Assigment 6 modules reflexion 2-3 pages.Apa seven . All instructions attached.

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Module 1: Social Determinants of Health

Slide 1: Social Determinants of Health

Hello, my name is Lori Thuente, and I’m here to present social determinants of health, which is module 1 in our mini course for public health professionals. We're going to be talking to you overall about the foundations of population health science in practice.

Slide 2: Acknowledgements

This education module is made possible through a cooperative agreement between the Centers for Disease Control and Prevention and the Association for Prevention, Teaching, and Research. Here are the six modules in the series I'll be presenting the first one, Social Determinants of Health.

Slide 3: Overall Learning Objective

Overall, our learning objective is to provide you with foundational knowledge and population health, science and best practices and population health, including the effective design, implementation and evaluation of these population health activities. We're hoping to target public health professionals, students in public health or health professions, allied health and health care providers.

Slide 4: Module 1 Objectives

So our module one objectives are to explain the concepts related to health inequities and structural racism, to explain the broad determinants of health outcomes and inequities, to utilize an equity perspective, to evaluate health data and to identify connect with an advocate for adversely impacted populations.

Slide 5: Warning

I'd like to just let you know that in this module we are talking about racism, classism, adverse childhood experiences, etc., and these might be difficult to engage with depending on your personal circumstances. So please take your time, pause the video if you need to, so that you can engage with this difficult time and still maintain your wellbeing.

Slide 6: Objectives 1 and 2

Our objectives wanted to explain concepts related to health inequities and structural racism and explain the broad determinants of health outcomes and inequities.

Slide 7: What makes us sick – Rishi Machanda

First, though, I'd like to share with you a video by Rishi Machanda, and he talks about upstream factors in health care and this video will help to set the framework for our talk today.

Module 1 Transcript | 10

VIDEO:

There are three friends who come to a river and it's a beautiful day, but that scene is pierced by the cries of people in the water, in the river crying out for help. They need a rescue. Oh, the three friends do what all of us do, especially those of us in health care. They jump right in to save those people, adults, children, the elderly. At first, the first round, the strongest swimmer says, I'm going to focus on those who are about to drown just at the edge of the waterfall.

Everybody applauds that decision. And, of course, it makes total sense to rescue those about to drown. And everybody doubles up and says, “Let's rescue people along the sides of the river” says, “Let's invest more resources, give that that rescuer what he or she needs.” But over time, it becomes clear that that's insufficient. People slip through the grasp, the rescuer, clearly something else is required. The second friend actually along there says, “You know what, to make this easier, to make our success rate go up, let's coordinate the branches along the banks of the river here and create a raft so we can usher more people to safety, prevent people from going further downstream in need of rescue.” We all applaud that the success rate goes up, fewer people in need of downstream rescue, more people on the raft getting closer to the riverbank. And yet, in the course of that work, the first friend and the second friend, the downstream rescuer, the raft builder, realized something is happening that they can't fully articulate, but they see it every day. The people keep coming. The success rate, while better still, isn't as good as they would want people slip through. They start getting tired, they start getting a little jaded. Perhaps they start saying things like to the people in the water, “Why don't you know how to swim?” They start considering other rivers to jump out into leaving.

Maybe be the purpose of rescuing. They start getting tired. But like a lot of us, they remain doubly committed to the work and they remain heroically, nobly committed to rescuing.

Despite this strange phenomenon. Finally, they realized that they came with a third friend, and they don't see that third friend. They finally spot her. She's in the water. She's rescuing people and she's going, but she's swimming away from them much further upstream. And they shout to her, “Where are you going? There are people here.” They're in dismay, they're wondering why their third friend, a vital part of their team, is now leaving them. Turns out she's not leaving them. She's actually in the water again, helping people. She's going and she shouts back to them, “I'm going to find out who or what is throwing these people in the water.”

