Partners in Care: The Providence Hospitals Heroes

Over the course of the ten years since we at National Health Foundation (NHF) have been honoring the work of the Hospital Heroes among us, we have come to know many staff members from one of our partner hospital networks in Southern California: Providence Health & Services, Southern California. This year we have 6 nominees from 6 of the Providence hospitals. The Providence mission of compassionate care to the poor and vulnerable is something that each of their nominees espouses, however, as heroes, they have gone above and beyond their hospital’s mission to deliver heartfelt care that has resonated with patients, their families and the community.

The 11^th Annual Hospital Heroes Awards Luncheon will be held this Friday, November 4^th, 2016. Nominees will be recognized and winners of the Hospital Heroes will be announced. It will be an opportunity to meet these nominees:

Carol Yokoyama has dedicated her career, and some would say her life to the mission of caring for infants in the Neonatal Intensive Care Unit (NICU) at Providence Little Company of Mary Medical Center Torrance. She has been an employee here for 45 years. Difficult as it can be with this population of delicate patients, the dedication and emotional bond a NICU nurse shares with the family of a premature or sick infant is often the thread that holds them together during the exhausting, heartbreaking journey a family experiences when their child is born sick or too early. Pictures of past patients line the walls in the break room and remind every one of this important work NICU nurses do every day. Carol is one of these nurses. She is the kind of nurse who has comforted mothers as they held their dying infants and the kind of nurse who shares in the joy of an infant born four months early, finally going home.

Alexis Schoffstall began working earlier this year as a kitchen worker at Providence Saint Joseph Medical Center. The mother of a little toddler with autism, she was hired on a per diem basis for a new hospitality program -  delivering meals to patients, providing coffee and other small comforts to visitors and offering a little companionship. She proved a perfect fit, living the Providence core value of compassion as she spent time with her patients, listening, chatting and engaging. One of her patients was losing his battle with cancer at just 39, his grieving mother rarely leaving his bedside, growing frail as she kept vigil. When Alexis went home, she made sandwiches, cut up fruit and vegetables, bought candy, and came back later that day, her child in tow to drop the food off for the mother. She wanted to be anonymous. Co-workers told the woman a secret admirer had dropped off the food. Hospital Chief Executive Julie Sprengel learned of Alexis’s act of kindness and said she was so touched she was moved to tears. “During this time of sadness and confusion across our nation and the world, we can sometimes forget that every day there are people all around us participating in selfless acts of kindness for each other and often for complete strangers,” shared Sprengel in a note to the entire staff.

Mary Smidderks, from Providence Holy Cross Medical Center, is a hero because she inspires patients and their families as well as uplifts staff too! Fellow nurses have called her “a ray of sunshine to our oncology patients” and her Tea Lady service, “balm for the spirit”.  Mary created her own program putting her love of tea, linens, and fresh flowers to work. She met with 12 different hospital leaders to share her plans. Together they created a ‘tea service’ program for oncology and palliative care patients. “Teresa” was recovering from extensive surgery for ovarian cancer and was understandably withdrawn, depressed and in pain. Despite encouragement, she was reluctant to get out of bed and take a few steps. Mary busied herself with preparing the tea service while sharing her own story of how she learned to appreciate the beautiful moments in life. Teresa selected a crocheted blanket for her lap, an English Rose teacup, Chamomile tea and embroidered linen for her bedside table. A small vase of flowers from Mary’s garden completed the transformation.

As Teresa sipped tea, she smiled and became more animated, sharing some of the details of her difficult journey. Later that day, two women walking in the hallway; it was Teresa and her mother. They smiled and expressed gratitude for the kindness offered by Mary. It was not medical facts that helped Teresa, it was quite simply human interaction and the act of service with compassion provided by the Tea Lady that set Teresa on the road towards healing.

