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Southside Coalition paving way for better communication, better care among health clinics in South L.A

By Robert Fulton
California Health Report

It is 9 a.m. on a Tuesday and the St. John’s Well Child & Family Wellness Center in South Los Angeles is busy. More than 40 adults and children sit in the clinic’s large waiting area while the sounds of friendly conversations in Spanish and English, ringing cell phones and fussing youngsters fill the air.

In the middle of this, Olivia Mendez stands and begins to speak, first in Spanish, then in English, her voice rising above the buzz while her partner Evelia Castaneda hands out literature.

Mendez and Castaneda are Promotoras de Salud, or community health workers, employed by the Southside Coalition of Community Health Centers, a consortia of eight community health clinics based in the greater South Los Angeles area. The nonprofit Southside Coalition was established nine years ago as a way for a small number of clinics located in a limited geographic area with common traits to better coordinate services, improve access to both primary and specialty care, and present a united voice when it comes resource allocation, workforce development and communicating with their members in the community.

“The community health workers are a beautiful example of how we can collaborate,” said Dr. Felix Aguilar, CEO and President at UMMA Community Clinic and former Chief Medical Officer at the South Central Family Health Center, both coalition members.

Mendez and Castaneda’s task that Tuesday morning at St. John’s was to inform the community about health care reform, something they’ve done for the last two years and one of the coalition’s priorities. The duo visits one or two clinics a day, handing out information about health care reform while answering questions.

“We talk about everything,” Mendez said. “Our goal is to reach more people.”

East Los Angeles resident Jonatan De Leon approached Mendez with a question while waiting for a family member at St. John’s. De Leon, 24, said he’s been a legal resident for four years and wanted to know in what ways health care reform would benefit him. Mendez explained that while he will enjoy some benefits, additional benefits take effect following five years of legal residency. Mendez added that one of the more common questions she receives from the community is how will health care reform impact undocumented residents.

Edgard Augusto Jimeno, 33, didn’t know if he qualified for health insurance because he lacks income, so he took a brochure titled “Health Reform: Seven Things You Need to Know.” The Inglewood resident admits he might not pursue the matter further.

“I don’t know if I’m ever going to call the numbers and all that,” Jimeno said. “It seems like it’s a lot of work, but I might be wrong.”

While the Promotoras are a prime example of the Southside Coalition’s effectiveness in working as a unit, the collaboration is not limited to community outreach. The eight clinics have made concerted efforts establishing an internal referral system and sharing specialty care. St. John’s now employs a podiatrist that coalition members may refer patients to, and the To Help Everyone (T.H.E.) Clinic secured a retinal camera through the coalition’s efforts. Eisner Pediatric and Family Medical Center boasts a strong prenatal practice and does most of the deliveries for coalition patients at California Hospital Medical Center. Any of the clinics within the coalition can refer expectant mothers to Eisner.

The Southside Coalition has also made strides in care coordination. A pilot program at St. Francis Medical Center features a care coordinator on site. When a coalition patient enters the emergency department at St. Francis, the care coordinator makes sure that the patient seeks follow ups with his or her primary care provider. This improves continuity between hospital-based and primary care, and reduces emergency services utilization through education.

“I foresee that our coalition will continue to do more to bring us together, to enhance services for patients, to provide for greater collaboration, and also to connect the patients better with services,” Dr. Aguilar said.

The eight federally qualified health centers of the Southside Coalition are Central City Community Health Center, Eisner Pediatric & Family Medical Center, St. John’s Well Child & Family Center, South Bay Family Health Care, South Central Family Health Center, T.H.E. Clinic, UMMA Community Clinic and the Watts Healthcare Corporation. All coalition members are located in the County of Los Angeles Public Health Department’s Service Planning Area 6, the community of Lennox, or the city of Hawthorne; or receive at least 60 percent of their patients from those areas.

The Southside Coalition first formed in 2004, hired Nina Vaccaro as its executive director in 2006, and received 501(c)(3) status in 2007. Vaccaro reports to a Board of Director comprised of the CEOs of the eight participating clinics.

“Politically I think one unified voice is heard a lot louder than eight small voices,” Vaccaro said. “On the other end of that, it’s not just political. It’s looking at how do we actually improve care, and we really do a better job of that if we’re working together and sharing best practices, looking at programs and services that maybe one agency is doing really well.

“It was just kind of every man to himself, and (they) found they were competing for the same resources, competing for the same doctors and grants and patients,” Vaccaro added. “It didn’t make sense for them to compete with one another. It really made more sense for them to collaborate.”