The reason I told the story that way is because in the American health care workforce and I think in the health care workforce, in many parts of the country of the world, we know that we have that first trend. We have that downstream rescuer, the trauma surgeon, the ICU nurse, the intensive case manager, the doctors, the oncologists. These are people that are vital, necessary parts of the workforce that we know we need. You want them when you're in dire states. We're now in the phase of that second front, the comprehensive list, the raft builder, the person who creates that primary care, patient centered medical home to usher more people to safety, to screen for certain issues, manage chronic diseases, make sure that those who are at risk of disease actually prevent or prevent it from becoming sicker. But we know increasingly now that while that's an important phenomenon right now and health care transformation in the US, the idea of the downstream rescuer and the raft builder primary care comprehensive is while we are in that phase, we know simply by looking at our patients and

simply looking at what health care looks like on the ground every day, that that model of the health care workforce is necessary but insufficient. What we have in the health care workforce right now, not nearly enough of but what we do have certainly are that third friend. We have the upstream. The upstream’s job is not to be the hero, nurse or hero, doctor or hero, community health worker who is independently, individually taking on rescuing people. But is instead, as many upstreams before us have done, thinking about how to systematically understand and address the social determinants of health, where people live, where they work, and bring that understanding into the workforce and the workflows of clinical medicine of health care.

Slide 8: Social Determinants of Health

Thinking about broad determinants of health, these are often but not always outcomes of structural racism and inequity. Social determinants of health truly do affect everyone because your health is impacted where we live, learn, work, pray and play. Some of the general categories you'll see here are economic stability, neighborhood and physical environment, education, food, community and social context in the healthcare system, and all of these lead to the health outcomes. But what's upstream is the factors that impact economic stability, that impact the neighborhoods and physical environment, etc. Let's talk about these for just a minute. When we talk about environment and safety, we're not talking just about physical safety from violence, but also we're thinking about air and water quality, access to services such as police, fire, EMS. When we're thinking about hunger, we're not just talking about access to food, but also access to healthy options, things that make people healthier, not less healthy.

When we talk about access to health care, we're talking about both access via physical proximity as well as the ability to pay. When we think about housing, we want to make sure that housing that is safe, it's clean, it's free from rodents and pests. It has running water and plumbing and electricity, etc. When we think about mental health, that living with chronic stress from poverty, abuse and outside violence truly does contribute to poor mental health. We know that one in five children still lives in a county that does not have a child psychiatrist. That having access to therapy and medication, along with someone to advocate for you when you cannot advocate for yourself is necessary for improvement in your in your health outcomes. Transportation is vital because without access to transportation, whether it's having access to a car, having money for bus fare, etc., our patients cannot get they can't access health care. They can't get to their appointments. They can't get to the pharmacy. We also need to consider education because we know that education equates to understanding health issues and treatments and that holding a job is something that contributes to the job that pays well, contributes to your overall well-being. We also need to think about incomes and jobs, for example, if the only jobs that are near people, especially if they don't have a car, are minimum wage jobs, then they're probably not going to be able to succeed. We also need to think about isolation, whether that's isolation due to a language barrier, whether it's isolation due to a disability, a physical or mental disability, lack of social connections, etc. All of these can lead to poor health outcomes.

Slide 9: It is believed by many that the primary root cause of social determinants of health is structural discrimination. So as we said earlier, it's believed by many that the primary root cause of social determinants of health is structural racism. So going upstream, we think about the root causes, the root causes of racism, sexism, abuse and classism, and these impact the laws that are created, the budgets that are decided, the regulations that are enforced. And that impact is on the different systems, public health, neighborhood and environment, education, economic stability. And again, all of those have an impact on the outcomes, the health and well-being of people.

Slide 10: Intersection of Health – Social Class – Race

So when we think about the intersection of health, social class and race, we know that it is directly tied to the distribution of resources. We know that the largest predictor of health is your place on the class pyramid. We know that upper income people, people in the upper class per say, if it's measured by income, schooling, occupation, those people have the most power and the resources and on average live longer and healthier lives. We know that, again, compared to the upper class, the middle class is twice as likely to die an early death and those at the bottom of the social class pyramid are four times as likely to die prematurely and that racism imposes an added burden. We know that black individuals typically have worse health and die sooner due to segregation. Social exclusion encounters prejudice, their degree of hope and optimism, and their access and treatment by the health care system, which we'll talk about in just a minute.