La Verna McMiller, from Providence Little Company of Mary Medical Center San Pedro, manages one of the most challenging patient care units in the state, the sub-acute care center at Providence Little Company of Mary Medical Center San Pedro. Patients are transferred from hospitals throughout the state with gunshot wounds, terminal cancer, and other life threatening conditions. She urges her nurses to never give up on a patient and shares her motto, “Miracles do happen”. La Verna leads her team with a sense of optimism resulting in amazing outcomes for patients who were never expected to return home. “I’ve always liked working with these patients who I believe have the greatest potential of getting better. I don’t give up on them,” shares La Verna. Over a 27-year tenure, La Verna has become known for the personal connection that she makes patients and their families and has an uncanny way of remembering details about them. She is a fierce guardian of safety especially around infection control, which is extremely important as most of her patients are ventilator, tracheostomy -dependent or in a vegetative state. La Verna single handedly manages this 125-bed specialty unit assuming both administrative and clinical oversight. La Verna is on call seven days a week and regularly comes in on weekends and evenings to meet with patient families and staff. She understands the value of recognition for her team and special events for her patients and makes sure that every birthday and holiday is a celebration.

Cara Armstrong, ED Clinical Nurse at Providence Tarzana Medical Center is a hero because she inspires her whole team. She often works with patients who are homeless and in need of more than just medical care. She takes her time with them, treating all with dignity, and helping them to shower or shave and get fresh clothing. Recently, she worked with an elderly couple in the ER on Christmas Day. The wife was admitted in a delicate and weakened state and her husband was weary but couldn’t bring himself to leave. Cara promised that his wife would not pass away alone. After a period of long deliberation, the husband was eased and left to rest with his family. As the wife’s condition continued to deteriorate, Cara stayed by her side and she did not die alone. Cara was able to share beautiful memories to help comfort the family. For Nurses Week, instead of receiving gifts, Cara motivated her department to give a scholarship to Lily, a beloved woman who helps clean rooms. She raised $3,000 toward a scholarship so Lily could attend classes to become a certified nurse’s assistant. Cara convinced doctors, clerks and others to contribute. Lily cried when she was surprised by Cara and the team with a scholarship check. “I can’t believe it,” she said. “I feel happy for my family too. I know it’s going to be different — for my son, for my daughter, for my grandson, for my mom.”

Dr. Brian Madden of the Providence St. John’s Health Center truly exemplifies the description of a Hospital Hero. He has made a special and lasting contribution in his role as the Director of Palliative Care Services in the past year. He provides compassionate care to patients who are suffering and the family members who provide support under extremely difficult circumstances. Dr. Madden has expanded the necessary scope of services at our hospital to care for patients, especially in our Critical Care Units. He has educated other physicians on the role of palliative care in providing needed support for all patients, not just those with terminal illnesses. Brian is a tireless champion who helps patients and families work with caregivers to make informed decisions for themselves and their families. He has worked with physicians both in and out of the hospital to educate them on the benefits of palliative care for their patients and the making of difficult decisions. Dr. Madden has expanded the scope of palliative care to include the entire continuum of care, bringing his services into the outpatient arena, helping patients and families understand their life choices and decisions at times that may not be so emotionally stressful. Brian is a deeply caring, empathic, and pragmatic physician who is dedicated to the complete care of his patients. His easy-going style and warm personality have helped him broach the difficult subject of palliative care with physicians on our medical staff at all levels.

For National Health Foundation, recognizing Hospital Heroes is especially important because we are a nonprofit that is dedicated to improving the health of individuals and underserved communities by taking action on the social determinants of health and bridging gaps in the health care system and it is through our partnerships in the community that we are able to effect change. Hospital Hero luncheon proceeds will directly benefit National Health Foundation programs.

For more information about National Health Foundation, please click here.

Hospital Heroes 2016: Care in Action

Since 2005, National Health Foundation has reached out to the Southern California health care community to nominate Hospital Heroes. These are individuals who, through their commitment to care, have left an indelible mark on their patients, coworkers, and communities. Since then, more than 200 medical, technical, clinical, administrative and volunteer staff members have been celebrated.

The 11^th Annual Hospital Heroes Awards Luncheon will be held Friday, November 4^th, 2016 and once again, we will shine the light on the incredible service of the health care community and award winners will be announced and recognized.

This year’s nominees include David Watkins, associate director of the Emergency Department (ED) of Cedars- Sinai Hospital, Brian Lugo, Emergency Preparedness Manager of Desert Valley Hospital and Tommy Covington, a hematology-oncology nurse at Children’s Hospital Los Angeles.

As ED nurse and leader at Cedars-Sinai, David Watkins is an inspiration to his peers, modeling outstanding patient- and family-centered care that has him consistently going the extra mile for the people he serves. For example, a recent patient needing medical attention refused to be admitted without first finding someone to care for his dog. David made a promise to the patient and personally walked and cared for the dog, in addition to ensuring the dog had a safe place to stay until the patient was treated and safely discharged several days later. 

