 2016

“We choose to go to the moon … not because it is easy, but because it is hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win.”

President John F. Kennedy’s famous speech at Rice University in September 1962 captured the tone of the United States. It was a time of extraordinary innovation, responding to deep and complex societal problems. Lyndon B. Johnson’s Great Society initiative brought us education reform and the earliest roots of community health centers, which we celebrate this week during National Health Center Week. Civil rights leaders like Malcolm X, Reverend Martin Luther King, Jr., and Medgar Evers, among many others, led the movement against Jim Crow and socially and legally institutionalized racism. Stonewall birthed a new age of LGBTQ activism, while second-wave feminism brought us Titles IX and X and a sea change in societal attitudes toward women.

Today, we face a different but no less daunting set of social ills. Homelessness and poverty, along with the deeply entrenched social and economic disparities that drive them, are problems of such breadth and depth that they can seem immovable. Social planners and others talk about the concept of wicked problems, not merely hard problems that can be solved with enough resources and time, but deeply complex and interdependent problems with no clear causes or easy solutions. Wicked problems challenge us to think with creativity and clarity, to work collaboratively, and to be willing to try harder every day. They are problems of such scale and urgency that we can do no less than bring our very best.

At Central City Concern, our 800 employees, together with the 10,000 people we are privileged to serve every year and our many community partners, are deeply motivated by the wicked problems of homelessness and poverty: challenges that cannot be postponed and must be won. Working with limited resources to solve problems that may seem unsolvable, rather than being Sisyphean, inspires (and requires) us to innovate every day.

In celebration of National Health Center Week, we are profiling Central City Concern staff, patients, and programs within our Federally Qualified Health Center sites who are working to develop innovative and thoughtful solutions to the complex problems we face in community health work. These profiles represent some of the best of what our organization has to offer. I challenge you all to address your problems, no matter how great or small, with the strength of innovation.

Leslie Tallyn
Chief Clinical Operations Officer

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Visit These Profiles of Innovation at Central City Concern!



NHCW 2016: Using Data to Ensure Patients Receive the Right Care

Aug 08, 2016

Not long ago, Central City Concern recognized a gap in our health services. CCC’s substance use disorder services and specialty mental health services had multiple tiers of programs designed to meet a variety of needs—including acute teams for more complex clients. Our primary care health services didn’t. To fill that need, CCC created the Summit team, a new care team based on the concept of an ambulatory intensive care unit.

Like our substance use disorder and mental health acute care services, the Summit team was designed to serve patients who usually have compound health issues that place them at greater risk for an extra, higher level of care. The team limited its size by design so patients receive streamlined, in-house care from the fewest people possible. “The idea with Summit is to improve care for those who really struggle,” says Matt Mitchell. “So much of the design philosophy around it is: let’s keep it small.”


The team's low patient-to-staff ratio affords patients longer visits, home or in-hospital visits, medication management, enhanced and around-the-clock access, and more. But CCC quickly found that having the Summit team providing care was only half the battle.

“It turns out identifying who Summit patients should be… is really difficult,” Matt says. By virtue of the type of care the Summit team provides, the criteria for pinpointing patients—advanced illness that’s expected to deteriorate without more intensive care, isolation, a need for extensive medication management, medical complexity driven by untreated or severe behavioral health condition, among others—is only partially helpful.

“There are over a thousand patients who can check all the right boxes on that [criteria] form,” says Matt. “But Summit isn’t meant to serve all of those patients.”

Identifying patients who would be best served by Summit is a balancing act.

“On one hand, the Summit team is trying to organically figure out who they can best serve and who’s right for Summit. The clinical judgment of the providers is so important.”

Matt, a data and quality specialist assigned to work exclusively with the Summit team, supplements their judgment with data. “On my end, I’m trying to do the same thing in parallel, but with data analysis to identify who are the highest risk patients we serve at Old Town Clinic [CCC’s primary care health center].”

When it comes to the care of patients as vulnerable as those Summit seeks to serve, it would be easy to choose sides or put more faith in one approach over another. Providers versus p-values. Informed hunches versus analysis. Matt doesn’t see it that way. In fact, he believes utilizing a balance of both approaches ultimately serves patients better.

“The clinical judgment piece is so important because there are things we just don’t have data on. Data isn’t truth, it gives us some ideas of where to go,” he says. “But I think it’s really important to put data in front of clinical staff and decision makers to help remind them of things they wouldn’t have thought about otherwise.”

Matt’s role as the Summit team’s dedicated data analyst has proven to be incredibly beneficial to the way he is able to support the aims of the team. He sits in on each morning’s team huddle, participates in their discussions about patients and priorities, and is part of the team’s thought processes—activities reminiscent of the time he spent as a Boston-area outreach worker.

“Understanding what’s happening on the ground and having an idea of what the patients’ stories are helps me understand the limitations of the data so that ultimately I can use that data more appropriately and effectively,” Matt says. “Otherwise I’m looking at numbers and statistics all day. Our patients are more than that.”

