Community + UCSF Mount Zion Awards

Mount Zion Health Fund

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Clinical and Educational Partnership to Improve Care for Children with Special Health-Care Needs

Submitted by Dylan Chan on October 13, 2022 - 9:36am Last revised by Dylan Chan on November 30, 2022 - 11:59pm.

Proposal Concept: Length = 1-2 page Status:

Open

In this project, UCSF Otolaryngology-Head and Neck Surgery and Primary-Care Pediatrics will partner with San Francisco Unified School District to develop a robust program to share information, communicate, and collaborate to improve coordinated care for children with special health-care needs.

Applicants

Dylan Chan, MD, PhD, FAAP, Associate Professor, UCSF Department of Otolaryngology-Head and Neck Surgery
Jennifer Albon, MD, MDev, FAAP, Clinical Assistant Professor, UCSF Pediatric Primary Care at Mt Zion
Jennifer Herges, Special Education Supervisor, San Francisco Unified School District

Contact information

Dylan Chan

2233 Post St., 3rd Floor

San Francisco, CA 94115

Dylan.chan@ucsf.edu

650-387-1765

Jennifer Albon

2330 Post St., Suite 320

San Francisco, CA 94115

jennifer.albon@ucsf.edu

415-493-860

Jennifer Herges

3045 Santiago St.

San Francisco, CA 94116

hergesj@sfusd.edu

831-320-5594

Project Overview:

Children with special health-care needs (SHCN), including those who are deaf or hard of hearing (D/HH), require care through both clinical and educational systems. In San Francisco, the majority of children with SHCN receive clinical care through UCSF and educational services through San Francisco Unified School District (SFUSD), the public school district for San Francisco City and County.

However, many systematic barriers exist to efficient, systematic, and equitable collaboration on shared children with SHCN. These barriers are a fundamental threat to the Medical Home model of pediatrics primary care. In this project, we will build on an existing UCSF/SFUSD partnership for children who are D/HH and, using this D/HH partnership as a model, establish a formal, sustainable system of cross-disciplinary care for children with SHCN shared by UCSF MZ Primary-Care Pediatrics and SFUSD.

List of goals:

To engage stakeholders to identify barriers to communication and information-sharing between educational and clinical providers and, using stakeholder input, develop specific pragmatic mechanisms to overcome them.
To establish a Memorandum of Understanding (MOU) between SFUSD and UCSF governing these mechanisms of data sharing, communication, and collaboration;
To implement these mechanisms for specific children whose care is shared between UCSF and SFUSD; and
To measure the impact of these mechanisms on healthcare outcomes.

Specific Aims:

Specific Aim 1: To engage stakeholders in SFUSD and UCSF to elicit specific barriers and opportunities for communication and collaboration on children with SHCNs

Specific Aim 2: To establish the mechanisms identified in Aim 1, complete an MOU between SFUSD and UCSF, and implement the mechanisms for defined populations of shared children.

Project Proposal:

Children with SHCN have their care managed across both clinical and educational systems. Both systems are critical to different aspects of care: clinical systems provide diagnosis and medical management; educational systems provide regular therapies and educational services. These different spheres of care are tightly entwined, with progress or concerns in one informing decisions in the other. However, there is no system of care coordination across clinical and educational settings. In fact, there are specific barriers to communication and collaboration. As a result, educational and clinical providers often struggle to share knowledge and collaborate on care for children with SHCN. This leads to delays in care, frustration for families, and inadequate care for children. Parents can bridge this gap and facilitate care coordination, but parents’ ability to do so is limited, especially for more vulnerable populations.

Through the UCSF Children’s Communication Center (CCC), we have engaged in an ad-hoc partnership for children who are D/HH with the SFUSD D/HH program for 8 years: activities have included:

UCSF/SFUSD D/HH provider care coordination meetings
UCSF CCC social worker participating in families’ Individualized Education Plan (IEP) and Individualized Family Service Plan (IFSP) meetings at SFUSD
SFUSD D/HH liaison participating in families’ clinical visits at UCSF

These activities have been successful in improving care for families that have received this coordination, but it has not been implemented in a systematic way.

In this project, we will use our experience with this ad-hoc partnership in D/HH kids to identify specific barriers to collaboration for these children and, more broadly, all children with SHCN, develop mechanisms to address these barriers, establish an MOU between SFUSD and UCSF to govern these mechanisms, and implement this inclusive system of communication and information sharing between SFUSD and UCSF for families of children with SHCNs served in both systems. We will use the D/HH population as an initial pilot group to establish processes that will support all children with SHCN. In this way, this process will yield a sustainable collaborative model that can persist even after the completion of this project.

To achieve Specific Aim 1, we will first identify stakeholders within UCSF and SFUSD who regularly work with children with SHCNs and need to communicate with providers outside their respective institutions. This includes, at UCSF: social workers in the Pediatrics and Otolaryngology/Audiology clinics (who regularly serve as liaisons on behalf of families for educational services); clinic staff (who manage communication and documentation); speech-language, physical, and occupational therapists (who have direct overlap with school-based services); and at SFUSD, early intervention providers (including teachers of the deaf and blind), administrators, nurses, and therapists at the district and school-site level. We will conduct structured interviews to elicit their perspectives on the barriers to facile communication on shared children and their “wish list” for strategies to make communication more effective and efficient. We will employ human-centered design (HCD) strategies to identify insights on the barriers experienced by the stakeholders. These insights will be developed into potential interventions, which will be considered and integrated with the specific interventions proposed by the stakeholders themselves.

In previous ad hoc discussions between UCSF CCC and SFUSD D/HH staff, proposed strategies have included 1) regular case-conference meetings on shared students; 2) simplification of the release-of-information (ROI) process; 3) clarification and dissemination of key personnel and contact information across institutions; and 4) providing families with tools to and empower them to manage their childrens’ care. We anticipate that expanding the scope of this stakeholder input and employing HCD strategies will yield a comprehensive and inclusive set of insights and, subsequently, actionable strategies. Through the Open Proposal platform, additional suggestions were made for creation of data-sharing portals, and universal or simplified forms.

For Specific Aim 2, a smaller, focused group of stakeholders from UCSF and SFUSD (including project leadership) will prioritize the proposed interventions in terms of 1) impact; 2) generalizability to children with SHCNs; 3) feasibility of implementation within SFUSD/UCSF systems; and 4) sustainability. We will use the PRISM (Practical Robust Implementation and Sustainability Model) and RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) frameworks to structure stakeholder input, identify organizational needs to achieve sustainable implementation and impact, and specify measurable outcomes to assess the success of these strategies. We anticipate that some strategies may encounter barriers to development and implementation, including low feasibility/sustainability potential (for example, strategies that require too much ongoing personnel commitment), or unsurmountable compliance barriers (such as free sharing of privileged/protected health or educational information across systems). Through an iterative process with stakeholders, which will include pilot testing and exploration of specific strategies with the D/HH population, we will ultimately produce a clearly defined set of mechanisms for collaboration that will then be formalized in an MOU between UCSF and SFUSD. Once this MOU is established, we will implement the collaborative plan for defined populations of children with SHCNs whose care is shared between UCSF and SFUSD. We will then measure implementation outcomes for this collaborative plan to assess whether the plan had the intended reach and impact. These outcomes will be specific to each strategy within the collaboration plan and will be defined using the output of the RE-AIM framework. These may include accomplishment of predefined goals and deliverables; repeat qualitative interviews with the initial broad pool of stakeholders and families impacted by these strategies; and quantification of the number of students impacted, quantity and quality of communication across institutions, and timing/delays in care such as establishment of IEPs (within SFUSD) and clinical appointments (within UCSF).

Our timeline for this project is as follows:

Year 1: Broad stakeholder interviews, identification of collaboration strategies for development, discussion, and pilot testing with D/HH programs.

Year 2: Focused stakeholder refinement of collaboration strategies, determination of the final set of collaborative mechanisms, and establishment of an MOU between UCSF and SFUSD

Year 3: Implementation of the collaborative plan and collection/analysis of implementation data.

Anticipated benefit for underserved or vulnerable communities in San Francisco

SFUSD and UCSF care for a highly vulnerable population of children in San Francisco. The UCSF Children’s Communication Center serves ~2,000 children, of which 69% are publicly insured (as a proxy for low-income); 38% are non-English-speaking at home; and 74% are racial/ethnic minorities. UCSF Primary Care Pediatrics serves ~15,000 children, of which 69% are non White/non-Hispanic ad 50% are publicly insured. The ~50,000 children in SFUSD are 53% socioeconomically disadvantaged; 27% English-language learners; and 86% non White/non-Hispanic. These vulnerable populations experience tremendous disparities in outcomes within both health and educational systems; when care is shared between these systems, particularly for children with SHCNs, complexity substantially increases for families and their communication challenges are amplified.

This project, which will build sustainable mechanisms to facilitate communication and collaboration between UCSF and SFUSD, will directly benefit these underserved and vulnerable populations. For example, if one of the project outcomes is to establish a regular series of case conference meetings between care providers in UCSF and SFUSD, the UCSF and SFUSD care teams for these children will more rapidly and effectively come to consensus about the child’s clinical and educational needs, leading directly to better care and clearer communication to the families. Furthermore, children who are lost to care in either system will immediately be brought to the system’s attention. These direct benefits will address two of the most significant challenges for families of children with SHCNs – integrating and reconciling (sometimes conflicting) plans from their clinical and educational teams; and delays or loss to follow-up care in either system. As another example, if we establish a more facile means of data sharing and universal release of information for families across UCSF and SFUSD, the significant barriers of requesting, obtaining, and disseminating information across clinical systems, which are often insurmountable for families with limited literacy, will be reduced. This will directly benefit these families in their ability to share information among their care teams at UCSF and SFUSD.

In our experience with ad hoc partnership between the UCSF CCC and SFUSD D/HH programs, with similar case conferences and other systematic collaborative efforts, families have repeatedly indicated to our social worker liaison these benefits – they have appreciated any direct and facilitated communication between their UCSF and SFUSD providers and assistance in re-establishing care.

How the project addresses UCSF Mount Zion priorities and compelling San Francisco healthcare needs

Children with SHCNs in San Francisco require closely coordinated care between their clinical and educational providers - this care coordination is a central tenet of the Medical Home model of Primary Care Pediatrics, according to the American Academy of Pediatrics - "an approach to providing comprehensive primary care that facilitates partnerships between patients, clinicians, medical staff, and families... that extends beyond the four walls of a clinical practice [to include[ specialty care, educational services, family support, and more." SFUSD and UCSF are the single largest providers of this care, and the most important non-clinical partnership that these children have. Because of the absence of structured care coordination between these institutions, however, many inefficiencies and gaps in care exist for these children, leading to poor health and developmental outcomes, a significant threat to the Medical Home model for children in San Francisco cared for at Mt Zion Primary Care Pediatrics. This project will close this gap, therefore addressing a critical and compelling San Francisco healthcare need and UCSF Mt Zion campus priority.

Type and duration of campus-community partnership

The existing partnership between the UCSF CCC and SFUSD D/HH programs has evolved over the past several years, with direct engagement in the form of care coordination conferences and UCSF/SFUSD personnel taking part in activities across institutions for the past 4 years. In this project, this partnership will expand to encompass UCSF MZ Primary Care Pediatrics and the broader system of care within SFUSD for children with SHCNs, including Home and Hospital and Special Education Services. The partnership will exist on multiple levels – project leadership includes both UCSF (Drs. Chan and Albon) and SFUSD (Ms. Herges) personnel, and the core project personnel (administrative support at both UCSF and SFUSD, and providers (social work, nursing, and therapist)) will be cross-institutional. Ultimately, the project will generate an MOU between UCSF and SFUSD covering the communication and collaboration plan which will govern the partnership. Though the active phase of the partnership, as described in this proposal, will last the duration of the project (three years), the MOU established will sustain the partnership after completion of the project.

How the community partner’s experience and expertise was integrated into proposal development

This proposal grew out of the existing partnership between the UCSF CCC and SFUSD D/HH programs. Through multiple partnership meetings, SFUSD staff, including district administrators, teachers of the deaf, speech-language pathologists, Early Start home- and center-based providers, and classroom teachers provided feedback on barriers to communication and collaboration with UCSF. These barriers, in many instances, were shared by UCSF staff and families. Ms. Herges, the SFUSD lead for this project, has worked as an administrator for D/HH services at SFUSD and has collaborated with the UCSF CCC team for 4 years, especially with Silvia Bellfort-Salinas, UCSF CCC social worker; over this time, Ms. Herges has heard this feedback from SFUSD personnel and integrated these experiences with her direct observations. This SFUSD stakeholder input illustrated the critical need for development of better systems for communication and collaboration as described broadly in this proposal, as well as specific examples of collaboration mechanisms (care conferences, personnel/contact lists, data-sharing agreements) that could be considered.

Subsequently, through pre-proposal development and the Open Proposal process, additional SFUSD stakeholder input has been solicited to expand the scope of the project to support all children with SHCNs. Ms. Herges, as head of the Home and Hospital program within SFUSD, brings additional experience and expertise on the educational needs of children with significant medical complexity; district and site nurses were engaged to understand the different populations of children and levels of collaboration to consider; and Jean Robertson, head of Special Education at SFUSD, has provided support and additional high-level insight into feasibility and operational needs of the project. This input has yielded several critical refinements to the project, including highlighting the importance of:

1) Engaging a broad set of stakeholders in SFUSD at both district and site levels for initial identification of barriers and priorities for collaboration

2) Considering different populations of children to target and support

3) Budgetary needs within SFUSD to achieve project goals

This project is designed as a true partnership between UCSF and SFUSD; engagement of a broad set of stakeholders within SFUSD will be critical for the ongoing development and conduct of this project.

Roles of UCSF and Community Partner: UCSF provides clinical care for children with SHCN, including those who are D/HH. For example, for D/HH children, audiologists make the initial diagnosis of hearing loss, monitor hearing, and manage hearing devices (hearing aids and cochlear implants). Speech-language pathologists perform therapy and evaluations for speech/language development in some children. Otolaryngologists manage the medical aspects of hearing. A social worker serves as a liaison for the family as they engage with the educational system. SFUSD, the community partner, provides therapy (PT, OT, speech/language) and educational care for children with SHCN. For example, for D/HH children, classroom teachers, specialized teachers of the deaf, and speech-language pathologists provide services as often as daily for children to support their developmental and educational needs. These providersparticipate with administrators and educational audiologists to work with families to develop Individualized Education Plans or other related frameworks to support the child’s needs. For children with SHCN they have other arrays of multidisciplinary care in the medical and educational system.

In this project, UCSF staff will be engaged in improving communication and collaboration with educational providers at SFUSD. This will occur in three phases – stakeholder engagement and interviews; development of collaboration mechanisms; and implementation and analysis. The UCSF/SFUSD partnership Program Coordinator, together with a counterpart in SFUSD, will coordinate these tasks, with clinical and educational providers serving in two principal roles: 1) a broad and representative set of stakeholders will be engaged to share their perspectives on needs and potential solutions; 2) a smaller core group of stakeholders (provided funding through this project) will serve as a working group to define and implement the collaboration plan.