It says “Emergency Preparedness Manager” on his badge but Brian Lugo is much more than that, not only to the Desert Valley Hospital family, but to the whole community. For over 12 years Brian has carved a place as an expert in all things emergency related.  With responsibilities at several hospitals in Southern California Brian must often place himself in the center of chaos such as the recent Pilot and Blue Cut Fires, and provide the staff with answers and solutions when his expertise is needed. In his role as Chaplain, as he has done from the kindness of his heart so many times, he has been that person who jumps in when a patient has passed away. He comforts the family and offers that much needed shoulder to lean on. 

Tommy Covington, RN, has worked the 7 pm – 7 am shift on the hematology-oncology floor of Children’s Hospital Los Angeles since 1975. His tireless work ethic is driven by his motto: “I try to live in the now and let the future develop around me.” Many of his patients succumb to their diseases. “When there’s a remission or a recovery, we rejoice in that.” Covington has remained in contact with many Children’s Hospital families. One family, whose child died 20 years ago, joins him on fishing trips. “We email, we talk, and we reminisce about their child we took care of and the love we shared,” he says.  “Love is the reason I do what I do.  It’s painful when you have a loss, but I love my job.”

For National Health Foundation, recognizing Hospital Heroes is especially important not only because we partner with many hospitals throughout Southern California, but because we are a nonprofit that is dedicated to improving the health of individuals and underserved communities by taking action on the social determinants of health and bridging gaps in the health care system. Hospital Hero luncheon proceeds will directly benefit National Health Foundation programs.

For more information about National Health Foundation, please click here.

Where Health and Care Meet: Frank’s Story

Frank, a 64-year-old Caucasian male, had a number of health issues that needed immediate attention, but he was facing an even larger issue than his failing health: he was homeless. For most of us who do have a place to call home, it is highly likely that we have a doctor, dentist and perhaps an urgent care clinic in our neighborhood that we feel we can turn to in the case of need. For the homeless, these basic needs fall to the wayside until an urgent health matter makes finding appropriate care a necessity and a challenge best tackled by a group of caring individuals.

When Frank came to National Health Foundation’s (NHF) PathwayRecuperative Care facility, he had been discharged from White MemorialHospital, a local partner hospital, and was in need of follow-up care. Denise, the LVN on Pathway’s staff immediately began the process of procuring a primary care physician for Frank at the Venice Family Clinic, knowing that Frank would need immediate support as well as prolonged follow-up for his chronic conditions once he was discharged from recuperative care. Upon further investigation, it was discovered that Frank would need to see a specialist for surgery. This set in motion a flurry of activity that most individuals would not think are part of accessing urgent medical care: A specialist from KeckMedicine of USC agreed to perform surgery but insurance issues needed to be addressed. In the mean time, Pathway staff worked with White Memorial to cover an extended stay for Frank in recuperative care, knowing that his health would deteriorate if he needed to wait for surgery whilst living on the street. With an additional 4 months of support from White Memorial, the staff at Venice Family Clinic then advocated for the patient and procured both the insurance clearance needed as well as made sure that the surgery was scheduled in the shortest time possible. With Frank’s most urgent medical needs met, there was one thing left to do: find Frank a place to call home.

Frank was the beneficiary of NHF’s Bridge Housing, a program that allows patients to stay in recuperative care for recovery and for the time that is needed to find a permanent housing solution. In Frank’s case, NHF was able to procure permanent supportive housing for him and once his most pressing health needs are under control, he will transition home.

Frank’s case is not an isolated one. For every homeless individual there is a health story that is unfolding. Thanks to partnerships with area hospitals and clinics, NHF is able to provide dignified and holistic solutions to the complex care needs of  our homeless neighbors.

A Community Comes Together for a Healthier Future

In 2015, National Health Foundation (NHF), CaliforniaHospital Medical Center (CHMC), and the Los Angeles County Department of PublicHealth (LACDPH) were awarded a BUILD Health Challenge planning grant to launch the BUILD Health LA initiative. The novel partnership had a specific goal: address the complex issues of obesity, diabetes and cardiovascular disease. Turning our attention to Historic South Central Los Angeles, the partnership sought to identify upstream solutions that address health disparities and inequities in the neighborhood by addressing the root causes of these issues. A team of nine emerging youth leaders from three South LA high schools was selected as community liaisons and led the comprehensive data collection efforts that informed the solutions identified by a community action plan.

