Cultural Rhetoric in the Writing Classroom By Rebecca Torres Valdovinos
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Siouxland Community Health Center
Resource Manual
Gabriela Valdovinos
Social Work Practice III
Sister Shirley Fineran
May 2, 2014
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Introduction
Siouxland Community Health Center (SCHC), a Federally Qualified Health Center
(FQHC) in Sioux City, Iowa has provided quality low cost health care services to the community
for over 20 years (Appendix 1).“The mission of Siouxland Community Health Center is to
provide primary health care that eliminates access barriers and improves the health of the
Siouxland community” (Appendix 2). In order to meet a wide range of needs, the health center
provided the following services under one roof: financial counseling and sliding scale fee
payments, primary medical care for adults and children, laboratory and radiology services,
chronic disease management and case management services, pharmacy with medication
counseling and medication financing assistance, behavioral health screening, evaluation,
treatment, as well as care coordination through behavioral health and social services, substance
abuse screening through the Screening, Brief Intervention and Referral to Treatment (SBIRT)
program, infectious disease prevention and care coordination services, language interpretation
services that includes Spanish, Vietnamese, French, Somali, Oromo, and Amharic. Siouxland
community Health Center has had the opportunity to provide a dental home for both adults and
children (Appendix 3).
Siouxland Community Health Center has gone through many changes over the years in
order to accommodate the expanding needs of the Siouxland community (Appendix 4). The
health center moved to a larger building in 2009 and continued to expand to meet the high
demand of health care services in the surrounding counties. To improve the delivery of the
services offered in the community, collaborative agencies also underwent changes. New services
were created, services had been removed, and other services were expanded, which made it
difficult for members of the community to stay updated.
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Gabriela Valdovinos was a senior social work major at Briar Cliff University in Sioux
City, Iowa. She began her internship in the social services department at Siouxland Community
Health Center on January 27, 2014. Her role in the department as a future social worker was to
be “the change agent.” As a change agent Miss Valdovinos was able to recognize the needs of
the community and plan for change. Miss Valdovinos recognized that change was always
happening and periodical updates needed to be made.
The Need for Change and Preparation for Change
At Siouxland Community Health Center, departments worked collaboratively to ensure
that patients received the appropriate services. If needed services could not be provided in the
health center, the social services department had a responsibility to refer patients to the adequate
agency. With the ongoing growth of services at the clinic, the behavioral health and social
services staff had an increasing number of tasks. However, the department had already been
short-staffed for several months which made it more difficult to meet with every patient that
would benefit from their assistance. In addition to assisting patients during their medical
appointments, the behavioral health counselors were responsible for administering Test’s of
Variables for Attention (TOVA) in order to provide Attention Deficit/Hyperactivity Disorder
evaluations (Appendix 5). They also completed psychiatric diagnostic evaluations; as well as,
provided psychotherapy for the patients who are patients of the medical clinic.
Leslie McDonald-Gonzalez, LISW, was a previous student of Briar Cliff University and
took the role as her internship supervisor. Gabriela Valdovinos had the opportunity to shadow
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her throughout her internship. During one of her encounters with a patient, her initial task was to
provide the patient with information on adult day care services in order to assist with her health
care and social needs. For the requested information, she searched the current resource manual
which included a list of services provided by agencies in the surrounding counties, and contact
information.
Miss Valdovinos soon realized that her task involved researching the information because
it had not been provided in the manual. She found information about adult day care agencies
around Siouxland, through the internet, that helped initiate her work. She quickly learned that the
agency had discontinued their services. As she continued her research, she discovered that
multiple agencies have changed their contact information, created new programs, discontinued
services, changed physical address, and even changed their agency name. For example, a major
resource for seniors is Connections Area Agency on Aging (Appendix 6), which was previously
known as Siouxland Aging (Appendix 7).
Gabriela Valdovinos recognized that change is always happening and updates to the
resource manual would need to be made. She discussed revising the current resource manual as a
change opportunity with her supervisor and the other member of the department, Shelly
Backhaus, LISW. As a team, they decided that reviewing local resources, identifying changes,
and updating the resource manual would be an essential task in order to continue to provide
accurate information to the medical providers while meeting the needs of the patients. Her
change process was to revise the Siouxland Community Health Center social service resource
manual. Before the change agent arrived, the social service department had been aware of the
need for updating and revising information in the manual. The Siouxland Community Health
Center was kept extremely busy during the day due to the high numbers of patients seen on a
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daily basis. For this reason other staff were not able to take on the project due to lack of time.
