Table 3 Major Themes and Quotes

Client-centered- Holistic understanding of clients and communities

“...the [clients’] lack of community often creates a level of fear, anxiety, and distrust that makes us have to engage this individual at least a half-dozen times before we can have a simple breakthrough like eye contact or, for that matter, dialogue.” – Frontline provider

Continuous system- multiple entry points, active outreach and engagement efforts, and comprehensive needs assessment based on clients’ priorities and eligibility for programs

“Because of the vulnerability of the people that we work with …. establishment of eye contact, and conversation is necessary for anything to begin. … in order to establish a level of contact, which is very seriously missing … .it’s important to understand that engagement with individuals relies on a consistent approach that does not provide barriers or judgement or rules that more often than not people have encountered when approaching service providers. … Start from a basic, very human level of understanding where people can communicate with each other pretty easily, we are confident those engagements will open a series of doors that will allow for us to better understand what a person needs.” – Executive     

“… it’s about going to them and being consistent and building the trusting relationship” – Management       

“… connecting with them where they’re at. Providing them with whatever service they need in the moment, and sometimes it’s just a cup of coffee and a bag of beef jerky.”- Frontline provider

“...walk them down the path, get them document ready, get them socially ready, get them ready mental health-wise …. Get them clean and sober.” – Frontline provider

Dependent on regional partnerships- service network to meet comprehensive clients’ needs

“If we refer somebody … we are there to support them and vice versa … agencies are really collaborating … there’s a system” – Management

“We’re built on collaboration, so we’re built as an organization to be a collaborative group. So, we divide up the cities in our area and say different organizations are the lead … [We] have multiple avenues of case conferencing, different committee work … we conference on our outreach clients … talking about who’s had interaction with these individuals? What’s the progress that you’ve seen? What are the challenges that you’ve seen? Oh, we’ve been able to make movement here. Okay, so it sounds like you have a better connection with that client; how do we support you in that instead of trying to be a different connection?” – Management

“sometimes … we might be providing the same services [as another agency], but there might not be connection between the worker and the clients. So whoever this person feels comfortable working with … (s) he has a chance to kind of choose. Because before it was like you work with one agency and you didn’t like the person, and sometimes that was the challenge because they didn’t want those services because there was no connection.” – Management

Benefits:

• Expand partnership networks

• Funding for social care programming (new services/resources)

• Employing those with lived experiences (Collaboration Team, patient navigators, and CHWs)

“Conceptually, the idea behind Whole Person Care, being able to … Be the person to kind of hand hold them through connecting with some of these resources. We thought that was brilliant. Brilliant!” – Frontline provider

“[WPC-LA programs] are taking the time to address all of these various groups of individuals that are a very vulnerable population. …. to try and create a system of care to address those needs …. that is fantastic and really necessary.” – Executive

“[WPC_LA is] one of the best changes that we’ve had in the justice system. Somebody finally woke up and said, “Look, what’s happening isn’t working. The way with things are, isn’t working.” I’m really, really happy to be a part of this community and to help it grow … I think it’s a new approach that is long overdue. It’s long overdue.” – Management

“the community health workers, who they are employing …. When I mention that to prospective clients … [that they will be] working with somebody who has lived experience and is just paying it forward and now they’re employed and—you could see their reaction … To feel like you can relate and somebody that can relate to you—you can’t measure that.” – Management

Challenges:

• Communication issues

• Overlap with CBOs work

• Continued limitation of “end” resources

“it was a little confusing in the beginning. It was a new program and so it wasn’t, like, clearly defined what exactly they were doing” – Management

“the lack of quality referrals …. we’re targeting the most vulnerable folks and it’s like these folks are already in bad spaces. It doesn’t take a whole lot to disappoint a disappointed person. You know, there’s a description in the Bible that says, “Hope deferred makes the heart sick, but a desire accomplishes a tree of life.” And I think we’ve deferred a lot of hopes.” – Executive 

“[they are] still trying to figure out what they can support us in that’s different than what we already do.” – Management

“We often don’t feel that our voice is heard and that we are often dealing with the consequences of decisions that are made by others that force us to have to restructure or retool what we do.” – Executive

“if the resources were actually out there, then we’d probably go straight to that resources as opposed to using them [WPC-LA} as a middleman.” – Management

“there’s all this emphasis on, quote, “systems” and “structures,” but none of this works unless I know somebody else’s name. … always dissolving into personal relationships, but also because of contracts and because of the official rhetoric around things, having to … give the illusion of a functioning system … .this isn’t a “system”, especially if getting somebody connected to services … is different every single time. You cannot predict timelines … predict quality of service …. hold anybody accountable …. really when people say “system,” I think what they actually mean is … very slowly prioritized services … prioritization are really just conversations about lack of resources …. you wouldn’t need to prioritize people for anything if it was all available …. conversations about systems are conversations about priority, which are ultimately conversations that you’re having when you’re not having a conversation about the allocation of money and resources.”- Management

• Build a more equitable partnerships with the healthcare sector

• Improve communication

• Advocate for continued funding to support their integrative work

“we need other parts of the system to radically change and alter what they do … unlearn what they’ve done for 50 years and retool themselves to a new approach.” – Executive

“It’s hard for anybody to embrace change and so if you have a consistent figure, someone that you trust and that … who values the very things that we talked about as effective, collaboration, training, empowerment, consistency is really helpful. If WPC-LA wants to be successful, they need to really invent themselves in communities, show up to meetings, participate and be consistent.” – Management

“I would implore [WPC-LA] to … understand that the dedication of the people who do this work … we are in need of dialogue, inclusion, and some seat at the table in order to share … [the] perspective from the frontlines.” – Executive

… the “more people you have working in the system that do not have a relationship with the people on the street, the worse that system is going to function with people on the street.” – Frontline provider

“Let’s bring the resources … bring the Whole Person Care team actively into the community but let’s also make sure that the professionals in each area knows who their Whole Person Care person is, has access to them and that they also know because services are changing all the time … so they know what’s going on” – Management

“my biggest thing would be WPC-LA possibly asking the county for … more resources … people in the community are in need of stuff that we can directly hand to them.” – Management