Slide 11: Structural Racism

Structural racism is really a combination of public policies, institutional practices, social forces and ideologies and processes that generate and perpetuate the inequities among the races. Current and historic discriminatory policies and practices have limited access and prevented people of color from attaining education and building wealth, that along with the socialization and implicit bias which we all have, really impact the attitudes and or stereotypes that we create that affect our understanding and actions and decisions really in an unconscious manner. These do not necessarily align with our declared beliefs or even reflect the stances that we would explicitly endorse. But however, they are held by everyone and they're equally likely for non-majority groups and more likely among those who consider themselves to be objective.

Slide 12: Which groups are affected by race and structural racism?

So which groups are affected by race and structural racism? Well, believe it or not, all of these are although the groups have significantly different experiences as they reside in the United States, all groups viewed as being nonwhite, have been subordinated, excluded and marginalized at one time or another. And these have been caused by institutional practices, by popular beliefs, habits that are implicitly or explicitly support white privilege. So white people have benefited from structural racism.

Slide 13: Structural Racism in Education

When we think about structural racism and education, just taking one segment of our concepts in order to think about more in depth, we can think about how the literature has demonstrated that black and Latino children are less likely to have parents with a college education at teachers starting in pre-K have rated black children lower than white children, even if they have identical non cognitive skills and test scores. We know for a fact that fewer black children are placed in gifted and talented programs. That black students are more likely to be taught by less experienced and lower paid teachers due to the neighborhoods in which the schools generally are black and Latino students perform less well on standardized tests due to less tutoring, things like that. Black and Latino students are less likely to go to college and also to graduate from college. And when they do graduate from college, they graduate with twenty-five thousand dollars more debt than white students. And finally, even with the same degree of black and Latino people do not make the same income.

Slide 14: Racial Equity

So racial equity. Racial equity is a condition that would be achieved if one's racial identity no longer predicted in a statistical sense, how one fares. So when we use this term, we're thinking about racial equity is just one part of racial justice. And thus we also include work to address root causes of inequities, not just their manifestations. We need to work to eliminate those upstream factors, the policies, the practices and attitudes and cultural messages that have reinforced these different outcomes by race or have failed to eliminate them.

Slide 15: Equality ≠ Equity

So we know that equality is not equity and that in health care, we need to provide patients with the individualized support and individualized resources that they need to be as healthy as possible. Giving everyone the same thing is not going to result in the same outcome by everyone. We know that health inequities are the differences in health status, in the distribution of health resources, which we're going to talk about in just a minute, between the different population groups. And again, these come from the social determinants of health.

These are unfair and can be reduced if we enact the right governmental policies.

Slide 16: Share of Nonelderly Adults Reporting Selected Barriers to Accessing Health Care by Race/Ethnicity, 2018

Here's an example of selected barriers to accessing health care. By race or ethnicity in twenty eighteen, and you can see that the three barriers that they have selected did not see a doctor due to cost delayed care due to other reasons or no usual source of care when sick other than the emergency room. Impact the different groups in different ways, but you can see as a general rule, white people have always fared better in terms of their stay in these barriers, do not impact them as greatly.

Slide 17: Historical Racial Barriers to Healthcare that continue today

There are historical races, racial barriers to health care that continue today, and we know from the literature that there is a lack of trust in the health care system due to issues, issues such as

forced sterilizations, unethical experimentations, racial stereotypes and unequal treatment by providers. We know that black people receive less pain medication than white people when they are in the E.R. And we know that a lack of providers who look and sound like them and listen to their fears impacts their desire to seek care. We know that a lack of individual of treatments towards various cultures such as Caribbean, African, etc., down to the country of origin really, truly does impact the outcome that they may have. And overall, they have a feeling that the care that they receive is inferior and this is truly supported in the literature.

One of the interventions which we're going to talk about towards the end of this module is to utilize community health workers. These are workers that help answer questions, gain acceptance and build trust.

Slide 18: Objective 3

Equity Objective three is an equity perspective to evaluate health data.

Slide 19: To achieve equity, it is not enough to just provide medical care. We must also use data to address the socioeconomic factors, health behaviors, and physical environment to improve health

To achieve equity, it's not enough just to provide medical care.

