LA County COVID-19 Community Equity Fund: A community-based continuum of care to address COVID-19

The Los Angeles (LA) County Department of Public Health (Public Health) works to advance the conditions that support optimal health and well-being for all residing in the largest county in the United States. LA County is home to nearly 10 million residents and a travel destination for millions yearly. The overall population is 49.1% Latino/a/x, 29.6% White, 7.6% Black/African American, 1.7% American Indian/Alaskan Native, 14.8% Asian, 0.2% Native Hawaiian/Pacific Islander (NHPI), 25.9% some other race, and 20.2% two or more races. Los Angeles County also has significant diversity within racial groups.  Six Asian subgroups (Chinese, Filipino, Korean, Japanese, Asian Indian, Vietnamese) have populations of at least 100,000, and there are NHPI enclaves of Native Hawaiians, Chamorros, Samoans, and Tongans in LA County.  Due to different socioeconomic, linguistic, and migration-related factors, substantial health disparities exist among subgroups within and across these larger racial categories. (2021 ACS)

For years, Public Health has worked tirelessly to eliminate the stark inequities - particularly among Black, Latinx, Native Hawaiian, Pacific Islander, American Indian, and Alaska Native residents largely due to long-standing structural, racist, and systemic drivers (such as unemployment/underemployed, overcrowded housing, food insecurity, and a lack of strong workplace protections). Direct community engagement is critical to connect with hard-to-reach populations, such as those that are linguistically and culturally isolated, disconnected from traditional service delivery systems, and have a mistrust in government and health institutions due to systematic mistreatment.

The COVID-19 pandemic further exacerbated inequities and led to devastating and persistent mortality, hospitalization, and vaccination/booster uptake disparities. Critical to the pandemic response is tailored investments to support community-based organizations (CBOs) to do what they do best: connect with residents, engage in policy and practice changes, and share vital information on risks and opportunities for improved health outcomes.  As they have proven for decades—and even more apparent throughout the pandemic — CBOs have the trust, the connections, the flexibility, and the knowledge to reach their neighbors with the health resources and information they need, in the language they know. They work regionally and in partnership with local health jurisdictions, to build power and strength among our most systemically excluded communities.   

In September 2020, Public Health and the Department of Health Services established the Los Angeles County COVID-19 Community Equity Fund (Equity Fund) to reduce the spread of COVID-19 in communities disproportionately impacted by the virus. The Fund formed partnerships with CBOs to advance community-driven outreach, engagement, and system navigation efforts around COVID-19 resources such as testing, vaccine, access to medical care and social resources. With Community Partners as the fiscal intermediary, Public Health initially funded 28  and then expanded to 43 CBOs to:

1. Enhance collaboration with CBOs with cultural expertise and community trust to facilitate increased access to health-promoting resources in historically underserved and hard-to-reach communities

2. Reduce the disproportionate impact of COVID-19 by supporting its partners in communities where health disparities from COVID-19 persist;

3. Establish a public-private partnership that provides funding, training, collaboration opportunities and technical assistance to community organizations that builds their internal infrastructure and workforce to sustain prevention efforts in under-served communities.

Funded CBOs serve as local anchor hubs providing:

1. Outreach and education in a culturally appropriate manner using trusted messengers

2. System navigation to link people to wrap-around services and resources to address COVID-19 exposure and recovery needs

Through the first round of the Equity Fund, over 3.4 million individuals were reached through outreach and education efforts, ranging from in-person to virtual events and social media activities. CBOs provided 7,000 service linkages to testing and vaccination resources, support for quarantine and isolation housing, and referrals for medical care and social services (such as food security and benefits, mental health resources, and domestic violence relief). Additionally, over 1 million units of personal protective equipment and antigen tests were distributed. Through a competitive application process, Public Health awarded $8.5 million to support 28 community-based organizations across Los Angeles County with deep expertise serving communities at the highest risk for COVID-19. Community Partners, as the fiscal intermediary, provided administrative, programmatic, and budgetary oversight of the Equity Fund. Leveraging established partnerships and contracts, Community Partners also streamlined training, communication, and PPE supports.

Los Angeles County has a proven track record of building and connecting to large networks of partners to address a wide range of health issues. Public Health deployed resources to bolster the capacity of community organizations serving as health ambassadors providing culturally inclusive and relevant health information to residents, thus expanding its reach to serve communities hardest hit by COVID-19.  Strategic investments were made to respond to emerging data that identified specific regions and populations within the County.

Because of the ever-changing landscape of responding to a new virus, Public Health needed to ensure that CBOs and trusted messengers have the necessary resources to offer timely, responsive, and easy-to-understand information regarding COVID-19 to the communities they serve. Additionally, the Department wanted insights on the effectiveness of the community-driven outreach efforts. Public Health and Community Partners established in-person and virtual forums to facilitate ongoing communication with community organizations to ensure that we were most responsive to the communities they served. Through bi-weekly office hours and weekly email communications, CBOs: receive updated guidance on health orders and protocols, addressed questions related to accessing County vaccinations and testing resources, advised Public Health on COVID-19 campaigns and messaging to ensure it is relevant to priority populations, facilitated linkages connecting residents to a myriad of recovery needs (such as quarantine housing, food security, tenant protections, and mental health resources). 

The public health infrastructure extends beyond the health department and requires investments in community organizations serving as formal and informal health ambassadors, supporting the residents they serve. Funding organizations with a history of working in communities most impacted by COVID-19 allowed Public Health to quicky deploy resources (PPE, vaccinations, testing kits) and health information in a manner that is responsive those community needs.

