Throughout the process of our innovation, we took several critical steps that were important for its success. Here are some of those steps and their significance: Needs Assessment: Conducting a thorough needs assessment was a crucial step. It involved gathering evidence, data, engaging with the community, and identifying the specific health disparities and social determinants of health affecting our target populations. This step provided a solid foundation for designing interventions that were tailored to our communities specific needs and priorities. Community Engagement: Actively engaging our communities throughout the innovation process was vital. We involved community members, leaders, and stakeholders in decision-making, program design, and implementation. This ensured that the innovation was responsive to their needs, incorporated their voices, and empowered them as partners in the process. Community engagement built trust, fostered ownership, and increased the likelihood of sustainable impact. Partnership Development: Building strong partnerships with various stakeholders, including healthcare systems, community organizations, and funders, was essential. Collaborative partnerships brought together diverse expertise, resources, and perspectives. They facilitated the sharing of knowledge, leveraged collective strengths, and ensured a comprehensive and coordinated approach to addressing health disparities and social determinants of health. Cultural Competence: Embedding cultural competence throughout the innovation process was critical. We recognized the importance of understanding and respecting the cultural nuances, beliefs, and values of the communities we serve. Cultural competence helped build trust, ensure the relevance of interventions, and improve health outcomes by tailoring approaches to align with the community’s cultural context. Evidence and Data Collection and Analysis: Collecting and analyzing evidence and data were fundamental steps in evaluating the impact of the innovation and informing ongoing improvements. We utilized both qualitative and quantitative evidence and data to monitor progress, measure outcomes, and identify areas for refinement. Evidence and Data provided evidence for advocacy, supported decision-making, and guided resource allocation to maximize the effectiveness of interventions. Evaluation and Learning: Incorporating an evaluation and learning component allowed us to assess the innovation’s effectiveness, identify lessons learned, and adapt our strategies accordingly. Regular evaluation and feedback loops ensured continuous improvement and enabled us to refine our approaches based on the evolving needs and realities of our communities. Sustainability Planning: Planning for sustainability from the outset was crucial. We developed strategies to ensure the long-term viability of the innovation beyond the initial funding period. This included exploring diverse funding sources, building organizational capacity, and fostering partnerships to secure ongoing support and resources. Each of these critical steps contributed to the success of our innovation by ensuring community-centeredness, cultural relevance, evidence and data-informed decision-making, and collaboration. By taking a comprehensive and systematic approach, we were able to address health disparities and social determinants of health more effectively, making a sustainable impact on the health and well-being of the communities we serve and are members of.

Weekly Community Meetings: These regular meetings were crucial for discussing health and health-related social needs issues. We emphasized cultural humility, which means being open and respectful to our cultures’ sameness and differences. These meetings were instrumental in fostering a sense of community and mutual understanding, which is vital for our work. Whole-Person Health Discussions: In these sessions, we focused on the concept of whole-person health, which means treating the whole person instead of just their illness. We strategized ways to improve access to healthcare and health-related social needs services for our community members. This holistic approach has led to an improvement in the overall health and wellbeing of our community members. Collaboration and Problem-Solving Sessions: These meetings were dedicated to collaborative problem-solving. We worked together to identify solutions to counter the impact of Medical Racism causing health and health- related problems. By pooling our resources and knowledge, we were able to identify and address issues that affect our community members. Evidence and Data Analysis Meetings: In these sessions, we used our evidence-data integration-qualitative-quantitative data analysis approach to seek and solve the continuing problems with the mismatch between what acute and chronic health problems we are experiencing versus the majority culture health narrative that “The Pandemic Is Over.” These data-driven meetings have been crucial in informing our strategies and interventions. Consultation with Unkitawa: We provided consultant services to Unkitawa to support their completion of site review for initial license to become a Behavioral Health agency. This collaboration has been key in expanding our scope and resources. Through these meetings, we have made significant progress towards our goals. We have seen a reduction in our death rate relative to white folks and an increase in client enrollment. We have also made strides in addressing the impact of Medical Racism and improving access to healthcare services. Despite the challenges we face, these meetings have been instrumental in driving our work forward.

Engaging our staff in this process was a multi-faceted approach that involved regular communication, collaborative problem-solving, and continuous training and development. Here’s how we engaged our staff: Regular Meetings: We held weekly meetings with our staff, which included healthcare professionals, social service professionals, multi-media specialists, data analysts, business and faith professionals. These meetings served as a platform for staff to voice their concerns, share their insights, and contribute to the decision-making process. Collaborative Problem-Solving: We encouraged our staff to work together to identify solutions to the challenges we faced, particularly in addressing the impact of Medical Racism and improving access to healthcare services. This collaborative approach fostered a sense of ownership and engagement among our staff. Continuous Training and Development: We provided ongoing training for our staff, particularly for those in the AT-HPP program and those hired as community health workers. This not only equipped them with the necessary skills to perform their roles effectively but also demonstrated our commitment to their professional growth. Our team comprises various members, each playing a critical role in our success: Healthcare Professionals: They provide the necessary medical expertise and guidance in addressing the health needs of our community members. Social Service Professionals: They address the social needs of our community members, providing necessary support and resources. Multi-Media Specialists: They help to culturally competent disseminate information and raise awareness about our work and the issues we address. Data Analysts: They play a crucial role in analyzing data to inform our strategies and interventions. Business and Faith Professionals: They provide necessary administrative support and foster a sense of community and faith among our members. Community Health Workers: They serve as the bridge between the community and the healthcare system, providing necessary support and resources to community members. Interns: They bring fresh perspectives and contribute to our work while gaining valuable experience and skills. Each team member plays a vital role in our work, and their engagement and commitment are critical to our success.

