Boyle Heights : The Wellness Center Case Study

Developing The Wellness Center At The Historic General Hospital: A Case Study









Prepared by:

Contributors Jorja Leap, Ph.D. Laura Rivas, M.S.W./M.P.P. Louisa Lau The Wellness Center represents the dedication and efforts of many individuals. It is, however, critical to note that without the vision, leadership and investment of Supervisor Gloria Molina, The California Endowment and the Boyle Heights community, The Wellness Center at The Historic General Hospital would not be a reality today. This case study was possible thanks to the commitment and hard work of many individuals and organizations that generously shared their time, reflections and ideas. We appreciate the staff from many different agencies that are committed to the overall wellness of the Boyle Heights community and beyond.

October 2014











TABLE OF CONTENTS

Introduction Literature Review Community‐Based Programming and Accessibility Client Empowerment and Advocacy Cultural Sensitivity Focus on Preventive Care and Health Promotion Historic General Hospital: An Overview Opening The Wellness Center Mission and Vision TWC Physical Space Funding, Staffing, and Administration Service Provision Place Matters: Boyle Heights The Wellness Center Case Study Methodology Interviewee Demographics First Month of Operations Key Successes Key Challenges TWC Model: Missing Pieces, Future, and Replicability Replicating TWC: MLK Jr. Community Hospital History of the MLK Hospital 2015: The New MLK Hospital Incorporating TWC Model Conclusion Works Cited Appendix A: Interview Protocol Appendix B: MLK General Hospital Extended Case Study Materials







1 3 3 3 5 5 6 8 14 15 16 22 26 29 29 32 33 36 41 49 53 53 55 57



58 62 65 66



INTRODUCTION

Three years ago, recognizing the future need to promote wellness and provide

preventive health care in the communities she served, Supervisor Gloria Molina envisioned the creation of an all‐encompassing health resource center. In a remarkable example of repurposing, it was further envisioned that this center be housed in an East Los Angeles community landmark – The Historic General Hospital. After an arduous planning and implementation process that involved community members, stakeholders and involved local and national organizations, The Wellness Center opened its doors to the residents of Boyle Heights in March 2014.











This case study carefully examines the relationship between The Wellness Center (TWC) and the community it is designated to serve, using a research‐based narrative to chart its development alongside the potential growth of resident engagement within Boyle Heights. Through interviews and ethnographic observation, the case study research explores the role of residents, stakeholders, and local officials in the visioning process, the thoughts and activities that accompanied the creation of the center, and how TWC is positioned to respond to the ongoing needs of this vibrant but marginalized and under‐ resourced community. In addition, the case study offers an instructive example of how TWC contributes to overall individual and community well‐being while advancing The California Endowment (TCE) mission of building healthy communities and transforming the way in which communities and the healthcare system think about and approach wellness. Interviews with TWC stakeholders and community residents, uncovered The Wellness Center response to community needs as well as the sensitivity of its service



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providers to the unique cultural concerns of Boyle Heights residents. The research process focused on: 1) 2) 3) 4)

How TWC is structured to respond to community needs. How TWC advances health care access and overall well‐being of residents. Community engagement in supporting and enlarging TWC functioning. Community perceptions and beliefs regarding the role of TWC in facilitating community wellness. 5) Role of community engagement and participation in visioning, executing, and sustaining TWC.

The research was strongly guided by the mission and vision of TWC and the

operating model of TCE, which together posit that individual health and community well‐ being are based on many factors including healthy life styles, family diet, positive behaviors, and the availability of community resources to help with both prevention and early disease detection and treatment. With its collaborative approach to combating the epidemic levels of obesity, hypertension, cancer, and other chronic diseases affecting marginalized populations, the case study worked to capture how TWC is uniquely positioned to empower residents and patients to take control of their own health, fostering its ability to improve overall health outcomes for the community through the expansion of preventive and responsive care services.

TWC represents the first community‐based wellness center in East Los Angeles, a

re‐imagining of a historic hospital setting, anchored in the community. Most importantly, it stands as an undertaking that has actively engaged officials, nonprofit organizations, and community members in its design, construction, and functioning. This case study will portray how TWC is an example of both community‐based health care and resident engagement.

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LITERATURE REVIEW Wellness is defined by multidimensional considerations including social, occupational, spiritual, physical, intellectual, and emotional.1 These dimensions are interrelated, interactive, and integrated within an individual or community system of functioning.2 Traditional wellness centers provide a diverse range of services, that may include fitness, nutrition and diet, relaxation/ meditation, mental health, and education with services designed to improve and promote individual and community health. An analysis of the literature revealed several dominant themes in the operation and effectiveness of wellness centers, including community‐based programming, preventive health care, client empowerment, and cultural sensitivity. Community‐Based Programming and Accessibility Any wellness center programming must be accessible and relevant to community residents in order for them to seek services. The centers with the greatest impact are located within the community where those in need of services live. This allows residents optimal access to resources, as well as increased opportunities for self‐efficacy and empowerment. Due to their intentional and direct integration into the communities they serve coupled with service provision that meets specific needs of the population they are serving, community‐based programs prove to be an effective model for outreach. Client Empowerment and Advocacy Nykänen and Seppälä (2012) describe how patient empowerment is integral to the citizen‐centered health care model and community wellness. Due to the fragmentation of 1 Suresh, Ravichandran, & Ganesan (2011) pg. 17. 2 Berrylin (2008). Pg. 19.



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health care today, patients must be pro‐active in both integrating and tracking the completeness of their care; they can no longer exist as passive consumers of services.3 Increased patient empowerment can ultimately lead to improved quality of care management through wiser and healthier lifestyle choices, healthier behaviors, better disease management, improved care coordination, and improved care recommendations. Empowerment is also viewed as helping to reduce health care costs, as clients assume more responsibility for their health, their commitment to wellness and disease prevention cuts down costs such as unnecessary or repeated hospital visits.4 It is also clear that the presence and use of wellness centers leads to both policy and environmental change even while enhancing individual and community wellness and health. The role of advocacy in wellness centers focused on prevention differs from traditional medical care settings. Wellness centers differ markedly from traditional facilities that often pose barriers for low‐income populations of color, who are often weary and distrustful of traditional care systems. In these community‐based centers, clients gain a sense of empowerment and control over their own health and well‐being and are inspired to act on behalf of their families. Client advocacy is enhanced through the involvement of community leaders, neighborhood social networks, mass communication campaigns in their native language, and grassroots education tactics. 5 A focus on assets rather than deficits empowers clients to act on their own behalf and to move more confidently through the healthcare system.



3 Nykänen & Seppälä (2012) pg. 118.

4 Nykänen & Seppälä (2012) pg. 118. 5 Merzel & D’Affitti (2003) pg. 558.





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Cultural Sensitivity According to Anderson (2005), efforts to create models for health services must take into account how people view their own general health, as well as how they experience symptoms of pain and illness and whether or not they judge their problems to be of sufficient importance to seek professional help. In fact, perceived need is never devoid of social context; perceived need is a largely social phenomenon and can be explained by culture, social structures and health beliefs.6 Merzel and D’Affitti (2003) cite the failure of programs to impact health behaviors in various communities because these programs focused mainly on individuals, and were not sufficiently tailored to reach population subgroups. Large‐scale health education often does not make more than a modest impact, primarily due to the lack of specific cultural considerations.7 In contrast to traditional health care settings, wellness centers consider cultural sensitivity to be fundamental and services are geared toward the needs of the specific target population. Focus on Preventive Care and Health Promotion Research on the effectiveness of wellness centers also portrays the effectiveness of their focus on preventive services and health promotion and education as opposed to providing direct health services. Promoting healthy eating, active living and an overall healthy lifestyle, with an emphasis on disease prevention, cuts down on healthcare costs by eliminating the need for unnecessary hospitalizations and emergency room visits. Nykänen and Seppälä (2012) contend that the citizen‐centered health care paradigm rests on preventive care, proactive services, and early detection/diagnosis to ensure patient’s 6 Anderson (2005), pg. 3.

7 Merzel & D’Affitti (2003), pg. 569.



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wellness makes up a strategy that is more beneficial and cost effective than the management of symptoms, illness and chronic disease.8

HISTORIC GENERAL HOSPITAL: AN OVERVIEW What is now known as the Historic General Hospital was first opened in 1878, when

Los Angeles County (LAC) established a 100‐bedroom hospital on Mission Road to serve the region’s needy population.9 Seven years later, in 1885, the General Hospital affiliated itself with the five‐year old University of Southern California (USC) Medical School, creating a “long and prosperous academic partnership”. 10 At that time, the Hospital consisted of 100 beds and 47 patients. This small structure soon proved inadequate to serving its target population. As a result, after construction beginning in 1928, in 1930, actress Mary Pickford dedicated the 8‐ton cornerstone of a new LAC General Hospital on State Street. In 1933, the modern Los Angeles County Hospital, affectionately referred to as “The Rock,” finally opened. The new hospital fulfilled what then Supervisor Shaw deemed to be “Los Angeles County’s Duty to the Needy”.11 This one million square foot facility would serve as a beacon of hope, setting an exemplary standard for high quality healthcare that was provided to the community for the next 75 years.



8 Nykänen & Seppälä (2012) pg. 117.

9 Supervisor Gloria Molina, First District. The Wellness Center at the Historic General Hospital. 10 Ibid. 11 Ibid.



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After its construction, the Loma Linda University Medical School, as well as the California College of Medicine became involved with the hospital but later withdrew. By 1968 USC remained the only medical school affiliated with Los Angeles County Hospital.12 That year, the LA County Board of Supervisors voted to change the name of the hospital to Los Angeles County – University of Southern California (LAC‐USC) Medical Center “to reflect the academic partnership that was held between the two.”13 However, while the partnership endured, the hospital began to deteriorate, ultimately failing to meet earthquake and fire codes implemented after the 1994 Northridge Earthquake. As a result, there was an unplanned and immediate need for a renovated space to handle the patients in the aftermath of the disaster.14 In November 2008, a 600‐bed state‐of‐the‐art facility operating as the replacement hospital opened to the public. The new edifice consisted of three towers – a clinic tower, diagnostic and treatment tower, and inpatient tower. Today, the LAC+USC Medical Center

12 Supervisor Gloria Molina, First District. The Wellness Center at the Historic General Hospital. 13 Health Services –Los Angeles County. LAC+USC Medical Center ‐ About Us.

14 Supervisor Gloria Molina, First District. The Wellness Center at the Historic General Hospital.



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serves as a Level‐One trauma center as well as a hub in the Los Angeles County‐based healthcare system. In total, the LAC+USC Medical Center serves over 10 million residents and community members.15 It is one of most recognizable buildings on the East Los Angeles County skyline, still representing health care and hope. As a beacon and holding historic landmark status, this historic building is now home to the recently opened Wellness Center.

