Leveraging & Strengthening Coalition Resources to Address a Commmunity Health Problem

Marilyn Willis: Tecumseh, obviously you were a leader prior to joining the Health Partners Fellowship. To what extent, though, were you involved in collaborative projects during this time?

Tecumseh Welch: Actually very little. I had been part of the local HIV Aids coordinating council, but that was more so in name only, not a true partnership or coordination. That was really about politics around the table and so I had very little experience with what a true partnership or what a true collaboration is.

Marilyn Willis: So What attracted you to our Health Partners Fellowship?

Tecumseh Welch: I certainly felt that there had to be something more to getting together and just stroking each other’s egos, that there had to be something in order to address disease or the issue at hand and something more than just chasing funding. And when the application and the information came across my desk regarding the Health Fellowship I was very excited to learn that there’s an opportunity for me to foster what my gut had already been telling me, to learn how to develop actual win-win situations so that we could actually move forward and pass the organizational ego, the collaborative ego, and actually make progress towards the goal that we were all supposedly there to address.

Marilyn Willis: And so what did you discover about yourself once you became involved?

Tecumseh Welch: One of the things I definitely discovered was internal balance, in that by struggling so much to try and make things work, and for example thinking " Well, isn’t it really about health care versus how much money certain organizations receive over some other organization?" I really thought that we were all about providing health care, or we were all about providing car seats for infants or whatever the topic was. I was pretty naïve actually.

One of the things that I learned was how to create those win-win situations so that we could all be far more productive and internally, personally, my own personal growth resulted in more balance. I didn’t feel like I was crawling so much uphill all by myself. I realized that there are tools that I have now after the Fellowship that I can put into place to actually move in the direction of a win-win situation where all parties involved feel so much better and so much more positive about the outcome.

Marilyn Willis: I know that when you returned to your health center you actually became involved in several of these new health initiatives. Can you share a little bit about a program that you are particularly proud of?

Tecumseh Welch: Well, there are several. One that really sticks out in my mind is our dental program, which is the Dental Access Program and that was where we had locally a huge need here in California, particularly Southern California, regarding cavities in little kids, particularly under six years old. And it’s two-fold really. I mean, the parents think that "Oh, we don’t have to worry about these teeth; they’re going to fall out anyway." And yet the child isn’t educated enough or developed enough in their own character to be able to understand the necessity of brushing their teeth twice a day.

Marilyn Willis: So, who was involved in this particular collaboration?

Tecumseh Welch: Well, one of the things we did was we stepped back and said, "We can’t do this as an Indian, American-Indian, organization ourselves, and who else is interested in dental?" That’s creating that partnership, something that I learned in the Fellowship. Pick out the other common areas and other allies that you may have in your own community.

Well, we had a County Health Department that was very much interested in dental issues. We had some other local parish nurses, for example, that were interested and we had the County Dental Society and we had a few private dentists that were interested in the subject as well.

I asked everyone to come together so that we could talk a bit about common goals and see how we might be able to begin to educate the community, begin to educate the possible funding sources to the need, the huge need for dental care for the under six-year-old population.

Marilyn Willis: Were you able to successfully get this program funded?

Tecumseh Welch: The program has been funded by a cigarette tax here in the State of California, named Proposition 10, and that is an additional tax per pack of cigarettes that has been levied and those additional dollars come to the different counties within the state. Our county in Santa Barbara receives a very large sum of Proposition 10 funds. This group that I put together was able to educate the County Health Department and ultimately the County Board of Supervisors were actually able to be convinced to put money aside and focus on the dental needs of the under six year olds.

The collaboration or coalition that I was able to put together was already poised and well situated and ready to receive the funding so that we can begin implementing a program for the under six-year-old population. That program has many different tiers and there were a lot of issues around the table that we had to work out as a coalition if we wanted to be successful.

Marilyn Willis: So, what do you think really helped you to get through this process? I know you assumed an initial leadership role, but how did it progress once you brought the people together?

Tecumseh Welch: One of the things that tends to bring people together is funding, or available financial rewards for their agency or their own cause, so that’s definitely one motivating factor that kept people at the table. The second one was my skills and talents that I had developed through the International Center for Health Leadership Development and creating the win-win situations around the table so that we could all come together and put an application in for those funds.

Now, it turns out that after about the first six months-eight months, I had to step back as the person who had the initial vision. I had to step back as the leader or the facilitator because of politics that started happening and shifting around the table. We turned to the Dental Society so that they could be the lead agency and they began running the meetings and the communication, making sure we had meetings every month and taking minutes. And those are things we had to flush out during the first year of our partnership. How do you communicate? Communication is absolutely one of the basic foundations in any kind of collaboration, especially if you’re going to share the responsibilities, the rewards, and the benefits of providing a service.

