Meeting Information

Meeting Type
Friday Coalition Meeting
Friday, 6/8/2018
9:00 AM
11:00 AM
Pathways program, Report on presentation to Human Services Select Committee, TCC programs for folks experiencing homelessness, and more
The Salvation Army Church


  • James Pogue, Comprehensive Life Resources
  • Listserv is public – no identifying information please



  • James – recently Comprehensive staff have had a bunch of pregnant clients connected with CLR – looking for resources we stumbled into ACH Pathways Program, so I invited them to come here and talk about it.
  • Liszet Chavez-Avila, Accountable Communities of Health - -  Community Engagement Coordinator - - 302.5508
  • From Arizona – moved here in 2013 – for school and to see rivers with water and hills with trees (flying in to Phoenix and seeing a brown landscape as far as the eye can see –it always makes me think that people shouldn’t be living there.  I love the desert, It’s a nice place to visit, but… –ed).
  • What are Accountable Communities of Health (ACH) (question for the audience. –ed.)?
    • Answer - decreasing 911 calls? Liszet - yes, that is one of the goals (person answering got a mystery prize from a bag.  I was envious. –ed).
    • Answer - Started from the Waiver to transform Medicaid? Liszet - yes, this all started from the Medicaid Waiver.  The waiver allows us to use Medicaid funds to do more innovative project and to work with all populations. (another mystery prize – what are they getting??? –ed.)
  • The ACH works to connect everyone working with patients together so we can serve our Medicaid population best.  Just because a client have access to healthcare doesn’t mean you will be healthy.  There are other barriers to health (like whipping cream tasting so good? –ed).  It can be housing or transportation or childcare. (well, yeah, stuff like that too, I suppose. –ed.)
  • Pierce County is 1 of 9 ACHs in Washington State.  Pierce County has 220,000 Medicaid clients.
  • ACH works to connect folks so all providers can all be on the same page in caring for folks.  Each type of provider has a different perspective, and we are working to bring all those approaches together for a patient health outcomes. 
  • 4 Main Projects:
    • Bi-direction integration of Care – primary care and mental health together
    • Community care coordination
    • Opioid crisis response
    • Chronic disease prevention and control
  • The State Health care authority proposed other programs, but the Pierce County board will be intertwining those programs into the 4 main project.
  • Pathways – what is it?
    • Resource for pregnant women?  Yes
    • Treatment? – no
    • It is care coordination – done with community health workers .  They are people who don’t do clinical work or treatment- they help clients know what resources they need, connect them to resources, even help them find resource.  They are not connected necessarily to a specific agency.  They work like a friend or a personal assistant to help clients organize – a bit like a navigator.
    • Started in Ohio 2001  – some providers saw patients were getting care – prescriptions for meds and such – but the clients were not following-up or seeing improvements in health.  Pathways model was created to fix this problem.
    • PATHWAYS HUB began in Ohio – now in Wisconsin, Michigan, New Mexico, (I put that last comma in but didn’t put in another location, so maybe it is in one or two other places with Pathways…-ed)
    • A “Hub” is a place people come to share information.
    • In Washington State – Pierce County is one of first counties to establish a HUB – it is exciting to be one of the first ones (like Beryl Markham – among other things, the first woman to fly solo across the Atlantic East to West.  If you’re looking for a good read, her memoir West with the Night is “a bloody wonderful book”, as Ernest Hemmingway put it.  If you can shake the cloud that hangs over Europe’s colonial past in Kenya, it is a superb story of adventure, a woman busting the social norms of the 20’s, and a zest for life.  She’s a truly gifted author, too.  If you liked Isak Dinesen’s Out of Africa, you’ll love this. Don’t bother with an audio book or kindle – this memoir was meant to be paper in your hand - -ed.).
  • Al – what is the difference between community healthcare worker, a navigator, and a case manager?  Liszet – interesting question – there is some discussion about what a community health care worker is.  A Community Health Care worker will help connect them to other resources usually outside of their own agency. 
  • Video ( ) – What is pathways community based care coordination?  A system designed to help folks connect better to the resources they need. Community Based Care Coordinators look at everything getting in the way of good health outcomes.  These barriers are identified and translated into pathways.  There are 20 core pathways:
    • Adult Education
    • Behavioral
    • Developmental Screening
    • Developmental Referral
    • Education
    • Employment
    • Family Planning
    • Health Insurance
    • Housing
    • Immunization Screening
    • Immunization Referral
    • Lead
    • Medical Home
    • Medical Referral
    • Medication Assessment
    • Medication Management
    • Postpartum
    • Pregnancy
    • Social Service Referral
    • Tobacco Cessation
  • Each pathways can be very complex
  • Pathways and progress are tracked electronically. 
  • Pathways are completed when cm verifies it is complete.  Document failures, too.
  • Community Based Care Coordinators receive at least 50% of payment from completing pathways.  A completed pathways means an identified risk factor has been successfully addressed or work was done but the risk factor was unable to be addressed. 

