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Please describe what Sisters in Common believes needs to happen in order for people that they serve, who receive Medicaid benefits in King County, to experience better health outcomes?

Sisters in Common believes there is a need “To re-integrate/retain cultural values, traditions and history that promote healing and empowerment for our children , youth, families and communities”, that prevent, address and build healthy resiliency/coping skills and remove/decrease SDoH concerns/issues, and the resulting physical/behavioral health issues and challenges that are further exacerbated by cultural and health care disparity/inequity, adverse childhood experiences (ACES) and trauma.

Basic needs (i.e. housing, hunger, mental health and medical health and stability-support needs, juvenile offense behavior, gang involvement and violence).

Why isn’t what Sisters in Common believes needs to occur is currently happening? What prevents it from happening?

Cultural and health care disparity/inequity, exacerbated by systemic oppressive “isms” (i.e. racism, sexism), resulting in communities of color being the victims of discrimination and prejudice, and being under-served.

How is Sisters in Common uniquely positioned to address its communities problems

As a culturally competent CBO/licensed Mental Health Agency (MHA) serving African American and East African families and children, Sisters in Common participates in many partnerships, including CBO’s, Managed Care Health Plans (MCOs), and county/state government budgeted agencies (i.e. SKCPH/HCA/DOH, ). Sisters in Common is
in alliances with other Community and Behavior Health Services (BHS) provider. Our
Board/Administration/front-line staff are members of the communities we serve, grounded in their respective community’s cultural and family paradigm

What solution does Sisters in Common propose that would help address this problem for the people Sisters in Common serves? What would Sisters in Common do? How would Sisters in Common do it?

Sisters in Common will use individual and family assessments, evaluations, health consultations/couching, case management, brief intervention, counselings, early child social/mood/emotional learning activities, and “real referral” services, to re-intergrate/retain cultural values, traditions and history, that promote healing and empowerment in our children, youth, families and communities,” to build healthy resiliency/coping skills, while preventing/removing/decreasing SDOH concerns/issues, and behavioral health issues and challenges exacerbated by cultural and health care disparity/inequity, (ACES) and trauma. What We Would Do-and -How We Would Do It- Childcare Health Consultation: Directly provide service, Counseling/advocacy- mental health/emotional support: Directly provide service, Counseling/advocacy- substance use: Provide referrals/navigation services to support access to service, Early child mood/emotional development activities: Directly provide service, Early Support Infant Toddler Mental Health: Directly provide service, Education, advocacy and/or case management related to finances- including budgeting, financial literacy, public benefit enrollment, etc.: Provide referrals/case management/ navigation services to support access to service, Food access- including food banks, soup kitchens, etc.: Provide referrals/navigation services to support access to service, Health screenings and education- including prevention programming, health literacy, etc.: Provide referrals/case management/navigation services to support access to service, Healthcare services-including clinics, primary care, dental services, etc.: Provide referral/navigation services to support access to service, Homelessness prevention: Provide referrals/navigation services to support access to service, job placement and/or job training: Provide referrals/navigation services to support access to service, Legal/justice related- including assistance with legal representation, family law, immigration, etc., Provide referrals/navigation services to support access to service.

How would client voice be included in the planning, design and implementation of Sisters in Common’s proposed solution?

The choice in services, goals setting/support, ensure improved outcomes in screening, assessment/evaluation, individualized service planning, referral, linkage, advocacy, coordination, case management, counseling, monitoring, including outreach and in-home/ in-community support, is guided by the client. Sisters in Common periodically requests information from clients about quantity and quality of services from first contact to discharge.Their experience, thoughts and their suggestions on how to improve services, are considered and included as part of services and future planning.

If successful, how would the proposed solution be sustained beyond the duration of Medicaid Transformation Project?

We are a BHA licensed to provide Counseling and Case management to medicaid clients. HCA has approved us as a BHS billing provider. The (MCOs) contract us to provide BHS to its Medicaid covered members. The current status is : Amerigroup: Active – formal (signed MOU, agreement, etc.), Community Health Plan: Active – informal (work together, but no signed/formal agreement), Coordinated Care Active -informal (work together, but no signed/formal agreement) Molina Healthcare: Active – formal (signed MOU, agreement) United Healthcare/Optum: Active -formal (signed MOU, agreement.)

Please describe how Sisters in Common’s proposed solution to the problem would improve health outcomes for the people identified in response to #15?

Sisters in Common is culturally competent CBO providing SDoH services to African American, East African children and their families, specifically those with behavioral health conditions, complicated by a history of physical health conditions, i.e. Asthma, COPD,Diabetes, End Stage Renal Failure, Heart Disease, homelessness, and transitioning from the hospital to home. We are licensed to provide BH: Outpatient; Individual mental health treatment services, Brief mental health Intervention/treatment services, Case management BH services and HBS. Sisters in Common have strong and effective partnerships with community stakeholders and continue to develop closer collaborative ties with community service agencies that serve our underserved community’s children/families and add value to each other services/programs. “Synergies created by combining effort and sharing expertise produce benefits greater than those achieved through individual effort”, and will greatly benefit our communities and children, particularly those agencies, are serving our primary population, who are COD and meet the WAC medical necessity criteria for mild, moderate, or sever BHS.

Please describe how Sisters in Common’s proposed solution to the problem would improve the experiences that the people identified in response to question #15 have when they attempt to access, or receive, healthcare services?

It will address and decrease fear and stigma, in our communities, for those who need BHS treatment, and when they do, services will be culturally competent, sensitive or appropriate. Client complaint that there is “no culturally competent system in place to provide ongoing, routine support to help African American and East African medicaid eligible children/families flourish, be resilient, physically AND emotionally healthy”. Children in our communities will be exposed to culturally competent activities that support integrated health- social/emotional/development. Culture, ethnicity and spirituality is a powerful factor in our medicaid eligible families’ often resulting in long delay in seeking services, and critical years for early whole person health care/ Interventions are lost. African American and East African families, when they choose BHS, will get services from professionals who they know and trust. immigrant families, who want BHS support from members from their own communities, and professionals who are fully engaged within their cultural values, including religion, will get it.

Please describe the demographics of the groups identified in response to question #19 who experience those disparities.

Sisters in Common is serving African American, Eritrean, Ethiopian-Oromo, Somali children, youth, adults and their communities, (specifically, English, Amharic, Tigrinya, Oromo and Somali speakers), who are ages (cradle to grave), undeserved and under-resourced, in King County. Health Plan; =99 percent receive medicaid benefits. Ages; Children( 0-12years of age) =28 percent, Teens (13-18 years of age)= 12 percent, Adults (19-64 Mars of age) =59 percent, Older adults (65+)= 1 percent. Gender/Identity; Women = 70 percent, Men = 29.99, Transgender – Male to Female = .001, Language ; Understand and speak English = 79 percent, Understand and speak Somali = 7 percent, Understand and speak Oromo = .006 percent, understand and speak Spanish = .004.

What, in Sister in Common’s opinion, causes those disparities and poor health outcomes?

Because of fear and stigma, eligible families, in our communities, rarely seek out existing BHS treatment and when they do, services are often not culturally competent, sensitive or appropriate. Client complaint that there is ” no culturally competent system in place to provide ongoing, routine support to help African American and East African medicaid eligible children/families flourish, be resilient, physically AND emotionally healthy”. Children in our communities are not exposed to culturally competent activities the support integrated health- social/emotional/mood development. Culture, ethnicity and spirituality is a powerful factor in our medicaid eligible families’ often resulting in long delay in seeking services. Thus, critical years for early whole person health care/Interventions are lost. Many African American and East African families, when they choose BHS, want BHS services from professionals they know and trust. Today, more immigrant parents want BHS support from members from their own communities, and professionals who are fully engaged in there cultural values, including religion.

How would Sisters in Common’s proposed solution address those disparities?

We have developed and maintain a professional multi-cultural and diverse staff. All services are provided in our client’s primary language. We recruit and train staff that are culturally competent, sensitive and aware of the diverse needs of our clients. Note: Staff are recruited from the community of the clients we served and further trained to provide resources for required trainings. In this way our staff have access to ongoing trainings, information and support to remain in compliance with their DOH licensure/certification training requirements. We also utilize our network of ethnic and culturally diverse relationships and resources in the client’s communities to better serve them.

Please describe what Sisters in Common would need from partners identified to ensure success of Sisters In Common’s proposed solution.

We, who are fully engaged in the transformation model and process, have to KEEP GETTING THE WORD OUT about THE NEW TO THE OVERWHELMING MAJORITY OF OUR CLIENTS, Washington State Health Care Authority (HCA) medicaid ” whole-person care, integrating physical health and behavioral health services and system – specifically, how and what we can do together in King County.

If Sisters in Common needs to build partnerships to achieve the success of Sisters in Common’s proposed solution, how would Sister in Common go about doing that?

We have to share strategies on HOW TO GET THE WORD OUT to our health, social and/or human services and networks about HOW TO USE the NEW TO OUR CLIENTS, Washington State Health Care Authority (HCA) medicaid “whole-person care, integrating physical health and behavioral health services and system- specifically how we do it in King County HealthierHere

What non-financial assistance, if any, would Sisters in Common need from HealthierHere to help Sisters in Common’s organization build, strengthen or maintain those partnerships?

We, NEED HH help, providing ongoing (routine and repeated) ACTIONS and/or ACTION PLANNING, TO KEEP GETTING THE WORD OUT! Why, Because this works! i.e. – Information Sessions for Community-based Organizations- Continuing to host or sponsor (Under HealthierHere’s Banner), informations sessions where community-based organizations can learn about; THE HOW TO of them getting involved with us and us getting involved with them in creating collaborative innovative efforts to collaboratively improve health and health equity in King County.

How would Sisters in Common know that what you were doing wa working? What would Sisters in Common measure to demonstrate that the proposed solution is working?

Sisters in Common maintain a quality improvement program to assures continued progress towards effective/efficient, age/gender/culturally competent services and client satisfaction/ outcomes. We monitor/review clients progress, analysis client/member outcome data, Client/member satisfaction surveys, internal work group(s)/ committee(s), File reviews/audits/grievances, and conduct client/member focus groups to identify and correct any deficiencies in services toward improving the quality of services. Note; All are looks at, for incorporating sessions learned into Sisters in Commons’ operations.

How would Sisters in Common gather, and maintain, the information needed to demonstrate that Sisters in Common’s proposed solutions is working?

Sisters in Common maintain individual client record and backup for clients receiving SDoH and BHS, in accordance with the department of health (DOH) requirements for agencies providing BHS (WAC 246-341-0425, WAC 246-341-0640, WAC 246-809-035). We maintain comprehensive clinical record system that includes policies and procedures that protect an individual’s personal health information; Ensure that the individual’s personal health information is shared or released only in compliance with applicable state and federal law.

If Sisters in Common’s proposed solution worked, and could e shared, how would Sisters in Common propose to share it with others?

Provide/host ongoing (routine) -Community Information Sessions for CBOs, community stakeholders and the client/members themselves – hosted or sponsored (with HealthierHere), where attendees can share and learn about what Community Base/driven (empowerment) health solutions “worked” and are sustainable.

Please describe what Sisters in Common believes needs to occur, on a system-wide level, to improve the way that community and clinical providers coordinate care, for people who receive Medicaid benefits in King County.

Coor-care needs to be deeply embedded in the communities they serve and have trusted relationships with the patients-clients, community leaders and stakeholders. Service setting; the client’s homes and community: (i.e. Schools, churches, mosque’s, and community centers). “client choice” is paramount, (“good treatment is what the client is willing to accept) in services, goal setting and getting support, ensure improved outcomes. Services need to be designed to be flexible/creative, to fit into the client’s unique life solution. Also, the strategies for providing effective services, keep the focus on service quality-effective- solution and outcome oriented, while promoting client empowerment.

What does Sisters in Common believe that HealthierHere Community, clinical and Tribal healthcare partners can do, as a collaborative body, to address that need?

1. Adhere and follow this definition of cultural competence; ” a set of congruent behaviors, attitudes, and policies, (that adheres to standards of equity), that come together in a systemic or organized way, to enable that system of organizations to work effectively in “cross-cultural” ways and situations”.

2. Become a culturally competent system of organizations that acknowledges and incorporates at all levels the importance of language and culture, assessment of cross-cultural relations, knowledge and acceptance of dynamics of cultural differences , expansion of cultural knowledge and adaptions of services to meet culturally unique needs.”

3. Recruit qualified staff from the community of clients served.

4.Provide further and ongoing training in Cultural Humility and Process of Inclusion and Empowerment.

5.Commit themselves to developing, maintaining a multi-cultural and diverse staff as well a utilizing their network of ethnic and culturally diverse relationships and resources in the client’s communities to better serve them.

Why isn’t what Sisters in Common believe needs to happen already happening in King County?

Cultural and health care disparity/inequity, exacerbated by systemic oppressive “isms” (i.e. racism, sexism), resulting in communities of color being the victims of discrimination and prejudice, and being under-served. There is no culturally competent system in place to provide ongoing, routine support to help our clients flourish, be resilient and physically AND emotionally healthy. Our communities are not exposed to activities that support integrated health- social/emotional/mood development.

Please describe examples of effective community-clinical care coordination that Sisters In Common has seen work well in King County or other places of the State or County.

We provide Childcare Health Consultations to family/friends/neighbors (FFN), who watch each other’s children. 25% are grandparents with health conditions, i.e. Diabetes, End Stage Renal Failure, Heart disease, and homelessness. Working with their (PCP), we provide case management (i.e. transportation, housing “real” referrals, doctors appointments support, prescription/med prep/ schedule compliance support, ADL planning, community activity risk assessment, natural support consualtuon, facilitate PCP- family consultations, and crisis prevention/intervention) services.

What does the phrase “person-centered care” mean to Sisters in Common and the community that Sisters in Common serves?

“Client Choice” is paramount; (“good treatment is what the client is willing to accept), in services, goals setting and support, and will ensure improved outcomes. Services should always be designed to be flexible and creative, to fit into the client’s unique life situation. Always, always, health care should be provided with clients and NEVER “TO” CLIENTS.

Describe what effective multi-organization, multi-sector care coordination for people who receive Medicaid benefits in King County could look like. Please cite examples of where this is currently happening.

First, Adhere/follow this definition of cultural competence; “a set of congruent behaviors/ attitudes, and policies, (that adheres to standards of equity), that come together in a systemic/organized way, to enable that system of organizations to work effectively in “cross-cultural” ways and situations”.
Second; become a culturally competent system of organizations that acknowledge/incorporates at all levels the importance of language, culture, assessment of cross-cultural relations, knowledge and acceptance of dynamics of cultural differences, expansion of cultural knowledge and adaptation of services to meet culturally unique needs”.
Third; recruit qualified staff from the community of clients served.
Fourth; provide further/ongoing training in Cultural Humility, Inclusion and empowerment.
Fifth; commit themselves to developing/maintaining a multi-cultural and diverse staff as well as utilizing their network of ethnic and culturally diverse relationships and resources in their client’s communities to better serve them. Sisters in Common engages providers who are actually competent, sensitive and aware of the diverse needs of the clients we serve.

When Sisters in Common refers to on of your existing clients to a Tribal healthcare provider, clinical provider, substance or opioid use disorder treatment provider, and/or community organizations for service, what information do you share about that client at the time of referral?

SISTERS IN COMMON POLICY AND PROCEDURES MANUAL; Pursuant to state law, client information, we disclose is as follows: Clinical Assessment; pages 12-13, Individual Service Plan; pages 14-15, Mandatory Reporting; page- 23, Medication Protocols; page-24, Client Information, Sharing Information, Confidentiality; pages 25-26.

Describe how Tribal healthcare providers, clinical providers, substance use disorder treatment and/or opioid use disorder treatment providers can help facilitate client referrals to Sisters in Common that will begin your relationship with shared client on a positive note.

Client feedback; it is/was our cultural competency (BOD officers, administration/staff is 99% African Americans and East Africans), high staff retention, skills -blend of SDoH and BHA services. “Client Choice and home base delivery model to our Specialty; African American and East Africans, Low income clients with behavioral health conditions, complicated by history of physical health conditions, i.e. Asthma, COPD, Diabetes, End Stage Renal Failure, Heart Disease, homelessness, speaking (English, Amharic, Tigrinya, Oromo and Somali speakers). Introduction.

Describe how Sisters in Common can help facilitate client referrals to Tribal healthcare providers, clinical providers, and/or substance or opioid use disorder treatment providers in a manner that will begin their relationship with your shared client on a positive note.

Share with Sisters in Common their client feedback; as to their cultural competency (BOD officers, administration/staff), staff retention, history, skills and blend of SDoH, PCP and BHA services/integration. Their service delivery modality (Site or home base) and client focus model coupled with their specialty population profile and language proficiencies.

Describe the most common gaps or misunderstandings that occur between community and clinical providers when referring clients to one another or receiving referrals from one another. What does Sisters in Common suggest that we do, through our collaborative work at HealthierHere, to address these gaps or misunderstandings?

The MAJOR issues is ” misinformation” between community and clinical providers staff and provided to clients, about what each other REALLY do and how we do it.. We, NEED HH help, providing ongoing, (continuing to host or sponsor), (routine and repeated) – Information Sessions for joint Community and Clinical organizations. Information sessions where we can learn about what each other ” Really do, TO KEEP GETTING THE WORD OUT! Because this works!

What is the most important thing that Sisters in Common wishes HealthierHere’s Tribal healthcare, clinical and community partners understood about Sisters in Common, they way that Sisters in Common works, or the people that Sisters in Common serves that might contribute to building and maintaining effective community-clinical partnerships for people who receive Medicaid benefits in King County?

Sisters in Common mission; “To re-introduce cultural values, traditions and history that promote healing and empowerment for youth, families and communities in crisis”. Our motto is “Cultural empowerment for families in crisis”. We are a 25-yr. old Non-profit CBO and, since 2009, DOH licensed Outpatient BHA- Mental Health. We are recognized as culturally competent in serving African Americans, Eritrean, Ethiopian-Oromo, and Somali children/adults, their families and communities, (English, Amharic, Tigrinya, Oromo and Somali speakers). Specialty; Low income clients with behavioral health conditions, many complicated by a history of trauma and physical health conditions, i.e. Asthma, COPD, Diabetes, End Stage Renal Failure, Heart Disease, homelessness, and transitioning from hospital to home. Our client feedback; it is cultural competency (BOD officers, administration/staff is 99% African American and East African), high staff retention, skills and blend of SDoH and BHA services. “Person centered Care” and our base services delivery model, keep them engaged in their healing and empowerment.

Describe the types of things that would help Sisters in Common build capacity and infrastructure to participate in transitioning the current healthcare system, developing partnerships with clinical providers, and/or expanding service delivery to improve health outcomes for people who receive Medicaid benefits in King County.

The Sisters in Common part time (FTEs) Certified Agency Affiliated Counselors- Community Health Workers (CAAR-CHW) are the back bone of our clients based on culture and languages spoken. They are teamed with our part time Counselors/ Case Managers, independent contractor Registered Nurse- PhD, Psychologist PhD, LMHC, SUDP, and all but one, is a DBHR/DOH Certified Mental Health Professional, Child Mental Health Specialist, Ethnic Minority Mental Specialist, Disability Mental Health Specialist, who are (specifically, English, Amharic, Tigrinya, Oromo and Somali speakers), communities. Sisters in Common would expand our flexible, person-centered-care services already in place. Similarly, we would add needed hours for Contractor-Specialist on retainer, (e.g. Psychologist, and Nurse for (Co-Occurring disorders (COD) clients), IT- Data and , medicaid billing specialists, and accounting for increase programs-funding-evalutation/reporting/ milage and travel.
BHS Case Managers and Counselors, teamed with our Registered Nurse- PhD and Psychologist LMHC, SUDP, All, but one are either a state qualified Mental Health Professional, Child Mental Health Specialist, Ethnic Minority Mental Health Specialist, Disability Mental Health Professional, or Certified Agency Affiliated Counselors- Community Health Worker, who are members of the (African American, Eritrean, Ethiopian-Oromo, and Somali) culture, and linguistic, (specifically, English, Amharic, Tigrinya, Oromo and Somali speakers), communities we serve. Our BHS part time (FTEs) Certified Agency Affiliated Counselors- Community Health Workers (CARR-CHW) is the backbone of our clients based cultural, language spoken in home, and geographic area. Sisters in Common would expand our flexible, person-centerd-care, home based services already in place. Staff hours would be increased to provide home-based services to more medicaid clients eligible for SHoH and BHS services. Similarly, add needed hours for Contractor-Specialists on retainer, (e.g. Psychologist, and Nurse to support Co-Occurring disorders (COD) client services, IT- Data Specialist on retainer, medicaid billing specialist, and accounting for increased programs-funding-evaluatioion- and reporting. Adequate funding for mileage and travel time will be incorporated into the program budget.

Describe the types of process improvements that Sisters in Common believes needs to occur in the current healthcare system to facilitate the coordination of care for the people that Sisters in Common Serves. Examples could include increasing the availability of substance use disorder treatment programs, etc.