In our innovation project, we implemented several new approaches to hiring and capacity building to better address the health and health-related social needs of our community members. Hiring from Within the Community: Recognizing the importance of cultural competency in healthcare, we prioritized hiring staff and interns from the communities we serve. This approach ensured that our team members have a deep understanding of the cultural nuances, language, and specific needs of our community members. This strategy has been successful in fostering trust and rapport with our community members, leading to improved engagement and outcomes. Training and Development Programs: We introduced the AT-HPP program and provided ongoing training for our staff, particularly those hired as community health workers. This approach aimed to equip our team with the necessary skills and knowledge to effectively address the health-related needs of our community members. While this has been successful in enhancing the competency of our staff, it also presented challenges in terms of time and resource investment. Collaborative Hiring Process: We implemented a collaborative hiring process where existing team members were involved in the selection of new hires. This approach aimed to ensure that new team members would be a good fit for our team culture and values. While this has been successful in fostering a cohesive team, it has also lengthened the hiring process. Capacity Building through Partnerships: We partnered with Unkitawa to support their completion of site review for initial license to become a Behavioral Health agency. This partnership not only expanded our scope and resources but also built our capacity to provide comprehensive health-related services. However, coordinating and managing partnerships also presented challenges in terms of communication and alignment of goals. Overall, while these new approaches have led to several successes, they have also presented challenges. We continue to learn from these experiences and adapt our strategies to better serve our community members.

Centering equity and anti-racism was a fundamental aspect of our planning and implementation process. We recognized the deep-rooted systemic inequities and the impact of racism on the health outcomes of our community members. Here’s how we centered equity and anti-racism: Cultural Humility: We emphasized cultural humility in our approach, which involves recognizing and respecting the diverse cultural backgrounds, experiences, and perspectives of our community members. This approach allowed us to foster trust and establish a foundation for equitable care and services. Community Representation: We ensured that our team included community representatives from African American, Eritrean, Somali, and Ethiopian Oromo-speaking communities. This representation allowed us to incorporate diverse voices and perspectives in our decision-making processes. Addressing Health Disparities: We specifically focused on addressing health disparities and the impact of Medical Racism. We analyzed data and evidence to identify disparities and actively sought solutions to counter them. By acknowledging and addressing the systemic factors that contribute to health inequities, we worked towards creating a more equitable healthcare system. Culturally Appropriate Services: We developed and provided culturally appropriate services that consider the unique needs and experiences of our community members. This included language support, cultural sensitivity training for staff, and tailoring healthcare services to align with cultural beliefs and practices. Engaging the Community: We actively engaged the community throughout the planning and implementation process. We sought input, listened to community needs and preferences, and incorporated their feedback into our programs and services. This community-centered approach ensured that our efforts were responsive to the community’s needs and priorities. Continuous Learning and Improvement: We continuously assessed and evaluated our practices to identify areas for improvement and ensure that our services were equitable and anti-racist. We actively sought feedback from community members and staff, embraced a culture of learning, and made necessary adjustments to our approach. By centering equity and anti-racism in our planning and implementation, we aimed to address the systemic barriers that contribute to health disparities and create a healthcare system that is more inclusive, just, and responsive to the needs of our diverse community members.

Asked and answered Incorporating accountability was a crucial aspect of our planning and implementation process. We recognized the importance of measuring our progress, evaluating the effectiveness of our strategies, and ensuring transparency in our actions. Here’s how we incorporated accountability: Establishing Clear Goals and Objectives: We set clear goals and objectives at the outset of our innovation project. These goals were specific, measurable, attainable, relevant, and time-bound (SMART). By defining our desired outcomes, we had a clear benchmark against which to measure our progress and hold ourselves accountable. Monitoring and Evaluation: We implemented a robust system for monitoring and evaluating our progress. This included regularly tracking key performance indicators (KPIs) and collecting data to assess the impact of our interventions. By consistently measuring our performance, we were able to identify areas of success and areas that required improvement. Evidence-Data Analysis and Reporting: We conducted evidence-data analysis to gain insights into the effectiveness of our strategies. This involved analyzing both qualitative and quantitative evidence and data to understand the outcomes and impact of our innovation. We prepared regular reports that documented our progress, successes, challenges, and lessons learned. These reports were shared with stakeholders and community members to ensure transparency and accountability. Stakeholder Engagement and Feedback: We actively sought input and feedback from stakeholders, including community members, staff, and partner organizations. This feedback helped us identify areas for improvement and make necessary adjustments to our approach. By engaging stakeholders throughout the process, we ensured their voices were heard and their perspectives were taken into account. Continuous Improvement: We embraced a culture of continuous improvement, where we regularly reviewed our processes, identified areas for enhancement, and implemented changes accordingly. This iterative approach allowed us to adapt and refine our strategies based on data and feedback. Responsibility and Ownership: We assigned clear responsibilities and roles to team members, ensuring that everyone understood their role in the implementation process. Each team member had specific tasks and deliverables, fostering a sense of ownership and accountability for their respective areas of responsibility. By incorporating accountability measures into our planning and implementation process, we were able to track our progress, assess our impact, and ensure that we remained committed to delivering high-quality, equitable, and effective services to our community members.