Following 23 key informant interviews, 51 references and 515 community surveys, the Youth-Driven Healthy South LA (BUILD Health LA) team identified a lack of access to healthy food, a lack of access to open space for physical activity, and safety concerns as the barriers to a healthy lifestyle for their community. The community liaisons, together with community partners, are now moving to implement innovative and upstream solutions that tackle these issues.

In a densely populated community unhealthy ‘junk’ food is available at an alarmingly disproportionate rate, prompting some to label South LA as a “food swamp.” A strategy to provide 16 corner store owners the opportunity to enroll in the Leadership for Urban Renewal Network’s (LURN) CommunityMarkets Purchasing Real and Affordable (COMPRA) Foods Program will infuse more healthy food options into the neighborhood. The purchasing program will allow market owners the opportunity to purchase fresh produce at a low-cost and thereby increase access to fresh fruit and produce for the community. The youth community health liaisons will identify the 16 markets and, with the support of the LACDPH, will help the markets to promote healthy food messaging at the stores.

With only .4 acres of park space per 100,000 residents, South Los Angeles stands in stark contrast with the recommended 3 acres per 1,000 people. Furthermore, residents report that the 10 parks and 4 pocket parks that do exist are often not maintained and are centers of crime making them unsafe for residents. The youth community health liaisons will take the lead in developing and advocating for park safety. With a keen eye on pedestrian and bicycle accessibility, the youth will conduct assessments to determine what types of infrastructure are needed to ensure all parks are safe and inviting to the community. The youth will then present their recommendations to local stakeholders to advocate for action.

The environmental scan further discovered that recreational facilities offer a limited number of affordable physical activity programs, and that the programs that are offered often have long waiting lists. Providing residents opportunities to engage in physical activity is crucial especially given the high numbers of obesity, diabetes and other disease related to sedentary lifestyles and inactivity. The project team will expand the capacity of a few local community-based organizations to offer additional physical activity programs for community members, specifically in park-poor areas of the neighborhood and areas with limited fitness programming, by connecting these organizations to California State University Northridge’s3WINS Fitness Program. These trained kinesiology students will teach free fitness classes that will be held outside in local parks near the host organizations. A Place Called Home and All People’s Community Center will outreach to residents to participate in these new programs.

With the plan in place, the youth and the community partners share a common goal: getting the word out about the healthy changes in the neighborhood. Currently, the community is saturated with unhealthy food messages on billboards, buses and street corners but the youth and the project partners have identified more than 70 service organizations that have regular contact with residents and could help maximize the awareness of and participation in this program. The youth will develop a comprehensive marketing campaign and, together with the project partners, will raise awareness of the health-related improvements in their community. The sustainability of policy, systems and the health of their neighbors are depending on their ability to connect residents to the fresh produce, safe parks and opportunities for fun physical activity sprouting up in their community.

USDA Tours National Health Foundation's Successful Youth-Led Health Academy Programs

U.S. Department of Agriculture (USDA) Administrator Audrey Rowe met with youth and leadership of the National Health Foundation's (NHF) innovative youth-led Health Academy program to highlight successful implementation of the Supplemental Nutrition Assistance Program –Education (SNAP-Ed) funded Champions for Change grant, administered locally by the Los Angeles County Public Health Department.  The goal of SNAP-Ed is to improve the likelihood that persons eligible for SNAP will make healthy food choices within a limited budget and choose physically active lifestyles.

The Health Academy, a youth-driven nutrition education and obesity prevention program, has been an opportunity for youth at Thomas Jefferson High School in South Los Angeles to create and implement upstream interventions to improve the health of their community. The focus of Rowe's visit will be the following Health Academy successes: The Mini Farm-Stand/Breakfast in the Classroom food waste abatement project, the school cafeteria makeover and the Healthy Marketing and Product placement corner store makeover projects. "We are honored to have been a part of Administrator Rowe's visit to southern California. The youth involved in Health Academy have impacted the health of their community in tangible ways that are rippling out beyond the school's walls. The enthusiasm of the Health Academy students is touching families and friends and creating a veritable shift in consciousness around what constitutes health," shared NHF President and CEO Kelly Bruno.