Marilyn Willis: When you think of your key challenges what would you list as among the key challenges? And not only new issues, but sometimes I think we forget to reflect on things that need to be let go of. So do you have some thoughts in that area?

Tecumseh Welch: Certainly, I think the key challenges were to come to terms with again the organizational egos that were around the table, the individual egos that are around the table and kind of figuring out the pecking order. There’s always a natural kind of pecking order that’s, you know, human-to-human. But then you bring in agency baggage and historical factors and how many staff you have and how many this and how many that and that was a key factor in sorting all of this out. I’m not so sure that we have it all sorted out yet, but I do know that we are actually providing some services.

I think personally one of the key factors that I needed to realize was that even though I have the vision and even though I know that I have the leadership skills, sometimes being a good leader is about letting go and fostering the other leaders around the table so that everyone has ownership of the program or the project.

Marilyn Willis: Were there any areas or topics that were not acceptable in the partnership?

Tecumseh Welch: Yes, absolutely. There are a number of topics that ended up being taboo. One of them, for example, was evaluation. How are we going to evaluate whether this program was a success or not? The people really felt that I, in particular, was asking them to be accountable as an individual. And I was really asking for us as a partnership to be accountable so that we could actually attract additional dollars.

I was looking at it as a positive. How do we collect our data? I know that we were serving almost 400-500 children, but if we don’t keep data on those children--on what is their income? What are their, you know, problems that we are treating? How many of them have baby bottle tooth decay? How many of them are actually showing up to their appointment?-- that we were never going to make progress towards the longer goal. And that’s really the difference and the true meaning of collaboration and coalition: to have a longer-term effect on whatever the issue is. Otherwise you’re really much more of a task force.

Marilyn Willis: That sounds like one opportunity for training. Did you actually do any training of partners or community persons regarding this particular project?

Tecumseh Welch: I actually did share quite a bit of information that I learned at the International Center for Health Leadership Development, but I still don’t think that they necessarily get the fact that we’re there about the issue versus one funding cycle to another funding cycle. I can start to begin to see the shift in a few of the key players around the table. Certainly the County Health Department has a longer-term vision and the County Dental Society does as well. I am not so sure some of the other community based organizations do, and that very well may be because of their internal organizational structure or length of time that they have been involved in some of these issues.

I think many times some community based organizations end up struggling year by year, sometimes project by project, just to keep their doors open. And when you’re in a financial situation where you’re struggling to keep your doors open and your lights on, looking at a long-term effect five years down the road seems almost an impossible dream.

Marilyn Willis: Well, that’s one thing good about having a collaboration because certain partners have talents to accomplish certain objectives, and if you put the two together, those who are involved in the service as well as those who can have the opportunity to do other things, then the end result is a much more effective and outcome orientated program.

Tecumseh Welch: Absolutely. And that is exactly the reason that we decided to bring the University into our coalition so that they could do the evaluation. They weren’t connected to any one of the organizations in the coalition directly. They were a neutral party. They also brought those initials behind their name, the expertise in developing an evaluation form that we could collect particular data throughout the project, and each one of us could collect that data and pool our data together. And that really helped a lot of people get over the anxiety of the evaluation, that we were looking at our partnership together versus individual components.

I think the other piece that one of the lessons learned out of this was many people talk about corporate images and we’re all familiar with those kinds of things, McDonald’s corporate image or, you know, whatever it is. But we also have images as a coalition whether that’s how we come together, do we meet over lunch, do we bring lunch, do we rotate where we meet so that it’s not always on one person’s territory so to speak. Do we share information about our organizations, what else is going on, or do we just talk about what’s happening at the coalition? Do we develop brochures or information packets or press releases together as a coalition or do we just leave it all up to the lead agency?

Those are lessons learned that we have implemented from some of the struggles that we’ve had during the first year. Lots have happened here and during the second year and it looks like we’re going to receive funding for the third year as well.

Marilyn Willis: Oh that is excellent, that is excellent.

Tecumseh Welch: Some of the other lessons that we’ve learned were politics play a huge role in the fact that even who the organization decides to send as a representative to the coalition. If they’re not very much invested in the topic, you will see some folks sending very low-level employees, people who don’t have the authorization to commit an organization to anything that the coalition is doing. Once you start to move up that ladder, and the executive directors or the program directors are at the table, it becomes so much more effective and so much more rewarding, I think, for all of the partners around the table.