Dr. Tracy Robinson, Chief Medical Officer at T.H.E., is quick to credit Vaccaro’s leadership as one of the reasons for the coalition’s success. “She’s very effective at communicating,” Dr. Robinson said.

The members of the Southside Coalition also belong to the Community Clinic Association of Los Angeles County. Fifty clinics spread out over the geographic expanse that is L.A. County make up the CCALAC, and Vaccaro stresses that the Southside is not in competition with CCLAC, but is instead a way for clinics with things in common to focus on their needs and challenges as a group.

According to Vaccaro, when the coalition was first established, the idea of referring and sharing patients made some in leadership nervous.

“Initially, we actually had a lot of conversations about what does it mean if I’m sending my patient over to your clinic,” Vaccaro said. “Do I trust that you’re going to send them back? We had some conversations initially with the administrators, and that was something they were really concerned about.”

According to Vaccaro, the medical providers assured administration that they had built relationships with patients, bonds not easily broken.

“We recognize that the benefits of collaboration outweigh the benefits of competition,” Dr. Aguilar said. “We emphasize through our community clinics a trust that they will send the patients back. Otherwise the system cannot work.”

Dr. Robinson of T.H.E. had a more pragmatic approach to the whole topic of referring patients.

“If a patient goes to another clinic because they have something there that we don’t have in our clinic, the patient is getting care,” Dr. Robinson said. That, he added, is a precious commodity for an underserved population.

By Chris Richard
California Health Report

Fifteen years ago, Los Angeles city officials reformed building inspections to crack down on slumlords, launching the nation’s first regular, building-by-building, room-by-room checks to make sure apartments met health and safety standards.

That was no mere bureaucratic adjustment. Before, the municipal Building and Safety Department checked up on a landlord only after receiving a complaint, an approach that drew criticism for overlooking abuses. Under the city Department of Housing’s “Systematic Code Enforcement Program” every one of LA’s 120,000 apartment buildings is inspected at least once every four years.

When the regular inspections started, officials identified 150,000 apartment units that failed to meet health codes. Today, the official count is a fraction of that, some 3,400.

Health activists say the dramatic statistical change could too easily lead to complacency. They’re calling for a new push focusing on allergens such as black mold and cockroach waste that they hold partially to blame for high asthma rates among children in some of the city’s poorest neighborhoods.

“We know that we have direct control over the indoor triggers that cause asthma and that are making our children sick,” said Jim Mangia, president of St. John Well Child & Family Center.

Mangia said St. John’s doctors must extract cockroaches from the infected ears of half a dozen children a week, and have no choice but to send them home to vermin-infested apartments where they face renewed attacks.

“What we need is more inspectors, what we need is more enforcement, and what we need is for inspectors to be educated about the ways that landlords will cover things up,” he said.

Mangia spoke at a recent press conference sponsored by the Asthma Coalition of Los Angeles County – to which St. John’s belongs – calling attention to the links between what they called poorly maintained slum housing and asthma.

According to the Los Angeles County Department of Public Health, just over 11 percent of the county’s adult residents and a little more than 14 percent of its children have asthma. But those are averages; in most neighborhoods, the asthma rate is from 5 to 8 percent. It’s considerably lower to the west and north, and much higher in the center city and South Los Angeles.

In one Asthma Coalition report, 28 percent of the children living in South Los Angeles’ Figueroa Corridor who were treated by St. John’s had chronic asthma. A survey by another Asthma Coalition organization found asthma rates of 24 percent for the population as a whole in the same neighborhood.

Last year, research by the University of Southern California identified a direct link between proximity to a heavy traffic and the prevalence of childhood asthma. Those findings have started to inform the discussion over air quality regulations. But two years ago, a Columbia University found a correlation as well between exposure to cockroach waste and dust mites and higher asthma rates among children. And activists say they haven’t seen a corresponding toughening of housing inspection rules to address that risk.

Activists and tenants say it’s too easy for slumlords to neglect basic maintenance.

At the Figueroa Corridor building where the recent Asthma Coalition event was held, tenant Gabriel Martinez said he repeatedly asked the building’s owner to repair a leak in the plumbing above his kitchen ceiling, but the problem went uncorrected for months. Martinez suspects the relentless moisture, which soaked a living room carpet, contributed to his three-year-old daughter Dana’s asthma.

“Everything seemed OK when we moved in, but when it comes to fixing problems, they’re not very good here,” Martinez said.

