Reframing housing as a health issue in Napa County, California

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June 14, 2018

About this case study

This case study is part of a series developed by the Berkeley Media Studies Group and supported by The California Endowment (TCE) that illuminates the innovative work local health departments in California are doing to advance health equity. The Public Health Division of Napa County's Health and Human Services Agency was one of three groups in the state recognized at "Advancing Health Equity Awards 2017: Highlighting Health Equity Practice in California Public Health Departments," a ceremony and set of awards created by The California Endowment and administered by a planning committee representing leaders in the field, to elevate promising practices among local health departments. The awardees received grants of $25,000, with a grand prize of $100,000 going to the Monterey County Health Department. The awards and case studies, along with a suite of companion videos, were created to inform and inspire other health departments looking to engage in similar work.

To access the series on BMSG's website, visit: http://www.bmsg.org/resources/publications/advancing-health-equity-awards-2017-highlighting-innovative-practice

To access the series on The California Endowment's website, visit: http://www.calendow.org/wp-content/uploads/Health-Equity-Case-Studies-2018-web-optimized.pdf

To see the award-winning health departments in action, visit: https://www.youtube.com/playlist?list=PLLwLn83VLbvxIzuUc28CM2xLQ2GcdeUU1

Introduction

When people think about California's Napa region, they often imagine world-class wines, fine dining and breathtaking mountain views. What they likely don't think about — and don't know about — is the area's struggles with poverty.

"People are very surprised when we talk about poverty in Napa County," said Cara Mae Wooledge, health education specialist for the Public Health Division of Napa County's Health and Human Services Agency (HHSA). "They think that everything is wine and cheese all the time, and it's really not that. We have a lot of disparity & and it's something that we're hoping to bring to the light and to show that this is something that we need to deal with in our community."

More than one-quarter of Napa County residents and one-third of families with children under age 18 live below 200 percent of the federal poverty level,1 making them "at risk of becoming homeless or marginally housed," explained Dr. Karen Relucio, health officer and director for HHSA's Public Health Division (NCPH).

That concern is compounded by the county's lack of housing that is affordable. It has been ranked one of our nation's least affordable areas, and the average rent for a one-bedroom apartment exceeds $2,300 — more than double what is considered affordable.2 Additionally, the wait time for Section 8 affordable housing in Napa is extremely long: Currently, city of Napa staff are helping people who have been on the list for more than six years.3

It is a jarring irony, then, that although the wine and hospitality industries form the backbone of the area's economy — in 2016 alone, tourists spent close to $2 billion in Napa County4 — the people who serve those tourists often have a hard time keeping a roof over their heads.

While some aspects of Napa's poverty and housing issues are located off the beaten path and away from major tourist destinations, others are hidden in plain sight. Tourists headed to downtown Napa's tasting rooms and bed and breakfasts can drive past homeless service providers like the Hope Resource Center, which provides showers, restrooms, mail, and laundry services, or The Table, which provides hot, nutritious meals, without even knowing it. And visitors to the Napa Premium Outlets can spend hundreds of dollars on a Coach purse or Cole Haan shoes and never realize that in the houses just behind those stores, many residents can barely pay their rent.

Even when people are looking for manifestations of inequality in Napa County, there is not always an easy distinction between poverty and wealth. Unlike in many larger cities, which often have clear signs of segregation, in Napa, low-income areas are scattered throughout the county's many neighborhoods. Although having integrated neighborhoods can be beneficial, it can also render issues like overcrowding and housing instability (in which more than one-third of a person's monthly income is spent on rent) invisible.

"You can have seven families living in apartments that [are] made for four people," said Alissa Abdo, the executive director of On the Move, a nonprofit that works closely with NCPH/HHSA on many projects. "But," she added, "you would only know if you were the person who is experiencing that in our community."

Together with community residents, elected officials, industry leaders, and community-based organizations, NCPH/HHSA is working to make these issues visible and to reframe housing as a health issue — not just for individuals, but for the entire community. They are also using a combination of community engagement, policy change, and strategic communication to push forward innovative solutions, including overhauling the county's housing and homeless system.

This case study explores the strategies NCPH is using to make housing more affordable for everyone in the county, discusses how they are overcoming challenges, and details lessons learned and next steps.

Napa aerial view

Why housing?

NCPH's drive to collaborate with partners to decrease homelessness and to make housing more affordable for everyone stems from research showing that housing is a health issue. Chronic stress from housing insecurity puts people at higher risk for chronic diseases, and homeless individuals tend to have poor health outcomes.

"[People who are homeless] live 30 to 40 years less than the average population, yet towards the end of their lives, they consume the most health care resources." Dr. Relucio said. "So, we're spending a lot of money to keep them sick."

