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C3: Community-Centered Care

C3: Community-Centered Care

There’s a difficult question facing health officials in Kansas City and across the country: how do you help patients get healthier and prevent their costly visits to emergency rooms? The ER is always the right choice in urgent health situations. But many visits can be prevented with smart primary care, nutrition and chronic disease management. A national dialogue surrounds this public health question — and here in Kansas City, the C3 program at Rodgers Health is part of the answer.

C3 — which stands for Community-Centered Care initiative — is a joint initiative with the Housing Authority of Kansas City, Truman Medical Center (TMC) and Rodgers Health. Program participants reside in two housing developments near Rodgers Health. Both are in the 64106 zip code, which has some of the highest rates of Emergency Room (ER) usage in Kansas City.

“C3 is all about empowerment,” says Paula Cousins, Director of Population Health. “The intent of C3 is to help these residents identify and access the health resources they need — both to minimize ER visits and maximize long-term health. Our ultimate goal, going back to the zip code, is that by embedding this team and helping people navigate, we might make a dent in ER usage. And we really have done that — we’ve seen great outcomes.”

A nurse care manager, a social worker and a behavioral care coordinator make up the C3 team. Residents might need a doctor or dentist, and some need food pantry access or utility assistance. The C3 team works with residents to assess needs, then help them navigate the path to care, removing barriers along the way. And since the Housing Authority bolsters C3 with space at community centers for screenings, coaching, education and offices, residents find support literally in their own backyard.

At the heart of C3 is education. Topics span the healthcare landscape; residents have experienced everything from cooking demonstrations and nutrition classes with Harvesters to a “What to do when your child is sick” course in partnership with Children’s Mercy.

Many C3 participants are immigrants and refugees, and sometimes barriers to primary care lie in cultural differences. Navigating an American grocery store, for example, can be challenging for immigrants — but it can make all the difference in family nutrition. That’s why some C3 programs are cultural in nature. A recent class about how to stay healthy during Ramadan, the Islamic holiday of fasting and feasting, was very popular.

Keeping chronic diseases in check drives lower ER usage, so it’s a key aspect of C3. “We aim to help those with chronic diseases be better able to manage,” Cousins says. These include diabetes, overweight/obesity, anxiety, asthma, hypertension, depression and PTSD (especially among refugees).

In helping residents get and stay healthy, there’s a stronger fabric growing between residents in the C3 program. Recently, a strong friendship was forged over the common goal of disease management. “One tenant who wanted to attend our classes had mobility difficulties, and to go from her apartment to the community center was more of a walk than she was capable of. We got approval to borrow a wheelchair from one of our clinics to get her to the class,” Cousins said.

It just so happened that her neighbor, who she’d never met, was in the class. Now, they’re great friends.

“They’ve formed a tight and supportive relationship, and now both are doing really well and encouraging each other,” Cousins says. “We don’t know that they would have met otherwise, but they’re a source of encouragement to each other.”

C3 has been remarkably well-received among residents. That Ramadan Health class, led by our partners at TMC, was so popular that an encore was requested — families wanted to learn nutrition not only during Ramadan, but during the whole year. So another class was held, along with a Mobile Market healthy food cart to overcome the food desert in their neighborhood. Also coming up is a class pairing nutrition and literacy, with a special emphasis on seasonal produce.

C3, at its core, is a KC-wide endeavor. “We work with so many different partners, from Harvesters to the United Way to the Kansas City Public Library. The team just amazes me with the programs they’re finding and partnering with. They’re always looking for ways to address the needs of the people they are working with. C3’s success is a testament to them.”

For Cousins and the C3 team, a strong example of the program’s success can be seen in a resident’s smile. The team repurposed funding to offer dental care scholarships to several tenants with severe dental issues — after all, the smile is one of the first things people see when they meet. “Now with the dental work she needed, she’s in medical coding training with a major insurance company here in KC. She’s setting herself up for a new career, and has her hope reinstilled. It’s a whole new world for her.”