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How a shooting's aftermath changed a 3-health-system transportation project—and where they're going from here

January 30, 2018

    Each year, 260 babies die before their first birthday in St. Louis.

    "We lose what would be the equivalent of 15 classrooms of kindergartens every year in St. Louis from infant mortality," said Kendra Copanas, executive director for Generate Health, which works to improve birth outcomes and community health in the St. Louis area via education and advocacy. "It's particularly remarkable when you consider that St. Louis is also home to world class medical care and groundbreaking health research."

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    Generate Health has evolved over 20 years as a long-standing maternal and infant health consortium, and in 2015, they formed the FLOURISH St. Louis initiative—a focused strategy that allowed its broad coalition of community organizations, from health systems to nonprofits—to come together to tackle the complex problem of infant mortality. In 2017, FLOURISH partners spent months laying the groundwork for a collaborative, full-scale effort to address transportation issues that hinder access to medical care, healthy foods, employment, and social services for low-income mothers, particularly for women of color—all of which can lead to greater infant mortality.

    Then, just as they were ready to launch, the aftermath of a local tragedy forced them to shift perspective.

    The groundwork coalition members had laid

    Coalition members had been laying the groundwork for the initiative for months:

    • Vision for Children at Risk, a community-based organization, had facilitated parent-led groups over eight months to take action on community-identified priorities. Their first priority was transportation, a key concern that also surfaced over two years of FLOURISH community dialogues.

    • Three provider organizations—SSM Health, St. Louis Children's and Barnes Jewish Hospitals, and Mercy Hospital St. Louis—and the City of St. Louis Department of Health had agreed to commit data and data coordinators to unearthing the scope of transportation barriers, and for leaders to undergo trauma and implicit bias training.

    • Generate Health led the charge by convening coalition members, resulting in a $250,000 two-year grant through the BUILD Health Challenge to improve transportation access for pregnant women and new parents living in two contiguous zip codes with infant mortality rates more than three times the state average. (BUILD is a national award program funded by The Advisory Board Company and 11 other organizations designed to foster and expand meaningful partnerships among health systems, community-based organizations, local health departments, and other organizations to address upstream problems that influence residents' health).

    • Upon notice the BUILD award, FLOURISH engaged two strategists to work in tandem: one focused on community mobilization and one focused on systems and policy change. The community mobilization strategist recommended a trauma-responsive, relationship-based approach focused on trust-building and community empowerment.

    The aftermath of a police shooting forces a change in plans

    And then, controversy shook St. Louis: The acquittal of a former St. Louis police officer in the shooting death of a black resident sparked outrage and unrest reminiscent of the widespread protests that erupted only a few years prior in nearby Ferguson, Missouri, according to Copanas.

    The officer was acquitted on Sept. 16—the same week FLOURISH held the first major planning meeting for the BUILD project in the 63106 and 63107 ZIP codes, in which African Americans make up more than 90% of residents.

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    As a result, the FLOURISH St. Louis leaders decided they should take a step back to "acknowledge the pain, trauma, and pervasive injustices that were crushing their St. Louis community," said Teresa Wilke, the systems and policy strategist. "Though recognition of trauma and toxic stress were part of the BUILD project before the verdict, the shock of the protests forced us to slow down, listen and immediately respond to the outcry of our community."

    "Trust had been eroded in a lot of places," Wilke said. "That wasn't the fault of Generate Health or the hospitals, but that's where we were. So we needed to make it an even bigger priority to figure out how we could strengthen our existing connection points and foster trusting, lasting relationships between residents and local organizations, since that would be the only way to achieve lasting change."

    A community- and data-driven approach

    As a result, FLOURISH decided to refine its trauma and implicit bias training for providers, policymakers, and institutional leaders. It also elected to increase its focus on community engagement and training early on in the initiative, accelerating engagement of grassroots advocates and community voices to help co-create solutions and hold policy makers accountable. "This effort is an opportunity for people of consciousness, sincere about saving babies, to build relationships with communities they have not traditionally had them with," said Steve Parish, the community mobilization strategist. We are using BUILD to give FLOURISH a greater chance to authentically become the type of partner people most affected by historic disparities need.”

    Alongside fostering trust with the community, another early objective of the BUILD Health project has been to better answer a surprisingly complicated question: What do stakeholders mean when they say there are "transportation problems" that affect residents? To find out, the coalition is gathering and analyzing patient-level clinical data, community-level health data, and mobility resources and rider data for the project's two zip codes to pinpoint the areas of greatest need.

    FLOURISH coalition members are also working with managed care organizations to pilot innovative models of delivering non-emergency medical transportation, and they expect to develop a targeted health/transportation policy agenda to drive structural change. FLOURISH's ultimate goal is to influence transportation policy, health sector planning, and population health strategies.

    The BUILD Health Challenge project, Wilke said, has "helped build scaffolding between those with a real passion for system-level work and the singular expertise of community activists, and helped both groups realize that neither can really create structural, lasting change without the other." Added Parish, "We want Generate Health to rub elbows with those who have been overlooked and find out a bit of what it's like to live this 'data.' By learning through these ongoing community connections, FLOURISH partners can hopefully better assist families in understanding how to navigate and use new resources in different ways to change outcomes." 

    Wilke said leaders will need to be willing to take risks and engage in frank conversations. "When we hear from residents that a program or protocol isn't serving as intended, that can be uncomfortable. When we talk about race openly in discussing disparities in care and access to resources, that can be uncomfortable."

    But when areas of St. Louis have infant mortality rates higher than many developing countries, Copanas said, and when black residents are disproportionally affected, those conversations are essential to reducing infant mortality. "There are people who are understandably fed up with the way these interconnected systems are working," Copanas said. "St. Louis babies are dying, and for too long our local residents haven't felt like anyone was doing much about it. By having tough conversations and bringing together all this passion and expertise from the community, we can save lives."

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