In Napa County, homeless system data show that close to 1,600 people are homeless or at risk of becoming homeless. Those numbers include adults, children, women fleeing domestic violence, chronically homeless people who have mental health issues, older adults, veterans coming back from war, and many others.5 Of Napa County's housing-insecure families with children, two-thirds are Latino.6

Although Napa County has many housing services, they are not well integrated. According to Relucio, Napa County's current housing system is inadequate, both for workforce populations that are housed but face increasingly unaffordable rent and for low-income and homeless populations. Napa homeless system data also indicate that many folks are cycling between the shelter system, the streets, and institutions.7

"A lot of what we were seeing is that people may go to the shelter and then they may be back out in the street, or else they may be in a shelter and go to the hospital or to jail," Relucio said. "So, we were not keeping them permanently housed, and this was causing increased numbers of people experiencing homelessness in Napa." Once people were back on the streets, they could not be contacted for follow-up care, creating a dangerous cycle.

Additionally, Napa County's housing strategy was not "housing first," Relucio explained. "It was not housing people unless they were clean and sober or they had controlled mental health issues. And as we know, the data out there suggest that people need to be housed first before we can deal with those issues."

Relucio has observed up close the health consequences of homelessness and housing insecurity. Prior to coming to Napa County, she served as the medical director for public health clinics in San Mateo County. During the last six months of her tenure there, three of her HIV-positive patients died. With each person, there was a link between health and housing. One client became homeless after losing his home in a fire, and two were "marginally housed."

"Those three cases really forced me to take a look at the entire medical paradigm," she said. "So, I used to think that providing evidence-based medical care can actually provide health for my patients. But where I couldn't help them was with housing. … This really compelled me to make the switch of really working further upstream to address the social determinants of health because that is a really big component of health. And I really didn't believe it in my heart until I saw it myself."

Last fall, Relucio's convictions were reinforced after she heard Dr. Josh Bamberger, the medical director for Mercy Housing, speak at a conference about providing permanent housing support to chronically homeless patients. Doing so, she recalled Bamberger say, saved more than a million dollars in health costs and improved health outcomes.

"Based on that, I just felt even more driven that this is something that we really should be focusing our efforts on," Relucio said.

Older adults are of particular concern in Napa County, with nearly one-quarter of the homeless population being longtime residents who are over age 50.8 "Napa County has one of the proportionately largest older adult populations in California, and we expect that to grow," Wooledge said, adding, "Seniors are one of the communities that are at highest risk of becoming homeless because many of them do live [on] fixed incomes and so, you know, they're one disaster away from potentially becoming homeless."

One of those disasters came in 2014 when the city of Napa's downtown sustained massive damage following a 6.0 magnitude earthquake, the largest in the Bay Area since the 1989 Loma Prieta quake. "There were a lot of the old houses that were affected by the earthquake and families that weren't able to make the repairs that they needed to continue living there," Wooledge said.

The ripple effect of shuttered businesses and vacant homes following the earthquake underscores the NCPH refrain that housing instability hurts everyone.

"Even though a small part of the community may be affected by homelessness or unhealthy housing, it really has a wider impact on the rest of the community, even though other community members may not know it," Relucio said.

For example, the county has had trouble recruiting and retaining many essential workers, such as teachers, nurses, first responders, and home health aides, who have been priced out of the area. To afford a median-priced home in Napa County, a household needs an income of $95,000. Yet in 2014, the median income of the county's workforce was $38,158.9

Wooledge described Napa's housing issue as "the canary in the coal mine." Many families move out of Napa County to more affordable areas to avoid becoming homeless. When that happens, school enrollment falls and budgets drop, so the issue ends up affecting the whole county.

"We just need to acknowledge that and see what we can do to fix that because we want Napa County to be a place where people can raise a family," she said.

Implementing systems and policy changes

Although NCPH/HHSA staff understand that homelessness is a national issue, with root causes that must be addressed over the long term, they are nonetheless working hard to create solutions that will have an immediate impact at the local level. And their housing efforts go far beyond raising awareness.

In recent years, Napa County has seen an increase in the number of homeless persons counted each year living outside and staying in shelters. In response, HHSA partnered with the city of Napa and engaged national experts to analyze Napa County's homeless system and make recommendations for improvement. The Corporation for Supportive Housing (CHS) and the National Alliance to End Homelessness (NAEH) facilitated multisector stakeholder meetings, analyzed homeless system data and funding resources, and analyzed the shelter system operations and processes.

In 2015, the consultants released a report calling for major changes to the homeless and housing system, including establishing a collaborative funding structure to braid disparate funding sources, creating a Flexible Housing Subsidy Pool to support the creation of more high-quality housing that is affordable, reimagining shelter operations, and leveraging opportunities to work more closely with the health sector. The approach draws on the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act of 2009, which established a federal goal of ensuring that individuals and families who become homeless are able to return to permanent housing within 30 days.

