HealthyCal.org

By Marty Graham
California Health Report

When the San Diego Unified Schools District began its Farms to School program three years ago, it had the extra leverage of serving 130,000 meals each day during the school year. That makes its purchases on par with a major grocery chain.

But with the goal of serving meals where at least 15 percent of the food is grown locally, that means finding an awful lot of food nearby.

“We asked ourselves, how can we get the food that’s served at white tablecloth restaurants here, in our schools for our kids,” said Vanessa Zafjens, the district’s Farm to School specialist. “Because of the relationships we have with local farmers and our ability to commit to large, regular purchases, we’ve been able to get very high quality, very fresh organic fruits and vegetables.”

Zafjens points out that she’s the only fulltime Farm to School specialist in a California school district.

Moving kids towards healthier food isn’t new to the district. The lunch program launched salad bars nine years ago, Zafjens points out.

“There are kids who’ve been eating with us their whole lives,” she said.

The school district wants to lead students towards healthier food at a time when childhood obesity has been declared an epidemic, by serving fruits and vegetables so tasty that kids will naturally come back for more.

“It’s a learning process for the kids and it’s picking up steam, said Fred Espinoza, manager of acquisition and production for the district. “We’ve implemented the federal Healthy, Hunger-Free Kids Act beginning this year.”

Healthy Kids is a shift from the Food Pyramid concept to the healthy plate idea, with emphasis on fruits and vegetables, healthier grains and better quality food – which means fresh and local.

“The whole nation is trying to get their arms around this,” Espinoza said. “It really helps us that we have a great farm to school program – we love to have kids eating food that’s nutritious and delicious, and that has to start with fresh and local.”

But the county’s declared obesity epidemic, and the childhood obesity initiative have brought stronger emphasis – and better financing – than ever before.

Our first year, we purchased 180,000 pounds of local food,” Zafjens said. “Last year, it was 360,000 pounds.”

“One of our problems is we can buy all the produce a farmer can grow,” she said. “But at first, that’s asking farms to take a lot of risk. Now we commit to large quantities and we’re a consistent purchaser so more things become available.”

For example, this year the district is buying local nuts and tofu, for the first time. Micro greens, from another local organic farm, are part of every salad and every salad bar.

“We get opportunity buys, like tomatoes, avocados, oranges and even blueberries and blackberries,” Zafjens said.

The school districts commitment to purchase has helped organic farmers, including Stehly Farms Organics and Suzie’s Farm, according to Jared Bray, produce manager for Stehly Frams Organics.

“We started a number of years ago with navel oranges – having a reliable client of this size helps us plan our farming,” Bray said. “And if we can sell at near the price we sell to our retail outlets and it helps get kids interested in fresh, healthy food then we’re happy to do it.”

How fresh?

“What we pick today we ship within 24 hours,” Bray said.

“We started a number of years ago with navel oranges – having a reliable client of this size helps us plan our farming,” Bray said. “Knowing I this extra 10,000 pounds sold, it allows me to plan my harvest.”

Right now, Stehly is getting ready to ship blackberries, a fruit the students probably didn’t get a lot of.

The prices Stehly offers the school district are lower than the rest of its retail outlets, but Bray sees that as a good deal.

“The kids thoroughly enjoy the fresh fruit – you get them young and give them an interest in fruit they probably wouldn’t have gotten from eating the weeks old trucked in produce that once was the norm,” he said. “The kids are driving the demand and what they want is often something new to them, something the schools were able to introduce because of our special relationship.”

Photo: Melissa Flores/California Health Report

By Melissa Flores
California Health Report

Stopping the rise of diabetes is an ongoing effort in California, especially in counties such as Monterey, where the rates of the illness are higher than the state average. In Monterey, local and regional programs are working to prevent the chronic illness, which carries a hefty price tag and toll on health, with support from statewide efforts.

In Monterey County, diabetes prevalence increased by 83 percent between 2003 and 2009, according to California Department of Public Health Statistics. The statewide rates rose by 29 percent. The rate of diabetes is higher among Latinos, Asians and African Americans than whites. Latinos in Monterey had a higher prevalence of diabetes than whites – 10.7 percent compared to 6.3 percent in 2009.

“There is no data that explains why the prevalence of diabetes is higher in certain populations and counties,” said Corey Egel, a spokesman for the California Department of Health.

