Health Care Pathways in LA
New Apprenticeship Opportunities as an Industry ChangesAbout
New Apprenticeship Opportunities as an Industry Changes
This case study would not have been possible without the generous response of so many in LA. We also extend our heartfelt thanks to all who were interviewed for this case study, including Diane Factor, Isabel Shawel, Janet Palacios, Jessenia Garcia, Wendy Morales, Adriana Pacheco, and Shani Byard. We are also grateful to Diane, Jessenia, Adriana, and Shani for their contributions and careful attention during the editing process. WERC oﬀers tremendous thanks also to The California Endowment, who matched LA Care’s funding and made WERC’s EMT and CHW programs possible.
At COWS, we thank the Andon Group, LLC for their research and writing on this report and we are grateful for the attentive work of our colleague Emily Miota for design and layout of this report.
Of California’s forty million residents, ten million reside in one county– Los Angeles. Reflecting the statewide trend, LA County’s Medi-Cal population exploded following the passage of the Affordable Care Act. The hospitals and clinics of LA’s safety net healthcare system faced an influx of nearly one million new Medi-Cal recipients. Many of these patients had endured unattended medical and behavioral health conditions for years, and knew very little about managed healthcare systems. Studies also indicated that patients experiencing multiple chronic conditions alongside challenges to employment, housing, food access, and personal safety may over-utilize emergency rooms and avoidable hospital stays. Patients needed a knowledgeable and trusted advisor with shared culture to help them navigate the system, comply with their care plan, and alleviate the social determinants affecting their wellbeing.
Community Health Workers, also known as Promotores de Salud (health promoters) and Care Navigators, are one solution. Once found primarily in community-based and public health programs, the Community Health Worker (CHW) is now a high-demand occupation in medical and primary care facilities. As non-licensed health professionals, CHWs work within a multi-disciplinary, patient-centered medical home team. Unlike physicians or nurses, CHW’s can dedicate time towards building trusted relationships with high-utilizer patients that focus on prolonged issues and concerns affecting compliance with a care plan. Given their extensive training in communication, empathy, and cultural humility, CHWs are often better prepared than clinical staff to provide this level of support.
The Worker Education and Resource Center (WERC) is a leader in preparing frontline healthcare workers who share cultural affinity with LA’s patient populations. WERC recruits low-income and at-risk young adults needing access to occupations that lead to career pathways. In partnership with LA County’s safety net healthcare employers, including public and non-profit community based clinics and health centers, WERC has recruited and trained over 230 community health workers to deliver services in their own neighborhoods. Influenced by behavioral health models valuing peer-based service, WERC’s Community Health Worker Program serves as a model for efficiently and effectively expanding the healthcare safety net. The program is designed to maximize the documented efficiencies produced by having trusted, culturally similar health workers embedded within local communities.
To be effective, community health workers must bridge the gap between the patient and clinical staff. This requires an ability to establish rapport and trust, extensive understanding of the patient as an individual, and working knowledge of the resources available in their community. To access this necessary skillset, the Community Health Worker program recruits from local neighborhoods rather than the healthcare field. WERC focuses on training people with backgrounds similar to the patient populations they will serve. Many of the program participants were bilingual and had prior personal experience with the safety net healthcare system.
Read the full brief
The Care Navigator Apprenticeship
In conjunction with an advisory team, WERC issued a request for proposals from community health clinics to host two Care Navigator Apprentices. WERC then tailored the curriculum and recruitment criteria to fit the unique services and local characteristics of the selected clinics. WERC also serves as the apprenticeship sponsor and employer of record for the navigators.
To demonstrate improved efficiencies in healthcare delivery, WERC worked closely with L.A. Care to adapt the original community health worker model for a clinic environment:
• Formal registration of the apprenticeship
• Six to ten months of clinic service under the guidance of an onsite mentor
• Customized curriculum including in-depth health system knowledge
• Performance metrics tracked through a mobile case management system
My cousin has a friend who is a community health worker and gave me the information about the program. Word of mouth is what works for the recruitment. You know your friends, you know who has the heart for this kind of work.”
Janet Palacios, Cohort One Care Navigator Apprentice, Current Patient Navigator
The Care Navigator Apprenticeship program launched in July 2016. WERC recruited applicants through a network of community-based organizations allied with healthcare, community services, workforce development, and labor organizations. WERC also targeted public and community health agencies to attract candidates likely to succeed in the pilot program. Recruiting through existing community networks was effective: every apprentice selected for the program learned of it through word-of-mouth or an ally organization.
WERC used its in-depth assessment process from the Community Health Worker Program to select ten care navigator apprentices from fifty applicants. Candidates wrote a one-page narrative application explaining why they were a good fit for the program and describing their experiences with the healthcare system. WERC then screened applicants to ensure basic qualifications for the job and explained the criteria for selection, including cultural affinity, clinic needs, clinic culture, and performance on formal assessments. This hands-on selection process enabled WERC staff to match candidates to clinics where their lived experience and cultural background would serve as an asset given the needs of patients and local community.