After CHS and NAEH issued their recommendations for system-wide changes, NCPH/HHSA, together with partners, set a goal of eliminating chronic homelessness in three to five years. For those who are housed, NCPH/HHSA wants to ensure that payments are affordable.

To help meet these goals, HHSA has contracted with a new homeless services provider, Abode Services, which is taking on a large portion of Napa County's homeless/housing system redesign. Abode is providing multidisciplinary outreach, housing navigation, landlord relation and housing stabilization services, and is operating a low-barrier, "housing first" shelter system that places housing resources directly at the shelters.

Abode is also operating Napa County's newly formed Flexible Housing Subsidy Pool, which gathers housing resources from multiple sources to prioritize and package them according to household needs. Part of this pool contains funds to incentivize landlords to rent to vulnerable populations. According to Relucio, the pool helps pay for damage done to housing so that landlords have an incentive to continue to rent to those who have been or are at risk of becoming homeless. The pool also provides funding for security deposits for households to secure units and supplies direct rental subsidies. HHSA has also applied to new private and government grants for housing resources, which will also be passed through to the pool.

Additionally, NAEH led a housing challenge where providers housed 75 households in 100 days in the community. This challenge led to increased collaboration, including a newly formed group focused on expanding the stock of housing that is affordable through landlord engagement.

At the policy level, NCPH/HHSA is tracking state legislation to make sure it is aligned with goals to increase housing that is affordable in Napa County. With the area's housing issues gaining visibility, Relucio said the city of Napa has increased its housing impact fee, which goes toward a different pool to build more housing that is affordable.

Engaging community to find solutions that benefit everyone

Although the recommendations from CHS and NAEH provide a robust roadmap for transforming Napa County's homeless and housing system, NCPH/HHSA's focus on housing began several years prior, based on feedback from and engagement with a wide variety of community partners.

In 2012, NCPH made community collaboration a priority, as part of larger shift toward focusing more on the social determinants of health. During this time, NCPH changed the way they collect data for the annual community health assessment that they produce alongside Kaiser Permanente, Queen of the Valley Hospital, and other local partners.

In addition to gathering data from traditional sources, such as vital records for birth and death outcomes, they began collecting qualitative data by engaging community members, industry, businesses, funders, and other nontraditional partners. First responders, representatives from public safety, community-based organizations, and other groups also had a seat at the table and were part of the data-gathering process.

"We offered trainings so different leaders from different organizations could learn to host focus groups for their communities," Wooledge said, noting that trainings were offered bilingually and in many different locations to allow the Public Health Division to better capture data from underrepresented groups, such as Latinos and older adults.

The new data allowed the Public Health Division to begin looking more closely at health inequities, asking not only which ones were present, but also why they were occurring. While NCPH still offers traditional services, such as immunizations, they have expanded their scope, and staff are now conducting outreach and education to help the community understand health equity — the attainment of the highest level of health for all people — and why it matters.

Then in 2013, NCPH, along with traditional health care and nonprofit partners, formed Live Healthy Napa County (LHNC — phonetically called "link"), a multisector collaborative of private sector, public sector, nonprofit and community members all working to promote health equity. Public health staff comprise its backbone and take a collective impact approach, which involves using a common agenda, shared measures of progress and other forms of collaboration to effect change. After a period of strategic planning, including engaging with residents through surveys, town halls, and other meetings, the collaborative found that housing and cost of living were among the community's top concerns.

To further engage the community on housing issues, NCPH, in partnership with the Healthy Aging Population Initiative, the Napa County Commission on Aging, and the Gasser Foundation, held two large housing summits. The first summit, in June 2016, focused on how a lack of housing that is affordable results in negative health impacts. For example, a lack of housing that people can afford can lead to chronic absenteeism among students, which decreases their chances of graduating from high school — another major health indicator. And for older adults on a fixed income, high housing costs can force them into difficult situations, such as having to choose between food and medication or foregoing necessary doctor appointments. Relucio noted that a lack of housing that is affordable also means that many people commute into Napa County for work because they can't afford to live there. The increased stress from long commutes can also manifest itself both through poor health outcomes and negative environmental impacts, like air pollution.

Summit participants also learned how these housing challenges impact families and businesses alike; heard about innovative efforts happening to increase all types of housing (including low-income, middle-income, and "workforce" housing) in Napa County; and connected with opportunities to partner with other advocates to be part of the solution.