Miss Valdovinos as part of the team was able to take on the project along with her other
responsibilities as an intern.
Phase I. Identifying the Change Opportunity
In the medical clinic, behavioral health and social services are offered to patients to
improve their mental health as well as their physical health. The social service department had
two behavioral health counselors that provided integrated health care services to the patients at
the request of the medical providers. An integrated healthcare facility’s definition indicated that
the facility provided mental health, substance abuse, and primary care services (Appendix 8).
Most patients came to the health center because they had physical symptoms of an illness or
disease. During the visit with the medical provider, patients were asked to fill out a Patient
Health Questionnaire PHQ-9 (Appendix 9), which is an initial screen for depression. If a patient
scored ten or more, the screen was considered positive and required further assessment by a
behavioral health counselor. After she gathered additional information, the behavioral health
counselor would review the resource manual in order to refer the patient to available services. It
was essential to have information on available services within reach to provide better patient
care.
Resource manual updates required many individuals to contribute their knowledge and
expertise. In this project, the Initiator System, defined by Fineran (2001; 2014) as “individuals or
groups who bring the situation or need to the attention of the change agent,” (p. 44) were Leslie
McDonald-Gonzales, LISW and Shelly Backhaus, LISW. As the change agent, Gabriela
Valdovinos brought the need of updating the manual to the attention of other staff.
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The Client system defined as “individuals, groups, organizations, communities who will
be the beneficiaries of the change process. There are primary beneficiaries who will benefit
directly. Secondary clients benefit indirectly. Client system may be an agency that has a work
agreement or contract, whether formal or informal, with the change agency,” (Fineran, p. 45).
The client system identifies agencies that benefit from the referrals made by the providers at
Siouxland Community Health Center. The primary beneficiaries are identified as the patients
who are referred to the agencies that provide the services required. The secondary clients are the
providers who benefit from being equipped with correct and updated information. ‘Target
Systems consists of “the people who are the targets of the change effort; the people who need to
be changed to accomplish the goals of the change strategy and produce the benefits for the client
system’ (Fineran, p. 45). In the case of this project the target system are the staff that will use the
manual. The sanctioning system defined as “The people with the formal authority and capacity
to approve and order the implementation of the proposed change strategy” (Fineran, p.45). For
this change process Leslie McDonald-Gonzales assumed the role of the supervisor and wrote the
sanctioning letter (Appendix 10). She supervised the change agent and also participated in
providing input for the project.
The supervisor accepted the change process, and the Change Agent System was selected.
The Change Agent System are “the people who will do work directly to produce the change,
including the change agent, the social worker, any social action organizations and groups, and
the people who belong to the social work agency or who employ the organization working to
produce the change” (Fineran, p. 45). The following individuals participated in the Change Agent
System, as well as, the Action System and the Planning Committee: Gabriela Valdovinos, the
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change agent, Leslie McDonald-Gonzales, LISW, Shelly Backhaus, LISW, Elizabeth Giles,
LBSW, Jason Byers, BSW, Jessica Maxwell, BA, Marcelina Cockburn, CADC, Michael Piplani,
MD, Stephen Pallone, MD, Natasha Ritchison, RN, and Alexandria Kohn, RN. These individuals
incorporated their knowledge and input to see the project completed.
The social service department members agreed that this project would be very beneficial
for Siouxland Community Center to use. As this was a very time consuming project, the change
agent needed to start working as soon as possible. Valdovinos was able to use the information
already provided on the manual to guide her through the project. She planned to use the internet,
phone and other individuals to gather her information. Valdovinos anticipated some boundaries
as she began her project. She knew that the clinic was a busy facility since day one. Her concern
was not being able to have the time to make calls during the morning in order to contact the
agencies. The reason for her concern was that some of the agencies were closed during the
weekends and some were only open at certain times, such as 8:00 am-5:00 pm. These were the
hours that she was at the Siouxland Community Health Center and conflicted with getting the
calls completed. Miss Valdovinos was not discouraged and continued her change process.
Phase II. Analyzing the Change Opportunity
Valdovinos was able to complete her research for the updated resource manual in
between meeting with patients in the medical clinic. She began by calling agencies identified on
the internet, and stated that she was working on updating a resource manual for Siouxland
Community Health Center. Agency employees confirmed changes to programs, verified
addresses and phone numbers; as well as, provided website information, and agency marketing
materials.