The Department's website is http://publichealth.lacounty.gov

While COVID-19 impacted every community throughout the County, data throughout the pandemic - and particularly during surges and resource scarcity - demonstrated devastating impacts among American Indians/Alaska Natives, Black/African Americans, Latino/a/x, Native Hawaiian/Pacific Islanders, Limited English Proficient communities, people with disabilities, immigrants (non-US born persons), and LGBTQ+ residents. 

As early as April 2020, with 19,516 confirmed COVID-19 cases in LA County (excluding Long Beach and Pasadena), and racial and ethnic disparities in COVID-19 case rates and age adjusted death rates were already taking shape in surveillance data. Native Hawaiians and Pacific Islanders had the highest population rate of COVID-19 cases (840 per 100,000) and death rate (71 per 100,000), followed by Latinx (114 per 100,000 case rate, 9.8 per 100,000 death rate), African Americans (102 per 100,000 case rate, 13.2 per 100,000 death rate), Whites (78 per 100,000 case rate, 5.7 per 100,000 death rate), Asians (73 per 100,000 case rate, 7.9 death rate) and American Indian Alaska Natives (50 per 100,000 case rate, 2.9 per 100,000 death rate) (Department of Public Health).

By April 2021, the County's age-adjusted case rate was 11,886 per 100,000 residents, and the age-adjusted death rate was 217 per 100,000; however, Native Hawaiians and Pacific Islanders, Latinos/Latinx, American Indians/Alaska Natives, and Black/African Americans continued to experience higher case and death rates than the county average and/or their White counterparts.  Native Hawaiians and Pacific Islanders (21,070 per 100,000 case rate, 374 per 100,000 death rate), Latinx (12,783 per 100,000 case rate, 355 per 100,000 death rate), American Indian/Alaska Native (8,866 per 100,000 case rate, 188 per 100,000 death rate), Black/African Americans (5,539 per 100,000 case rate, 202 per 100,000 death rate), Whites (4,592 per 100,000 case rate, 120 per 100,000 death rate) (Department of Public Health).

Race and ethnicity are not the only predictors of increased vulnerability to COVID-19 infection and death or overall health disparities.  Of the 9,309.771 Los Angeles County residents over 5 years old, more than 55% speak a language other than English at home.  Limited English Proficiency is considered a critical vulnerability for health and mental health, particularly for elderly immigrants.  Additionally, individuals with disabilities comprise approximately 10.8% of the population (2021 ACS).  Individuals with disabilities face increased health vulnerabilities, report their health to be poor to fair at four times the rate of people with no disabilities (Krahn, G. L., et al., 2015), and are disproportionately affected by the hardships of COVID-19 (Administration for Community Living, 2022). Immigrants comprise 33.3% of the LA County population, and their access to care and quality of care is affected by poverty level, immigration status, language proficiency, residential location, and stigma, marginalization, and racism.  The LGBTQ+ population in LA County is estimated to be approximately 4.6% of the adult resident population (Gallup, 2015), or 361,658.  LGBTQ+ individuals smoke more than heterosexual and cis gender peers (CDC, 27 June 2022) and experience higher rates of HIV and cancer (Olsen, K. , 2021), meaning potentially increased vulnerability to COVID-19. (2021 ACS)

This intervention prioritizes those most impacted and people living in vulnerable geographies by focusing on specific communities identified from the Healthy Places Index (HPI)+2.0. HPI combines 25 community characteristics, like access to healthcare, housing, education, and more, into a single indexed HPI score (total population 4,878,877). The healthier a community, the higher the HPI score. Equity Fund reached 3,072,711 people through outreach activities and 5770 individuals through system navigation.   It is difficult to note what percent of the target population has been reached by outreach and education efforts due to how data was collected and the nature of large community events or virtual events, which obscures granular demographic or geographic details.

Prior to COVID-19, in Los Angeles County, historically marginalized populations and neighborhoods were already facing inequitable exposure to socioeconomic risks such as stable employment, housing, and access to other public benefits and social services.  The pandemic exacerbated existing inequities and created dramatic and persistent disparities in the rates of infection, mortality, hospitalization, and vaccination/booster uptake.  Moreover, due to the highly infectious nature of COVID-19, long-term persistence of infection in any group, no matter how small or isolated, puts the broader community and county at risk of further infection.

LA County is home to over 7 million BIPOC (Black, Indigenous, People of Color) individuals who have suffered the greatest health and social economic conditions (US Census, 2019; Portrait of Los Angeles County, 2017-2018; LA County Health Study/Community Health Profiles; Catalyst California, 2020), including:

- High rates of underlying health and chronic conditions,

- Most likely to have essential jobs that require interaction with people outside their household and many with limited or non-existent worker protections

- Many living in overcrowded multigenerational households and experiencing disproportionate rates of homelessness

- Barriers to healthcare access including lack of health insurance, immigration status, cost, linguistic and cultural barriers, in addition to distrust of governmental and health entities due to historical trauma

- Lower income levels and higher rates of joblessness

- Lower life expectancies

These systemic drivers laid the groundwork for inequitable trajectories during this pandemic, making these communities most vulnerable to adverse outcomes due to COVID-19 (higher rates of positive COVID-19 cases, hospitalizations, and deaths).