(I had to take a call from the Boss Man, so I missed a bit here. –ed.).

  • Step 1 – Find – work with clients to determine Pathways – work on things the clients want to work on
  • Step 2 – Treat – work through the decided on Pathways
  • Step 3 – Measure – see if pathways is complete or if another treatment is needed
  • Within one family alone, there could be 3 or more care coordinators working independently.  Pathways tries to help the family organize itself and centralize information, as well as not duplicate services
  • Work to supplement services already being received.  For example, if you work with a pregnant woman, that person may not realize they eligible for maternity support services (Maternal Support Services, if you are reading this, come and present at a homeless provider meeting –ed.).  If you do a Maternal Support Services assessment – you get assigned a level of resources based on the level of risk.  Those unit are often used up in a few visits.  With better care coordination provided by Community Based Care Coordination, Maternal Support Services can use their units just for the medical piece, and pathways can do the other supports that aren’t medical.
  • Within Pierce county, there are 4 care coordination agencies for pathways Community health workers 
    • Korean Women’s Association
    • Community Health Care
    • Sea Mar
    • HopeSparks
    • These Community Based Care Coordinators aren’t tied to specific agencies – they do work for agencies - but enter data in a centralized cloud based system.
    • Train Community Health Workers – they have an 8 week training with a practicum. 
  • Care Coordination agencies had a short time to get good staff hired, and they did a great job. 
  • Currently have 100 referrals for pregnant women.  Target is 250 at least.  That may seem like a lot, but nationally, the caseload for Community Health Workers is like 50. 
  • Tacoma Pierce County Health Department – focused originally on areas with low birth weight.  Used other risk criteria – past low birthweight child, past drug or alcohol use to determine who to help.  Focus  on patients with high risk. 
  • Can call or text 253-444-3070 to get resources (crappy photo of lovely flyer attached –ed).
  • Pathways is a care tool – translates risk factor into pathways to take action to address them.  Measure based on what worked. 
  • The community hub tracks the pathways – where all the data is stored.  Work to eliminate duplication – have a single location for referrals. 
  • Attempt to move from current system where different providers don’t know what services are being provided.
  • If a client signs an  ROI, we can show other agencies we are working with what the client is working on and the progress they are making. 
  • Marybeth – what if the client isn’t happy with the referral to one agency they receive?  Can they switch?  Also, you mentioned outcome payments are based on completed pathways, how does that encourage good outcomes?  Liszet – reward is for work done even if there is no outcome. We can switch an agency they were referred to if a client doesn’t like working with an agency.  If an agency is a barrier, we can move them to a different agency.  We are trying to get good information about what works and what doesn’t work – part of the purpose of the ACH community voice council
  • Patricia – is there support for terminating a pregnancy?  Lizette – yes, if that is the support they want we will work to supply it.
  • Al – There is a lot of overlap between what the case managers in this room do and the work of the Community Health Worker.  How would could someone become a community health care worker? Liszet- this is still a trial project, and want to make sure it works before adding more target populations. 
  • Questions – I Have a lady I discovered who is 5 months pregnant – they migrate around – not sure I’ll see her next week?  How to assist?  Lizette – we are focused on Pierce county – can help folks migrating in pierce county.  We’ll try to help someone stay in one place, and find out what they would need to get that.  Will work with them. 
  • Kenny – Peer counselors? Liszet -Community health worker in this phase I program only work with pregnant women
  • Charleen – just 4 zip codes or all county?  Lizette – it is all pierce county.
  • Question – how long after deliver is there support?  Liszet – for 2 months after delivery. 
  • Do you have a stock of housing?  Lizette – no, we do not have a stock of housing. 
  • James – if you have a pregnant client – Maternal Support Services and Pathways are both great places to refer clients. 