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The resource manual would be used by various departments and employees at clinic,
Miss Valdovinos was thoughtful about the organization of the materials. During this process, she
sought feedback to assure the manual would be accessible and that resources would be quickly
identified. She received strong support from the social service department, and felt that other
departments or teams lacked support due to the location of their offices. E-mail was the
identified form of communication but it was not as beneficial. This was due to not being able to
access Siouxland Community Health Center E-mail from home (Appendix 11).
During this phase, Miss Valdovinos also searched the internet for information on how
resource manuals were used at other facilities. The Institutional Effectiveness Resource Manual
was developed to guide and measure the effectiveness of the quality of teaching and learning at
Elizabeth City State University. This manual was used by the faculty to help them create an
appropriate an effective assessment plan. It was user friendly and listed steps of how to develop
an assessment plan. This was a current update of the previous manual Policies and Procedures
Manual for Institutional Effectiveness (Appendix 12). This manual served as an example that
changes and updates were highly important in order to improve the services for the community.
Phase III. Setting Goals and Outcomes
“The mission of Siouxland Community Health Center is to provide primary health care
that eliminates access barriers and improves the health of the Siouxland community” (Appendix
2). The mission statement was able to give the change agent an idea of how she could be able to
fulfill it with her change process. During the change agent's internship, she was able to come up
with goals, objectives and outcomes, along with her supervisor. This was in order for the team
to be able to stay on track with the change process. The following are the goals for the project.
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Goal One: To identify and analyze the need to update the social service community resource
manual.
Objective One: To review the resource manual and have a clear understanding of what needs to
be updated by January 31, 2014.
Objective Two: To create a list of agencies to research in order to verify contact information by
February 7, 2014.
Outcome One: Patients will benefit from accurate community resources.
Goal Two: To create a collaborate committee that includes participants from various
departments.
Objective One: Identify the departments that will be asked to be involved in the change process
by February 24, 2014.
Objective Two: Send an email to all participants informing them of the change process and to
invite them to be part of the committee by February 26, 2014.
Outcome Two: Patients will benefit from having employees from different departments
identify their needs in order to provide a comprehensive list of community resources.
Goal Three: To verify and make corrections to information provided in the current resource
manual.
Objective One: To research agencies on “Google” and compare the information provided in the
current resource manual and the information provided by Google by March 14, 2014.
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Objective Two: To use the information provided by “Google” and the current resource manual
and make phone calls to verify that all contact information is up to date by March 21, 2014.
Outcome Three: Patients benefit by being provided the correct information for resources.
Goal Four: To create a table of contents for the social service resource manual to be user
friendly.
Objective One: To discuss with the committee about the items that will be included in the
manual by March 28, 2014.
Objective Two: To print and organize the updated sheets of information for the manual by
April 23, 2014.
Outcome Four: Employees save time by having updated information readily available to
provide to patients. Patients benefit from waiting less time to be provided with resources they
need.
Goal Five: To create an evaluation survey for all provider teams to obtain insight on how
helpful the manual is for them.
Objective One: To create an evaluation survey of the use of the manual for provider teams by
May 1, 2014.
Objective Two: To handout the surveys to the provider teams and gather feedback by May 6,
2014.
Outcome Five: The patients will benefit by the clinic staff using an updated resource manual
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“Goals, objectives, and activities can be tracked on a Gantt Chart. The Gantt chart can
keep the change agent and the process on target. It provides the opportunity for the change agent
to plan when activities need to be accomplished, making sure that tasks get finished on time”
(Fineran, pg. 64). Valdovinos used the Gantt chart to keep track of her work and make sure that
her goals, objectives, and outcomes were completed by the set dates (Appendix 13).
Phase IV. Designing and Structuring the Change Effort
Miss Valdovinos had the overall responsibility during this project. She made sure that the
Change Agent System was involved and provided input while she worked on the manual. She
was responsible for sending out e-mails and communicating with committee members when she
encountered them in the building. It was also her responsibility to accept feedback and make
adjustments as needed. She was responsible for making the calls to verify community resource
information, update the information on the sheets, and organize it into a binder. She also ordered
information online from National Institute of Mental Health website that allowed her to provide
easy to read information on mental illnesses (Appendix 14). These pamphlets or booklets were
provided in a section of the manual. She also gathered ideas from additional providers, nurses,
and staff at the clinic who had not been members of the Change Agent System.