OPENING THE WELLNESS CENTER TWC is the product of a public‐private and community partnership between The California Endowment, the Office of the First District County Supervisor Gloria Molina, the Los Angeles County Departments of Health Services, Public Health, and Mental Health, and a number of health‐minded nonprofit “tenant” organizations. With all of the entities involved, the LAC‐USC Medical Center, an independent 501(c)(3) nonprofit organization, continues to serve as a predominant, lead partner in the establishment of The Wellness Center. The former General Hospital was chosen as the site for TWC in response to the desire of County leaders to honor and continue the legacy of healing that would promote health, prevention, and collaboration as its main goals.16 Based on stakeholder interviews and document review, it was clear that this effort was driven by Supervisor Molina’s vision of creating an all‐encompassing resource service to be housed in the previously underutilized General Hospital, transforming a previously recognizable monument in Boyle Heights to a beacon of health and opportunity.

15 Health Services –Los Angeles County. LAC+USC Medical Center ‐ About Us.

16 Ybarra, Jennifer. (April 30, 2012). Memorandum: Boyle Heights Wellness Center at the Historic General

Hospital. Pg. 1



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From the time the new LAC‐USC Medical Center was opened in 2008, the 77,000 square foot area on the first floor of the old hospital building comprised vacant space owned by Los Angeles County. The building included offices, meeting rooms, educational space, an auditorium, a cafeteria, and a kitchen. After convening a stakeholder meetings and garnering input from community members, project partners decided that the first floor of the building provided the most appropriate setting to achieve TWC goals, offering a common space that would be ideal for facilitating collaboration between nonprofit partners. Invested parties, with the help of TCE leadership, conducted an informal needs assessment of the surrounding communities. According to one interviewee, “The process was not as iterative as it should have been…there was a general sense of the areas of highest impact,” and service providers would need to meet these identified service gaps. As TWC was designed, these partners would be working together to perform a broad range of functions. As they organized in different configurations and collaborations, aided by their offices in the same structure and the common space, the resident partners could easily work to develop programming, share knowledge and advantageous practices, and combat high levels of diseases (such as obesity, stroke, heart disease, cancer) within the East Los Angeles community.17 With this vision, TWC would serve as a co‐located and collaborative model: agencies are not only located in under one roof but are required to collaborate on programming.

17 Ybarra, Jennifer. (April 30, 2012). Memorandum: Boyle Heights Wellness Center at the Historic General

Hospital. Pg. 1.



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TWC was initially planned as a project that would be developed in several phases



spanning five years. However, early on, based on responses from partners and community members, it was clear that this multi‐phase, multi‐year plan was not going to work. Instead, planning activities composed an initial phase of preparation in the spring 2011, with the building completion and opening slated for late fall 2012.18 As a part of this initial planning phase, start‐up activities included a “request for proposals” (RFP) process for Wellness Center partners. These partners would operate under the auspices of TWC and would expand their services to the Boyle Heights community.19 Based on community input, and to ensure that all partner organizations were aligned with the previously noted needs assessment conducted by TWC planning committee, the RFP required that all applicants demonstrate the capacity to provide culturally competent and linguistically appropriate programs. Additionally, agencies had to show a commitment to reducing medical costs



18 In our document review, this initial phase was referred to as “Phase I.” For our purposes, we have removed

this language because subsequent phases were not clearly delineated.

19 TWC Case Statement. (November 2013). Pg 3.



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through prevention‐based service provision. The RFP required all applicants to provide services in the following areas:20 Chronic Disease Management Wellness and Prevention Supportive Services Community Building Activities The RFP process attracted 46 applicants, and ultimately led to the selection of 14 nonprofit partners. The planning phase also focused on aspects of building production including financing, construction, and internal structure. In an attempt to begin process and preliminary outcome evaluation efforts, The Nonprofit Network conducted a capacity assessment from fall 2012 thru 2013. The Network was hired to summarize and articulate capacity issues experienced by the TWC project as well as offer recommendations for moving forward, including ideas about how to implement its strategic plan over the next three years.21 22 The Capacity Plan memo that The Network submitted noted that their team completed surveys and interviews at “a moment in time before tenants had full knowledge of the leasing terms…before the tenants had started meaningful work together.”23 Informal interviews revealed that many individuals felt this kept the process stuck in “planning.” However, there were key operational considerations and



20 Request for Proposal. Rent‐Free Space: First Floor at the Los Angeles County Wellness Center at the

Historic General Hospital. (2011).

21 The Nonprofit Centers Network. (March 7, 2013). Memo: Wellness Center Business Plan: Part I, Capacity

Plan. Pg. 1.

22 TWC Case Statement. (November 2013). Pg. 4.

23 The Nonprofit Centers Network. (March 7, 2013). Memo: Wellness Center Business Plan: Part I, Capacity

Plan. Pg. 1



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recommendations reported in both a final memo and Business Plan PowerPoint. These included:24 25 Need for Medical Director to interface with the Hospital to “establish client flow and educate the staff”. Facilitation of client referrals is crucial for driving visitors. Design a data collection strategy. Employing information technology solutions employed by other nonprofits. Enhance outreach/community relation’s role, marketing, and promotion efforts. Ensure usage of TWC by addressing transportation and access issues. Collaboration among the tenants should be TWC’s primary focus and should be facilitated by the Executive Director with clear expectations and trust. Consider long‐range planning goals and financial sustainability. Collaborating with The Network to ensure that TWC was properly positioned to meet the needs of the community and ensuring appropriate service provision was an important step. Development was in a constant state of flux as leadership learned that building rehabilitation would take one year, ultimately; this process took 2 ½ years. The opening of The Wellness Center had tentatively been scheduled for December 2012, but accounts indicated that it was pushed back as many as four times. After being repeatedly and consistently delayed, many organizations had put the notion of TWC aside to focus on core programming. Fearing that the process had become “too much about the building and not enough about TWC programming,” the leadership team held luncheons, meetings, and presentations to keep the tenant organizations invested in the project. This delayed timeline proved most frustrating for smaller organizations that were dependent on securing grant funding prior to opening their Wellness Center offices for programming. 24 Ibid. Pg. 2‐3.



25 The Nonprofit Centers Network. (March 8, 2013). PPT Presentation ‐ Business Plan: Part I Capacity Plan.



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Tenants were provided with little knowledge about the facilities timeline, and when it was finally announced that it was “time to move‐in,” tenants were ill‐prepared. Due to lost funding as a result of the delays, many tenants had not finalized new programmatic deliverables or scopes or work. Without a cohort of full‐time Center staff, tenants were left confused – they had “more questions than answers.” Despite these challenges, the move to TWC proceeded. After two to three years of construction, building and administrative delays, tenants moved in over the span of several weeks and once they were settled in they had a grand opening celebration on March 15, 2014. Despite tenants feeling a bit unsettled, the grand opening was truly a time of great joy and celebration. Illustrating that spirit, the photographs above depict TWC supporters at the front entrance of The Historic General Hospital and Supervisor Molina watching a cooking demonstration in the building’s shared demonstration kitchen facilities. Throughout the day, community members had a chance meet with and hear from local officials and Hospital staff, attend healthy cooking demonstrations, and watch local musicians and cultural dancers. They were also entered



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in various drawings to win prizes and receive giveaways. The event truly embodied Molina’s commitment to health and wellness in the Boyle Heights community. Most significantly, community members in attendance saw first hand the investments made on behalf of city officials, LAC+USC healthcare personnel, and local and national nonprofit organizations. Alongside appreciating the public‐private investments, community members were truly engaged with the mission of TCE and its BHC initiatives, the community, actively talking and learning about healthy eating and active living and how critical these behaviors are to ensuring health and wellness. Residents were empowered to take advantage of the culturally and linguistically appropriate health care services and to advocate for the needs of their families. Mission and Vision The grand opening symbolized the many individuals that were involved in creating the mission and vision of TWC. From the onset, input from community members, local officials, and Wellness Center tenants and staff helped to shape TWC mission: “to inspire and empower residents and patients to take control of their own health and wellbeing by providing culturally sensitive wellness and prevention services and resources that enable prevention, address the root cause of disease and improve health outcomes.”26 According to several Center publications, the vision is very broad and inclusive, consisting of a commitment to the values listed below:27



26 TWC. (2014) About the Wellness Center.



27 TWC Partners List and Fact Sheet. (December 2013). Pg 2.



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Provide culturally sensitive programming to the residents of the area in order to address the root causes of disease prevalent in the community. Enable residents/patients to empower themselves and to exercise autonomy over their health and lives. Support the Affordable Care Act by promoting preventive practices in order to reduce health care costs and preventing unnecessary hospital readmissions. Improve health outcomes for the patients and community by expanding preventive care services. Encourage collaboration among nonprofit organizations to provide programming and services and events to community residents. Attract community development and investment in a predominantly indigent population. Become a key component of an East Los Angeles regional integrated health care delivery system. TWC Physical Space The Center is characterized by an expansive and interesting lay‐out, which is depicted in Figure 1 below, including the display of the proposed outdoor space. In viewing the floor plan it is important to note the demonstration kitchen, the dance studio, and the tenant offices along with shared space.28 Eventually, the entire Wellness Center space will incorporate several sustainable and culturally relevant features including but not limited to: native plants, low impact development, public art, and LED lighting. After the grand opening, the entrance to TWC was moved from the front of the building to the side. Although this may not be as architecturally consonant with the structure, it was important to move the entrance in order to meet accessibility standards as outlined by the Americans with Disabilities Act. The yellow arrows in the graphic below indicate these

28 TWC Presentation. (March 2014). Slide 8.





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two locations. Parking for TWC is in a nearby structure and is not displayed on the map below.



1 Playground 5 2 Demo. Garden 6 3 Seating Area 7 4

Splash Pad

8

Performance Space Gazebo Fitness Trail

9 10 11

Healing Garden

12

Restroom/Prgm Office Parking Bike Racks Native Plant Habitat

13 14 15 16

Meditation Area Tot Area ADA Ramp Mayan/Aztec Elements

Figure 1: The Wellness Center Floor Plan Funding, Staffing, and Administration

In support of the public‐private partnership providing preventive services to a

community in need, local and national organizations pledged funding for the model early in the process. Start‐up funding for facilities, amenities, and building transformation were



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estimated at $14.4 million and the table below outlines funding secured as of 2012.29 These corporate and philanthropic funds would cover Wi‐Fi access, staff salaries, software development, as well as renovations and repurposing. Additional funds from The California Endowment, First District Office and Proposition A grants were received later and are not documented below. As portrayed in Table 1, a broad range of funders with specific programmatic aims invested in TWC.30 31

Funders

Purpose

CDC Community Transformation Grant (administered by LAC DPH)

Executive Director Salary (75% excluding benefits)

Amount $475,00 ‐ $500,000 over 5 years $90,000 ‐ $95,000 over 1 year

The California Endowment

Start‐up funds

LA Health Care Plan

Development of Wellness Center capacity assessment, business plan, and strategic plan

$150,000 over 1 year

The California Wellness Foundation

Information technology assessment

$100,000 over 6 months

Design/build play area for children 0‐5 years on the side of the State lot Street entrance to the building Rehabilitate/repurpose outdoor areas surrounding General Hospital

First 5 LA

California State Parks First District and County CEO’s Office LAC (transferred to Amigos de los Rios Spring 2012)

$280,000 for 1 year $1.839 million

Rent‐free office space to tenants

$5.8 million

Outdoor rehabilitation

$250,000







29 Numbers in the Table below reflect the amount of funding available from each entity according to 2012‐ 1013 reports. Be advised that across publications, these numbers varied slightly. 30 TWC Funds (2012 Overview), pg. 1‐2. 31 TWC Case Statement. (November 2013). pg. 2‐5.