In addition to our answer to question 37 and 46; 1. developing a share-cared plan, 2. improving access to translation and interpreter services for non-cultural and linguistic-embedded providers, 3. expanding the use of traditional healing and 4. culturally-centered care, where possible, 5. chronic condition prevention and case management support programs that target early child, youth and the elderly, 6. improving health literacy, targeting family, friends, and neighbors (FFN) childcare providers 7. Community engagement ROLL-OUT informational session, on (a) the NEW medicaid system and (b) HOW the (FIVE) different Manage Care Health Plans (MCO)”REALLY” work, to maximizing prevention care which has been proven to minimizing high health care cost, 8. increase the number of cultural competent community health workers, to supercharge the cultural community “deep -dive” to achieve better health outcomes and reduce fear and stigma.

Describe the types of things Sisters in Common would need to enable Sisters in Common to participate in the design of these system wide process improvements.

Due to funding and resource limitation, most of Sisters in Common management team, (specifically; (1) administrator, (2) Part time Administrative Assistants and (2) Part time Clinical Supervisors), in addition to their WAC required Administrative, Quality Assurance, and Management duties, ALSO, provide “direct” SDoH and BHS Counseling and Case Management services to our clients. ” WE work double duty. We would need funding for added FTE hours to ensure to enable Sisters in Common organization to participate in the design of these systems wide process improvement.

Describe the most innovative idea that Sisters in Common has for a program or service that Sisters in Common wish could provide for the people that Sisters in Common serves. What is innovate about the idea? What would it serve? Why are you not currently available to offer the program or service? Why would it result in the improvement of health outcomes for people who receive Medicaid benefits in King County?

Because “Social Justice” Lawyers -are- Counselors, make them an integral part of our SDoH/BHS teams (CBO_BHS routinely pro-bono vice from attorneys and firms), for purpose of collectively affecting a education in the “Coping Ugly” behavioral, stress levels and trauma symptoms, in/of our medicaid clients members, (in the African American, Eritrean, Ethiopian-Oromo, and Somali culture and linguistic, specifically English, Amharic, Tigrinya, Oromo and Somali speaking communities.) They would provide ” direct resolution-medication-mitigating ADVICE support- ONLY”, to support the client as they navigate and deal with issues of health disparity/inequity, toward increasing client empowerment, which can reduce their incidents of stress/trauma symptoms responses.

Describe how Sisters in Common’s engagement with HealthierHere has benefited Sisters in Common, and the people that Sisters in Common serves, thus far.

Meeting Laurel A. Lee, MHW VP. Member & Community Engagement, at HH 6/2019- “Building…For Successful Community Partnerships, Their leadership approved Sisters in Common to join their network. To date, used HH funds to pay the cost of; MCO credentialing processing/ follow through (Two MCOs still pend funding time.) Search-MCO medicaid billing specialist (full system setup pending funding. Search/ licensing, IT/ EMR (not EHR) system (fully develop/ implementing pending funding), and specialist search/system set up support client’s physical health-COD screening (i.e. RN PhD Nurse).

What recommendations does Sisters in Common have to keep HealthierHere’s partners engaged as we continue to work together?

Help, with start up infrastructures/workflow-capacity funding, while providing ongoing KEEP GETTING THE WORD OUT! by continuing to host and/or sponsor COB-PCP- (Under Healthier’s Banner), information sessions where CBO-PCP-MCO can partner and learn with and from each other about; THE HOW TOs…. while creating innovative efforts to collaboratively improve health and health equity in King County.

Please describe Sisters in Common’s program model and how it will accomplish the following components of the scope of work for this RFP: assessment, intervention and referrals, consultation, multi-lingual/multi-cultural service, and timely response.

Sisters in Common (SIC) is requesting GRAT funding to support two (2) culturally embedded “Person Centered Care” Geriatric Regional Assessment Teams (GRAT). The home-visiting teams will provide intergrated Behavior Health (BH) and Social Determinants of Health (SDoH) services, to (55+) seniors who meet ALL the following criteria:

*African American, or Eritreans, or Ethiopian-Oromo, or Somali
*Low income eligible
*have challenges or acute or chronic behavioral health condition (mental health) and
*have challenges of acute or chronic physical health conditions (medical).

Sisters in Common has a unique model, specifically designed and delivered by and for the African American and East African communities specified above. As a licensed mental health agency, we provide the full range of assessment, mental health treatment, case management and referral services. We also provide integrated services regarding the Social Determinants of Health, addressing presenting client issues related to: economic stability, neighborhood and physical environment, education, food, community and social context and health care system access, with eligible clients.
The Sisters in Common GRATs will focus on isolated eligible clients to prevent inappropriate or avoidable institutionalization. In addition tour core mental health/case management GRAT team, Sisters in Common has a nurse and psychologist on contract for consultation.

multi-lingual/multi-cultural service- All GRAT senior services will be provided in the client’s primary language, (English, Amharic, Tigrinya, Oromo and Somali). We recruit and train BH staff that are culturally competent, sensitive and aware of the diverse needs of our BH clients. Note: GRAT Staff are recruited from the cultural community of the clients we serve, and further training is provided with resources for required professional growth. In this way, we ensure that our GRAT staff bring their cultural knowledge and sensibilities to service delivery, and have access to on going training and support. This results in high quality GRAT client service, in compliance with their DOH requirements. In our collaborative, community approach we access the GRAT client’s networks of ethnic and culturally diverse relationships and resources in the GRAT client’s communities to better serve them.

Referral- Sisters in Common already gets senior referrals from 5 managed care organizations, and our HealthierHere collaborative partners. Legally mandated, mental health services can only be provided with the permission and request of the client over the age of 12. However, doctor tell there patients to make the call. Referrals can be supported by referring agencies, with client permission. The GRAT senior clients can set-referral, and community/family members can refer with client permission. The referral process can be extended to GRAT partners. Through our extensive, multidisciplinary, GRAT clients will have access to all specialty services needed, including substance abuse, psychiatry and others.

Assessment-Eligibility for BH assessment is determined through a telephone request, followed by an in come screening process. In appropriate. Sisters in Common staff conduct a psychosocial assessment and Individual services plan (ISP). The psychosocial assessment is provided in a manner that respects and includes consideration of the client’s, culture, and is conducted, with an embedded understanding of the BH client’s cultural context.

The BH assessment is comprehensive and includes sufficient data to determine a DSM-5 diagnosis (includes cognitive impairments, dementia and substance use). The BH assessment determines and is built on the GRAT clients strengths and needs and will list client goals and desired outcomes in their own words as much as possible. The assessment may also include strengths and desired outcomes of significant others in client’s life. The assessment is flexible and creative to fit into the client’s unique life situation and meets the unique needs of the client. As part of the GRAT senior’s BH assessment they are informed about the importance of their active participation in services, and are asked to sign an informed consent before services are provided.

Case management: It is the practice of Sisters in Common to assist clients in obtaining needed services that are not available at Sisters in Common and to plan for discharge from services. GRAT senior clients will be actively involved in their planning and discharge process. At the GRAT senior clients request, Sisters in Common will continue its services until such time that the referral has successfully taken place, unless requested otherwise by the client.

Interventions: Sisters in Common provides Individual mental health counseling services, Brief mental health Intervention- treatment services, and case management mental health services. The service design; 1. Assist an individual in attaining the goals identified in their individual service plan, (ISP), 2. Are solution focused and outcome-oriented cognitive and behavioral interventions, and 3. Are intended to resolve situational disturbances and meet the ongoing assessment, facilitation, care coordination and advocacy for options and services to meet an individual’s needs through communication and available resources, while promoting quality and effective outcomes. Rehabilitative case management services support individual employment, education, and participation in other daily activities appropriate to the individual’s age, gender, and culture, and assist individuals in resolving crises in the least restrictive setting.

Consultation- In collaboration and coordination with other agencies partnerships, (e.g. Substance Use Disorder, or psychiatric services) that we have developed through our HealthierHere of King County community-clinical partnerships and linkages, for appropriate recommendations, guidance and education, to improve health outcomes. Sisters in Common have strong partnerships with our community stakeholders and collaborative ties with community service agencies. Sisters in Common Psychologist and Nursing consultant’s recommendations may be incorporated into GRAT client’s Individual Service Plan.

Timely manner: Phone calls are returned no later than 24 hours of receiving them. Messages received from clients are forwarded to identified staff immediately. Whenever a client enrolled in the Sisters in Common BHS contracts “crisis response services” Sisters in Common BHS staff will make a face to face contract with this client within 24 hours of being notified that such a contract occurred. Clients are scheduled for set appointment times to eliminate any unnecessary waiting times for the GRAT clients (48 hours).

List Sisters In Common’s proposed GRAT team of staff and describe each of their roles and responsibilities. Please describe how Sisters in Common plans to stand up this team of professionals.

Sisters in Common will maintain no less than two culturally embedded GRAT teams. Each team will consist of one DOH licensed Counselor-Mental Health Professional (MPH), one BH Certified Agency Affiliated Counselor-Community Health Worker (CHW), and one Master’s or PhD level supervisor. The MHP supervisor will have licensed specialties in Disabilities and Substance Abuse Disorders, skilled in providing geriatric services. Each team member is expert and experienced in serving African American, Eritrean-Ethiopian- Oromo or Somali seniors, their families and communities.

Our BH Community Health Worker (CHW), and Mental Health Professional will be the backbone of our GRAT home-bass services. The CHW will provide GRAT BH and SDoH case management and brief Intervention services. The MHP will provide individual mental health counseling, Brief mental health-treament services, and Clinical case management mental health services.

The GRAT MHP is responsible to lead the GRAT senior’s services and progress, together with the CHW. The MHP will conduct the assessment and provide individual mental health counseling, brief mental health-treatment services and oversee all rehabilitative case management services. This includes an Individual Service Plan (ISP) review and a review of any extraordinary events. The MHP assess client progress, identifies service obstacles and deficiencies, and determines appropriate next steps. Reviews are documented in the GRAT client record.

Sisters in Common team supervisor will review GRAT client progress focused on effectiveness, appropriateness and utilization of services. They are available to consult and assist GRAT staff with qualifications/skill set needed, and /or use their network of community and organization connections for the expertise needed. They review clinical documentation, provide on-going clinical supervision, training and staff support to the GRAT. The supervisor will focus on clinical and SDoH skills, reviewing the team and client progress, performance issues, and identity areas for improvement. The GRAT core team meets every week, ensuring high quality integrated and multidisciplinary services are provided to meet client needs. Sisters in Common psychologist and nursing consultants are utilized as needed and their recommendations may be included in GRAT client’s Individual Service Plans. Sisters in Common also has after-hours on-call MHP for GRAT client emergency and requests for services.

INCREASING STAFF: Sisters in Common has the full range of staffing needed for GRAT client services and most of our staff are part-time. Staff hours can be increased, matching language capacity, cultural match and geographic areas. We would add hours for Contract-Specialist, (Psychologist, and RN Nurse to enhance support for GRAT clients.

An additional GRAT team will be hired, using CIS team staff model. CIS has individuals identified who can be hired to provide GRAT services. Also, IT, Data tools and management hours will also be increased, along with Medicaid billing specialists.

Describe the populations you propose to serve and the geographic coverage of Sisters in Common’s program.

Sisters in Common specializes in African American, Eritrean, Ethiopian-Oromo, Somali, (specifically, English, Amharic, Tigrinya, Oromo and Somali speakers)

Note: Using data from the 2016 US Census and the 2012-2016 American Community Survey Data from the US Census; five of the ten cities in Washington State with the highest Black/ African American populations are in King County.

GEOGRAPHIC COVERAGE- Sisters in Common will serve clients in the areas where significant number of African American and East Africans immigrant families reside. Based on our long history of services to these communities, Sisters in Common is very familiar with the geographic areas where our populations reside.

That includes the cities in South King County- specifically Renton, Tukwila, Federal way, Kent, and SeaTac. Within the city of Seattle, we will provide prioritize Central/ South Seattle- South of the Ship Canal. In North King County, specifically, Shoreline, and Lake Forest Park, there are areas of concentration of East African families.

Describe the proposed methods Sisters in Common will use to reach and serve these clients.

To decrease barriers that keep GRAT clients from accessing services, Sisters in Common’s GRAT home-visiting teams will work with the client at locations accessible to them (homebred). Sisters in Common is deeply embedded in the communities we serve and already has trusted relationships with our clients, community leaders and stakeholders. We are culturally grounded CBO that has, over the last 25 years, specialized in provided our both our SDoH and BH services in our client’s homes and community setting, (e.g. schools, churches, mosque’s, and community centers. ) We have developed a nimble, flexible service delivery system that focuses on client and community repulsiveness, rather than office-based fixed hours. The innovative model works best for our diverse client life situations, as well as those our multicultural staff.

This responsive model that serves community in their places is the basis of all Sisters in Common services. For example; 95% of our current BH/SDoH clients, including our GRAT eligible clients, receive home-based services. All our current senior BH clients receive home-base services. Our staff are in community settings and meet clients where they are, literally. Services are provided in their client’s primary language and at times and locations that are best for them. Our staff utilizes “sheets”, a digital timesheet system that tracks flexible staff hours collecting data on locations, service types ,etc. We recruit and train staff that are culturally competent, sensitive and aware of the diverse needs of our clients. Note: BH Staff were recruited from the community of the clients we serve and further train, as well as we utilize our network of ethnic and culturally diverse relationships and resources in the client’s communities to better serve them.

Because of our culturally imbedded services and deep trusted relationships, both East Africans and African American families and communities will continue to reach out to us for GRAT support, (whereas they would not do so with traditional mental health institutions.) We are the first point of entry for many in of underserved community members.

Also, under Sisters in Common formal agreements with Washington contracted Managed Care Organizations (MCOs) Health plans, Amerigroup, United Health Care/ OPTUM and Molina, we provide Behavior Health Services and SDoH services to their members. And under Client-Specific Authorization, with Community Health Plan of Washington, and Coordinated Care, we provide Behavioral Health Services to their members. Based on GRAT client managed care providers, we can serve them and collaborate closely with other specialty services.

With our increase GRAT ability, we will have an increased ability to case-find, respond to referrals and serve clients- from the collaborative agencies,hosptials, and community based agencies, referred GRAT eligible seniors.

Describe Sisters in Common’s plan to screen, prioritize and triage referrals.

Sisters in Common will provide services to GRAT clients who meet WAC BH services and DSM5 eligibility requirements; 1. in accordance to their choice (i.e. their homes and/or community), as part of best practice. 2. to expedites client access to services and provides services in the fastest way possible, 3. in the client’s primary language (note: Sisters in Common staff speak their client’s primary language). (There is no additional charge or wait list for GRAT clients receiving WA Medicaid program services.)

Eligibility for BH assessment is determined through a telephone or face to face request and/or screening process, (GRAT clients can Self-referral, and /or community member or family members can directly refer themselves, if they have permission of the client). All screenings are followed by a face to face BH assessment to justify, or rule out, a DSM 5 diagnosis. (Note: If the client has a high lethality reading, screening, the GRAT BH assessment staff will, per Sisters in Common BH p&p, immediately consult with the GRAT Supervisor for intervention).

In accordance with state law GRAT Medicaid and non- Medicaid clients, referred for screening, will receive the same clinical services and speedy appointments as any other client. In cases where appointment times conflict, GRAT Medicaid clients will be given preference. In these circumstances the other client is served as soon as possible.

On Call Response: Per our DOH approved BH P&P manual, will maintaining our On Call after-hours phone line for GRAT senior client emergency and acute requests for services, and offer emotional support and linkage. It will be our policy to resolve GRAT senior crises in least restrictive settings (home and community).

If a GRAT senior client has crisis plan it may become part of their GRAT services. GRAT clients may establish a crisis plan together with GRAT staff while receiving services. The plan may list medical history, chemical dependency history, history of violence and related event including incarceration and involvement with criminal justice system. It may include information on baseline functioning, signs of decompensation, effective intervention techniques and history of access to crisis response services. If the GRAT client has a crisis plan GRAT staff may provide a copy of the crisis plan to the GRAT client natural support, where appropriate.

Sisters in Common responds to “extraordinary events” as legally required. These circumstances may include:

-Death of the GRAT senior clients defined as incidents related to the psychiatric care of client, suicide or homicide,
-Injury of GRAt senior client while receiving services defined as the international infliction of bodily harm (including an overdose and suicide attempt) which causes the GRAT senior client and/or other persons to seek emergency/ urgent medical care.
-Incidents of abuse, neglect and exploitation of GRAT senior client.
-Damage to property defined as intentional damage by the GRAT senior client to property, which requires either the filing of a police report of voluntary or involuntary hospitalization of the GRAT senior client.
-GRAT senior Client Behavior defined as behavior so bizarre, disruptive or threatening that it places others in reasonable fear of harm and might trigger “DUTY TO WARN”. This includes incidents of abuse, neglect or exploitation of the GRAT senior client that lead to mandatory reports.

In case of extraordinary events taking place during services to the GRAT clients, the GRAT staff is required to record the event in the clinical record. GRAt staff must immediately present review these events with their GRAT Supervisor. This review will determine appropriate interventions and next steps, which may include reporting the events to authorities.

Whenever a GRAT client enrolled in GRAT services, contacts “crisis response services” GRAT staff will make a face to face contact with this client within 24 hours of being notified that such a contact occurred.

If identified in the GRAT client record and the crisis plan, the GRAT CAAR/CHW may be used to assure accurate communication with those GRAT senior clients who are limited English speaking.

Sisters in Common FRAT senior ” office” services will be Monday through Friday 10:00AM to 6:00PM. As a part of our regular operations we will respond to GRAT client crisis by making face to face contacts with clients during regular work hours. During such contact we may provide in home or in community stabilization serviced and referrals, including support to the other members of the household, as appropriate.

In those instances where crisis cannot be resolved during the same day it occurs, GRAT senior clients and Sisters in Common after-hours FRAT MHP staff are informed of the emergency and provided detailed instructions on how to access each other. They will provide all required information on the nature of the crisis, what services were provided, effective interventions and any other information deemed necessary in the event of an after-hours crisis.

Organization Capacity Experience : Provide a short description of Sisters in Common and Sisters in Common’s mission. In case of a collaborative application, please outline each organization, its role in the collaborative and who is serving as the lead applicant.

Sisters in Common (SIC) mission is, “To re-introduce cultural values, traditions and history that promote healing and empowerment for youth, families and communities in crisis”. Our motto is, “Cultural empowerment for families in crisis”.

Sisters in Common is a DOH-licensed Behavioral Health agency. We are recognized as culturally competent in serving African American. Eritrean, Ethiopian- Oromo, and Somali children, youth, adults, and their families and communities. We service ages from infants to seniors (cradle to the grave). The goal and purpose for all clients is to prevent, address, and build healthier resiliency and coping skills, while removing and decreasing Social Determinants of Health (SDoH) concerns and issues , and the resulting physical/ behavioral health issues and challenges that are further exacerbated by racism, health care disparity, inequity, adverse childhood experiences (ACES) and trauma.

Sisters in Common was founded in 1992, by a volunteer group of precessional African American (AA) women, to address critical issues with AA female youth which were not addresses in “traditional” social service and treatment agencies. In 1998, we broadened our services to cover whole family, providing culturally competent (SDoH) services and what is now titled Behavior Health Services. Our leadership remains African American and our staff are African American, Eritrean, Ethiopian- Oromo, and Somali.

Sisters in Common began serving GRAT eligible seniors in 1998, promoted by the devastating effects of the “Crack Cocaine” drug epidemic, coupled with mental illness, incarceration, economic hardships, domestic violence, and other challenges, on the already struggling Black families we served. Due to its devastating and disproportionate effects, AA children were being removed from tier families, and in many cases places with their senior relative or fictive kin, (average age 50-60yrs), to raise. These seniors were “ALONE”, without culturally competent health or human services support and found themselves “coping ugly” in whatever way they could with the children in their care. CPS became and remains a routine threat. There is a saying ” When the water is dirty, the fish get sick”. Thus, many of our children ended up in the King County juvenile system and victims of ACEs and trauma. Sisters in Common begin providing culturally competent, appropriate and responsive, home and community-based family preservation services to these grandparents. Sisters in Common Family Preservation Therapist provided services and served on CPS Child Protection Teams, where time and time again AA seniors were given temporary or permanent custody of children. In 2001, with support of the WA Division of Children and Family Services (DCFS), Sisters in Common formalized our Home-Based-Family Preservations Services.

Sister in Common continue our efforts to support African American and East African seniors, and their families , and to this day, their health and human services needs remain a core driver of both service systems and services delivery modeling.

Please describe Sisters in Common’s experience in providing home-based behavioral health and/or cognitive assessments and evaluations to older adults who may be at risk for loss of housing or loss of ability to remain independently housed due to a behavioral health or cognitive condition.