In response to complaints from Strategic Actions for a Just Economy, or SAJE, regarding Martinez’ building, Los Angeles County Public Health investigators alleged 22 violations of county housing laws during an April 24 inspection. The listed problems included mold contamination and cockroach infestation, said Gary Hirschtick, chief environmental health specialist for the health department’s mid-city district.

An inspector can order a landlord to remove the infestation or remove mold and its source, but can’t direct how that is to be done, Hirshtick said. Typically, a property owner will call in a pest-control company to fumigate against cockroaches.

As for moldy walls, “If we saw them painting over mold, we wouldn’t allow that. But after the fact, it’s kind of hard to determine how it was corrected,” Hirshtick said.

Greg Spiegel, public policy director at the Inner City Law Center, wants to see officials giving much more specific direction.

“If it was about the building structure, where the second floor wasn’t adequately supported, you wouldn’t say, ‘Just fix it however you want to,’” he said. “You’d require a certain kind of beam. You’d use the building code.”

As for vermin, he likened spraying poison along baseboards to kill roaches to “hitting them with a hammer. We know from 30 years of research that that only kills the cockroaches it hits or who come along while it’s still fresh. The cockroaches walk around it.”

Instead, Spiegel advocates removing food and water sources – covering trash cans and fixing broken plumbing – then sealing cracks in apartment walls. Using gel baits, which the cockroaches take back to their nests, eliminates infestations at their source, Spiegel said. Activists say they’re determined to ensure that’s what happens in the building where Martinez and his family live.

A Los Angeles city housing department official inspected the building on the day of the Asthma Coalition event, responding to tenant complaints about mold and vermin. The official took photographs, but further results of that inspection are not yet available in the city’s online database.

Paulina Gonzalez, SAJE executive director, said last September, in order to meet a city building inspection, the owner of the 14-unit building fumigated against cockroaches, repainted some walls and removed moldy carpet.

But she said some building walls continued to feel damp to the touch after the work was completed, a common indication that there may be corroded, leaking pipes inside. In such cases, cockroaches typically return after a temporary retreat, Gonzalez said.

Beverly Hills resident Joseph Heffesse, the building’s owner, did not respond to a request for an interview left with his office on May 7. On May 10, a woman who answered the telephone at his office said that Heffesse and his wife Sandra, who is listed on county records as the building manager, would not grant an interview.

Nancy Halpern Ibrahim, executive director of the nonprofit Esperanza Community Housing Corp., an Asthma Coalition member, acknowledged that this building didn’t approach the level of horrific neglect by other property owners that has occasionally sparked political denunciations and official crackdowns.

City records show that this property has cleared some 20 official visits since September 2005. City “systematic” inspections in December 2007 and September 2012 both noted unnamed violations and ordered remediation, which the landlord performed, records show.

But in April, when health activists investigated tenant complaints, they found sufficient evidence in a single day to support ten complaints, Ibrahim noted. Those were the same complaints investigated in the May 7 Housing Department inspection.

“County environmental health does some inspections, the Housing Department does others and Building and Safety is responsible for another kind,” she said. “And what we’re saying is that this is a fractured system.

“There’s a lot of ‘Well, that’s another agency’s responsibility.’”

Spiegel of the Inner City Law Center points to state Health and Safety Code section 17920.3, which describes vermin infestations “as determined by a health officer.”

Housing Department inspectors, not being officially designated as health officers, interpret this as meaning they can’t identify infestations and order them removed, Spiegel said. He says for the public good, they need that authority.

Finally, Spiegel envisions the city and county agencies collaborating on building-by-building problems. He said county inspectors, who check each building yearly, lack the time for follow-through.

“I could see a system where the county’s kind of doing triage, and if think a building’s dangerous, referring it to the city for a more full inspection,” Spiegel said.

“But right now, they don’t coordinate at all.”

By Rosa Ramirez
California Health Report

Several weeks after her 15th birthday, Alicia Flores simply stopped showing up to school. As a child, she dreamed of becoming a veterinarian or working in a day care center. But those dreams began to gradually erode. Teenage rebellion, peer pressure and her parent’s divorce began to occupy her mind.

Her entire ninth grade was a struggle. She couldn’t pay attention in school. She began missing classes. “I was doing bad in school,” she says.

By the time Flores was in the tenth grade at Junipero Serra High School in Tierrasanta, many of her friends were already spending more time hanging out in the park or at friends’ homes instead of the classrooms. It wasn’t long before she did the same.

