January 2013 Caring for the Whole Person A Paradigm of Holistic Integrated Care The Jesse Tree Resource Coordination & Chronic Conditions Management Program Training Serving the Ineligible and Unfunded Caring for the Whole Person

January 2013

Caring for the Whole Person In the beginning…. In 2000, The Houston Food Bank approached The Jesse Tree and other local providers to consider hosting a “Food Fair.”. Each event: Provided up to 20 TONS of produce, Attracted up to 500 individuals representing several thousand family members, Created a “Farmer’s Market” style venue for healthcare screenings and social service information, Required demographic data collection and reports.

January 2013 Community Access Program At the same time, The Jesse Tree and other local healthcare providers had embarked on The Community Access program (CAP) to expand services to the uninsured. At that time: 38% of Galveston County residents were uninsured,  $40 MILLION in Food Stamp dollars and $200 MILLION Earned Income Tax Credit went unclaimed each year in Galveston County; 80% eligible seniors failed to apply for Qualified Medicare Beneficiary (QMB); 60% eligible women failed to enroll for Women, Infants, Children Program (WIC) – the numbers are staggering.

January 2013 CAP – cont’d  The obstacles to enrollment :  Transportation;  Translation/Interpretation;  Lack of ID’s birth certificates, etc.,  Complicated enrollment applications; 40% eligible applicants denied;  80% of Food Fair attendees and their family members were uninsured; over 60% readily indentified at least one chronic medical condition (hypertension, diabetes, etc.) and most represented two- (low) income households,  Who cares for the “un-fundable? The ineligible?

January 2013

on Services Added to Food Fairs NUTRITION Houston Food Bank-Produce distribution Lone Star Legal Foundation Food Stamp Outreach Network Texas A&M Cooperative Extension Service-Healthy cooking MENTAL HEALTH/SUBSTANCE ABUSE ADA Women's Center Bay Area Council on Drugs and Alcohol (BACODA) Pathways to Recovery The Gulf Coast (MHMR) Center TRANSPORTATION Gulf Coast (MHMR) Center "Connect" - Countywide Medical appointments The City of Galveston-Hurricane preparedness, Island Transit (citywide bus)

January 2013 on Services Added to Food Fairs – cont’d HEALTH & SAFETY AIDS Coalition of Coastal Texas (ACCT) American Cancer Society American Heart Association Bay Area Council on Drugs and Alcohol (BACODA)-Smoking Cessation Cancer Coalition of Galveston County CHIP (Children's Health Insurance Program) Chris Jackson Insurance Agency & UTMB, Geriatrics- Medicare Part D Coastal Area Health Education Center City of Galveston Emergency Medical Services-Vital of Life Enrollment Assistance Galveston Beach Patrol-Water Safety Galveston County Health District-Immunizations & Flu vaccines.

January 2013 on Services Added to Food Fairs – cont’d HEALTH & SAFETY – cont’d Galveston Fire Marshal-Fire prevention & alarm programs Gulf Coast Center-HIV testing Holy Trinity Health Care, AMED & Genesis Home health agencies: St. Vincent's Episcopal House Clinic, UTMB School of Allied Health Sciences students, Galveston County Health District, Stark Diabetes Center, UTMB-Blood Pressure, Glucose and Cholesterol screenings. Maternal/Child Health/UTMB St. Vincent's House WelCare Program and Clinic Save Our Sisters Breast Cancer Coalition Take Action Diabetes Education Texas Society to Prevent Blindness-Vision Screenings

January 2013 on Services Added to Food Fairs – cont’d EMPLOYMENT Christian Women's Job Corps Sunshine Center-Employment for people with developmental disabilities Texas Rehabilitation Commission UTILITIES Community Action Council-Energy Assistance Program Community Outreach, UTMB-Energy Conservation, reducing utility bills LEGAL SERVICES/CRIME PREVENTION/NEIGHBORHOOD IMPROVEMENT Crime Stoppers of Galveston Inc. Galveston Police Department-ID Theft Lone Star Legal Foundation Food Stamp Network Old Central/Carver Neighborhood Association FINANCES Consumer Credit Counseling Services University Federal Credit Union

January 2013

on Services Added to Food Fairs – cont’d THE JESSE TREE PROGRAMS Case Management, Chronic Conditions Management Classes, Diabetes Classes, Homeless Management Information System (HMIS)-Enrollment OTHER Area Agency on Aging/Dickinson Hearing Aid Services Ecumenical Network Participants-Blessing prior to food distribution Galveston County Emergency Communications District Galveston County Senior Services Galveston Housing Authority-Section 8 Applications Head Start-Early Childhood Education Holistic CDC/Literacy Galveston/Live Musical Entertainment Resource and Crisis Center-Crisis Intervention Social Security Administration Office /The Luke Society/ Veterans Services Voter Registration & Congressional Region Information Services

January 2013

Locations across Galveston Co. Eventually, Food Fair hubs were established at 18 different locations across Galveston County; Churches provide the venue and volunteers at no cost, Trained coaches provide Chronic Conditions Management classes, Jesse Tree provides electronic tools to screen, assess, create an adherence plan and begin enrollment on-site. Electronic, (wireless), case- management provides follow-up and maintains the files on each applicant. “ETO Impact (Efforts to Outcome)” a software by Social Solutions a robust central location for all data with an emphasis on performance measure- ments.

January 2013

The Houston Food Bank…

January 2013 Address ALL Chronic Conditions Chronic Social Conditions:Chronic Medical Conditions: Poverty Un or under-employment Homelessness Co-Dependency Hypertension (high blood pressure) Diabetes Cardiovascular disease (stroke/heart) Obstructive lung disease (including asthma) Caner Mental Illness/Substance Abuse/Stress Chronic infection and pain

January 2013 Natural Disaster Then along came Hurricane Ike…and a $2 million dollar loss…..

January 2013 “The Model Food Fair” The Houston Food Bank and The Jesse Tree are currently collaborating on the development of “The Model Food Fair” to serve as a site at which the integrated, holistic services can be observed and replicated. The project is called, “Cast your bread upon the waters…”

January 2013 The Jesse Tree "We see people; not problems": (409) "A shoot will come up from the stem of Jesse; from his roots a branch will bear fruit." Isaiah 11:1