Salud Para La Gente and Watsonville Law Center

Transforming Health Care Through Strategic Partnerships

In 2016, Salud Para La Gente, a federally qualified health center serving California's Central Coast, and local legal aid nonprofit Watsonville Law Center entered into a formal collaboration to more effectively address patients' health-related social needs. Such medical-legal partnerships trace their roots to pioneering experiments in the '60s, '70s, and '80s, but have taken on new momentum in the last 15 years as growing recognition of the social determinants of health and health care reform have lifted up a more integrated vision of health and wellness.

Salud Para La Gente (Salud) and Watsonville Law Center (WLC), which serve a largely Latino population in an agricultural region, had a history of cooperation through cross-referrals helping farm workers with occupational health matters. This new partnership deepens their relationship to include joint back-office administration and shared staff that not only facilitates a more comprehensive response to the needs of Salud's 28,000 patients from two counties, but provides a stronger, combined organizational structure to support that work.

In this article, we talk with Salud CEO, Dori Rose Inda, and WLC Legal Director, Henry Martin, about their collaborative strategy, what they are learning, and what's next.

What inspired your partnership?

Dori: The big idea that motivated us is the transition in health care from volume to value, and our respective boards' conviction that this means addressing patient needs outside of the clinical in order to produce value for them and improve their wellbeing and health status.

Henry: We think there's real power in going beyond the typical referral model of coordinated services to an actual extended care team. It can be frustrating to get bounced around between agencies; patients want to feel like everyone's part of the same group helping them. With a partnership like this, we can cover a lot more of patients' lived experience and more fully address their needs.

So how have you structured your partnership?

Dori: We have a strategic partnership, captured in a two-year renewable agreement. It's not a merger, in part because some funding might be lost otherwise. Also, on both sides of the table, there was a high level of caution about what would be successful and what might be lost in a full merger in terms of control and identity. We weren't ready to jump in fully, so this approach felt safer. It also allows for some testing.

And how is it going so far?

Dori: We've been in it for a year, and we've made great progress. We're looking now at doing some assessment and evaluation to help inform what might be next for us. As for what it looks like right now, we're developing systems where patients can be referred directly to and connected with legal staff. We have some co-located staff already and look forward to increasing that over time. So for any legal issues that a patient brings up, our staff can make a warm handoff to legal staff. We don't really have a seamless service model yet, but that's what we're working toward.

Henry: In the meantime, it looks like how folks might envision services, in that they only have to tell their story or express a need once, and the service provider helps them with that, so it's more of a one-stop experience. We are still just beginning, but already we're far ahead of where we were last year. And we're seeing all kinds of legal issues. We actually came in thinking there was a pretty narrow set of things WLC would do, but we learned that on the health center side, they're dealing with all kinds of legal issues, and we can actually take a lot off the health care providers' plate. Working together, we're doing it a lot better -- and faster -- than before.

Dori: In a way, it feels like it's just beginning. The last year has focused so much on the back end, business side of things. Salud is a much larger organization than WLC, and we have the systems that a small organization does not, so this was an opportunity to provide that sustainability. So it took a lot of work to get the funding in place, develop job descriptions, build out the IT infrastructure, etc. But now, sharing our back-office infrastructure allows WLC to focus its energies on program work.

Were there success factors that made this partnership easier to get off the ground? Or what kinds of challenges have you experienced?

Henry: Because we'd worked together before, I'd like to say that made the process easier. Our relationship helped us see the possibilities of deeper partnership and to take that leap. It gave us courage. That said, there are lots of organizational culture issues to overcome, and we appreciate our consultant's help in doing that. At the staff level, there was a long period of communication and sharing information about services, etc. before we formalized the partnership -- and it's still ongoing. We're learning what we each respectively do. This happens through staff trainings, mutual review of formal processes and client/patient "journeys," and regular staff meeting time. Early on, that was especially important, to ask and answer: What kind of legal issues are coming up for your patients, and how can we help deliver value to those patients? And building trust and confidence in one another.

Dori: WLC staff may be burdened the most with this culture shock, since our staff is so big, they're the minority. They may also feel the loss of flexibility they had being part of a smaller organization. Culturally, legal aid tends to be a very progressive industry, and health care can be less so, which can also be a culture shock. It's one I experienced personally when I moved from WLC where I had been director over to Salud.

Henry: That was a big success factor, too. WLC's board was ready to hear the case for partnership, in large part because it had been Dori's board prior. And she had also laid the foundation for the Salud board, which probably had less reason to trust the idea going in -- but they really embraced it. It was a leap of faith, and an investment of good will granted by the Salud board, that they were able to think about what it could mean for the community. They respected WLC and what we do, and wanted to support us. And to our credit, we were able to make a great value proposition to Salud, and have made good on their leap of faith.

How will you know this partnership is succeeding in its goals?

Dori: We built some of that into our agreement. We directed ourselves to make the business changes, and those are probably the easiest to track. There are goals around increased financial stability for WLC, and for more integrated services.

Henry: And to look at what each organization is getting out of it: How is this making it easier for us to accomplish our mission and do what we do? Our consultant advocated for having strong metrics and thinking broadly about what are the benefits, from the less obvious to the most aspirational. Like in administration: What's going to be more cost effective? For the community: How will we have a bigger impact? One thing we're seeing is that we're achieving our initial goals, but it's also opening up a new vista of possibilities -- things we didn't even think about achieving separately, that weren't necessarily visible to us when we began. We've really done an incredible amount in a short period of time.

Do you have any advice for other organizations looking to form similar partnerships?

Dori: The key question, from a health center perspective, is: Is the partner ready to deliver services to the patient base, and is the patient base sizeable enough and a good enough match to make it work? I'd also say, based on our experience, that it's worthwhile.

Henry: And that it's possible. That it's something organizations should think about. The natural reaction of a lot of nonprofits is that this kind of partnership is scary or overwhelming. In a private sector merger, the moral courage comes from CFOs, who make the money argument. You don't have that in nonprofits. So there has to be visionary leadership that puts the mission forward and champions that. Part of our motivation at WLC was sustainability, and that need helped create the willingness to talk about this -- you have to have a good business case -- but it's not enough on its own. The gains aren't just for the organization, but a potential benefit to the community. That should give us courage: the desire to be transformative to the community.