“I was just not interested in school at all,” she says. “I didn’t think it was going to take me anywhere.”

Far from her home in Paradise Hill, a neighborhood in southeast San Diego, policy makers, academics and educators deliberate on ways to help the thousands of young people in California who like Flores, at one point, are neither in school nor work. Young people who miss out on early work experience are more likely to face unemployment in adulthood and are less likely to achieve higher levels of career success. Such missed opportunities invariably impacts their quality of life and health.

Deemed ‘disconnected,’ these youngsters are entering adulthood without formal education, work experience or social skills to compete in a changing work environment.

Nationally, more than 5.8 million–or one in seven– young people between the ages of 16 and 24 are neither in school nor in the workforce, a recent report titled “One in Seven: Ranking Youth Disconnection in the 25 Largest Metro Areas” found. The rates among disconnected black, Hispanic and lower-income youths are consistently and disproportionately high.

At 29 percent, blacks between the ages of 20 to 24 have the highest rates of disconnection than any other group, according to a December Annie E. Casey Foundation and Children Now study “Youth and Work: Restoring Teen and Young Adult Connections to Opportunity.”

In California, the number of disconnected youths has been on the rise.

More than 850,000 teens and young adults–roughly 18 percent–between the ages of 16 and 24 are disconnected, according to the Dec. 3 report. The state’s figures are higher than the national average (17 percent) and 35 percent higher since 2000. The report also found youth employment is at it’s lowest since World War II, with California ranking near the bottom.

Some observers say the problem can be traced to the nation’s changing work environment–one in which youths face stiffer competition for limited jobs. As an older generation delays retirement, fewer spots are freeing up for entry-level workers to move up, leaving college and high-school graduates to compete with experienced laborers for positions previously filled by workers with little or no work-history.

“More young people are taking part-time jobs just to pay the bills. Some are taking unpaid internships so they can have the experience. And many more are doing volunteer work to keep their resumes fresh,” says Terence Grado, director of national and state policy at Generation Opportunity.

Least-qualified workers, who generally tend to be those without education or work-experience, hurt the most.
“I felt it was hard for me to find a job because I didn’t have a high school diploma,” Flores tells the California Health Report.

She handed in dozens of résumés in person and submitted job applications online. She applied in grocery stores, family restaurants and fast-food chains. When a chain sandwich restaurant hired her but she never got any hours, Flores decided to join the Urban Corps of San Diego, a conservation corps and charter school that helps young people obtain a high school diploma and gain job skills.

“I had no way to pay for the things I wanted. No money for the bus,” Flores recalls. “I tried looking for work but did not have nice clothes to wear to the interview. I felt like I wasn’t the kind of person they wanted to employ.”

Being disconnected goes beyond not having spending cash. Research shows that joblessness as youths result in lower wages for years to come due to foregone work experience and missed opportunities to develop professional skills.

Disconnection can stunt their personal growth and hurts their self-esteem, stresses Kristen Lewis, co-author of the One in Seven report. “This is the time when you are deciding who you are. You are gaining educational credentials, you are building your networks–your very identity,” she says.

Myrna Contreras, director of student services with Urban Corps of San Diego, understands such hurdles. Many young people come to the Corps with limited or no work experience. Some arrive with the belief that “I’m not good enough. I don’t have good skills to compete in the workforce,” she says.

She says the program teaches them about personal responsibility—military style. Boys must shave daily and have their hair two inches from the scalp. Participants must tuck in their shirts. Punctuality is important. Being one minute late can get them sent home, Contreras says. They earn their high school diploma and get paid for cleaning streets, planting trees and removing graffiti.

About 36 percent are immigrants and refugees, with the rest being San Diegans; some 24 percent are women. “From the moment they walk into the door, we have expectations,” Contreras says.

Stephen Alcaraz, 21, of San Diego, said he wanted to help his single mother financially but didn’t have the credentials or confidence to find employment since dropping out of high school. He joined Urban Corps when a friend told him about the program.

Since joining the program, Alcaraz has learned about his talents and learned how to set and meet career goals.

“I’m good at math and formulas and problem-solving,” Alcaraz, who recently received a scholarship to pay his classes at a local community college, says proudly. He plans to transfer to a four-year university to study to become a civil engineer.

As for Flores, she has also noticed many transformations in herself since joining the program. She can talk to adults and groups. She can shake people’s hands and look them in the eyes. “I’ve learned a lot of skills,” she says. “I see a future.”