LA County Public Health has a well-established approach to utilizing best practices around community outreach and engagement, including direct community events and services at County facilities, community advisory boards, and subcontracting services with local community-based organizations.  Many of these activities and the community networks tend to be narrowly focused on a particular health issue (ie. tobacco, nutrition, or maternal and infant health) and/or may center on a specific geographic area.  These issue-specific initiatives can address focused health topics and resources to address them for those who are affected by them.  Additionally, place-based community outreach can reach diverse local communities and address multiple health issues.  This dual-pronged approach of issue-driven and place-based community outreach offers a balance of topical expertise and broad reach.

The Equity Fund model addresses health inequities by partnering with CBOs that provide services in priority areas, serving the target populations addressing drivers of disparity.  Culturally competent messaging, different conceptualizations and perceptions about health, linguistic access to health information, access to health information through traditional and mainstream access points, understanding how to navigate county processes, cultural barriers to self-advocacy, socioeconomic factors such as poverty, and geographic factors such as distance all contribute to disparities in access to health care and supportive service resources.  These CBOs understand how to advocate for and help individuals access local healthcare, social services, and government assistance from complex and often siloed systems.

COVID-19 has impacted multiple aspects of an individual's health and life across many social determinants of health.  As such, it needs a multi-faceted approach, with resources drawn from various sources, and a broad-based partnership. The Equity Fund serves a critical role within that approach, building upon traditional models of outreach and navigation by creating integrated and responsive networks designed to adapt to emergent needs. 

Equity Fund CBOs can provide culturally competent services to educate the public, provide navigation support and resources, and build community trust.  Community members who are uninformed or misinformed about COVID-19 and its transmission risk contributing to community spread.  Community members unable to adhere to quarantine and isolation guidelines risk exposing others to infection.  As COVID-19 spread and variants created an air of unpredictability, having trusted partners in the community address questions was of utmost importance.  Communities and subpopulations with more barriers to information and fewer resources experience even more vulnerability to adverse health outcomes, and therefore, building community trust is a critical priority for Equity Fund.  The foundation of having no wrong door” allows partners to address the myriad challenges created by COVID-19 beyond the infection itself.  Telling community members Equity Fund can help them with their needs has been critical to achieving the explicit objectives of the initiative and building community trust in an environment where trust in public health messaging was not assured.

Furthermore, using real-time data allows the CBOs to pivot to different communities strategically and address emergent service needs.  As clusters of infection appeared, CBOs serving those areas deployed workers and tailored resources as necessary. As medical sheltering needs sharply increased during the Delta surge, navigators worked with the Public Health's quarantine and isolation intake line to ensure our most vulnerable clients could safely isolate.

Health equity is achieved when everyone has access to the goods, services, resources, and power they need for optimal health and well-being.  The principles this definition is constructed on behind this are 1. Commitment to racial justice and social change; 2. Accountability to the community and each other; 3. Integrity and transparency in our internal and external processes; 4. Collaboration and shared learning.

Public Health strategies for realizing these principles include: 1. Increasing organizational competency and capacity to engage in sustained equity work; 2. Communicating in ways that amplify community voices and authentic narratives to drive action; 3. Supporting/building community capacity to engage in efforts that eliminate inequities; 4. Forging partnerships to enhance and promote efforts that result in equitable health outcomes; 5. Aligning current resources to work that eliminates inequities. 

Equity Fund implements those strategies by investing resources in a vast CBO partnership network across LA County, supporting a workforce with the cultural and lived expertise to serve diverse communities across the County.  This in turn guarantees that concerns communicated by residents are lifted up and utilized to inform Public Health's broader COVID-19 mitigation strategies (including strategies around vaccinations, testing, messaging, etc).

Equity Fund brings together two interconnected networks – outreach/education and system navigation – created a community-based continuum of care for COVID-19.  The Outreach & Education program supports CBOs with existing footprints in their communities and leveraged cultural expertise and community trust to effectively convey essential COVID-19 information and messaging. System navigators facilitate culturally and linguistically appropriate connections to wrap-around services, effectively linking individuals and families to resources that address COVID-related needs - such as medical sheltering, COVID-19 testing and vaccinations services, and social supports (i.e, government assistance, housing, and food).

While an innovative approach to design and implementation, the Equity Fund strategies (outreach/education and system navigation) are built on well-established Evidence Based Practices.  The instrumental and ethical importance of cultural competency in health education and outreach has drawn from several Evidence Based Practices including promatoras de salud, which has long demonstrated the effectiveness of trusted lay health educators to transmit and translate health information to both better understand public health issues, and support behavior change around health screening and healthy living (Balcazar, H.G. et al., 2009;  Forster-Cox, S. C., et al. , 2007).

The system navigation program builds on the patient navigators” model, which helps patients navigate the myriad issues related to complex disease management, such as cancer (Freeman, H.P., 2004). Particularly within historically marginalized communities, the combination of lack of trust, high stress, logistical complexity, and potential cultural hostility of medical treatment plans, the need to navigate patients through a process and connect them with resources is highly beneficial. This enhances the experience, supports compliance with treatment, and ensures that required protocols are followed.  Equity Fund system navigation was structured on this rationale to address challenges with confusing and ever-changing information during moments of COVID-19 illness and stress to improve access to resources, ensure compliance with health and safety protocols, and ultimately improve health outcomes. 

The overarching goal of the project was to reduce the transmission of COVID-19 through timely access to data regarding vaccination, testing, and information about COVID-19 safety.

