Zeroing in on Hardest-Hit Neighborhoods – and Focusing on Individual Needs

To further ensure we're being responsive to local needs, we refined the Future Well Communities program to deliver even greater impact in the years ahead.

First, we centered the program around prioritizing neighborhoods in Stockton that are facing the greatest challenges from diabetes and other diseases – including the downtown area, Southeast Stockton and the northwest. Within these underserved communities, we set a new goal: to improve the health of 10,000 people affected by diabetes by meeting their individual needs – linking them to multiple services and driving consistent usage.

A key part of this approach is to address multiple gaps by providing more than just one specific service. This is because we know that effectively attacking social challenges requires care that is all-encompassing. Every person faces different challenges. That's why we provide the customized, connected health and social services each person needs. We are bringing services to people, vs. the traditional model where people need to seek out the care they need.

We've also learned how important it is that services be provided by people who are a part of, and trusted by, the communities they serve – and that efforts need to be coordinated for maximum impact. So we're working together with new community-based partners, and putting a strong focus on collaboration across organizations and settings – making new connections to take a holistic approach in meeting people's individual needs.

Below is an overview of our partnerships across our three program pillars:

1. Making Healthcare More Accessible

• With Community Medical Centers (CMC), we're providing "group medical visits" to people with diabetes for education and peer support in managing their condition.
• With El Concilio California, one of the largest community-based, nonprofit social service providers in the Central Valley, we're providing door-to-door transportation services, making it easier for more people to get to their medical appointments and access other services.
• To address the shortage of trained healthcare workers providing diabetes care in Stockton, we partnered with University of the Pacific to:
  • Create four new educational programs: two diabetes certificates for clinicians and non-clinicians to help them better understand and manage diabetes; and a diabetes track within social work and nursing degree programs.
  • Award scholarships to Stockton residents committed to working in Stockton after completing their education to ensure local workforce needs are met, with services provided by people from the communities they serve.
  • Provide training placements for students in our Future Well Communities priority neighborhoods so they can gain first-hand experience, help provide vital services to their own communities, and build ongoing trust.

2. Reducing Barriers to Health Through Targeted Social Services

• With the Public Health Institute's Center for Wellness and Nutrition (PHI CWN), Community Medical Centers (CMC) and the Emergency Food Bank, we're piloting a Healthy Food Rx program to provide "food as medicine" to people living with diabetes. Food "prescriptions" are offered to people enrolled in the program through home-delivered healthy food twice a month for six months. Together with virtual cooking classes and nutrition education provided by PHI CWN and the Emergency Food Bank, these services help people eat healthier.
• With APSARA, a nonprofit providing services that promote economic independence, we're mobilizing a diverse, multi-lingual community health worker team that reflects the people they serve. Teams educate and deliver diabetes management tools, where residents are comfortable gathering. These efforts provide 1:1 community-based health and nutrition education in each of the priority neighborhoods, offering lifestyle coaching and case management to patients with diabetes – ensuring access to other health and social services as needed.
• We will work with multiple partners to conduct community awareness campaigns and health screenings to drive diabetes awareness and education across the priority Future Well Communities neighborhoods throughout the year.

3. Linking Services Together and Building Systems – For Maximum Impact

• With Dignity Health and others, we're working to establish an integrated system that will help to sustainably deliver community-based care for people with or at-risk for diabetes by addressing the social determinants of health. This coordinated care model elevates the role of community health workers (CHWs) to connect people with the specific health and social services they need in a standardized, outcomes-driven way. This work will help inform and is aligned with a broader CHW model in development in San Joaquin County, aimed at providing a centralized system to track services and tie payments to outcomes that improve the health of underserved communities.
• We are partnering with Unite US, an end-to-end solution technology company that builds coordinated care networks, to capture data on which healthcare and social services are being used and how often, while maintaining patient confidentiality. This will provide insights to allow healthcare providers to deliver better patient outcomes – and community workers to know which services are most effective.
• We're working with local partners to reinforce healthy lessons beyond the clinic and create local "health hubs" in neighborhoods. The sites, which may include community gardens, parks and health centers, are designed to encourage a sense of community and serve as welcoming areas where people can access the information and supporting services they need, such as food and health screenings.

We look forward to our continued work in Stockton — learning, iterating and adapting — to best serve the community in the ways that work best for them. We are committed to evolving the program and sharing the model with others to have an even greater impact in advancing health equity and transforming health for those who need it most.