Throughout our history, Sisters in Common has expanded its home-based mental health and case management arrives to Black and East African seniors, at greatest risk of crisis and potential loss of housing and family stability. This is reflected in our contracts with King County institutions and other agencies that have sought out Sisters in Common culturally competent services for our undeserved communities.
Because our communities are cohesive intergenerationally, all of these interventions inclded services to GRAT eligible seniors. Describe seniors as caregivers here- describe the program development briefly.
-2001 Sisters in Common contracted with the State of Washington, Department of Social and Health Services, Division of Children and Family Services.
-2007 Contracted with King County Superior Court to provide Intensive Counseling for Juveniles on Probation.
-2009 Contracted with Atlantic Street Center to provide Counseling Services.
-2011 Sisters in Common licensed by DSHS/ DBHR to provide Community Mental Health Services.
-2013 Under Sisters in Common DBHR License to provide Brief Intervention Treatment, Individual Treatment and Case Management,
-Member of NAVOS BHA Sub- Contractor Consortium, we provided Brief Intervention Treatment, Individual Treatment and Case Management
– May 2018, award from King County Best Starts for Kids, to provide Family, Friends, and Neighbors (FFN) Child Care Health Consultation services designed to support African Americans, Eritrean, Ethiopian-Oromo, and Somali FFN childcare providers. We provided Brief intervention Treatment, Individual Treatment and Case Management services to GRAT eligible seniors, who are caregivers.
-July 2018, Sisters in Common was Licensed by the Department of Health to provide Behavior Health Services (Counseling and Case Management).
-August 2018, Sisters in Common become a Medicaid provider authorized, in the State of Washington, to provide managed health care services (Behavioral Health) to GRAt eligible seniors.
-March 2019, became a BH provider to Amerigroup Health plan.
-October 2019, Sister in Common became a BH provider for OPTUM- United Health Care -plan Health plan
-October 2019, Sisters in Common authorized as a HealthierHere King County Level 1 Community Practice Partner
-November 2019, Sisters in Common became a BH provider to Molina Health Plan.

Please describe Sisters in Common’s current capacity to provide, or how Sisters in Common will develop the capacity to provide, multi-lingual support to a diversity of people experiencing crises in King County.

Sisters in Common have the full range BHS staff who are members of the (African American. Eritrean, Ethiopian- Oromo, and Somali) culture, and linguistic, (specifically, English, Amharic, Tigrinya, Oromo and Somali speakers), communities we serve. All services will be provided in the GRAT senior’s primary language.

Sisters in Common has a MHP supervisor that speaks 5 languages, including the Amharic language so we have never has a problem. Note: (95% of all Somali speak Amharic) however on the off chance a GRAT client ONLY speaks Somali, GRAT CAAR.CHW will interpret and we have access to the DOH language translator bank if need be.

This Includes The Full Range Of Professionals: made up of BHA Administrator-Counselor, BHA Supervisors- Counselors, Health Consultation Program Manager-Counselor, Child Care Health Consultation Program Supervisor-Counselors, Intensive Counseling Services Coordinator- Counselor, Licensed Certified Counselors, Licensed Mental Health Counselor, Licensed Substance Use Disorder Professional-Counselor, Licensed Independent Clinical Social Worker- Counselor, Certified Agency Affiliated Counselors, and Registered Nurse- PhD. all, but one, are either a state qualified Mental Health Professional, Ethnic Minority Mental Health Specialist, Disability Mental Health Specialist, or Certified Agency Affiliated Counselors-Community Health Worker.

Staff Recruitment: In our communities, relational networking has always been the most effective recruitment tool. In addition to the word of mouth referrals, we have utilized the information from the communities themselves to develop our strategic recruitment plans. This include community organizations, places they live, where they go, places they gather, and people identified as natural leaders. Sisters in Common Part-Time CAAR/ Community Health Workers (CHW) were recruited from and with the expressed support of their cultural . ethnic communities. Their communities supported and recommenced their recruitment to endure truss/relationship to support both initially and ongoing client engagement into ur services and programs. They continue to do an effective job working with their community members to both. formal and informally inform (“Get Out and pass the Word”, providing modeling and support to other community members to develop their community engagement skills. Person to Person engagement is combined with (integrated services their community medical and basic needs supportive services providers:), and their involvement and membership with their Ethnic Community Care as well as the mosque’s and churches. Culturally, it has proven essential to get buy in from the religious leaders, first and continuing to provided culturally appropriate services. Sisters in Common has that. We also provide written information in the communities for those who can read in their Native Language and/or English. We know from twenty years of experience, in working with out communities, that trust is essential, and people will come to you for help when other people in their community tell them they were helped by you and you can be trusted.

Please Describe Sisters in Common’s experience partnering with other agencies for specialized expertise, consultations or referrals, and discuss how your organization will leverage partnerships to provide responsive and appropriate services for individuals served by GRAT.

Sisters in Common is a HealthierHere (HH), of King County Level 1 Community Practice Partner. As such, we are part of a multidisciplinary systemwide collective effort to improve health outcomes and advance health equity with, and for, all King County community members. As a HH Level 1 community partner, we will coordinate services for our GRAT seniors with other HH partnership agencies, when other specialized expertise is needed. Through these partnerships, we access additional specialty services that GRAT clients may need. We also Lin with providers to provide all other support services that may be needed.

Sisters in Common is a contracted MH provider with managed care providers in KC, including Community Health Plan, Amerigroup, Coordinated Care, Molina Healthcare and United Healthcare. Sisters in Common partners with hospitals and health clinics, such as Country Doctor Community Health Centers, Fairfax Hospital, Harborview Medical Center, Healthpoint, Swedish Health Services, University of Washington (including Northwest Hospital), and Valley Medical Center Clinic.

We collaborate with our other behavioral health partners, including Navos, Sound Mental Health, Community Psychiatric Clinic Collaboration.

As a licensed mental health provider with a ling history of addressing relevant social determinants of health (economic stability, physical environment, educations, food, community and social context), we collaborate with a wide range of service supports to meet our clients needs. GRAT seniors will have access to this full range of community and culturally based services. We partner with and collaborate with community based organizations and agencies, including :
Downtown Emergency Service Center (DESC), Somali Health board, Center for Multicultural Health,
Additionally, as a culturally-imbedded community-based provider, Sisters in Common leverages partnerships with community support systems essential for our clients: Our case management services build on the community and cultural relationships for the GRAT seniors, to maximize

Sisters in Common appreciate most about our current partnerships is that they understand the need to treat the while person and the need to address and provide SDoH as an integrated component of clients physical health, BH, recovery and wellness. The collaborative (Integrated health and SDoH focus on African American and East communities Health, and input, They understand the need to tract the whole GRAT senior and they are committed to integrated health model as a CBO, in their respective communizes, with a specialty is person of/in ethic minority communities and, they , understand the need to address and provide SDoH as an integrated component of GRAD senior recovery and wellness.

Friends of Youth- Housing referral, move-in community funds and, support BH case management services and employment support for MCO member with sever ADHD

Seattle -King County, Valley Medical Car, DSHS (work first), King County DA, case management support for collaborative services success.

Please describe Sisters in Common’s commitment to diversity and equity, with a specific focus on your ability or plan to provide culturally relevant services to the isolated seniors (55+) living in King County who are experiencing crisis due to factors such as behavioral health, or cognitive issues.

Sisters in Common maintains a mult-culture and diverse mental health services professional (MHO) staff. All Services will be provided in our FRAT client’s primary language. We will recruit and train GRAT staff that are culturally competent, sensitive and aware of the diverse needs of our clients. Note: To better serve them, GRAT staff are recruited from the community of the GRAT seniors we will serve and are throughly trained and supported to provide culturally appropriate professional services.

We will utilize our network of ethnic and culturally diverse relationships and resources in the GRAT seniors’ communities to better serve them. We recruited GRAT staff from and with the expressed support of their cultural/ethnic communities. Their communities supported and recommended their recruitment to ensure trustt/relationship to support both initially and ongoing client engagement into our services and programs. Person to Person engagement is combined with ( “integrated services their community medical and basic needs supportive services providers”), and their involvement and membership with their Ethnic Community Centers as well as the mosque’s and churches. Culturally, it has proven to get buy in from the religious leaders, in first and continuing to provided culturally appropriate services. Sisters in Common has that. We also provide written information in the communities for those that can read in their Native Language and/or English.

Per our Department of Health (DOH), approved, BH staff policy and procedures manual of instructions on how clients access services, we comply with all AFA accessibility requirements. Access to def and hearing-impaired clients; Sisters in Common participates in the Washington Relay Services and if appropriate certified language services. The GRAT After hours, On Call MHP staff is the contact person who will handle GRAT seniors accessing GRAT services or receiving messages from GRAt clients and forwards received messages to identified GRAt staff. The Accessing Services Manuals is kept in both E-desk and hard copy.

Sisters in Common has created many innovative practices to maximize responsiveness to our culturally diverse clients and staff. Fro example, we provide a flexible work schedule that allows GRAt staff members to accommodate GRAT client’s unique life situations (i.e. even if they occur on weekends). Our nimble tracking system to record and total time, services, locations, etc supports our staff ability to be flexible in meeting our clients at times and locations best for them, while also providing efficient way to log in all data.

Consultations will be the identified GRAt seniors language, needs and ares of inserts. Sisters in Common Equity values are embedded within our mission statement, cultural competency, and anti-discrimination policies. Sisters in Common plan to advance Equity for GRAT staff clients. by providing services at locations accessible to them. (i.e. homes/community). Clients appointment times are set to eliminate any unnecessary waiting.

Describe Sisters in Common’s interest in building capacity to collect, report, and use data for continuous improvement of services. If Sisters in Common has already engaged in this type of work, please give examples. If Sisters in Common has not uses data for continuous improvement previously, please give examples of ways that you would like to use data to inform programming in the future.

Capacity for continuous improvement of service. For example, we have a 63year old AA woman, diagnosis as Bi-Polar, with heart disease, high blood pressure and end-stage renal disease., with history of being hospitalized about 4 times a year, stabilized then return home with 12 medications to take daily. We teamed to chart her activities of daily living for 30days and discover she was routinely providing childcare to her 3 grandchildren (ages 2-7), during which time she did not manage her medication (from the bottles) time to prep well. We used the information we gathered to change several things. 1. We bought her a pill box. 2. her CHW 1X each week setup her medication pillbox and monitored her compliance. 3. We collaborated with her primary care team to work out an awake and sleep schedule (though-out the day), and 4. Provided child-care resources support to greatly decrease her role as “grandparent as parent” Her having to hospitalized has decreased to 1X per year (unsealed to the presenting issues above).

Sisters in Common definition of success: In accordance with client choice, provide culturally competent counseling, brief intervention treatment and case management services to support client health, in their homes and community, as part of best practice , toward expediting and enhancing (medicaid/ Medicaid-Medicare and non medicate) client access to the appropriate level health services while providing services in the fastest way possible, while providing services in the client’s primary language.

Capacity to collect dat, generate reports and use data for continuous improvement of services.

Capacity to use data for continuous improvement of services.

The BHS Supervisors maintains all Quality Management (QM), information in serpent QM file.

Sisters in Common management team, (specifically the administrator, and Clinical Supervisor), reviews all Sisters in Common operations periodically. QM feedback is incorporated in this review. The review evaluates findings and forwards suggestions and proposals to the Sisters in Common Board of Directors for inclusion into agency operations and procedures, as deemed appropriate.

Quality Management information will be an integrated part of the GRAT supervision. Supervisor’s credentials include those of a Mental Health Professional. Supervision assures that services are provided efficiently, in culturally, gender and age appropriate manner, and that they are effective in reaching the client’s choice set goals and outcomes.

GRAt staff may evaluate progress towards goals and outcomes with all involved collaborators as client needs and circumstances warrant.

Sisters in Common periodically request information from GRAT clients about quality of services from first contact to discharge, their experience while receiving service at Sisters in Common and their thoughts on how to improve services further. All responses and suggestions from GRAT clients will be in included in GRAT services and future planning.

To assure quality at all levels Sisters in Common will monitor all services for compliance with state and federal law, as well as Sisters in Common use of evidence based and promising practices. The GRAT staff are responsible to conduct reviews of client’s progress in accordance with state law.

it is the practice of Sisters in Common to maintain a quality improvement program that assures continued progress towards effective and efficient age, gender, and culturally competent services and improves client satisfaction and outcomes.

Customer and community feedback: We will use survey information from GRAT clients and community about quantity and quality of services from first contact to completion, thiner experience while receiving services, and their thoughts on how to improve services. Responses/suggestions are included in program services and future planning. We will conduct periodic GRAt client conversations and focus groups. We will use these sessions for/ input on program content and prioritize services. We use will use these methods to gauge on-going satisfaction and ideas for GRAT services improvement.

The QM process also includes a review of any/all filed grievances and/or complaints, as well as serious critical incidents. Serious and emergent incidents are defined as those situations that require an investigation by the Sisters in Common management team in accordance with Sisters in Common personnel procedures. This part of the review evaluates the course of the grievance and incident reviews from inception to a resolution and looks at incorporating lessons learned into the operations of BHS.

To assure continued quality improvement in the GRAT BH services, Sisters in Common has the following procedures in place:
At the GRAT MHO Staff Level:
– Follow closely all established procedures, expectations and timelines, including
-Check with all team members regular, more often if GRAt clients situation so warrants
-Track RAT client progress pro-actively
-Involve others (e.g. referrals, housing, social worker ) as deemed necessary for GRAT client success
-Document smartly: In ways that the GRAT client and/or guardians understand
-Incorporate QA findings into services

At the Supervisory Level:

-REview assessment, plans (e.g. service plan or crisis plan ) after initial review
– Suggest needed changes (e.g. assessment, service and/or crisis plan ) after initial review
-Review service delivery
-Review level of care
-Review QA reviews as part of GRAT staff evaluation

At the QA Level:

-Focus on GRAT staff strengths, with QA oversight
-Address and report (to BH services administrator ) non-compliance of corrections to findings.
-Monitor and assist in implementation of findings
-Client appropriate intervention strategies and services are employed
-Interventions are GRAT client focused/ directed, age appropriate and culturally competent and relevant
-Focus is on available alternatives to hospitalization
-Least intrusive measures are considered
-Services consider multi-system collaboration to promote a better services outcome
-A range of service options is available
– Services are tailored to the unique needs of the client that may or may not include a variety social determinate of health services

It is the practice of Sisters in Common to monitor compliance with all state and federal rules and laws that govern agency licensing and certification requirements

The performance of GRAT staff is evaluated, along with annual state background check timelines, and includes trainings to improve skills or addressunders performance. Any reports of serious and emergent incidents as well as client grievances are included in the scope of the performance evaluation.

GRAT staff review clinical records from all GRAT staff. The review includes identifying deficiencies in services and how to address deficiencies and improve the quality of service. The GRAT Supervisor provides feedback to GRAT staff, which may include but is not limited to the following:

-Client services process, Client Assessment, Service Planning, Clients willingness toward services, Effectiveness and competency (age, cultural) of Services, Client utilization of Services, Collaboration with community services, progress towards client’s choice goals and outcomes.

Describe Sisters in Common’s approach to and tools for clinical documentation and data management.

IT and database functionality maintenance are OUTSOURCED/CONTRACTED. Please note, Sisters in Common already has a set of HP servers (G7and G8) ready for deployment. Sisters in Common method to send and/or receives referrals electronically is Secure Email.

Sisters in Common list the software(s) use for client information storage. tracking, tools for clinical decimation and data management;
(1) Apricot, (2) WordPress plugins: Formidable Pro WpDataTables, (3) WpDataTables-Formidable Pro Integration, (4) Microsoft Words, (5) Microsoft Excel, and (6) Adobe PDF. Not all client data is stored in electronic format. Information that is not stored electronically: Client signed documents: (a.) Informed Consent, (b) Individual Rights, (c) Therapist disclosure receipt, (d0 ROI, and (f) Collateral Correspondence,

Sisters in Common would benefit from the following:
1. Access to dedicated high bandwidth connection.
2. Support hardware to house rack of servers (incl. a small rack with a keyboard and monitor).
3. Funding for IT service personal to create and administer multilingual, culturally aware Health Awarenes, Health Instruction, Data Collection, and Survey systems.

Describe Sisters in Common’s approach to and tools for clinical documentation and data management.

IT and database functionality maintenance are OUTSOURCED/CONTRACTED. Please note, Sisters in Common already has a set of HP servers (G7and G8) ready for deployment. Sisters in Common method to send and/or receives referrals electronically is Secure Email.

Sisters in Common list the software(s) use for client information storage. tracking, tools for clinical decimation and data management;
(1) Apricot, (2) WordPress plugins: Formidable Pro WpDataTables, (3) WpDataTables-Formidable Pro Integration, (4) Microsoft Words, (5) Microsoft Excel, and (6) Adobe PDF. Not all client data is stored in electronic format. Information that is not stored electronically: Client signed documents: (a.) Informed Consent, (b) Individual Rights, (c) Therapist disclosure receipt, (d0 ROI, and (f) Collateral Correspondence,

Sisters in Common would benefit from the following:
1. Access to dedicated high bandwidth connection.
2. Support hardware to house rack of servers (incl. a small rack with a keyboard and monitor).
3. Funding for IT service personal to create and administer multilingual, culturally aware Health Awarenes, Health Instruction, Data Collection, and Survey systems.

Please provide a narrative summary of the ways in which Sisters In Common has implemented Access and Engagement activities over the reporting period.

The Access and Engagement funding has supported our ability to increase our part time (.5FTE) Community Health Worker staff from eight (8) to Thirteen (13). The increase in out CHW workforce, increased the number of CHW work hours that supported our client’s access and engagement with their providers, and SDoH related services by 48.7 percent. As stated, before Sisters In Common client’s are 99 percent low income African American, Eritrean, Ethiopian-Oromo, and Somali community members.

The funding ensured that SDoH services continued to be 1.) culture- community specific, 2) valued by our client community members, and 3) embedded in the cultural and ethnic values of our client’s communities.

The funding support our ability to ensure that we maintain culture appropriate SDoH screenings and services. It supported that our health screening tools and processes were modified to ensure their cultural competency, and that our skill-train staff provided SDoH services based on the CHW’s understanding of how their work address the Health Related Social Needs successes of themselves, their families, friends, and neighbors.

The added CHW staffing enhanced our ability and services to mitigate the negative effect of COVID-19 on our community members. Our clients still cite Sisters In Common SDoH Resources/ Alert tool as critical in supporting them accessing culturally competent healthcare information about services to maintain their healthcare without forsaking their’ cultural values, traditions, and ethnic identities. ( The community and their representative evaluations of Sisters In Common services remains, without exception, the highest grades possible, infall areas of engagement.

The funding help support our weekly Sunday Evidence Integrated – Quantitive- Qualitative data analysis, to inform and sustain our better providing “whole person” SDoH care coordinated, collaborative services and delivery to our clients, their families, friends, and neighbor community members. To date the number of clients enrolled, total 106. Our data show 46.7% “real referrals to address the client health related needs and 46.3% were ” how to prevent and mitigate the spread of illness.” Based on the data from our “Social Determinants of Health Evidence Summary” we estimate we are providing services to = 538.

A. Increased Community Health Workers providing ( Numbers please community members) with Sixty-two (62) SDoH Community Resources and Alerts that address their health related access to COVID prevention, mitigation, treatments, and intervention services, to increase the safety of the clients, their families, friends, and neighbors.
B. CHW increased SDoH client enrollment of clients with their families, friends, and neighbor’s network.
C. CHWs recruited and enrolled 61 Intern Community Support Workers, (CSW), working to complete their Peer coaching and training to become DOH certified Community Health Workers.
D. CHW Supported 61 Intern CSW complete and certified in HealthierHere partnered with the University of Washington AIMS Center Online Course tilted: Supported the Medical Care of People Living with Serious Mental Illness. (Note: 41 Intern CSWs were English as second language).
E. CHWs directly engaged 106 clients and supported them by 261 SDoH service consultations. ( Note: 46.7% were “real referrals to address the client health related needs and 46.3% were how to prevent and mitigate the spread of illness.)
F. CHWs Ongoing weekly trainings regarding health benefit navigations and services (note CHWs completed the HealthierHere partnered with the University of Washington AIMs Center Online Course titled: Supporting the Medical People Living with Serious Metal Illness.

Please select the ways Sisters In Common invested in Access and Engagement activities over reporting period.

* Increased staff capacity *Purchasing equipment to support capacity to serve priority populations *Costs associated with enhancing capabilities to conduct remote outreach (internet and mobile phone voice/data plan) *Staff training *Consumer facing educations, communication, and outreach activities

Please select the ways Sisters In Common invested in Access and Engagement activities over the reporting period.

RN Remote Wellness Check to support client after their become COVID-LONG-COVID-19 infections to support the client community member being cause in the matter of their own wellness.

Increased staff capacity

Purchasing equipment to support increased capacity to serve priority populations

Costs associated with enhancing capabilities to conduct remote. outreach (internet and mobile phone voice/data plan).

Staff training

Consumer facing education, communication, and other outreach activities

Other-
1. Increased Community Health Workers providing (Numbers please community members) with Sisto-two (62) SDoH Community Resources and Alerts that addressed their health related access to COVID prevention, mitigation, treatments, and intervention services, to increase the safety of the clients, their families, friends, and neighbors. 2. CHW increased SDoH clients enrollment of clients with their families, friends, and nieghbor’s network. 3. CHWs recruited ad enrolled 61 Intern Community Support Workers, (CHW), working to complete their Peer coaching and training to become DOH certified Community Health Workers. 4. CHW Supported 61 Intern CSW complete and certificate in HealthierHere partnered with the University of Washington AIMS Center Online Course tilted: Supporting the Medical Care of People Living with Serious Mental Illness. (Note: 41 Intern CSWs were English as second language). 5. CHWs engaged 106 clients and supported them by 261 SDoH service were how to prevent and mitigate the spread of illness. 6. CHW Ongoing weekly trainings regarding health benefit navigation and services ( note: CHWs completed the HealthierHere partnered with the University of Washington AIMS Center Online Course tilted: Supporting the Medical Care of People Living with Serious Mental Illness.