Project leaders

UCSF

Dylan Chan – Associate Professor, Otolaryngology-Head and Neck Surgery and Director, Children’s Communication Center (CCC)
Jennifer Albon, Clinical Assistant Professor, Pediatrics Primary Care at MZ

Dr. Chan developed the multidisciplinary clinical care program and initial SFUSD partnership for children who are D/HH, which will serve as the initial model for this project. Dr. Albon is a primary-care pediatrician focusing on children with SHCN, who will direct the expansion of this D/HH-focused model to encompass children with SHCN cared for at MZ Primary Care Pediatrics.

There are four key personnel that have specifically been engaged already in a UCSF/SFUSD partnership – UCSF-based social workers (Silvia Bellfort-Salinas (OHNS) and Kristin Flores and Alina Woolford (Pediatrics)); a UCSF-based program coordinator (Jenny Stephans); and an SFUSD-based educational liaison (Jennifer Herges).

These individuals have collaborated ad-hoc to improve communication and collaboration on joint UCSF/SFUSD children. Dr. Chan has also successfully taken a MZHF-funded collaborative project with SFUSD — development of classroom lessons on hearing and noise, taught by UCSF staff in SFUSD 4th-grade classrooms — through this process of program development, MOU establishment with SFUSD, and sustainability after MZHF grant completion.

SFUSD

Jennifer Herges – Special Education Supervisor

Ms. Herges is the special education administrator directing care for all children who are D/HH in SFUSD. She also heads the Home and Hospital program within SFUSD which provides instruction to the most medically fragile children with a variety of conditions. A D/HH individual herself, she has collaborated with Dr. Chan and the CCC for 5 years. She has participated in clinical visits with SFUSD families, served as a liaison with our CCC social worker to discuss specific SFUSD/UCSF cases, and led the SFUSD D/HH team during joint SFUSD/UCSF care conferences. She is ideally positioned in SFUSD to understand and address the barriers to communication and facilitate systems-level changes at SFUSD.

MZHF values

This project embodies the six MZHF values:

Service: This project will directly provide a service to children with SHCN and their families, by facilitating direct collaboration between their clinical and educational providers.
Social justice: By developing a systematic way to support all children with SHCN, we will directly address inequities in healthcare in SF.
Community building: By establishing a regular and facile means of communication and collaboration between SFUSD and UCSF providers, we will build relationships among this community of pediatric healthcare professionals.
Education and Leadership: By facilitating this transfer of information across professional settings, we will provide critical cross-disciplinary education.
Innovation: Direct collaboration across educational and clinical systems is rarely performed, and a major gap in pediatric healthcare. This project seeks to establish a novel system to bridge this gap.
Compassion: Families of children who with SHCN often articulate that a significant challenge is how to navigate the multiple systems of their child’s care. This program addresses this need with compassion and empathy.

Project start date and duration

Start date: March 1, 2023
End date: February 28, 2026

Supporting Documents:

Letter of Institutional Support from Jean Robertson, Chief of Special Education at SFUSD

Poetic Medicine for Health, Dignity & Social Justice

Submitted by Michael Rabow on October 18, 2022 - 2:50pm Last revised by Michael Rabow on November 30, 2022 - 1:13pm.

Proposal Concept: Length = 1-2 page Status:

Open

In the setting of a toxic mix of pressing healthcare needs, poverty, and structural social injustice, the UCSF/Mount Zion MERI Center for Education in Palliative Care and Glide Memorial Church will collaborate to build, operate, and sustain a Poetic Medicine program to promote health and dignity for members of the San Francisco Tenderloin Community, to foster resiliency for the Glide volunteers, congregants, and staff who serve this community, as well as to encourage interest and compassion among UCSF pre-professional learners for working with BIPOC communities.

Poetic Medicine for Health, Dignity & Social Justice

Applicant/s name; title; UCSF Mount Zion academic affiliation; Community Partner affiliation (if applicable)

Michael Rabow, MD, Director of the UCSF/Mount Zion MERI Center for Palliative Care Education

Marvin White, MDiv, Director of Celebration, Glide Memorial Church / GLIDE Foundation

Contact information: address, email, phone

Michael Rabow, MD

The UCSF/Mount Zion MERI Center

1545 Divisadero St, 4^th Floor

San Francisco, CA 94115

415-215-4904

Project Title

Poetic Medicine for Health, Dignity & Social Justice

Brief Project Description (including the following elements):

One Sentence Project Summary

Development of the MERI Mission

The MERI Center launched as a Mount Zion Health Fund-supported program at UCSF in July of 2018 to promote “primary palliative care” education for UCSF/Mount Zion healthcare providers across a range of specialty areas so they could better care for their patients facing serious illness and the end of life. Over the subsequent years, as a result of the distress, losses, and re-evaluation of priorities due to the COVID pandemic and the truth of the Black Lives Matter and other social justice movements, MERI has adapted and grown to focus on “universal palliative care” education for all people, beyond just healthcare workers. Our target audience is expanding to include more diverse communities and our mission is enhanced to include explicitly the principles of equity, inclusion, and anti-oppression. Notably, our educational offerings now include a focus on the utilization of the Humanities, specifically the burgeoning field of “Poetic Medicine.”

List of Goals

(1) Develop a sustainable Poetic Medicine program as a collaboration between the UCSF/Mount Zion MERI Center and Glide Memorial Church, serving Glide’s underserved BIPOC population living in the San Francisco Tenderloin community

(2) Promote health equity in the provision of palliative care via Poetic Medicine with a social justice focus

(3) Promote resiliency among providers, staff, congregants, and volunteers at Glide Church via Poetic Medicine with a “Wounded Healer” focus

(4) Promote the dignity of self-expression and the normalization of the varied and personal reactions to loss via public dissemination of poetry created, including payment to the published/presented poets

(5) Create training opportunities for UCSF learners (students, residents, fellows) to improve their facility with and commitment to engage in service to marginalized communities

(6) Further the development of the academic field of Poetic Medicine, building on MERI’s co-authorship of the seminal paper “Poetry as a Healing Modality in Medicine: Current State and Common Structures for Implementation and Research,”published in 2022 in the Journal of Pain and Symptom Management.

Specific Aims

Specific Aim 1: to have Glide and MERI collaborate on a customized, sustainable series of Poetic Medicine programs for Glide’s SF Tenderloin BIPOC clients, their families, and staff/volunteers/congregants, as well as for UCSF pre-professional learners.

Specific Aim 2: to generate testable hypotheses, via participant observations, on the benefits to BIPOC participants and to health pre-professional learners of engaging with Poetic Medicine and specifically what is “healing” about Poetic Medicine.

Details of Poetic Medicine Sessions

Current MERI Poetic Medicine sessions have been extremely well-received, with more than 4100 non-unique participants from around the world over the last three years. MERI Poetic Medicine sessions follow a shared pedagogical outline, including poem reading (2 poems/session), a writing prompt, a 5-minute poem write, and participant poem reading & reflection. Evaluation (detailed in the JPSM paper) shows the sessions to be extremely valuable to participants. In the current Open Proposals submission, one former participant described it as “transformational.”

For the proposed project, MERI and Glide will develop customized Poetic Medicine Sessions to serve three core communities within Glide: the Poetic Medicine Street Intervention, Poetic Medicine for Congregational Life Groups, and Poetic Medicine for other Glide Groups (e.g. Glide’s yoga class). Across these three arms, Poetic Medicine will be available to Glide Clients, Care-partners (families and friends), Staff/Volunteers/Congregants, and Pre-professional UCSF Learners. The Poetic Medicine sessions will be developed serially over the course of project Years 1 and 2, and run through Year 3 of the project.

With the guidance of the Glide Poetic Medicine Resident (see below), the creation of each session will be launched with an initial needs assessment/community exploration to understand how stories are currently being told in the community and how people in the community want to be trained. We will start with the creation of a new Poetic Medicine for Congregational Life Group of congregants. Ultimately, each session will be developed with a specific plan for each of the following design elements: facilitators, marketing, group size, frequency of sessions, session duration, session location, session format, and evaluation strategy (see below). Notably, given that many participants may be unhoused and given the possibility of additional COVID lock-downs, the Poetic Medicine sessions will utilize both in-person attendance and video meeting technology.

Facilitators will be a team comprised of an experienced poetic medicine facilitator (White, Keyssar, or Rabow) working with the newly-established, annual “Glide Poetic Medicine Resident” (also known as the “Glide Poet-in-Residence”). The Glide Poetic Medicine Resident will be hired from the local community, paid a living wage for their work, and serve for a year each as a core collaborator and leader for the further visualization and implementation of this project. A Poetic Medicine Resident will be selected annually for each year of the project. Poems and prompts will be selected by the facilitator pairs and will typically include particular themes customized for the relevant session (e.g. hope, resiliency, wounded healer).

Session poems as well as poetic prompt selection will be directed to serve the participant community and session goals, and might include prompts such as:

-What is a poem that you would want to write?

-What do you wish you had said during a difficult personal or health care interaction?

-What would you have like to have been said to you?

-What does healing sound like, read like, or look like to you?

-Do you feel like you have been fully heard or listened to?

A Community Advisory Group (comprised of volunteers from prior MERI Poetic Medicine Groups and from Glide Memorial Church) will assist in the development and implementation of the Poetic Medicine Sessions. Of note, one of the commentators in the Open Proposal system has already volunteered to be a part of this group.

Details of Poetry Dissemination

Participants will be invited to share their work (a public extension of the safe space and powerful experience of self-disclosure from the inidividual Poetic Medicine groups). During year 1, professional session facilitators will work with the Poetic Medicine Resident to decide on how poems may be documented and distributed in the community, and at what frequency. Based on MERI, Glide, and Open Proposal feedback, possible dissemination strategies include:

-Publication of a printed book

-Filming of a documentary video

-Dissemination via the internet (i.e. digital exhibition) or social media (e.g. Instagram, You Tube)

-Public performance (poetry reading and slam)

-Posters, post cards, banners for the community

Key to all of these strategies is being respectful of the personal elements of this poetry and promoting dignity of authors by including them in the selection of the dissemination strategy and by fairly compensating them for their creative work. Of note, additional funding will be sought for strategies not possible with the currently submitted grant funds.

Evaluation, Dissemination, & Sustainability

Accomplishment of the project goals and specific aims will be addressed by a rigorous evaluation and research effort, directed by Dr. Rabow. Both quantitative and qualitative methods will be used to evaluate the project outcomes and will include assessing for program feasibility & accessibility (Specific Aim 1), program impact (Specific Aims 1 & 2), and mechanism of program impact (Specific Aim 2).

(1) Feasibility and accessibility will be determined for each of the Poetic Medicine courses based on attendance and narrative feedback from participants.

(2) Program impact will be measured using pre/post session evaluation and will include:

For all participants

-Being Seen & Heard

-Comfort & Emotional Safety

-Grief & Bereavement

-Empathy & Compassion

-Resiliency & Burn-out

For pre-professional learners

-Professional development including:

-Commitment to BIPOC population

-Clinical skills used

-Skills learned also used elsewhere in training

Quantitative evaluation tools for the above outcomes will be used, including well-accepted, brief, validated instruments, including the “Maslach Burnout Inventory” and the “Seen & Heard” evaluation survey (see also References in the Supplementary Materials submitted).

(3) Dr. Rabow will supervise pre-professional UCSF learner participation in further formal research analysis, including the development of a qualitative interview guide, the interviews themselves, and formal analysis/write-up. Free response survey and qualitative interviews of participants, facilitators, and learners will generate hypotheses to explore the research questions addressing Specific Aim 2: “How does Poetic Medicine promote resiliency” and “How does Poetic Medicine heal?”

Dissemination of program findings will occur via presentation at national conferences (including the American Association of Hospice and Palliative Medicine Annual Meeting and their palliative care safety-net interest group) and publication in peer reviewed journals (including a follow-up article from our original in the Journal of Pain & Symptom Management).

Evaluation results will determine next steps for the program, including which innovations should be continued and the most effective strategies for public dissemination of the products of the Poetic Medicine sessions. Ultimately, sustainability of the Poetic Medicine program after the MZHF Community grant project period ends will be developed during Year 3 of the project period and will be achieved via a combination of: (1) incorporating the Poetic Medicine program administrative responsibilities into existing Glide structures (e.g. the Congregational Life program); (2) developing an ongoing train-the-trainer session for community facilitators (i.e. future Poetic Medicine Residents); and (3) building a philanthropic fund to support both community facilitators and the poetry dissemination project elements. These funds may include contributions both from Glide as well as from MERI supporters.

Summary of healthcare-related needs being addressed

In prior, foundational work supported by the Mount Zion Health Fund, the UCSF/Mount Zion MERI Center has made more than 4100 Poetic Medicine contacts with participants from around the world. Based on the MERI Center’s 3-year experience helping to develop the field of Poetic Medicine and Glide Church’s remarkable 50-year history of work in social services and social justice and its experience as a “Writer’s Church,” the “Poetic Medicine for Health, Dignity & Social Justice” program will address three core healthcare-related needs.

(1) People living in the Tenderloin Community face illnesses created and/or exacerbated by social determinants of health. Palliative care is focused on supporting patients to live as well as possible in the setting of serious illness. However, the primarily BIPOC community in the Tenderloin is underserved by palliative care expertise and access to services. As one Open Proposals commentor wrote: “We desperately need more models of intervention for palliative and end-of-life care that address the needs of people experiencing homelessness and their families.”

As an instrument for palliation in the face of suffering, Poetic Medicine serves patients facing illness by promoting recognition, processing and integration of the diagnosis of serious illness and its implications, including the prospect of loss of function, suffering, and death. Patients dealing with illness who have participated in MERI’s existing Poetic Medicine programs and published their work in its anthologies have reported amazing value from the processing and community promoted in Poetic Medicine sessions. One participant remarked: “Our poetry hour has grown on the zoom squares into a safe and sacred space. Writing poetry through 2 years now of being part of the poetic medicine community is the discovery of our own stories, sharing them and having them received so lovingly. Many of us began not believing we were poets. Perhaps one of the most important things poetic medicine delivers is the discovery that we all have the power to heal through creative arts.” Participants have learned how to listen carefully and connect with others who are suffering, and through this process of listening and connecting, to heal their own pain and suffering.

(2) Family and Friends of those facing illness in the Tenderloin are underserved with regard to support for sustainable caregiving and grief around loss, including complicated grief in the setting of sudden or potentially preventable death. Poetic Medicine includes a focus on loss and grief, promoting healthy bereavement in the context of self-expression and a supportive community. Participants from MERI’s current Poetic Medicine “Loss, Losing, and Loosening” sessions have reported Poetic Medicine to be among the most helpful bereavement resources they have encountered. One commented: “I know that my healing through grieving the loss of my wife was made hopeful and productive because of our fabulous Loss, Losing and Loosening gathering every Tuesday.”