Presentation to the Pierce County Select Committee on Human Services

  • Cynthia Stewart – League of Women Voters
  • Talked about the presentation at the homeless forum in April
  • Talked about data about homelessness ( data at –ed.)
    • 10k people experiencing homelessness
    • 5k Mckinny-Vento homeless students
  • Homelessness is a product of the current economy.  Many people believe that the visible homeless are the typical homeless, which is not the case.  Need more folks to understand the hidden homeless.
  • Talked about the gap between earnings and the cost of renting an apartment. 
  • Talked about gap between the number of housing units available relative to where you are in the spectrum of poverty, and how large the gap is at the lower end of the income spectrum.
  • Mentioned how over ½ of folks experiencing homelessness are people of color, but people of color are a much lower percentage of the general population.  That disproportionality takes special effort and consideration.
  • Larry discussed prevention – how homelessness is about problem education, income, healthcare, medical bills, etc..  And homelessness exasperates all these issues as well (nobody sees a real positive health turn around while living on the streets.  No one says “I think I’ll do a turn homeless so I can kick my opioid habit” either. –ed.) 
  • What can be done?
    • County has regional governance role that covers all jurisdictions in the county.  Pierce county can exercise more of that role, and define homelessness as an emergency. 
      • Put together public/private and nonprofits group to make
      • Establish a policy of prevention.
      • The county can move ahead, even with little money – it is understood that there is no money for housing crusade.  But we can get taxes passed for mental health and for affordable housing.  That funding will be a help, although it doesn’t get you all the way to success.  
      • Land trust discussed as an option. 
      • County has fewer revenue resources than cities and the state – must rely on property and sales tax – very regressive (Speaking of being First, Washington has the most regressive tax system of any state in the Union. –ed).  We can support the county if they want to go forward for new revenue authorities.
      • Recommend do something with landlords and retaliator – incentives to allow the people who provide housing to do so at lower cost by changing development codes and zoning requirements. 
    • Council member are looking at coming – 3 council members need extra attention – no names mentioned (none needed. –ed) – if you know anyone if council district 1 or the candidates that are running in that district – District 2 is not running for reelection for a couple years – but could use some attention from constituents.  District 3 is in the same situation. 
    • Maureen – what is the League’s next step?  Cynthia – not sure, we are certainly not going away, have a membership meeting tomorrow to discuss plans for the coming year.  Will be doing something, but not sure what.  Maureen – recommend at least a quarterly update to this group.  Cynthia- absolutely will do this.  Looking at doing a presentation to the city of Tacoma similar to the one to the County’s Select Committee on human services.
    • Maryann – can we get this powerpoint electronically – (yep - –Ed.)
    • Al – I’d like to suggest that this group hold a series of candidate forums for each district.  Can bring them all in since we meet so often.  James – we are working on this.
    • Al – what more can we do to help?  Cynthia – tell County Councilmembers to move forward with the recommendations. 
    • Comment – We need to not vote in cowards who are unwilling to take on these issues. 
    • Cynthia – none of this would have been possible without all of you –providing speakers and information and such.
    • Video of the presentation: – fast forward to 19 minutes in.  