More than 200 people participated in the first summit, and the organizers carried that momentum forward into a second summit, held in October 2016, which focused on action planning and developing collective action agreements. Three priority areas of work emerged from the group's planning: identifying a shared vision for success and metrics for measuring outcomes; creating a countywide storytelling campaign — now called "Housing is Healthcare" — to reframe housing as a health issue and make the case for housing that is affordable to all; and coordinating action among community partners to make those goals a reality.

Out of that summit came an important insight: Napa's efforts to increase the amount of housing that is affordable presented the opportunity to coordinate data and create messaging for greater impact. To make progress in these areas, a group of public-private stakeholders already active in housing convened a Housing for All workgroup that included two task forces: one to leverage data to better understand the county's housing needs and track progress over time, and another to put a human face to the data through community stories and coordinated messaging. NCPH will help support both task forces; however, they will be community-led.

Partnering with community groups to expand public health's reach

Although they provide backbone support for LHNC and the two housing summit task forces, the Public Health Division's role is often a supportive, rather than leading, one. This is in part because NCPH must remain politically neutral.

"We can't weigh in on particular policies, saying, go for it or go against it … but what we can do is provide education on the health impacts of policy." Relucio said.

"Our role," she added, "is to prepare our community partners, and for our community partners to prepare their clients, so they actually have a lot more say in what the community needs are, and they can actually help design what [the solution] looks like."

How these roles intersect is evident in NCPH's partnership with On the Move, whose mission is to develop the next generation of public sector leaders and ensure that they better represent the diversity of their communities. On the Move also addresses a range of equity issues from mental health to the achievement gap between Caucasian and Latino students.

On the Move and NCPH have a long history of working together and leveraging complementary resource and skill sets to achieve a common vision. Using an "inside/outside" strategy, each partner pushes forward or pulls back, depending on the situation and what they want to achieve. To be effective, this approach requires the Public Health Division to know what its community partners can do and when, as well as be aware of its own strengths and limitations.

"In the partnership, we each bring our own expertise to the table to combine forces and be able to advocate for the needs of our community," said On the Move's Abdo, who also co-chairs LHNC. "On the Move has expertise in finding and developing the voice of community, and Public Health has the expertise of knowing what the issues are, being able to provide the data to back that up, and navigat[ing] bureaucratic systems."

While On the Move is not a direct housing provider, they assist community members in finding and retaining safe housing that they can afford. That could involve helping residents fill out housing applications or doing referrals to other housing-related services. According to Abdo, On the Move brings these and other services "outside of the county buildings and walls and into places where the community can seamlessly access those services."

One way On the Move does this is by co-locating services on school campuses. For example, McPherson and Phillips elementary schools now have family resource centers that serve a primarily low-income Latino population. On the Move also operates a bilingual, bicultural program called Parent University at several of Napa County's Title I elementary schools, which receive federal funding based on their high numbers of students from low-income families. Grounded in a knowledge of the social determinants of health, the program helps families gain the information and skills they need to become active members of their community and more engaged in their child's school. Participants can take classes to improve their English, gain computer skills, learn stress-reduction techniques, and much more.

Abdo described Parent University as "wildly successful" in that parents have become more involved, gotten connected to the services they need, and kids' test scores are rising.

"There was a lot of engagement, and I think an unintended benefit was that the parents were starting to get connected to each other instead of being isolated," said Abdo, explaining that it is common for low-income populations to face challenges in connecting to services and to one another.

To further assess community priorities and gaps between the resources needed and resources available in the Phillips neighborhood, On the Move and the Public Health Division partnered together, along with the Napa Valley Unified School District, in 2015 to organize a health fair, town hall meeting, and series of focus groups.10 On the Move brought in speakers; did outreach and recruitment to get families to attend; involved students as both presenters and emcees; worked with NCPH to provide concrete context for the data to make it more relatable; and designed a small-group format with bilingual, bicultural facilitators to allow for more intimate conversations.

Approximately 140 people attended, and financial stability emerged as one of the community's top concerns. To meet that need, the United Way provided funding to transform On the Move's Phillips Family Resource Center into a SparkPoint financial education center. The center helps families learn ways to raise their incomes and better understand and use public benefits; provides case management; connects them with job opportunities; and offers one-on-one coaching, goal-setting, and skill-building.

According to Lupita Melgoza, the center's coordinator, it has become "the heart of the community." The center helps families with everything from medical applications to taxes and, Melgoza noted, is particularly critical for the neighborhood's many stay-at-home moms who do not drive or have control of their finances.

The center also provides referrals to housing-related services for clients, many of whom have lost or are at risk of losing their homes. "We've heard from students when they're in class telling the teachers, 'Oh, I slept in the car last night.'" Melgoza said.

"A lot of the students that are homeless right now, they're moving out of Napa, so that's also affecting the district enrollment," Melgoza added, explaining that the district is now facing budget cuts, including to parent engagement programs, which puts services like those offered through the center at risk. "We're asking those parents to speak up and share their stories [about] how helpful it has been for them … having the services around this community," she said.

