Leadership Stories

Building Bridges to Create Healthier Communities: Let's Get the Ball Rolling!
Joel Hornberger, MHS

Joel Hornberger earned a Bachelor of Science degree from Lebanon Valley College and a Master of Health Science in health service administration and planning from the Johns Hopkins University School of Hygiene and Public Health. Mr. Hornberger serves as chief operating officer for Cherokee Health Systems (CHS), a comprehensive health services organization serving a ten county area in East Tennessee. As chief operating officer, he leads a staff of over 400 professionals who provide medical, dental and mental health services at 18 locations. CHS is committed to an integrated care model, one which requires strong internal collaboration across clinical disciplines - primary care physicians, psychologists, psychiatrists, dentists and nurse practitioners. The ICHLD fellowship allowed Mr. Hornberger to extend his collaborative skills outward, looking towards community-based organizations, East Tennessee's faith-based communities, social service agencies and volunteers to reach underserved residents in rural areas. A version of this story first appeared in Rural Roads, volume 1, number 1, a quarterly magazine of the National Rural Health Association.

When Mr. Hornberger joined the 2000 ICHLD Fellows class, he thought of it as another management program. Given the size and scope of Cherokee Health Systems (CHS) - over 400 employees at 18 locations scattered across a 10 county area who deliver integrated services to a population of 840,000 - Mr. Hornberger appreciated opportunities to refine his management skills. (See Figure 1.) He was knowledgeable about internal collaboration and comfortable working through the issues common to multiprofessional care. However, ICHLD views collaboration as a strategy for building healthy communities; as such, the fellowship seeks to develop specific collaborative skills in the participants. As Mr. Hornberger remembers, "I realized I was going to spend two years concentrating on relationship building. Fortunately, I came from an environment that stressed internal collaboration and I had a CEO who believed strongly in networking as part of strategic planning. So while this was a stretch for me personally and for CHS as an organization, I had a lot of support from my organization."

Partnership Building

ICHLD uses myriad learning tools, but perhaps the most integral are site visits to ongoing collaborative efforts in the U.S. and abroad. "The site visits were very important for me. I learn from observation and through interaction. And, when learning about collaboration, it is very important to see how people work together and the community in which they work," Mr. Hornberger explains. "It also got me in the habit of being 'out there' - out in the community, in unfamiliar surroundings, mixing with people from different backgrounds all of whom are interested in the broad CHS mission - healthy communities."

During one fellows' week, Mr. Hornberger attended the International Conference on the University as Citizen: Engaging Universities and Communities. At this conference, sponsored by the University of South Florida, Mr. Hornberger heard presentations from a number of university/community partnerships in the U. S. and abroad. "I had an opportunity to meet people from around the country who were struggling with the same kinds of challenges I face in Tennessee," he says. "I learned that relationship building is required for true collaboration and that it takes patience and persistence. This realization gave me a great deal of encouragement that effective collaboration could and would occur in Tennessee."

In Pittsburgh, Mr. Hornberger participated in a discussion with a local community group about its relationship with the University of Pittsburgh Medical Center. The group brainstormed ways to create opportunities for other potential university and community partnerships. "The project we saw in Pittsburgh put everything into perspective for me," Hornberger recalls. The ICHLD Fellows conducted focus groups with community residents concerning community health needs and the powerful role of collaboration. "Conducting the focus groups taught me how important it is to listen to community people instead of making assumptions about problems and solutions. One of the focus groups was made up of high school kids. This was very interesting. When they talked about what they needed to improve their health, they didn't even talk about medical issues, they said they needed streetlights. Safety is a real concern - and a real health hazard - in their neighborhood," Mr. Hornberger remembers.

"Things often referred to as soft skills are very important in collaborations. Listening is one of those soft skills. The Pittsburgh project really stressed their importance," he continues. After seeing first hand the benefits of community-university partnership, Mr. Hornberger started looking for ways to use the model to increase access to psychiatric and other behavioral health services. When an opportunity arose for CHS to collaborate with the University of Tennessee to develop a Primary Care Behavioral Health Fellowship Program, Mr. Hornberger chose to participate. "This behavioral health fellowship will increase rural area access to primary care physicians with specialized training in behavioral health," Mr. Hornberger explains. As chief operating officer for CHS, Mr. Hornberger is able to influence the organization's general approach to collaboration. At this time, he is working with senior staff to ensure that coalition building is viewed as one of their responsibilities. "I have become convinced that community health is based on multiple factors - systems issues, socio-economic factors, behavior and life choices, along with genetics, all play a role. How can all these issues be addressed if we work in isolation?" Mr. Hornberger asks.

Mr. Hornberger has been elected vice-chair of the Friendly Access Coalition, which provides services to pregnant women and children under the age of five. Friendly Access is aimed at breaking down barriers to care by creating trans-organizational processes that are more inviting to patients. This coalition has a formal structure with signed agreements, by-laws and a committee structure to support its efforts to change the health care delivery system in 19 counties.