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LAC (transferred to the Foundation in Spring 2012) LAC (transferred to the Foundation Fall 2012) LAC (transferred to the Foundation in December 2012)

Construction (Architecture)

$250,000

Construction (Project Manager)

$150,000

Construction (Demolition and Rehabilitation)

$5.144 million

Table 1: TWC Funders With this significant investment, it is clear that the administrative and accountability structure of TWC is critical to its effectiveness and functioning. In the day‐ to‐day administration of TWC, the Executive Director, currently Ms. Nancy Mullenax, is accountable to the LAC‐USC Medical Center Foundation Board of Directors. It is the executive director’s responsibility to oversee the “leadership, planning, fundraising, and comprehensive management of the Center.”32 Additionally, the Executive Director is also in charge of the development of “an operating and sustainability plan…as well as a common evaluation system that measures Wellness Center client outcomes.” This process is explored in detail as part of the analysis below. The administrative structure appears to be a “work in progress.” During interviews that will be discussed in detail later in the report several individuals expressed their concern that many of these responsibilities have not been implemented or shared with TWC tenants. Individuals also pointed out that the roles and responsibilities of TWC staff and tenants have neither been agreed upon nor clearly articulated. Figures 2 and 3 below portray the contrast between the current TWC staffing structure as of early 2014 (developed by Leap and Associates) and the proposed structure by The Network, respectively.33 34

32 TWC Case Statement. (November 2013). 33 TWC Directory. Pgs. 1‐4.



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Figure 2: Current TWC Staff (as of early 2014) Staffing – Medical Proposed Foundation President/CEO Wellness Center Medical Director Director Communications & Fundraising Program Manager (Staff or Consultant) Information Promotoras Technology Administrative Support Figure 3: Nonprofit Center – Proposed Staffing Model 32



© 2013 The NonprofitCenters Network & Tides



34 The Nonprofit Centers Network. (March 8, 2013). PPT Presentation ‐ Business Plan: Part I Capacity Plan.

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The administrative structure of TWC continues to be ongoing challenge. From the project’s inception, there have been several instances of turnover and staffing changes. In order to provide comprehensive services and conduct community outreach, the Center continues to grapple with the need for more full‐time staff with clear roles and responsibilities. In an effort to fill in some of these employment gaps and address vital needs, TWC tenant workgroups lead the programmatic discussions before permanent personnel were hired. According to interviewees, the tenants originally created and staffed four workgroups: 1. Data 2. Program Collaboration 3. Promotoras 4. Operations After suggestions from key personnel, a fifth group, “Outreach,” was developed. These workgroups met for several months prior to the grand opening and continue to evolve, focused on defining their roles and responsibilities within the larger TWC framework. During the planning phase and under the direction of the Interim Executive Director, Joanne Pineda, workgroups flourished. Ms. Pineda, who originally worked as a consultant on the project prior to her appointment as interim director, did not have the assistance of full‐time staff. For the length of her 5‐month tenure from November 2012 – March 2013, she facilitated monthly program partner meetings. To ensure that there were no duplicative services, all of the partners were surveyed to determine their capacity and primary service area. It is critical to note that prior to November 2012, much of the work



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on TWC had been focused on facilities and construction concerns. However, with the introduction of fulltime Wellness Center staff including the permanent director Ms. Mullenax, in the second half of 2013, workgroups were no longer considered the driving force behind the project. Amid pressures to begin outreach and programming, tenant staff did not feel encouraged to participate in the workgroups, nor did they feel that their opinions were respected or valued. Several individuals who were interviewed discussed how their workgroup had labored intensively and proposed several structural changes regarding roles and responsibilities that were repeatedly dismissed. Even now, the role of the workgroups continues to be in flux and part of the developing identity of TWC, a dynamic process that is moving towards a more positive resolution. Probably the most significant example of how the workgroups and tenant partners are struggling to define themselves within the current structure involves the promotoras. Promotoras, or patient navigators, were initially hired to engage in outreach with community residents and to refer them to resources. The promotoras assist individuals in maneuvering through the current healthcare system and its various complexities. As part of their efforts, promotoras were responsible for building relationships with clients, assisting residents in signing up for health insurance, and ensuring that prevention screening and follow up treatments are available to those in need. However, now their role within the Center is unclear and some tenants feel that they are acting as “glorified secretaries.” Current tenants expressed concern that promotoras have not been given proper training or tools to oversee the Center’s common messaging, distribution of marketing materials, or community outreach efforts.



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The tenant organizations are listed in Table 2 below. These organizations are housed, rent‐free, on the first floor of TWC.35 The agencies are expected to meet the previously outlined RFP requirements and to collaborate on health and wellness‐based programming efforts. Despite difficulties, this is a unique and important model, with an exciting design for service provision. Alma Family Services

East LA YMCA

Maternal and Child Health Access

American Diabetes Association

Jovenes, Inc.

Mexican American Opportunity Foundation

American Heart Association Arthritis Foundation Building Healthy Communities – Boyle Heights

LA Care Health Plan Family Resource Center LAC Department of Health Service

National Multiple Sclerosis Society

LAC Department of Mental Health

Neighborhood Legal Services of LA County Proyecto Jardin

LAC Department of Worker Education and Public Health Resource Center Table 2: Wellness Center Tenant Organizations/Program Partners East LA Women's Center

Service Provision As an integrated model, TWC was created and designed to provide a comprehensive range of services such as health education, support programs, healthy eating and active living behaviors for the community via the nonprofit organizations within TWC.36 The tenant organizations located within the Wellness Center are working zealously to provide services for predominantly Boyle Heights based clients, with an emphasis on improving

35 TWC Case Statement. (November 2013). Pg. 4 36 TWC Case Statement. (November 2013). Pg. 3‐4.



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health outcomes for the community, encouraging residents to take charge of their own wellness and to live healthier lives. As part of TWC mission, they are all focused on educating the public to avoid and understand the root causes of disease within the community while providing a safe opportunity for residents to be able to exercise and participate in community events. TWC was consistently defined by individuals interviewed, participants at the opening and involved community members as a one‐stop shop of health and social services resources for the underserved community of Boyle Heights. Once the center is running at full capacity, and in more purposeful collaboration with the Hospital and referring physicians, TWC tenant organization staff hope to provide a new pathway toward coordinated and managed health care. TWC connects to patients at the LAC‐USC Medical Center through a referral process. In order to ensure that clients are aware of the comprehensive preventive services offered at TWC, LAC+USC physicians issue referral, termed “Wellness and Park Prescriptions” to their patients.37 These referrals will facilitate engagement, helping community members take ownership of their own health and well‐being. Based on the clients’ needs, referrals will be made to the appropriate Wellness Center agencies. A wide range of services is provided by the tenant agencies through self‐run and collaborative programs. Such services include, but are not limited to what is portrayed in Table 3 below.38



37 Ybarra, Jennifer. (April 30, 2012). Memorandum: Boyle Heights Wellness Center at the Historic General Hospital. Pg. 1. 38 TWC Summary of Services. (February 10, 2014). Pgs. 1‐11.



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Service Areas Mental Health Services/Support Groups

Examples of Services Provided Alma Family Services: Grief and loss groups as well as individual, family, and group counseling.

Senior Services

Mexican American Opportunity Foundation: Senior Hispanic Information Assistance Program (SHIAS) connects non‐English speaking seniors to state and community based services that increase and aid in building self‐sufficiency and improved quality of life including medical counseling, caregiver support, coping with disease, and exercises classes.

Disability Services

Arthritis Foundation: Walk with Ease includes stretching, health education, strengthening exercise, and motivational strategies for individuals with arthritis. This program is designed to decrease pain and depression, increase increasing physical activity and walking distance. American Diabetes Association: Diabetes‐Related Information and Education is for

Diabetes Prevention and individuals who would like to know how to prevent diabetes, and will assist those living with Management diabetes with daily self‐management for the prevention of complications related to diabetes.

Heart Health Services

American Heart Association: Alcanza Tu Meta is a four‐month program that focuses on blood pressure management. Participants learn how to control their blood pressure by adopting healthier behaviors and following medication.

Advice from Nurses

LA County Department of Public Health: Ask A Nurse Sessions are scheduled with Public Health nurses to answer any health‐related questions and discuss concerns

Services for Sexually Transmitted Infections

East LA Women’s Center: Women and Families Living with HIV provides comprehensive and culturally sensitive, individualized services to women and their families who are affected by HIV/AIDS. Aims to provide resources and access to health services, improve overall quality of life for women and their families, strengthen family relationships, improve physical, emotional, and mental well‐being, and improve natural support networks.

Emergency Preparedness

L.A. Care Health Plan Family Resource Center: Red Cross First Aid, CPR (cardiopulmonary resuscitation) and AED (automated external defibrillator) training and certification to meet the needs of workplace responders, professional rescuers, school staffs, professional responders and healthcare providers, and the general public

Disease Prevention

LA County Department of Public Health: Disease Prevention Classes about sexually transmitted infections/safe sex, Food Borne Illnesses, Children and Adult Immunizations, Flu Prevention, Tuberculosis, Pertussis, and other public health disease prevention topics.

Legal/Immigration/ Housing Rights

Neighborhood Legal Services of LA County: Medical‐Legal Community Partnership (MLCP) allows patients to receive one‐on‐one support and legal counsel from an advocate on site. Information for housing and immigration rights also provided.

Health Advocacy

Maternal and Child Health Access: Provides outreach to uninsured/underinsured individuals and families to increase enrollment into free and low cost health coverage programs. Provides assistance for individuals enrolling in CalFresh.

Healthcare Benefits/ Insurance Services

L.A. Care Health Plan Family Resource Center: Provide education and assistance to families about free and low‐cost health insurance options, including Covered CA.



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Community Organizing/Advocacy

Building Healthy Communities – Boyle Heights: Provide support to 14 Building Healthy Communities with the goal of improving employment opportunities, education, housing, neighborhood safety, unhealthy environmental conditions, and access to healthy foods.