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Gabriela Valdovinos, Leslie McDonald-Gonzales, Shelly Backhaus, Elizabeth Giles,
Jason Byers, Jessica Maxwell, Marce Cockburn, Michael Piplani, Stephen Pallone, Natasha
Ritchison and Alexandria Kohn made up the committee. They were responsible for sending
information and communicating by word of mouth when encountering situations that needed
further research regarding available resources. The committee was also responsible for reviewing
the manual and making any suggestions on how it can improve.
Phase V. Determining Resources
‘The value of the change process and the support from the staff may be high but if the
change will incur money that has not been budgeted nor available for this fiscal year – and
maybe none in the near future – the idea will simply “go down the drain”’(Fineran, Pg. 74).
Luckily, revising the resource manual did not require much money.
Miss Valdovinos and her supervisor discussed the change process expense requirements.
They listed the supplies that were needed and create a budget that allowed them to see the
expenses of the change process. At Siouxland Community Health Center a budget was created
for each department within the clinic. The fiscal year started in February and prior to that a
budget was submitted to the clinic directors. After the clinic directors reviewed the budget, it was
submitted to the board of directors. The approved budget was then discussed with the department
manager. In the budget all the items necessary for the change process were included. This
included telephone, computers, internet, printing supplies, a binder, sheet protectors and
separators for the different sections of the manual. There was no additional cost for the change
process which was beneficial for the social service department. The following was the budget
created by the change agent for her change process.
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Community Resource Manual
Revenue SCHCProject
Client Fees$100,000.00 $0.00
Contracts$150,000.00 $0.00
Grants$500,000.00 $0.00
Total$750,000.00 $0.00
Expenses SCHCProject
Personnel$650,000.00 $0.00
Rent$82,500.00 $0.00
Supplies$5,000.00
$42.73
Telephone$4,000.00 $0.00
Copying and Printing$3,500.00 $8.29
Equipment$50,000.00 $0.00
Travel$5,000.00 $0.00
Total$750,000.00
$51.02
Phase VI. Implementing the Change Process
This phase described the process of the change that was implemented at Siouxland
Community Health Center. Gabriela Valdovinos started with the beginning stages of the process
as soon as her supervisor approved the change. This happened at the beginning of February
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2014. She reviewed the old manual and created the list that was used as a guide when she created
the table of contents. An email was sent to the committee members: Leslie McDonald-Gonzales,
Shelly Backhaus, Elizabeth Giles, Jason Byers, Jessica Maxwell, Marce Cockburn, Michael
Piplani, Stephen Pallone, Natasha Ritchison and Alexandria Kohn; to notify them of the change
process and how their assistance would be needed (Appendix 10) (Appendix 11). Their role was
to continuously assist the change agent by providing her with ideas on the items to be included
on the manual. There was resistance, change residue, and lack of support from some of the
committee members. When the email was sent only a few members replied to the message.
Gabriela Valdovinos used face to face communication in the hallways of the exam rooms to
communicate with some of the members that did not reply to email. She wanted all members to
participate in the process and she tried to make things run easy for everyone if they could not
make it to their email during the day. By walking around and asking the committee members to
give any updates on the encounters and needs of the patients, Gabriela Valdovinos was able to
manage this conflict.
The change was managed by Gabriela Valdovinos but with the help of the committee
members she was able to gather other ideas for services or agencies to be added to the manual.
All the sheets needed to be retyped into a word or excel document because there were no saved
documents from the previous information in the manual. Also the documents did not have page
numbers and the change agent wanted to make the manual user friendly. For this reason she
numbered the pages accordingly and separated them into sections.
Miss Valdovinos worked on the change process at the clinic but also outside clinic hours.
She called agencies to update information and also picked up brochures that have been updated.
Most of the work was done through calling and researching on the internet. She also consulted
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other social workers, Giles, Backhaus, and McDonald-Gonzales for feedback on the verification
of some of the services that they used frequently to provide to patients.
Every day a patient would come with an issue that gave the change agent or other social
workers ideas on adding items to the manual. This was something that the change agent was able
to recognize early in time. She notified the committee that a closing date was set for April 20,
2014 (Appendix 15). The reason was that this could be an ongoing change. Items can be added
every day, but the change agent wanted to be able to evaluate the change process for at least two
weeks. This would allow the change agent to have an evaluation sheet about how valuable the
change process was for the clinic patients.
When the change process began to be implemented providers were able to refer to the
manual. The manual was available to all clinic staff and their patients. All providers would be
able to take the evaluation survey after the two weeks that the manual was available to be used
(Appendix 16). The survey would be used to gather information on how valuable the change
process was for the providers to hand to their patients. It also would provide a space where they
could request for future additions.