Melgoza understands firsthand how important the Phillips Family Resource Center and other services like it are. A native of Mexico, Melgoza and her family came to Napa when she was nine, and she watched as her parents struggled with many of the same issues facing the center's parents (Melgoza emphasized she doesn't like to refer to them as "clients"), such as accessing health insurance, overcoming language barriers, and working long hours to survive. Fortunately for Melgoza's parents, they found a community liaison to help with those challenges.

"I always remember Pilar, the person that really helped my parents when I was in fifth grade, and that's why I wanna give back," Melgoza said.

So far, data show the SparkPoint Center is working. "Ninety percent of the parents who have participated in the program have increased their financial standing," Abdo said. "That means they've either improved their credit score, reduced their amount of debt, or increased the amount of money that they've been able to save from their paychecks."

The same town hall meeting that ultimately gave rise to the SparkPoint Center also led to an opportunity in 2016 to engage youth in addressing another of the community's concerns: poor infrastructure. On the Move worked with a group of fifth-grade students at Phillips Elementary School to identify things that were making it hard for them to be healthy. What they found, Abdo said, was that insufficient lighting and a lack of sidewalks were making it hard for students to ride their bikes to school and feel safe at night.

On the Move then helped the students to figure out which government entities could implement the changes, advocate for the resources they needed, and, ultimately, get the sidewalks and lights installed.

Beyond the infrastructure improvements, the youth gained a sense of empowerment and ownership. "They were so proud. … They still talk about [it] when they walk by the sidewalk: 'This is the sidewalk that I made happen here in my community,'" Abdo recalled the youth saying.

While the Public Health Division's role in these and other efforts has been to provide data and other forms of support (such as access to public agencies), the leadership, solutions, and related impact could not have happened without On the Move's strategic engagement with and responsiveness to the community.

Meeting short-term demand with an eye toward long-term need

While NCPH/HHSA is working to address the housing crisis through community engagement and empowerment and broad systems-level changes, the agency has also thrown its support behind groups working on the front lines of the issue. One of these is a facility called the Nightingale Center, run by Catholic Charities. Once a Bikrham yoga studio, the respite care center aims to end the revolving door between hospitals and the streets by providing a place for people without homes to be able to heal.

To support the opening of Nightingale, NCPH/HHSA provided data and talking points on homelessness, and several executive directors of partner community-based organizations from Live Healthy Napa County testified before the City of Napa Planning Commission.

The center, which offers a safe location for social workers, medical professionals, and others to provide care, is intended to be a "stop-gap as part of a longer solution," Wooledge said.

"While they're here in this facility, they will be provided with three meals a day, a loving and warm environment, clean clothes, clean beds — you know, the things that every human being should have," said Jenna Bolyarde, a longtime Napa resident and site specialist at the Nightingale Center.

Nightingale, which opened in April 2017, has 11 beds in a co-ed dorm-style layout, with partitions to separate male and female residents. Each person gets a nightstand, two bins for personal belongings, and access to showers, lockers, a laundry room, and a common area with a fully stocked fridge, new TV, and plenty of seating to allow for a range of events, such as Alcoholics Anonymous meetings and movie nights.

As she walks through the space, carefully describing each of its amenities, it is clear that Bolyarde's connection to the space is deeply personal. "This facility is desperately needed here in Napa," said Bolyarde, who was homeless for about 15 years and now has devoted her career to improving outcomes for Napa's most vulnerable. "I've actually been on the medical side where I'm needing to receive medical benefits and have no place to go," she added.

Bolyarde said that while she was on the street, she spent time in and out of rehab and jail, and lost her children to Child Welfare Services. But after reaching out to the Department of Rehabilitation and getting connected with community resources, she was able to get a job, go to school, and develop a strong relationship with both of her kids.

"I really just have a heart to let people know that there actually are resources, and there are people sitting on the other side of those resources who really care," she said. Bolyarde, who is now pursuing her bachelor's degree in social work and aiming to become a case manager, said she hopes that her experience on both sides of the issue will help to reduce the "us against them" mentality that can develop around the issue. And, ultimately, she wants to help connect people with the care they need to thrive again.

"There is nothing quite like seeing a person come back to health and the light come on behind their eyes, you know, and all of a sudden developing goals," Bolyarde said, explaining that it's "hard to participate in life" when you're on the street and you feel "sub-human."

Clients can stay at Nightingale for up to 180 days. During that time, the goal is not only to help them heal but to connect them with housing and other services so that when they leave, they are not returning to the streets.

