Wednesday, May 28, 2008

What I Learned in West Virginia: Build It From the Ground Up!

As a District CATCH facilitator for the AAP,  once or twice a year, I get to visit projects funded through the Healthy Tomorrows program of the Maternal and Child Health Bureau of your Federal Government.  The programs work well, as you will see in a soon to published article in Pediatrics.  I've been to programs in Rhode Island, Massachusetts, Idaho, Mississippi and Hawaii over the past few years-  learned much from all of them.  But somehow this visit in West Virginia, one of the poorest states in the nation, really showed me how community and common sense can do a lot of good. The CARES project has the potential to really help a lot of kids in that part of the universe, and has something to teach us as we develop collaborative efforts in the provision of mental health services in the Rosie D. Settlement.

They began by telling us about the cultural landscape (I wish that I could post their slides- it was masterfully done):

The ten values common to Appalachians which should be considered for culturally appropriate health care include:
  1. Individualism, Self-Reliance, Pride- most obvious characteristics; do things for oneself while not wanting to be beholding to others
  2. Religion- determines values and meaning to life; fatalistic outside factors (fate) control one’s life; believe things happen for a reason and will
  3. Neighborliness and Hospitality- help each other out, but suspicious of strangers
  4. Family Solidarity or Familism- family centered; responsibility may extend beyond immediate family; “blood is thicker than water”
  5. Lengths to keep from offending others; getting along is more important than letting one’s feelings be known
  6. Love of Place- never forget “back home” and go there as often as possible; sometimes stay in places where there is no hope of maintaining decent lives
  7. Modesty and Being Oneself- believe one should not put on airs nor pretend to be something you’re not or boastful; “don’t get above your raising”
  8. Sense of Beauty-displayed through folksongs, poems, arts, crafts, colorful language metaphors such as “I’m as nervous as a long-tailed cat in a room Full of rocking chairs”
  9. Sense of Humor-although seem dour, quick to laugh at themselves but do not appreciate being laughed at
  10. Patriotism-goes back to Civil War times; flag, land, relationships are important; shows up in community celebrations and festivals
-Jones, L. and Brunner, W. (2000) Appalachian values. New York, NY Berea Press

Then they told us how they wove that understanding of the culture into the fabric of their program design.  The project is called  
CARES (Coordinating Access to Resources and Emergency Services) and is a collaboration between the Department of Pediatrics at Marshall University's Joan Edwards School of Medicine /  Cabell Huntington Hospital and a variety of community and state agencies, notably the Huntington City Mission , to coordinate services for homeless children and children in foster care in Huntington, a city located on the Ohio River at the junction of Kentucky, Ohio and West Virginia.  The project hinges on two things:  an incredible Program Coordinator, who ensures that the partners collaboration happens, and the Parent Care Coordinators, who form the relationships that make the program work.  The program has been very successful in it's first year of operation, largely because of the wonderful relationship between the Clinic and the Mission.  Why is that?  Because, in the context of Appalachian culture (see above), it really all about relationship, and these folks have incorporated this into the core of their program.

What they, the Parent Care Coordinators, stressing their description of the program was that the CARES Project, if it was to work, needed people in the project to actually care about the families that they were trying to help in a real way, respecting them within the language and culture of Appalachia.  They saw their job as the key to that relationship:  they HAD to see the homeless family as a family, paying attention to what the family had to say and listening for a while before offering assistance.  Their first question was always: “Are they from this area?”, paying close attention to ties of family and land and acknowledging the courage needed for an Appalachian family to ask for help outside of kin.  They sat with families, at the mission, for hours, listening, taking notes, and emphasizing the strengths that the family brings to the relationship that is going to develop.  After working through that process, then they discuss the types of services available within the CARES project, and the relationship that could be forged with the "Medical Home" in the Primary Care Clinic.  They build on the respect afforded these families by the Mission, and tie that into a relationship that allows them to make their program happen.

One of the keys to their success has been the partner for this initial phase of the program.  The Huntington City Mission is a non-denominational Christian organization that has built a reputation for care for the Homeless of Appalachia over the last 60 years.  They are part of the fabric of the community of Huntington, and, by partnering with them, the medical folks have unbelievable access to the community.

So, what does all of this mean for the future of the Rosie D settlement?  First and foremost, it reminds us that as we are building CSAs and EMH mobile teams and Parent Partners, we absolutely MUST respect the culture and relationships that exist already within the communities of Massachusetts.  Worcester County needs to be served by a Worcester agency, if they are are to build on the relationships necessary to this work.  Second, it really needs to role out in stages.  Initially these folks were going to take on homeless and foster children at once, and their advisory board wisely set them on another course.  Finally, we need to listen the parents in order to make this work.  Sometimes that is hard, especially in the DSS involved families.  But we HAVE to do it, or the whole thing is as fleeting as the fog rolling through a West Virgina hollow.

Nice work, CARES PROJECT.  Thanks for letting us visit.

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