Please share Sisters In Common’s experience with hiring and retention in service of Access and Engagement activities, including successes and challenges. (Optional, suggested for organizations that hire new Taff as part of this investment .)

Because Sisters In Common recruit staff Community Health Workers and Intern Community Support Workers (CSW). from the communities they serve, our ability to hire and retain are not a benefit that support their ability to deep dive and effectively serve their communities. CHW’s and CSW’s are matched with their community member clients based on culture and languages spoken. We always hire directly from the client’s cultural and ethnic communities to ensure community-informed & culturally-competent services to better address the client’s Health Related Social and Health Needs in ways that support their empowerment and healing. Both the CHWs and Intern CSWs are representatives of their respective communities, (Note: their individual community leadership and stakeholders are required vetting and endorsing partner in both CHW and Intern CSW recommendations and specific CHW hiring process). This practice has proved vital to continue to ensure that services, education and trainings continue to be 1.) culture & community specific, 2) valued by the community, and 3) embedded in the cultural and ethnic values of their communities.

Please share Sisters In Commons best estimate of total persons served by Access and Engagement activities over the course of the reporting period.

538

If data is easily available, please share an estimate of persons served in each of the priority populations for the Access and Engagement fund over the course of the reporting period.

Individuals who identify as African American/ Black

Elders

Individuals experiencing homelessness/housing instability

Individuals who identify as Indigenous/ Native American

Individuals who identify as Latinx

Members of the refugee and/or immigrant communities

Populations for whom English is not their primary language

Individuals with disabilities

Other populations experiencing disparities are not listed above (specific below)
N/A

Please select the most common needs from those served by your Access and Engagement efforts.

Housing

Rental Assistance

Food- access and nutrition

Employment

Healthcare coverage

K-12 education support

Cultural services

(note: 46.7% were “real friends to address the client health related needs and 46.3% were how to prevent and mitigate the spread of illness.

How does Sisters In Common define equity? What process was used to develop this definition? How is this definition communicated throughout Sisters In Common?

Our core tenet to ensure positive outcomes in each community member’s Social Determinants of Health, (SDoH), requires that we address their Health Related Social Needs (HRSN), in ways that make it clear that “form each of us according to our abilities to heal and empower, to each of us according to our need of healing and empowerment.” We base this on; 1. our collective and individual experiences and victimization by systemic SDOH disparity and inequity, driven by systemic racism. 2. our 25 year experience in providing community informed, culturally competent SDoH services, which address our HRSN, in ways that support the empowerment and healing, in community members. We hire directly from our cultural and ethnic communities. They are passionate about collaborating with their community members. They ensure SDoH services continue to be culture community specific, valued by the community, and embedded in the cultural and ethnic values of their communities. We create tools and skill train staff to provide SDoH services based on their clear understanding of how their work address the HRSN successes of their families, friends, and neighbors.

What has Sisters In Common identified as a strategy to address Sisters In Common’s goal that would advance individual equity outcomes within Sisters In Common over the next 18 months?

King County systemic SDoH, physical and behavioral healthcare system inequities continue to negatively impact a wide range of our clients an our community member’s health and life risk and outcomes.

Exacerbated by the COVID-19 pandemic, our clients and community members are reporting that they are experiencing an increase in the negative impact of the inequities in their SDoH conditions. The result has been a measurable increase in client SDoH -request for support and services to help them address their Health Related Social Needs.

Note: In year 2021 we saw a 57.1 percent increase in our client “need-request” for services to address their SDoH- Health Related Social Needs, (HRSN). Most of the request for services were specifically related to Covid-19 issues on how to prevent and/or mitigate the spread of disease and illnesses in their homes and among their families, friends, and neighbors, and how to navigate and access SDoH assistance services in King County.

As “community”, we routinely gather, (nearly every week), to discuss what we could do to effect ” REAL aka SUSTAINABLE change to eliminate King County systemic SDoH, physical and behavioral healthcare system inequities.

We concluded, as community, to effect ” REAL aka SUSTAINABLE change to eliminate King County systemic SDoH, physical, and behavioral healthcare system inequities, we needed a “advancement to health professions pipeline”, (AT-HPP), By and Of our community members.

Our AT-HPP plan and goal is.

(a) Advancement from stipend Intern Community Service Workers, (CSW), to status Community Health Workers (CHW), trained and employable status as Community Health Workers (CHW), providing SDoH-HRSN services to our repective community members in our massive King County health system. And/ or
(b). AT-HPP interns will continue their health profession education and skills training (e.g., CHW, CPC, CNA, CD, CMA, BSN, RN, MSN, ARP, MD, DO, PhD, MHP, SUPD…) and become employable providing Whole person care services to our respective community members in our massive King County health care system.

We plan to continue the work and design n establishing our “advancement to health professions pipeline”, (AT-HPP), of Stipend Community Service Worker (CSW) BY and OF our community members.

2.We will continue our practice of hiring directly from our cultural and ethnic communities we serve. This is to continue to ensure that SDoH services continue to be 1. culture-community specific, 2. valued by the community, and 3. embedded in the cultural and ethnic values of their communities.

B. Advancement from stipend Inter Community Service Workers, (CSW) status, to employment status Community Health Workers (CHW).

Our goal is that after completing their stipend-internship training as CSW, they would either; 1. be able to become employees working as Community Health Workers, providing SDoH services or 2. continue their education and become health care system employee providing whole person health services.

Why does Sisters In Common believe that achieving this goal would advance individual equity outcomes within Sisters In Common

Because we are members of the communities we serves, and we routinely request information, and feedback from our staff, clients and community leadership/stakeholders about types, quantitively, and quality of services, including their thoughts on how to improve services further. We hire directly from our cultural and ethnic communities. This ensure SDoH services continue to be culture community specific, valued by the community, and embedded in the cultural and ethnic values of their communities.

What process did Sisters In Common use to identify this goal? Who was involved in identifying this goal? How did you develop the goal?

Because we are members of the communities we serve, we routinely request information, and feedback fro. our staff, clients and community leadership/stakeholders about types, quantity, and quality of services, including their thoughts on how to improve services further. We do it this was because of our 25 year experiencing in providing community informed, culturally competent SDoH services, which address our HRSN, in ways that support the empowerment and healing, in our community members.

What specific actions will Sisters In Common take it achieve this goal?

All trainings are provided with CHW (same culture) staff support. All trainings that are provided, are supported in the stipend intern’s primary language. We have developed and maintain by professional multi-cultural, multi-lingual, and diverse staff. Sisters In Common provides stipend CSW trainings with CHW Mentor staff support in several ways, including, but not limited to *Providing a flexible work schedule that allows Intern and staff members to attend trainings even if the occur on weekends. * Conducting in-services-consultaions that are based on identified Intern and staff needs and areas towards goals. Intern mentor for these in-serives training come from within the agency. Also, training are added from other health, education, and community organizations that are experts in their respective fields. It is the practice of Sister In Common to provide resources for required trainings. Our practice is to have our stipend Interns and staff have quality and 24/7 access to ongoing trainings and staff support.

How will Sisters In Common measure progress towards achieving this goal?

How many stipend CSW Interns, Ofer completing their stipend-internship training as CSWs;1. become employees working as Community Health Workers, providing SDoH services or 2. continue their education and become an employee providing behavior health services.

Because we are members of the communities, we are well connected to our community members, who are our family, friends, clients, and neighbors. We routinely information, and feedback from them our community leadership/stakeholders about types, quantity, and quality of services, regularly including their thoughts on how to improve ALL trainings and services further.

How will Sisters In Common adjust as Sisters In Common learns and measures the effectiveness of the implementation strategies?

We are a CBO licensed to provide BHS. As members of our communities, routinely request and collaborate and problem solve and use our “check out-feedback loops” with our staff, client’s and community leadership/stakeholders about types, quantity, and quality of our trainings and services, including their thoughts on how to improve services further. The real proof is that stipend Intern CSWs will be 1. become employees working as Community Health Workers, providing SDoH services or 2. continue their education and become an employee providing behavioral health services.

Who, within Sisters In Common, will be involved in supporting the implantation of this goal?

Community Service Worker Intern Coordinator, Community Health Worker Supervisor MSW, CHW Mentor, The IT Multi-Media-Specialist, The Admin. Assist-Remote Time management -evaluation, The Data Analytics Specialist, RN Health Wellness Consultant,. 6. BHS Specialist, Disability Mental Health Specialist, Ethnic Minority Mental Health Specialist, Child Mental Health Specialist.

How will the people most affected by the implementation of this goal be included in the planning, design, decison-making, implementation, and success measurement for this goal?

We use survey information from clients/ community members, leadership/stakeholders about quantity and quality of services from first contact to completion, including their experiences while receiving SDoH services, and their thoughts on how to improve services. Responses/ suggestions are included in all services and future planning. We conduct periodic conversations / focus groups. We have used these sessions for / input on services content and prioritize services. We use these methods to gauge on-going ensure SDoH services continue to be culture community specific, valued by the community, and embedded in the cultural and ethnic values of their communities.

How will Sisters In Common communicate this goal, and progress toward achieving this goal, throughout Sisters In Common?

Our part time CHWs are the backbone of our ability to deep dive and effectively serve our communities. CHW’s are matched with their community member client’s based on culture and language spoken. They are representatives of their respective communities, (Note: their individual community leadership and stakeholders are a required vetting and endorsing partner in the CHW recommendations and hiring process.) Added, we have created and made a part of our agencies web site and phone based communications infrastructure our “Community Alerts” tool (check it out at sistersincommon.org, on the operations menu tab). Our Community Alerts tools is proving to be very effective in sharing SDoH and HRSN information while providing ongoing KEEP GETTING THE WORD OUT to all

How will Sisters In Common share lessons learned during the implementation of straggles to achieve this goal with others outside of your organization ?

HealthierHere continuing in its role to help and support with “whole person care health system integration” collaboration as proven to be a perfect vehicle to partner and share information about lessons learned. Also, we have our CHWs, who representatives of their respective communities, (note: their individual community leadership and stakeholders are a required vetting and endorsing partner in the CHW recommendations and hiring process). Added, we have created and made a part of our agencies wen site and phone based communications infrastructure our ” Community Alerts” tool (check it out at sistersincommon.org, on the operations menu tab) Our Community Alert tools is proving to be very effective in sharing SDoH and HRSN information while providing ongoing KEEP GETTING THE WORD OUT to all, including supporting some of our professional partners in assisting them I. getting the work out to their client and community stakeholders. We have additional innovative efforts we are collaboratively working with our communities to complete and launch to effect maximum community engagement.

What does Sisters in Common hope to learn by implementing strategies to achieve this goal?

How to create and sustain a culturally competent CHW workforce through creating a pipeline for advancement to CHW employee status, after being a stipend Intern Community Service Workers, (CSW), with the CSW completing their stipend-internship training as CSWs, then either; 1. Becoming our or other employed Community Health Worker, providing SDoH services or 2. continue their education and become an employed providing behavioral health services.

What technical assistance, training and/or support does Sisters In Common believe would be of value as Sisters In Common implements strategies to achieve this goal?

HealthierHere continuing in its role to help and support with “whole person care health system integration” collaboration has proven to be a perfect vehicle to partner and share information about lessons learned.

How will Sisters In Common operationalize the strategies used to achieve this goal within Sisters In Common to ensure sustainability of the progress that Sisters In Common makes?

Based on reports from our MCO partners work performed by CBOs licensed to provide BHS, CHW employee- CAAR-SDoH work hours is billable.

Organization

SISTERS IN COMMON

Name of person filling out form

JC EPHRAIM

Email address for point of contact

sistersincommon@aol.com

Please provide a narrative summary of the ways in which your organization has implemented Access and Engagement activities over the reporting period.

The Access and Engagement funding has supported our ability to increase our part time (.5FTE) Community Health Worker staff from eight (8) to Thirteen (13). Our CHW workforce, increased the number of CHW work hours with their clients. The increase in CHW support increased the CHW -client community member engagement time. The result was an increase in the client’s SDoH related services by 48.7 percent. The funding ensured that SDoH workforce and services continued to be 1) culture-community specific, 2) valued by our clients, an 3) embedded in the cultural and ethnic values of our client’s communities.

The funding support our ability to ensure that we maintain culture appropriate workforce to provide SDoH screenings and services. It supported our client’s health related social needs, (HRSN) screening tools and process modifications to ensure staff-client cultural competency, and skill-train staff providing SDoH services based on the CHW’s understanding of how their work address the HRSN, of themselves, their families, friends, and neighbors.

The added CHW staffing enhanced our ability and services to mitigate the negative effect of COVID-19 on our clients. Our clients still cite Sisters In Common SDoH services, resources, and community alerts as critical in supporting them accessing culturally competent healthcare and health related information about services to maintain their health without forsaking their’ cultural values, traditions, and ethnic identities. ( The clients community representative evaluate Sisters In Common services, without exception, the highest, in all areas of engagement.)

Please select the ways Sisters In Common invested in Access and Engagement activities over the reporting period.

* increased staff capacity *purchasing equipment t support increased capacity to serve priority populations *Cost associated with enhancing capabilities to conduct remote outreach (internet and mobile phone voice/data plan) *staff training *consumer facing education, communication, and other outreach activities *RN Remote Wellness Check support client after their become COVID-LONG-COVID-19 infections to support the client community member being cause in the matter of their own wellness.

Please share your experience with hiring and retention in service of Access and Engagement activities, including success and challenges.(optional, suggested for organizations that hired nw staff as part of this investment )

A. The depth of our community members current RISK of COVID-LONG-COVID and its impact on the inflect members and their families, friends, and neighbors and ADLs. ( i.e., work and workforce shortages and gaps)
b. The depth of our community members inequitable and current pandemic exposure to SARS-CoV-2 infections. (Covid-Long -Covid lifestyles)
C. The depth of our community members inequitable and current negative healthcare outcomes and ever increasing due to ALL CAUSE Illness and Deaths exacerbated by our SARS-CoV-2 infections (Covid-Long-Covid lifestyles)
D. The depth of our community members current lack of healthcare access getting worst due to healthcare system workforce shortages due to Covid-Long-Covid lifestyles, exacerbating ALL CAUSE Illness and Deaths exacerbated by our SARS-CoV-2 infections (note:repeat COVID is riskier than first infection study finds-Reuters, Nov. 10,2022)
E. The depth of the systemic racism in our current healthcare system. Workforce sustainability.
F. As a CBO we must help our workforce find new ways to reinvent work. ” There is a real crisis in the Imbalances in equitable -culturally competent talent supply and demand in health care to service our community health and health related social needs. Covid -19 has changed not only how people healthcare work.

As Sisters In Common reflect on the total reporting period of the Access and Engagement Fund, what is Sisters In Common top 2-3 takeaways from your work on tis effort ?

A. As a culturally competent CBO we must rapidly identify the skills to support our workforce recovery. We are actively deciding ” on strategies that will shore up the future work we need to do to support healing and empowerment of our families, friends, and neighbors. We have to “quickly identify crucial value drivers and employee groups.”
B. As a culturally competent CBO we are working to rapidly identify the skills our recovery model depends on. We are mapping out which skill pools will disproportionately affect it and drive it forward. To do this, we are working to quickly identify crucial value drivers and to create employee cross train groups.”

C. As a culturally competent CBO we must continue ” working to build employee skills critical to our new healthcare service model.” We have ” started up skilling the critical workforce pools (i.e., AT-HPP Interns) that will drive a disproportionate amount of value in our adjusted healthcare services model.” ^ We have “launched tailored learning journeys to close critical healthcare skills gaps. This is only a beginning. It is important to go deeper on strategic workforce planning. Our community leaders and stakeholders need to adopt a detail view not only of the core SDoH-HRSN and Transformation integration activities that critical healthcare provider groups, (CBO,DR, Nurses,) groups will begin undertaking, but also of which skills each of these groups will need.”

Please share Sisters In Common best estimate of Toal persons served by Access and Engagement activities over the course of the reporting period.

854

If data is easily available, please share an estimate of persons served in each of the priority populations for Access and Engagement fund over the course of the reporting period.

Individuals who identify as African American/ Black

Elders

Individuals experiencing homelessness/ housing instability

Individuals who identify as Latinx

Members of the refugee and/or immigrant communities

Populations for whom English is not their primary language

Individuals with disabilities

Other populations experiencing disparities are not listed above

Individuals and household who requested HRSN services for their Cold-Long-Covid Disease and complications

Please select the most common needs from those served by Sisters In Common Access and Engagement efforts.

*housing *rental assistance *food-access and nutrition *healthcare coverage *cultural services *COIVD-LONG-COVID PREVENTION, MITIGATION, WELLNESS, INFORMATION, AND ACCESS TO HEALTHCARE AND HEALTH RELATED SOCIAL NEEDS SERVICES AND TREATMENTS

Expenses Line Items Details 08/15/21-11/15/21

-Health Resource Consultant-RN, PhD: Our Wellness Check support post vaccination an Covid-19 Infection’s follow-up consultations. (Is a registered Nurse who specialize in providing human virus infection health interventions and education services to people of African heritage.)

– Developing culturally and linguistically appropriate materials and tools and devices that communicate important information regarding the vaccines, including partial support for completion of Vaccine Cheat Sheet tool for making culturally appropriate changes to Vaccine information over time.

Amin. Cost of Overhead

– B&O Taxes, WA State

If Sisters in Common is applying for activity #2, please complete this section.

-COVID-19 Health Department-Liaison

-Intern Community Support Workers Stipends. Interns CSW crated and worked providing Covid-19 PPE at Community Church Tent Revival between (9/21-11/21).

– Health Resource Consultant-PhD-SUDP engagement and assessments and referrals

-Payroll Taxes

– Admin. Cost of Overhead

-B&O Taxes, WA State

1. Intern made phone calls doing outreach in culturally appropriate manner to their church community leadership and community stakeholders andElders and engaged in coordination, collaboration, and support providing vaccination information sharing efforts with their church and community members and coaching and support their learning how to setup and support PPE station at their church tent revival between 9/21-11/21, while coaching their community members in ” THE HOW TO” about vaccine eligibility processes and sharing available information about the timelines of eligibility and RE-eligibility.
2. Hosting virtual conversations where community member’s questions are received, and information is shared about members vaccine options in support their social goals and relatedness to individual in their life. Sharing culturally and linguistically appropriate materials through. community networks that are accessible and culturally relevant (i.e., phone calls, social media, flyers, community alert tool, etc.)
3. Health Resource Consultant- RN, PhD: Our Wellness Check support pre-vaccination-post vaccination and COVID-19 INFECTIONS follow-up consultations. Note: Health Consultations are both stakeholders and leaders in their communities as registered Nurse PhD and Psychologist PhD-SUDP who specialize in providing human virus infection health interventions and SUDP education and treatment/ referral services to people of African heritage.

Using what is JC’s said answer the following. What activities has Sisters In Common focussed on pertaining to the focus areas, Recruitment and Retention Strategies, and Staff Wellness and Burnout Prevention?

Based on the information provided by speaker 2, Sisters In Common has been actively involved in several of the focus areas you mentioned:

1. HEALTH AND SOCIAL APPRENTICESHIPS AND INTERNSHIPS: Sisters In Common has implemented a program they refer to as “add hip” or “advanced to professional practice.” This program training program serves as an apprenticeship or internship, providing practical experience and skills to individuals who can then support their community effectively.
2. LICENSURE SUPERVISORY SUPPORT: While Speaker 2 didn’t explicitly mention licensure supervisory support, they did mention that Sisters In Common expanded to include licensure with the Department of Health, suggesting that they likely provide support and guidance for staff in achieving and maintaining necessary licensure.
3. RECRUITMENT AND RETENTION STRATEGIES: Sisters In Common has a strong focus on retention. They have used funds from HealthierHere to incentivize their staff to stay, recognizing the value that bring to the community. They also recruit from within the communities they serve, ensuring that their staff are deeply connected to the people they are helping.
4. ACADEMIC PARTNERSHIPS: Speaker 2 didn’t specifically mention academic partnerships in their discussion. However, they did mention that their staff often move into other healthcare systems, suggesting that there may be partnerships with other institutions or academic entities for further training or career progression.
5. STAFF WELLNESS AND BURNOUT PREVENTION: Sisters In Common has implemented a unique model of work that allows their staff to continue serving their community even during personal challenges. They have created a system where staff can cover for each other, ensuring that no one is overworked and that everyone has the support they need. This approach helps to prevent burnout and maintain staff wellness. They also have a policy of “do no harm”, which means staff are not supposed to work just because they need the money, but because they are fit and able to do so, further supporting staff wellness.

Using what speaker 2 said answer the following What progress has Sisters In Common made related to those activities?