We must also use data to address the socioeconomic health behaviors and physical environment to improve health, because we know that only 20 percent of health is impacted by health care. All of the other things, the socioeconomic factors, the health behaviors such as tobacco use, etc.,

in the physical environment of people, are comprise 80 percent of the issues that impact health by people. And if we can address those, we can really, truly make an impact on their health outcomes.

Slide 20: Inequities by Zip Code

Let's look at inequities by zip code. We talked a little bit before about how you place placed on the social class system truly impacts your health and where you live is the result of that. Where you live impacts your social determinants of health. You can see there are two towns that are very close together, North Chicago, Illinois, and Lake Forest, Illinois. These are in north eastern Illinois, just north of Chicago. They're about five miles, almost six miles apart. And they have reasonably similar numbers in terms of population. However, that's where the similarity ends.

Slide 21: North Chicago, IL vs. Lake Forest, IL

Again, five point six miles apart, but yet the median household income per year in north Chicago is about forty-two thousand in north Chicago and then in Lake Forest, it's about one hundred and seventy thousand. Median home value varies greatly. One hundred and four thousand seven hundred and thirty-three thousand. Unemployment rates differ, but also the level of violence differs. You can see that there's a greater amount of violence in north Chicago than there is in Lake Forest. Another thing is how people in impoverished neighborhoods are targeted by certain places such as liquor stores. There are eight liquor stores in North Chicago and there are only two in Lake Forest. But perhaps what is most startling are the differences in

the schools, the graduation rate in north Chicago is 60 percent. In Lake Forest, it's ninety six percent. More startling even now is the math proficiency rates in north Chicago. Less than five percent of the students graduate proficient in math in Lake Forest. Seventy two percent of the students graduate proficient in math. It's very similar in terms of reading and language proficiency of almost 95 percent of students receive free lunch in north Chicago versus two percent, and you'll see that the spending per pupil is more than double in Lake Forest than it is in north Chicago.

Slide 22: Reflection Question 1

So let's take a moment to think about what we've just learned. And perhaps try to apply it, so in North Chicago and Lake Forest, how did the social determinants of health likely influence the population in each city related to the physical and mental health status of the people who live there and their access to preventative care? So take a moment. You can pause before you go to the next slide and. That's where the answers will be.

Slide 23: Reflection Question 1 – ANSWERS

So answers, it's likely that those in the more affluent city have better physical and mental health, probably due to the fact that they have more providers available to them. There are more health care organizations available, and that's probably because there are more people who are likely to be insured or have the ability to pay and have the transportation to get their. It's also that people in the less affluent community have a greater need for the services due to the impact of social determinants of health. So people in the more affluent city have less need, but more services. The people in the less affluent community have a greater need for the services but are less likely to get them. The ability of the population to engage with preventative measures, preventative measures such as well-checks, screening tests, vaccines, cetera, those are more accessible to people with insurance or private funding. They have the transportation to get there. They have the education to know that that might be what is needed. They probably also have access to healthy food, are able to exercise more because they live in a safe neighborhood. And so overall are probably healthier.

Slide 24: Where You Live Matters

Let's look at another example of where you live matters. We're going to look at North Little Rock. Arkansas and Sherwood, Arkansas, these two are also five miles apart, but the life expectancy varies greatly in Sherwood, Arkansas. It's almost 80 years old. In North Little Rock, however, it's almost 68 years old, and that is significantly different, and we need to look at the factors that might be contributing to that. There is a much higher percentage of Caucasian people, those people are more likely to be insured through private insurance, more likely to have a college degree, which results generally in a higher income. And they also have more health care services, the health care clinics and different centers and providers. So those things all contribute to their overall health outcome.

Slide 25: Reflection Question 2

So to reflect again, do we think that the people in North Little Rock have the same resources as those in Sherwood? And do we think that these two groups of people have the same or different means? You can pause a moment to think about that before you click to the next slide.