Changing internal practices

To bolster its external efforts to advance health equity, NCPH/HHSA has made internal changes as well. Since 2012, when community health assessment work began, the agency has increased its cross-division work, including collaboration with operations (homeless services); mental health, alcohol, and drug services; self-sufficiency (which administers CalWorks, CalFresh, and Medi-Cal, the state-funded programs that provide low-income residents with cash assistance, food aid, and medical care, respectively); child welfare services; and comprehensive services for older adults.

"We have made more of an effort to work better together, with a goal of looking at social determinants of health because it's something that we're all working on in different ways," Wooledge said. "Housing is a cross-cutting issue."

Now, when tackling a given issue like housing, Wooledge said that staff ask questions like, "What does this mean for mental health?" and "What does this mean for self-sufficiency?"

The increased collaboration between the public health and self-sufficiency divisions and the Napa Continuum of Care, a consortium of nonprofit, faith-based, and government agencies working to end homelessness in the county, has already resulted in the creation of Napa R.E.N.T.S. (Respecting Everyone's Need To Be Self-Sufficient). Born out of a community housing challenge led by the National Alliance to End Homelessness, the project's goal is to match landlords and property managers with local service providers whose clients are homeless or at risk of becoming homeless.

"Being able to move upstream or take a birds-eye view helps us internally at HHSA to work together for a common goal," Wooledge said.

As a member of the Bay Area Regional Health Inequities Initiative (BARHII), NCPH/HHSA is further institutionalizing its focus on health equity by implementing a health equity assessment toolkit from BARHII. Through a series of conversations and trainings, as well as a survey, Napa County's HHSA has implemented the toolkit not just in its Public Health Division, but across the entire agency of 600+ employees and community partners. Doing so involved a steep learning curve for many staff and was time-consuming to implement; however, Wooledge said the results have been worth it.

"That has been very positive in terms of helping our own employees understand why we're doing this," she said. It helps answer the question, "Why is public health talking about housing?"

Rather than being an item on a checklist, Wooledge said adopting the toolkit is now embedded in the agency's ongoing health equity practices, which will continue to evolve over time.

Overcoming challenges

As with any campaign aimed at changing deeply entrenched social causes of poor health, NCPH/HHSA's housing work has come with its fair share of challenges.

It is expensive to subsidize housing that is affordable, and even if budgets were not a concern, Napa is an agricultural preserve, meaning much of the land cannot be developed. Wooledge suggested that possible solutions could be to convert more buildings into high-density and multiple-family housing and to make it easier for people to build and rent junior accessory dwelling units (JADU), often referred to as "in-law units," within their property, both to defray housing costs for the homeowner and to increase affordable units for low-income families. In conjunction with the city of Napa and a local hospital community benefits program, HHSA is working on innovative financing strategies through its involvement in the Robert Wood Johnson Foundation's Invest Health project for homeowners who have the desire to build a JADU.

Napa's history of conservation may also be contributing to some locals' fears that increasing the number of housing units would lead to overpopulation, a myth NCPH/HHSA is trying to dispel. "We're not trying to bring new people into our community; we're trying to take care of the people that live here now," Wooledge said.

Additionally, NCPH is small. The division has only about 60 employees and one epidemiologist, and although its capacity has been growing, it still faces limitations because of its small size.

Still, perhaps the largest hurdle NCPH/HHSA and partners have faced in their housing work so far has been a "not in my backyard" mentality, or NIMBYism. It is a manifestation of the stigma that surrounds housing issues and the "us against them" mentality that advocates like Bolyarde are working so hard to undo.

NIMBYism crops up most often when projects to build or open new housing are proposed. In fact, it almost derailed the opening of the Nightingale facility. When the project went before the city's planning commission, they initially rejected it because of neighbors' concerns.

Later, NCPH crafted some talking points, and Dr. Relucio, along with another physician, spoke before the commission about the health consequences of not having Nightingale. "We also brought out data on how people that are homeless were three to five times as likely to be seen in the emergency department and twice as likely to be hospitalized," Relucio said.

Additionally, NCPH/HHSA shared numbers on how much those ER visits cost the community. In doing so, Wooledge said, they were trying to bridge economic and health arguments. "What's best for the community is for everyone to be healthy; and for them to be healthy, they have to have stable housing," she said.

Ultimately, NCPH/HHSA was successful, and the Nightingale Project was approved; however, NIMBYism persists in some neighborhoods. For example, the area around Old Sonoma Road has experienced backlash following conversations about how the space could potentially be used for housing. Yard signs in that area read, "Say no to high-density housing project in our neighborhood."

"My response to NIMBYism is, you know, okay, if you don't want it in your backyard, we'll put it in your front yard," Bolyarde said, noting that it has taken a lot of education to garner public support for places like Nightingale.