In addition to analyzing and incorporating data to identify Summit patients, Matt is working on an exciting project that visually maps out the characteristics of all Old Town Clinic patients, onto which he’ll overlay Summit patients data points to identify areas they tend to cluster. “Hopefully this will give us a new perspective on identifying the patients who are really right for Summit,” he says.

The benefits of this innovative solution won’t be confined to Summit. Matt plans to use this project to explore patients of other specialized teams at CCC, like Community Outreach Recovery & Engagement (CORE) and Integrated Health & Recovery Treatment (IHART).

Matt relishes the freedom he has as Summit’s data analyst to sit with and think through problems. Ultimately, his approach, process, and solutions end up being richer and deeper, which means his work can be valuable beyond Summit.

“Our hope is that Summit can operate like a learning lab for the rest of Old Town Clinic, and ideas and things we pilot can be expanded elsewhere.”

And even when he finds himself deep in numbers, formulas, and maps, Matt is intentional about not losing sight of the people Summit serves.

“I love these patients; this is a population I care about. It’s important to me to use data to ensure that people get the things they need.”

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Visit These Profiles of Innovation at Central City Concern!



NHCW 2016: Creating Safety from Race-Based Traumatic Stress

Aug 08, 2016

Since opening a year ago, Central City Concern’s Imani Center program has been providing outpatient mental health and drug and alcohol addiction treatment services specifically tailored to address barriers uniquely experienced by African Americans in mainstream treatment programs.

JoAnna Smith, the Imani Center’s Lead Mental Health Counselor, quickly recognized a trend in the center’s clients that she had begun to see in African-American clients she saw in prior years: addiction and mental health struggles triggered, maintained, and exacerbated by the trauma of racial oppressions.

“We see so many clients with post-traumatic stress disorder, a lot of people struggling with unresolved trauma histories,” JoAnna says. “Many of our clients have felt unsafe, unwelcome, targeted and discriminated against by the community for much of their lives.”

JoAnna recognizes the power of past experiences, particularly how they can profoundly shape people, for better or worse. She’s quick to point out that her own past—growing up in Portland, accessing great education, honing her counseling and social work skills at internships in South Central Los Angeles—has culminated in the fortunate position she finds herself in now. JoAnna extends that understanding to Imani Center clients, whose presenting mental health and addiction symptoms are rooted in their trauma.

Looking for ways to improve how she served Imani Center clients, JoAnna started learning about trauma-informed care, which is a framework used in CCC programs. She dove headfirst into learning more about the approach, completing a trauma-informed service certification program.

“Trauma-informed care is not a therapy, it’s not an intervention; it’s a way of understanding those we serve,” explains JoAnna. “It’s a framework that acknowledges how trauma affects people. And it’s an important part of supporting our clients who come to Imani with co-occurring disorders.”

Learning about trauma-informed care excited JoAnna so much that she brought it to the rest of the Imani Center staff, asking them which area of the program they thought could benefit most from utilizing the approach. Unanimously, they decided that they wanted to bring the framework into group work. Doing so, JoAnna says, begins and ends with creating safety.

“According to trauma-informed care, safety is the treatment. Each Imani Center group facilitator is responsible for creating an environment that is safe. Maybe more than anything else that we do, more than any other intervention, if we’ve created a safe environment for our clients, we’ve done our job.”

Each Imani Center staff member has now been trained to be mindful of three areas in their groups to create the safety so essential to bringing trauma-informed care to clients: presentation, tone, and structure. And though this approach was initially geared to integrate into group work, JoAnna is thrilled that trauma-informed care has spread to all parts of the program.

“Starting from when a client enters our building and meets our office manager, to when they do their first intake appointment and screening, to the groups, we ask ourselves, ‘Are we treating clients with worth, dignity, and respect?’” says JoAnna. “That happens when we understand people are coming to us with a lot of trauma history and we remain mindful of that.”

Though a relatively new program, the Imani Center has courageously embraced an effective trauma-informed approach that asks more of each staff member—as JoAnna summarizes, “even more awareness, more hospitality, more compassion”—to better serve their clients. And it’s paying off.

“A safe environment enables clients to integrate their traumatic experiences into their life stories instead of having them at odds,” JoAnna says.

A core goal of the Imani Center is to be a place where clients can be who they are, where they can bring their past and current experiences—with addiction and mental health struggles, homelessness, unemployment, and criminality, as well as race-based discrimination and prejudice—in the hopes of finding healing. JoAnna believes that the training and awareness she and her colleagues have integrated into the program is helping clients do just that.

“We the staff are the agents of the structure. When we approach our clients from that trauma lens, we understand that we get to create the environment of safety for them, which makes a world of a difference.”

• • •

Visit These Profiles of Innovation at Central City Concern!



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