Classroom training began in July 2016. The training used a peer-learning model to simultaneously deliver content knowledge and skill development. To support the Care Navigator’s dual roles as healthcare educator and advocate, the apprentices received extensive instruction in patient-centered healthcare delivery, managed care systems and insurance, and social service programs. Apprentices learned the value and skill of patient-centered language and code-switching: employing one communication style for professional audiences and another to build trusted relationships with patients. WERC further prepared apprentices for community-based practice by exploring concepts relevant to recipient populations, including cultural fluency, secondary trauma, homelessness, and LGBTQ+ health.
On the Job Learning
After graduating from the classroom training, the apprentices completed an onboarding process at their assigned clinic. Initially, they spent three days a week on the job and two days in the classroom. At the clinics, mentors worked with apprentices to train them on case management practices, and orient them to the professional culture and structure of the multi-disciplinary medical home team. Mentors also exposed the apprentices to the broader community health ecosystem, introducing them to allied social service organizations and helping them develop professional networks.
WERC’s high-touch mentor program provides critical support to apprentices as they adapt. Selected mentors have extensive practice expertise and relatable lived experience. They are also responsive, passionate, and generous with their time and advice. Mentors teach real-world skills by modeling patient management practices and guiding apprentices through patient cases. They instill the art of problem solving with compassion.
Technical training and guidance helped apprentices do the job, but emotional support enabled apprentices to stay on the job.
Some of our patients die, and it’s hard. Our work involves relationships and caring. Then, the people we’ve been caring about are gone. We don’t want to set our apprentices up for failure.”
Jessenia, Patient Navigator
Apprentices are taught boundary management and self-care as critical skills for the profession. Mentors provide real-time opportunities to discuss emotionally difficult cases, and instill self-care practices into daily check-ins and formal case review. By sharing their struggles, mentors create an environment for apprentices to share and accept help with theirs.
Homeless Services Program Coordinator & Care Navigator Mentor
“Jessenia knows what works because she’s had to deal with the issue before. She has a huge network of resources, and knows where there are services and how to connect people. Agencies are always shifting and closing but Jessenia knows what is available now for people.”
Isabel, Cohort One Care Navigator Apprentice
An LA native and first generation American, Jessenia brings professional and lived experienced to her position.
Jessenia Garcia joined St. John’s Clinic in 2014 as the Homeless Services Program Coordinator. This program runs mobile clinics for the homeless in Downtown and South Los Angeles. The clinic’s patients present both acute and chronic conditions requiring intensive case management, and many
face significant barriers to health due to generational poverty and toxic environmental conditions. An LA native and first generation American, Jessenia brings professional and lived experienced to her position. Jessenia’s sixteen-year career in social services has focused on some of LA’s most vulnerable populations, including interpersonal violence among homeless women and men and abused immigrants. Her parents’ experience as immigrants from Ecuador and Cuba allows Jessenia to recognize assets among the most marginalized, appreciate the struggle of survival, and understand the importance of a caring community. She teaches respect for the fortitude and ingenuity required to survive difficult conditions. Jessenia sees her role as “someone to talk to as issues with patients come up. No classroom training can prepare you for this work. The apprentices need a lot of guidance. They would have been lost without a mentor when first on the job.”
Jessenia’s long history with LA’s homeless population allowed her to efficiently assess the
apprentices’ ability to perform the work. The classroom training developed strong technical
skills. However, the apprentices needed a strong sense of compassion for and comfort among
the homeless, as well as an understanding of the broader social issues and networks impacting
the population. Jessenia used the probation period to expose her two apprentices to homeless
encampments and to policy meetings where she strongly emphasized their role as advocate.
The apprentices helped the mobile care team advocate for the homeless to receive free public
transportation to doctor’s appointments.
Jessenia’s two apprentices, Janet and Isabel shared the importance of having a mentor with real
world experience: “Jessenia knows what works because she’s had to deal with the issue before. She has a huge network of resources, and knows where there are services and how to connect people. Agencies are always shifting and closing but Jessenia knows what is available now for people.” - Isabel, Cohort One Care Navigator Apprentice
WERC staff also appreciated Jessenia ’s commitment to the program and her efforts to tailor the
apprenticeship training for the unique culture of the mobile clinic. Jessenia continues to help
WERC understand how best to set expectations and provide support to the apprentices. WERC
Founding Director, Diane Factor, notes, “Jessenia has great vision in that sense. She gives critical
feedback to the program, and will reach out to seek guidance from apprenticeship program staff.”
Leverage to Pursue Equity
When the Affordable Care Act increased eligibility and access for LA County residents, WERC began by assessing the problem from the employer’s perspective. L.A. Care clinics faced challenges applying a patient-centered medical home model to the influx of new Medi-Cal patients. After years of inconsistent health coverage, many of these patients experienced multiple chronic conditions and socio-economic barriers to health. They required in-depth health education and longer-term assistance.