The change agent was hired during her internship; she accepted the job and will be
returning after graduation. The change agent was able to hold the responsibility of this ongoing
project. Her responsibility was to ensure that the manual would stay up to date. She was also
responsible to keep in contact with nurses, providers, and other teams to assist with the
continuation of the updated resource manual. This responsibility was not included in her job
description but was discussed with Leslie McDonald-Gonzalez and Shelly Backhaus (Appendix
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17). As a team they decided that it would be beneficial for all since the change agent has all the
documents saved and has been working on the change process thus far.
Phase VII. Monitoring the Change Process
This time consuming change process needed to be monitored by the change agent
in order to be to be used by staff by the scheduled date. “Monitoring involves developing a
process ---and a simple tangible method ---to keep the change effort on course and to keep track
of implementation activities” (Fineran pg. 77). Gabriela Valdovinos recognized that that this was
a very important part of the change process to be able to finish the project. Miss Valdovinos used
all the handouts that were provided by the old manual. The sheets on the manual are different but
the change agent was able to create a list of agencies to research and call to verify contact and
program information (Appendix 18). She went down the list and in the process was able to also
add the agencies that were provided by the committee.
The change agent also used a Gantt chart to be able to monitor her change progress and
the goals of this project. Gabriela Valdovinos had a goal of completing the manual at least two
weeks before she finished her internship. The Gantt chart allowed her to see the progress
throughout time. She was able to keep her goals as planned, although there were some
unexpected situations. Since she was having a hard time communicating with the committee, she
needed to make time walk around during the day and talk to providers and nurses. Gabriela
Valdovinos was also busy consulting with patients and documenting about their visit. This made
it more difficult for her to have extra time to walk around and consult with the committee. She
was able to handle the situation by continuing to email members and making time during clinic
hours to have a brief conversation. The change was able to proceed as planned and be able to be
completed according to her goal.
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As change continued to happen throughout time, Miss Valdovinos acknowledged that the
resource manual would need to be kept updated. Her plan was to revise the manual every year
but also when visiting a patient she will be able to assist the patient calling the agency. This will
allow her to see that the agency has not changed and continues to provide the services specified.
Although, the change process was completed by April, Gabriela Valdovinos will be able to
continue to add and modify the manual.
Phase VIII. Evaluating the Change Process
“Evaluation is making a value judgment about the worth of the change” (Fineran Pg. 81).
During this stage Gabriela Valdovinos developed a survey that allowed her to see how
valuable her change process was considered (Appendix 16). She will be able to hand the surveys
to the providers, nurses, and committee members that used the resource manual. Now that the
change was completed she will be able to receive feedback from the individuals that will take the
survey. She will also have an opportunity to make any appropriate changes to the manual as
suggested by the staff.
Phase IX Reassessing and Stabilizing the Change
According to Fineran (2001; 2014), “Most change agents either leave the agency after a
major change episode or move to a different position in the agency” (p. 86). Fineran described
reassessing and stabilizing as a time to transfer responsibility. Fortunately Gabriela Valdovinos
received an opportunity to continue working at Siouxland Community Health Center. She will
remain with the agency and after graduation she will be taking the Behavioral Health Care
Coordinator position. The change process was part of the agency and one of her responsibilities
will be to continue to update any outdated information that patients or staff members encounter.
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Valdovinos will need to make all staff aware that she will continue to work as needed, on the
resource manual after her return to the clinic. Shelly Backhaus and Leslie McDonald-Gonzales
were both involved in the change process and were involved in the decision of having Gabriela
Valdovinos as the responsible individual for the community resource manual and its proper
maintenance. Miss Valdovinos will also use the evaluation surveys filled out by the staff to
consider any changes recommended. The support of the committee and other staff members
allowed for the change to be completed.
The new Social Service Manual allowed the clinic to be able to provide contact
information, informational handouts, program information and other community resources that
are frequently used by the patients. “The mission of Siouxland Community Health Center is to
provide primary health care that eliminates access barriers and improves the health of the
Siouxland community” (Appendix 1). With the completion of the project, the cooperation of the
staff and the services provided by the health center; Siouxland Community Health Center was
able to live by its mission.
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References
Fineran, S. (2001; 2014). Macro social work change process handbook. Sioux City, IA, Briar
Cliff University.
Office of Institutional Effectiveness, Research, and Assessment (2012) Institutional
Effectiveness Resource Manual. Retrieved on April 2, 2014, from
http://www.ecsu.edu/iera/docs/InstitutionalEffectivenessResourceManual.pdf