The cost of caring for patients with diabetes in California is $24.5 billion a year, according to a report from the California Diabetes Program. The report also found especially high rates of diabetes in California’s Central Valley region and among the uninsured.

The California Diabetes Program, started in 1981, has been working for the last three decades to create partnerships with organizations to prevent the continuing rise of diabetes, especially in communities with high rights of the illness.

Some behavioral and health access risks make patients especially vulnerable to developing complications from diabetes, including blindness, kidney failure and other problems. The risk factors include use of tobacco (20 percent), heart disease (8 percent), high rates of un-insurance (30 percent) and low rates of receipt of recommended services such as eye exams and influenza vaccinations.

But the larger task of the California Diabetes Program is to make connections with community organizations that work directly with residents on prevention and patients on management. In 2007, they hosted a strategic planning workshop with community partners in Monterey, Santa Cruz and San Benito counties to address prevention through disease management.

“A strategic plan to address diabetes prevention and control was then developed by the Regional Diabetes Collaborative, a program of the Pajaro Valley Community Health Trust,” Egel said.

One of the models that has been deemed successful for working with Spanish-speaking communities is called Project Dulce (Project Sweet.) It was developed by the Scripps Whittier Diabetes Institute in Southern California and is now being implemented through a grant from the Centers for Disease Control and Prevention by the National Alliance for Hispanic Health. Through the program, newly diagnosed patients learn from a peer educator how to control their blood glucose, blood pressure and cholesterol. The program has been shown to be successful at helping patients manage their diabetes.

The first classes offered through the grant started in December 2012, with another round of the 12-week session to start April 4. The local program is being administered through Salud Para La Gente, a federally-qualified health center that offers services in Santa Cruz and Monterey counties to uninsured residents and migrant workers.

Part of the CDC five-year grant will also be used to conduct a community-needs assessment to create strategic, action and evaluation plans that will guide future efforts.

One local hospital in Salinas is also working hard to combat one of the main health risks by offering education on healthy eating and lifestyles to patients at risk of developing diabetes.

According to 2009 state statistics, 63.1 percent of adults in Monterey County were overweight or obese, leading them to higher risk of developing diabetes. The same report, released in 2011, found there has been an increase in the number of adults who participate in moderate or vigorous activity between 2005 and 2007. Overall, however, less than 15 percent of adults engage in vigorous activity.

The Diabetes Education Program at the Natividad Medical Center in Salinas encourages patients to eat healthy meals in an effort to prevent diabetes. They hosted the Harvest Fiesta in October to show residents how to get active and eat healthy.

The event included fitness demonstrations, educational cooking demonstrations and samples of fresh food from vendors. A farmers’ market was also held during the activity to allow residents to buy healthy produce. The fiesta included sponsorship from other organizations focused on preventing diabetes and fostering a healthy lifestyle such as the Clinica de Salud de Valle de Salinas, the federally-qualified health center in Monterey, and the Monterey County Public Health Department.

The Natividad program tries to encourage healthy eating year round. They offer advice on the types of foods to eat such as dark, leafy greens, citrus, whole grains and fat-free milk or yogurt – items they refer to as “superfoods” – and provide recipes for using the ingredients in meals.

Egel, of the state health department, said California was also one of 10 states to receive funds to focus on smoking cessation, especially for residents with diabetes. In Monterey County, 18.6 percent of those with diabetes also smoke, which puts them at an increased risk for stroke and heart disease as well.

“The California Diabetes Program is conducting outreach to promote the incentives and drive traffic to the California Smokers’ Helpline for free cessation counseling,” he said.

Clinical care accounts for only twenty percent of overall, health according to the system used by the University of Wisconsin's County Health Rankings.

By Suzanne Potter
California Health Report

At 10:30 each workday morning, the employees at AnythingWeather in Palm Desert take a walk around the track at a park next door to the office. It’s a voluntary, paid 15-minute exercise break.

It doesn’t cost much – but on a large scale, getting more people to exercise could make a big difference. Studies show that regular exercise improves quality of life and can bring down healthcare costs by forestalling chronic problems like obesity, diabetes and heart disease.

This small effort is just the type of thing the Clinton Health Matters Initiative wants to encourage in four target regions: the Coachella Valley; Little Rock, Arkansas; Houston, Texas; and Jacksonville, Florida.

