What we're going to do now, is to walk through a couple of real-world examples of community engagement and CBPR that both Dr. [inaudible] and I have been involved with for the past few years. In thinking though, before we launch into the work that we've done, there are some things to consider about the timing of engaging the community. So we've talked about the fact that CBPR is really marked by an approach to engaging community members and other stakeholders in every phase. Whether it's the grant proposal phase where you're setting priorities for the actual study or the post-funding study development phase, where you as a group are developing the intervention and considering strategies to tailor the intervention to different populations bearing in mind the relevance of the intervention and cultural sensitivity to the actual conduct of the study itself, whether it is the intervention that is not a trial, or it is a randomized controlled trial. You're thinking about issues surrounding recruitment, data collection, and other pertinent factors that are apart of this phase. Again, when it comes to evaluating the results, and then thinking through sustainability of the intervention, and putting the results into action. The first example that we'd like to discuss is the Tumaini or Hope for Health Project, which was a community academic partnership that I had the privilege of being involved with. The Tumaini program was a joint partnership between Johns Hopkins Health System, Sisters Together and Reaching, and the Men and Families Center. Those two organizations are local organizations here in the East Baltimore area. When we think about why Tumaini was created, we must certainly consider the local, social, and environmental context under which this program came into being. So some factors that come into play in terms of the Tumaini program, is that first of all, there has historically been a poor relationship between the predominantly low income African American communities in East Baltimore, and the broader Johns Hopkins enterprise. Within these neighborhoods, there have been several assets. So there are certainly a number of community leaders, longstanding community members who have had a strong interest in sustaining the community and really trying to shepherd the community through different phases of wealth. Then now currently to some extent, some deterioration. So with that, these communities or the neighborhoods that are in the communities right outside of Hopkins, do have some unfortunate characteristics, concentrated poverty and deprivation, disparate health outcomes in comparison to more affluent communities that are merely miles away. But then again, as I said in terms of assets, there is a strong network of community-based organizations, community-placed resources, then partnerships and lifelong citizens. So these neighborhoods are closely located to Johns Hopkins Health System which has several different assets of its own, but unfortunately is fractured in many ways in terms of the delivery of health care. So the Tumaini (Hope) for Health program, was as I mentioned before, a collaborative effort between the partnering entities, Johns Hopkins Medicine, STAR and the Men and Families Center. What the program tried to do was to implement a multi-level community health worker program. So Sisters Together and Reaching had community health worker care managers, that were trained and employed by STAR, and then the Men and Families Center trained volunteers and oversaw their work, and their volunteers were called neighborhood navigators. Neighborhood navigators in a lot of ways are really akin to the lay health worker model where you have community members who live right in that community, that do not have formal training in medicine or social services, helping their other neighbors. It's like a neighborhood block captain. So the Tumaini catchment area was made up of three ZIP codes, all three of them being right outside of Hopkins; 21202, 21205, 21213. The Tumaini (Hope) for Health program aimed to reduce barriers to accessing healthcare and to facilitate the uptake of social and health services for residents of the Tumaini catchment area. The conceptual model that guided the Tumaini (Hope) for Health program, is displayed on this slide, and it is a series of circles, all connected to the patient at the very middle, and right outside of the patient is the family and social network. That was done intentionally to convey the notion that, the family and social network are just as important in thinking about the patient's care as the primary care provider, and then other members of the care team. In fact this conceptual model does display different facets of the patient's care team: the provider, behavioral health, social work, and then the neighborhood navigator, the community health worker and a registered nurse serving as the patient's case manager. The objectives of the project are listed next to this conceptual framework, and there were several objectives: to produce better health outcomes. To coordinate care and reduce cost. To find coverage options for the uninsured, which was primarily the tasks associated with the neighborhood navigators. To educate, empower, and activate patients for better health outcomes. Deliver culturally sensitive services. Reach the vulnerable, underserved, and/or isolated. Effectively tackle health disparities in part through the delivery of culturally sensitive services. Then finally, to link patients to community services and organizations. The Tumaini (Hope) for Health program was guided by several core implementation principles. The first was that, the project strove to use community-based, community-placed strategies to improve patient health and well-being. What this looked like in real life was that, the recruitment for the staff for the program, came from the community itself. So most of the community health workers and all of the neighborhood navigators, are residents or were residents of the Tumaini catchment area. Furthermore, there was community ownership and involvement. The Tumaini (Hope) for Health program, was actually created jointly by Reverend Debra Hickman at STAR and Mr. Leon Purnell at the Men and Families Center. They helped to spearhead the development of this project in consultation and partnership with their own staff and community members who solicit