Objectives:

1. Enhance collaboration with CBOs with cultural expertise and community trust to facilitate increased access to health-promoting resources in historically underserved and hard-to-reach communities

2. Reduce the disproportionate impact of COVID-19 by supporting its partners in communities where health disparities from COVID-19 persist;

3. Establish a public-private partnership that provides funding, training, collaboration opportunities and technical assistance to community organizations that builds their internal infrastructure and workforce to sustain prevention efforts in under-served communities.

The Equity Fund formed partnerships with grassroots CBOs to provide outreach, education, engagement, contact tracing, and system navigation. CBOs were selected with cultural and linguistic expertise and their community's trust to reach historically under-resourced and hard-to-reach communities.  Of these organizations, many had expertise serving immigrants, LGBTQ+ individuals, and individuals with disabilities, and providing culturally competent services to each of the main racial groups and a variety of ethnic sub-populations.  Additionally, the network focused on the regions of Historic South Central, Southeast Los Angeles, Northeast San Fernando Valley, and Antelope Valley.

Outreach organizations connected with individuals through various activities including one-on-one encounters to community presentations conducted in-person and/or virtually. Virtual events included social media, online meeting platforms, texting, and phone-banking. In-person events included meetings, residential outreach, street outreach, venue visits, and COVID-19 testing sites.  Effective outreach and education require targeted communications that reach and engage populations disproportionately impacted by COVID-19. This includes supporting the development and dissemination of culturally, linguistically, and literacy appropriate materials and messaging that equip communities with the information and skills they need to access services, help reduce their risk for COVID-19, and protect their families and friends.

Furthermore, Community health workers (CHWs) were utilized to promote preventive behaviors that protect people from getting or passing along COVID-19. Information shared included what COVID-19 is, how it can spread, what to do when you have it, and how to stay safe. They also promote quarantine and isolation procedures, the importance of mask wearing, and vaccines and testing resources. While promoting testing and vaccinations, CHWs can also help community members obtain appointments for both.

System navigators have primarily supported individuals referred from the Los Angeles County Case and Contact Interview Branch (CCIB), which works to contact any COVID-19 positive case or contact. These individuals are asked if they are interested in being referred to a system navigator and if yes are transferred through the CCIB system into the system navigation tracker database.

- Clients are assigned to prospective system navigation organizations based on language capacity and geographic area. Assigning clients based on language capacity addresses disparities in hard-to-reach communities and builds trust in services being provided by ensuring the client is being assisted in a language they are comfortable speaking in and can understand best. The geographic regions are monitored and assigned accordingly due to organizations having better capacity and knowledge in the service planning areas (SPAs) they serve. The system navigation organizations were able to provide both linguistically and culturally appropriate services to those in need, creating a trusted relationship in Los Angeles communities.

- Given that clients are either COVID-19 positive or a close contact, system navigators must attempt an initial to contact within 24 hours. The timeline was crucial as CDC guidelines for quarantine and isolation periods shifted throughout the pandemic. Clients are contacted a minimum of 3 times before being marked as non-responsive although are allowed to return for services at any time, and their case within the tracker would be reopened. This is also applicable to clients that have services rendered and return at a future date with additional needs.

- Service linkages have ranged from childcare resources, COVID-19 testing, COVID-19 vaccine, disability resources, domestic violence resources, elder care resources, employment, food resources, financial resources, flu vaccine, long-term housing, mental health, medical and dental health, transportation, women's health, utilities assistance, and temporary housing/medical sheltering. The services in most demand included food resources, financial resources, COVID-19 testing, utilities assistance, and medical and dental health.

- Depending on the client and the need some are simply provided information/education or the contact information for another agency.  Others receive a warm handoff to another agency, provided enrollment assistance (such as the DPH nutrition program or DPH medical sheltering), or provided direct assistance with non-DPH programs and resources.

From the start of the pandemic Public Health began distributing PPE items, initially in the form of masks and sanitizer, then antigen tests once they became available. These items were distributed through various community investments and strategies including the Equity Fund partners.  Being able to educate and provide PPE to the communities of Los Angeles County was a method for spreading awareness and reducing the disproportionate impact of COVID-19. This coincides with the importance of increasing outreach messaging goals around the topic of masking and social distancing. Educating around how masks are a form of protection, and the difference between a face cloth, KN95 and N95 in terms of layers and increased protection is vital to reducing the risk of transmission. In addition, organizations distributing antigen tests to the community has increased accessibility and increased the rate of testing, better protecting the most vulnerable communities that may not have the ability to travel to testing sites or pay for quick antigen tests prior to gatherings or while feeling sick.

Several opportunities have been offered to ensure that CBOs and their staff are properly equipped and up to date on COVID-19, resources available and other emerging issues.  

- Trainings: CBO staff are required to participate in key training prior to engaging with community residents.  Topics include COVID-19 Overview, testing, vaccine, field outreach guidelines, field safety, outreach skills, and effective outreach and engagement. They are constantly being updated due to the ever-changing nature of the COVID-19 pandemic. Supplemental trainings are offered to equip community health workers in providing services and conducting outreach. The range of topics include motivational interviewing, vaccine confidence, benefits for immigrants and resources for medical sheltering.

