Why a Check Off the List Isn’t Enough

At Contra Costa Health Services (CCHS), “do no harm” just doesn’t cut it. The county health system, serving an area in California where social health factors can make up to a two-decade difference in life expectancy, has a much different goal in mind: to make Contra Costa County “the healthiest community in the nation” by 2020. That means doubling down on its commitment to address the complete health needs of patients and their families, however they define them.

A key hand in bringing that vision to reality is Mariana Noy, Mental Health Program Chief of Outpatient Social Services. In her role, Mariana oversees a diverse team of over 50 medical social workers, peer supporters, community health workers, health navigators, clerical staff and mental health clinicians across 14 clinics.

A former social worker herself, Mariana is no stranger to the day-to-day challenges and joys of social service professions. She applies her social work experience and focus on relationship-building and compassion to her work today, whether overseeing the launch of an autism evaluation center or steering a 5 year resource connection pilot project for super-utilizers of the system.

We sat down with Mariana to reflect on CCHS’s efforts to build trust with its community, how resource referral programs can avoid marginalizing patients, and why the future of health sits with community health workers.


Health Leads: How did CCHS start building a relationship with the community?

Mariana: We started with a conversation. In 2014, we had a team that went out to waiting rooms and asked patients about their biggest health needs. We expected to hear about their diagnoses and disease processes, but it was really about having enough access to healthy food and transportation to their appointments. That started our thinking about our role and responsibility to connect patients to resources essential to health.

Now we facilitate conversations with community members wherever we can. We bring in consumer panels to talk to executives and the line staff about their experience with our system – the good and the bad. We involve patients in co-design and improvement projects. Sometimes we run focus groups and go out to the community where people are already holding meetings and get their feedback.

Really, building trust is about being brave enough to go out there and listen and hear what our gaps are — hear where we’re doing well and where we’re failing — and take it as an opportunity to go deeper and change.

So once a program is in place, how do you engage patients regarding their needs without further marginalizing them or losing trust?

The work of ensuring people have their essential needs met isn’t just checking off a list of standard screening questions and giving someone resource information. It’s actually about making a connection with patients. So ask their permission. Do they want to continue with the survey? Do they want to stop it at any point or revisit their answers at any point? Respect their responses and go along with where they are in wanting to address those problems. A lot of times we prioritize getting something done, but it’s not always the right time to talk about food insecurity or housing assistance. If you offer resource assistance and they say, “No, I’m fine,” then respect that.

What are some of the pieces in place at CCHS that set it up for successful social services navigation, and what challenge is Contra Costa grappling with now?

We’re lucky to have leadership buy in and understanding that providing these resources is in our system’s and our community’s best interests, so the challenge for us is engaging all the workforces that are doing this work already — clinical social workers, community health workers, public health nurses — and coordinating their work at scale. We’re also really good at testing new workflows and trying new things. It’s one thing to fill a gap at one clinic, but we want to address essential resource needs in a more systematic way so we need to actually push pilots outs so that everybody that touches our system has equal access to addressing their social health needs.

What are some well-regarded resources or best practices to train community health workers?

Training curriculums and resources aren’t rare, but reality is dynamic. Each community and system is different. Our programs have to flex with changing waivers and available resources. So we’ve found that often homegrown trainings make the most sense.

A good example is The Spirit Program, a partnership with our local community college to train people who have been consumers of our mental health system to work as cultural brokers in our behavioral health department and health services. It came about because funding was made available through the Mental Health Services Act to hire a peer workforce, but there wasn’t a standard training available. So now the college trains them and offers college credit.

What needs to be done to ensure that community health workers are a sustainable role?

First, health services are based on billing. It’s easier to sustain the services that we can bill health plans, so we need a mechanism in which we can bill these services. Right now, Mental Health Services Act is the biggest source of funding our peer programs and in an ideal state, we would be able to bill all contacts that address social needs much like doctors and mental health clinicians bill for services. That’s one piece.

Second, bringing in people from the community with lived experience is crucial to the success of these roles. When I say lived experience, I’m talking about people that have been in prison or in jail, so they can help people transitioning with chronic health conditions back into the community. People who have immigrated to this country and can help support others in their native language. A lot of the people who access our system don’t necessarily trust our system. We need cultural brokers to reach out to patients, and we need to show we value their expert lived experience like any other with our funding.

What kind of commitments or actions do we still need to see from institutions to achieve health equity?

Our current state is the result of decades of explicit and implicit bias against communities of color. To achieve health equity, we need to acknowledge institutional racism as a cause of generational poverty and commit to the belief that everyone deserves to experience well-being and optimum health. Health systems need to examine their sphere of influence and become more active within their communities.

At CCHS, we participate in a program called Healthy Richmond, where we not only look at improving access within our system, but also our entire community health network. We also focus on improving health literacy across the county so our patients are better able to understand information and make appropriate health decisions. We have a workforce development initiative that brings together community stakeholders to provide learning opportunities in healthcare for youth. And that’s just off the top of my head.

Ultimately, until everyone has a fair opportunity to live a long healthy life no matter what age, race, ethnicity, gender-identity, income or neighborhood or other social condition, our work isn’t finished. We need to acknowledge that and then start building these types of bridges.

How do you stay motivated and continue in this challenging and emotionally draining work?

This is really hard work. In the documentary What Counts, you can see the CareConnect program team reflect back on the story of Jerry dying with dignity. What wasn’t shown in that movie was that our staff were in the room when he actually passed. We’re dealing with human conditions, death and dying, chronic conditions, homelessness. Even in a system like CCHS where the leadership commitment to address social needs is really high, it’s still really hard work. But it’s also really fun and important work. When you hear “no” or encounter a barrier, take it as a gift. You know what the barrier is, so build around it. Don’t give up, believe in your work, believe in your teams — and create teams that believe in this work too.