(3) Caregivers: In the setting of the desperate health and social challenges in the Tenderloin community, Volunteers, Congregants, and Staff at Glide face significant threats to their well-being and resiliency, including compassion fatigue, vicarious trauma, and burnout. Current participants from MERI’s Poetic Medicine “Wounded Healer” sessions have reported on the unique benefits of Poetic Medicine to explore the demands and promise of caregiving. One concluded: “Connecting with like-minded Souls "lights up my Life and gives me Hope to carry on" as the song goes.”

In addition, UCSF nursing and medicine learners currently are inadequately exposed to the unique challenges of promoting health among marginalized populations and can potentially graduate from UCSF’s programs with an unrealistic understanding of the needs and opportunities of service in marginalized communities. These UCSF learners (including Zion-based housestaff in General Medicine, Women’s Health, Pediatrics, Radiation Oncology, Neurology, Dermatology, and Otolaryngology) will be able to join the MERI/Glide Poetic Medicine program as participants or facilitator trainees. Importantly, Glide clients may be learning a clinical language for stress and illness; UCSF learners will be learning a poetic language for their clinical work. As one Open Proposals commentator wrote: “I think poetry is the language that sits smack dab in the middle of the vernacular and the clinical. We can meet there and speak in poetics. We can believe that every who meets there in that middle language, is trying to express something beautiful.”

Collaboration between Glide Memorial Church and MERI

The proposed MERI/Glide Poetic Medicine program represents a deepening of existing efforts and collaboration between MERI and Glide. The proposed Poetic Medicine project will further the developing medical services programming at Glide, including a current focus on end-of-life care case management. The proposed MERI/Glide collaboration will add to MERI’s current collaboration with Glide (partially funded by the Stupski Foundation) to support improved communication around serious illness for Glide clients, staff, volunteers, and congregants.

Both Glide and MERI have histories of Poetic Medicine dating from their respective creations as organizations and including the belief that poetry is one way individuals can heal and a community can come together. MERI has become a leader in Poetic Medicine in the health care environment and within academic medicine. Glide’s Marvin White is a well-known poet and has brought poetry to Glide’s congregants. Glide’s founder, Janice Mirikitani, created the “Writer’s Church” with a focus on writing and storytelling as revolutionary tools. With the current proposal, Glide and MERI will be collaborating to achieve Janice’s vision to not leave anyone out of poetry.

As one Open Proposals commentator wrote: “It's super-exciting to think about how GLIDE and UCSF might harness and channel their respective superpowers in this project.” As another wrote: “I couldn't think of a more GLIDE initiative! Especially now that GLIDE Memorial Church is a writer's church and the Minster is a poet. Serving our community in this way is aligned with GLIDE's core values on every level.”

MERI and Glide have already begun work with each other, with MERI serving Glide as a consultant in a palliative care services navigation project funded by the Stupski Foundation. We have continued this collaboration with the conception and development of this proposed and submitted Poetic Medicine project. Members from both the Glide Community and the UCSF Division of Palliative Medicine have actively participated in this proposal development via comments and suggestions on the Open Proposals platform. Importantly, the Poetic Medicine format will be customized for specific communities at Glide in their development and operationalization. Adapting Poetic Medicine for participants who are unhoused will be a particularly challenging but central piece of this project and will rely on the experience and creativity of Glide’s leadership and the Poetic Medicine Resident.

MERI and Glide staff will work together on nearly all aspects of the Poetic Medicine program, including co-facilitating Poetic Medicine sessions, co-training the Poetic Medicine Resident to serve as the session co-facilitator, and seeking ongoing funding to sustain the program. MERI and Glide will work together to integrate Poetic Medicine services with the emerging medical services and advocacy currently being developed at Glide (as above, with MERI’s consultation and technical assistance). The formal collaboration between Glide and MERI will continue throughout the project period and is expected to then continue in an ongoing fashion.

Glide will take the lead in structuring community participation in the Poetic Medicine programs, including with logistics and advertising. MERI will take the lead in training facilitators around Poetic Medicine principles and facilitation techniques and will be responsible for program evaluation and quality improvement efforts. Understanding the feasibility and disseminating the impacts of a Poetic Medicine program for social justice is central to the goals of our program.

Name(s), title(s), agency/department/division(s) of individuals who will lead the project, with brief background information relevant to ability to accomplish the project activities

Marvin K. White, MDiv, is the Minister of Celebration at Glide Church and the energy behind much of Glide’s social justice and advocacy work. He is a writer, artist, preacher and public theologian. He is the author of four collections of poetry and his poetry has been adapted for stage and screen. He holds a fellowship in the national African-American poetry organization, Cave Canem, and founded and sat on the board of two BIPOC and LGBTQ writer’s organizations: Fire & Ink and B/GLAM. In 2019, Yerba Buena Center for the Arts named him as one of the “YBCA 100”.

Redwing Keyssar, RN, is MERI’s Director of Patient and Family Education and the co-lead of MERI’s 3 current Poetic Medicine offerings. She is a published poet and palliative care author. Redwing was a driving force behind the development and publishing of the academic paper on Poetic Medicine published in 2022.

Gayle Kojimoto is the coordinator of the MERI Center, co-lead of MERI’s current Poetic Medicine offerings, co-Chairperson of the DEI Committee in the UCSF Division of Palliative Medicine, and a poet herself.

Michael Rabow, MD, is the founding Director of the MERI Center, Medical Director of Palliative Care at the Helen Diller Family Comprehensive Cancer Center at UCSF, Associate Chief of Education in the UCSF Division of Palliative Medicine, and an award-winning poet (https://med.stanford.edu/medicineandthemuse/events/paul-kalanithi-essay-contest.html). Mike was the senior author on the Poetic Medicine academic paper. He is fellowship-trained in education research and evaluation.

Note which of the six MZHF values the project embodies

The UCSF/Mount Zion MERI Center was founded in 2018 as an instrumental part of the history and values of the Mount Zion campus. The MERI Center works with the clinical programs at Mount Zion and its office is located on the Zion campus, within the offices of the Division of General Internal Medicine. The proposed MERI/Glide Poetic Medicine program embodies the Jewish values at the core of the Mount Zion Health Fund and updates the history of how these values are manifest at UCSF and in San Francisco.

• The MERI/Glide Poetic Medicine program is about service (Avodah) as it is structured to support Glide volunteers and staff, as well as UCSF learners, in sustainable service to the Tenderloin community, specifically geared to address patient and family healthcare needs, including adjustment to illness, identification of needs, and the processing of potentially life-threatening illness and its associated grief.

• The MERI/Glide Poetic Medicine program is being proposed to promote social justice (Tikkun Olam) in providing service to members of an under-served community in the middle of a city full of world-class medical institutions often unavailable to our neighbors.

• The MERI/Glide Poetic Medicine program seeks to help build community (Kehilah) within the Tenderloin district itself, bringing together community members in a safe setting of disclosure and self-expression, as well as to deepen the historic connections between Glide and UCSF.

• The MERI/Glide Poetic Medicine program will engage UCSF learners (students, housestaff, and fellows) as participants or facilitator trainees, exposing these learners to the complexity, truth, collegiality, and unique opportunities of healthcare practice in under-served communities (Limud u’Manhigut).

• The MERI/Glide Poetic Medicine program is innovative (Hidush), building on the nascent field of Poetic Medicine and customizing it for a BIPOC, vulnerable, and under-served community. Understanding and promoting the learnings from this program is key to the success of this project

• The MERI/Glide Poetic Medicine program is founded on the principle of compassion (Rahamin) with the intent to promote the dignity of those facing illness in the harshest of economic and social situations.

Project start date and duration (earliest start date is December 1, 2022)

Start date 7/1/23 (This is the day after the completion of foundational funding for the UCSF/Mount Zion MERI Center by the MZHF Harris M. Fishbon, MD, Fund).

Duration: 3 years (Project period 7/1/23 – 6/30/26).

Total budget required and the amount requested from MZHF

Amount requested from the MZHF: $150,000/year for 3 years (to be shared between MERI and Glide).

Total budget: $150,000/year for 3 years.

Please see attached budgets and budget justifications for both MERI and Glide (including additional financial information from Glide).

Supporting Documents:

References, Boards, and Poems

Building and Sustaining Community Partnerships to Advance Integrative Health Equity

Submitted by Maria Chao on October 20, 2022 - 3:34pm Last revised by Maria Chao on November 30, 2022 - 3:41pm.

Proposal Concept: Length = 1-2 page Status:

Open

Background

Integrative health equity (IHE) is defined as optimal health for all through a whole person approach that explicitly recognizes cultural, social, and structural determinants of health across the life course. Integrative health equity is a unique, innovative approach to addressing unmet health needs. The UCSF Osher Center for Integrative Health (OCIH) has partnered with numerous community organizations on IHE projects, with support from MZHF. Through community-academic partnerships, we developed and tested strategies for integrative health equity by (1) creating interventions that are socio-culturally tailored for historically marginalized populations and (2) increasing access to integrative healthcare (e.g., acupuncture, mindfulness) in safety-net and community-based settings. These projects have demonstrated positive impacts of integrative healthcare for the management of pain, stress, and chronic conditions in marginalized populations. We see these experiences reflected in the work of colleagues around the country who are working towards IHE through clinical practice and innovative research.

Community engagement is recognized as a critical element for improving health outcomes in historically marginalized populations and reducing healthcare inequalities (O’Mara-Eves et al., 2015). Our prior community partnerships combined IHE and community engagement strategies to address significant public health needs among vulnerable populations in San Francisco (e.g., diabetes self-management in Cantonese-speaking elders; psychosocial needs of low-income individuals with complex chronic conditions; and undertreated chronic pain in diverse safety-net primary care patients). After nearly three years of the COVID-19 pandemic, the needs of these communities have in many cases been intensified by socio-structural factors including racism, social isolation, and delayed medical care. Despite the success of these projects, sustaining integrative healthcare programs beyond grant funding periods has been challenging, limiting the longer-term impacts of our partnerships. Supporting ongoing partnerships by sustaining and expanding them is critical for advancing health equity beyond incremental progress. Centering MZHF values of Innovation (Hidush), Service (Avodah), and Community Building (Kehilah), we will develop a scalable and sustainable infrastructure that fundamentally shifts the way we partner. by moving away from transactional research-driven projects to a relational, mutual process centering community needs.

List of Goals

The overarching goal of our current proposal is to build structures and processes to support sustainable community-academic partnerships for integrative health equity. Throughout the project we aim to foster high levels of community engagement by centering the voices of individuals with lived experience, planning in ways that are community driven, and prioritizing the relationships between collaborators. The proposed project will develop long-term work towards integrative health equity at OCIH on the Mt Zion campus in collaborative partnership with community-based organizations to make integrative healthcare a core element of accessible, culturally responsive care. Our proposal draws on principles of community-based participatory research as well as recommendations from the UCSF study of Accelerating Systematic Stakeholder Patient and Institution Research Engagement (ASPIRE). This proposal is part of a broader Osher Center Integrative Health Equity Initiative, aimed at creating sustainable structural change and being a national model. We aim to support existing community-academic partnerships while creating infrastructure that will demonstrate long-term commitment to this approach.

Specific Aims

Towards this goal, the current proposal aims to:

(1) Build capacity for three community-academic partnerships to advance integrative health equity in San Francisco. We will do this by embedding integrative health services into existing programming at On Lok and the Shanti Project, providing integrative medicine training to biomedical clinicians (e.g., family medicine residents) through San Francisco Health Network, and providing community-engaged learning to integrative health trainees.

(2) Create mechanisms for ongoing feedback from and accountability to community partners of the Osher Center. We will establish an Osher Center Community Advisory Board (CAB) that includes staff member and patient representatives from four partner organizations. This CAB will meet quarterly with Osher Center leadership to advise on IHE priorities and projects. CAB activities will also include opportunities for co-learning across the projects described in Aim 1 as well as experiential learning about integrative health.

(3) Identify and disseminate promising practices for community-academic partnerships focused on integrative health equity. We will conduct a needs assessment of integrative health equity partnerships in San Francisco, followed by an in-depth evaluation of the three partnerships described in Aim 1. We will then disseminate learnings to local and national networks of community-based and academic organizations involved with integrative health equity work.

Approach/Activities for Aim 1: Build capacity for three community partnerships to advance IHE in SF.

We will continue developing three community-academic partnerships that support the physical and mental health of adults with chronic conditions in San Francisco who are low-income, people of color, LGBTQ+, and/or have limited English proficiency (see attached document “Community Partnership Details” which provides descriptions of each project team, community partner, project goals, and timeline). We selected partnerships that have several commonalities:

Share a common motivation to increase access to integrative healthcare and advance health equity
Serve marginalized communities focusing on adults living with chronic conditions that have been exacerbated by the COVID pandemic and resulting social isolation
Offer group-based interventions with high potential for sustaining integrative health services in low-resource settings
Have received past funding from MZHF and would benefit from capacity-building support to sustain their programs

These partnerships are delivered in distinct settings, address multiple components of integrative health equity, involve multiple OCIH employees, and provide community-engaged learning opportunities for trainees in OCIH fellowship programs. We intentionally chose projects with a history of community partnership at different phases of program development. Collaborating with three separate partners serving distinct populations will allow for testingmultiple strategies for capacity-building, meeting the needs of each organization. This will also allow us to refine and institutionalize key factors common across partnerships to better support integrative health equity (IHE).

IHE strategies employed by the projects in Aim 1 include providing whole person, culturally responsive care to low-income people living with chronic conditions. Each site has IHE champions who have been involved in the development of this proposal. The focus on capacity-building in three organizations (e.g., train the trainer models) will support IHE sustainability beyond the period of the proposed grant, and facilitate longer-term expansion of access to integrative care.

1a. Integrative Approaches to Healthy Aging with On Lok. Asian American elders experienced heightened stress, fear, and anxiety amidst increased anti-Asian hate and violence over the past two years. This project will expand the Integrative Nutritional Counseling (INC) program—which combines Chinese medicinal foods principles with biomedical nutrition advice—to include movement/exercise groups such as tai chi and qi gong adaptable for a range of physical abilities and to provide mental health support. We will partner with On Lok Program of All-Inclusive Care for the Elderly, whose clientele is 72% Asian and 55% Chinese speaking and experiences a high burden of chronic conditions addressed by INC. We will build sustainability by training On Lok staff to deliver the INC nutrition and movement program as part of existing services. This will address gaps identified by our partners at On Lok, who shared the need for culturally responsive movement programs for elderly people with a range of abilities: “One site is not currently offering any tai chi and another only shows YouTube videos. One concern in offering tai chi classes to seniors is that many of them use walkers and canes when standing, thus practicing standing tai chi may not be easy.”