- Office Hours: Once per month, the Equity Fund outreach and education cohort and system navigation cohort each meet as a group with the TPA and the Equity Fund team to collectively discuss opportunities and challenges related to the contracted work (e.g., PPE distribution, high demands for quarantine and isolation resources, referral portal, dispelling vaccine myths and COVID-19 misinformation), contracting issues, and current community questions and concerns.  Office hours serve as an opportunity to provide updates but also are an opportunity to facilitate transparent communication among the larger group, collectively strategize and problem solve around emerging issues, and create a through-line of communication from community to DPH.

- Briefings: Initially on an ad hoc basis and then monthly Public Health offers briefings for all community and faith-based partners supporting with COVID-19 response.  These have brought key Public Health leadership and subject matter experts to provide updates on COVID-19 data, plans, vaccinations, therapeutics, and other emerging issues.

For Equity Fund to be successful Public Health sought to create a public-private partnership that included County Departments, philanthropy, and CBOs.  This partnership insured funding, training and technical assistance was available to invest in CBOs to build their internal infrastructure, workforce, and sustainability to provide prevention services in communities. The Los Angeles County Departments of Public Health and Health Services collaborated on the initial iteration of Equity Fund by creating mechanisms to receive federal funding and disseminate funds out the community.  The identification of a Third-Party administrator, Community Partners, allowed for swift establishment of contracts with CBOs with a longstanding history of serving as trusted messengers in communities where they share the ethnicity, language, and life experiences of the residents they serve.

The initial collaboration between the Los Angeles County Departments of Health Services and Public Health began in the in the Winter 2020 and subcontracts with CBOs were administered from January 2021 through May 2022. The second iteration of Equity Fund began in September 2022 with some CBO subcontracts beginning in February 2022 with rest coming online in June 2022.  For Equity Fund to succeed other community partners were engaged to support with trainings.  For the System Navigation organizations were provided topical trainings such as Improving Vaccine Confidence by the Planning and Public Partnerships for the Vaccine Preventable Disease Control Program (VPDC), Benefits and Services for Immigrants Training by the Office of Immigrant Affairs, and Food Assistance Programs Training by the Nutrition and Physical Activity Program. A system navigation organization, Maternal and Child Health Access, facilitated a Health coverage, CalFresh, and Cash Aid Programs Training. Additionally, Together Toward Health, a project of the Public Health Institute administered philanthropic funds for a few agencies that couldn't receive federal funds and/or struggled with some of the county requirement such as insurance levels.

For the first iteration of Equity Fund, Public Health and Health Services creatively implemented and executed the project by utilizing the internal government infrastructure to design and build out the program. To quickly establish the contract with the Third-Party Administrator, Community Partners, an existing agreement held by Health Services was leveraged. Work order solicitations were developed to enter into the agreement with Public Health.  Both agencies shared a commitment to invest in community partnerships.  Health Services contributed state funds to support 28 organization, Public Health used Federal dollars to support another 28 organizations and 8 organizations were supported through philanthropic dollars. Collaboration between Public Health and Health Services facilitated the streamlining of the application review and selection process.  Both coordinated their outreach and education network specifically on addressing case cluster responses and ensuring the appropriate size and expertise of CBO deployments. Additionally, Public Health and Health Services co-convened office hours to leverage the breadth of the expertise and capacity of each agency to support the CBOs and leverage the breadth and the expertise of the larger overall CBO network to inform the Public Health and DHS approaches.

To foster collaboration among the stakeholders, Public Health staff assigned to manage Equity Fund were chosen because of their capacity and experience working with community on similar projects and the ability to work collaboratively across various departments to get information into the hand of CBOs and into the community.

Working with the CBOs requires technical assistance and walkthroughs for certain areas of the contract. For example, insurance coverage requirements delayed contract executions as many of the smaller CBOs did not have the appropriate coverages to participate in this program. The lack of initial clarity from the federal government about what funds could be used for caused confusion among CBOs. Criteria and technical assistance were provided along with updates to mini trainings to support the CBOs. The CBOs also needed support accessing the CRM trackers utilized for data reporting due to authentication challenges. It required Public Health to maintain a close connection with the information technology team to troubleshoot. Once access was granted to the trackers, multiple technical assistance sessions were necessary for CBOs to understand the performance measures tied to their scope of work, and how to utilize the tracker itself to reflect those required metrics.

Technical assistance was also provided to the TPA, Community Partners (CP) on this program. Initially, the TPA was using flexible documentation protocols, which made it less burdensome for CBOs but made invoices more difficult to track and approaches were less stringent than the contract required, exposing the TPA to audit findings.  In addition, Public Health needed to take time to clearly define roles and provide technical assistance to ensure that Community Partners was able to meet all their requirements.  Public Health also provided significant support to Community Partners in initial meetings with CBOs and contract negotiations as the contracting process of this scale required more support personnel than the TPA could handle in the prescribed timeline.

The Equity Fund Program has been successful in meeting its objectives and further reinforced how critical it is to use CBOs to serve as local anchors hubs to connect residents' health information and resources. It also showcased the importance of leveraging existing community partnerships and collaborations already in place to facilitate a quick launch.

CBOs have been selected to cover several COVID-19 impacted areas across Los Angeles County and serve many of the impacted populations. All CBOs have been able to provide linguistically and culturally appropriate services. The outreach groups are successful in spreading education and updated information, assisting communities lacking knowledge in areas around COVID-19 vaccination, the importance of testing, mask-wearing, and updated Health Officer Orders.  The system navigation groups are successful in providing COVID-19 specific and other supportive public resources to individuals and families under quarantine and isolation, and otherwise directly affected by COVID-19.