About the Health Academy Projects  The Mini Farm-Stand project was designed by students to provide classmates access to healthy snacks while curbing food waste. Students placed attractive baskets in pilot classrooms and filled them with the fruit and foods left over from the Breakfast in the Classroom program. Typically, these foods would have been discarded, however, by placing them in the Farm-Stand baskets, students were able to simply take a piece of fruit at any time in the day, as needed. The results of the pilot were remarkable. Food waste was significantly reduced and students greatly appreciated having access to healthy options to the typical snack bar and vending machine fare offered between school meals. The Mini Farm-Stand project has been expanded through two Los Angeles Unified School District (LAUSD) schools and is recognized as a potential model for district-wide implementation.

Students in the Health Academy also tackled the issue of low participation in the school lunch program. The youth polled their fellow students and learned that the layout and appearance of the cafeteria was not conducive to purchasing and consuming a meal in the allotted 30-minute lunch break and that many students were consuming snack foods for lunch rather than tackle the lunch lines. With a few minor tweaks to the layout and a creative point-of-purchase marketing scheme complete with posters touting the value of school lunches, the youth were able to significantly increase participation in the school lunch program.

The Health Academy youth shifted their attention to the community around their school and have begun to offer local merchants 'Store Makeovers'. Recognizing that South Los Angeles, with its high number of fast-food restaurants and liquor stores constitutes a food desert, the students set out to make fresh produce and water available at the corner stores closest to their school. Students worked with Mercado Garibaldi owner, Joel, to increase the visibility of bottled water as an option to sugary beverages, and they worked with La Favorita owner, Carlos, to increase the availability of fresh fruits and vegetables. Both retailers embraced the changes and the energy of the students and plan to continue offering healthy options year-around.                                               

School-Based Teen Pregnancy Prevention Program Leads to Longer, Healthier Lives

Designed and facilitated by NHF, Be a STAR girls is a school-based teen pregnancy prevention program for adolescent females at-risk for a first time pregnancy. The program focuses on healthy behaviors, family planning, skill development, communication, and goal oriented behavior to empower teen girls to prevent unplanned pregnancies and improve their overall health, well-being, and success in life.

We recently caught up with one of our Be a STAR graduates, Ty’Kese, before she headed off to college. Ty’kese epitomizes what Be a STAR is all about. She is a Successful Teen Acting Responsibly. Pregnancy and parenthood cause many young, promising teens to drop out of school. And dropping out of school can completely devastate their lives and shut down otherwise bright futures.

High school drop-outs face unemployment, poverty – and shorter lives. Yes, you read that correctly. There is a significant link between education and health. High school graduates live longer than high school dropouts. College graduates have even longer life spans, better access to health care, better dietary and health practices, and overall better health.

Ty’Kese is smart and interested in making a difference in others’ lives. She’s a vegetarian. She wants to study psychology and social work as an undergraduate and then earn her master’s degree. She prides herself on asking questions and being well informed in the classroom and in the world at large.

Ty’Kese was surprised when the social worker at her high school recommended she get involved with NHF’s Be a STAR girls program. Although she’d had a few pregnancy scares, she really didn’t think she was at-risk of becoming pregnant. Plus, helping to take care of her younger brother at home, she felt, gave her a good idea of what it would be like to be a young mother. It didn’t seem like it would be that hard.

The truth is she didn’t want anything to do with Be a STAR girls, but she sat in on one session and was hooked. She loved getting honest, factual information about health and sexuality. She loved being in an atmosphere where she could freely ask questions. She appreciated having the opportunity to learn more about her own body in a safe environment with other girls. And it was eye opening for her to have myths such as, "you can’t become pregnant when you have your period" debunked.

What is shocking is that Ty’Kese had taken several other health and sex education classes and said she learned more in just a couple of Be a STAR sessions than she ever learned before. Be a STAR prepared her for adulthood by giving her full information about her birth control options and helping her set forth her personal goals for the next two, five, and ten years.

The goal setting exercises caught her attention. Yes, she enjoyed helping take care of her little brother, but now she saw how completely different this would be from actually being a young mom. In one exercise, Ty’Kese created a daily schedule of what her life would be like as a parent. This “as if” schedule showed her an unending string of early mornings, grueling days, and the difficulty of getting someone to watch her baby while she went to school. She could see how extremely difficult, if not impossible, it would be to reach her goals in these circumstances.