Shifting the narrative on housing

Thanks to the work of NCPH/HHSA and community partners, NIMBYism's days are numbered, and a new narrative is taking shape — one that frames housing as a matter of health, fairness, and community. The goal of Napa's housing practice is to "create community-wide understanding that the lack of housing that is affordable in Napa affects your life, regardless of who you are," explained Jennifer Palmer, a public health staff services analyst who helps provide backbone support for both Live Healthy Napa County and for the storytelling task force that emerged from Napa's housing summits.

The storytelling task force is hastening that shift in thinking — from housing as optional to housing as critical, and from health as an individual issue to a community one — by going beyond dispassionate research and expert testimonies and using a combination of community voices, infographics, and other visuals to make stories more relatable.

"People that are against affordable housing or higher density housing where it's needed need to be told the stories on how that type of thinking actually leads to decreased health of the population," Relucio said, adding, "The ability to integrate data and storytelling can facilitate community advocacy to increase housing that is affordable in Napa County."

Many community members' stories, including those of homeless residents, are featured in online videos and photo essays on the website Homeless of Napa, which is run by a small group of local advocates who are collaborating with the "Housing is Healthcare" campaign to reframe housing as a health issue. The website also includes a variety of resources for those needing food, shelter, clothing, or other services, a list of volunteer opportunities, and links to the group's social media platforms.

Storytelling has also been used to end stigma — and to promote healing — at the Innovations Community Center, a project of On the Move that provides clients with mental health needs a safe space to access services and activities, such as peer-led support groups, art workshops, and mindfulness classes. Most participants are low-income adults with mental health problems, and some are homeless.

Turning points exhibit"Our goal here is to create a safe place for people to come in, feel accepted," said Denisse Madrigal, site director for the center. "There's a lot of stigma out there with mental health. This is a place where people can come in, get involved if there's activities, and/or volunteer, or just come find out what mental health really is."

The space is lined with photos and quotes from both staff and community members who shared various truths and lessons from turning points in their lives, often in the aftermath of grief, abuse, and trauma. More than 150 stories were captured as part of the project, in which everyone from stay-at-home moms to students to city staff told and then acted out their stories.

"We kind of blurred the line between providers and consumers," Sara Tirado, the center's informa-tion services coordinator, said. "It was the idea that we all have been there; we all have a story."

Lessons learned

Several lessons have emerged from the successes and challenges NCPH/HHSA has faced in its housing campaigns:

Community engagement is essential. Local health departments cannot act as islands. Rather, it is important for them to involve community both in identifying problems, as NCPH did with its qualitative approach to gathering data, and in crafting — and advancing — solutions.

Engage elected officials and other county leadership early. Being more inclusive from the start can help to accelerate the work, explained Wooledge. This is a lesson that NCPH learned after the first housing summit, when staff realized some important stakeholders had not been part of the planning process. Not engaging these stakeholders early enough on cross-cutting issues like housing can lead to turf issues and other points of conflict. "Sometimes we're all very busy with different priorities, but by having a conversation and saying how we're engaging community, I think we … may have averted some of the difficulties we ran into," Relucio said.

Listen to opposing viewpoints. Doing so may be tense at times, but it leads to better results. "Differences in philosophy are opportunities for learning, and it actually helps to drive the [work] going forward because we're hearing all viewpoints, and we get buy-in for the community," Relucio said, adding that the opposition are "the ones that really help in thinking about other angles that we may not have thought of with this work."

Besides including residents, community-based organizations, and elected officials, NCPH also prioritized including industry voices. "Political division isn't an option here in Napa County," Wooledge said. "We know we have the assets and wealth that we do because of the ag and hospitality industries." Thus, she explained, it was critical for the Public Health Division to be transparent with them and hear their perspectives. "It's about respecting each other, building trust, and having conversations where all voices are brought to the table," she said.

Understand the history of an issue. Knowing how a problem developed and evolved over time and ensuring all stakeholders are aware of that history can make it easier to build consensus and make decisions. "Then we can start from the area where the barriers were present instead of trying to rehash the past issues again," Relucio said.

Words are powerful — choose them carefully. Although the language that is effective or ineffective will differ from place to place, it is worth investing time in identifying weak spots in messaging. In Napa County, the phrase "housing that is affordable" resonates better than "affordable housing" — an idea that originated with Calistoga, the county's northernmost city. "Affordable housing," noted Wooledge, triggers stereotypes and misconceptions about Section 8 housing and fears about affordable homes driving down property values.

Elevate authentic voices. Dr. Relucio, Lupita Melgoza, and Jenna Bolyarde all either have firsthand experience with or personal connections to housing issues. Stories like theirs have helped bring data to life and have made it easier for people to see the human costs of homelessness and housing instability and understand why urgent action is needed.