The other thing that we’ve learned certainly is about that organizational egos and individual egos. It’s like having another extended family and trying to figure it all out and realize and learn about new friendships where--what is the button in this person or what is that organizational button, you know, or they lost funding from some grant you don’t ever want to bring that up, you know, there’s taboos that we don’t necessarily want to talk about.

Marilyn Willis: But it sounds like, Tecumseh, also that you’ve increased your sensitivity and are tuning in to other people’s problems. I think sometimes we get involved with our own projects and we want to see certain things accomplished and we don’t pay as much attention to each other from an organizational point of view, not from a personal, you know, friendship point of view. The other thing that you said I wondered if you could add a little bit more to. And that related to the recognition from the community. Were you able to achieve recognition by certain community groups?

Tecumseh Welch: Well, we have, actually. We’ve been recognized by several different groups. The Latino community has recognized our work within their community. We’ve also been recognized by the California Dental Association and locally I think which is much more rewarding, we’ve been really recognized by the local community as one of the heroes of our local community in providing direct dental services. You know, some of the programs that we offer through this is we teach kids proper brushing techniques, not to saw your teeth in half, but, you know, the up and down and the circles and all of that and flossing. You know many people don’t really know how to properly floss. It’s very easy once you learn how to even handle the darn floss. Even I have been retrained. And to teach parents about baby bottle tooth decay, there is nothing simpler to prevent cavities not only in those teeth that are going to go away, but in the new permanent teeth as well.

And then we also have a level of treatment where we provide fillings for cavities and fluoride treatments and some other basic treatment elements and cleanings on a regular basis, but you know I think one of the best things that we’ve implemented in the dental chair is when that child comes to the dentist for the very first time--I don’t know where they learn this, but the dentist is the bogeyman. You know, every kid thinks the dentist is the bogeyman. I don’t know, they must have like that’s the first story that they ever learn from each other in kindergarten or even preschool.

Marilyn Willis: Or they see the needle.

Tecumseh Welch: Or they whatever. So the very first appointment in our dental program, we don’t do anything. They come in and they just walk around the dental chair and they get to hold the drill and they get to do the different things. They get to sit in the chair and that’s it. And the other key thing is we don’t give them suckers afterwards. So, their first experience, we really try to make it a positive experience. Now some of the kids won’t even leave the waiting room--and that’s okay. The dentist comes out to the waiting room and sits on the couch and we talk together. They talk together about brushing. We can teach them to brush their teeth when they’re sitting on the couch just as well as when they’re sitting in the dentist chair. And just visually looking at their teeth without any x-rays or anything can tell an awful lot.

The other key piece to this is we screen for diabetes in those under six-year-old kids and one of the ways that diabetes presents itself is in oral hygiene first. You can see signs of diabetes in a person’s mouth ** way before you can see it within their eating or drinking or other signs and symptoms of diabetes. We have had our dentists specially trained in diabetic dental care. So even by just people think at first they thought, "Oh you’re crazy, that’ll never work." Well, it turns out it works really well.

Marilyn Willis: And you also go into the homes I think you had mentioned to me at one other time.

Tecumseh Welch: Yes, we do home visits because many people work during the day and if they’re working particularly a couple part-time jobs, they can’t afford to take the time off. If they do take the time off they don’t get paid and then their part-time employers start the routine of, you know, "if you want this job you need to show up or I’ll find somebody that does," you know, and all the pressures that go on and on. And if they take time out to take their child to the dentist as prevention, then they’re actually losing money. Well, one of the things that we’ve found is that there’s no better way to do dental education particularly about the proper brushing and flossing techniques than to do it in the home.

We take new toothbrushes and we go to the home and we teach them how to brush their teeth right there in their environment, in front of their sink. And if they don’t get it quite right, we’ll review it with them. But again it’s in their environment, they’re not scared, and we’re able to take a look around and make sure that their environment is safe as well. For example, we also check in our dental education program, does the family have a smoke alarm. It’s very simple. It doesn’t always have to be just about what we--

Marilyn Willis: --about the dental care--

Tecumseh Welch: Yes.

Marilyn Willis: Right.