Ty’Kese is more concerned, careful, and knowledgeable about birth control than she used to be. Her eyes are wide open. She pays attention to her own body and is self-aware. She wishes Be a STAR was required for all girls at her former high school.

She wants to be a mom one day, when she’s ready, perhaps in a decade, after she has completed her education and has a good job as a social worker. For now, Ty’Kese wants to enjoy being a student and focus on her goals for a life that will be filled with achievements and the prospect of long-term health.

Teens Bring Mini-Farm Stands to the Classroom, Reduce Food Waste in the Process

Youth engagement provides young people with the opportunity to develop leadership skills and address challenges they face head-on in their own communities. For the past three years, National Health Foundation’s Health Academy has been working alongside youth from Historic South Central Los Angeles to address upstream barriers to healthy weight such as access to healthy food in their community. NHF Health Academy’s “Legion of Health” youth team is one of four teams in the program that engaged in youth participatory action research to identify issues impacting access to healthy food and food waste and develop and implement solutions to tackle those barriers. Here is one example of their success.

In the fall of 2014, Los Angeles Unified School District implemented Breakfast in the Classroom (BIC), a program that enables students to eat breakfast provided by the school in their classrooms rather than before they get to school. This was especially important at Thomas Jefferson High School where the surrounding community is labeled a food desert¹ and access to healthy foods is an extreme challenge. Living in a “food desert” means that at least one third of the residents live more than one mile from a grocery store and in a dense urban environment, that is a significant barrier. In addition, those grocery stores serve significantly more people than in areas with better access. A 2010 Community Health Councils report indicated that South Los Angeles’s 60 full-service grocery stores serve approximately 22,156 residents each. In comparison, West LA’s 57 grocery stores each serve approximately half the number of residents. Layer onto this story the fact that 60% of South Los Angeles eateries are fast food restaurants. Clearly, BIC was an essential program providing increased access to fresh, healthy foods and students needed to take greater advantage of this opportunity. Within these statistics, the Legion of Health youth team saw an opportunity to make real impact.

As the Legion of Health team investigated the BIC program, they discovered that one of the unintended consequences was an increase in food waste, specifically the fruit accompanying the breakfast meal. A meeting and tour of the cafeteria with the Cafeteria Manager gave the youth real insight into the actual volume of food waste. The youth team began re-envisioning the BIC program as a way to encourage consumption by recovering the food and offering it as a snack to students throughout the day. This option would reducing food waste and minimize cost of healthy snacks. Legion of Health developed a pilot project to provide healthy snacks throughout the day at no cost to students by saving the surplus of fruit and/or non-perishable food items from the BIC program. Youth placed decorative baskets in classrooms and set uneaten food from BIC into the basket. Legion of Health named their project “Health Academy Mini-Farm Stand” and designed baskets to hold the fruit in classrooms. Legion of Health partnered with several of their high school teachers to implement the pilot project in select classrooms. Youth also developed a tracking system to record the number of students that grabbed a snack. Legion of Health hypothesized that students would consume all the items by the end of each school day.

The project findings proved the Legion of Health’s hypothesis to be correct: all food from the farm stand baskets were consumed by the end of each school day. Legion of Health presented these findings to school administration and advocated for school-wide implementation. School leaders agreed to implement the project school-wide so that every classroom would have a “Health Academy Mini-Farm Stand” basket and students would have access to healthy food anytime of the school day in any classroom on campus. Since school-wide implementation, the Cafeteria Manager is reporting a near complete reduction of food waste from BIC.

Legion of Health recently expanded the “Health Academy Mini-Farm Stand” project to Nava College Prep Academy. Legion of Health presented the benefits of the baskets to students and staff along with delivering baskets to each of the classrooms. This past school year, Legion of Health met with Laura Benavides Co-Director of LAUSD Food Services who applauded the youth’s efforts. In the coming year, Health Academy’s Legion of Health will seek out partnerships at other schools to expand the program in hopes of ultimately meeting with the LAUSD School Board to advocate for district-wide implementation.

^[1] ‘Free and Reduced Meal,’ Analysis, Measurement, & Accountability Reporting Division. California Department of Education, 2013; http://www.cdph.ca.gov/programs/cpns/Documents/SNAP-Ed%20FFY%2015%20Att%201%20FRPM%202013%2005%2024.pdf