The innovation had a significant impact on our organization, including workflow, staff, and overall change management. Here’s how these aspects were affected and how we approached change management: Workflow Changes: The implementation of the innovation necessitated changes in our workflow. We had to adapt our processes to incorporate new practices, such as regular meetings, collaborative problem-solving, and evidence- data analysis. This required a shift in how tasks were organized, coordinated, and executed.   We encouraged open communication and provided training and resources to support staff in adjusting to the new workflow. Staff Engagement and Empowerment: The innovation empowered our staff to actively participate In decision-making processes and contribute their expertise. Their roles expanded to include collaborative problem-solving, community engagement, and Evidence- data analysis. We fostered a culture of engagement, encouraging staff to voice their ideas, concerns, and suggestions. We recognized the importance of staff buy-in and ensured they felt valued and empowered throughout the change process. Change Approach: We approached change management by focusing on communication, collaboration, and support. We clearly communicated the purpose and benefits of the innovation to staff, ensuring they understood the rationale and importance of the changes. We provided training and development opportunities to equip staff with the necessary skills to succeed in their expanded roles. We created avenues for staff input and feedback, seeking their perspectives and actively incorporating their ideas into the implementation process. Leadership Support: Effective change management required strong leadership support. We ensured that leaders actively championed the innovation, reinforcing its importance, and creating a supportive environment for staff. Leaders provided guidance, direction, and resources to facilitate the transition, addressing any concerns or resistance that arose. Continuous Learning and Adaptation: Change is an ongoing process, and we recognized the need for continuous learning and adaptation. We actively sought feedback from staff and community members, evaluating the impact of the innovation and making adjustments as necessary. This iterative approach allowed us to refine our practices, address challenges, and maximize the positive impact of the innovation. By approaching change management with a focus on staff engagement, empowerment, and continuous learning, we were able to navigate the organizational shifts and ensure successful implementation of the innovation. Staff members felt supported and motivated, contributing to the overall success of the initiative.


While the text does not provide specific dates or a detailed timeline, I can provide a general sequence of key activities that Sisters In Common (SIC) l followed for the development, launch, ramp-up, and ongoing implementation of our innovation:

* Needs Assessment: Conduct a comprehensive community needs assessment to identify the Social Determinants of Health (SDoH) and Health Related Social Needs (HRSN) of the community. This involve survey meetings, focus groups meeting, and other forms of community engagement to understand the specific needs and challenges of our community members.

* Planning and Development Based on the needs assessment, develop a detailed plan for addressing these needs. This included the creation of a pipeline for advancing Community   Service Workers (CSW) to Community Health Workers (CHW), and the development of culturally competent SDoH services.

* Partnership Formation Identify potential partners who share SIC’s commitment to equity and can contribute resources, expertise, or other support to the project. Negotiate and formalize these partnerships, ensuring that roles, responsibilities, and expectations are clearly defined.

* Staff Recruitment and Training: Recruit and train staff from the cultural and ethnic communities we serve, ensuring cultural competence in our services. This included both initial training and ongoing professional development opportunities.

* Launch of Services : Begin providing SDoH services to the community members, with a focus on addressing HRSN. This involve outreach and engagement efforts to ensure that community members are aware of and able to access these services.

*Implementation of Feedback Establish a checkout-feedback loop with staff, clients, and community leadership/stakeholders to gather information and feedback about the services. This involve regular check-ins, weekly community representatives meetings, and other forms of feedback collection.

* Launch of Community Alerts Tool Develop and launch the “Community Alerts” tool to share information and gather feedback from the community. This tool is integrated into SIC’s website and phone-based communications infrastructure.

* Ongoing Training and Support: Provide ongoing training and support to CSW Interns, with the goal of advancing them to CHW or other roles. This involve mentorship, in-service consultations, and other forms of support.

* Ongoing Evaluation and Adjustment: Continually evaluate the effectiveness of the services based on feedback and other measures, and adjust the services as needed to improve their impact. This involve regular reviews of the feedback, evidence and data collected, and the implementation of changes based on this information.

* Sustainability Planning: Develop strategies for sustaining the progress made, This involve financial planning, partnership development, and other sustainability strategies.

* Note: the specific timing and order of these activities varied depending on the specific needs and circumstances of the community, our members, and the project.


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