College Housing Assistance Program and SPace available to Respond to the Unemployed through  College Education. -

  • College Housing Assistance Program  (CARP)
    • Marybeth McCarthy, Resource Navigator, Tacoma Community College, 253-566-5063,
    • Housing project is a collaboration between community college and housing authority.
    • 55% transfer students
    • 47% receive financial aid
    • 2015 survey of 10 community colleges in the country, 13% of the folks that responded were homeless.  Another 39% were housing insecure. 
    • Started 25 voucher pilot program in 2014 – working with Tacoma Housing Authority – partial vouchers – worth 50% of usual section 8 voucher. 
    • Now going all out with 150 vouchers.
    • Eligibility – look at students in credit bearing classes – focus on students paying tuition as well as Fresh Start (college and high school).  Must be Washington state residents at least for 12 months, and over 18 years old.  Can be part time at first, but must be full time within 2 quarters and have 2.0 grade point average.  Must fit housing authority rules as well (criminal background and not owing housing authorities money, among other rules).
    • 2 general open periods 10 days after the start of fall and winter quarter for near homeless or housing insecure – couch surfing, living in a car but not engaged with an agency.
    • Federal definition of homelessness can apply anytime if they are in class, if their classes are paid for, and they are HUD definition literally homeless (living outside, in their car, in a homeless shelter, a motel paid for by a charity, someplace without heat or running water, or fleeing or attempting to flee domestic violence – ed.).
    • Starting a program to move Department of Corrections clients into an apartment complex owned by the Housing authority.  
    • The voucher isn’t always enough
    • Voucher is good for 2 or 3 years if in good standing at the College.
  • Space Available to respond to the unemployed through  college education (SPRUCE)
    • Have a variety of funding sources.
    • Tuition waiver program – students don’t register in advance and attend on a space available basis. 
    • Prior to the term starting, the student meets with advisor and comes up with a wish list, and attend classes until 3rd day when they can get in if space is available.
    • Funding lasts just 2 quarters  - but TCC works hard to get folks on financial aid to allow them to continue on
    • Provide help with the cost of books.
    • Get a $5 bus pass for the whole quarter (like all TCC students –ed.)
    • Might be a great way for folks to get started in getting educated. 
    • The 3 credit student success class, taught by the counseling, is a recommended starting point. 
    • We are funded by the City of Tacoma, TCC Foundation and the Kilworth Foundation.
    • Must be 21 or over and not have attended college in the past 6 months and not be receiving unemployment benefits
    • To get in, call 253-566-5201 – Scott Seely with MDC will do a phone screening
    • Folks on spruce can apply for the housing program and would then move on to traditional financial aid and full time schooling at that time
  • Department of Correction program starts in winter quarter in January – working with folks inside prison and working on release plans.  Hoping to still use spruce funds there, even if they were in college when they were incarcerated.  Can’t go online to do the FAFAS while incarcerated.
  • Quesetion: Is anyone reaching out to landlords about taking these vouchers?  Marybeth - It is the same criteria as an Section 8 voucher.  We write a letter to provide to landlords to help alleviate some of their fears.
  • Carolyn – do you track data by race and look at the race?  We are working with Temple University to look over this data.
  • Theresa – shout out to TCC and several folks have come out of incarceration and been successful with SPRUCE.  (thunderous clapping ensued. –ed).
  • Question - Why is this the only program?  Marybeth - this came from a past Dean of Student’s personal relationships.  
  • Make sure TCC is the best option for your clients – Bates or Clover Park could be better matches. 
  • Question - How far out can someone get housing?  Marybeth - must be in class on the 10th day before can help with housing.
  • James – if you bump into an unemployed, pregnant TCC student, we can solve their homelessness today. 