services at their organization. The other thing that guided the Tumaini (Hope) for Health program, was partnership for program infrastructure. So in thinking about CBPR and the idea of leveraging assets across partnering entities, what Johns Hopkins Health System brought to the table was; support for the equipment and supplies, documentation and information management, development of the referral systems to the Tumaini program, and then the development of linkages to Johns Hopkins Medicine staff at the clinics that were part of the Tumaini program. The clinics where their patients were receiving care. All the partnering entities were invested in providing strong supervision and oversight. Not only at a more corporate level with the organizations themselves, but also individual performance evaluation for the neighborhood navigators and community health workers. To that end, ongoing training provided by all three of the partnering organizations. So developing strong linkages to the health system, through frequent meetings with members of the Johns Hopkins Medicine Leadership Team, as well as rounding with providers at the clinics that Tumaini patients receive care at. Then finally, program performance monitoring and evaluation in order to identify emerging issues of quality, control, and then monitoring the program's effectiveness, in short-term and long-term objectives. So the Tumaini Hope for Health Neighborhood Navigators adopted a block-by-block approach for community organizing for health. They really served four primary roles. They helped with general neighborhood education and outreach, so that occurred neighborhood wide. They engaged in informal monitoring and surveillance of unmet needs, that were related to accessing health care and social services. They performed regular home visits in order to provide social support and promote engagement with care among a small caseload of high-risk patients. So patients who were frequent visitors to the emergency room, but also patients who had a number of social determinants of health that precluded their ability to successfully manage their conditions, which contributed to their over-use of emergency department services. Finally, the last major role that they played was, capacity-building and mobilizing through regular participation in and presentation to neighborhood association meetings. So the Men & Families Center actually used neighborhood association meetings as one way of recruiting neighborhood navigators to the program. As mentioned before, the Men & Families Center were tasked with training and overseeing the neighborhood navigators. The neighborhood navigators reside in specific neighborhoods within the Madison-East End community statistical areas. So that's in the 21205 ZIP code, which is right next to Hopkins. They were compensated through stipends that were based on living wage. The way that they documented their work was through a system developed by the Johns Hopkins Health System, which modified what they call their telewatch system and adapted it for use for the neighborhood navigators. The image that is displayed on this screen is courtesy of a Tumaini Hope for Health Program, and this is one of their training meetings where you can see in the corner on the right, Mr. Leon Purnell directing the training, and the people sitting in that image are the neighborhood navigators. Then the Tumaini Hope for Health community health worker case managers were trained and overseen by Sisters Together and Reaching. The CHW's efforts were actually focused primarily on Johns Hopkins Health System patients that resided in the Tumaini catchment area. This differed from the neighborhood navigators who are paragnostic. So the community health worker care managers were focused on assisting Medicaid and Medicare recipients. The neighborhood navigators assisted anyone who lived in their neighborhoods. With the CHWCM's, they also engaged in intensive ongoing community-based case management and they were overseen by the nurse case manager who was stationed at Star and a CHW supervisor. In a manner that was similar to the neighborhood navigators, the CHW's also resided in the East Baltimore neighborhoods where their patients lived, and they documented their work in a Tumaini case-management database system that was created jointly by Star and the Johns Hopkins Health System. In this slide, you'll see an image of the type of work that the CHW would be doing. So they would go to either the patient's homes, or to a local community space and support patients by meeting them there. So when we think about all of the different phases in which the community was engaged in the Tumaini Hope for Health Program, there were four main stages where that took place. The work that was a part of the Tumaini program was created by Reverend Hickman and Leon Purnell for a different funding mechanism that didn't end up coming to fruition, but got incorporated into a broader health system initiative underway at Hopkins. Where they came into play with this health system initiative, was post funding. They spearheaded developing the intervention and then tailoring it for the Tumaini catchment area residents, and also tailoring the community health worker, care management model as well as the work that the neighborhood navigators did. The work that they did in this tailoring helped to ensure that the interventions they deployed were relevant and culturally sensitive. They were also involved in the intervention phase. So the Tumaini Hope for Health Program was not a randomized controlled trial. It was part of a broader demonstration project that was funded by the Centers for Medicaid and Medicare. But where the community was engaged in the Tumaini program was recruiting the community health workers and neighborhood navigators and in the data collection process. They've also been involved in evaluating the results of the program and this evaluation is actually underway right now. So they have been involved in the data analysis evaluation, and manuscript preparation and submission. Then finally in terms of sustainability, talks about sustainability were initiated from the inception of the Tumaini Hope for Health Program and occurred with great frequency throughout the program because there was a concern and a commitment to making sure that the Tumaini interventions were sustained over time.