The skills Mr. Hornberger acquired during his fellowship have helped him realize that working in collaboration takes patience and persistence, and he remains encouraged by these additional effective collaborations.

Dealing with Diversity

The ICHLD Health Partners Fellowship is based upon the belief that efforts to improve the health of communities must include support from a variety of sectors, including professional organizations, civic and community groups, the business and corporate worlds, and community residents. More often than not, this means bringing together people of varied racial and ethnic backgrounds. "Issues of diversity were very timely for me and for CHS," Mr. Hornberger remembers. "The population of East Tennessee has been changing rapidly. Hamblen County now has a significant Latino population - largely undocumented persons. And, CHS has recently expanded to the east Knoxville metropolitan area which has a significant African American population," he explains.

The Mechanicsville Health Center, located in east Knoxville, is modeled after a child and adolescent center that Mr. Hornberger toured during a site visit in El Paso, Texas arranged for the Health Partners Fellows Class of 2004 and ICHLD alumni. Mr. Hornberger is working to develop a community center wing attached to the standard clinical practice space that will provide computer labs, GED and literacy classrooms, and other services based on community needs. The effort is being developed through collaboration with existing agencies and volunteers.

During one site visit, Mr. Hornberger toured a local community with three African-American ICHLD fellows. "It was a unique experience to hear, from an African American perspective, the history, values, assets and problems faced in a community," he recalls. "I think I was blind to many of the things shared with me by the fellows." He heard how past policies and continuing disparate treatment affect racial minorities. Hornberger believes now he is better prepared to understand people of different races and backgrounds, though he admits that his insights, "did not come immediately or easily."

Mr. Hornberger tapped into that experience while developing a project to provide services to rural Tennessee's growing Latino community. "We formed an Hispanic Outreach Coalition, pulling together faith-based organizations, community organizations, health care and social service providers. The coalition includes Baptists and Catholics, including Carson Newman College. The Red Cross, Central Services, Appalachian Outreach - almost everyone interested in serving the local Hispanic population also participates," Mr. Hornberger explains. The coalition has a broad focus, dealing with housing, food, jobs and identification problems.

The coalition has undertaken many creative outreach efforts to promote health. A soccer game which matched community players with a local college team attracted a crowd of 500 people. Families saw a great game (the college team won), but more importantly, they received information about immunization, access to screening and detection services, Medicaid enrollment and prenatal services. A local Spanish language newspaper featured the Hispanic Outreach Team on its cover with the headline, "Un Regalo de Dios" (A Gift from God).

The coalition has been very successful at linking Latino residents with much-needed local services. Progress is already measurable. In 2001, CHS clinicians in Hamblen saw no Latino children. Currently, the pediatric clinic sees approximately 350 Hispanic children per month. "In the Hamblin County practice, we've gone from no Hispanic children to an 18% Latino client practice," Mr. Hornberger explains. The effort has been so successful that CHS has hired a bilingual outreach worker and a bilingual physician. Other clinic staff members are learning Spanish, and the group is coordinating services with other providers and state-funded programs.

While the Hispanic outreach coalition was originally an unfunded effort, in April 2002 a threeyear federal grant was received. This grant funds outreach and clinical services for Grainger, Hamblen and Jefferson counties.

In addition to working with the outreach coalition, Mr. Hornberger is working with a group of concerned citizens to start a free clinic to serve some of the estimated 7,000-8,000 uninsured county residents. "We have a large population of working poor here in East Tennessee. Many people work for small businesses and health insurance is unavailable, or it's so expensive it's practically unavailable," Mr. Hornberger comments.

"We have a local retired physician who is pulling together a free clinic, Helping Hands. Right now, incorporation papers are being filed with the state. The mission and by-laws have been written and a house has been donated in Morristown," Mr. Hornberger explains.

"CHS has an important role to play in this community. At CHS, everyone receives care - it is not based on insurance coverage or ability to pay," Mr. Hornberger explains. This is very important in Tennessee, a state with a restricted indigent care plan (TennCare). "If you are undocumented, you are not covered by TennCare. If you have a baby, the baby is covered, but the family is not. At CHS, we treat the entire family in an integrated manner - providing medical, dental and behavioral health. We have a sliding fee schedule based on federal poverty guidelines," he points out.

Mr. Hornberger also recognizes the need for continuing education for health care providers who find themselves serving a more diverse population. To this end, he invited an expert on curanderismo (Mexican folk medicine) to visit Tennessee and speak about Mexican immigrants' culture and beliefs.

Hornberger credits the success of the health outreach projects at CHS to the Health Partners Fellowship and says he returned from each session eager to forge collaborations within his community. "I know that this would not have happened without ICHLD," he says. "I got the ball rolling and it took on a life of its own."