CBOs have been able to implement outreach methods that varied depending on the needs of the community. For example, one contracted organization, Comunidades Indigenas en Liderazgo (CIELO), utilized videos as a form of outreach messaging. These videos were both linguistically and culturally appropriate for indigenous communities compared to other outreach materials. These video materials took great effort but had lasting impact on indigenous communities. Another organization, Young Invincibles, who had a large social media platform and was able to navigate and spread awareness through multiple social media outlets. This was important towards outreaching the tech-savvy population that may not see outreach materials otherwise.

System navigation CBOs ensured that people have been able to follow the proper quarantine and isolation orders through the facilitation of culturally and linguistically appropriate connections to wrap-around services. System navigators prioritize quarantine and isolation practices and provide general social support to assist with recovery from the effects of COVID-19 on communities. They promote access to healthcare, social services, government assistance, housing and food. System navigators are equipped in helping individuals overcome system-connection challenges, including those that preceded COVID-19. They provide light case management, ensuring service linkages are made to the requested resources and are able to identify and address immediate client needs. For example, Esperanza Community Housing Corporation assisted families that were under quarantine with no source of income by providing each family with a gift card to a grocery store of their choice, alleviating some of the financial burden during an uncertain time. Another system navigation agency, Southern California Pacific Islander COVID-19 Response Team, was able to assist Pacific Islander college students who had no family in Los Angeles County by providing medical sheltering during their quarantine period, along with groceries.

Over the course of the intervention Public Health has developed innovative key strategies to furnish CBOs with the resources to ensure they could effectively address community needs. Equity Fund Partners receive:

- Detailed outreach hotspot data from both departments that helped partners focus their outreach efforts on census tracts where vaccination rates were relatively low and infection positivity rates were high.

- Data on test positivity, vaccine rates and areas deemed as priorities by the State of California.

- Weekly talking points tailored to help organizations communicate effectively using strategies, materials, and assets that were culturally and linguistically appropriate.

- Trainings on using Canvas, an online system, that covered COVID-19 basics and system navigation.

- Supplemental topical trainings around vaccine confidence, food access and programs, medical sheltering, and benefits and services for immigrants. All trainings aimed to increase the capacity and knowledge in the communities served.

The practice uses performance outcome and process measurements.  Only primary data was initially collected.  Impact evaluation with system navigation clients has been started, but the results of the analysis are not yet complete.  Conducting impact analysis of the overall target population was not feasible considering the size of the population and the multiple confounding factors that could affect knowledge, understanding, and behavior regarding COVID-19. 

The following qualitative data was collected:

Outreach events are tracked via a CRM tracker, which is a secure database that community health workers can utilize to input data from outreach events. There are fields to gauge the type of event, the messaging, and the outcomes of the events. Outreach methods include both in-person and virtual outreach. It includes events, meetings, residential door drops, street outreach, vaccine outreach, venue visits, emails, telephone, virtual meeting or presentations, and social media.  The tracker also has fields to collect data on number of participants, location of in-person events, and demographic attributes such as race/ethnicity, language, priority target populations.  However, for outreach, the demographic data are unreliable due to the challenges collecting individual level attributes in large group or virtual settings.

- System Navigation clients are tracked using a CRM database that allows system navigators to input client information, the needed services, and the services rendered into a secure system. When a client is sent over to the system navigation tracker via CCIB, the administrative DPH team and Community Partners assigns clients to prospective system navigation organizations to be contacted for needed services.   The system navigation tracker also has fields to collect data on demographic attributes such as age, address, contact information, and demographics such as race/ethnicity, sexual orientation and gender identity, language, and priority target population.  These are optional fields and are often incomplete.  These more granular client-level data both support in assigning cases to CBOs with capacity to serve specific clients, but also help Equity Fund to evaluate the reach of services and analyze patterns of needs among different subpopulations.

For qualitative data, Equity Fund CBOs share any successes, challenges and technical assistance needed through monthly office hours and quarterly reports.  Similarly, meetings with and reports from the Third-Party Administrator provide additional data about the program and their processes.

The program measures and outcome for the first iteration which ran through May 2022 are as follows:

Outreach & Education:

1. Organizations were to complete 6 hours of training and curriculum around COVID-19 and effective outreach methods prior to engaging with the community. In addition, they were required to have a minimum of 1 staff member attend monthly office hours. Outreach organizations were expected to engage in briefings and ad hoc trainings due to the nature of the everchanging pandemic.

- 100% of community health workers successfully completed their trainings and were granted access to the CHW CRM tracker to document outreach. All organizations met the criteria of having a minimum of 1 staff member present during office hours, and many attending the ad hoc briefings to stay updated with new information.

2. Organizations were to conduct 8 virtual outreach events, 8 in-person outreach events, and 100 interactions with the community per full time equivalent staff member.

- 13,911 outreach events took place both in-person and virtually, reaching 3,072,711 individuals.  

- The protocols in place at the time, struggled to accurately track allotted FTE for each team, however, in aggregate across the 18 teams, there was an estimated 70 FTE conducting outreach and education. This would set the performance goals at 6,900 events for both in-person and virtual. The virtual events exceeded this expectation; however, given that most of the lifespan of this program was under strict quarantine and isolation orders, the in-person events fell short in numbers. The overall reach exceeded expectations as social media and virtual platforms reached a large audience.