Based on the information provided by Speaker 2, Sisters In Common has made significant progress in the mentioned activities:

1. HEALTH AND SOCIAL SERVICE APPRENTICESHIPS AND INTERNSHIPS: The “add hip” or “advanced to professional practice” program has been successful in training individuals from the community to step in as community health workers. This has allowed Sisters In Common to maintain continuity of service even when primary staff members are unavailable due to illness or other reasons.
2. LICENSURE SUPERVISORY SUPPORT: Sisters In Common has successfully expanded to include licensure with the Department of Health, which suggest that they have been able to provide the necessary support for their staff to achieve and maintain these licenses.
3. RECRUITMENT AND RETENTION STRATEGIES: Sisters In Common has been successful in retaining their staff, with Speaker 2 mentioning that people rarely leave Sisters In Common unless they are leaving the country. They have also been successful in recruiting from within th communities they serve, ensuring a deep connection between their staff and the people they are helping.
4. ACADEMIC PARTNERSHIPS: While Speaker 2 didn’t specifically mention progress in academic partnerships, they did mention that their staff often move into other healthcare systems. This suggests that their staff are gaining skills and experience necessary to progress in their careers, which could be a result of successful academic partnerships.
5. STAFF WELLNESS AND BURNOUT PREVENTION: The unique work model implemented by Sisters In Common has been effective in preventing burnout and maintaining staff wellness. They have been able to create a system where staff can cover for each other, ensuring that no is overworked. Their policy ” do no harm” has also been effective in ensuring that staff only work when they are fit and able to do so.

sing what Speaker 2 said answer the following, How have staff members of Sisters In Common been impacted through these activities?

Based in Speaker 2’s statements, the staff members of Sisters In Common have been significantly impacted through these activities in the following ways:

1. HEALTH AND SOICAL SERVICE APPRENTICESHIPS AND INTERNSHIPS: The “add hip” or ” advanced to professional practice” program has provided staff members with the opportunity to gain additional skills and training. This has not only increased their professional capabilities but also allowed them to step in and provide shrives when primary staff members are unavailable.
2. LICENSURE SUPERVISORY SUPPORT: By expanding to include licensure with the Department of Health, Sisters In Common has likely increased the professional credibility and capabilities of their staff. This support has likely helped staff members navigate the licensure process and maintain their licenses.
3. RECRUITMENT AND RETENTION STRATEGIES: The strategies employed by Sisters In Common have resulted in a high retention rate. Staff members are deeply connected to their communities, which likely increases their job satisfaction and commitment to the organization. The recruitment strategies have also ensured that the staff is representative of the communities they serve, which likely enhances their ability to provide effective services.
4.ACADEMIC PARTNERSHIPS: While not explicitly mentioned by Speaker 2, the fact that staff members often move into other healthcare systems suggests that they are gaining valuable skills and experience that are recognized and valued by other organizations. This likely enhances their career and prospects and professional development.
5. STAFF WELLNESS AND BURNOUT PREVENTION: The unique work model of Sisters In Common, which includes a system where staff can cover for each other and a policy of ” do no harm”, has likely has significant positive impact on staff wellness. This model likely reduces stress and prevents burnout, contributing to better overall wellbeing for the staff. Furthermore, the organization’s focus on mission rather than money likely contributes to a sense of purpose and fulfillment among staff members.

Write a detailed outline of what Speaker 2 said about Sisters In Common and output in a table.

Sure, here’s a detailed outline of what Speaker 2 said about Sisters In Common, presented in a table format:

Topic/DETAILS:

FUNDING AND HISTORY – Sisters In Common was founded in the early 90s by a group of African heritage women in response to the issue of African American girls ending up in the juvenile justice system.

INITAL FOCUS – The organization initially focused on interventions for these girls, but soon realized that they home environment was a significant factor. This led to an expansion of focus to include family services.

PARTNERSHIPS AND EXPANSION – Sisters In Common first partnered with the city’s Justice Department for interventions, then expanded to Family Services with the state of Washington. They also became licensed as a behavioral health agency under the Department of Health.

MISSION AND VISION- The mission of Sisters In Common is healing and empowerment for the communities they serve, which include African American, Ethiopian, Oromo, and Somali communities in King County and the state of Washington. Their ultimate goal is to go out of business because their mission is completed.

IMPACT OF COVID-19 – The pandemic has had a significant impact on the organization, with over 66% of staff being infected despite moving to a remote work model. This has led to changes in their business model and a need for additional staff to maintain continuity of service.

WORKFORCE RETENTION TRAINING: Sisters In Common has focused on workforce retention and training, including creating a pipeline of community health workers through their ” add hip” or advanced to professional practice” program. They have also implemented an incentive system for staff retention.

FUNDING AND REIMBURSEMENT: The organization operate on a cost reimbursement model, with funds coming from sources like HealthierHere. These funds are used for workforce retention, training, and hiring additional staff.

FUTURE OUTLOOK: Despite the challenges posed by the pandemic, Sisters In Common plans to continue their work, with a focus on maintaining staff and providing services to their communities. They aim to adapt to the changing circumstances and continuing fulfilling their mission.

HEALTH AND SOCIAL SERVICE APPRENTICESHIPS AND INTERNSHIPS- Sisters In Common has developed a program to train community health workers, which includes internships and apprenticeships. This program is designed to create a pipeline of workers who can provide culturally appropriate care to the communities they serve.

LICENSURE SUPERVISORY SUPPORT – The organization provides support for staff seeking licensure, including supervision and mentorship. This is part of their effort to develop a skilled and diverse workforce.

RECRUITMENT AND RETENTION STRATEGIES – Sisters In Common has implemented an incentive system to retain staff, which includes bonuses and other benefits. They also focus on recruiting from the communities their serve to ensure cultural competency.

ACADEMIC PARTNERSHIPS – They have established partnerships with academic institutions, which provide additional resources and support for their programs. These partnerships also help in the development of their training programs.

STAFF WELLNESS AND BURNOUT PREVENTION – The organization has put a strong emphasis on staff wellness and burnout prevention, especially in light of the challenges posed by the COVID-19 pandemic. This includes providing support for staff who have been infected with the virus and implementing measures to prevent burnout.

PROGRESS MADE – Despite the challenges of the pandemic, Sisters In Common has made significant progress in their work. They have been able to maintain their services, continue training community health workers, and retain their staff.

IMPACT ON STAFF – The activities of Sisters In Common have had a positive impact on staff. They have been able to continue working and serving their communities despite the pandemic, and have received support from the organization in terms of health and wellness, training, and incentives.

COMMUNITY ENGAGEMENT- Sisters in Common has a strong focus on community engagement. Staff members are deeply rooted in the communities they serve, and the organization works closely with community leaders and stakeholders.

COVID-19 RESPONSE – The organization has adapted its operations in response to the COIV-19 pandemic. this includes moving to a remote work model, providing support for staff and community members affected but the virus, and adjusting their services to address the ongoing health crisis.

FUNDING AND REIMBURSEMENT – Sisters In Common operates on a cost reimbursement model, receiving funds from various sources including the Department of Health and the organization HealthierHere. These funds are sued to support their programs and services, as well as to provide incentives for staff retention.

FUTURE GOALS – The ultimate goal of Sisters In Common is to go out of business – that is , to address the issues facing their communities to the point where their services are no longer needed. They are committed to healing and empowerment, and aim to reduce the problems they are working to address.

CHALLENGES – The organizations faces a number of challenges, including the ongoing impact of the COVID-19 pandemic, the need for effective interventions for health issues caused by the virus, and the need for sustainable funding. Despite these challenges, they remain committed to their mission and their communities.

What activities have speaker 2 talked about pertaining to the focus the areas and category Staff Wellness?

Speaker 2 discussed the importance of staff wellness in the context of the COVID-19 pandemic. They mentioned that over 66% of their staff have been infected with the virus, even though they moved to a remote work model. This has had a significant impact on their staff’s physical and mental health, leading to a cycle of sickness and wellness.

In response to these challenges, Sisters In Common has implemented strategies to support their staff’s wellness. They have adjusted their work model to accommodate the changing needs of their staff, including allowing flexible work hours and remote work. They have also implemented a system where they train additional staff members who can step in when primary staff members are unable to work due to illness.

Additionally, they have established an incentive system to retain their staff, recognizing the value of their work and their commitment to their communities. This system is funded through the workforce retention funding they received from Healthier Here.

However, Speaker 2 did not provide specific details on programs or initiatives directly related to staff wellness such as mental health support programs, wellness activities, or other similar initiatives

How does your organization define equity? What process was used to develop this definition? How is this definition communicated throughout your organization?

Our core tenet to ensure positive outcomes in each community member’s Social Determinants of Health, (SDoH), requires that we address their Health Related Social needs, (HRSN), in ways that make it clear that “from each of us according to our abilities to healed and empower, to each of us according to our need of healing and empowerment.” We base this on; 1. our collective and individual experiences and victimization by systemic SDoH disparity and inequity, driven by systemic racism. 2. Our 25 year experience in providing community informed, culturally competent SDoH services, which address our HRSN, in ways that support the empowerment and healing, in our community members. We hire directly from our cultural and ethnic communities. They are passionate about collaborating with their community members. They ensure SDoH services continue to be culture community specific, valued by the community, and embedded in the cultural and ethnic values of their communities. We create tools and skill train staff to provide SDoH services based on their clear understanding of how their work address the HRSN successes of their families, friends, and neighbors.

What has your organization identified as a strategy to address your goal that would advance individual equity outcomes within your organization over the next 18 months?

King County systemic SDoH, physical and behavioral healthcare system inequities continue to negatively impact a wide range of our clients and our community member’s health and life risk and outcomes.

Exacerbated by the Covid19 pandemic, our clients and community members are reporting that they are experiencing an increase in the negative impact of the inequities in their SDoH conditions. The result has been a measurable increase in client SDoH- request for support and services to help them address their Health Related Social Needs.

Note: In year 2021 we saw a 57.1 percent increase in our client “need-request” for services to address their SDoH- Health Related Social Needs, HRSN). most of the request for services were specifically related to Covid-19 issues on how to prevent and/or mitigate the spread of disease and illness in their homes and among their families. Friends and neighbors, and how to navigate and access SDoH assistance services in King County.

As “community”, we routinely gather, (nearly every week), to discussed what we could do to effect “REAL aka SUSTAINABLE change to eliminate King County systemic SDoH, physical and behavioral healthcare system inequities.

We concluded, as community, to effect “REAL aka SUSTAINABLE” change to eliminate King County systemic SDoH, physical, and behavioral healthcare system inequities, we needed a “advancement to health professions pipeline”, (AT-HPP), BY and OF our community members.

Our AT-HPP plan and goal is:

(a) Advancement from stipend Intern Community Service Workers, (CSW), to status Community Health Workers (CHW), trained and employee;le stays as Community Health Workers (CHW), providing SDoH-HRSN services to our respective community members in our massive King County health system. And/ or
(b) AT_HPP interns will continue their health profession education and skills training (e.g., CHW, CPC, CNA,CD,CMA,BSN,RN,MSN,ARBP,MD,DO,PhD,MHP, SUDP…) and become employable providing Whole person care services to our respective community members in our massive King County health care system.

We plan to continue the work and design in establishing our ” advancement to health professions pipeline”, (AT-HPP), of Stipend Community Service Worker (CSW) BY and OF our community members.

(2) We will continue our practice of hiring directly from our cultural and ethnic communities we serve. This is to continue to ensure that SDoH services continue to be 1. culture -community specific, 2. valued by the community, and 3. embedded in the cultural and ethnic values of their communities.

b. Advancement from stipend Intern Community Service Workers, (CSW) status, to employment status Community Health Workers (CHW).

Our goal is that after completing their stipend-internship training as CSW, they would either; 1. be able to become employees working as Community Health Workers, providing SDoH services or 2. continue their education and become an health care system employee providing whole person health services.

Why do you believe that achieving this goal would advance individual equity outcomes within your organization?

Because we are members of the community we serve, and we routinely request information, and feedback from our staff, client’s and community leadership/stakeholders about types, quantity, and quality of services, including their thoughts on how to improve services further. We hire directly from our cultural and ethnic communities. This ensure SDoH services continue to be culture community specific, valued by the community, and embedded in the cultural and ethnic values of their communities.

What process did you use within your organization to identify this goal? Who was involved in identifying this goal? How did you develop the goal?

Because we are members of the communities we serve, we routinely request information, and feedback from our staff, client’s and community leadership/ stakeholders about types, quantity, and quality of services, including their thoughts on how to improve services further. We do it this way because of our 25 year experience in providing community informed, culturally competent SDoH services, which address our HRSN, in ways that support the empowerment and healing, in our community members.

What specific actions will you take to achieve this goal ?

All trainings are provided with CHW (same culture) staff support. All trainings that are provided, are supported in the stipend intern’s primary language. We have developed and maintain by a professional multi-cultural, multi-lingual, and diverse staff. Sisters In Common provides stipend CSW trainings with CHW Mentor staff support in several ways, including, but not limited to *Providing a flexible work schedule that allows Intern and staff members to attend trainings even if they occur on weekends. *Conducting in-services-consultations that are based on identified Intern and staff needs and areas towards goals. Intern mentor for these in-services training come from within the agency. Also, trainings are added from other health, education, and community organizations that are experts in their respective fields. It is the practice of Sisters In Common to provide resources for required trainings. Our practice is to have our stipend Interns and staff have quality and 24/7 access to ongoing trainings and staff support.

How will Sisters In Common measure progress toward achieving this goal?

How many stipend CSW Interns, after completing their stipend-internship training as CSWs; 1. become employees working as Community Health Workers, providing SDoH services or 2. continue their education and become an employee providing behavioral health services.

Because we are members of the communities, we are well connected to our community members, who are our family, friends, clients, and neighbors. We routinely request information, and feedback from them and our community leadership/stakeholders about types, quantity, and quality of services, regularly including their thoughts on how to improve ALL trainings and services further.

How will Sisters In Common adjust as you learn and measure the effectiveness of the implementation strategies ?

We are CBO licensed to provide BHS. As members of our communities, routinely request and collaborate and problem solve and use our “check out-feedback loops” with our staff, client’s and community leadership/stakeholders about types, quantity, and quality of our trainings and services, including their thoughts on how to improve services further. The real proof is that stipend Intern CSWs will 1. become employees working as Community Health Workers, providing SDoH services or 2. continue their education and become an employee providing behavioral health services.

Who, within Sisters In Common, will be involved in supporting the implementation of this goal ?

Community Service Worker Intern Coordinator, Community Health Worker Supervisor MSW, CHW Mentor, The IT Multi-Media-Speacilaist, The Admin. Assist-Remote Time Management-evaluation, The Data Analytics Specialist, RN Health Wellness Consult, 6. BHS Specialist, Disability Mental Health Specialist, Ethnic Minority Mental Health Specialist, Child Mental Health Specialist.

How will the people most affected by the implementation of this goal be included in the planning, design, decision-making, implementation, and success measurement for this goal?

We survey information from clients/community members, leadership/stakeholders about quantity and quality of services from first contact to completion, including their experiences while receiving SDoH services, and their thoughts on how to improve services. Responses / suggestions are included in all services and future planning. We conduct periodic conversations/ focus groups. We have used these sessions for/ input on service content and prioritize services. We use these methods to gauge on -going satisfaction and ideas for improvement. We hire directly from our cultural and ethnic communities. This ensure SDoH services continue to be culture community specific, valued by the community, and embedded in the cultural and ethnic values of their communities.

How will Sisters In Common communicate this goal, and progress toward achieving this goal, throughout your organization?

Our part time CHWs are the backbone of our ability to deep dive and effectively serve our communities. CHW’s are matched with their community members client’s based on culture and language spoken. They are representatives of their respective communities, (Note: their individual community leadership and stakeholders are required vetting and endorsing partner in the CHW recommendations and hiring process.) Added, we have created and made a part of our agencies we site and phone based communications infrastructure our “Community Alerts” tool (check it out at sistersincommon.org, on the operations menu tab.). Our Community Alert tools is proving to be very effective in sharing SDoH and HRSN information while providing ongoing KEEP GETTING THE WORD OUT to all

How will Sisters In Common share lessons learned during the implementation of strategies to achieve this goal with others outside of your organization?

HealthierHere continuing in its role to help and support with “whole person care health system integration” collaboration has proven to be a perfect vehicle to partner and share information about lessons learned. Also, we have our CHWs, who are representative of their respective communities, (Note: their individual community leadership and stakeholders are a required vetting and endorsing partner in the CHW recommendations and hiring process). Added, we have created and made a part of our agencies web site and phone based communications infrastructure our “Community Alerts” tool (check it out at sistersincommon.org, on the operations menu tab.) Our Community Alerts tools is proving to be very effective in sharing SDoH and HRSN information while providing ongoing KEEP GETTING THE WORD OUT to all, including supporting some of our professional partners in assisting them in getting the work out to their client and community stakeholders. We have additional innovative efforts we are collaboratively working with our communities to complete and launch to effect maximum community engagement.

What does Sisters In Common hope to learn by implementing strategies to achieve this goal ?

How to create and sustain a culturally competent CHW workforce through creating a pipeline for advancement to CHW employee status, after being a stipend Intern Community Service Workers, (CSW), with the CSW completing their stipend-internship training as CSW, then either; 1. becoming our or other employed Community Health Worker, providing SDoH services or 2. continue their education and become and employed providing behavioral health services.

What technical assistance, training and/or support does Sisters In Common believe would be of value as your organization implements strategies to achieve this goal?

HealthierHere continuing in its role to help and support with “whole person care health system integration” collaboration has proven to be a prefect vehicle to partner and share information about lessons learned.

How will Sisters In Common operationalize the strategies used to achieve this goal within your organization to ensure sustainability of the progress that you make ?

Based on reports from our MCO partners work performed by CBOs licensed to provided BHS, CHW employee – CAAR SDoH work hours is billable.

How will Sisters In Common operationalize the strategies used to achieve this goal within your organization to ensure sustainability of the progress that you make ?

Based on reports from our MCO partners work performed by CBOs licensed to provided BHS, CHW employee – CAAR SDoH work hours is billable.

This COVID-19 PANDEMIC BRIDGE LOAN AGREEMENT is made and entered into as per…..by and between :

(1) SISTERS IN COMMON, with address 15 S GRADY WAY, SUITE 310, RENTON, WA 98057, a private NOT FOR PORFIT corporation (company) existing under the laws of the state of Washington, with its corporate UBI registration number 602254754, under the laws of WASHINGTON STATE, (BORROWER); and
(2)…………, a private INDIVIDUAL and RESIDENT OF WASHINGTON STATE, (Lender).

WHEREAS
The company requires immediate financial support to enable it to bridge its corona virus disease (COVID-19) pandemic services that address the health related needs to their client’s in King County and survive the potential impact of such pandemic on the Company’s short- time business operations, improbability of being able to use category specific cash on hand from DOH, or receive reimbursement funding from current King County HealthierHere Project Services Agreements (PSA), which are delayed beyond normal conditions), and the Lender is prepared and able to support the Company in these extraordinary times by providing the Company with a loan subject to the terms and conditions of this agreement.

IT IS HEREBY AGREED AS FOLLOWS

DEFINITIONS AND INTERPRETATION

Definitions

In addition to the terms defined elsewhere in this agreement, the capitalized words set out below shall have the following meanings throughout this agreement:

Commencement Date has the meaning given thereto in Clause 2 (Loan).
Company has the meaning given thereto in the introduction.
Event of Default has the meaning given thereto in Clause 8 ( Events of Default);
Exit means an intended change in the legal form of the Company or to being the Company under the control of Washington State, in virtually the same proportions immediately prior to the completion of such transaction;
Financing Agreement has the meaning given thereto in Clause 7 (Subordination);
Lender has the meaning given thereto in the introduction.
Loan has the meaning given thereto in Clause 2 ( Loan);
Maturity Date means the earlier of (a) the Ultimate Maturity Date; and (b) the date which falls one business day following the date on which an Exit takes place; and
Ultimate Maturity Date means the date which is (6) months from the Commencement Date.

Rules of Construction
As used in this agreement (i) all pronouns and any variation thereof shall be deemed to refer to the masculine, feminine or neuter, singular or plural, as identity of the person or persons may require, (ii) the word “include” and variations thereof, shall be deemed to mean ” includes”, without limitations”, and variations thereof, (iii) the word “in writing” and “written” will mean by letter, email or message transmitted via other means of modern communication and which can be received in written form, provided that the identity of the sender can be determined with adequate certainty, and (iv) references to any Tim of day are to the time on that day in the Netherlands.

LOAN

The Lender shall provide and make available to the Company a loan in the aggregate principal amount of USD 30,000 and the Company accepts such loan (the Loan). The Lender will make the Loan available to the Company by no later than the 5th business day after the MONTH heron (such date, the Commencement Date ) by payment of the principal amount of the Loan into the Company’s bank account as specified in this agreement, in writing by the Company to the Lender.

PURPOSE

The Company will apply all amounts borrowed by it under the Loan solely to finance its workings capital and operating funding needs. The Lender is not obligated to verify whether the Loan is used in accordance with agreed purpose.

COST OF THE LOAN
As from the Commencement Date, COST OF THE LOAN shall BE CALCULATED on the outstanding principal amount of the Loan at a flat rate of USD 1200 per month, per USD 30,000. THE FIRST PAYMENT shall be payable UPON payment of the principal amount of the Loan into the Company’s bank account as specified in this agreement and shall continue EACH MONTH, before 5th DAY OF THIS MONTH, until the Loan is repaid or prepaid in full accordance with terms and conditions of this agreement.