1b. Sharing Humanity through Arts, Reflection, and Expression (SHARE) with the Shanti Project. Cultivating social connectedness is critical for addressing isolation and loneliness exacerbated by the COVID-19 pandemic. SHARE provides integrative support to multiple Shanti programs, of whose clientele, 60% receive disability for a diagnosis of primary mental illness, and 37% for an unexplained mind-body syndrome. Monthly in-person group meetings will offer experiential integrative health opportunities such as mind-body skills practice, Ayurveda, East Asian Medicine, and biofeedback. SHARE broadens approaches to integrative health communication by including immersive experiences, the arts, and mind-body awareness. Groups will address topics that impact a large number of Shanti clients—HIV, cancer, and aging—as well as personalize the experience for the participants based on their needs. This aligns with feedback we received from Shanti clients, who spoke to how “People want to know who is going to be there, who is going to be leading it, will they be safe” and want “to access acupuncture, massage, biofeedback in a familiar environment.”

1c. Expanding Integrative Pain Management, with the Tom Waddell Urban Health Clinic and San Francisco Health Network (SFHN). Over 20% of adults suffer from chronic pain and rates are higher among low-income individuals. With the ongoing opioid crisis, providing non-medication approaches for pain is an urgent priority. The Integrative Pain Management Program (IPMP) was established to broaden access to group-based integrative care for racially and ethnically diverse patients in a primary care safety net clinic in the Tenderloin, with the vision to expand access to integrative care for all SFHN patients with chronic pain. This project will provide training on integrative health and group facilitation to SFHN clinicians and clinicians in existing UCSF/SFHN training programs (e.g., addiction medicine fellowship, primary care residencies). We will build capacity by training clinicians to expand integrative pain care to racially and linguistically diverse safety-net patients throughout the city. This responds to patient feedback about the need for integrative pain management in primary care: “IPMP reinforced stuff that I knew I should be doing. But of course, I can’t do acupuncture on myself. I can’t do massage on myself. I’m poor – like really poor – and I can’t afford to go and get that stuff done at some slinky spa somewhere. So, it’s great to have access to it in my primary care clinic.”

Approach/Activities for Aim 2: Create mechanisms for ongoing feedback from and accountability to community partners of the Osher Center.

We will establish a Community Advisory Board (CAB) to provide a forum for co-learning across integrative health equity partnerships (including those described in Aim 1) and to advise on OCIH’s clinical, research, education, and community programs. This group will meet with OCIH leadership every three months, and participants will receive honorariums for their time and expertise. CAB participants will include a staff member and a client/patient from four community-based organizations (3 established and 1 new partnership), and two OCIH patients who received support through our Community Care Fund. We will regularly elicit feedback and assess the impact of the CAB. This will allow us to promptly respond to feedback with the goal of strengthening engagement of CAB members and developing tools that can be used by other Mount Zion based community partnerships.

The Osher Center CAB will be aligned with broader UCSF efforts to increase community engagement, such as the Center for Community Engagement and best practices identified by the UCSF ASPIRE study. The CAB will:

Foster ongoing relationships focused on developing and sustaining integrative health equity.
Enhance collective learning to strengthen community-academic partnerships.
Provide experiential opportunities for CAB members to familiarize themselves with a range of integrative health practices, strengthening their experience in advising on Osher Center research and education programs.
Inform OCIH priorities and practices.
Include a mechanism for recruiting appropriate advisors for ongoing individual projects (e.g., a project focused on integrative pediatric care that would benefit from community advisors who are parents or work with children).

In Year 1, we will identify CAB members and establish group processes, including a practical and experiential orientation to the Osher Center’s work. In years 1-3, the CAB will have quarterly meetings with the OCIH leadership team including the Center Director, Clinic Director, Director of Research, Director of Education, and Associate Director for Health Equity and Diversity. The Integrative Health Equity Program Manager will coordinate the CAB meetings and support CAB members in providing feedback on community-based projects, such as the ones described in Aim 1. OCIH leadership will benefit from consistent guidance from the CAB on how to ensure that Osher programming serves the needs of a diverse range of San Francisco residents.

Approach/Activities for Aim 3: Identify and disseminate promising practices for community-academic partnerships focused on integrative health equity.

In order to provide data and models that can be employed in San Francisco and beyond, Aim 3 focuses on evaluation and dissemination across projects. In Year 1, we will conduct a citywide scan of integrative health equity partnerships, including but not limited to the community-academic partnerships in Aim 1. Interviews with community-based organization staff and clients as well as their academic collaborators will elicit successes, challenges, and recommendations for strengthening partnerships at an organizational level and towards community impact. We will include ongoing and partnerships between community-based organizations and researchers (e.g., Homeless Prenatal Program, Larkin Street Youth Services, Year Up Bay Area, Sisterweb, Rafiki Coalition, the ARCH/TCM working group, and Mujeres Unidas y Activas). This broad scan will allow us to begin identifying best practices in IHE partnerships.

In Year 2, we will evaluate the three partnerships that are part of Aim 1 using mixed methods instruments developed for community partnerships (Reese et al., 2019). We will use frameworks developed for realist evaluations which focus on answering questions such as what works, for whom, in which circumstances, and why. Using interviews and program implementation data, we will examine factors contributing to sustainability at institutional and programmatic levels (e.g., organizational capacity, program characteristics, funding, staff champions) (Bodkin & Hakimi, 2020). Building on past literature, we will assess how these partnerships have facilitated capacity-building for each of the three partners to offer integrative health services.

In Year 3, we will focus on dissemination of what we have learned about community-academic partnerships for integrative health equity. We will share preliminary findings with the Community Advisory Board (see Aim 2), then integrate their feedback to create accessible materials summarizing these findings. These materials will be disseminated to community and academic partners locally and nationally through networks conducting integrative health equity work, including the 11 academic centers of the Osher Collaborative for Integrative Health, as well as Integrative Medicine for the Underserved, a national organization. Finally, we will host a daylong event for community-based organizations and researchers focused on IHE partnerships.

Summary of healthcare-related needs being addressed: Integrative medicine can reduce health disparities and advance health equity through whole person, culturally responsive care for complex conditions that disproportionately impact historically marginalized populations. However, integrative health is not equally accessible for all due to high out-of-pocket expenses and other barriers. The partnerships described in Aim 1 support adults from marginalized communities with a disproportionate burden of chronic conditions, including diabetes, chronic pain, HIV, cancer, and mental health challenges. Aims 2 and 3 will address a broader range of healthcare-related needs across the lifespan, including specific needs emerging from the COVID-19 pandemic (e.g., impacts on mental health, social isolation). The project is designed to strengthen partnerships that respond to current and emerging healthcare needs of vulnerable populations in San Francisco.

MZHF/Jewish values: Based at the Mount Zion Campus, the UCSF Osher Center for Integrative Health will serve as the hub for all proposed project activities. This includes the core academic team (Drs. Chao, Thompson-Lastad, Adler and Chan), the program manager, and OCIH staff involved with the community partnerships. Administrative, fiscal, and programmatic oversight will all be located at the Mount Zion Campus. The community organizations serve populations within the Mount Zion catchment area, focusing on historically marginalized communities. The proposed integrative health equity program embodies MZHF’s core Jewish values:

Avodah (service): Community-based organizations in these partnerships serve adults with chronic conditions in multiple ways, including increased access to integrative health services. These efforts are recovering from the COVID-19 pandemic, which increased physical and mental health needs in marginalized communities. The IHE program plans to address this by providing financial and technical support to community-based organizations.
Tikkun Olam (social justice): The focus of the IHE program is to address socioeconomic and racial inequities in access to integrative medicine and institutional resources more broadly.
Kehilah (community building): One of the successes of community partnerships is building relationships among community organizations and university representatives. The COVID-19 pandemic has in some cases worsened silos between organizations and sectors, while creating new partnership opportunities in other cases. Our hope is that the IHE initiative will foster connection and build community among organizations and the people that are part of them.
Limud u’Manhigut (education and leadership): This project will support and involve leadership of community organizations and develop collaboration between the UCSF Osher Center and a range of community organizations. It will also contribute to education programs by providing opportunities for community-engaged learning and applied research projects for trainees at UCSF and other institutions.
Hidush (innovation): The proposal takes an innovative approach to community-academic partnership and increasing access to integrative healthcare, with a focus on capacity-building that will last beyond the period of this grant.

Information about Partners

Community Project Partners include representation from multiple San Francisco-based organizations:

Sunny Pak, Associate Medical Director, On Lok,
Evelyn Y. Ho, Professor, University of San Francisco
Tammy Kremer, Public Health Communications Specialist, California Prevention Training Center
Liz Stumm, Director of Community Partnerships and Program Evaluation, Shanti Project;
Jesse Wennik, Nurse Practitioner, San Francisco Health Network
Pamela Swedlow, Physician, San Francisco Health Network
Folashade Wolfe-Modupe, Physician, San Francisco Health Network

Partners from UCSF Osher Center for Integrative Health (OCIH) include

Maria T. Chao, Associate Director for Health Equity and Diversity
Ariana Thompson-Lastad, Assistant Professor
Shelley Adler, Director
Selena Chan, Interim Director of Clinical Programs

Roles of Partners: Partners will jointly foster community engagement by centering the voices of individuals with lived experiences, planning in ways that are community-driven, and prioritizing relationships between collaborators. Community partners will provide an established presence in their respective communities, relevant lived experiences, and informed perspectives on community priorities and feasibility. OCIH partners will provide administrative coordination, technical support for evaluation, and expertise in integrative health.

Project leadership and background: All partners named above have extensive skill sets and experience with community partnerships, integrative health, and healthcare in marginalized communities. The principal investigators, Drs. Chao and Thompson-Lastad, have led multiple community-academic collaborations on integrative health equity, have 10 years of experience working together, and will ensure that project activities are accomplished.

Project start date: April 1, 2023, three-year duration.

Estimated total budget: $250k/year; the amount requested from MZHF is $150k/year.

Supporting Documents:

Community Partnership Details for Aim 1

Supporting Information & References

Developing a Community + UCSF Mount Zion Inaugural Climate, Health, and Equity Community Action Partnership

Submitted by Elizabeth Griffiths on October 21, 2022 - 8:44am Last revised by Elizabeth Griffiths on November 30, 2022 - 3:07pm.

Proposal Concept: Length = 1-2 page Status:

Open

List of goals and specific aims: Climate policies and solutions are too often implemented in silos, without health and equity as key considerations, and without fully and equitably engaging communities whose lived experience needs to be incorporated into effective solutions. The proposed initiative will begin to address these issues by forging a model community-academic partnership to protect some of San Francisco’s communities that are most systemically vulnerable to the adverse effects of climate change on health. We propose the inaugural Climate, Health, and Equity Community Action Partnership (CHE CAP) based at UCSF Mount Zion in partnership with a community-based organization (CBO) focused on climate justice. To achieve this broader goal, we propose the following specific aims:

Create a comprehensive listing of CBOs focused on climate justice in San Francisco and the Bay Area. We will use initial search and outreach, followed by snowball sampling to identify climate-focused CBOs as well as those beginning to express concern about how climate change will affect the communities they serve. Both types of organizations are likely to benefit from support and capacity building.
Conduct a landscape analysis to identify the health impact of heatwaves and wildfires, the state’s foremost health threats, on Mount Zion’s patients and health care system through focus groups and/or key informant interviews with clinical leadership and members of patient and family advisory councils (PFACs). We will also review and compile available data on the number of Mount Zion patients with climate-sensitive health risks (e.g., asthma, COPD/emphysema, immunocompromise, heart disease, anxiety, and depression).
Based on Aims 1 and 2, select a leading climate justice CBO to partner with the UC Center for Climate, Health, and Equity (CCHE) in designing and co-leading a multi-stakeholder convening, as described below. The primary CBO will be selected based on congruence with the shared mission of climate, health and equity, CBO interest and bandwidth, trust within at least one marginalized community, other networks of CBOs with whom they collaborate, and ability to conduct broader outreach in San Francisco
Plan and facilitate an inaugural multi-stakeholder Bay Area convening co-designed and co-led by the primary CBO identified in Aim 3, and attended by the CBOs identified in Aim 1. UCSF faculty, staff, and trainees interested in climate justice, policymakers and policy staff, and Department of Public Health staff, will also participate, helping to identify research and solution-based climate health equity priorities for San Francisco.
Select two San Francisco-based community-partnered action research projects identified as high priorities by participants at the convening described in Aim 4, which will be prioritized for future funding and support from CCHE. These projects will be jointly led by a UC partner and a CBO working on climate health equity and will focus on producing rapid research targeting a specific implementation or policy issue prioritized by the community.

The model described in Aims 3-5 is similar to the San Francisco Health Improvement Project (SFHIP) model, which was initially successfully launched at UCSF and is now supported by the San Francisco Department of Public Health, which serves as the ongoing backbone organization. Based on the learnings of this inaugural partnership, we hope to scale this model statewide by leveraging the other 9 UC campuses participating in CCHE. The long-term goal is to model new forms of equitable academic-community partnerships that can shape the direction of CCHE.

Anticipated benefit for underserved or vulnerable communities in San Francisco:

Evidence shows that the negative impacts of climate change on health disproportionately affect marginalized communities. This occurs through multiple systemic pathways including: greater exposure to extreme weather events, poorer air quality in lower-income communities and communities of color, higher rates of climate-sensitive health risks due to the stress of systemic and interpersonal oppression, and poorer access to health care to mitigate these health impacts. Mitigating the damage of climate change on health positively impacts systemically vulnerable communities and these communities must be intentionally prioritized in work to address climate change. For this project, we are intentionally partnering with CBOs that represent marginalized communities. We will select a lead CBO with strong ties in at least one marginalized community to co-design and co-lead the project. Through the convening, we also plan to build a broader network of CBOs throughout San Francisco focused on or with burgeoning interest in climate justice. Ultimately, we expect that the CHE CAP model will be scaled statewide and will model new forms of equitable academic-community partnerships and catalyze translation of evidence to policy and action to mitigate the harms of climate change on the health of marginalized communities, which are likely to further worsen over time. Building anticipatory capacity through community and university partnerships may help create improved responses.

How the project addresses UCSF Mount Zion priorities and compelling San Francisco healthcare needs: This is an unprecedented time when health at every stage of life is being shaped by the climate crisis. Evidence is mounting that changes in temperature exacerbate infectious and chronic diseases, negatively impact mental health, and lead to injuries and premature death, and that these impacts disproportionately affect marginalized communities. San Francisco is already grappling with many of these impacts as each year our communities face more frequent and severe heat waves, poor air quality from wildfires in surrounding areas, drought, and rising sea levels. Despite nascent efforts to mitigate and adapt to the harmful effects of climate change, San Francisco’s healthcare workforce and health systems lack the preparedness and response capacity needed to address accelerating climate-health impacts.

