Join NCACH as we shine a light on some of the amazing work our incredible partners are doing! This month, NCACH staffer, Caroline Tillier, got to connect with Communities in Schools of North Central Washington (CISNCW), who is one of our community-based care coordination partners in the region.

It is so inspiring and fulfilling to connect with people doing amazing direct-service work in our community – they are the hearts and souls that show up every day to help our communities thrive. And here’s a case in point.

Meet Edgar, Irma, Molly and Jessica!

They are the awesome and hopefully growing team from Communities in Schools of North Central Washington, dedicated to supporting students so they can be successful not just in school but in life.

Communities in Schools is a national model with 13 affiliates in Washington State, including our very own North Central team currently serving Waterville and Orondo school districts. What’s especially exciting is the way CIS of North Central Washington is figuring out how to adapt the model to our rural region – as the most rural affiliate in our state, they are trailblazers!

(Video provided by CISNCW)

CIS of North Central Washington shares our 4-county region, and NCACH has supported their expansion efforts through our Coalition for Health Improvement and Community-Based Care Coordination funds.

Why does their work fit into our Community-Based Care Coordination efforts?

  • Because they help students (who oftentimes go unnoticed or unheard) with complex navigation across systems and services.
  • They draw on an approach that is person-centered and all about relationships.
  • They are embedded in the schools and do home visits, meeting with the students face-to-face.
  • They hire their site coordinators very intentionally so that those working directly with students reflect the communities they are serving. In some cases, the site coordinators have been in the students’ shoes, which gives them an understanding and passion for the work. Students notice and feel that, which helps with trust and hope!
  • They surround the whole school, and the whole child (and their family) with a variety of supports – because they recognize that many interconnected needs and assets influence the well-being of each individual student.

Do you want to learn about their piece in this grand community-based care coordination puzzle?

Do you want to accelerate their amazing work?

Read more about their efforts below, in Edgar and Jessica’s own words!

Describe your program to us in a nutshell

Communities in Schools offers support to the whole student so that they can be successful not just in school but in life. We embed ourselves within schools by placing a site coordinator in the school that offers 3 kinds of supports:
(1) whole school support (family nights, food pantry, clothing bank, etc.)
(2) focus group services (tutoring, mentoring, clubs, after school programs, etc.)
(3) case management (one on one work with students, setting goals and building relationships to learn about any additional needs/supports)
We often encounter students from a school staff referral, and often times, the initial reason for referral is not the actual issue. Many children are struggling with multiple things and we work hard to build strong relationships so that we can support the child and their family to be successful.


CISNCW helps connect families to emergent resources and services across the region. (Photo provided by CISNCW)

Tell us a story that illustrates how you go about doing your work and why it matters.

Edgar: The work that we do matters because we create a space for students that a lot of the time go unnoticed or unheard. We support them and push them to reach goals that, without someone that has been in there shoes before, maybe they would not accomplish. I have a student that I work with whose English is not perfect yet. He is a very smart young man but deals with a lot of language barriers which leads to a lack of confidence/motivation. Before I started working with him he didn’t have a go to person, he didn’t have someone he could trust. Despite being a smart young man he didn’t see himself going to college. He has now been admitted to 2 universities and 1 college.
Jessica: We also were working on some academic supports for a student during a home (yard) visit. As the child began to open up to our staff, they explained that their home did not have any beds to sleep on, they explained that they flip a coin nightly to determine who gets to sleep with the blanket each evening. It became clear that the academic support, while necessary, was likely stemming from a lack of sleep during the night. We were able to support the family in receiving beds to sleep in, so that the child could be well-rested to attend school. Watch the video above for more stories!

How do your efforts advance health equity?

Jessica: While our goal is often seen as academic support because we are a school-based model, our overall goal is to ensure children and families have everything they need to be successful. We put students at the center and create access to critical resources like food, housing, healthcare, counseling and remote technologies so they can take charge of the future they want for themselves, their communities, and each other.
Edgar: We help advance health equity by building the student’s confidence and courage to advocate for themselves. We promote that it’s okay to not be okay, but it’s not okay to not ask for help.

What are you learning about the value of cross sector partnerships? What’s hard?

Edgar: Cross sector partnership is very important as it prevents us from duplicating our efforts and it helps us focus on what we are good at and brokering what others are best at. Our work would not be possible without partnerships.

Jessica: They are critical! What is hard is that sometimes we are unaware of the right resources, or there is a lack of communication and we end up not partnering up. It’s challenging to match the right resource with the right family, and we don’t always know what other services they have plugged into or tried to apply for. So we may be duplicating efforts…

What are some patterns or issues you’re noticing related to community-based care coordination that are keeping you (or our region) stuck?

Edgar: Communication. We need more knowledge/awareness of all the resources.
Jessica: Another challenge is that the need is great, but the right resources are not always available, especially for the remote and rural communities we serve.

Deep in your bones, what do you know we need to do to promote person-centered care coordination (even if we aren’t doing it)?

Jessica: We need to meet families where they are. We need to collaborate and work together across sectors to ensure that we are doing the best we can for the communities we serve. Often social service organizations are supported through grant funds. In areas like ours, we often compete against one another for the pots of money that do become available. How can we find a way to ensure we all have what is necessary, while working together and serve families?
Edgar: We also need to focus on hiring practices and equitable access to higher education/trainings. If we had equitable access to education and trainings, we would have more qualified and passionate people applying to do this work. If programs focus on hiring people that are truly passionate for the work, we will see more person-centered work. I believe that when programs are system-centered rather than person-centered, it is because there is a lack of passion and understanding for the work.

A car full of food for families in need. CISNCW identifies and serves families through several school districts in the North Central Region. (Photo provided by CISNCW)

What gives you optimism? What keeps you in the work? How do you stay motivated?

Edgar: Knowing that there are a lot of people genuinely wanting to do and be better keeps me optimistic. This line of work is my passion. I have always wanted to give back to my community and support it the same way it one day supported me. I stay motivated because I know that when someone makes it out, someone else moves in and although that can be daunting it keeps me motivated because I know there is a need for the work.
Jessica: I know that we have not arrived at all the solutions, but I know this region is working collectively to find solutions. I am optimistic about the future of how we do our work!

If there was one “game-changing” thing we could do to make our network of care coordination more cohesive and more responsive to the needs of our community members, what would it be?

Jessica: To find a way to serve our rural and remote areas with the necessary services that they need. It would be a game changer if every family that needs a service could connect to a service provider in their community.
Edgar: A hub or community center where all the programs could have their offices, meetings, and events. It would be a one-stop shop. Whenever someone from the community needed anything, they would come to the one-stop shop and all the support would be there.