REPAYMENT AT MATURITY
To the extent that (i) the principal amount remains outstanding on the Maturity Date, and (ii) the Lender shall have demanded , in writing, payment of the principal amount of the Loan and all accused but unpaid COST Theron, the Company shall pay an amount in cash to the Lender equal to the outstanding principal amount of the Loan and all accused but unpaid COST Theron through the date of repayment in full of such amounts.

VOLUNTARY PREPAYMENT PRIOR TO MATURITY
The Company may elect in its sole and absolute discretion, by giving not less than 5 business days’ prior written notice to Lender (which notice will be irrevocable and will specify the date fixed for repayment) to voluntarily prepay the Loan in whole or in part on any business day prior to the Ultimate Maturity Date, without becoming liable to the Lender for any penalty or other form of compensation, provided always that any amount of partial repayment will be divisible by USD 1200, and every prepayment will be made together with any unpaid accused but not paid interest.

SUBORDINATION
The parties confirm and agree that:

(i) their respective rights and obligations under this agreement shall be subject to the terms of any bank or loan facility agreement in place for the financing of the Company ( a Financing Agreement) ; and
(ii) the payment of the principal of , interest on, and all commission, claims, indemnities and any other amounts owing in respect of this agreement SHALL NOT be subordinated to claims from the counterparts to any Financing Agreement under such Financing Agreement, and SHALL Not be deferred and subordinated and junior in right of payment, to the prior payment in full of any outstanding amounts under any Financing Agreement.

EVENTS OF DEFAULT
The Loan will accelerate and all principal and accused but unpaid COST OF THE LOAN thereon will at the option and upon the declaration of the Lender and upon written notice to the Company (which election and written notice will not be required in the case of (iii) below) become immediately due and payable, without any judicial intervention being required, if any of the following events (each an Event of Default) occurs:
(i) default is made in the payment of any amount in the respect of the Loan on the due date for payment thereof and such default is not remedied within 10 business days.
(ii) the Company fails to comply with any of its other obligations under this agreement, unless such failure to comply is capable of remedy and is remedied pithing 10 business days of the earlier of the Lender giving written notice thereof to the Company;
(ii) the Company or any other person takes action and/or starts legal proceedings and/or takes steps (a)for the Company to be declared bankrupt or insolvent, (b)for the Company to be granted a suspension of payments or other judicial postponement of payments of debts, (c) to wind- up or liquidate the Company, or (d) to appoint a custodian, receiver, trustee or assignee for the benefit of creditors (or other similar official ) to take possession, custody or control of any property of the Company.
8.2 Notification
The Company will be obligated to inform the Lender immediately in writing if any when it becomes aware of (i) Event of Default, or (ii) of any event which with the lapse of time would reasonably constitute and Event of Default.
8.3 Enforcement Costs
In the event of Event Default, the company will pay all reasonable attorneys’ fee and court cost incurred by the Lender in enforcing and collecting any part of the Loan.
9. SECURITY
The Loan is will be secured.
10. PAYMENTS
All payments by the Company pursuant to or in connection with this agreement will be made in USD and at the bank account as indicated by the Lender from time to time. All payments shall be applied first to accrued COST OF THE LOAN, and thereafter to the principle amount.
11. NO SET-OFF OR SUSPENSION
All payments by the Company under this agreement will be made without set-off, counter claim and / or suspension, unless expressly provided otherwise herein.

12. NOTICES
Any notice regarding a breach of this agreement must be delivered personally or by registered mail to the addresses appearing in the heading of this agreement, with a copy by electronic mail (which copy shall not constitute a valid notice) to the email addresses set forth opposite each party’s name on such party’s signature page hereto or such other email address as such party may subsequently designate in writing to the other parties for the purpose of this agreement. All other notices under this agreement may be sent the same way, but instead also be sent by regular mail and electronic email only.

SOPHISTICATION
The Lender acknowledges that (a) HE has such knowledge and experiences in COMMUNITY ORGANIZATION business matter that HE is capable of evaluating the merits and risks of the loan contemplated by this agreement in view of the coronavirus disease (COVID-19) pandemic, and the terms of the HIS loan to the Company involves a high degree of risk.

MISCELLANEOUS

Further Assurances
At any time or from time to time after the date hereof, the parties agree to cooperate with each other and at the request of any other party, to execute and deliver further instruments or documents and to take all such further action as the other party may reasonably request in order to evidence or effectuate the provisions contemplated hereby and to otherwise carry out the intent of the parties hereunder.

Entire Agreement
This agreement constitutes the whole agreement between the parties and supersedes any previous agreements or arrangements between them relating to the subject matter of this agreement.

Severability

In the event that one or more provisions of this agreement turn out to be invalid, the remaining provisions will remain effective. The parties will discuss the invalid provisions in order to agree upon and alternative arrangement that is valid and which is closely as possible corresponds with the contents of the provisions to be replaced.

REMEDIES
Each party herby waives its rights to rescind or nullify, or invoke the rescission or nullification of, this agreement. Furthermore, a party in error shall bear the risk of that error in making agreement.

Amendments
No amendment or variation of and/or modification to this agreement will be effective unless it is made or confirmed in a written document signed by all of the parties, which may be any number of counterparts, all of which taken together will constitute one and the same instrument.

Assignment
Except as expressly contemplated by this agreement, the rights and obligations of the parties under this agreement cannot be assigned or transferred to any third party without the prior consent of the other party.

Cost
All cost and advisory fees incurred by the parties in connection with the preparation, negotiation and implementation of this agreement shall be borne by the Company, unless expressly provided otherwise herein.

Capacity
Each party warrants to the other party hereto that it has obtained and complied with all consents, approvals and authorizations necessary, and has all powers and capacity, to enter into this agreement and that this agreement is valid and binding on such party in accordance with its terms.

GOVERNING LAW
This agreement will be governed by and construed in accordance with the laws of the state of Washington.

DISPUTE RESOLUTION
Any dispute that may arise in connection with this agreement shall in first instance exclusively be referred to the competent civil court of Washington State.

COUNTERPARTS
This agreement may be entered into any number of counterparts and by each of the parties on separate counterparts but will not be effective until each party to this agreement has executed at least one counterpart. Each counterpart, when executed, will constitute an original, but all the counterparts will together constitute one and the same instrument. Counterparts may be delivered via facsimile, email (including pdf or any electronic signature) or other transmission method and any counterpart so delivered will be deemed to have been duly validly delivered and be valid and effective for all purposes.

Company :
SISTERS IN COMMON

BY:
NAME: JC EPHRAIM
Title: EXECUTIVE DIRECTOR authorized director

Problem Statement

As listed on Sisters In Common’s website Our mission is “To re-introduce cultural values, traditions and history that promote healing and empowerment for youth, families, and communities in crisis”. Our motto is ” Cultural empowerment or families in crisis”. In order words, we need “to re-integrate/retain cultural values, traditions and history that promote healing and empowerment for our children, youth, families, and communities”, that prevent, address and build healthy resiliency/coping skills and remove/decrease SDoH concerns/issues, and the resulting physical/behavioral health issues and challenges that are further exacerbated by cultural and health care disparity/inequity, adverse childhood experiences (ACES) and trauma.

Our goal will be to use our collective experience and learning to “implement and test cultural appropriate and responsive SDoH community-base strategies to help our community members manage chronic health conditions, including their many chronic illnesses exacerbated by their post-acute sequelae SARS-CoV-2 infection (PASC) aka “Long Covid”.

It is urgent and necessary that we do our part to meet this challenge NOW, due to :

1. Our community members inequitable and current pandemic exposure to SARS-COV-2 infections. Research and studies show, (as early as April 2021 to as last as January 20,2023), That SARS-CoV-2 infections is actively causing and exacerbating post-acute sequelae SARS-CoV-2 infections (PASC) aka “Long Covid” amount news release on October 7,2021, “One U.S. child loses a parent or caregiver for every four COVID_19 associated deaths.” Children of racial and ethnic minorities accounted for 65% of those who lost a primary caregiver due to the pandemic.

2. King County’s systemic SDoH and physical & behavioral healthcare system inequities continue to negatively affect a wide range of our clients and our community members’ health & life risks and outcomes.
3. As “community”, we routinely gather , (nearly every week), to discuss what we can do to effect REAL (aka SUSTAINABLE) change to end King County’s systemic doH and physical & behavioral healthcare system inequities. We concluded, as a community, that to effect REAL (aka SUSTAINABLE) changes to eliminate King County systemic SDoH and physical & behavioral healthcare system inequities, we need an advancement to health professions pipeline (AT-HPP) BY and OF our community members.
4. MIXED information about Covid-19 risk and impact of infection AND very LIMITED information about Long COVID and its impact, continues to overwhelm our staff, families , friends, and neighbors. The challenge to go through information and see what is driven by health consideration vs economic consideration for our major community is increasingly time intensive.
5. Limited culturally appropriate Covid-19 infection resources that focus on our community health-venerable populations (i.e., Immune-compromised).
6. The MIXED & LIMITED information about COIVD-19 continues to contribute to more fear and doubt, which is putting more members in the ” wait and see mode” ( Black people in King County are relatively slow to change their COVID-19 prevention and mitigation behaviors). We are increasingly more resistant to get tested, in greater numbers, as more households are experiencing increased infections.

Exacerbated by the COVID19 pandemic, our client and community members are reporting that they are experiencing an increase in the negative impact of the inequities in their SDoH conditions. The result has been a measurable increase in client -SDoH “need-requests” for support and services to help them address their Health Related Social Needs.

Note: In year 2021, in King County, with 5 FTE we provided 2,247 SDoH services to communities that addressed 313 clients that addressed the health related social needs of the clients, plus their families, friends, and neighbors. There was a 57.1 percent increase in our clients “need-request” for services to address their SDoH-Health Related Social Needs (HRSN). 48.2% of services were specifically related to Covid-19 issues on
1) how to prevent and/or mitigate the spread of disease & illnesses in their homes and among their families, friends, and neighbors (FFN), of which 49.1% requested and required a Covid-19 health provider referral.
2) Although 92.3% reported experiencing communication barriers when seeking SDoH- HRSN and physical & behavioral health services, at clients’ request, we coached and trained 58.8% of clients on how to self-navigate and access SDoH assistance services in King County.

Project Description

In 2021, we concluded, “as community”, to effect REAL (aka SUSTAINABLE) changes in how we manage their chronic health conditions, to improve their health outcome, decrease our health disparities, and eliminate the system gap caused by the King County systemic SDoH and physical & behavioral healthcare system inequities, we can, with HealthierHere investment and the collaborative support of our Healthier partners, Sisters In Common (SIC) service our Family, Friends, Neighbors (FFN) in King County’s underserved and under-resourced communities that make up our client base: low-income, African American, Eritrean, Somali, and Ethiopian communities specifically Oromo, English, AAVE, Amharic, Tigrinya, and Somali speakers in King County.
1. Continue to provide and promote Social Determinants of Health (SDoH) as a necessary and integral piece in addressing our physical and behavioral health needs and services. ( Note: ” Studies show that 80 percent of health outcomes are driven by factors that occur outside of the healthcare delivery system”, HealthierHere, Robert Wood Johnson Foundation, Medicaid’s Role in Addressing Social Determinate of Health, 02/02/2019.)
(Note: Our outcome data is showing improved “whole person” Covid-19 prevention and mitigation health related outcomes. Our data is showing an increase in our communities Covid-19 and related outcomes. Our data is showing an increase in our communities Covid-19 and related health responses even as er continue to be challenged by systemic public health messaging and strategies that appear to undermine our health messaging and efforts and support disparities and inequities).
Again, our CHWs are and remain the backbone of our ability to deep dive and effectively serve our communities. CHW’s are matched with their community member clients based on culture and language spoken. We always hire directly from our cultural and ethnic communities to ensure community-informed & culturally- competent services to better address our HRSNs in ways that support our empowerment and healing. They are representatives of their respective communities, (Note: their individual community leadership and stakeholders are a required vetting and endorsing partner in the CHW recommendations and hiring process). This practice is vital to continue to ensure that SDoH services continue to be 1) culture & community specific, 2) valued by the community, and 3)embedded in the cultural and ethnic values of their communities.
2. Create, Recruit, Enroll, Orientate, and Educate our community members in an Advancement to Health Professions Pipeline (AT-HPP) BY and OF our community members. They as Stipend Intern Community Service Workers (CSW) will become trained & employable as Community Health Workers (CHW),providing SDoH-HRSN services to our community members in our massive King County healthcare system. This will give them a real foundation to choose to continue their health education and skills training (e.g., CHW, CPC, CNA, CD, CMAH, BSB, RN, MSN, ARNP, MD , DO , PhD, MHP, SUDP…) to become employable providing SDoH Whole Person Care Services to ur community members in our massive King County healthcare system.
3. Continue this work, further designing and building our Stipend Community Service Worker (CSW) Internship pipeline, AT-HPP.
4. Continue our current practice of hiring directly from the cultural and ethnic communities that we serve.
5. Continue to provide and make improvements to health screening tools that promote and ensure culturally competent health equity for our staff, clients, families, friends, neighbors, and communities including creating and posting SDoH, culturally-competent self-empowerment and supportive tools on our public web site.
6. Continue providing to our Community Heath Workers additional resources, education, and training to help them support their client navigation and engagement with their health providers, empowering them to be “cause in the matter” of their own health and wellness.
7. Continue to make Improvements to the Health Related Social Needs screening tool and the SDoH Resources/ Community and Health Alerts tools. Note: we have added three additional culturally competent novel self-screening tools that empower our clients to self access, update and review their status and progress in their self-care. These tools continue to demonstrate the value of embedding the integrated-quantitave-qualitative data analysis of our African Heritage populations to inform and sustain the delivery of “whole person” SDoH care services to our communities.
8. Continue to provide and make improvements to the tools that promote and ensure cultural equity for our staff, clients, families, friends, neighbors , and communities.
9. Also, because we are members of the communities we serve, we ill continue our practice of routinely requesting information, and feedback from our staff, clients’ and community leadership/ stakeholders about types, quantity, and quality of services, including their thoughts on how to improve services further.
10. Our data collection and analysis (i.e., using the method of “integrated-quantitative-qualitative” data analysis) continue to be a cornerstone in support of our culture-equity practices to ensure that:
11. We meet value-based healthcare provider requirements for providing the highest quality care to our clients & communities – at a lower cost to us and our healthcare partners .
12. We determined the equitable (re)allocation of resources on an ongoing basis to serve our communities according to each community’s ability and each community’s needs.

Experience

As a culturally competent HealthierHere Level 1 Partner – CBO and licensed Mental Health Agency (MHA) serving King County African Americans. Eritrean, Somali and Ethiopian-Oromo speaking clients and their families, friends, and neighbors. We have long and effectively served those with behavioral health conditions, complications by a history of physical health conditions, i.e.,Asthma, COPD, Diabetes, End Stage Renal Failure, Heart disease, homelessness, and transitioning from the hospital to home. We are licensed to provide Behavioral Health: Outpatient; Individual mental health treatment services, Brief mental health Intervention/treatment services, Case management BH services and HBS. Sisters In Common have strong and effective partnerships with our community stakeholders and continue to develop closer collaborative ties with community service agencies that serve our underserved community members and add value to each others’s services/programs.

Over 25 years, Sisters In Common staff have participated in SDoH Care Consultations, providing SDoH services and Mental/ Behavioral Consultation to ur community members and their families, friends, and neighbors. The fact that Sisters In Common has been a team member in consultation models for over twenty-five years in an indication in itself that expected program outcomes were met. Our current staff is 99% African American and East African who are licensed, certified and trained as Child Mental Health Specialists, Ethnic Minority Mental Health Specialists (African American, East African Cultures), Disability Mental Health Specialists, Licensed/ Certified Counselors, Chemical Dependency Counselors, Parent Coaches, Family Preservation Therapists, Home-Based Services Providers Home Builders) and Strengthen Family Program Facilitators. We have two IT Consultants to support us in developing any programs needed to track and evaluate services and expertly address whatever electronic supports our staff need and use as a community resource. We also have staff and contracted consultants of African Heritage and on contract who are PhDs, MS, RN, BSN, LMHC, ICSW, MSW, MA, and SUDP.

We participate in many partnerships, including CBO’s, Managed Care Health Plans (MCOs), and county / state government budgeted agencies (e.g. SKCPH, HCA, and DOH). We are in alliances with other Community and Behavioral Health Services (BHS) providers. Our Board/ Administration / front-line staff are members of the communities we serve, grounded in their respective community’s cultural and family paradigms. We are a BHA licensed to provide Counseling and Case Management to medicaid clients. Our current MCO status is: Amerigroup : Active- In Network, Community Health Plan: Active- In network, Coordinated cAre: Active -In Network, Molina Healthcare: Active- In Network, United Healthcare/Optum: Active -In Network.

We are skilled and trained and in good standing and full compliance with WAC 246-341 Behavior Health Agency Licensing and Certification Requirements. This includes WAC246-341-410 Agency administration codes- Administrator Key Responsibilities and WAC 246-341-0420 Agency polices and procedures regarding Quality Management (QM) and Quality Assurance (AQ),. Our WAC 241-341 OQ and OM policy and procedures manual requirements will function to ensure that project goals, outcomes and deliverables are achieved.

Partners

Unkitawa’s is a 501x.3 community based organization, centered in traditional practices to help heal and support communities through ceremony, art, and culture, with dedicated programs include: RE-ENTRY, INDIGENOUS WELLNESS, INDIGENOUS YOUTH, VETERANS, and COMMUNITY ENGAGEMENT. The organization was formed at a pivotal moment when fiscal sponsorship with The Common Acre was coming to an end. Members of the original firewood project, ceremony family and others, decided to create and organization to have access to more resources for the Indigenous communities. Work in community was already being done before the Standing Rock movement by some of the members of the ceremony family, the work has always been centered in the traditional values; which have been the grounding values of Unkitawa.

We are both community partners with HealthierHere and have been in collaborative leadership and development with HealthierHere since 2020.

Sisters In Common and Unkitawa will function as mutual consultants to each, on the principle from each according to our ability to each according to ur need. Unkitawa and Sisters In Common, together will work collaboratively to address the historic gap in healthcare systemic funding. The goal is to address ensuring each other have a sustainable solution to fund culturally grounded SDoH services for our respective community members. As a innovation, Sisters In Common will provide ” REAL” Consultation services to Unkitwa that support their becoming a culturally competent licensed Behavioral Health agency, centers in the traditional values; which have been the grounding values of Unkitwa. Regular and routine meetings with Unkitawa supported by electronic software and staff support will ensure that we are in communication, and engaged to compete are required processes necessary to ensure full BH licensing by December 31,2023.

Use of Funding

The funding will be used to support the following:

1) Staffing to implement and build capacity of community-level healthcare professionals. Community Service Worker (CSW) interns will be recruited and trained to become employable as Community Health Workers within their communities. Additionally, CSW interns will be supported to continue their SDoH development as healthcare professionals.
2) Direct & culture-appropriate SDoH support of community members experiencing Long Covid individually and in a virtual group setting.
3) Addressing the SDoH client service gap by providing on-call services before and after our designated office hours to provide 24/7/365 SDoH support for our communities.
4) Development of tools & infrastructure to support the tracking, measurement, and analysis training, service delivery, and management of all key activates.
5) Provide community provision in the form of COVID Prevention & Mitigation supplies and culture-appropriate food to directly address SDoH inequities on a “need-request” basis.
6) Travel milage reimbursement to support the devilry of COVID Prevention & Mitigation supplies to directly address SDoH inequities on a “needs-request” basis.

The funding from HealthierHere will help Sisters In Common to convert said capital into community value, previously lacking from King County healthcare system barriers to improved healthcare outcomes for our communities. Our mission. enable by HealthierHere’s Funding and put into practice by our model of community endorsement, community recruitment, community engagement, system and Whole Person Care, will provide culturally-appropriate access to healthcare to address SDoH and Health Related Social Needs to our communities who are historically and presently deprived of equitable healthcare.

Process Tracking & Evaluation

SDoH Clients Outreach, Enrollment, and Consultations/Services to address their SDoH & Health-Related Social Needs

Consultation with Unkitawa to support their becoming a LICENSED Behavioral Health agency.

We have systems in place to track, report on, and analyze measurements of the milestones above.
Additionally , examples of the data we measure and report on fo all of our SDoH & Health -Related Social Needs:
Client (including Consultations and Client Longitudinal Record)
Attained Goals
Community Health Worker ( or Community Service Worker)
Cultural Community
SDoH category
Specific SDoH request
Health- Related Social Needs
Covid Prevention & Mitigation community provision
Culture-Appropriate food community provision

Importantly, clients may access to the details and a summary of the consultations addressing their SDoH and Health- Related Social Needs, as a means to keep the client informed of their progress as well as provide transparency to our communities.

Note: The culturally-informed solutions are “designed” not our mission & practice in the following ways:
1) All staff, CHWs, and CSW interns are members OF their cultural communities and endorsed BY their leadership and stakeholders in their cultural communities as representative os their respective communities.
2) We are engaged and involved as community representatives to feed back directly to ur community members directly. Our practice involves culturally- appropriate access to healthcare while addressing our communities’ SDoH and Health- Related Social Needs.