Tecumseh Welch: It doesn’t have to be about what we think this is about. It doesn’t have to be what just is the obvious. Coalitions and collaborations allow you the freedom. Once the trust is built, allow you the freedom to be creative and assist each other organization in obtaining goals. Our goal as a health agency involved in this coalition was to prevent dental carries and other health-related issues that really start by oral or bad oral hygiene. Another one of the partners, the [Santa Barbara] County Health Department brought in their WIC Program to the coalition to talk about good nutrition and how that has an effect on dental. Now that helps the WIC Program, it helps us. Then we had a third element come in, and that’s the people who brought the smoke detectors to us. And we said, "Well, why not? If we’re already in the home all we have to do is look up."

Marilyn Willis: Absolutely.

Tecumseh Welch: Just look up. And how else would the fire department or the injury prevention specialists get into a person’s home? So there we are with our free toothbrush program going into the people’s home, teaching the child, and oftentimes the parents, proper brushing, proper flossing techniques and talking to the family about baby bottle tooth decay and all we had to do was look up. You know how many children die each year, how many family homes burn down because they didn’t have a smoke alarm?

Marilyn Willis: Right, right.

Tecumseh Welch: So we have been able to create this coalition and move it forward because, quite frankly, I learned skills and talents from the International Center for Health Leadership Development, I brought those skills and talents back home and I had the will to implement them locally and now we all in this collaboration are moving forward and helping our own community people.

Marilyn Willis: Seh, let me ask you one other question because throughout this conversation it just seems to me that you created a level of trust. I mean I hear it in the nature of how you are communicating. And how do you think you went about creating that level of trust?

Tecumseh Welch: That goes back to those creating win-win situations. If you and I were involved in a project and if it was all about me, you wouldn’t trust me. But if every now and again I said, "Now what about you?" It would begin a trust relationship. It’s very simple really. Once both partners realize that you’re going to look out for yourself, and you have to be honest about that, but once the other partner realizes that you’re going to look out for them too, it becomes so much easier.

Marilyn Willis: Well, you know it also sounds like you created a level of respect too, a respect for talents and resources of the other collaborators.

Tecumseh Welch: Certainly hope so. I don’t know if I’ve always been able to project that. It’s difficult work, it really is. You know, that first year was just beat your head against the wall, but all of a sudden things started turning around and we started seeing things happening and I think that there’s been a few really uncomfortable situations in the coalition and not all of the original partners are still at the table, but we have to have faith in each other and move forward as we all have the same vision and goal.

Marilyn Willis: One last question, I think I said last before, but I’ll try one last one again, any other accomplishments that you want to add to what you’ve already said in terms of the services and the recognition?

Tecumseh Welch: I think some of the accomplishments, not only within this true partnership, you know, you really need the exchange of information, the flexibility within the activities, sharing the resources, the capacity for mutual benefit and all the common purpose stuff. But you also have to share the risk, the liabilities, as well as the benefits and the positive aspects, the respect for the talents and resources of the various folks around the table, the direct services that we’re actually providing to the clients.

You know, so far this year alone, we have had 410 children treated, 1,100 educated about dental care. We’ve got recognition from the community and we’ve got mechanisms in place to support the communication now, and some problem-solving mechanisms are routine now as well. I think that some of the other well accomplishments are that now other people are starting to look at our coalition and saying, "Well, hey, if they can do it, we can do it." And that has got to be the biggest accomplishment ever.

Marilyn Willis: That somebody else is willing to take the same risk that you did, but obviously with a little more benefit because you have paved the way and that’s terrific.

Tecumseh Welch: I hope so. I really think that more and more people, more and more organizations can utilize some of the skills and trade secrets so to speak in developing coalitions and collaborations. I wish that everyone could attend the International Center for Health Leadership Development Fellowship Program and learn the real meaning of collaboration, the real meaning of coalition, and the real meaning of bridges.

Marilyn Willis: Well, I think one other thought that I have is that I know that you are continuing to work with us. You worked with us on the Indian Health Service Program and I know you’re sitting on the Board for Diversity in Health Management, a local initiative that came about because of the link to the Fellowship. And I’d like to hope that in addition to us providing training, that in essence it’s a mutual exchange, the Fellows are giving us something in return because the whole focus of our program is not only to train individuals, to enhance their capacity, but also to continue the networking so that over time we have a group of people who have like minds to actually accomplish, like you say health outcomes. We’re looking at policies. We’re looking at impacting on people’s lives and not just obviously education, you know, for the sake of education. So, I’ve been thrilled since I’ve been here to be able to see the kinds of interactions that the Center does have with the Fellows as well as to look at what Fellows are doing in their own environment.

Tecumseh Welch: It’s truly about a win-win situation.

** Additional resources on this topic:

Indian Health Service (IHS) National Diabetes Program

Indian Health Service (IHS) Dental Program

End of Interview