Violence Prevention

East LA Women’s Center: All My Relationships Program is a violence prevention program for teenagers, including a 12‐week youth leadership development program and peer‐to‐peer training.

Nutrition/Healthy Eating

American Diabetes Association: Food preparation classes for diabetics and individuals at risk of diabetes, teach participants how to prepare foods in healthier ways, portion size, and healthy choices outside the home.

Physical Therapy

National Multiple Sclerosis Society: Provides physical/ occupational therapy programs with group exercise classes.

Computer Literacy Fitness/Physical Activity Maternal/Child Health Work Training/ Vocational Rehabilitation Promotoras Meditation/Relaxation Gardening

East LA Weingart YMCA: Youth Institute offers programs for career and college readiness, learning graphic design, digital media, web design, and movie making. Maternal and Child Health Access: Best Babies Collaborative/Prenatal Outreach offers a walking club. Maternal and Child Health Access: Best Babies Collaborative provides 2‐year care management, home visits, extra food, walking club, and breastfeeding support. Worker Education & Resource Center: Healthcare career counseling for careers such as medical assistant, home health aide, diagnostic technicians, etc. Also offers computer literacy classes to prepare for such careers. East Los Angeles Women’s Center: Trainings for promotoras concentrating on domestic violence, sexual violence, and HIV. Arthritis Foundation: Tai Chi classes to help with relaxation. Proyecto Jardín: Offers food preparation demonstrations and guided tours of the garden.

Literacy

L.A. Care Health Plan Family Resource Center: Lap Read is an early education program for children 0‐5 years old. Children have fun reading, singing, and do arts and crafts together.

Public Education Campaigns

LA County Department of Public Health: Public education campaign topics include reducing injuries, violence prevention, reducing tobacco use and exposure, active living, and healthy eating.

Table 3: Service Areas and Service Provision



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PLACE MATTERS: BOYLE HEIGHTS To gain a full understanding of the impact of The Wellness Center on the health and well‐being of community residents, it is crucial to take a closer look at the Boyle Heights community. This vibrant and diverse neighborhood is located in the heart of the Los Angeles Basin, directly east of downtown Los Angeles. Its geographic area, as well as the location of TWC, is depicted in the map provided below in Figure 4.

Figure 4: Map of Boyle Heights (with TWC Inset)





Boyle Heights is an old, historically significant neighborhood in East Los Angeles populated with approximately 90,000 residents; it is characterized by a strong community and cultural identity. 39 For over 40 years, Boyle Heights has been the home of one of the largest Chicano/Mexican populations in the United States.40 Many Boyle Heights residents speak Spanish as well as English, including the newer Spanish‐speaking immigrants

39 BHC Connect: Building Health Communities: “Boyle Heights Community”. 40 The Wellness Center. Website.



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arriving from Central America. The community continues to grapple with persistently elevated numbers of high school dropouts, the presence and impact of gangs, violence, and teen pregnancy. Despite the persistence of these challenges, the community also possesses multiple assets and strengths. The California Healthy Interview Survey details other critical demographic information for Boyle Heights is portrayed below:41 42 98% Latino (vs. 51% in LA County) 1% White (vs. 24% in LA County) 1% African American (vs. 8% in LA County) 68.8% of the population have less than a high school diploma 32.8% live below the poverty line 62% low‐income households (vs. 44% in LA County) 62% limited English proficiency (vs. 67% in LA County) 15% Unemployed (vs. 13% in LA County) Boyle Heights has continued to encounter challenges in terms of economic growth, education, public safety, and public health. These challenges have persisted throughout its history as a community. As outlined previously, TWC was formed largely in an effort to help Boyle Heights and its inhabitants grow into a healthier community. Through “the patient‐centered medical home” model, TWC relies on preventive care as the primary medium by which services are administered.43 These emphases are vital: Boyle Heights is the site of epidemic levels of obesity, hypertension, stroke, cancer, and various other long‐ term chronic diseases within the East Los Angeles area.44 Based on statistics from the California Health Interview Survey, more than 33% of Boyle Heights residents are

41 The California Endowment. Making Health Happen by Building Healthy Communities. Boyle Heights. 42 UCLA Center for Health Policy Research. Building Healthy Communities: Boyle Heights ‐ Health Profile.

43 Ybarra, Jennifer. (April 30, 2012). Memorandum: Boyle Heights Wellness Center at the Historic General Hospital. Pg. 2. 44 TWC Case Statement 2013, pg. 1.



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overweight and 23% are obese. These rates correlate with chronic diseases and an overall poor quality of life. Furthermore, in comparison to most cities in Los Angeles, Boyle Heights also experiences a profound lack of open green space. With low levels of educational attainment, the widespread lack of health literacy as well as deficits in health outcomes is to be expected but not accepted. Boyle Heights represented an optimal location for TWC due to its rich community characteristics and challenges. They are the same factors that drove its selection as one of TCE’s Building Healthy Communities (BHC) Initiative 14 target sites across California. Clearly, Boyle Heights is an exemplary model of a community ready for change and The Wellness Center is positioned to serve as a catalyst for positive community change and individual well‐being, while reducing healthcare costs to residents through preventive health care services. The need for such services is vital in the low‐income underprivileged community of Boyle Heights.45 Additionally, through the BHC initiative, TCE is working to promote “healthy homes” in the BHC sites and is prioritizing partnerships with public hospitals and linkages to services that promote health, wellness, and prevention.46 To further reinforce this relationship, today, BHC Boyle Heights is a supportive tenant/partner of TWC, as they are leading the way in collaboration with other local and national tenants to provide education to residents. Partnership with the BHC has allowed for the burgeoning of local leaders, youth advocacy efforts, and a culture of active community‐based organizations. Clearly, BHC and TWC perfectly align in their joint efforts to: “increase



45 TWC Case Statement 2013, pg. 1.

46 Ybarra, Jennifer. (April 30, 2012). Memorandum: Boyle Heights Wellness Center at the Historic General

Hospital. Pg. 2.



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access to health and social services for youth and adult residents, create safe spaces for youth programming, and advance projects that utilize community building strategies.”47

THE WELLNESS CENTER CASE STUDY Methodology

The case study research methodology represents an effective and useful approach to

understanding community and systems change while offering a guide to future interventions and initiatives. Employing rigorous case study methodology, qualitative and quantitative data (where applicable) was collected, coded, and analyzed for this comprehensive final report. The case study specifically sought to document the creation of TWC, examining how stakeholders are involved in and helping advance its work.

The case study began with a period of informal ethnographic observation,

information interviews, and document review. From these efforts, an interview questionnaire (see Appendix A) was constructed, integrating topics and issues that arose frequently and repeatedly during this period of preliminary research. The protocol was pilot tested in three initial interviews to ensure that questionnaire was capturing meaningful information, helping to paint an accurate picture of the development, successes, and challenges faced by TWC staff, community, and organizations.

Case studies provide a holistic understanding of a broader issue through a detailed

contextual analysis of real‐life scenarios. Jack and Baxter (2008) explain the use of case studies when they state:



“Qualitative case study is an approach to research that facilitates

47 Ibid.



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exploration of a phenomenon within its context using a variety of data sources. This ensures that the issue is not explored through one lens, but rather a variety of lenses, which allows for multiple facets of the phenomenon to be revealed and understood…[Case studies] ensure that the topic of interest is well explored…”48 This quotation highlights the primary motivation for using the case study approach; case studies allow us to collect information in the depth needed to understand organizations and communities including the processes and changes that comprise their structure and functioning. In particular, The Wellness Center case study truly required this sort of “informational depth” to ultimately produce the most useful and valid findings that emerged from multiple interviews, observation and document analysis. Drawing upon this, the case study represents an effort to create a fundamental understanding of what took place during the development of TWC, what occurred during its initial months of service, and the outline of its future prospects. Additionally, the material from this case study will be used to inform other organizations about the innovative and remarkable work happening on the first floor of Historic General Hospital. In particular, this work can be used a starting point to guide further research into the potential for, and efficacy of, wellness centers in other TCE sponsored Building Healthy Community sites. As such, this case study can serve as a guide for other sites working on improve the health and wellness of their communities.

As part of this, the research assessed many facets of community engagement as well

as the level to which the ideals and practices of a healthier community were being promoted. Drawing upon multiple approaches, researchers utilized depth interviews, ethnographic observation, and detailed analysis of available documents. Both the research 48 Baxter, P. and Jack, S. (December 2008). Pg. 544.



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approach and interview protocols broadly engaged government representatives, stakeholders, and community residents, allowing them to present each of their viewpoints and experiences. The interview process was both participatory and intentional and involved face‐to‐face interviews were conducted with individuals from each the following groups:

Local and national nonprofit tenants of TWC LAC+USC Medical Center Office of First District Supervisor Gloria Molina The California Endowment Boyle Heights Community members BHC‐BH members To identify and recruit participants for the case study, the research team relied on a purposive sampling method, working closely with The California Endowment to identify key stakeholders. From there, each individual interviewed was asked for the names and contact information for other key participants and people they believed would be valuable to interview. Participation in the case study was completely voluntary and participants were not compensated for completing the interview. While most individuals were extremely helpful and cooperative when approached for an interview, there were others who did not respond. This is an understandable reaction to requests of this nature – particularly as people’s schedules and concerns are multiple and demanding.

With permission from interview subjects, the evaluation team recorded all

interviews. These recorded interviews were then transcribed and the transcripts were analyzed using an open coding process. To develop preliminary themes, members of the

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evaluation team listened to a random sampling of three interviews and created a comprehensive list of over 30 line items. To ensure that the list of themes was all‐ encompassing, all interviews were then played back twice and coded based on this complete list. Using codes developed from the open coding process, the second coding process created more highly refined key themes. The most prominent themes are discussed below; these were themes present in at least 25% of interviews, with some mentioned in as much as 83% of the interviews. This coding process provided the research team with the qualitative context for the table presented below. This data triangulation helped to ensure internal validity. As demonstrated in the following section, interviews illuminated the ways in which the establishment of The Wellness Center continues to meet community needs and in effect, enlarges upon TCE‐BHC drivers of change: collaboration, resident and youth leadership, and policy and systems change. These formal interviews were augmented with informal interviews and lengthy discussion with community members. While these were not part of the coding process, the additional qualitative data gathering was used to augment the formal interview material. Interviewee Demographics

The research team completed 12 formal interviews over the course of several

months with a variety of stakeholders who reported wide‐ranging levels of involvement with the project since its inception. The graph portrayed in Figure 5 below depicts the breakdown of respondent categories: one interview was conducted with two staff members from the 1st District office. The majority of interviewees were center tenants, which included seven local organizations and two national organizations. In the interest of



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candor and in sensitivity to respondent requests, the specific individuals and their agencies are being kept confidential.