However, the role and funding structure for medical home team members did not allow deep engagement. Adding entry-level Care Navigators to the teams presented a solution. The Care Navigators bridged healthcare and social services to provide dedicated assistance to the five percent of clinic patients utilizing fifty percent of healthcare services.
Individual clinics could not afford to prototype a Care Navigator model. Support from The California Endowment for curriculum development, training costs, and apprentice wages made the registered apprenticeship an ideal platform for placing navigators across L.A. Care clinics.
Employers want people with skills to be a value added, to be more cost effective, and to provide high quality care. We sold apprenticeship as a training model that delivers that.”
Diane Factor, Founding Director, WERC
Having offered a solution to a critical industry challenge, WERC gained leverage with funders and employers to design for equity.
Design for Equity
Experience with the Community Health Worker program helped WERC identify apprentice diversity as a shared goal of funders and clinics. To be effective, Care Navigators must gain patient trust quickly. Members of the local community who share cultural background with patients have a foundation for building trust. Most of the partner clinics are in diverse, low-income communities. The mobile Health Access Express Clinics serve Downtown and South Los Angeles where the homeless population is largely African American and Latinx. Care Navigators must understand people who are reluctant to confide in medical personnel, and need language and nonverbal skills that facilitate communication around difficult and frequently stigmatized issues of health history and safety. WERC, the funders, and clinics have united around the need to train Care Navigators that reflect the communities they serve. The partners all view diverse cultural background and lived experience as assets for doing the job and for yielding skilled professionals with compassion, respect, and relatability.
Cohort One Care Navigator Apprentice, Current Patient Navigator
Cohort One Care Navigator Apprentice, Current Patient Navigator
“The apprenticeship brought everything together—social work and healthcare. A good Care Navigator is compassionate, not judgmental, and willing to go beyond 9-5 for the patient. For me, the advocacy part is the most important part. There are a lot of barriers in this kind of work. You need to be willing to go through them.”
Janet Palacios, Cohort One Care Navigator Apprentice, Current Patient Navigator
Janet Palacios and Isabel Shawel worked for St. John’s Health Access Express Clinics as Care Navigator Apprentices. The apprenticeship provided both women with entry into community health work.
WERC has a long history of “targeting cultural affinity and lived experience so that you get workers who are like the patients and who understand having barriers.” —Diane. Most of the apprentices were low income or unemployed when the program started. Approximately 50% of the apprentices had a college degree but lived in underserved communities without access to career positions. The cohort was 70% Latinx and 30% African American. All the apprentices were bilingual Spanish speakers. WERC also selected apprentices based on age diversity. The majority (80%) of apprentices were aged 35 or younger.
By providing apprentices with clinic experience, the Care Navigator Apprenticeship serves as an entry point for healthcare positions with the County of Los Angeles and fills a critical gap for workers from low income communities. The professional experiences of the Care Navigator apprentices demonstrate how difficult it can be for people to get clinic experience. Apprenticeships breaks down that barrier, and the efforts of L.A. Care, the provider clinics, and WERC ensure the marketability of apprentices for county civil service jobs and for positions with other community health providers.
Proof of Concept: Success on the Job
In traditional clinic settings, Care Navigators have successfully filled the gap between health providers and social service agencies. Providers and medical assistants are better able to concentrate on health issues and patient volume when care navigators focus on the problems facing high-utilizers. They attend appointments with the patient, explain next steps, help complete paperwork, and provide referrals.
We try to understand what they are saying, and can take the time to solve the problem. Empathy is our job. Meeting patients where they are at is our job.”
Wendy, Cohort One Care Navigator Apprentice
The apprentices also help clinicians learn the social service aspects of healthcare. They reinforce the process of understanding and incorporating the cultural background and socioeconomic experiences of patients.
In order to collect and analyze performance measures, L.A. Care has extended the project and continued funding to cover the Care Navigator wage for an additional year. WERC will also provide continuing education and coaching for the Care Navigators.
The LA EMT Apprenticeship Prototype
With funding from the California Endowment and California Workforce Development Board’s Accelerator Grant Program, WERC recently prototyped a Los Angeles Emergency Medical Technician (LA EMT) Apprenticeship in partnership with LA County Supervisor Mark Ridley-Thomas’ Office and the LA County Fire Department.”
WERC Apprenticeship Innovation Framework
Apprenticeship is a training approach that happens within a context. It is this context that will determine the success of the program in delivering positive outcomes for workers and equity.
WERC’s context for apprenticeship innovation includes:
- Apprentice recruitment and training that utilizes lived-experience and cultural affinity
- Peer-based classroom instruction utilizing scenarios and clinic exposure
- Employer incentives such as subsidized wages
- Continuous improvement program design incorporating consistent funder, employer, and apprentice feedback.