Slide 26: Reflection Question 2 – Answer

Most likely the two neighborhoods don't have the same resources or the same things, again, the population in the less affluent neighborhood probably has a greater need for both preventative care and complex care, because when you don't get the preventative care, you're often sicker. By the time you seek treatment, they probably have greater people in the more affluent neighborhood, probably have greater access to fresh food and a safe neighborhood.

So therefore, their outcomes are probably different.

Slide 27: Reflection Question 3

Why do we think there's such a discrepancy in life expectancy between these two neighborhoods? Again, you can pause before you go to the next slide.

Slide 28: Reflection Question 3 – Answer

And going back again is probably due to safety, safety, cleanliness of the environment, higher rates of education, which lead to better paying jobs, which lead to having insurance. So when you have insurance, you can have health care generally and you generally have greater access to transportation.

Slide 29: Ways to Reduce Health Inequities: Going Upstream

Let's go back to our upstream concepts. Dr. Chanda talked about how in rivers the downstream water is impacted by the conditions upstream. So if we think about upstream factors like systemic racism, poverty, family experiences, these are the toxins sort of which one is exposed and also the type of housing that can be available. These can all feed into downstream outcomes and those result in a lower life expectancy, more chronic illness, higher infant mortality rates, etc. But again, if we go back and we impact the factors upstream, we can improve the factors downstream.

Slide 30: A public health framework for reducing health inequities

This just gives you a little different picture of this and how policy certain policies can impact, if we look from the right side of the slide, we'll see that that's mortality that is downstream.

Again, going back upstream if we try to address. Institutional inequities of corporations and businesses and government agencies, through strategic partnerships, through advocacy between health systems, not for profit organizations, laws and regulations. These can all impact the living conditions in which people currently reside. If we try to enact community capacity building. Organizing civic engagement, we can also try to improve these living conditions, and if we can improve the living conditions, then we can improve or decrease the risky behaviors that are currently occurring. We can do this through individualized health,

education, and then if we can address many of the risk behaviors, we can decrease the incidence of disease and injury and therefore truly impact mortality.

Slide 31: Case Example for Upstream/Downstream Equity Issues

We're going to look at a case example of upstream downstream equity issues, so this is a case that presented to the E.R. The patient is a thirty-seven-year-old Spanish speaking male who was found on the sidewalk awake but disoriented. So thinking about how people receive care in the hospital, he is known as a frequent flier in the emergency room, which means he's well known there. But this is a derogatory term for someone who is a repeat patient there. He's there often with alcohol related trauma and withdrawal associated with seizures. Frequent flier is not a positive term and should not be used by providers in any circumstances. We know that his social history, he has heavy alcohol use, we don't know about his other habits, but he's apparently homeless. Again, our health providers are calling him noncompliant. Again, another derogatory term with all of his meds, meaning that he doesn't take them. He is on, he was discharged after his last hospitalization on foliate diamine, a multivitamin and seizure prevention medication. So at this point, the providers just are assuming that he's just not taking his medications. Neurological and mental status. He's muttering incoherently in Spanish. He's not consistently able to answer yes or no questions or follow simple commands. But let's take a minute to look at what might be the upstream and downstream issues of which are impacting his health outcome currently.

Slide 32: Flow Chart of Case Example

So we're up here in the upper left hand corner, we're in the emergency room after being found on the street. Let's go back in his history. OK, let's go back to the point where he was a fourth- generation corn farmer in Mexico. But he couldn't make a living because of the influx of cheap

U.S. corn. He was not able to make a living wage selling corn to the US. So he moved to San Francisco to try to earn a living and he began working as a day laborer. However, he got injured and can't work. And because he's a day laborer, he doesn't have benefits and so therefore doesn't have paid time off. For example, he can't pay his rent if he can't work and he ends up moving to the streets, living on the street, he gets assaulted. Having gotten assaulted, he begins drinking more heavily and now we're back to where we are in the emergency room. So let's look at some other factors, some upstream factors of what might be impacting him and having this result of being in the emergency room.

