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A California County Focuses on Equity to Improve Community Health

An initiative in Orange County, Calif., is taking an innovative approach to reducing social determinants of poor health. Screenings are vital, but social and environmental factors set the stage for the problems they detect.

Health care is not the only factor influencing the well-being of people, families and communities. Others play a larger role.
(Equity in OC)
In Brief:
  • The pandemic highlighted the greater vulnerability of Americans with underlying health conditions.
  • To a great extent, these conditions are the result of social and environmental factors.
  • An initiative in Orange County, Calif., is using data, GIS mapping and community engagement to focus services on citizens most likely to experience health problems as result of these social determinants.

  • Over more than a decade in behavioral health services for the Orange County, Calif., Health Care Agency, Dr. Clayton Chau saw how hard it was for people in distress to get the care they need. As worried as he was about their mental problems, he knew they were more likely to be struck down by physical illness.

    The county has among the largest immigrant populations in the U.S., and Chau focused his work on vulnerable populations. When the Affordable Care Act passed, he made a move to the insurance industry to understand how decisions about care are made. Under a multiyear federal grant, he explored what it would take for physicians to embrace “whole person care,” integrating health care, behavioral health and social services.

    When COVID-19 emerged, the health department asked him to return. He was named director in May 2020, when his predecessor resigned in the face of protests and a death threat over a mask order.

    A partner came forward who shared his commitment to equity and evidence-based approaches. Data scientist Katie Kalvoda had left the world of finance to create a nonprofit, Advance OC, with a mission to close social and health disparities using data and technology innovation. COVID-19 created an unprecedented need and use case for its tools, and Chau became the nonprofit’s first client.

    The collaboration born during the pandemic continues with Equity in OC, an Orange County health department initiative using data and community engagement to address the social determinants of health (SDOH). Going beyond early detection of disease, it provides targeted services that foster population health and equity.
    COVID Vulnerability Map.png
    A COVID Vulnerability Map developed by an Orange County nonprofit, Advance OC, gives a picture of relative risk in neighborhoods in the county, drawing on both health and social progress indicators.
    (Advance OC, OC Health Department)

    Proof of Concept

    To guide COVID-19 response, Advance OC created a “COVID vulnerability” map using health and comorbidity risk factors from the Centers for Disease Control and Prevention (CDC) and the Social Progress Index (SPI), a peer-reviewed set of social and environmental factors that affect well-being. GIS maps showed neighborhoods that were most vulnerable to the virus. Dr. Chau acted preemptively and set up education, testing and vaccination sites in them.

    “At some point, the positivity rate in these vulnerable neighborhoods was even better than the overall county number,” says Chau. “The state was scratching its head, asking what the hell we were doing.”

    “When we realized that it was social determinants of health more than comorbidity risk factors that were determining the spread and the prevalence of COVID in Orange County, that was a point of no return,” says Kalvoda. Addressing them needed to be a core element in the county’s health-care policy and budgeting.

    A $22 million grant from the CDC brought resources to make it a reality. Orange County is the only entity in the country to use pandemic funding to remedy factors that caused underserved minority communities to suffer disproportionately.

    Chau was determined to create a program that would continue after CDC funds were gone and to foster a return on investment in terms of outcomes that made it an indispensable asset to the health department. He created a “collective impact” model, bringing together community organizations that provided health care and social services.

    He did more than ask for their help. Grants of $10,000 per year were offered to 100 community-based organizations (CBOs). Grants from a “power building fund” were established for groups with budgets under $500,000, the programs of which address social determinants of health. Small grants were offered to community members who had experienced health inequities and wanted to be part of the Equity in OC task force.

    Broadly defined, SDOH include specific social and economic factors related to an individual's place in society, such as income, education or employment. The Equity Map Kalvoda created tracks 50 social and environmental metrics, but Chau wanted to take them up bit by bit. “What we needed to do is get the community together and prioritize them based on the needs of the community,” Chau says. “We would tackle three to five at a time and put all our efforts into it.”

    The inaugural trio of determinants prioritized by community members were housing, food insecurity and access to health care.
    OC Theory of Change.png
    A Theory of Change underlies Orange County's efforts to decrease health inequity.
    (Equity in OC)

    From Nurse to Activist

    HERstory, a nonprofit established by Shamiesha Ebhotemen, is among the recipients of Equity in OC grants. As a Black woman and longtime registered nurse, Ebhotemen had seen health inequity firsthand. The subject became much more personal when she had her first child at an Orange County hospital in 2017.

    She’d been adamant with her nurse that she wanted to breastfeed, but after her daughter was born, the nurse told her she was busy, set down a bottle of formula and left the room with no further instructions. Forty-five minutes later, the nurse returned and reprimanded Ebhotemen for overfeeding.

    Before she left the hospital, Ebhotemen got the help she wanted from a patient lactation consultant. “That lit a fire under me to find out more about the profession,” she says.
    Shameisha Ebhotemen.jpg
    Shameisha Ebhotemen, a registered nurse, founded a nonprofit to address inequity in maternal care available to BIPOC women after being treated dismissively when she asked a hospital nurse for help with breastfeeding her newborn first child.
    (Shameisha Ebhotemen)
    She discovered consultants were scarce in the county and earned a lactation certification. She hadn’t worked in women’s health in her nursing career up to that point, and as she researched issues around birthing, she learned more and more about inequity in the care offered to BIPOC women. (The maternal mortality rate in the U.S. is three times greater than in other high-income countries, and the rate for Black women is almost three times that for white and Hispanic women.)

    HERstory is the first and only nonprofit in the county specifically focused on the needs of this population. The grant was a big boost to the nonprofit’s work, Ebhotemen says. HERstory now offers childbirth and lactation classes, and a pilot project is providing free doula services to 20 families. The organization has set building a birthing center as a long-term goal.

    “We want to make sure this program becomes a staple in Orange County, so when families of color get pregnant, they know they have access to a free doula and free services here,” says Ebhotemen.

    Better Lives, Not Fixed Costs

    Offering care only after the stresses of unhealthy living conditions cause disease to develop is expensive. When a diabetic patient’s kidney fails, the dialysis they need to stay alive becomes a fixed cost to the health-care system.
    Orange County Health Officer Clayton Chau: "Creating programs and then shutting them down when a grant is over is really cruel. You need to spend energy and resources supporting programs that show a strong outcome in the community."
    (Equity in OC)

    It would save money as well as lives to go upstream and identify communities that are at high risk, that have no healthy food but where liquor stores and fast-food restaurants are around every corner, Chau says. The health-care system will bear increased costs if they don’t invest more in education, prevention and early intervention, as will the insured.

    The nonprofit Institute for Healthcare Improvement (IHI) has assisted equity projects in several regions, including the work in Orange County. “As equity is becoming more and more at the center, we’re seeing a rise in requests to IHI for help with quality and systems improvement — equity-focused work is systems work and complex adaptive change work,” says Niñon Lewis, IHI’s vice president.

    Other California jurisdictions have contacted Advance OC about their own maps, and Kalvoda is open to helping projects outside the state. “This can be a hundred percent replicable,” she says. “We can give them our tools, the coding behind many of our tools, or even put them together remotely.”

    Chau doesn’t necessarily find it encouraging when he hears more people are qualifying for Medicaid. “That's a sad thing, because it speaks to the fact that our communities are getting poorer and poorer — we should celebrate when people no longer qualify for Medicaid because they are doing better socially and economically.”
    Carl Smith is a senior staff writer for Governing and covers a broad range of issues affecting states and localities. He can be reached at or on Twitter at @governingwriter.
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