Respondent Breakdown 1

1 Ist District Office 2

Tenants: National Organizations LAC‐USC 1

Tenants: Local Organizations TWC Staff

7



Figure 5: Respondent Breakdown First Month of Operations

According to one of our interviewees, in her efforts as executive director, Ms.

Mullenax requested that the 16 tenants provide progress reports documenting the first month of service. The case study team asked tenants that were interviewed if they would provide their reports for review. Of the nine tenants interviewed, six provided their reports as requested. In order to paint a picture of the day‐to‐day operations at TWC, while not revealing the identity of the interviewees, the case study will highlight some of their work. All of the reports reviewed indicated that within the first month after opening, offices were full operational; this included the installation of phone lines, computers, other related media, and office furnishings. Office infrastructure was developed, staff was hired, and

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policies and procedures were finalized. After these initial steps, agencies began with the “promotion and delivery of quality services.” Perhaps most importantly, inter‐agency collaborations and referrals were initiated. One of the first steps in service provision was ensuring that the office was equipped with appropriate Wellness Center materials so that staff could begin building clientele. All of tenants described how they worked to establish relationships with the LAC+USC campus. As one individual explained, “We wanted to ensure open lines of communication, partnerships, and development of collaborative activities. This was important to us from the very beginning.”

These efforts quickly paid off. One of the local tenant organizations reported that

they had served 27 clients through 1‐on‐1 appointments that were both scheduled or occurred on a walk‐in basis and advocacy clinics during their first month of operation. “We just reached out to folks informally,” a staff member explained, “And people started to come in.” Several of the individuals from agencies interviewed indicated that from the moment they moved in, they began to collaborate on trainings to help community members understand the Affordable Care Act and other health coverage options. In a report, one tenant documented their work with 60 families that needed assistance with health care enrollment as well as efforts at troubleshooting with an additional 12 families seen for information and issues surrounding CalFresh. Another tenant, a national organization, reported serving eight clients through e‐consult with LAC+USC and has hosted exercise classes. Additionally, this agency has reached out to several LAC+USC departments included Rehabilitation Services, Wellness Committee, and Rheumatology. A third local tenant agency described their efforts at creating and offering trainings around Census Data



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and Social Media as well as hosting tours of the Wellness Center, reporting, “We have all sorts of agencies coming here like Teach for America. They want to learn about what we are doing – it’s a great model.” This enthusiasm was echoed in the words of the director of a fourth local agency, who reported: “We are able to help each other – we can benefit from having immediate access to experts in all sorts of field – we’re all in spaces close to each other. There is enhanced communication and all of us have strengthened the dialog that was already in existence. Co‐location is a great idea, the proximity to various experts in our field will foster collaborations.” This tenant proceeded to chronicle how their agency is hosting advisory council meetings at TWC and had 17 representatives from ten various Boyle Heights community based organizations participating. Additionally, they have provided direct service that included support groups, counseling, and case management to five clients.

From a review and analysis of the reports as well as informal exchanges with agency

personnel, it is clear that the first month activities were largely administrative and operational. However, as their comments and reports reveal, agencies did not limit these efforts strictly to these efforts. Instead, workshops, information sessions, and client meetings were held and even in their early months of operation, TWC tenants managed to make an initial but important positive contribution to the health and well‐being of their clients. Individuals sought and received vital information regarding health care access, support groups, and exercise. Informal interviews with community members and discussions upheld these accounts. This is not to say that the early months of operation passed without challenges, which will examined. However, responses show how community needs were being met.

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Key Successes

Despite the concerns of the individuals interviewed and the challenges they

highlighted throughout the interviews, there was tremendously positive response to The Wellness Center. What was apparent is that even in its earliest months of operation, the tenant enthusiasm was matched by community response and engagement. The chart below illustrates the most prominent successes experienced by TWC and those involved with it that emerged from the interviews conducted. Through coding and meta‐analysis, the research team identified five key successes that occurred with the greatest frequency. These are depicted in Figure 6 below.

Key Successes 12 10 8

7 6

6

5 4

4

3

2 0 Collaboration (58%)

Moving In/Grand Opening (42%)

Organizational Growth (50%)

Community Access (33%)

Unique Model (25%)



Figure 6: Key Successes Theme One: From the beginning, individuals viewed the greatest success of The Wellness Center as providing the opportunity for collaboration. Among the majority of the respondents, there was consistent enthusiasm over the prospects for building

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working relationships and effective partnerships. Of the individuals interviewed, 58% of respondents agreed that fostering collaboration represented a key victory for TWC. The significance of this theme was reinforced by content from interviews with TWC Staff and staff from the First District office. All of these interviews highlighted the high value of collaboration in the Wellness Center model. Several individuals also focused on the idea that TWC is not merely about co‐location. These were ideas that also emerged from the literature review. One individual observed: “The partners, generally speaking, learned to work together well. There was a bonding experience. And from the beginning, the partners all endured struggles and frustrations. Instead of letting things get us down or upset us, we all bonded over the experience of creating this together.” Another individual offered his thoughts about what was developing within TWC, saying, “There are definitely collaborations happening within the building. We are supporting one another through this process. These connections would not have occurred if we were not under one roof.”

Theme Two: Alongside the significance of collaboration, another key success noted was the opportunity for organizational growth. Half of the respondents believed that this was both a strength as well as a success for TWC. Interview analysis revealed that organizational growth occurred in two ways: organizations expanded their presence in the community and organizations expanded the services they delivered. One individual developed this theme during her interview:



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“We are more involved with the Boyle Heights community, with other agencies and with the medical community. We have been able to build our connections to the community in a way we never could have accomplished on our own. It’s a tremendous opportunity and a real success for community‐based prevention efforts.” Another individual observed that, “Several agencies are expanding. Agencies are providing new services and a wider range of services.” These developments were positive achievements for both the organizations that experienced them and for the community that benefited from them. Community members weighed in during informal discussions, talking about the organizations they did not know provided services that they could access and use in their everyday lives. Theme Three: Although the move‐in was not trouble‐free, hosting the grand opening and finally occupying the facility was viewed as a key success. The celebratory event that marked the creation of The Wellness Center was a source of both joy and pride – with many individuals remarking how meaningful it was to share this with the Boyle Heights Community. While 42% of the individuals entered remarked upon the effectiveness of the event, among community members, the support for the event was even stronger. In an informal discussion group held after a BHC gathering, one woman recalled, “It was a wonderful day – a great party and a great event. And now we’re here.” Her experience was matched by that of one tenant who recalled, smiling, “Despite complicated pseudo‐County processes and all the bureaucracy, we got it done…nicely.” The grand opening served as a kind of healing event, enabling the tenant agencies to move past their frustration. Another individual interviewed detailed the process:

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“Let’s be honest – the projected move‐in was delayed once or twice, I stopped counting after a certain point. But through it all, the agencies who were tenants developed a kind of camaraderie. We worked through everything and trusted the process together. The celebration was great and now we can look at each other and we’re thinking, we did it, we’re in!” Overall, there was a tremendous sense of accomplishment that after much planning, The Wellness Center was finally a reality. Some of the individuals interviewed focused on the difficulties of the moving in process but eventually even the most critical voiced their satisfaction that they were finally settled and working to partner with one another and with the community. Theme Four: Although the response was not as strong as with other key successes, one third of those interviewed, stated that increased community access represented a major victory. One individual described the intrinsic value of community access, commenting: “It’s so important and empowering that we have secured this facility, this space has been re‐envisioned as a space of healing – this is for the community. We help to staff it, we are here to serve, but in some very real way this is “owned” by the community. It is their center.”

Another respondent expressed their belief that TWC “can thrive as a community center – we all see a vision of success.” The need for the Boyle Heights community to both possess and

use a community‐based wellness center was viewed as integral to family and neighborhood health. During interviews, several respondents expressed similar opinions that this center fulfilled a long‐standing need in this marginalized community. “I don’t know why it took so

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long,” one interviewee offered, “But I think we are all glad the center is finally here.” This was a tone that persisted throughout all of the interviews: whatever the critique, there was consistent acknowledgement that the establishment of TWC represented an important accomplishment that would serve Boyle Heights in the year to come. Theme Five: The final key success was a sentiment expressed by respondents who felt it was important to be part of and play a role in the development of a unique model. Throughout all of the interviews, there was a general sentiment that this was an innovative endeavor, and a vast improvement on previous efforts. One out of four individuals interviewed expressed their commitment to the development of a new model of community based preventive health care. “It feels good to be part of something that is new and innovative,” one individual exclaimed. Another interviewee offered a succinct summary of the unusual character of TWC, saying: “There are places that are co‐located but not places that underscore the importance of collaboration across partners to this level. There are also collaboratives that are not co‐located – and while they engage with partner, there is no sense of being able to walk across the hall to another office. For these reasons, The Wellness Center is unique.” These words were reinforced by the observations of another interviewee who maintained that The Wellness Center presented an important opportunity because “the model is a great one, we looked at other venues, but nothing of this scope is out there. It doesn’t make sense, there should be more places like The Wellness Center – these multipurpose/ multidisciplinary centers are crucial to good health.” Cultural sensitivity is a critical aspect of this unique model of wellness and effective health promotion, and is one of the areas where TWC in

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Boyle Heights thrives. While TWC is looking to incorporate additional programming for other “communities”, notably for the disabled and for LGBT‐identified folks, the RFP process ensured that their tenants were providing culturally relevant and linguistically appropriate services for the predominantly Latino population. Key Challenges

Throughout interviews, individuals raised and discussed several structural and

administrative challenges that The Wellness Center faces. The chart below, portrayed in Figure 7, depicts the major challenges described by interviewees. As with the successes highlighted above, a wide range of challenges was described. As part of a meta‐analysis of qualitative data, the case study team combined ideas to create overarching thematic areas. Again relying on the coding process, six key challenges and three “additional challenges” themes have been identified. These were the ideas that were coded with the greatest frequency, with key challenges present in at least 58% of interviews. The three additional themes (TWC Staffing, Lack of Clear Roles/Responsibilities, and Sustainability Concerns) were coded with slightly less frequency and were present in at least 41% of interviews.



