The "Cliff Effect" refers to a sudden and unexpected decrease in public benefits that can occur with small increases in earnings. In systemic poverty, wages have not kept up with inflation and the cost for basic human needs have skyrocketed. Within that, families need help and need work. We need to shift from thinking "getting off benefits" to "keeping people employed and increasing their financial freedom and security."

Most parents cannot afford high quality EEC; one parent usually has to drop out of the workforce (which is disproportionately women). Families facing economic hardship have less access to high quality EEC and may be less prepared for kindergarten than their peers coming from more affluent households.

There is longstanding evidence that families who receive home visiting services throughout their infant/toddlers' first two years have improved outcomes. By starting to implement one time home visits, our community steps closer to both destigmatizing AND assessing the actual needs in our community for longer-range programs that really are more about the longitudinal support in these early years.

Transportation is and continues to be a major barrier to care for folks without personal means, those with disabilities and those with young children. Increased capacity for services to provide quality and ADA compliant transportation to clients is necessary to ensure disability equity in our community.

The community expressed a need to categorize internet access as an essential service. This became highly apparent during the height of COVID-19, a crisis that revealed a major disparity between those who have uninterrupted access to communication and information via the internet, and those who do not.

The community reported that inequities in being able to access housing and rental assistance obtaining safe and affordable homes. In the community conversations, interview participants also expressed a need for rent control or some means to managing increasing housing and rental costs, as voucher programs are only able to cover rental payments that are within the Fair Market Rent (FMR).

Community members report a need for accessible travel modes.

The community reported a need for a specialized crisis response system to be put in place for crises involving mental health issues or substance use disorder issues, as an alternative to traditional public safety systems.

In our region and across the nation, lifespans are increasing, but good health indicators unfortunately are not. There are not currently services meeting the demands of the rapidly aging population.

Agencies report that with improved reimbursement rates, wages could increase leading to improved recruitment and retention rates - improving availability of services, reducing waitlists for clients and patients.

Youth report the need for comprehensive sex education within the school structure that they can rely on for accurate information. Youth also report feeling more secure knowing they have a trusted adult they can speak to about difficult topics like sex outside of their peer-groups.

The Coalition will support by implementing systems for understanding ongoing community priorities and respond to them.

Community members report experiencing limited access to services due to barriers, including: transportation, translation, cultural humility, citizenship status, institutional trust and safe spaces.

Community members reported need for multi-translated resources distributed in frequented spaces and forums led by knowledge leaders.

Community members reported experiencing implicit bias and racism, and poor customer service when in direct communication with service providers. Community members expressed a desire for anti-racism, trauma-informed training for residential counselors; customer service training for patient navigators and hospital admin; and having people with lived-experience co-lead trainings.

Community members expressed struggling with referrals made by PCP or LICSW due to: lack of transportation; lack of translation; not being able to reach a Care Coordinator through a phone tree/long wait times; discomfort speaking with Care Coordinators due to perceived impatience or lacking cultural responsiveness; uncertainty about insurance coverage/bills.

The community reports feeling implicit biases, impatience and condescension when trying to communicate with patient navigators due to inadequate communication and cultural responsiveness.

There is a clear identified need to not only collect local health data, but to properly communicate data to the broader community. The Coalition and CHIP partners recognize there's a severe lack of census level health data disaggregated by race and ethnicity, amongst other demographic factors. Without disaggregated data, health disparities are challenging to identify, and strategies to close those gaps are less targeted. 2018 CHA data limitations included availability of timely data, as much of the available data used was already 3+ years old. The quantitative data was not stratified by age, race/ethnicity or income, which severely limited the CHA's ability to identify the most at-risk segments of the population in an objective way. The qualitative data sources did allow us to explore these issues but the lack of objective quantitative data highly constrained this effort.