3. Messaging was to focus on COVID-19 general education, vaccine information, linking to resources, promoting testing, and outbreak information.

- 34.95% of all events included answering questions and providing additional education, 19.05% requests for information about the COVID-19 vaccine, 10.80% had individuals schedule COVID-19 vaccine appointments, 8.59% involved packet drop offs, 5.89% displayed posters, and 5.53% referred individuals to supportive services.

4. Organizations were to help reduce disparities by distributing personal protective equipment (PPE) to the community.

- Throughout the program 922,194 face masks were distributed, 105,074 hand sanitizers, and 299,064 other items (face shields, gowns, gloves, testing kits, and flyers).

System navigation

1. Organizations were to complete a 2-hour HIPAA training, and 7 hours of training and curriculum that included COVID-19 basics and topical trainings. These trainings were required prior to community engagement, and the HIPAA training served as necessary given the nature of the system navigation work.

- 100% of system navigators successfully completed their trainings and were granted access to the system navigation CRM tracker to provide services.

2. Organizations were recommended to have 30 open cases or clients being assisted per month for every full time equivalent (FTE) staff.

- There were 10 organizations conducting system navigation, and no set measures for accounting for real-time FTE. This has served as a lesson learned and proper tracking measures are not implemented. It is estimated that the performance expectations were met, given that some cases are open for longer periods of time than others, depending on the needed services of the clients.

- 5,570 clients were assisted, and 14,268 unique services were provided to assist communities in Los Angeles County.

All data is analyzed on a regular basis. Monthly data entered into Outreach and System Navigation trackers are summarized and reviewed to determine overall impact of the program and to identify any challenges overall and for individual CBOs. The qualitative data such as those from office hours and narrative reports are also reviewed monthly to identify the successes and challenges of the program and the community engagement experiences from residents of Los Angeles.  Any concerning results are discussed with Community Partners and/or CBO(s) to determine the root of the problem, and if it reflected a challenge with program implementation or a systemic issue.

As data is reviewed, outreach and system navigation services are modified as needed, new systems created and/or new CBO trainings developed.  Overall, evaluating the results from this program has raised highlighted pre-existing and new inequities as result of the COVID-19 pandemic and changes were to the program to meet those inequities. Originally, the program centered around quarantine and isolation needs and services. However, because of broader impact of COVID-19, system navigation services expanded to include services that encompassed the detriments the community faced such as a lack of long-term housing, lack of medical and dental care, employment, and immigration services.

During this initial iteration of Equity Fund process evaluation data informed modifications to program implementation on several occasions, some of which led to immediate program improvements and some informed improvements to subsequent iterations of Equity Fund.  For example, the ongoing process evaluation identified surge periods as a time when referrals overwhelmed the capacity of system navigators.  As a result, surge protocols were developed for to triage and prioritize referrals during surge periods. The protocol directs that during a surge, clients be prioritized for services based on Healthy Place Index (HPI) zip codes and the requested services. The prioritized requests for urgent services including medical sheltering, food resources, COVID-19 testing, and COVID-19 vaccine. Although navigators aimed to contact all client referrals within 48 hours these requested services and HPI zip codes were prioritized for a 24-hour contact turnaround period. This protocol was based on lessons learned around not having the sufficient capacity to help community members during the greatest time of need for resources and assistance.

During the implementation this first iteration of Equity Fund, Public Health applied and was awarded funding to support the current iteration of Equity Fund.  While practice was designed to address the COVID-19 pandemic there were key lessons learned will continue to inform Public Health practices into the future as well as the current iteration of Equity Fund.

The practice is predicated on integration and adaptability, therefore so as challenges arose in outreach or navigation service deliver, or when gaps revealed themselves, the Equity Fund team had to analyze the problem and develop a solution to address it. 

1. For the system navigation, requiring a caseload capacity” of 30 clients per 100% FTE proved challenging.  This works for patient navigators that develop long term relationship with their clients, however, with Equity Fund system navigators the client relationships are shorter.  The purpose of the service is to understand the nature of the client's urgent needs and then connect them to the appropriate resource.  Typically, these relationships last anywhere from a single phone call, to several weeks.  This constant short-term turnover made it very difficult to evaluate and understand the process of system navigation that was built around a caseload.  Additionally, and more critically, the caseload model made it more challenging to meet the needs of COVID-19 case referrals that fluctuated dramatically.  Case referrals could be anywhere from a dozen total referrals per day during periods of low daily infections to hundreds of referrals per day during a surge.  Thus, during periods of low infection, navigators did not have enough cases to maintain a full case load and during a surge, navigators did not have enough capacity to take on new cases.  Additionally, some cases were more complex than others; some clients asked for assistance getting a food delivery and others requested support applying for CalFresh benefits.  As a result, for the second iteration of the program, the unit of service was changed from case” to linkage.”  This has allowed navigators to have more flexibility in how many cases they maintained and reoriented the focus to the type of services delivered. 

2. Community outreach workers reported that frequently they would receive requests for resources from members of the community while conducting outreach.  However, because providing resources was outside of their scope of practice. To address this, at the end of 2021 Public Health created a referral portal for those in the Outreach and Education network to connect clients with those in the System Navigation network.  This became even more important with the emergence of antigen at-home tests, which meant individuals who tested positive would not have access to system navigation resources because their tests were never processed though the county and referred to Equity Fund.  This has also provided an additional source of referrals to system navigators to moderate the fluctuation of referrals from community infection.  In the current iteration of Equity Fund other Public Health COVID-19 community investments also have access to the System Navigation Referral Portal.