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Key Challenges 12

Lack of Accessibility (58%) 10

10

9

TWC Staffing

9

Funding (58%)

8

8

7

Delayed Move‐In (67%)

7 6

6

5

Logistics/Infrastructure (75%)

5

Lack of Commmunication/Cohesion (75%)

4

Sustainability Concerns No Clear Understanding of Roles/ Responsibilities Marketing ‐ Outreach and Promotion (83%)

2

0



Figure 7: Key Challenges Theme One: In defining key challenges, Outreach and Promotion emerged as the most prominent theme, with 83% of respondents specifically citing problems with marketing. First and foremost for TWC to be successful, there must be a common understanding of what TWC is and what it represents for Boyle Heights. There was extensive concern about mission and messaging. Several individuals felt that an overall outreach strategy was missing – and truly needed. One tenant captured this belief, observing, “There is a lack of consensus about what TWC truly is – what it represents – this is crucial. We need to decide just what we are and get the message out there.” Interviewees agreed that the Center and its administrative structure needs to make a more thoughtful and intentional effort at creating marketing materials that accurately represent all facets of the Center. Another tenant offered their opinion that, “We need an outreach plan – we need

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materials and we need bodies to do the outreach.” There was great concern that not everyone in the Boyle Heights community was aware of TWC and the services it offered. “There are people we need to reach, who don’t know about us – and many of them have the greatest health needs,” one individual explained. It is clear that there is a desire for effective leadership in this arena. These interviews aligned with one of the key recommendations raised early on by The Network – the need for a unified and comprehensive marketing/outreach plan. Tenants raised concern that many of these recommendations continue to fall by the wayside. Raising the question as to why the evaluation was conducted in the first place and whether the recommendations made were taken seriously by TWC administration. Theme Two: Another key challenge that emerged focused on problems with communication and cohesion with the vast majority of individuals describing problems in this area. This challenge was very strongly connected with the marketing concerns previously identified. The interwoven uneasiness characterized 75% of the individuals interviewed – their thoughts and feelings were repeated in multiple interviews. Tenants expressed strong feelings about the lack of clear and concise communication between TWC Staff and the tenants. For many, their concerns were best captured in the words of one individual who noted, “There are just no realistic goals and clear expectations” about what is needed from the tenants. Several noted that their capacity has changed since drafting their original proposal but despite this, the Center staff has not been willing to engage in conversations or updates. One individual discussed his concerns:



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“There is a serious need for a strategic plan. Right now I don’t think there is one and that’s not a good thing – this all fosters anxiety and a negative reaction from folks. We need to feel like we are all in this together and that we all have a road map for change.” This theme also tied in closely with individual concerns about roles and responsibilities. One individual reinforced the need for a strategic plan and alignment saying, “There are a lot of hands in the pot, we need to come together intentionally and strategically – our realities need to align.” What clearly emerged from the themes identified through interview analysis was the need for The Wellness Center to create and present a united, integrated front to both Boyle Heights residents and to the medical community. TWC staff must recognize that not all tenants are service providers, not all have the same levels of capacity, and finally, not all tenants have enough funding to meet TWC demands without being allotted the time and space to secure additional funding. Theme Three: The majority of individuals interviewed expressed concerns about the TWC structure, particularly logistics and infrastructure, with problems surrounding their lack of voice in any planning or structure. This challenge was consistently cited by 75% of the individuals interviewed and represents an area warranting future attention. One individual was very direct, noting “Partners do not have enough say in the process.” Again, this theme overlaps with other challenges, particularly the lack of communication and the inability to define roles and responsibilities. From interview accounts, it appears that the needs of tenants were consistently overlooked in the planning process. Given the multiple agendas operating throughout the planning process, this is not surprising, but the



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interviewees were insistent that this now had to be addressed. A related concern was well summarized by one individual who described how “the intake process is really complicated…it’s unnecessarily invasive and repetitive.” This belief represents serious concerns on the part of tenants who are required to ensure confidentiality and respect HIPPA. Interviewees raised related concerns surrounding specific leadership and bureaucratic concerns. Many respondents believe that there are key structural pieces missing from TWC model, namely, communication, transparency, and accountability. This issue is exacerbated by the lack of a clear relationship between funding entities, LAC, TWC administration, and tenants. Overall, TCW tenants concerns clustered the belief expressed by one interviewee who seemed to express what many were feeling: “The Center is wonderful and it’s important to the community but it needs to live up to its promise. Right now we all are feeling that the center is lacking a sense of organizational effectiveness – time, planning, and cooperation are all missing – and this is key. All of the agencies here are dedicated to what we are doing but we need good, strong infrastructure and communicated. For some reason, this isn’t happening.” Theme Four: Challenges that resulted from the delayed move represented a key theme for two‐thirds of the individuals interviewed. Along with this strong emphasis on post‐move‐in problems, over half of the interviewees described now facing funding problems that resulted from the late move‐in. One individual embodied the reaction of many interviewees as they explained the problems that faced their agency: “We were forced to develop our infrastructure all at once. The building was not functional before move‐in, which impacted programmatic deliverables, timelines, and scope of work – it caused confusion. We expected to move into a stable environment – we knew there would be problems,

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but nothing approached what we found when we tried to move in. Nothing was ready.” There was confusion, lack of preparation, and no sign of infrastructure. Several tenants discussed their inability to secure funding as a direct result of the continually delayed move‐in; this was a problem most notably for the smaller, local agencies. One individual who was interviewed recalled, “We expected to hit the ground running, and it was a rude awakening when we had to stop in our tracks and take care of things – like getting the phone hooked up – that should have been taken care of for us. Only now that we are actually in the facility can we begin fundraising. This has been a serious problem for us.” Many of the interviewees revealed their feelings of surprise that the infrastructure of TWC was not as well organized as they had anticipated. There was recognition that problems were anticipated, but not the type or extent that was experienced. Attending to all of these problems diverted their attention and energies from fundraising and maintaining relationships with ongoing and sustaining funders. “We thought we wouldn’t have to deal with any of this,” one individual recalled, “that’s why we joined the Center. But we wound up experiencing double the problems.” Funding loomed large as an ongoing challenge, exacerbated by the delayed move. Again aligning with The Network recommendations, this ongoing concern regarding funding adds to the anxiety about the sustainability of TWC model. Related to sustainability, several tenants expressed the need for outcome development in order to measure – and validate – the Center’s success. When coupled with the concern about building a solid clientele, many of the interviewees feel that the Center’s future is troubled and uncertain.



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Theme Five: Lack of accessibility presented a major challenge facing The Wellness Center, a perception shared by tenants and community members. This is the one challenge that arose in both formal interviews and informal discussion with community members. For the most part, tenants and district office staff agreed on challenges and problems, while community members were simply thrilled to have The Wellness Center operating. However, with this challenge, everyone was in agreement. In addition, there was a strong sense of urgency accompanying the remarks of those who discussed accessibility. As one individual insisted, “This is far more important than any of the administrative, structural, and marketing concerns and needs to be solved immediately. I am embarrassed to try giving directions to clients. I keep thinking of how someone might try to walk to the Wellness Center from the parking lot – if they try to come up that staircase, they could slip and fall. And we’ve got clients who are already uncertain about the health care system. It’s difficult enough to navigate online – now it’s difficult to navigate from the parking lot.” Another individual described how, “The complex landscape of the LAC‐USC campus and parking lot is enough to keep them from setting foot at TWC.” There was a significant amount of concern expressed “about the safety of consumers coming to TWC." One tenant raised their concern that, “there is not enough signage – we have to give extensive directions, which exacerbates the pressure to get people here.” Four community members were quite vocal in their concerns noting, “The Center is great but I can’t park and walk there – they’re crazy if they think it’s easy to get to,” while another older woman asked, “What are we going to do when it rains?” The following photographs and instructions depicted in Figure



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8 and 9 are two sections of a handout created by TWC tenants to provide understandable directions to clients.49



Figure 8: Parking Directions

For those who cannot or choose not to make the 7‐10 minute walk up the steep

staircase, TWC has implemented a free shuttle service. Still, for the tenants interviewed, this was not enough. The shuttle, they suggested, should run through the nearby communities and work to coordinate schedules with the metro lines for those who not have reliable transportation. Below is a map depicting the shuttle schedule and route. The shuttle is expected to stop at four “convenient” locations at 15‐minute intervals. For those dependent on the shuttle service, they must leave ample time for parking and transport when calculating the time needed to arrive on time for their appointments. Community members claimed that this was an unrealistic and “un‐welcoming” plan; one suggested that 49 TWC Parking. (2014).



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there be a town hall meeting to discuss how to create better access to The Wellness Center. “I don’t want to wind up with a broken leg,” one remarked while another laughingly added, “I want to go to The Wellness Center for preventive medicine – not rehabilitation.”



Figure 9: The Wellness Center Shuttle TWC Model: Missing Pieces, Future, and Replicability

Nearly all of the individuals interviewed expressed their belief that if TWC were

operating at full capacity, the Center would be representative of and responsive to the needs of the Boyle Heights community. At this time, however, and as a result of the challenges listed above, interviewees agreed that the Center has not yet reached full capacity. Moving forward, respondents identified several services that they felt could be enhanced:





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Disability Services/Accessibility Immigration Services Direct Health Services (ex: Dental) Substance Abuse Services Cancer Services (National Organization) Support Group Services Culturally and linguistically appropriate programming Youth programming (Arts and Sports) Respondents agreed that this first year represented a critical time for TWC. As part of this, tenants expressed hope that the Center will develop both internal and external (third‐ party) evaluation models so that they can more thoroughly measure their successes and desired outcomes. There was careful thought about the future and the vision that would best guide TWC. The individuals interviewed were very clear about what was both needed and desired in the months ahead: See a steady flow of traffic and expanded services. Become a nationally recognized model funded by the Federal government. Build stronger relationships with the medical and nonprofit sectors Develop trust amongst members of the East Los Angeles community. Gain a better understanding of the role of all stakeholders Set specific benchmarks/outcomes identified that are achievable and transformational Provide “programming worth coming back for.”

During interviews, the issue of replicability was discussed at length. It is key to

note that the discussions of the prospects for replicability of a model refers to The Wellness Center model as a whole – most notably, a co‐located multi‐tenant model with collaborative programming. There were varying degrees of enthusiasm about this model, as portrayed in Figure 10, with 91% of respondents voicing their belief that the comprehensive and holistic model of providing health care services, education, and prevention methods is replicable. However, once the interviewer drilled down into perceptions and nuances, one

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out of four individuals voiced some hesitation. Individuals explained that to truly determine if the model was replicable, the Center must first have the time and opportunity to operate at full capacity and with full effectiveness. One respondent indicated that the model is not yet replicable explaining that the internal structure, lack of transparency and accountability, and poor definition of roles and responsibilities remain as key areas of concern.

Is TWC Model Replicable? 1

3

Yes (Absolutely) Yes (With Hesitation) 8

No



Figure 10: Is TWC Model Replicable?