What is the COVID Vaccination Investment Fund ?

HealthierHere’s Governing Board approved the reallocation of $840,000 to support the COVID-19 vaccination effort in King County. 50 % of the $840.000 approved budget, or $420,000, is available for Community Based Organization partners. HealthierHere will implement an investment strategy is structured to support community, state and local funding for vaccine efforts and will amplify the strengths go HealthierHere’s various sectors of participating partners and enhance efforts to implement an equitable, accessible vaccination campaign in King County.
The objective of this funding is to resource a sub-set of HealthierHere partners crucial to an equitable vaccine strategy with startup funds for capacity building around information-sharing, outreach, and vaccine coordination activities. Funds will also be available for developing and implementing partnership to support equitable access to the vaccine in King County. Resources will be directed to those organizations serving the populations most impacted by COVID who need additional support to learn about, and access, the vaccine in the community and with providers they trust.

The Fund’s goals for Activity 1 and Activity 2 are to:

* support equitable distribution of vaccine and vaccination information to communities experiencing disparities and hard-to-reach communities.
* support development of communication capacity building for equitable access to vaccine appointments and/or vaccination events for communities experiencing disparities and hard to-reach- communities.

Impermissible uses of funding include, but are not limited to :

* Direct payments to individuals or families (e.g., cash assistance, rental payments, utility assistance , etc. )
* Marketing materials ( Restriction does not apply to in-language outreach or educational materials)
* Real estate investments, developments and other capital projects
* Salary support for executive leadership
* Debt restructuring and bad debt
* Defense and prosecution of criminal and civil proceedings, and claims
* Donations and contributions
* Entertainment
* Alcoholic beverages
* Furniture
* Fines and penalties
* Fundraising and investment management costs
* Idle facilities and idle capacity
* Interest expense
* Lobbying
* Research, assessment and evaluation activities

Who is Eligible?

The following. organizations are eligible to apply:

* HealthierHere Tier 1 and Tier 2 Community Practice Partners
* HealthierHere Community Grants Alumni

Additionally, applicants must currently meet ALL of the following criteria:

*Employ staff who are from the communities they serve and provide support services in a person’s primary home language.
* Serve communities disproportionately impacted by the effects of COVID-19.
* Can meet the needs of communities experiencing disparities in hard-to-reach communities, including elders, individuals with limited English proficiency, refugees, immigrants, homeless/ unstably housed, and racial / ethnic groups being disproportionately impacted by COVID-19.

HH will prioritize applications by organizations that self-identify as being led by Black, Indigenous, and/or People of Color (BIPOC). This is defined as having 51% or more of the organization’s board member and staff leadership identify as being member of the Black, Indigenous, and/or People of Color community.

How Can the Funds be Used?

If your organization has applied for and/or received other funding for COVID-19 vaccine implementation, outreach and/or education activities from organizations other that HealthierHere, you will be asked to describe how this request is complementary to, and not duplicative of, your other request/awards.

Funds will be available under the following categories:

Activity 1:

* Awards estimated not exceed $10,000 will be available for COVID Vaccination Information Sharing Activities. COVID-19 Vaccination Information Sharing Activities will be based on listening to community members about their concerns and answering questions about the vaccinations options, without pressing anyone to get vaccinated. Activities can include, but are not limited to, the following examples:
* Hosting virtual conversations where questions ae received, and information is shared about the vaccine options.
* Developing culturally and linguistically appropriate materials that communicate important information regarding the vaccines.
* Sharing culturally and linguistically appropriate materials though community networks that are accessible and culturally relevant (i.e., phone calls. socials media, flyers, etc.)
* paring information-sharing activities with other events such as during food distribution days, care package delivery, wellness checks, or any other previously scheduled event to serve the community.

Activity 2:
* Awards estimated not exceed $15,000 will be available for COVID Outreach and Eligibility Engagement Activities. COVID-19 Outreach and Eligibility Engagement Activities will involve reach out to community members to determine who is interested in learning more about their eligibility for the vaccines based on age and other factors; and determining who would like to be contacted again to schedule an appointment for the vaccine when they are eligible and the vaccine is available. Activities can include, but are limited to, the following examples :
* Making phone calls ( or doing outreach in any culturally appropriate manner) to community members to: a) ask them if they are interested in learning more about their eligibility, b) share available information about the timeline of their eligibility, c) determined if they want to be contacted by the organization in the future to receive support to get signed up for an appointment whenever they become eligible and vaccine becomes available.
* Following up with community members who said they wanted support getting signed up for an appointment when the time comes to sign up.
* Helping clients navigate Phasefinder.
* Helping clients make an appointment for COVID-19 vaccine and providing a reminder of the appointment.
* Working to remove barriers for clients wherever possible including through referrals, warm hands -offs, transportation, or other community efforts.

What are the Payment Terms?

Amount
* Award amounts will be based on the partner’s application for Activities ! and 2, with a maximum award amount estimated not to exceed $25,000.

Payment Terms
*Funds will be distributed 60% after signing agreement with HealthierHere, 20% after submission of first narrative report and 20% after submission of final narrative report.
*HealthierHere reserves that right to determine award amount.
*Awardees should launch or enhance services as soon as they have capacity to do so, and no later than May 15.
*All approved funds must be expended no later than November 15,2021.
*These are other payment terms will be detailed in an agreement between the awardee and HealthierHere.

Documentation and Reporting –
*Awardees must submit documentation regarding their use of funds included within their contract by December 15, 2021.
* HealthierHere reserves the right to schedule check-in calls during the funding period to confirm service delivery is on track and consistent with HealthierHere’s intent.
* Organizations who do not submit the requested documentation in a timely manner will be subject to fund recoupment.
*Organizations receiving funds under the COVID Vaccination Investment Fund are subject to audit by HealthierHere (or a third party engaged by HealthierHere for such purposes) to confirm compliance. Awardees should retain all appropriate supporting documentation ( e.g., invoices, receipts, timesheets, etc.) All such audits will be conducted during regular business hours and with reasonable prior notice.

What is the Application Process and Timeline?

Applicants must complete the Application Form using the template in Attachment 1. The dates below are subject to change.

*Application release date — March 22,2021
*Application due by 11:59pm PST —–March 31, 2021
*Open office hours for application questions —–March 24,2021 11:30-12:30pm
https://us02web.zoom.us/j/88012868087
*Open office hours for application questions —–March 26, 2021 1:00pm-2:200pm
https://us02web.zoom.us/j/89255937998
Awards announced FOR ACTIVITIES 1& 2 —–April 9, 2021

Please email completed applications to both Abriel Johnny, Community and Tribal Engagement Manager at ajohnny@healthierhere.org and Myani Guetta-Gilbert, Commity and Tribal Engagement Manager, at mguetta@healthierhere.org.

What is the Review Process?

HealthierHere staff will review applications as they received and may request that applicants answer clarifying questions. Submissions of an applicant does not guarantee approval.

Decision-making criteria will include, but not limited to, the following:

*Demonstrated ability to effectively provide vaccine and vaccination information in a culturally appropriate, responsive, and respectful way:
* track record of effective information delivery and outreach
* track record of judicious use of funds an ability to positively impact community
* track record of serving community in a culturally appropriate, responsive, and respectful way

* Organizations’s ability to reach and effectively serve focus populations
* Organizations that provide services to individuals:
* experiencing disparities and hard-to-reach communities,
* including elders,
* individuals with limited English proficiency,
* refugees,
* immigrants
* homeless/unstably housed, and
* racial/ ethnic groups being disproportionately impacted by COVID-19

HealthierHere continues to review data as it is released to understand which communities are disproportionately impacted-directly and indirectly- by COVID-19. healthierHere will monitor https://kingcounty.gov/depts/health/covid-19/data/race-ethnicity.aspx as well as information gathered from its community and tribal partners.

Applicant Name

Sisters In Common

Contact Information

JC EPHRAIM, Executive Director
sistersincommon@aol.com
206-726-0430

Partner Type

Tier 1 Community Practice Partner

Geographies Served

* Central/ South Seattle – South of the Ship Canal—including Downtown, Pioneer Square, Magnolia, Beacon Hill, Delridge, etc.

* North King County–including Shoreline, Lake Forest Park, Mountlake Terrace, etc.

* South King County —including Burien, Tukwila, Federal Way, Kent, etc.

BIPOC-led

HH defines “BIPOC-led” as organizations with 51% or more of board members and staff leadership identifying as being a member of the Black, Indigenous, and/or People of Color community. Please self-identify your organization as one of the following:

* Our organization is Black-led

Organization size and budget

Please tell us how many full-time staff work at your organization: 8FTE

Please tell us your organization’s annual operating budget: estimate $500k

Please provide a range of the number of volunteers your organization works with on a given program or event: 10-15

Which award/s is Sisters in Common interested in requesting in this application?

* COVID Vaccination Information -Sharing Activities. ($10,000)

* COVID Outreach and Eligibility Engagement Activities. ($15,000)

Populations to be Served

About Us (sistersincommon.org)
Sisters In Common, (SIC) provides a solution-focused outcome-oriented services to reduce the “cradle to grave” impact of inequities and disparities on the Social Determinants of Health (SDoH) of the adults, children, and families in our communities. All our services are community-informed and culturally competent. The services refocus on addressing the SDoH and Health Related Social Needs (HRSN) of our families, friends, and neighbors. Our service model is community-driven and builds the capacity of the whole community.

Our ethnic-cultural communities are African American, Eritrean, Ethiopian-Oromo, and Somali. tow thirds of our community members report English as their second language. They typical English reading level is 6th to 10th grade. Our most common languages are African American Vernacular English (AAVE), Amharic, English, Tigrinya, Oromo and Somali.

99.9% of our clients are Medicaid eligible. Relevant to COVID-19, our community members are overrepresented with respect to chronic health issues (e.g. heart, kidney, high blood pressure, diabetes and diseases.) These disparities are, in large part, due to systemic SDoH inequities including racism.

We have 25+ years of proven history of trust and respect with our communities. We effectively communicate with members of our communities and have demonstrated our abilities to stretch every dollar of available resources. In doing so we are helping to empower our communities to overcome the systemic health inequities and disparities, allowing to attainment four individual health and wellness goals.

We are full professional and interdisciplinary team of staff and consultants. We are members of the ethnic-cultural communities we serve. Several of our staff are certified to do COVID-19 Contact Tracing (John Hopkins). The backbone of our service model is our Community Health Workers. they are grounded in their community’s ethnic-cultural-history-, values, beliefs, traditions, and languages. They are trained in strength-based, trauma-informed, and reflective practices.

Activity #1: Covid Vaccination Information-Sharing Activities ($10,000)

1) Please share 2-3 ways Sisters In Common would use the funding to share information with community members about COVID vaccinations. If you are building on existing work that you have been doing to share information, please describe how the funding would help continue this work. Otherwise, please include a description of how this funding will be used for information-sharing activities that make community members feel heard and give them the opportunity to learn , ask questions, and receive answers.

1) Increase capacity (e.g., New hire). (AA, Eritrean, Ethiopian- Oromo and Somali)
Making phone calls ( or doing outreach in a culturally appropriate manner) to community members to : a) ask them tif they are interested in learning more about their eligibility, b) share available information about the timeline of their eligibility, c) determine if they want to be contacted by the organization in the future to receive support to get signed up for an appointment whenever they become eligible, and a vaccine becomes available.

Hosting virtual conversations where community member’s questions are received, and information is shared about the members vaccine options in support their social goals and rrelatedness to individual in their life. Sharing culturally and linguistically appropriate materials though community networks that are accessible and culturally relevant (i.e, phone calls, social media, flyers, etc.)
2) Health Resource Consultant -RN, PhD: Our Wellness Check support post vaccination follow-up consultations. Is a registered Nurse who specialize in providing human virus infection health interventions and education services to people of African heritage.
3) Developing and maintaining culturally and linguistically appropriate materials, tools and devices that communicate important information regarding the vaccines.

2) Please share what languages, in addition to English , if any, Sisters In Common would conduct information- spring activities.
Our “common” languages are African American Vernacular English (AAVE), Amharic, Tigrinya, Oromo, and Somali.

3) Please share an estimate of the number of households or individuals in King County information sharing efforts will reach.
COVID-19 Related Information 27. Would like more information about how to protect yourself against the Covid 10 virus. Out of 335 Clients, 311 answered yes.

Activity #2 Covid Outreach and Eligibility Engagement

1) Please share 2-3 ways you would use the funding to conduct outreach and eligibility engagement activities with community members about the COVID vaccinations. If you are building on existing work that you have been doing to do outreach and eligibility engagement activities already, please describe how this funding would help continue this work. Otherwise, please include a description of how this funding will be used for outreach and eligibility engagement activities that provide community members with the opportunity to learn about their eligibility and get connected with support to receive a vaccination.

1) Oversight of service activity, p prepare and submit narratives and documentation regarding our use of funds. Participate in check-in calls during the funding period to confirm service delivery is on track and consistent with HealthierHere’s intent. A) making phone calls or doing outreach in culturally appropriate manner to our community leadership and stakeholders and Elders to ask and engage in coordination, collaboration, and support vaccination information sharing effort with our community members and coaching and support in ” THE HOW TO” about vaccine eligibility processes and sharing available information about the timeline of eligibility.

2. Increase capacity (e.g., New Hire/increase FTW time). (AA, Eritrean, Ethiopian-Oromo and Somali).
Making phone calls (or doing outreach in a culturally appropriate manner) to community members to : a) ask them if they are interested in learning about the timeline of their eligibility, b) share available information about the timeline of their eligibility, c) determine if they want to be contacted by the organization in the forte to receive support to get signed up for an appointment whenever they become eligible and a vaccine becomes available, Hosting virtual conversations where community member’s questions are received, and information is shared about the members vaccine options in support their goals and relatedness to individual in their lif. Sharing culturally and linguistically appropriate materials through community networks that are accessible and culturally relevant. )i.e., phone calls, social media, flyers, etc).
3. Health Related Consultant -RN, PhD: Our Wellness Check support pre-vaccination -post vaccination follow-up consolations. Is. a registered Nurse who specialize in providing human virus infection health interventions and education services to people of African heritage.

2)Please share what languages, in addition to English, if any, you would conduct and eligibility engagement activities.
Our “common” languages are African American Vernacular English (AAVE), Amharic, Tigrinya, Oromo, and Somali.

3) Please share an estimate of the number of households or individuals in King county that the outreach and eligibility engagement efforts will reach.

Covid 19 Related Information
27. Would you like more information to protect yourself against Covid 19 virus.
Out of 335 Clients, 311 answered said “yes”

Activity #1 Covid Vaccination Sharing Activities ( up to $10,000)

Budget Line Item Amount

Community Service Worker – 6,240
,04 FTE (AA, Eritrean, Ethiopian- Oromo and Somali)
Hosting virtual conversations where questions are received, and information is shared about the vaccine options. Sharing culturally and linguistically appropriate materials through community networks that are accessible and culturally relevant (i.e., phone calls, social media, flyers, etc.)

Health Resources Consultant-RN, 750
PhD: Our wellness Check Support post vaccination follow-up consultations. Is a registered Nurse who specialize in providing human virus infection health interventions and education services to people of African heritage.
IT: Developing culturally and 1,229.58
linguistically appropriate materials and tools and devices that communicate important information regarding the vaccines.
Payroll Taxes 499.20
Amin. Cost of Overhead 1,133.44
B&O Takes, WA State 147.78

Activity #2 COVID Outreach and Eligibility Engagement ($15,000)

Budget Line Item Amount

COVID-19 Health Department-Liaison 3,250.00
1.25 FTE

Community Health Worker -( AA, Eritrean, Ethiopian -Oromo, Somali) 8,260
.40 FTE

Health Resources Consultant- PhD 645.46
Payroll Taxes 920.92
Amin. Cost of Overhead 1,700.16
B&O Taxes, Wa State. 221.67

Total amount request : $24,997.29

Internt form Explained:

This will serve as an interest form if an organization is interested in applying for Activity 3 funding to support Community-based COVID Vaccination Pop-Up Clinic Coordination and Partnership Activities. Award eligibility will be dependent upon organizations participating in a Partnership Matchmaking activity on April 8th. Then organizations interested in applying for Activity 3 will submit an application identifying a clinical partner after the Partnership Development Convening on April 8, 2021 from 3:00-5:00pm.

For Interest form, please also fill out organization information on pages 7-8 of the application.

AWARDS ARE DEPENDENT ON MATCHMAKING ACTIVITY. THE APPLICATION PROCESS FOR THIS FUNDING INCLUDES MANDATORY ATTENDANCE AT A MATCHMAKING MEETING. THERE. PARTNERSHIP WILL BE DETERMINED BY PARTICIPANTS AND FOLLOWED BY A DETERMINATION ABOUT FUNDING.

How Can Funds for Activity 3 be Used?

Funds will be available under the following categories:

Activity 3:

* Awards of up to $15.000 will be available for COVID Vaccination Pop-Up Clinic Coordination and Partnership Activities. COVID Vaccination Pop-Up Coordination and Partnership Activities will be focused on actively supporting community members to receive a vaccination if they have decided that they want to receive a COVIF vaccine. This includes a variety of coordination activities that require partnership with an entity approved by HelathierHere that host a partnership pairing meeting to offer an opportunity for your organization to determine a suitable clinical entity with which to partner on a vaccination effort .
* Activities required for this award include:
*partnering with a HealthierHere Vaccinator Partner to plan one or both of the following COVID vaccination efforts:
* Pop-up vaccine clinics at a community site that will make the vaccine more accessible for communities disproportionately impacted by COVID-19 or harder to reach communities by bringing the vaccine to trusted places where they gather.
* Assisting with filling vaccine appointment reserved by a HealthierHere Vaccinator Partner for specific communities.This will include activities such as: 1) navigation vaccination appointment systems such as online portal or phone line required to set up and confirm a vaccination appointment, and 2) locating and providing resources to help overcome barriers to attending the appointment such as transportation, or other incentives.

Attachment B: Proposed Budget

As a component of the RFA evaluation process, HealthierHere will be evaluating the application of requested funds to the organization’s proposed innovation strategy. Using the template below, please provide a proposed budget that includes detailed descriptions of the following budget items (as applicable):
* Direct Programmatic Costs for the duration of the innovation March 1, 2022 through December 31, 2023; do not include future ongoing operational or recurring costs beyond this timeline)
* Indirect Costs associated with organizational infrastructure organizational operations. Please identify either the components of the indirect amount identified (e.g. executive level salaries and benefits), or the indirect rate utilized.
* Lead Entity of Partnership associated with the organization’s innovation strategy. Please indicate the nature of the partnership and if possible, what % the total organization’s budget this represents. If it is a sub-contract or fee for specific services, please describe those.

Funds Usage Category —Amount Budgeted ($)—-Description and Details of Budgeted Amount

*Direct service costs offered to community provision-$12,375.00-Composition of direct service cost amount and description how budgeted dollar will support the organization’s innovation strategy.
* Personal/ staffing (wages/salary, benefits.etc)-$372,753.27-# of staff or FTE% dedicated to the innovation strategy, position/type/title, rate of pa, etc.
* Capacity building /training/ technical assistance – $30,000,00- Description/ type of training and how the training supports the innovation strategy, duration, # of staff trained
* Infrastructure (equipment, supples and software)-$14,400.00- Equipment, supplies, and software purchased.
*Other (e.g., marketing materials, office supplies, transportation/travel, per diem, etc, )-$14,678.34-Please delineate each item.
* [Insert indirect cost line item- e.g., organizational overhead create or federally negotiated rate for Tribal/Native CBO]-$7,935.96-Information Technology ($16,500), Registered Nurse/ RN.. PD $13,200), Post-Acute Sequelae of COVID ($10,560), Cleint Services Before & After Business Hours ($44,597.43)

Lead Entity/ Partnership Costs

*Information Technology -$16,500.00 –
*Registered Nurse (RN,PhD)-$13,200.00
*Post-Acute Sequelae of COVID-$10,560.00
*Client Services Before & After Business Hours – $44,597.43

Total Funds requested : $537,000.00

Organizational Budget Comparison
Total Organization’s Operating Budget (Annual) -$525,800.00
Calculated % Total Funds Requested for Innovation Project/ Total Organization’s Operating Budget –102%

Whats is the COVID-19 Resilience Fund?

HealthierHere recognizes the impact the COVID-19 is having on our community including lack of access to healthcare, decreased accessibility to essential supplies and services, reduced wages and job loss, heightened vulnerability and social isolation, and economic distress of small business.

HealthierHere’s COVID-19 Resilience Fund will provide funding to HealthierHere’s partners that are providing critical services to communities adversely impacted by COVID-19. Funding is intended to support the provision of critical direct clinical and Social Determinant of Health (SDoH) services that correlate to improved health outcomes for community members impacted by coronavirus, paying particular attention to those experiencing health disparities. These services are anticipated to include, but not limited to, such things as ensuring access to the following services: healthcare, emergency food distribution, housing stability, recovery support services, social services, wrap-around support services, care transitions, healthy grieving, and behavioral, emotional and spiritual care. Any services provided pursuant to this funding must be delivered in a culturally appropriate, responsive, and respectful way.