“We do change from the ground up, but also work on policy decisions – do lots and lots and lots.”  (random words I the middle of my notes – said by someone wise, no doubt. –ed). 



  • Kelly Blucher, Goodwill, – “Holy Hire253”. 
  • Some Numbers:
    • 80 employers
    • 542 attendees - Kelly thought 150, Sherri “called” 500 (she should have gotten something out of the prize bag…-ed.)
    • 357 free lunches served (or were they free lunches? –as much as I would have loved to have given Milton Freedman a swirly- when I think Free Lunch, I think of him. –ed.)
    • Total Cost: less than $1,700 (all lunches, employers, swag bags)
    • Employers
    • Over 225 interviews yesterday, today, at the event
    • Don’t know number of folks employed yet – lots of people stopped Kelly to say they got a job, though.
    • Great partnerships – Goodwill folks asked how they got 542 people – it is all the partners.
    • Big thank you to Sherri – this is a briain child of Sherri’s – make other people’s ideas your ideas (I mistyped this originally as “peepholes” instead of “people’s ideas”, which is not a bad maxim, although not just a little disturbing. –ed.).  Sherri – thank you, thank you, thank you.
  • Future of Hire253? I’ve been bombarded by folks across the state asking to do a similar event (Roadtrip…-ed.)
  • Will update you on numbers next week.  I know we changed some lives. 
  • Pat yourselves on the back.  Thanks everyone
  • James – the work that happens here is having a big successes.  I really appreciate everyone coming here and being here every week. 


Tiny House Update

  • The Recovery Foundation brought their partner, Ken Patterson, property owner, in.
  • He has 2+ acres of property that will make a great tiny home village.
  • Councilmember Talbert is leaving office, but is very excited about making a tiny house village happen.
  • The area is zoned correctly, so got a green light to move forward.  It is kind of a perfect piece of property.  Need to figure out some zoning cases.
  • Rick Talbert is spearheading the community neighborhood conversations.
  • We’ll need a nonprofit to run it, and fundraising and lots of other work, but it is nice to have a real start.

Good of the Order

  • Al – fil out the surveys from the Accountable Communities of Health (surveys attached)
  • Al don’t’ forget to sit by someone you don’t know. 
  • Down to 15 occupied units at Tiki apartments – making progress
  • Praise Report from Byron – contacted about mother with 2 month old – got them into Adams Street Shelter – thanks to the network
  • For providers that work with special populations – they often come for a presentation and don’t come back - would love to encourage us to try to get those folks here regularly. 
  • James – every agency has its own book of resources – please send us your master list resource.  Have a product by Halloween.  With an interactive map with contact information and such.  Will have data person Rainey creating it. 

Coming Attractions

  • June 15th - Prosperity Wellness Center and ACTS Behavioral Health & Recovery Overview
  • June 21st – Summer Solstice
  • June 22nd - Concerto Health
  • June 29th - The Rescue Mission
  • James - The Salvation Army is restructuring the Shield center a bit – want a discussion about what they can do to better serve our populations.  But, they are not quite ready for that discussion this week – so that will be a coming event.  

Restaurant Review

There are very few things not to love about Shake, Shake, Shake (124 N Tacoma Ave, Tacoma, WA 98403).  Tacoma Restauranteur (it is the vowels that get me every time. –ed) grand masters Gordon and Steven Naccarato (Pacific Grill, Beach House, Smoke + cedar) put Shake Shake Shake together about 10 years ago.  If you like a good burger, fries and a shake, this is the place to go.  I’ve never ventured into the complicated shakes – I’m a berry shake guy - but I love sitting at the bar and watching them put the shakes together – all the fruits and syrups and whipping cream and sprinkles and cherries on top - with names like the Tiger Shake and Banana Brulee – what is there not to like?  You can even booze them up, but that seems all wrong.  I may be making some enemies here, but alcohol has no place in a classic burger joint.  I’m fine with hamburgers on the menu at a bar, but you can’t serve hard liquor at a burger stand.  Trends are trends, though - there’s no stopping them…  The fries are Naccarato style – thin and crispy.  They have tots and corn dogs and the like, but they really shine in the burger department.  I’m sure the veggie burger on a gluten free bun in a joy, but I’m more experienced with the Famous Hickory Burger.  It is juicy, flavorful, and exactly as messy as a proper burger should be.  Décor-wise, the inside is all the orange you need for the week – but alive with energy – and they have picnic tables on the lawn out back.  The burgers take a few minute to cook, so bring some uno cards and see how close to tears you can bring your low-blood-sugar children before the food arrives.  Highly recommended.    