UCSF Mount Zion is home to general internal medicine and pediatric primary care, women’s health, hospital and surgical facilities, the Osher Center for Integrative Medicine, and dermatology, ENT, oncology, pain medicine and occupational medicine specialists, among others. Patients at UCSF Mount Zion often seek care here because of underlying health conditions that include many of the climate-sensitive health risks (e.g., asthma, COPD/emphysema, chronic allergies, skin disease, being immunocompromised, heart disease, anxiety, and depression). As described below regarding MZHF values, UCSF Mount Zion has a long history of serving the community, social justice, innovation, and education. The Covid-19 pandemic has been no exception, with the re-opening of UCSF Mount Zion’s hospital facilities initially to respond to the needs of patients hospitalized with Covid-19. As we begin to emerge from the Covid-19 pandemic, now is the time for UCSF Mount Zion to proactively prepare for and mitigate the growing crisis of climate change and its impact on the health of UCSF Mount Zion’s patients and the broader San Francisco community. This project does just that, by designing the inaugural Climate, Health, and Equity Community Action Partnership (CHE CAP) based at UCSF Mount Zion in partnership with a CBO focused on climate justice, conducting a landscape analysis of the impact of climate change on the health of UCSF Mount Zion’s patients, and hosting the first multi-stakeholder convening to identify research and solution-based climate health equity priorities for San Francisco.

Link to MZHF values: This project is based on all of Mount Zion Health Fund’s values and particularly emphasizes service (avodah), social justice (tikkun olam), community building (kehillah), and education and leadership (limud u’manhigut). The project centers on addressing what some might reasonably argue is the most pressing health need of our time—climate change. While mitigating climate change is a global challenge, each community must come together to do its part to mitigate and prepare for climate change’s threat. This project proposes to build those bridges here in San Francisco, with an eye toward modeling a partnership that can be scaled statewide and beyond. The project also explicitly seeks to correct the unjustly disproportionate impact of climate change on the health of marginalized communities in San Francisco by focusing on developing projects that will be co-led by and address the needs identified by these communities, including UCSF Mount Zion patients from these communities. The project also seeks to further develop CBO staff as statewide leaders in climate justice and to involve UCSF learners with a passion for addressing climate health equity.

Roles of UCSF and Community Partners: CCHE was launched by the UC Office of the President in 2021 to advance equitable and just climate solutions that promote human health and a healthy planet. Housed at UCSF and with strong partnerships across the UC system, CCHE is catalyzing “missing link” research on climate-health impacts, educating a 21st century health workforce to work at the climate-health interface, fostering climate-smart health systems, and maximizing health and equity in climate policy by meaningfully engaging community stakeholders. One of the aims of this project is to create a comprehensive list of CBOs in San Francisco and the Bay Area focused on climate health justice and potentially others beginning on their journey and collaborate with one leading CBO to bring them together in a multi-stakeholder convening. The CBO selected in Aim 3 to co-lead the workshops with CCHE will co-develop the content, agenda, and guest lists, as well as help design brief evaluation questions and participate in reviewing evaluation results, and it will receive significant funding to do so. Convening participants will include CBO staff, community members, and diverse Mount Zion patients (some already engaged with Dr. Griffiths’ community engaged advocacy curriculum for internal medicine residents), who will receive stipends funded through this grant.

Collaborators and Contact Information:

Elizabeth (Beth) Griffiths, MD, MPH is Assistant Clinical Professor in the Division of General Internal Medicine (DGIM) at Mount Zion, Co-Associate Director of Training and Policy Programs at the UCSF Institute for Health Policy Studies, and Director of Advocacy and Community Engagement for the internal medicine residency Health Equity and Advocacy Pathway. To contact the team, please contact Dr. Griffiths at 1701 Divisadero St San Francisco, CA 94115, elizabeth.griffiths@ucsf.edu, or 415-353-7999.
Arianne Teherani, PhD is Professor of Medicine, Founding Co-Director of CCHE, and Director of Program Evaluation for the UCSF School of Medicine. Dr. Teherani has launched and lead multiple programs focused on climate health and justice. As a program evaluation expert, she has worked on large-scale evaluation of national initiatives.
Sheri Weiser MD, MPH is Professor of Medicine, Founding Co-Director of CCHE, and a member of the National Academies Climate Security Roundtable. Dr. Weiser is a social scientist and epidemiologist who leads research on how food insecurity and other social and economic factors, within the context of climate change, undermine health equity.
Laura Schmidt PhD, MSW, MPH is Professor of Health Policy in the UCSF School of Medicine. Dr. Schmidt is a sociologist and public health researcher whose research seeks to understand how socioeconomic inequities translate into health inequities. From 2010-2016, Dr. Schmidt served as one of the lead UCSF faculty on the San Francisco Health Improvement Partnership (SFHIP.org), a robust university-community effort to reduce health inequities in San Francisco.
Claire D. Brindis, Dr. P.H. is Distinguished Professor in the Department of Pediatrics, Strategic Advisor for CCHE, and a member of the National Academy of Medicine’s Climate Change Collaborative. She is a bi-lingual, bi-cultural Argentinean immigrant, whose career has been devoted to community-based, participatory research, program evaluation, and effective translation of research into policy.

Project start date and duration: July 1, 2023 through June 30, 2024.

Implementation of a Structured Exercise Program for Oncology Patients

Submitted by Shannon Fogh on October 21, 2022 - 12:09pm Last revised by Shannon Fogh on November 30, 2022 - 7:04pm.

Proposal Concept: Length = 1-2 page Status:

Open

Applicant/s name; title; UCSF Mount Zion academic affiliation; Community Partner affiliation (if applicable)

Applicant: Dr. Shannon Fogh, Associate Professor of Radiation Oncology

Community Partner: Maple Tree Cancer Alliance

Project Title: Implementation of a Structured Exercise Program for Oncology Patients

List of Goals:

Demonstrate the feasibility of patient participation and adherence to a prescribed exercise program. Specifically, the percent of patients exercising >150 minutes per week at baseline, 6 and 12 weeks and frequency and type of adverse events.
Understand and validate the best exercise strategies for patients with cancer and modifications appropriate for different places in the patients’ disease and treatment.
Measure and evaluate the functional outcomes of participation, including Timed-up and Go (TUG) test, 30 Second Chair Stand, Four Stage Balance Test and BMI.
Evaluate patient-reported health-related quality of life as measured by the global QOL, physical functioning, role functioning, and social functioning domains on the EORTC Quality of Life Questionnaire (QLQ-C30).
Understand unique patient preferences and barriers to participation for patients with varying functional status and across different demographics.
Assess relationships between functional outcomes and quality of life.
Assess health care utilization, including ER visits and hospitalizations of participants.

Summary of healthcare-related needs being addressed:

Cancer is a significant national health problem. The long-term physical and psychological side effects of cancer and its treatment negatively impact the cancer survivor’s quality of life, causing cancer to be classified as a chronic disease by the Centers of Disease Control. Survival, while the most common outcome measure, may not address components of a patient’s quality of life. How toxicities of treatment are managed makes a great difference in quality of life both during and after treatment.

Exercise has been demonstrated to positively impact patients with cancer, and government and leading health organizations such as the American Institute for Cancer Research, American Cancer Society (Clark et al), and the American Society of Clinical Oncology (Ligibel et al 2022) have included exercise among cancer-prevention guidelines. The 2019 Exercise Guidelines for Cancer Survivors was based on a consensus statement from an International Multidisciplinary Roundtable recommending a combination of aerobic and resistance exercise based on multiple studies demonstrating benefit in cancer patients across multiple symptom domains from fatigue and functional status to mood and quality of life. Importantly, many studies have also demonstrated an overall survival benefit when exercise guidelines are met. Conversely, studies have demonstrated a fivefold increase in death in patients who are not active.

Despite these recommendations, most hospitals and clinics have not implemented personalized cancer exercise programs due to workforce, funding, and infrastructure limitations. This represents a quality gap between what we know benefits patients with cancer and the implemenation of an intervention which has continuously demonstated a positive impact on patients. Specifically, when provided as part of a comprehensive cancer plan, individualized exercise has clear benefits, including reductions in treatment-related side effects, higher chemotherapy completion rates, improved physical fitness and functionality, and increases in health-related quality of life. Further, reductions in health care utilization have been reported. This is noteworthy as unplanned hospitalizations contribute half of the cost of cancer care. Nevertheless, 85% of patients are sedentary at the time of their diagnosis, and shockingly, less than 5% engage in exercise programs during cancer treatment. Furthermore, less then 5% of cancer patients are ever referred to an exercise program, and approximately 2% of patients meet the published exercise recommendations.

Challenges inherent to creating a generalizable program for all patients include the wide range of physical deficits patients can present with, depending on the location of the cancer and prior and current treatments and medications. This can lead to considerable variability in baseline strength, balance, and muscle mass. Steroid use, as well, can deplete muscle mass and create difficulty with completing traditional exercises. This is exacerbated by fluctuating side effects, including radiation-induced fatigue, arguing for an individualized and flexible program providing patients with options when side effects of treatment are more prevalent.

The UCSF Cancer Exercise Counseling Program has led an important effort within the Cancer Center to offer one-on-one fitness counseling to adult cancer patients and survivors. During a one-hour session with an exercise counselor, patients receive education and training on activities related to cardio, strength, balance, and flexibility. These efforts are entirely supported by gift funds, and there is no cost to patients. While this program has been an incredible asset to patient care, important limitations include:

1) Exclusion of patients who do not speak English as a primary language.

2) Availability: Currently only one exercise specialist is available with 8 clinic slots per week.

3) Exclusion of many of our patients based on physical abilities: This service is limited to fully functional patients who are able to safely perform these activities at a baseline level.

4) A focus on exercise counseling vs. implementation of a true exercise intervention.

These limitations exclude many of our patients who have graduated from physical therapy and could benefit from a structured exercise program. Specific examples include patients who do not speak English as a primary language, as well as patients who have deficits from their primary tumor or treatment. This includes patients who are non-ambulatory or who have pain or neurologic symptoms, including cognitive changes, motor function, balance, visual symptoms, and other physical deficits which can be amplified by traditional treatments including surgery, systemic therapy, and radiation therapy.

While there are challenges inherent to creating a generalizable program for all patients, the Maple Tree Cancer Alliance has created exercise programing for patients with both physical limitations and has made substantial efforts to offer exercise programs to patients who do not speak English. Maple Tree has developed trainers with experience in working with patients with functional deficits, including patients who are not ambulatory or have pain or other physical limitations. Additionally, they have developed materials that are available in Spanish, Mandarin, Portuguese, and Arabic. They are actively hiring trainers proficient in multiple languages and are comfortable offering sessions with the assistance of an interpreter, as well.

The purpose of this proposal is to demonstrate the feasibility of implementing individualized exercise programs for patients with cancer and their impact on functional measures and patient reported quality of life and cognition. We will also assess patient exercise preferences, barriers to activity and modifications appropriate for different functional limitations. Our long-term goal is to develop programs for every patient in the cancer center, regardless of their functional limitations, primary language, or socioeconomic status, and to engage them as early as possible and support them through their treatment journey.

Roles of UCSF and Community Partner(s), if applicable

Name(s), title(s), agency/department/division(s) of individuals who will lead the project, with brief background information relevant to ability to accomplish the project activities

Dr. Shannon Elizabeth Fogh is a Radiation Oncologist and Integrative Oncologist. After completing her fellowship in Integrative Medicine, Dr. Fogh joined the faculty at the Osher Center for Integrative Health with a practice focused on integrative approaches for all patients living with a cancer diagnosis. Her research interests are centered on developing and implementing integrative treatments to improve survival, reduce treatment toxicities and improve quality of life and preservation of neurocognitive function. She was integral to the efforts to implement and study the impact of a dedicated exercise program for patients with primary brain tumors and is dedicated to implementing individualized exercise programs for patients living with and beyond cancer.

Karen Wonders, Ph.D., FACSM, is the Founder of Maple Tree Cancer Alliance. She also serves as a Professor of Exercise Physiology at Wright State University and Program Director over the undergraduate Exercise Science Program. The primary focus of her research is on the physiological and financial impact of exercise during cancer treatment.

Other Investigators/Collaborators:

Kavita Mishra; Integrative Oncologist, Osher Center Faculty

Donald Abrams: Integrative Oncologist, Osher Center Faculty

Natalie Marshal: Integrative fellowship graduate with expertise in implementation of exercise programs for cancer patients.

Note which of the six MZHF values the project embodies:

Service (Avodah): A major goal of this project is serving all patients with a cancer diagnosis who can and should be able to benefit from the impact exercise can have on survival, functional status, and quality of life.
Social Justice (Tikkun Olam): This project seeks to create inclusive exercise programing by including patients with physical limitations and patients who do not speak English as a primary language.
Innovation (Hidush): We seek to be one of the first cancer centers in the United States to implement exercise programming and to measure the qualitative and quantitative impact of formal exercise programing.
Compassion (Rahamin): By creating programs that do not exclude participation based on physical ability, socioeconomic status, or language barriers.

Project start date and duration (earliest start date is January 1, 2023):

March 1, 2023-March 2024

Estimate of total budget required and the amount requested from MZHF.

$75,000

Proposal:

1: Specific Aims:

The aims of the proposed project are to understand the feasibility of and barriers to implementing a comprehensive exercise program for patients with cancer, as well as the program’s impact on functional outcomes and health related quality of life. We will also assess patient exercise preferences, barriers to activity and modifications appropriate for different functional limitations. Our long-term goal is to develop programs for every patient in the cancer center and engage patients as early as possible and support them through their treatment journey.

The hypothesis will be tested by addressing the following aims:

Demonstrate the feasibility of patient participation and adherence to a prescribed exercise program. Specifically, the percent of patients exercising >150 minutes per week at baseline, 6 and 12 weeks and frequency and type of adverse events.
Understand and validate the best exercise strategies for patients with cancer and modifications appropriate for different places in the patient’s disease and treatment.
Measure and evaluate the functional outcomes of participation including Timed-up and Go (TUG) test, 30 Second Chair Stand, Four Stage Balance Test and BMI.
Evaluate patient-reported health-related quality of life (HRQOL), as measured by the global QOL, physical functioning, role functioning, emotion functioning and social functioning domains on the EORTC Quality of Life Questionnaire (QLQ-C30). In addition, to measure patient-reported cognitive function, as measured by the cognitive functioning subscale of the EORTC QLQ-C30.
Understand unique patient preferences and barriers to participation in patients with varying functional status and across different cultures and socioeconomic status.
Assess relationships between functional outcomes and quality of life.
Assess health care utilization including ER visits and hospitalizations of participants.

Experimental Design and Methodology:

This is an observational, mixed methods implementation science pilot study examining the feasibility, adherence, and impact of a tailored exercise program for patients with cancer.

Patients will be referred to a certified exercise specialist by e-mail or through the electronic medical record (EMR). Following this referral, a patient intake appointment is completed to assess baseline functional and quality of life status, health concerns, health history, current fitness/activity levels, available resources, and desired goals. Patients will be assessed for function and quality of life at 3 time points throughout the duration of the trial. These include at initial assessment and at 6 weeks and 12 weeks, after starting the program. Completion of quality-of-life forms will be done electronically or by patient interview. Quality of life forms are offered in multiple languages and support will be provided to patients who may not have access to computers or other means to complete the survey and/or patients who might struggle with navigating an online survey.

As this program is intended to complement and supplement existing exercise resources, we will work closely with relevant stakeholders to maximize availability of services to patients. Priority will be given to vulnerable patient populations including but not limited to, patients with physical limitations or impairments, patients with limited access to exercise resources and patients who do not speak English.