Building on this discussion, and based on the research at other community based wellness centers, multi‐tenant nonprofit organizations offering health and wellness services to residents are characterized by both the capacity to grow and the ability to be



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replicated. What is clear from these external studies and from the research conducted at TCW, is that the following components must in place:50 Beginning with a shared vision of health concerns Using self‐help support circles as a tool for enhancing personal/collective empowerment Developing health education and promotion workshops that actively involve participants, enabling them to share experiences in support circles while in the program Housing the program in an accessible and welcoming space in the community Providing on‐site exercise classes and equipment Establishing and maintaining supportive and collaborative community partnerships. Alongside replicability, the issue of scalability was also raised. Many respondents voiced their belief that while the model itself is too complicated for replication, elements of the model could be incorporated into existing health care campuses on a smaller scale. Tenants believed that this would be a much more seamless process. The lessons learned from the establishment of TWC could be used to inform the process of creating another wellness center at a BHC site in California. While some interviewees believed it was essential to build other centers in historical buildings, the majority of individuals expressed their concern about how effective it would be to avoid using a historical structure ultimately ensuring a quicker construction or renovation process. Certainly, in southern California there is another community that would warrant this innovative and exciting approach to engaging residents and building community health. South Los Angeles shares many of the same strengths and challenges as Boyle Heights and represents fertile ground for future innovation.

50 Elliot Brown, Jemmott, Mitchell, & Walton (1998), pg. 151‐152.



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REPLICATING THE WELLNESS CENTER: MARTIN LUTHER KING, JR. COMMUNITY HOSPITAL History of the Martin Luther King, Jr. Community Hospital In South Los Angeles, Martin Luther King, Jr. County Hospital first opened its doors in 1972. It was constructed after the Watts Riots and traces its origins directly to the local as well as national belief that the absence of health services contributed to civil unrest.51 At the time, the community of South Los Angeles lacked ‐‐ and desperately needed ‐‐ a general hospital. Individuals were actually forced to travel to Los Angeles County Hospital in Boyle Heights to receive services. Addressing From these challenges as part of Los Angeles County’s commitment to change, the original Martin Luther King, Jr. General Hospital came into existence. The Hospital began as a 461‐bed general acute hospital – one of the few facilities that catered to the poorest and most underserved residents of the community.52 Its existence represented hope to people who had never experienced good care in their own community.





51 Martin Luther King, Jr. Community Hospital. Our Story. 52 Ibid.





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Sadly, over time, the promise and hope gave way to problems and ultimately crisis in terms of medical care and service delivery. In August 2007, after a long history of well‐ documented operational difficulties, the hospital lost its accreditation and was forced to close. District Two Supervisor Mark Ridley‐Thomas and Los Angeles County leadership remained committed to providing health care and critical emergency services to South LA. But the question remained: How?

In October 2007, the South Los Angeles Medical Services Preservation Fund was

signed into law, guaranteeing that Los Angeles County would provide funding to build a new, state‐of‐the‐art hospital that would replace MLK and provide the highest quality health care. The old hospital has continued to provide outpatient services through the Martin Luther King, Jr. Multi Service Ambulatory Care Center (MACC), which still functions today.

There was ongoing concern about funding and capacity. As a result, in 2008, LAC

approached the UC Regents and Governor Schwarzenegger to ask for additional assistance in building a new hospital. The following year, the UC agreed, transforming the hospital into an independent, 501(c)(3) nonprofit organization. In 2010, the partnership sponsored Assembly Bill 2599 to provide financial stability to the new hospital, which was signed into law by September. Ridley‐Thomas and LAC leadership held a series of community meetings to discuss plans for establishing and staffing the new hospital and to obtain input from civic leaders, business owners, health care advocates, and local residents.53

Based upon the public‐private partnership established by LAC and the University of

California to address the health needs of the community, the collaboration created an 53 Martin Luther King, Jr. Community Hospital. Our Story.



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independent nonprofit organization, the Martin Luther King, Jr.‐Los Angeles Healthcare Corporation, which was charged with overseeing the administration of the Hospital. In 2011, the Corporation’s board of directors created the Martin Luther King, Jr. Community Health Foundation to support the work of the new Hospital. The Foundation will meet the needs of the public by increasing access to resources concerning health and wellness, creating initiatives that ensure better service to the community, conducting outreach, and obtaining funds. All of this is important to note in understanding that a substantial infrastructure for this health care facility. 2015: The New Martin Luther King, Jr. Community Hospital

The new Martin Luther King, Jr. (MLK) Community Hospital represents a “priority

project” for Supervisor Mark Ridley‐Thomas and is an integral piece of his 2013 Master Plan.54 The Hospital will have 131 in‐patient beds and is set to open in early 2015. Envisioned as a central hub in an integrated system of care, the Hospital will be providing the highest quality of medical services and offering health education and community outreach programs both on the site and with regional community partners, ultimately creating a comprehensive system of wellness services.55 Designed to effectively serve the 1.2 million residents of South Los Angeles, including Compton, Inglewood, Watts, and Lynwood, MLK will offer inpatient primary care, basic emergency services, as well as health education and outreach services for the community.56 Outpatient services will be located nearby and will

54

Ibid. About the Hospital. Martin Luther King Community Health Foundation. (2014). About. 56 Ibid. 55



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be offered through the Martin Luther King, Jr. Center for Public Health, which will focus on preventive care, and the Augustus Hawkins Mental Health Center.







According to the Los Angeles County Department of Public Health, South Los

Angeles is home to some of LA’s most vulnerable populations with several health concerns.57 The following table portrays South LA’s population distribution and the problems they encounter. 74% Hispanic and 23% African American 35% of community is under 18 years 30% of South LA adults report their health to be fair or poor 38% uninsured 29% have no regular health care 45% of adults have difficulty accessing medical care

Accessibility has proven to be a crucial problem for these vulnerable populations

and for the community. After the original Hospital was shuttered and services were shut down, many residents lost crucial access to healthcare and resources – including emergency services, surgical care, and general medical care. Although patients from the former Hospital were absorbed into other local hospitals around the area, most of the

57 Ibid. Statistics from the 2013 LA County Department of Public Health survey.



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hospitals were not as accessible. Public transportation was an ongoing problem as was the lack of outreach and follow‐up. For this reason, the establishment of a modern hospital to provide optimal services and community‐based care to the indigent and marginalized residents of South LA is of utmost importance. Incorporating TWC Model

Considering the Hospital’s rich history and its new position as a “hub” for South Los

Angeles health and wellness needs, the MLK model mirrors that of the TWC at The Historic General Hospital. With its commitment to including community voices, elements of “TWC Model” would be important as well as invaluable to the development of community based wellness efforts in South Los Angeles. Integrating this model within the existing Foundation initiatives would be ideal, fitting together “matching” strategies. There several local community organizations emphasizing health and wellness in South LA that could play a critical role as thought and leadership partners, providing significant, community‐ based resources and services that are integral to the wellness of South Los Angeles residents. These local organizations are listed below in Table 4:58

Type of Service Family/Community Social Service Centers

Community Health Clinics

Organizations Providing Services Al Wooten Jr. Heritage Center El Nido Family Center‐Manchester Para Los Niños Watts Labor Community Action Committee Bradley/Milken Youth and Family Center Watts Health Center South Central Family Health Center St. John’s Well Child and Family Center Crenshaw Community Health Center





58 Martin Luther King Community Health Foundation. (2014). Community Resources.



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Food Banks

APLA Health and Wellness Center Hubert Humphrey Comprehensive Health Center Mental Wellness/ Didi Hirsch Community Mental Health Center Counseling House of Uhuru Counseling Center YMCA Fitness/Exercise Challengers Boys and Girls Club Higher Goals, Inc. Shelters/Temp Housing Homeless Outreach Program & Integrated Care System San Miguel Church Spiritual Wellness West Angeles Church of God in Christ Urban League Worksource Center Workforce Development/ Jordan Downs Portal Employment Southeast‐LA–Crenshaw Center Compton CareerLink Table 4: South LA‐Based Service Providers



CONCLUSION

This case study explored and identified the creation of The Wellness Center

alongside its relationship to the Boyle Heights community. Today, TWC has been operating for roughly eight months and despite structural and administrative complications – it has and will continue to positively impact individual and community well‐being. Significantly, the model aligns with the mission and vision of The California Endowment’s Building Healthy Communities initiative. TWC is an embodiment of two key tenets of the “Health Happens Here” mantra – Health Happens with Prevention and Health Happens in Neighborhoods. In its efforts throughout California in general and in Boyle Heights in particular, TCE has moved the discussion of health and wellness beyond the traditional doctor’s office walls to the areas where we “live, learn, and play.” TWC is an important asset for a community like Boyle Heights – rich in culture and activism yet lacking the knowledge and resources to achieve healthy eating and active living on its own.

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With the implementation of significant policy changes under the Affordable Care Act, the current political and economic environment provides a unique opportunity for TWC to thrive. With these emerging transformations in the health care system, TWC is positioned to ensure that low‐income minority communities are afforded access to health coverage, insurance and resources. Most importantly, TWC encourages its clients to begin their wellness journey by addressing the root causes of illnesses. Community engagement is a central component of this model and is integral to providing appropriate education and services to meet the needs of Boyle Heights residents. As a result, residents are now taking charge of their healthcare and becoming advocates for healthy eating and active living in their underserved community. In alignment with the research on wellness centers nationwide, TWC stakeholders identified several key successes: collaboration among tenant organizations, improved community‐based programming, and increased access to culturally and linguistically appropriate services. The Wellness Center model has proven to be unique: it is co‐located and collaborative. Research suggests that different agencies clustered under one roof raises awareness of various partners’ particular service areas and ultimately attracts greater public support and engagement.59 In the same vein, co‐location is critical to enhancing resident participation and increasing access to services. Research demonstrates that co‐located nonprofit centers not only have the capacity to grow and expand but to be replicated throughout the country. In fact, co‐located nonprofit centers have been on the rise for years, and are favorably viewed because of lower tenant costs, emphasis on organizational development, efficiency, and effectiveness, and better coordination of client



59 Vinokur‐Kaplan & McBeath (2014), pg. 79.



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services.60 TWC tenants believe that sharing the same physical space provides the opportunity for a diverse set of organizations to interact in ways not previously possible, allowing for the creation of a “one‐stop‐shop,” and helping to broad their programming to better reflect community needs.61 Collaboration among healthcare providers has also proven to be an important factor in the provision of comprehensive services. In many examples of these community‐based programming efforts, the patient is placed at the center of the model – which is crucial to ensuring continued engagement.

In light of the increased awareness of these co‐located and collaborative wellness

center models, this case study offered an example of South LA’s Martin Luther King, Jr. Hospital as a community‐based medical facility that could potentially benefit from implementing elements of TWC model. As a part of its foundation initiatives, MLK could amplify nontraditional health and wellness services and place an emphasis on prevention. As in Boyle Heights, the research team identified several health‐minded nonprofit organizations in that could collaborate to provide these resources.

To effectively meet emerging challenges, TWC tenants voiced a need for more

effective communication among all stakeholders – tenants, funders, and staff. There needs to be a clearer understanding of roles and responsibilities and increased accountability and transparency among TWC staff. In order to ensure continued reliance on Wellness Center services, staff is working on implementing a more comprehensive marketing program combined with intentional outreach and referral to and from the LAC+USC Hospital. Issues concerning funding/sustainability can be better addressed after TWC has been operating 60 Ibid.