Slide 33: Flow Chart Continued

Again, let's go back, there's a legacy of colonialism, systemic marginalization and violence against indigenous communities in Mexico. Therefore, even in his own country, he could not make a living and the North American Free Trade Agreement, or NAFTA. It's the price of corn being imported into the US, thus enabling him to make a living, so we move to health. He moved to San Francisco. He began working as a day laborer, but he got injured and can't work. But because of the US health care system, he has no access to care. Looking above that, we can see that racism and radicalized are racialized, low wage market markets and US immigration policy have put him in the position of having to become a day laborer, being injured, not being

able to work and then moving to the streets because he can't pay rent has been a result of city and federal policies that have contributed to the gentrification and displacement. So there's really no place he can afford to live. As a result, he gets assaulted, he begins drinking more heavily, and now he's found in the emergency room, so things are not always as they appear. You might have a patient who's found in the E.R. who appears to be homeless and drunk and noncompliant with his medications. But if we think about it and we try to go back further into his history, we can see that there are many factors that are affecting him that are out of his control.

Slide 34: Examples of Federal Response to Addressing Social Determinants of Health, Starting with Education and Poverty

Let's talk about some of the impacts some of the federal resources that are addressing the social determinants of health, starting with education and poverty. So, again, if we think about this as a pyramid, OK, we want to look at the things that have the largest impact. And so we want to address. The socioeconomic factors, because we know we address the things that have the largest impact, we will have less reason to address the things at the top of the pyramid. So starting by addressing education and poverty, then we can try to change the context. OK, so if we make the default decisions healthy, then we make it easier for people to make the healthy choice. If we enact tobacco taxes right or health laws, those will make it easier for people to make the healthier choice. If we have long lasting, productive interventions such as smoking cessation treatments and we make those affordable to people, we can also impact their overall health status and reduce their incidence of risky behaviors such as smoking. We might look at clinical interventions, so this is where we get more individualized treatments, so medications for high blood pressure, medications for diabetes, these are all things that impact people on an individual level. If we can make those affordable for people, that makes them more accessible and then also really trying to start counseling and educating patients on healthy behaviors. We can do this by implementing fresh fruits and vegetables in schools, physical education classes, things like that that would reduce obesity, for example. And that is how some of the ways that the CDC is trying to address health and the social determinants of health.

Slide 35: Examples of Health Impact in 5 Years

Some other examples of health impact in five years. This is through the CDC as well. And this is trying to address the social determinants of health. So if we think about biggest impact at the bottom to smallest impact of the top, again, social determinants of health, education and poverty are the bottom tier. We need to look at early education for children, pre-K making that free for everyone. We can clean up the air quality by having clean diesel bus fleets. We can increase people's access to health care through public transportation, making home improvement loans and grants available to people so that they can improve their housing and make it safer and healthier. The earned income tax credits are ways that the government can subsidize people's income by allowing them to truly keep more of it in another way to do it is perhaps through water fluoridation. And that is one way to help or help impact oral care.

Ways that we can consider changing the context. OK, making the healthy choice, the easy choice, if we have the school-based programs like increased physical activity, we try to address

violence prevention in schools. We make safe routes to school so that kids can walk to school and therefore they get exercise. They don't take a bus, which keeps the air cleaner. We focus on preventing motorcycle injuries. We focus on trying to control smoking for people who are IV drug users, access to clean syringes has proven to truly be a method to decrease illness in this population. If we change our pricing strategies for alcohol products, making it a less attractive choice will help to decrease the incidence of alcoholism. And then a multi component worksite obesity prevention program trying to address obesity in the workplace is a great way for employers to help improve the health of their workers. So these are just some of the examples of programs that are being put into place.

Slide 36: Objective 4

Objective four: identify and connect with an advocate for adversely impacted populations.

Slide 37: Identify Adversely Affected Populations

So when we think about the other modules that we have created, you will be able to also utilize modules two and three to help you identify adversely affected populations, the population health assessment module, which is module two and also the population health surveillance, which is module three.