Based on the results of the initial assessment, an exercise prescription is developed. This exercise intervention is individualized according to the patient’s current health status and goals and is in-line with ACSM’s published guidelines on exercise for cancer patients. Exercises will include cardiorespiratory endurance, muscular strength, and balance. Exercise duration and intensity are systematically progressed based on patient tolerance. All sessions are completed one-on-one with a trainer who holds a minimum of a bachelor’s degree in an Exercise Science-related field and a nationally accredited Exercise Oncology Instructor certification. The individualized program will be sent to the patient through the EMR with links to the appropriate resources for further assistance.

The individualized exercise program will last 6-12 weeks depending on the individual plan created for the patient.

After completion of the program, participants will repeat the assessments done at baseline pertaining to functional status, cognitive function, and quality of life. Patient adherence will also be measured. These assessments will be repeated at 12 weeks following the start of the program to assess for sustainability of program recommendations for exercise and functional and quality of life outcomes.

Primary Objectives/outcomes:

Patient demographics including age, diagnosis, sex, previous and current treatment, and medications including dose and duration of steroids and antiepileptic medications.
Number of patients referred and individual and overall adherence with the program, including number of prescribed sessions completed percent of patients exercising >150 minutes per week at baseline, 6 and 12 weeks (as able).

Patients’ ability to complete prescribed exercise as well as any feedback about challenges or difficulties they faced in completing certain exercises. We will track modifications based on this feedback. This will allow us to understand and validate the best exercise strategies for individual patients and modifications appropriate for different places in the patient’s disease and treatment. This qualitative data will be collected by interviews, open text boxes for feedback as part of electronic surveys and ongoing dialogue with the exercise counselor during visits.
Cardiovascular fitness/functional status will be measured by:

Timed-up and Go (TUG)
30 Second Chair Stand
Four Stage Balance Test

Body Mass Index (BMI) based on height and weight recorded at a clinic visit within 3 months or self-reported

Current weekly steps as self-reported by a mobile fitness app (if available)

Patient-reported health-related quality of life (HRQOL), as measured by the global QOL, physical functioning, role functioning, emotion functioning and social functioning domains on the EORTC Quality of Life Questionnaire (QLQ-C30).

Patient-reported cognitive function, as measured by the cognitive functioning subscale of the EORTC QLQ-C30.

Adverse events: Determined by frequency, type or absence of significant adverse events recorded during the study period to include experiencing chest pain, shortness of breath, falls, and dizziness (without falls) during exercising. Minor adverse events could include muscle pain and use of OTC pain medication after exercising.

Health care utilization including ER visits and hospitalizations of participants.

Primary Objective:

The primary objective of this investigation is to assess the feasibility, recruitment, adherence, and impact of a patient’s participation in a supervised, individualized exercise program for oncology patients. The intervention will be considered feasible and with a high adherence if this study produces less than 20% exercise dropout rate and 70% completion of prescribed exercises over the 6-week program.

Secondary Objectives:

Changes in functional outcomes from baseline to post-intervention at 6 weeks and 3 months including

Timed-up and Go (TUG)
30 Second Chair Stand
Four Stage Balance Test
Body Mass Index (BMI) based on height and weight recorded at a clinic visit within 3 months or self-reported
Current weekly steps

Changes in patient-reported health-related quality of life (HRQOL), as measured by the global QOL, physical functioning, role functioning, emotion functioning and social functioning domains on the EORTC Quality of Life Questionnaire (QLQ-C30) post-intervention (6 weeks) and 3 months.

Changes in patient-reported cognitive function, as measured by the cognitive functioning subscale of the EORTC QLQ-C30 at initial assessment and at three months from baseline.

Quality of Life and Functional Outcomes assessment tools

The EORTC QLQ-C30 is the instrument most frequently used to measure quality of life (QOL) in cancer patients. Importantly, it is offered and is validated in over 50 languages.

The Timed Up and Go (TUG) test is a performance-based measure of functional mobility that was initially developed to identify mobility and balance impairments in older adults. It measures both static and dynamic balance and is used to help determine current performance level and how safe it is to complete certain activities. It will be used in this patient population to help determine the appropriate exercise program and to monitor progress throughout the program. [https://www.cdc.gov/steadi/pdf/TUG_test-print.pdf]

The Four-Stage Balance Test is used in conjunction with other measures such as the 30 second Chair Stand Test and TUG test as an assessment of postural hypotension which can help indicate if a patient is a risk of falling. In this test, patients are asked to perform four progressively more challenging positions without the help of an assistive device. Specific positions each held for 10 seconds with patients eyes open include a parallel stance, semi-tandem stance, tandem (Heel-Toe) stance and one-legged stance. [https://www.cdc.gov/steadi/pdf/4-Stage_Balance_Test-print.pdf]

The 30 Second Chair Stand, combined with other tests can help evaluate risk of postural hypotension and a patient’s risk of falling in addition to leg strength and endurance. The number of times patients can rise to a full standing position and return to a seated position during a 30 second interval is documented. This can be helpful in creating an appropriate exercise program as well as monitoring progress as patients increase activity. [https://www.cdc.gov/steadi/pdf/STEADI-Assessment-30Sec-508.pdf]

Data collection:

Data will be collected by electronic survey and patient interviews and stored in a REDCAP database.

Plan for evaluation and data analysis:

Primary endpoint:

The primary endpoint is feasibility, defined by adherence of patient’s participation in a customized exercise program for patients with cancer. The intervention will be considered feasible with a less than 20% drop out rate and 70% completion of exercises in patients enrolled. We anticipate enrolling 50 patients in one year.

Secondary endpoints:

Changes in patient functional outcomes from baseline, post-intervention and 3 months assessed for each individually:

Timed-up and Go (TUG)
30 Second Chair Stand
Four Stage Balance Test
Body Mass Index (BMI) based on height and weight recorded at a clinic visit within 3 months or self-reported
Current weekly steps as self-reported by a mobile fitness app (if available)

Improvement in patient-reported health-related quality of life (HRQOL), as measured by the global QOL, physical functioning, role functioning, emotion functioning and social functioning domains on the EORTC Quality of Life Questionnaire (QLQ-C30) at baseline, post-intervention and at 3 months. Since higher scores indicate better functioning, an increase of 10% from baseline indicates an improvement in function.

Improvement from baseline to post-intervention and 3 months following the intervention in the following subscales will be assessed and compared using Fisher’s exact test: global QOL, physical functioning, role functioning, emotional functioning, and social functioning domains along with fatigue and pain items.

Exploratory Outcomes:

Assess barriers for participants to participating in an exercise program by a survey conducted within the first 2 weeks of study participation. Results of a survey will be presented using descriptive statistics.

Aim five focuses on understanding the barriers and facilitators to uptake and successful completion of the exercise program by a demographically diverse group of participants. Pilot data we have collected indicates that exercise preferences and barriers differ across patients from different cultures, functional and socioeconomic status. To ensure diversity of responses we will perform one-on one interviews with 15 Mandarin, Spanish and English-speaking patients selected for varying levels of completion of the pilot program. Additionally, we will interview 15 patients with high functional status (defined as KPS of 90 or above) and compare to patients with low functional status < KPS of 80) or with an identified physical deficit. All patient interviews and surveys will be additionally stratified by socioeconomic factors including but not limited to income and education level.

Interviews will focus on asking patients if they were able to exercise as much as they had planned, what barriers they faced to exercising, their satisfaction with the program, what factors associated with the program helped them exercise more, how the program helped them cope with cancer and how their quality of life was affected by the program.

Additionally, we hope to assess relationships between functional outcomes and quality of life.

Finally, we hope to analyze hospitalizations and urgent care visits of participating patients to develop pilot data for understanding the impact of exercise on health care utilization.

2. Anticipated benefit for underserved or vulnerable communities in San Francisco:

One in three people will develop cancer in their lifetime and between 54.4-90% will have some physical or functional limitations depending on the location of the cancer and prior and current treatments and medications. This can lead to considerable variability in baseline strength, balance, and muscle mass. Steroid use can deplete muscle mass and create difficulty with completing traditional exercises. This is exacerbated by fluctuating side effects including radiation-induced fatigue. This can lead to challenges leaving the home, social isolation, navigating physical barriers at home such as stairs and even completing activities of daily living, creating vulnerabilities in this patient population. Importantly, approximately 40% of patients diagnosed with cancer do not speak English and 20% are at or below the poverty level without financial means to pay for in-house therapy, personal trainers, access to gyms or exercise equipment.

The UCSF Cancer Exercise Counseling Program has led an important effort within the cancer center to offer one-on-one fitness counseling to adult cancer patients and survivors. During a one-hour session with an exercise counselor, patients receive education and training on activities related to cardio, strength, balance, and flexibility. These efforts are entirely supported by gift funds. While this program has been an incredible asset to patient care, important limitations include:

Exclusion of patients who do not speak English as a primary language.
Availability: Currently only one exercise specialist is available with 8 clinic slots per week.
Exclusion of many of our patients based on physical abilities: This service is limited to fully functional patients who are able to safely perform these activities at a baseline level.
A focus on exercise counseling vs a true exercise intervention.

These limitations exclude many of our patients who have graduated from physical therapy and could benefit from a structured exercise program. Specific examples include patients who have deficits from their primary tumor or treatment, such as patients who are non-ambulatory, have pain or neurologic symptoms including cognitive changes, motor function, balance, visual symptoms, and other physical deficits which can be amplified by traditional treatments including surgery, systemic therapy, and radiation therapy. Importantly, this also excludes patients who do not speak English as a primary language.

Role of Community Partner:

While there are challenges inherent to creating a generalizable program for all patients, the Maple Tree Cancer Alliance has created exercise programing for patients with both physical limitations and has made substantial efforts to offer exercise programs to patients who do not speak English. They have developed trainers with experience in working with patients with functional deficits, including patients who are not ambulatory or have pain or other physical limitations. Additionally, they have developed materials that are available in Spanish, Mandarin, Portuguese, and Arabic. They are actively hiring trainers proficient in multiple languages and are comfortable offering sessions with the assistance of an interpreter as well.

3: How the project addresses UCSF Mount Zion priorities and compelling San Francisco healthcare needs.

This project would provide a critical service free of charge to underserved and vulnerable patients diagnosed with cancer. There is a significant gap between national guidelines that recommend exercise to benefit quality of life, mitigate treatment related symptoms and improve survival and, access to resources to facilitate this. This is a significant unmet health-related need impacting all our cancer patients in San Francisco, including our patients seen and treated at our Mt. Zion location and patients seen in our Integrative Oncology practice at the Osher Center for Integrative Health.

Both our patients and providers want access to these resources as well! Our preliminary needs assessment, consisting of qualitative interviews and surveys with patients and multidisciplinary team members, including physicians, indicated that 100% of providers and patients reported that exercise is Important to Very Important for patients' lifestyle. Most providers (92%) reported that exercise was Important for patients' lifestyle and 80% felt it should be integrated into the treatment of patients with cancer. Ninety-six percent felt that exercise improved quality of life, decreased fatigue (100%) and reduced treatment-related side effects (92%). While patients and providers were motivated to refer and support patients’ participation in a customized exercise program, there is very limited availability of exercise counselors. Additionally, patient feedback indicated a preference to be part of a more structured program with more frequent visits, to assess progress and modify exercises if needed.

This project embodies many of the MZHF values, including Social Justice, as we seek to create inclusive exercise programing by including patients with physical limitations and patients who do not speak English as a primary language; Innovation, as we seek to be one of the first cancer centers in the United States to implement clinical access, research, as we measure the impact of formal exercise programing; and Compassion, by creating programs that do not exclude participation based on physical ability, ability to pay, or language barriers.

4.Type and duration of campus-community partnership, if applicable:

Plan for sustainability:

Pilot data from this grant will be critical to determining both need for services, guidance for widespread implementation and outcomes in cancer patients including demonstration of exercise on cost savings. Specifically, there is growing evidence that exercise oncology, when properly performed, improves functional outcomes, quality of life, survival and serves as a cost savings event by reducing unplanned visits to the emergency room and decreasing the number of hospitalizations needed to manage the complications that can occur during and after treatment.

Despite evidence that exercise can be beneficial to patients’ quality of life and survival, in addition to providing cost saving, widespread incorporation of exercise into the treatment plan of newly diagnosed cancer patients has been severely limited by the absence of many of the conventional methods for clinical activity reimbursement.

Our overall goal is to ensure this service is available to all cancer patients. We are actively working to obtain Category III CPT codes for exercise interventions. These codes are temporary codes for new and emerging therapies that allow data collection and assessment of new services to substantiate widespread usage of new and emerging interventions to justify the establishment of a permanent Category I CPT code.

We believe pilot data from this program would be integral to this effort and to UCSF through the Mt. Zion Health Fund, which would be leading this effort to obtain reimbursement for exercise nationally and to create a national model for exercise counseling.

Pilot data from this program will also be presented to the Cancer Center leadership and be critical for ongoing infrastructure, dissemination, and support.

5.How the community partner's experience and expertise was integrated into proposal development:

The exercise program will be offered through a partnership with Maple Tree Cancer Alliance, a 501(c)(3) non-profit organization that has developed a unique, evidence-based model of exercise programming that has gained national attention. Maple Tree Cancer Alliance is dedicated to improving the quality of life of individuals who battle cancer that creates program of supervised, individualized exercise training. In other types of cancers, they have demonstrated improved patient outcomes in terms of increased fitness parameters, decreased symptom severity, and decreased health care utilization.

Program Outcomes: The following charts represent the outcomes data Maple Tree has measured on the patients who have completed their programs showing improvement in domains including quality of life, multiple fitness parameters and health care utilization (see supporting documents).

Contact information: address, email, phone

505 Parnassus Ave., Room L-08, Box 0226 San Francisco, CA 94143
Shannon.fogh@ucsf.edu
(617) 460-0900

Supporting Documents:

non-profit_determination_letter_1.pdf

board_of_directors.2022.pdf

_maple_tree_program_outcomes.pdf

finalmt._zion_final_grant.pdf

Pediatric Food Pharmacy

Submitted by Reed Hausser on October 21, 2022 - 2:27pm Last revised by Karen Staller on December 2, 2022 - 4:13pm.

Proposal Concept: Length = 1-2 page Status:

Open

In 2019, members of the Department of General Internal Medicine (DGIM) started a Food Pharmacy for general medicine patients with food insecurity. Pediatric residents from the General Pediatric Practice (GPP) at Mt. Zion heard about this program in 2021. They conducted a survey of 150 of their patients and found that nearly 20% rate had food insecurity. In March 2021, pediatric resident Priya Pathak contacted Dr. Moreno-John about starting a food program for their patients. DGIM Food Pharmacy members and the pediatric residents began a collaboration and the first DGIM+Peds Food Pharmacy was conducted on 7/12/21. Currently, only patients of pediatric residents are being referred to the DGIM+Peds Food Pharmacy although there are many patients with food insecurity at the GPP.