The health argument isn't always enough. "One of the things we've realized," Wooledge said, is that "you can win the hearts and minds of some people with storytelling, but some people don't think that way. They think in terms of dollars and cents." This is why Dr. Relucio and others incorporated economic, health, and community themes into their testimonies to persuade city planners to approve the Nightingale project.

As Bolyarde said, "You are creating a taxpayer. You are creating somebody like me who wants to give back."

Next steps and vision for the future

While the Public Health Division recognizes that housing insecurity and homelessness are national issues with complex social and historical causes, and that truly ending them would require a connection to larger social movements and coordinated action among many counties, that is not stopping NCPH/HHSA from setting ambitious goals for the future and directing significant time, energy, and resources toward combatting the issue in Napa County.

For example, the Public Health Division is "using its expertise in epidemiology and evaluation to create a data-driven picture of the county's housing crisis," said Jennifer Henn, public health manager and epidemiologist for NCPH's Chronic Disease and Health Equity Unit. In partnership with LHNC, NCPH is developing a new health assessment that has a focus on housing that is affordable.

"The resource will help the Public Health Division more effectively solidify the connection between housing and health outcomes in the community," Henn said.

In the near term, NCPH/HHSA also aims to ramp up communication efforts to increase support for making housing that is affordable available to the entire community. For instance, NCPH/HHSA is working with partners to promote the Napa R.E.N.T.S. project using the newly created slogan, "Health Starts with a Home." Although Napa has a small media market, the campaign will include a combination of paid radio public service announcements, print and digital advertising, earned media coverage with local news outlets, and social media marketing.

NCPH/HHSA will further leverage the power of personal storytelling to advance its health equity work. In collaboration with the videographer who created the "Homeless of Napa" videos, NCPH will elevate the story of a person who was homeless but later gained housing, as well as Dr. Relucio's experience of losing three of her HIV-positive patients in the aftermath of housing struggles.

The Public Health Division recently received a $10,000 grant from The California Endowment to apply to its communication campaigns. The idea, Wooledge said, is to "influence people to think about the issue differently — to think of affordable housing as attractive to the whole community, not just some."

Additionally, NCPH housing efforts and feedback from various community forums have led to the realization that reducing the cost of living in other areas, such as food, can help alleviate the burden of housing costs in the short term by helping families to free up more of their income. As a result, the Public Health Division and many of its partners are now working to expand access to affordable, nutritious food.

Asked what success for Napa County would look like in the longer term, On the Move's Abdo said: "I would like to see in the next five to 10 years a community that is welcoming, that helps to raise up the voices of our children and youth … an inclusive community, one where every member of our community — regardless of their race, their sexuality, their income level, where they live — they all have access to the same opportunities." Ultimately, that type of inclusivity and acceptance would translate to better health.

"If I were to see a map of Napa County where we have differences in health outcomes and life expectancy maps, we have red zones, meaning … a neighborhood doesn't do as well, and green zones where people do better," Relucio said. "And my hope is that one day we can look at the data, and the color across Napa County is the same color — green, meaning that we're all going to be healthy."

To view video highlights from NCPH/HHSA's work, visit https://www.youtube.com/watch?v=n8n6mhJO5S4&feature=youtu.be.

Acknowledgments

This case study was written by Heather Gehlert. BMSG would like to thank Cookie Carosella for contributing reporting to this case study. We also thank the following reviewers for their insightful feedback: Nui Bezaire, Napa County Health and Human Services Agency, Operations Division; Jonathan Heller, Human Impact Partners; Jennifer Henn, Napa County Health and Human Services Agency, Public Health Division; Rachel Poulain, The California Endowment; Bob Prentice, former director (retired) of the Bay Area Regional Health Inequities Initiative (BARHII); Karen Relucio, Napa County Health and Human Services Agency, Public Health Division; and Cara Mae Wooledge, Napa County Health and Human Services Agency, Public Health Division.

This case study was funded by The California Endowment.

© 2018 Berkeley Media Studies Group, a project of the Public Health Institute, and The California Endowment

References

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3 City of Napa Housing Authority data, 2015.

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7 Annual Progress Report. (2016). Napa Homeless Management Information Database.

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9 Huffman, J. (2017). Napa Stat: $95,000. Napa Valley Register. Available at http://napavalleyregister. com/business/napa-stat/article_ef6cb714-22d9-55cc-a244-f976f5118f09.html. Last accessed November 2, 2017.

10 Phillips School Town Hall Meeting, Final Report (2015, April 16). On the Move, Napa Valley Unified School District, Napa County. Available at http://www.livehealthynapacounty.org/uploads/5/1/4/4/51449431/phillips_school_town_hall_final_report_041615.pdf. Last accessed June 5, 2017.

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