Slide 38: Considerations When You are Connecting with Adversely Impacted Populations… We're going to think about some considerations when we're trying to connect with and work with adversely impacted populations. We need to go in with an appreciation for how systemic discrimination can impact our ability to connect with these populations. So will people be able to. Get to where you are trying to educate them, would they be able to do so? Do they have transportation? Do they have education? Do they have any sort of language barriers? These are things that you might want to consider when you are working with an adversely impacted population, when you are working for an organization that is working with adversely impacted populations. We want to make sure that all employees have been provided with cultural competence training, especially for the population with whom you are working, you want to meet people where they are in the community, perhaps there's a centralized community location, it might be a church, it might be a park or something like that. So, you want to make the location of where you are easily accessible. You want to make sure that you're providing tangible assistance. OK, so when you meet, are people going to be able to come because they like, do you have the meeting in the evening because people would be working during the day if they come, would they be needing to bring their children? So maybe, perhaps do you need to provide child care or transportation? Perhaps the most important thing you can do when you're trying to connect with people who have been adversely impacted is truly to listen and to take notes and then summarize what the needs of this population is and make sure that you repeat it back to them so that you have a true understanding of what it is that they need.

Slide 39: Community Health Workers

So we started to talk about community health workers earlier in this module in community health workers are an amazing intervention to connecting with adversely impacted populations. Community health workers are frontline public people who are trusted members of their community. They have an understanding of the community in which they serve. And this breeds trust and a relationship which enables the worker to serve as really a liaison or a link between the health and social services and the community. Community health workers can facilitate access to services, they can improve the quality and cultural competence of the service delivery. And really collaborate with other health care teams to make sure that patients are getting the needed resources that will help to improve their health outcomes.

Slide 40: Why are CHWs Important for New Mexico?

So, this is an example of community health workers in New Mexico. And a great example of some of the things that they do, they do cultural, they work as a cultural liaison, they help the population navigate the systems that are available. They help to coordinate their care and to manage their cases. They provide home based support, help do health promotion and health coaching, doing community assessments, etc. So, community health workers have really changed the health outcomes for their populations in New Mexico.

Slide 41: Incorporating Partners to Address the Needs of the Population

So some a few other ways to incorporate partners to address the needs of populations. One great way to do this is for a local health clinic to partner with a local law school. And the professors and the students can be co-located in the clinic space and help to provide legal aid to the patients who come there. Often people who come to a free clinic, for example, have significant legal needs, and this is a great way for them to get some of the services addressed that they need. We can also try to increase our utilization of the electronic health record. We can set up screening tools in the health record to identify needs such as nutrition, social work, utility assistance. And by making sure that we're screening for these needs, then we can have someone on our team that help can provide onsite referrals to these different locations and needs and fill these needs that people have. Another place that we might be able to help to address needs of the population is a community organization that perhaps is in an affluent neighborhood. So, for example, a church to partner with the help health care organization in a low income neighborhood, and they sponsor staff, a food bank or another needed resource. An example of this is the food bank that is sponsored at West Suburban Hospital in Oak Park, Illinois, and it is sponsored by Temple Jeremiah, a temple that is in the north shore of Chicago. They fund the food bank and they partner with the health care organization so that the providers write prescriptions for patients to go to the food bank. And when they go to the food bank, they're given healthy meals and easy recipes. And it has resulted in the patient population being better able to control their diabetes, hypertension or heart disease, etc.

Slide 42: Tools to Identify, Assess and Address SDH

Here are some tools for module 1 that might be helpful to you. We've provided some tools to identify, assess and address social determinants of health. These are assessment tools that you can use. You can adapt for your own use. And then there's an excellent example called the Neighborhood Navigator. And you go into that and you can put in the zip code of the community that you're trying to serve, and it will demonstrate to you what resources are available in that community.

Slide 43: Local Examples of Implementing CHW

Here are some local examples of implementing community health workers through the Sinai Urban Health Institute, New Mexico Office of Community Health Workers, Massachusetts and Vermont Health Workers.

Slide 44: Additional Resources

Some additional resources, the Upstream Doctors by Rishi Manchanda is an excellent book, Upstream Medicine. These are just books and podcasts that might be helpful to you.

Slide 45: Resources Continued

Here are a few more examples of some resources.

Slide 46 - end: References by slide

And then we have the references by slides. So if you're interested in a particular slide, you can come here and find the reference for it. And then at the end, we have all of the references just listed in order. Thank you so much. I hope you enjoy the other modules as well.