This grant would support a Food Pharmacy at the GPP for all food-insecure pediatric patients. Our program would use the infrastructure that DGIM created and will be adapted to our patients’ needs. Our program will include a Food Pharmacy at the GPP site twice a month. We will distribute bags of fresh produce, a grain, and a protein, as well as take-away meals. We will also distribute a smaller bag of healthy non-perishables to families at the time of positive screening so they have an immediate take-home product. We will provide literature on healthy eating and recipes to utilize the contents of the grocery bags in the dominant languages of patients' at the practice. During windows when children are returning to school, we will include school supplies to help address other sources of financial strain on families.

List of Goals

Identify patients and families who are either experiencing or at risk of experiencing food insecurity at the GPP through medical screenings conducted during medical visits
Provide referrals to patients and families to a GPP food pharmacy where they are able to acquire fresh produce and groceries on a bi-weekly basis
Provide home delivery of groceries to patients who are experiencing food insecurity and have limited transportation/ambulation
Reduce food insecurity among the pediatric patients
Quantify and track participation and outcomes
Train and educate staff and faculty on food insecurity and federal nutrition programs and the local resources available to patients
Provide assistance and support in connecting eligible patients to federal nutrition programs
Incorporate efforts in addressing food insecurity in clinic/institutional workflow

Summary of healthcare-related needs being addressed

This GPP Food Pharmacy will be treating the medical and social consequences of food insecurity in our patient population because children experience an increased rate of developmental risk, poor academic performance, school absenteeism, asthma and less access to routine and urgent care (20). They also have higher rates of obesity, mental health diagnoses, an increased risk of all-cause mortality, and health-risking behaviors such as meal rationing and avoiding medical care (5,6,7).

We are addressing health and social inequalities for African American, Latinx, and Indigenous populations, single-parent families, patients with low English proficiency and Medi-Cal patients, as these groups have higher rates of food insecurity than others (The Department of Health and Human Services). 4 million children (1 in 6) in the U.S. will likely experience food insecurity (14).

Roles of UCSF and Community Partner(s)

Arcadio’s Produce (produce and other foods), Farming Hope (take-away meals), The Family as Medicine Collaborative of the SF Department of Public Health (funding, support), the SF Marin Food Bank (pantry at home, delivery of food to house-bound patients)

Name, title, division of individuals who will lead the project, with brief background information relevant to ability to accomplish the project activities:

Joslyn Nolasco, MD, Associate Clinical Professor, Pediatrics. Joslyn has maintained the pediatric component of the food pharmacy alliance for multiple years as well and has expanded site buy-in and provided mentorship to multiple residents throughout grant writing and organizational processes.
Consultant - Gina Moreno-John, MD, MPH, Director of Diversity, Equity, and Inclusion, Department of General Internal Medicine. Gina has been involved in the existing food pharmacy for multiple years from the adult medicine side and has maintained community relationships that have thus far helped keep the project alive.

MZHF values the project embodies

Service (Avodah): MZHF supports organizations and projects that serve society by addressing community health needs.
Social Justice (Tikkun Olam): MZHF supports organizations and projects that seek to correct imbalances, inequities, and injustices in health and healthcare.
Community Building (Kehilah): MZHF supports organizations and projects that build community on the UCSF Mount Zion Campus and across San Francisco.
Innovation (Hidush): MZHF supports pioneering clinical, research, and educational programs that advance new standards of prevention, screening, diagnosis, and treatment of illness as well as the promotion of health and wellbeing.

Project start date and duration (earliest start date is January 1, 2023): January 1, 2023

Estimate of total budget required and the amount requested from MZHF: $150,000

Applicant name, division

Joslyn Nolasco, MD, Pediatrics;
Traci Barnes, MD, Pediatrics;
Reed Hausser, MD, Pediatrics

Contact info

Pediatric Food Pharmacy, Phase 2 proposal

Joslyn Nolasco, MD, Reed Hausser, MD, Traci Barnes, MD

Specific aims:

Identify patients and families who are either experiencing or at risk of experiencing food insecurity at the General Pediatric Practice (GPP) through medical screenings conducted during medical visits
Provide referrals to patients and families to a GPP food pharmacy where they are able to acquire fresh produce and groceries on a bi-weekly basis
Provide home delivery of groceries to patients who are experiencing food insecurity and have limited transportation/ambulation
Reduce food insecurity among the pediatric patients
Quantify and track participation and outcomes
Train and educate staff and faculty on food insecurity and federal nutrition programs and the local resources available to patients
Provide assistance and support in connecting eligible patients to federal nutrition programs
Incorporate efforts in addressing food insecurity in clinic/institutional workflow
Anticipated benefit for underserved or vulnerable communities in San Francisco

Anticipated benefit for underserved or vulnerable communities in San Francisco

Targeted screening would directly identify, support, and refer on an immediate timeline, those most economically and socially vulnerable. The Pediatric Food Pharmacy would then establish continued support and provisions to ensure sustained benefit, thus supporting these children’s ongoing health and development. This could have immense impact on their general mental and physical health throughout their life. In addition to promoting the long-term wellbeing of the most vulnerable children, we will be able to uplift their families and communities, freeing up resources for continued quality of life improvements. Once these patients are identified, the Pediatric Food Pharmacy can also identify and meet other needs these families may have. The resources provided would compliment the various other social safety nets, which are falling short for these patients.

How the project addresses UCSF Mount Zion priorities and compelling San Francisco healthcare needs

This Gen Peds Food Pharmacy will be treating the medical and social consequences of food insecurity in our patient population because children experience an increased rate of developmental risk, poor academic performance, school absenteeism, asthma and less access to routine and urgent care (20). They also have higher rates of obesity, mental health diagnoses, an increased risk of all-cause mortality, and health-risking behaviors such as meal rationing and avoiding medical care (5,6,7).

Type and duration of campus-community partnership, if applicable.

Through our partnership with the Department of General Internal Medicine (DGIM) Food Pharmacy, we have worked with Food as Medicine Collaborative, who is supported by the Public Health Initiative. We have also worked with Farming Hope through this joint program. We joined the GDIM Food Pharmacy in 2021, and both programs have been working with the DGIM Food Pharmacy since 2019. We will continue to work with both

How the community partner's experience and expertise was integrated into proposal development

Farming Hope works with formerly incarcerated or formerly homeless adults to create meals for food insecure people in San Francisco. They offer job training and source “cosmetically imperfect” (read: funny-looking) produce. Farming Hope has given us a list of their typical meals to make sure that they are healthy and acceptable to our clients. They offer vegetarian meals when requested. This collaboration is particularly meaningful as many of the staff and leadership have a deep empathy for and experience with food insecurity.

For each community partner (if applicable):

1)Food as Medicine Collaborative: The Food as Medicine Collaborative is a fiscally sponsored project of the nonprofit San Francisco Public Health Foundation and is based within the San Francisco Department of Public Health. They have agreed to supply food for first 6 months through our partnership with DGIM Food Pharmacy.

2)Farming Hope: See the attached IRS exemption letter verifying 501(c)(3) status for Farming Hope.

Farming Hope Board of Directors:

Lyndsey Boucherle
Shelley Dyer
Michael Fu
Lucia Gaia Pohlman
Xochitl Hernandez
Sheena Jain
Ilana Lipsett
Savannah Schoelen
Salim Zymet

7. Total proposed project budget with justification: $146,394/year for 3 years

Requested grant period: 3 years
See attached Line-item breakdown of revenue and expenses, including individual project team members' percent effort

Supporting Documents:

food_pharmacy_index.pdf

FIRE AT DGIM (Food Insecurity Reduction Efforts at DGIM for Staff and Residents

Submitted by Gina Moreno-John on October 21, 2022 - 5:04pm Last revised by Gina Moreno-John on November 29, 2022 - 5:18pm.

Proposal Concept: Length = 1-2 page Status:

Open

Food insecurity rates have been increasing in the last two decades and this has been exacerbated by the Covid-19 pandemic (Srinivasan 2021). For example, 50% of SF Food Bank clients did not use food programs before the pandemic (SF Food Security Task Force, 2022). Fortunately, food programs for patients are on the rise (De Marchis 2019).

The Division of General Internal Medicine (DGIM) at Mt. Zion has created a successful food bank for patients. However, healthcare workers are 5 times more likely to have food insecurity compared to clinicians (Srinivasan 2021). A new, ongoing survey of DGIM staff members, residents and fellows found that 42% had mild food insecurity and 27% had severe food insecurity. Appallingly, 71% of DGIM staff members (without resident or fellow data) have mild food insecurity and 48% have severe food insecurity. (See Phase 2 Information below, rates are lower with more surveys collected).

These are higher rates than our patient clientele. These are vulnerable populations hidden within our healthcare system because they are not patients. These rates are also higher than the San Francisco rates of 25% therefore this is an unmet need (SF Food Security Task Force, 2022). To our knowledge, there is only one published article on food insecurity among healthcare workers and no published articles on food insecurity among medical residents. There are no food programs at UCSF for staff members, residents or fellows. This will be a novel program and we will work to share our work with others over time.

Our DGIM food program for Staff, Residents and Fellows will include:

A weekly meal. Staff, residents and fellows will choose which meals (ie breakfast, lunch, or a combination), food sources, and types of meals ordered.
Weekly nutrition tips, cooking instructions, and menus. They will be culturally appropriate and budget friendly. This information will be prepared by Dr. Diana Thiara, Director of Culinary Medicine at DGIM.
A monthly $5 UCSF Cafeteria coupon to supplement food purchased at UCSF.
A $20 supermarket gift card in December.
Support for one Medical Assistant (MA) and one Nurse Practitioner (NP) to help run the program that is staff- and resident/fellow-focused.

Needs and perspectives of the intended beneficiaries have been integrated into the plan. As noted, this program is a direct action in response to input from staff, residents and fellows about their food security status. We will hire an NP and MA to lead staff inclusion. We will also work directly with residents and fellows working at DGIM.They will choose the dates, times for meal distribution, meal choices, and restaurants used.

List of Goals

Reduce food insecurity among staff, residents & fellows
Finish collecting Staff, Resident, and Fellow surveys; distribute the survey to faculty
Include all staff, residents, fellows and a DGIM Wellness champion in planning & executing this program
Distribute our program information to other MZ practices as well as other UCSF clinical programs
Write academic articles outlining our program as there are little or no publications on this topic
Look for sustained funding to continue this program

Summary of healthcare-related needs being addressed

Food insecurity is associated with poor health outcomes such as heart disease, diabetes and depression. It is also associated with missed primary care appointments, increased Emergency Room visits, and an increase in all-cause mortality. Reducing food insecurity reduces these risks. Thus, providing healthy meals for our employees is helping to improve their health-related outcomes

Partners

We partner with the UCSF Health Nutrition & Food Services department, to purchase UCSF Cafeteria Coupons. We will work with Christy Carrillo, CDM, CFPP, manager of the Mount Zion Café, who has already sent us information about ordering coupons and working with UCSF catering. We will purchase meals from Farming Hope, an organization that works with formerly incarcerated or homeless adults to create meals for food-insecure people in San Francisco. They offer job training and source “cosmetically imperfect” (read: funny-looking) produce. Other meals will come from restaurants chosen by our trainees and staff based on their preferences. If possible, we will target women- and minority-owned restaurants.

Evaluation plan

We created a questionnaire that includes the two-question Vital Hunger Sign, a validated instrument to screen for food insecurity. It also includes a USDA question about eating unhealthy due to financial constraints. These are quantitative questions. We asked if it would be helpful to have meals available at work and why (for morale, financial reasons or convenience). These are qualitative questions. We have collected 94 surveys to date and will continue to collect them until we reach 75% participation rate. We will create and distribute a follow-up survey that is more extensive. It will include questions about food insecurity, unhealthy meals, food budget, and satisfaction questions. We will also ask about gender, race and ethnicity, and job titles to further analyze demographics.

Name, title, division of individuals who will lead the project

Gina Moreno-John, Director of Diversity, Equity and Inclusion and Medical Director of the DGIM Food Pharmacy. She has been leading the DGIM Food Pharmacy since 2019 and helping 3 other clinical programs at UCSF who have started clinical Food Programs.
Diana Thiara, Medical Director of the Culinary Medicine Program in the DGIM Food Pharmacy and Medical Director of the UCSF Weight Management program. She created menus and food demonstrations with Culinary Medicine principles.
DGIM leadership has agreed to support this program.
A Medical Assistant and a Nurse Practitioner will be supported to help run this program.

MZHF values the project embodies

Service (Avodah): This project is serving residents and staff, who are vulnerable populations due to salary constraints.
Social Justice (Tikkun Olam): This project aims to reduce the inequity of residents and healthcare workers not having the same access to food as clinicians. In addition, DGIM staff are largely comprised of Latinx, African American and Asian employees, thus we are aiming to reduce racial and ethnic social disparities as well.
Community Building (Kehilah): We will build community and morale at DGIM with a food program for employees. 96% of survey responders say that having meals at work will be helpful for the following reasons, in order: Morale, Financial Support, Convenience.
Innovation (Hidush): To our knowledge, there are NO published articles about food insecurity among primary care healthcare workers an NO published articles about food insecurity among medical residents. The programs we develop will be the first of their kind and will be shared widely over time, at UCSF and disseminated through academic journal articles.

Plan for sustained funding

The Hellman Foundation is helping to support the DGIM Food Pharmacy and we will discuss expanding support to include staff members, residents and fellows. UCSF leaders have expressed support for food programs at UCSF. We will continue to engage them to create future, ongoing support. Finally, Gina Moreno-John is meeting with Janna Cordeiro from the SF Department of Public Health to discuss programs potentially tailored to support this effort.

Project start date and duration (earliest start date is January 1, 2023): February 1, 2023 – January 31, 2026.

Estimate of total budget requested from MZHF: $149.350 annually (see new amount below in Phase 2 Info below)

Applicant

Gina Moreno-John, M.D., M.P.H., Professor of Medicine, Division of General Internal Medicine.
Community Partner Affiliations: 1) Food as Medicine Collaborative of the SF Department of Public Health, 2) Farming Hope.

Contact info:

DGIM, 1545 Divisadero St., San Francisco, CA 94115
Gina.Moreno-John@ucsf.edu
(415) 652-8299

PHASE TWO INFORMATION INCLUDING NEW BACKGROUND INFORMATION AND SURVEY DATA

1. Background Introduction and Survey Data

Food insecurity is defined as a lack of consistent access to enough food to live an active, healthy life according to the USDA. In 2013, one in four San Francisco residents were at-risk for food insecurity. The number is higher due to the Covid-19 pandemic. In a recent San Francisco Marin Food Bank (SFMFB) survey, half of the respondents had not used food programs prior to the pandemic and 72% stated that they have not recovered financially after losing a job or earning less money due to the pandemic. The SFMFB has given out 67% more food in the last year (2021) compared to the year before. The number of SF residents on CalFresh (a federally mandated food program for low-income people) has increased by 40% (SFDPH, SFMFB). Unfortunately, many workers make incomes that are too high to qualify for assistance programs but are too low to meet the food needs of their families and even with stable incomes; rising expenses make food insecurity more likely at any given income level (Srinivasan). It is critical to address food insecurity because it has been identified as a social determinant of health and has serious implications for mental and physical health. People with food insecurity have a higher risk of obesity, chronic diseases such as diabetes, heart disease, and hypertension, malnutrition and depression, among other medical conditions(Holben, SFMFB, Srinivasan).