The Fund’s goals are to:
*support organizations’ COVID-19 response and mitigation strategies and their ability to serve the community.
*support the development of infrastructure for distribution of resources (e.g. rental assistance, grocery delivery, etc.) to help meet the urgent distribution of resources (e.g. rental assistance, grocery delivery, etc.) to help meet the urgent needs of individuals residing in King County and impacted by COVID-19 -either directly (e.g. those who have tested positive or in a high-risk category for adverse health outcomes related to COVID-19 exposure), or indirectly (e.g. those experiencing job loss or reduced income)
*promote foundational system change that bridges the gap been clinical, tribal, and community partners, in alignment with the goal of HealthierHere’s Medicaid Transformation Project Work

HealthierHere is prioritizing organizations that can meet the needs of communities experiencing disparities and hard-to-reach communities, including elders, individuals with limited English proficiency, refugees, immigrants, homeless/unstably housed, and racial/ethnic groups being disproportionately impacted by COVID-19. HealthierHere will also prioritize applications that strengthen bi-directional partnerships between community and clinical partners to meet the holistic needs of individuals served.

HealthierHere anticipates distributing up to $3.6 million in two distant cohorts at two different times to current HealthierHere clinical, community and tribal partners through this funding.

HealthierHere will determine award amounts based on the partner’s application, with up to amounts varying by partner type. All interested and eligible Partners should respond to this RFA.

Who is Eligible ?

Eligible HealthierHere Partners will receive an official invitation via email. As these invitations are uniquely tailored to the Partner Type , we respectfully ask that these invitations and Request for Applications (RFA) not to be shared and/or forwarded to other organizations as it will not alter the eligibility criteria for this funding.

Partners that are officially recognized by HealthierHere as both Clinical and Community Partners may submit an application to deliver both Clinical and Community-based SDoH services. The HealthierHere Partner selection process closed in 2019. If you are a clinical partner have questions about which Partner Cohorts (s) you are in, please contact Tavish Donahue, Senior Practice Transformation Manager at tdonahue@healthierhere.org. And, if you are a community partner or community grants receipt and have questions about which Parent Cohorts(s) you are in, please contact Abriel Johnny, Community and Tribal Engagement Manager at ajohnny@healtherher.org.

If submitting an application for both types of services, the Partner must indicate how these services will integrate and complement each investment. Clinical fund should not be used to fund community based SDoH services and vice versa, community funds should not be used to fund clinical services.

Cohort 1- HealhierHere Partners:

* Clinical Practice Partners
*Community Practice Partners
* Community Grants Recipients (that are NOT recognized as Clinical and.or Community Practice or Innovation Partners)
*Native-led/ native-serving Community Innovation Partners

Partner Type

*Clinical Practice Partner – $50,000
*Community Practice Partner – $20,000
*Community Grant Recipient -$20,000
* Native-led / Native Serving Community Innovation Partners -$20,000

* Clinical + Community Practice Partner – $70,000

Cohort 2- HealthierHer Partners

*Clinical Innovation Partner- $50,000
*Community Innovation Partner – $20,00

Clinical + Community Innovation Partner – $70,000

HealthierHere reserves the rich to add additional partner types to the above categories, based on available funds and areas of need.

How Can the Funds be Used?

Funds ma be used in the following areas:
*Direct Service Provision. HealthierHere is interested in supporting organizations in their ability to be responsive to the urgent needs of communities in the midst of the pandemic, including but not limited to the provision of and access to services related to healthcare, emergency food distribution, housing stability, recovery support services, social services, wrap-around support services, care transitions, healthy grieving, and behavioral, emotional and spiritual care. Any services provided pursuant to this funding must be delivered in a culturally appropriate, responsive, and respectful way. Organization may use funds to:

*Continue a critical service at-risk of going away due to budgetary challenges
*Enhance or expand current services to meet increased need due to COVID-19
*Provide new services targeted at mitigating COVID-19 impact and improving community resilience

* Infrastructure and Operational Needs. HealthierHere is interested in supporting organizations’ needs to allow them to shift and/or expand existing work to support direct services to be provided consistent with the Resilience Fund purpose. Examples of how funds may be used include:
-Infrastructure to support direct service provision ( e.g., equipment, supplies, and software)
-Economic support to hire, retain and/or retain workforce providing direct services
-Indirect costs are capped at %15 of total budget request (applicants will be requested to explain their request for funding for indirect costs) Note indirect costs for Indian Health Care Providers and Tribal Health Care Providers will be capped at an amount not to exceed the Provider’s Federally negotiated indirect rate.
*Other. Partners are encourages to propose other activities in addition to any of the above that meet the goals of the fund. Examples of how funds may be used include:
-support with basic household items (e.g. cleaning supplies, diapers, food, personal hygiene items, etc) and/or grocery store gift cards (not to exceed $50/individual and $100/family on a single card. ) It is the recipient’s responsibility to report gift cars for tax purposes, if applicable.
-support with transportation to and from healthcare an/or social service appointments
-testing and implementing new wats of delivering care in response to COVID-19
-Community outreach related to the provision of direct services to be provided with Resilience Funds
-In-language and/or culturally specific COVID-19 education materials aimed at ensuring high-rise individuals are aware of COVId-19 services available to them
-Alternative approaches to providing the same medicine that is provided through Canoe journey, pow wows, Celebration 2020 (since many public events may have been cancelled or postponed this year) and/or Ceremony

Applicants will be asked to estimate the number of individuals their organization anticipates being able to provide services to as a result of the funding. applicants should consider social distancing guidelines during the COVID- 19 pandemic and aim face-to -face contact in adherence with prevailing guidelines.

Impermissible use of funding include, but not limited to :

*Direct payments to individuals or families (e.g. cash assurance , rental payments, utility assistance, etc.)
*Marketing materials (Restriction does not apply to in-language outreach or educational materials)
*Video or audio production and media campaigns
*Real estate investments, dalveopemtns, and other capital projects
*Salary support for executive leadership
*Debt restructuring and bad debt
*Defense and prosecution of criminal and civil proceedings and claims
*Donations and contributions
*Entertainment
*Alcoholic Beverages
*Furniture
*Fines and Penalties
*Fundraising and investment management costs
*Idle facilities and idle capacity
*Interest expense
*lobbying
*research, assessment, and evaluation activities

Payment Terms

*Funds will be distributed to successful Cohort 1 applicants in one payment upon execution of an agreement with HealthierHere.
*Funds will be distributed to successful Cohort 2 applicants approximately 2 weeks following distribution of funds to Cohort 1and in one payment upon execution of an agreement with HealthierHere.
*HealthierHere reserves the right to determine award amount.
*Cohort 1 Awardees should launch or enhance services as soon as they have capacity to do so , but later the July 13,2020.
*Cohort 2 Awardees should launch or enhance services as soon as they have capacity to do so , but no later than July 27,2020
* Awardees must are to remain a partner though the remainder of the Medicaid Transformation Project .
*All approved fund must be expended by November 30,2020.
* Funding awarded by HealthierHere is intended to be complementary and not duplicated of the funding to support infrastructure, operations, and their response to COVID-19. For example, if the organization ha applied to other COVID funds or foundation funds, please describe how resilience funds will address remaining needs.
*These and other payments terms will be detailed in an agreement between the awardee and HealthierHere.

What is the Review Process?

HealthierHere staff will review applicants and may request that applicants answer clarifying questions. Submission of an application does not guarantee that funds will be awarded.

Decision-making criteria will include:
*Demonstrated ability to effectively provide direct services in a culturally appropriate, responsive , and respectful way:
-Track record of effective service delivery
-Track record of judicious use of funds and ability to positively impact community
-Track record of serving community in a culturally appropriate, responsive, and respectful way

Ability to serve high risk individuals:

*organizations that provide services to communities experiencing disparities and hard-to-reach communities, including elders, groups for whom English is not their first language, refugees, immigrants, homeless/ unstably housed, and racial/ ethnic groups being disproportionaley impacted by COVID-19
*organizations that provide services that are supportive of the COVID-19 response (e.g. providers of essentials services to COVID-19 high-risk populations, including older adults, unstably housed/homeless, pregnant women, and people who have serious underlying medical conditions like heart disease, diabetes, asthma, lung disease) or are critical to the COVID-19 response and recovery effort.
*Organizations that provide services in geographic areas in King County that have a significant number of COVID-19 at-risk populations or face disproportionate barriers when accessing services.
*Organizations that serve a significant portions of low-income, under-served and/or COVID-19 mitigation strategies.

*Access to other COVID-related emergency relief/resilience funding:
-organizations that have insufficient resources to help them in the COVID-19 response

*Organizational capacity to delver proposed services:
– Community Partners: Capacity determined based on information provided in Community Partner Assessment and/or Community Partner System Transformation Plan

-Clinical Partner : Capacity determined based on information available through assessments, evaluation, and publicly available patient volume data.

– Community Grants Recipients: Capacity determined based on size and scope of community engagement conducted as part of Community Grants Program

COVID-19 Resilience Fund Budget Request

*Direct Service Provision- Amount Requested = $19,704.15 – 600 people provided with Emergency Food Distribution and COVID-19 Isolation Hygiene Kits via; Gift Certificated to support culture-appropriate purchases (e.g. goat meat, Halal food, and herbs for medicinal purposes ).Each gift card is not to exceed $25/ individual and $100 family on a single Health Related Social Needs Request. SDoH. 3 Ply BFE (95-99) Masks @1200 masks per case. Costco Kirkland signature Diapers for sizes 1-6. Costco Kirkland Signature Baby Wipes 900 ct.

Infrastructure to support direct service provision

infrastructure to support the service delivery IS NOT FROM the requested funds

Personnel: hiring, retaining, and/or retaining workforce providing direct services

Personnel to support the service IS NOT FROM the requested funds

Other

Amount requested = $295.56 – B&O Taxes, WA State

Total Amount Requested = $19,999.71

Populations to be Served

How many individuals do you estimate your organization will provide services to through the efforts described in this application?
600

HealthierHere has identified specific communities and populations who are experiencing disproportionate impacts during COVID-19 pandemic. Using the list below, please select who you will be serving though these efforts:

– Older adults, 65 years and older
– Groups at higher risk for severe illness, including:

-people with underlying medical conditions (e.g., asthma/lung disease, heart conditions, severe obesity, diabetes, chronic kidney disease, liver disease, and conditions that can cause a person to be immunocompromised )
-Racial / ethnic groups being disproportionately impacted (please describe): African-American, Eritrean, Ethiopian-Oromo, Somali
-People experiencing health disparities (please describe): Poverty, low wage veneerers, ALICE ( Asset Limited Income Constrained, Employed), higher layoffs, and Higher COVID-19 illness and Mortality, Stay at home COVID-19 “Probable cased” ( those that show evidence of infection without confirmation of lab test)
– People with limited English proficiency (please describe languages): Tigrinya, Oromo, Amharic, Somali
– Refugees and immigrants
– People experiencing homelessness or housing instability
– Other(please describe): ” Specific- Culture-Appropriate” business (rotes), who are financially struggling to stay afloat to continue providing “culture-appropriate” food, health and herbs for medical purposes needs of the target populations(s).

Please provide a description of the populations(s) you plan to serve with the funds, including demographics information and details on their specific needs/challenges faced due to COVID-19.Please consider including the following:

-Demographics (e.g., reface, ethnicity, English proficiency, poverty level)
-SDoH Characteristics (e.g. economic instability, housing instability)
-Health Profile (e.g. for adult clients, percent with a chronic condition (e.g. diabetes, asthma, COPD, hypertension)

African American, Eritrean, Ethiopian-Oromo and Somali, (specifically Amharic, Tigrinya and Somali speakers), would benefit from funded services. Many are refugees or immigrants who do not read or write in their native languages, nor do they read or write in English. Most understand and speak English at a basic level, have low-moderate literacy levels, and tend to be older adults, with underlying health conditions, e.g. diabetes, asthma, COPD, hypertension, and end state renal disease) Their living situation is shared or supported housing. Employment situation; Medicaid eligible, ALICE workers, or low wage earners in high-COIVD-19 risk settings, or unemployed. Note: Some, due to COVID-19 impact, they have to rely on family members, friends, and neighbors to provide then with basic needs, ( as a Social Determinants of Health, SDoH), i.e. Health Hazards and, Access to Healthcare and PsychoSocial services information.) Our communities count health stressors due to society social inequities (i.e. last hired, first first fired, health access, mis-information and mis-communication), as one of their daily over-arching challenges. Note: Many members of our communities rarely seek out COVID-19 and behavioral health service options and when they do, those services are often neither culturally competent nor culturally proper. As COVID-19 related unemployment disproportionately increases and spread in our communities, the need to preserve culture-appropriate business services that help them and us provided cultural-appropriate services that affects us all has never been greater. In addition, to mitigate the negative effect of COVID-19 on our communities, Inter-generational support and dialog is critical in supporting government-provided COVID-19 health guidelines (i.e. social distancing) and fostering innovative ways to maintain our core communities’ cultural values, traditional and ethnic identities, which is greatly challenged by core government -provided COVID-19 health guidelines (e.g. social distancing).

Please describe the types of services and/or infrastructure needs to support that service delivery with the request funds.

Types of services:
Emergency Food Distribution and COVID-19 Isolation Hygiene Kits via; Gift Certificates to support culture-appropriate purchase (e.g. goat meat, Halal food, and heard for medicinal purposes) Each gist card is not to exceed $25/individual and $100/family on a single Health Related Social Needs Request. SDoH + 3-ply BFE (95-99)
Masks @1200 masks per case + Costco Kirkland Signature Diapers for sizes 1-6 + Costco Kirkland Baby Wipes 900 ct per package.
Personnel to support the service delivery NOT FROM the requested funds

JC Ephraim Jr, Executive Director, HH Medicaid Transformation Liaison

Manage Resilience Fund operations, evaluation and ensure project compliance with HH medicaid system transformation requirements and outcomes and agreement requirements. (Note: FTE time is funded as part of HH medicaid system transformation project liaison duties amended to support response to the COVID-19 outbreak in King County)
FTE 10%

Behavioral Health Emotional Support MHP, EMMHS, CMHS, DMHS Project Evaluator

Provided behavioral health screening, emotional support and referral to the COVID-19 impacted community members and facilitate collaboration/ partnerships with their communities.FTE TIME NOT FUNDED BY THIS APPLICATION.
FTE 15%
Work to evaluate Resilience Fund project, sousing SDoH evaluation tools. Collect data from program information, evaluation data and priced reports of information.. FTW TIME NOT FUNDED BY THIS APPLICATION.
FTE10%

CAAR Community Health Worker (Ethiopian-Oromo Community)

Provide SDoH emergency food distribution support services in a culturally appropriate, responsive, and respectful way. (Note: FTE time is funded as part of HH Engagement, Navigation duties in response to the COVID-19 outbreak in King County)
FTE 15%

CAAR Community Health Worker (Somali Community)

Provide SDoH emergency food distribution support services in a culturally appropriate, responsive, and respectful ay (Note: FTE time is funded as part of HH Engagement. Navigation duties in response to the COVID-19 outbreak in King County)
FTE 15%

CAAR Community Health Worker (Eritrean Community)

Provide SDoH emergency food distribution support services in a culturally appropriate, responsive, and respectful way. (Note: FTE time if funded as a part of HH Engagement, Navigation duties in response to the COVID-19 outbreak in King County)
FTE 15%

CAAR Community Health Worker (African American Community)

Provide SDoH emergency food distribution support services in a culturally appropriate, responsive, and respectful way ( Note: FTE time is funded as part of HH Engagement, Navigation duties in response to the COVID-19 outbreak in King County)
FTE 15%

Description of Request and Impact

Goal :
” To continue a critical service at-risk of going away due to budgetary challenges” (i.e. business-stores providing culture-appropriate food distribution) (e.g. Food)
We will use funds to support the purchase of gift certificates (cards), from ” specific-culture-appropriate business” (stores), who are struggling to continue serving the application target population. Many of these business have been providing Halal foods (e.g. goat meat, and herbs for medicinal purposes…) The first cars will be provided to members of the target communities whose Health -Related Social Needs screening demonstrated the SDoH “culture-appropriate” food need from the “specific-culture- appropriate business” (stores) Note: Each gift is not to exceed $25/individual and $100/family on a single Health Related Social Needs Request. The Community Health Workers, (CHWs), will screen the applicants and provide the gift certificates to their community members to shop at the specific-culture-appropriate-businesses” (stores).
“Provide new services target at mitigating COVID-19 impact and improving community resilience and, to continue critical service at-risk of going away due to budgetary challenges” (i.e. business-stores providing culture-appropriate food distribution), (e.g. Healthcare)
We will use funds to purchase gift certificates (cards), to make culture-appropriate purchases, from “specific-culture-appropriate business” (stores), who are struggling to continue serving the application target populations. Some business have been providing herbs for medicinal purposes) We will use funds to buy gift certificates from culture-appropriate business who seek to their communities COVID-19 Isolation and quarantine Hygiene Kits and been providing herbs for medicinal purposes) Note: Each gist card is not to exceed $25/individual and $50/ family on a single Health Related Social Needs Request. The Community Health Workers. (CHWs), will screen the applicants and provide the gift certificates to their community members to shop at the specific-culture-appropriate businesses” (stores)

Description of Clinical and Community linkages and partnerships

We are a 25+ year culturally competent CBO/licensed Mental Health Agency (MHA) serving African American and East Africans. We participate in many partnerships, including CBO’s (i.e. CMCH, The Mary’s Mahoney’s,..) Manages Care Health Plans (MCOs), and county/ state concernment budgeted agencies (i.e. SKCPH/HCA/DOH) We are in alliances with other Community and Behavior Health Services (BHS) providers. We engage and get the word out to 1. our culture-appropriate business (stores) and 2. our community members who the stores serve. Our client base is 66% African-American, 33% East African refugees and immigrants. Our entire staff supporting the project, specifically our Community Health Workers, (CHWs), Mental Health Professionals, (MHPs), and Ethnic Minority Mental Health Specialist, (EMMHS), are members of the communities we serve and our Board/Administration/ front-line staff are members of the communities we serve, grounded in our respective community’s cultural and family paradigm. All our CHWs were recommended and approved by the leaders and/or stakeholders of their cultural community to work collaboratively with them and provide SDoH consultation serves to their communities.

Alignment with Organization’s Medicaid Transformation Project (MTP) Objectives

As we stated in our transformation plan, in order for our community members, who receive Medicaid benefits in King County, to ” re-integrate /retain cultural values, traditions and history that promote healing and empowerment for our children, youth, families and communities”, that prevent, address and build healthy resiliency/coping skills and remove/ decrease SDoH concerns/ issues, and the resulting physical/ behavioral health issues and challenges that are further exacerbated by cultural and healthcare disparity/inequity, adverse childhood experiences (ACES) and trauma. Retaining our specific-culture-appropriate business (stores) that provide our health related needs, by supporting our relationship with our culture-appropriate business communities goes reducing that already great systemic disparity/inequity, by retaining a vital part of what we need that provide ongoing, routine support to help us flourish, be resilient, physically, AND emotionally healthy during the COVID-19 epidemic that is raging in communities.

Other COVID-related funding:

WE have received funding for the following. COVID-19 community navigator Fund $74,926.18 Hire personnel to ” Perform outreach services: to provide and support navigation/ referral/enrollment to the COVID-19 to our target populations.
COVID-19 Telehealth/Remote Social Determinants of Health (SDoH) Services, Fund ; $10,000
Build or enhance our infrastructure to provide remote Social Determinant of Health (SDoH) services to compact the spread and/ or mitigate the impact of COVID-19. (I.e. licenses for remote base service platforms. technologies are Zoom for SDoH participant engagement. G suite (Internal Communications remote staff), Doxy.me for CHW-client SDoH engagement , enhancing internet and network capabilities; Redundant ISP (serrate ISP provider) ( ICD soft and Go Daddy, Upgrade Comcast Business)
“why those resources are insufficient to meet your service delivery goals”
The COVID-19 epidemic is further exacerbating our cultural and healthcare disparity, inequity, and trauma, compounding the already GREAT systemic disparity/inequity, by destroying our relationship, patronage, and ability to retain our culture-appropriate businesses, that support our health related social needs, (our culture-appropriate stores are disproportionally going out of business PERMANENTLY)
“how Resilience Funds will be complementary and not duplicative of this resources”
Make no mistake, our culture-appropriate business are a vital part of what we need to retain because they will continue to provide ongoing, routine support to help us long after COVID-19 epidemic is over.
The above stated Telehealth/Remote Infrastructure and the Medicaid Transformation, Community Navigator positions are NOT FUNDED BY THIS COVID-19 APPLICATION. However they are are vital and complementary and not duplicative resources; Executive Director, HH Medicaid Transformation Liaison, Behavioral Health-Emotional Support MHP, EMMHS, CMHS, DMHS, Project Evaluator, CAAR Community HealthWorker (Ethiopian-Oromo Community), CAAR Community Health Worker (Somali Community), CAAR Community Health Worker (Eritrean Community), CAAR Community Health Worker (African American Community). They are vital to the effectiveness of this project in ensuring the funding goals of this funds are used to support healing and empowerment for our communities in this COVID-19 crisis.

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