3. Acknowledging that each CBO provides other services (i.e., health coverage enrollment), had unique language skills, and distinct expertise, Public Health created an Equity Fund resource dashboard which allowed CBOs to connect with each other.  This flexibility is critical to address linguistic needs. for instance, an organization that may encounter individuals who need support in a specific language they cannot accommodate, can now make a connection with another Equity Fund partner who can support that language.  Similarly, this has facilitated connections for specific services as a Medi-Cal enroller or a food bank site.

The nature of this practice was to be collaborative and leverage the experience and capacity of all partners. 

1. In the effort to serve communities with the most barriers to health access, Equity Fund partners with CBOs with the experience of these communities.  However, each has its own unique dimensions of vulnerability and barriers to healthcare access and quality. Many of the CBOs are often small and specialized and of limited capacity to administer a complex or demanding program.  This resulted in concerns about equity in the contracting process, particularly around rote County and Federal funding requirements.  Insurance coverage baselines, financial administration protocols, and background checks, all of which may be straightforward requirements for larger CBOs or CBOs with experience as county contractors, caused major hurdles for some CBO partners to execute and implement these contracts.  Equity Fund developed FAQs and fact sheets and provided trainings to help clarify these requirements. 

2. The Third-Party Administrator (TPA), Community Partners served as the organizational program manager, administering funds, and overseeing implementation of the program, and facilitating the connection between the Equity Fund team and CBO subcontractors.  With so many CBO subcontractors, constantly evolving landscape of COVID-19, and demanding contract requirements, Public Health quickly learned that the TPA needed capacity development and support.  To address these needs, the Equity Fund team developed templates and guides for financial administration, contract monitoring, protocols for addressing different kinds of subcontractor requests, and provided capacity training.  Although this contractor had served as a TPA before, given the differences and complexity of the Equity Fund model and the federal funding source, it was important to have directive training and develop tool & templates designed for the specific aspects of this program and contract was an important takeaway.

Equity Fund prioritized working in historically marginalized communities and geographies which were, by definition, some of the hardest to reach populations.  Therefore, having representative organizations who could inform the broader COVID-19 pandemic strategy was critical.  Public Health received important feedback from Equity Fund outreach workers relayed that messaging focused exclusively on vaccination, which had varying levels of community interest and support, missed opportunities to educate community on other safety measures such as masking, congregated outdoors, and social distancing, that could be used in addition to vaccination to promote community health.  A shift to harm reduction messaging reduced feelings of alienation and improved the trust necessary to improve community vaccination rates.   

The mechanisms involved in funding this work were one-time CDC grant funds.  In some ways these funds were flexible and could accommodate a variety of outreach practices, including 1) the production of an in-language animated video for mono-lingual communities with limited literacy, 2) driving a bus with an electronic billboard 3) pop up events in community spaces, 4) event tabling and 5) door knocking.  In other ways, the funding requirements were restrictive, particularly an embargo on expenses for promotional items or strict guidelines for incentives.  The importance of promotional items for an outreach campaign meant to change public perception and behavior cannot be overstated.  And the limitations on incentive items made them all but impossible to utilize.  As a result, CBOs leveraged other funding sources to purchase incentives, borrowed from other programs they offered, or connected with other County initiatives that had incentives to offer. 

Additionally, the documentation requirements for this funding source are extensive and to ensure compliance, both training and tools to support are necessary.  Through office hours, the team was able to gauge topics of interest and gaps in knowledge, allowing internal Public Health teams to create FAQs around most asked questions and discrepancies. Office hours also allowed for community health workers to share challenges regarding documentation and reporting mechanisms. Additional training and technological assistance was necessary to ensure performance was being properly documented, along with an understanding of the external CRM tracker tools being used for this work.

A cost benefit analysis was not one of the techniques Public Health utilized to evaluate this program.  The emergency context of the program and the priority communities meant that the Equity Fund invested disproportionately but not inequitably in an effort to make inroads in community health education and access to resources.  This ultimately reflects the value of Equity Fund in closing the gaps in health disparities by making great investments in impacted communities and populations.. 

CBOs stakeholders have expressed enthusiasm about continuing the program.  Other Public Health programs with more limited community networks have continued to approach Equity Fund with collaboration opportunities or public health messaging to disseminate.  Many of the Equity Fund CBO partners have diverse outreach and education funding sources that could be leveraged if there was a need to, however, this could only be done in a limited capacity.  Furthermore, they would not be able to carry on without additional Public Health supports like trainings and the CRM system for data collection. Additionally, Equity Fund CBO partners have now been well-trained in COVID-19 and DPH resources and that information may be incorporate into their other funded outreach activities focused on different community health issues.

Equity Fund is currently being sustained through additional federal funds to support outreach and system navigation networks of 43 CBOs.  Utilizing the resource dashboard allows the network to connect with each other directly, amplifying its reach and impact.  Furthermore, these CBOs have effectively facilitated bi-directional relationships between Public Health and communities and have become strong avenue of communication regarding critical public health issues.  Even if Equity Fund cannot be maintained in its current form, maintaining the roster of trained and experienced CBOs and supporting their collaboration remains a top priority for Public Health and its broader outreach goals. In this way, sustainability for Equity Fund beyond its current funding support looks like moving it into a key position in the DPH community outreach apparatus.  Public Health continues to explore options to sustain the program.