Risk factors for food insecurity include low wages, a high cost of living and lack of affordable housing (Feeding America, SFDPH). Unfortunately, even when food programs exist, people may avoid utilizing resources due to the associated social stigma and shame (Gould-Werth, SFDPH). There is a misconception that individuals experiencing food insecurity are homeless when in fact, only 5% of clients at the local food bank are unhoused (SFMFB). Children, seniors, single parents, unemployed persons and low-wage workers are the majority of clients at the SFMFB. National studies identify these other populations as high-risk for food insecurity: pregnant women, low-income families with children, immigrants, residents of single-room occupancy hotels, African American, Latinx, Native American populations, LGBTQI+ group, people who identify as non-binary, as well as people with disabilities (Cerasani, Riddle, Goldric, Coleman-Jensen). Food insecurity is a health issue as well as a racial and social justice issue.

Food insecurity is a pervasive issue in healthcare affecting not only the patient populations but also healthcare employees who are staffing these clinical practices. In addition to patients with food insecurity at the Division of General Internal Medicine (DGIM), many DGIM staff members and internal medicine residents experience food insecurity. DGIM leadership will address this issue by 1) ordering meals at more DGIM and staff meetings, 2) requesting that faculty members order food for small group meetings when they can, 3) streamlining the process by which faculty members are reimbursed when ordering food for meetings, 4) supporting the publication of a DGIM cookbook that includes a “budget tip” from each member and 5) discussing this issue widely among all DGIM members to create group solutions for this critical problem. With support from the Mount Zion Health Fund, we will build off of the successful DGIM patient Food Pharmacy as we create a novel program with meals, food coupons, nutrition and food budgeting education for the people who keep DGIM doors open and working. This project will re-affirm DGIM as a leader at UCSF in addressing social determinants of health for all, including residents and healthcare staff.

Health Care Worker Food Insecurity

To our knowledge, only one study has reviewed food insecurity among health care workers. In a study of 5,516 healthcare workers in hospitals, ambulatory care facilities and residential care facilities, the food insecurity rate for diagnosing/treating clinicians was 1.7%, and 19.7% for health care support workers. Food insecurity rates were also higher among health care workers with children than among those without (Srivinasan). The healthcare industry is the largest employment sector in the U.S. and the wellbeing of healthcare workers impacts the health of patients, making this a critical issue (Srinivasan, Sunesan).

At DGIM, staff member salaries range from $40,000 per year for Medical Assistants (MA) to $160,000 for Nurse Practitioners (NP). We found an initial mild food insecurity rate of 71% among staff members. It is now much lower. We hypothesize that staff members with the most need responded to the survey right away. Later, as Nurse Practitioners and Staff Managers also responded, the rate fell. In the future we will separate staff members by job title as many likely have much higher rates of food insecurity than seen here. The current rates of food insecurity found in 84 DGIM staff respondents (67% participation rate) is seen below (Table 1). For comparison, there is a 3.7% food insecurity rate among DGIM faculty members.

TABLE ONE

SURVEY QUESTION	DGIM STAFF	Interpretation
In the last year, have you worried whether your food would run out before you got money to buy more?	25.6%	Mild Food Insecurity
In the last year, has the food you bought not lasted and you didn't have money to buy more?	20.3%	Severe Food Insecurity
In the last year, have you ever had to eat an unhealthy meal because of money concerns?	18.6%	Unhealthy Diet
Would it be helpful to have occasional free meals offered at DGIM?	97.1%	Preferences

Resident Food Insecurity

UCSF medical resident salaries are $5,363 per month. Average student loan debt payments are $2,480 per month and average rental prices in San Francisco are $2,356 per month (educationdata.org, rent.com). After paying rent and student loans, residents only have $527 monthly for utilities, healthcare, clothing, household goods and food. The average resident does not have enough income to meet the cost of living for a single person in SF, especially if they have student loan debt (numbeo.com).

Despite both professional decrees stating that a healthy diet is essential for resident wellness (ACGME 2022, Parsons) and residents’ beliefs that their eating habits are vital to their well-being as physicians (Diaz Baez), there are no studies in the literature reviewing food insecurity in medical residents. Medical students are believed to have a food insecurity rate of 28%, but no data exists as of now for medical residents (DeMunter).

At UCSF, residents get $240 per month for food when they are working at the UCSF hospital on Parnassus Avenue. They get substantially less when working at the VA Hospital or the Zuckerberg SF General Hospital. When working in ambulatory clinical rotations, they get even less. While local leadership hopes to address this element of resident wellness by appropriately advocating for healthy food programs (Montgomery), a gap currently exists in ensuring residents are food secure.

A total of 72 UCSF internal medicine residents care for patients in the DGIM practices. A recent all-clinic survey at DGIM found significant food insecurity rates in 52 resident respondents (72% participation rate) below (Table 2). For comparison, the same survey found that DGIM Fellows have a 0% food insecurity rate.

TABLE TWO

SURVEY QUESTION	DGIM RESIDENTS	Interpretation
In the last year, have you worried whether your food would run out before you got money to buy more?	16.4%	Mild Food Insecurity
In the last year, has the food you bought not lasted and you didn't have money to buy more?	10.6%	Severe Food Insecurity
In the last year, have you ever had to eat an unhealthy meal because of money concerns?	31.7%	Unhealthy Diet
Would it be helpful to have occasional free meals offered at DGIM?	98.1%	Preferences

2. Specific aims

Aim 1. Assess Needs and Trends: collect Staff, Resident, Fellow and Faculty Food Insecurity rates at DGIM. We created a survey that includes the two-question Vital Hunger Sign, a validated screening instrument for food insecurity. We also included a USDA question about eating unhealthy foods due to financial constraints. This survey is on-going, and we will continue to collect responses until we have at least a 75% participation rate among staff members and residents. Before we begin distributing meals to residents and staff members, we will create a new baseline food insecurity questionnaire and collect data by job title, gender, race, and ethnicity to further analyze demographic differences. Among staff, we hypothesize that staff members with lower incomes (ie MAs) will have higher rates of food insecurity than NPs. A follow-up survey will be conducted at 12 months. Evaluation Summary: data analysis will be performed on the current screening survey, the upcoming baseline survey and the 12-month follow-up survey for trends on food insecurity at DGIM.

Aim 2. Reduce food insecurity among DGIM staff members and residents. This aim will be achieved with a combination of free meals and UCSF cafeteria coupons and food budgeting information. Below is a summary of the program we will implement. We will work with community partners from Farming Hope, the UCSF cafeteria program, and caterers and restaurants. We will include all staff, residents in planning & executing this program. Evaluation summary: We will measure participation by tracking the number of meals and coupons dispersed. We will send a follow up survey at 12 months to assess employee satisfaction with the program and success in reducing food insecurity.

PROGRAM SUMMARY

- For DGIM Staff Members: Take-home meals from Farming Hope twice a month, Restaurant meals once a month and $11.00 UCSF Cafeteria Coupons once a month. Total: equivalent of 4 meals a month

- For DGIM Fellows: Take-home meal from Farming Hope monthly

- For DGIM Residents: $25 UCSF cafeteria coupons or 2.5 meals per month every month OR 6 meals per month when they are based at DGIM. This will be based on resident preference. Total: equivalent of 2.5 meals each month or 6 months when working at DGIM

- For 5 DGIM Staff Consultants: $200 Supermarket gift card each, once

Aim 3. Improve DGIM employee understanding of the impact of food on health outcomes. Nutrition education and resource management skills can improve food security and healthy eating. One randomized intervention study of a low-income population found that nutrition education, which included information about food preparation and budgeting, improved food security status (Eicher-Miller). A second study of low-income residents who received the USDA’s Expanded Food and Nutrition Education Program also demonstrated increased food security (Farell). By providing staff and residents with programming that includes nutrition tips, meal plans, budgeting skills, and cooking demonstrations (building off of other nutrition pilot programs for patients at DGIM), we hypothesize that increased education around nutrition and resource utilization will also address food security. Evaluation Summary: We will administer a baseline and follow up survey with questions regarding patients’ fruit and vegetable intake and self-efficacy regarding the use of food as medicine, to evaluate a change in knowledgeabout healthy nutrition.

Aim 4. Distribute program information to other MZ practices, UCSF residency programs and to other clinical practices outside of San Francisco. As there is limited literature addressing the important issue of food insecurity among healthcare staff members and residents, we will publish our findings and program data through UCSF newsletters, peer-reviewed articles, academic conferences like SGIM and ACP, and medical-related and mainstream social media platforms. Evaluation summary: we will evaluate our impact by the number of citations and requests for information for other practices and programs.

Aim 5. Secure funds for program sustainability. Janna Cordeiro from the Food as Medicine Collaborative, supported by the SF Public Health Initiative, will look for programs potentially tailored to support this effort. The Hellman Foundation is helping to support the DGIM patient Food Pharmacy, and we will discuss expanding support to include staff members and medical residents in the future. UCSF leaders have expressed support for food programs at UCSF, and we will meet with executive leadership to review the data for food insecurity among staff members and medical residents. We will continue to engage them to create future, on-going support. Evaluation summary: We will evaluate the impact of our program by the number of ambulatory practices and residency programs at UCSF who collect food insecurity data on staff members and medical residents.

3. Anticipated benefit for underserved or vulnerable communities in San Francisco

Helping people become less food insecure means that adults are less likely to eat one meal a day, ration their food or purchase fast food in order to make food last. Ensuring staff and residents are food secure means adults are not forced to choose between spending money on rent, utilities or medical care over food. In light of the aforementioned data [EK10] that food insecurity has a disparate effect on communities of color, our program would address health implications of food insecurity and thus improve glycemic control and increase patients’ fruit and vegetable intake, self-efficacy, and medication adherence. When patients are food secure, there is less emotional distress. Reducing food insecurity also reduces associated risks of acute and chronic diseases, reduces no-show rates at medical appointments, and reduces Emergency Department visits.

Another benefit includes higher morale. Approximately 96% of DGIM survey responders say that meals at DGIM will be helpful for the following reasons, in order: Morale, Financial Support, then Convenience. We also expect increased employee engagement. Addressing occupational stress especially as related to an identified inequity is known to result in higher employee engagement (Qualtrics). Finally, there is an anticipated benefit to DGIM patients. As healthcare workers’ health and morale improve, they can provide better care to patients.

4. How the project addresses UCSF Mount Zion priorities and compelling San Francisco healthcare needs.

Healthcare workers are a vulnerable community. Women are overrepresented in the US healthcare workforce, accounting for nearly three-quarters of this group. Women of color are more likely than White women to have low-wage positions in healthcare (Srinivasan). As noted, people of color are more likely to be food insecure than their white counterparts (Coleman-Jensen). This is related to income inequality. In SF, the White population makes almost twice the income of those in the next highest group (Asians) and almost three times the income of Native Americans, Latinx and Black/African American populations (SFHIP).

At DGIM, there are higher representations of Asian, African American and Latinx staff members compared with physicians. It’s disheartening that just over 1 in 4 DGIM staff members have food insecurity, higher than the rates found in the one published article on this topic. This rate mirrors the SF rate of 25% and it is considered an unmet need (SFDPH). DGIM staff members are an especially vulnerable population hidden within our health care system because they are not patients whose needs and gaps in care are regularly tracked.

The SF Food Task Force and the SF Health Improvement Partnership (SFHIP) mandate that we focus on critical food programs to help communities of need to obtain nutrient-dense, culturally relevant food (SFDPH, SFHIP). Bringing food through our innovative program to DGIM staff, who are mostly women and are racially diverse, addresses an important SF healthcare need.

Our program also reflects MZHF values by improving the physical, financial, and emotional health of DGIM staff members and residents, both vulnerable populations in SF. As noted in our proposal, this project also aligns with core values rooted in the history of the MZ hospital: Service (Avodah) serve residents and staff who have financial and food constraints; Social Justice (Tikkun Olam ) reduce inequity for healthcare workers, residents and fellows; Community Building (Kehilah) build deeper community and improved morale at DGIM; Innovation (Hidush) create one of the first food programs for healthcare workers.

5. Type and duration of campus-community partnership

We have been working with the Food as Medicine Collaborative (FAMC) since the summer of 2019 before we opened the DGIM Food Pharmacy. We begain discussions first with Erin Franey and now with Zoe Womack and Janna Cordeiro. The FAMC is supported by the SF Public Health Initiative. They offer expertise in running patient Food Pharmacies, write grants to support our food programming and distribute funding for produce for Food Pharmacy patients. We have been working with Farming Hope for 12 months. They provide take-away meals onc a month for our Food Pharmacy patients since January 2022. By working with Farming Hope, we also support their mission of training formerly incarcerated and/or homeless clients to build business and restaurant job skills.

6. How the community partner's experience and expertise was integrated into proposal development

Farming Hope works with formerly incarcerated or formerly homeless adults to create meals for food insecure people in San Francisco. They offer job training and source “cosmetically imperfect” (read: funny-looking) produce. Farming Hope has given us a list of their typical meals to make sure that they are healthy and acceptable to our clients. They offer vegetarian meals when requested. They have reassured us that they have the resources and personnel to create meals for our staff members and medical residents as well as our Food Pharmacy patients.

We will also partner with the UCSF Health Nutrition & Food Services department, to purchase UCSF Cafeteria Coupons. Christy Carrillo, CDM, CFPP, manager of the Mount Zion Café, sent us information about ordering coupons and working with UCSF catering. We integrated her suggestions into our budgeting plan.

Other meals will come from restaurants chosen by our trainees and staff members. If possible, we will target women- and minority-owned restaurants. We will listen to their expertise when creating meals and menus for DGIM employees.

7. For each community partner (if applicable): Farming Hope

See the attached IRS exemption letter verifying 501(c)(3) status for Farming Hope
Farming Hope Board of Directors:
- Lyndsey Boucherle
- Shelley Dyer
- Michael Fu
- Lucia Gaia Pohlman
- Xochitl Hernandez
- Sheena Jain
- Ilana Lipsett
- Savannah Schoelen
- Salim Zymet

8. Total proposed project budget with justification

Justification: we have several leaders for this new program: A medical director responsible for overseeing the project, creating and analyzing surveys, and disseminating academic information. Two residency directors who will share responsibility to work with residents and their schedules to distribute food. A Wellness Champion who is also a staff member to oversee distribution of meals to staff members. A nutrition specialist to create education for all DGIM members. The majority of the budget will be to purchase food coupons and meals. We will distribute 1 meal a week to staff, 2.5 meals a month to residents when they are working in clinic, monthly meals to fellows, and supermarket gift cards for the 5 DGIM staff member consultants.
Requested grant period: 2023 - 2026
Line-item breakdown of revenue and expenses, including individual project team members' percent effort included in budget

Supporting Documents:

Index

Farming Hope 501(c)