The initiative recently released the Coachella Valley Blueprint for Action report, which was produced at a marathon brainstorming session in December by 125 local health-care experts. The blueprint aims to help people live longer, healthier lives – and it encompasses many factors, not just access to health care.

The blueprint uses the County Health Rankings Model, which was developed by the University of Wisconsin. The model estimates that a whopping 40 percent of people’s health is determined by social and economic factors: levels of education, employment and income, social support from family and friends, plus the safety of the community.

Thirty percent of people’s health is attributable to their behavior: smoking rates, diet and exercise, alcohol use and sexual activity.

The environment, such as the quality of the air and water – and the layout of your town or city – account for another 10 percent. Michael Ozur, from the Riverside County Department of Public Health, says towns should be built to encourage physical activity: “If you can’t walk anywhere, bicycle anywhere, if it’s impossible to get anywhere except by driving, it’s a problem.”

Only 20 percent of people’s health is linked to clinical care, which encompasses access to health care and the quality of care a patient receives.

“We as a society are ignoring the other 80 percent,” says Dr. Glen Grayman, who is a leader with the initiative and serves on the board of the Desert Healthcare District and the Health Assessment Resource Center. “Health is not synonymous with health care.”

The Affordable Healthcare Act addresses only a small part of the problem, Grayman says. “We’re spending roughly 97 percent of our (private and public) money on clinical care. And nearly 100 percent of the ACA. Ninety-seven percent of our money is going to something that constitutes 20 percent of our health.”

“We look at health very holistically,” says Ginny Ehrlich, Director of the Clinton Health Matters Initiative. “We are looking at a model that not only talks about health care, but also talks about prevention and lifestyle factors, plus social and economic factors.” The blueprint identifies nine lines of attack and defines five bold steps that need to be taken for each category. Then it establishes a five year benchmark for success on each score.

One of the more ambitious goals is to establish a healthcare district for the eastern half of the Coachella Valley. It would be similar to the Desert Healthcare District, which is based in the wealthier West Valley and owns Desert Regional Medical Center and JFK Memorial Hospital.

Another goal is to put a system in place for electronic health data to be exchanged between all types of medical facilities.

The blueprint also calls for a plan to finally do something to save the Salton Sea, which could blanket Palm Springs with polluted dust if the Sea is allowed to dry up.

Other ambitious goals include doubling the number of local high school graduates who go on to college. And the valley hopes to attract 12,000 new good-paying jobs.

The initiative has hired a full-time administrator, Tricia Gehrlein, to coordinate efforts in the Coachella Valley. “I need to sit down and prioritize and identify what is already happening,” Gerhlein says. The goal is work with and build existing plans and projects.

“It’s really a balance of building upon what’s already there but then taking it to the next level,” Ginny Ehrlich adds, “and setting the bar even higher.”

The initiative will be tracking progress on the bold steps identified in the blueprint. They will maintain a quarterly dashboard on their website and issue an annual report charting the efforts. Their progress will also be highlighted at the annual Clinton Health Matters Conference, which is held each January in La Quinta in conjunction with the Humana Challenge Golf Tournament.

Steven Sample, an L.A. Care member, turned to the program when he was unemployed and needed surgery for a broken ankle. Photo: Robert Fulton/California Health Report

By Robert Fulton
California Health Report

When Steven Sample’s health provider quit accepting Medi-Cal, he didn’t know where to turn until he heard about L.A. Care Health Plan at a meeting near where he lived in downtown Los Angeles at the time.

Sample’s health emergency was a broken ankle he suffered stepping off a bus, and the injury required surgery.

“They paid for it, everything,” Sample, 63 and unemployed, said while enjoying a cup of tea of at Gold Star Hamburger in Glendale.

That first interaction with L.A. Care was more than a decade ago, and Sample continues to access the organization for health care benefits. He visits nearby Glendale Memorial Hospital and Health Center for his regular health needs, and is seeking treatment for diabetes and a kidney ailment.

L.A. Care Health Plan is the nation’s largest public health plan, providing coverage to approximately a little more than one million Los Angeles County residents. Medi-Cal eligible members can access care directly from L.A. Care, or through one of the health plans that L.A. Care works with, such as Anthem Blue Cross, Care 1st Health Plan or Kaiser. L.A. Care also provides free and low-cost coverage through its own Healthy Families, Healthy Kids and Medicare Advantage plans to low-income residents.