  • Cynthia Stewart, League of Women Voters
  • Larry Seaquist, League of Women Voters
  • Joseph Kisembo, Catholic Community Services
  • Anisha Fernando, Catholic Community Services
  • Adrianna Milton, Catholic Community Services
  • Emerald Gipson, Catholic Community Services
  • Carrie Ching, Molina Healthcare
  • Pamm Silver, Molina Healthcare
  • Barbara Kaelberer, Accountable Communities of Health Community Voice Council
  • Sheila Miraflor, Sound Outreach
  • Caroline Belleci, Pierce County Human Services
  • Carolyn Weisz, University of Puget Sound
  • C Mendoza, Metropolitan Development Council
  • Marge Blount, PCHD
  • Lynn Jones, Catholic Community Services of Western Washington
  • Al Ratcliffe , Individual Choking on Icelandic Yogurt
  • Brandon Chun, Metropolitan Development Council
  • Zachary Kinneman, What’s Next Washington/Pierce County
  • Patricia Menzies, Tent City Tacoma
  • Charleen Fitzgerald, Coordinated Care
  • LaVada Kent-Napier, Zydeco Queen 
  • Rodney Richardson, Sidewalk Rescue
  • Maureen Howard, Housing Advocate
  • Shane Wise – Washington Worksource
  • Nick Wood, Washington Low Income Housing Alliance
  • Kara Cooper, Metropolitan Development Council
  • Chelsea Perry , Metropolitan Development Council
  • Nick Wood, Washingotn Low Income Housing Alliance
  • Marybeth McCarthy, Tacoma Community College
  • Richard Berghammer, Fellowship Bible Church
  • Kenneth Moultry, Recovery Foundation
  • Daryl Jones, Recovery Foundation
  • Liz Murphy, Comprehensive Life Resources
  • Bonnie Rico, Comprehensive Life Resources
  • Dru Gonia, Tacoma Salvation Army
  • Benjamin Feldbush, Comprehensive Life Resources
  • Wesley Bailey, Metropolitan Development Council
  • Joseph Denton, Sound Outreach
  • Kelly Blucher, Goodwill
  • Greg Walker, Valeo Vocation
  • Jessica Hall, Greater Lakes Mental Health
  • Latisha Bones, Greater Lakes Mental Health
  • Sherri Jensen – Valeo Vocation
  • Stephanie Wright, Adonai Counseling and Employment
  • Dawna Bryant, Comprehensive Life Resources
  • Calvin Kennon Sr, Comprehensive Life Resources
  • Sarah Bellamy, Comprehensive Life Resources
  • Nathan Blackmer, Comprehensive Life Resources
  • Effran Davis, Pierce County District Court
  • Angela Delgado, Sea Mar
  • Victoria Vass, Tacoma/Pierce County Habitat for Humanity
  • Julio Quan, Community Activist
  • Theresa Power-Drutis, New Connections
  • Byron Corzo, Tacoma Rescue Mission
  • Zachary Roadhouse, Tacoma Rescue Mission
  • Cheri Beavers, Tacoma Rescue Mission
  • Gerrit Nyland, Catholic Community Services
  • Linda Older, Metropolitan Development Council
  • Liszet Chavez-Avila, Pierce County Accountable Communities of Health
  • Judy Flannigan, Tacoma Salvation Army