61 Ibid.



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for over a year. These challenges mimicked those addressed in the literature, suggesting that with more time, TWC’s unique model has the potential to flourish not only in the Boyle Heights, but to inspire community engagement and resident activism in other underserved low‐income minority communities.









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Works Cited62

Andersen, R. M. (1995). Revisiting the Behavioral Model and Access to Medical Care: Does It Matter. Journal of Health and Social Behavior, 36(1), 1‐10. Bates, T. W. (2011). Community and Collaboration: New Shared Workplaces for Evolving Community Practices (Master's thesis, Massachusetts Institute of Technology). Baxter, P. and Jack, S. (December 2008). “Qualitative Case Study Methodology: Study Design and Implementation for Novice Researchers” in The Qualitative Report, 13(4). 544‐ 559. http://www.nova.edu/ssss/QR/QR13‐4/baxter.pdf. BHC Connect: Building Healthy Communities. “Boyle Heights Community”. http://www.bhcconnect.org/health‐happens‐here/boyle‐heights/our‐community. The California Endowment. Making Health Happen by Building Healthy Communities. Boyle Heights. http://www.calendow.org/communities/building‐healthy‐ communities/. California Health Interview Survey (CHIS). (2003‐2005). Healthy City: Information + Action for Social Change. “Zip Codes: 90033, 90063: Quick Stats.” www.healthycity.org. Elliot Brown, K. A., Jemmott, F. E., Mitchell, H. J., & Walton, M. L. (1998). The Well: A Neighborhood‐Based Health Promotion Model for Black Women. Health & Social Work, 23(2), 146‐152. Health Services – Los Angeles County. LAC+USC Medical Center: About Us. http://dhs.lacounty.gov/wps/portal/dhs/lacusc/. Martin Luther King Community Health Foundation. (2014). Our Community. http://mlk‐chf.org/about/. Martin Luther King, Jr. Community Hospital. http://www.mlkcommunityhospital.org/. Merzel, C. & D'Afflitti, J. (2003). Reconsidering Community‐Based Health Promotion: Promise, Performance, and Potential. American Journal of Public Health, 93(4), 557‐ 574. DOI: 10.2105/AJPH.93.4.557. The Nonprofit Centers Network. (March 7, 2013). Memo: Wellness Center Business Plan: Part I, Capacity Plan.

62 Wellness Center Staff and TCE personnel provided many of the documents referenced herein. Documents

are referenced by their titles and dates (when available). Complete citations provided where applicable.



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The Nonprofit Centers Network. (March 8, 2013). PPT Presentation – Business Plan: Part I, Capacity Plan. Nykänen, P. & Seppälä, A. (2012). Collaborative Approach for Sustainable Citizen‐Centered Health Care. In Critical issues for the development of sustainable e‐health solutions (pp. 115‐134). DOI: 10.1007/978‐1‐4614‐1536‐7_8. Request for Proposal. Rent‐Free Space: First Floor at the Los Angeles County Wellness Center at the Historic General Hospital. (2011). Rosenberg, A. (November 19, 2009). UC to help reopen South L.A.'s MLK hospital. http://newsroom.ucla.edu/stories/uc‐to‐help‐reopen‐south‐l‐a‐s‐112842. Suresh, S., Ravichandran, S. & P. G.. (2011) Understanding Wellness Center Loyalty Through Lifestyle Analysis, Health Marketing Quarterly, 28:1, 16‐37. http://dx.doi.org/10.1080/07359683.2011.545307. Steinhauer, J. (November 22, 2009). Deal Will Turn a Los Angeles Hospital Private. The New York Times. http://www.nytimes.com/2009/11/23/us/23hospital.html?_r=0. Supervisor Gloria Molina, First District. The Wellness Center at the Historic General Hospital. Retrieved from: http://gloriamolina.org/the‐wellness‐center‐at‐the‐historic‐general‐%20hospital/. Thompson, C. W., Monsen, K. A., Wanamaker, K., Augustyniak, K., & Thompson, S. L. (2012) Using the Omaha System as a Framework to Demonstrate the Value of Nurse Managed Wellness Center Services for Vulnerable Populations. Journal of Community Health Nursing, 29:1, 1‐11, DOI: 10.1080/07370016.2012.645721. The Wellness Center. (2014). Homepage. http://www.thewellnesscenterla.org/. TWC Case Statement. (November 2013). Pages 1 – 5. TWC Funds. (2012 Overview). TWC Parking. (2014). TWC Partners List and Fact Sheet. (December 2013). Pages 1‐3. TWC PowerPoint Presentation. (March 2014). TWC Summary of Services. (February 10, 2014). Pages 1 – 11.

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UCLA Center for Health Policy Research. Building Healthy Communities: Boyle Heights ‐ HealthProfile.http://www.calendow.org/uploadedFiles/Health_Happends_Here/ Communities/Our Places/BHC%20Fact_Sheet_Boyle%20Heights.pdf. Vinokur‐Kaplan, D. & McBeath, B. (2014), Co‐located Nonprofit Centers. Nonprofit Management and Leadership, 25: 77–91. DOI: 10.1002/nml.21110 Ybarra, Jennifer. (April 30, 2012). Memorandum: Boyle Heights Wellness Center at the Historic General Hospital.





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APPENDIX A: INTERVIEW PROTOCOL 1. Please tell me how the TWC came into being – how did the process begin? What took place over time? In other words – please discuss the story of TWC. 2. Are there things you would change about the process of creating TWC? 3. What were the biggest challenges in that journey? Biggest successes? 4. Where did the best support come from? 5. What is the future of TWC? Where do you envision TWC being 5 years from now? 6. Is this a model that that is replicable – what is your sense of that? What are the key elements? 7. How were the agencies chosen to participate in TWC? 8. What pieces do you think need to be added to TWC? 9. Anything else you want to discuss or add to the case study? 10. Who are some additional key stakeholders I should reach out to?



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APPENDIX B: MARTIN LUTHER KING, JR. GENERAL HOSPITAL EXTENDED CASE MATERIAL Mission and Vision

Martin Luther King, Jr. Hospital’s mission is to provide high quality health care,

comprised of a compassionate, integrated, coordinated, and collaborative approach towards its community to improve overall health among its children and families. To achieve this goal, the hospital leadership will collaborate with other healthcare facilities and providers within the community to make services not available in the hospital readily accessible to the public. 63 Funding Partners

Fundraising to construct and establish the new Martin Luther King, Jr. Hospital has

received generous, widespread support from both public and private community partners. In considering how TWC can inform the creation of a wellness center in South Los Angeles, it is critical to note that several of these partners are also supporters of TWC. In particular, The California Endowment and LA Care are noted as providing “valuable start‐up support.”

Funders

Purpose

Amount

LA County

Startup funds for expenses/operating costs

$50 million64

LA County

Care for uninsured patients

$13.3 million a year65

LA County

Capital project commitment

$353.8 million66



63 Martin Luther King, Jr. Community Hospital. About the Hospital.

64 Steinhauer, J. (2009, November 22). Deal Will Turn a Los Angeles Hospital Private. The New York Times. 65 Ibid

66 Rosenberg, A. (2009, November 19). UC to help reopen South L.A.'s MLK hospital.



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LA County

Annual operating funds

$63 million67

(major lending institution)

Operating funds for first 6yrs

$100 million (credit letter)68

Kaiser Permanente

Labor/Delivery Department

$2 million

Weingart Foundation

Healthy Babies,



Healthy Beginnings Initiative

The Ralph M. Parsons Foundation

Healthy Babies,

LA County

The Ahmanson Foundation

The David and Lucille Packard Foundation

Healthy Beginnings Initiative Siemens’s Symphony MRI

NA

$750,000 $500,000

Expansion of obstetric services and maternity programs _________________________________

$800,000

Healthy Babies, Healthy Beginnings Initiative

Good Hope Medical Foundation with UCLA Health System and David Geffen School of Medicine

Planning and pilot programs to establish The Learning Center

$100,000

The Annenberg Foundation

Planning and pilot work related to The Learning Center

$151,880

The Walt Disney Company

Art Fund Initiative to establish a healing art program at the hospital

NA

Table 5: MLK Funders Service Provision 67 Ibid 68 Ibid



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In addition to high quality and comprehensive medical care and mental health care

services, the MLK Foundation will be overseeing community‐based initiatives.69 These efforts will be both innovative and accountable for meeting community needs and interests. For example, the Art Fund will ensure that the traditionally sterile hospital environment will be adorned with art to foster a restorative, calming, and peaceful ambiance. The Healthy Babies, Healthy Beginnings effort is designed to ensure that mothers in South LA have accessible and compassionate care irrespective of their economic standing. In another facet of comprehensive care, the Learning Center will serve as the connection between the Hospital and community residents, providers, and organizers. The Center will provide education for residents as they navigate the complex healthcare system while collaborating with other local and national organizations to ensure completeness of care. The provision of outpatient treatment is essential to a comprehensive health care model and will be offered through the Hospital’s Transitional Care Program. In partnership with David Geffen School of Medicine at UCLA, this Program will “strengthen the safety net” through the utilization of care teams with the goal of improved health outcomes and enhanced experience for recently discharged patients who may need additional help managing their care. This program is intended to “shift care delivery from hospital to community.”70 Finally, the Hospital is relying on health care innovations such as “telemedicine” to connect to other facilities and ensure proper diagnoses and treatments as



69 Martin Luther King Community Health Foundation. (2014). Initiatives. 70 Martin Luther King Community Health Foundation. (2014). Initiatives.



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well as “smart beds” and “advanced nurse call systems” to ensure effective communication. On the following page, Table 6 provides a basic overview of the Hospital services.71

Facility/Organization

Services Provided

Martin Luther King, Jr. Hospital

Anesthesiology Cardiology (medical and diagnostic) Emergency medicine Endocrinology Gastroenterology General Medicine Gynecology General Surgery Neurology Obstetrics Oncology Ophthalmology Orthopedics (including spine) Otolaryngology Pathology Radiology Reconstructive Surgery Pulmonary Medicine Urology MLK Jr. Multi Service Urgent care Ambulatory Care Center Additional services including: general medicine, (MACC) cardiology, dermatology, dentistry, geriatrics, HIV/AIDS, neurology, orthopedics, and physical therapy Augustus Hawkins Mental Outpatient and inpatient psychiatric care and mental Health Center health services MLK Foundation Community Based Initiatives Art Fund Healthy Babies, Healthy Beginnings The Learning Center Strengthening the Safety Net Health Care Innovation Table 6: Services Provided by MLK Community Hospital



71 Martin Luther King Community Hospital. Medical Services.



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For services not provided at the Hospital (ex: Cardiology, Chemical Dependency,

Transplant, and Trauma), there will be agreements and MOUs in place with other nearby hospitals to ensure that patients receive the most comprehensive care available.



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