With the Affordable Care Act ramping up and the impending implementation of a state health insurance exchange, L.A. Care’s role in the new world of health care is evolving along with the reform.

“A lot more has become clear, but not final,” L.A. Care Chief Executive Officer Howard Kahn said of how health care reform is impacting the work his organization does. “The ACA is keeping us busy.”

Kahn estimates that between 600,000 and 700,000 people will benefit from Medi-Cal expansion in L.A. County, and half will access L.A. Care. He added that “whether or not we’ll participate in the exchange more generally is really something that we’re yet to determine.”

One of the roles that Kahn sees for L.A. Care is the organization acting like a bridge for health care consumers who experience a change in status or eligibility.

“The idea is that there needs to be bridges between key programs,” Kahn explained. “One of the concerns is that people who are moving in and out of different levels of income, poverty level and up, there needs to be continuity. There’s always historically been a lot of churn and people come on and off of Medicaid eligibility as they get a job or they get temporary work, etcetera, that there needs to be some continuity, and so there should be a bridge between Medicaid and other programs.”

“We’d probably be the biggest of the bridges,” Kahn continued. “We’ve been very actively involved in working with the exchange and the exchange staff on the concepts behind it.”

L.A. Care communicates with the wider Los Angeles community through its eleven Regional Community Advisory Committees, made up of members, providers and advocates. The RCACs are the eyes and ears of the organization, both dispersing information and receiving feedback. It was from an RCAC meeting that Steven Sample initially heard about L.A. Care.

Barbara Cook, Chief of Human and Community Resources for L.A. Care, said that the RCACs have heard plenty of questions and concerns as to how the Affordable Care Act will impact the organization’s members.

“We found that peer to peer education is far more significant than someone coming in on a white coat and saying these changes are going to happen and they’ll be good for you,” Cook said. “But actually getting your neighborhood involved and talking to you about these changes has really made a significant impact.”

L.A. Care’s RCAC system is part of what Chief Medical Officer Dr. Gertrude Carter said is the organization’s member-centric focus.

The oldest of 10 children originally from inner-city Detroit, Dr. Carter said she has an understanding of the challenges that an underserved population faces beyond just getting an appointment with a doctor.

With the Affordable Care Act, she sees L.A. Care’s member-focused approach all that more essential.

“It just gives you more members to focus on,” Dr. Carter said. “It’s always interesting to me that the industry classifies people by who pays for their insurance. The core work for medical is the core work no matter how the insurance is being paid for. The ACA only gives us more people to be able to do that core work best.”

Founded in 1997 and located on 7th Street near downtown Los Angeles, L.A. Care is a public agency guided by a 13-member board. The health plan is funded primarily through state and federal capitation.

Kahn sees little change in the way an L.A. Care member or consumer such as Steven Sample interacts with the organization. Actually, he hopes to see more continuity.

“Somebody who is already in L.A. Care’s Medi-Cal product, their interaction will not essentially change,” Kahn said. “The only thing that we hope, for their sake as well as ours, that they won’t churn on and off as much. Everybody in theory is supposed to be covered. Hopefully what will happen is, and this is one of the values of the Affordable Care Act, is that people will not suddenly lose their eligibility when they get a little bit of work. Instead what they’ll get is a subsidized product where they have to pay in a bit more in order to keep coverage. Hopefully what will result from that is a more robust, longer-term relationship with L.A. Care, or with any other health plan.”

Despite the challenges ahead, Kahn gets excited when talking about the future of health care and how the system will adapt, particularly having non physicians picking up more work such as pharmacies offering immunizations. Kahn is particularly adamant about moving away from the fee for service model of health care.

“The exciting thing for me is that we’re finally starting to address the issues that we have in health care, and the first one was to get most people covered,” Kahn said. “You don’t really face the questions, the challenges of, we spend too much for what we get, the quality of the system, etcetera, until you get everybody covered, because as long as a big chunk of people are not covered, it’s easier for them to slip through the cracks.”

Kahn uses an analogy of driving forward while keeping your eyes on the rear-view mirror.

Dr. Carter prefers to lay down a little philosophy.

“The solutions that you have today were to the questions that you had yesterday,” the CMO said. “The challenge here at L.A. Care is how do you start to morph into the system that we need for tomorrow.”