CARE Maternal/Child Health ProgramMargie Widener, MSN,CNMSaint Alphonsus Women’s Health

Marla Lipscomb, MSW,LCSWCARE Maternal/Child Health ProgramFamily Medicine Residency of Idaho

Eunice Njiraini, Senior Health AdvisorCARE Maternal/Child Health Program

Judith Hobbs, RN, BSNManagerSaint Alphonsus Family CenterCARE Maternal/Child Health Program

Saint Alphonsus Mission Statement"We serve together at Saint Alphonsus Regional Medical Center in Trinity Health in the spirit of the Gospel, to heal body, mind and spirit, to improve the health of our communities and to steward the resources entrusted to us."

Emergency Announcement

Idaho Refugee Resettlement ProgramIdaho Refugee EthnicitiesUS Arrival: 1/1/2010 to 9/21/2010Ethnicity Number PercentageLhotsampa 166 23.35 %Kurd 1 0.14 %Mon 1 0.14 %Mixed 2 0.28 %Karenni 12 1.69 %Iranian 3 0.42 %Hutu 16 2.25 %Karen 87 12.24 %Iraqi 35 4.92 %Oromo 1 0.14 %Pashtun 10 1.41 %Other 47 6.61 %Sabbean Mandean 9 1.27 %Russian 8 1.13 %Hema 1 0.14 %Banyamulenge 9 1.27 %Banjuni 7 0.98 %Bhutanese 18 2.53 %Bembe 10 1.41 %Bajuni 1 0.14 %

Idaho Refugee Resettlement (con’t)Idaho Refugee EthnicitiesUS Arrival: 1/1/2010 to 9/21/2010

Ethnicity Number PercentageArab 86 12.10 %Afghan 7 0.98 %Bahai 1 0.14 %Asharaf 1 0.14 %Great Russian 2 0.28 %Ethiopian 5 0.70 %Hazara 4 0.56 %Hawiye 9 1.27 %Darod 12 1.69 %Chaldean 10 1.41 %Burmese 20 2.81 %Cuban 2 0.28 %Chin 25 3.52 %Tutsi 6 0.84 %Tigryan 33 4.64 %Uzbek 11 1.55 %Unknown 12 1.69 %Somali 7 0.98 %Sudanese 1 0.14 %Tajik 13 1.83 %

Boise, Idaho 91% Caucasian

Barriers to Access of Care

Boise – Limited cultural competency No mass transitLimited bus service, predominately male taxi driversDifferent time orientationScheduling conflictsLimited availability of trained medical interpreters

Understanding the Profound Challenges

Impact on resettlement groups who have lived several generations in refugee camps Pre-literacy Limited numerical understandingUnfamiliar with Western amenities

On the Other Hand …Many are professionals and are very familiar with Western Medicine

Focus Groups:Somali Bantu Focus GroupsWomen’s HealthBoise PediatricsMaternal Fetal MedicineFamily Maternity CenterSchool for Pregnant TeensCommunity Partners

Resettlement AgenciesBoise State University/Nursing Department for Research

“In our country, first you educate, we get to ask questions, then you do the exam.”

Challenges to “Navigating”the Healthcare System

“In my country, you always wait for the clinic to open. Here you go into the building. I did not know how to get to the second floor.”“Every building is big and looks the same.”

Barriers… In the Beginning…

Women’s HealthDifferent time orientationNo shows – above 25%Limited time for provider/patient interaction Limited understanding of scheduled appointmentsMedical history incomplete from Western medicine’s standardsHigh rates of ER visits

Barriers to Providing Quality CareBarriers and Issues from Providers

One to two hour delays in seeing patientsDecreased productivity/RVU’sProvider frustrationProvider refusing to see refugee patientsInterpreter not provided for “preferred language”System and Model of Care

Not culturally appropriate in providing quality care to linguistically and culturally diverse populationsNeed for cultural awareness training for medical providers

Barriers to Providing Quality CareBarriers and issues from Nursing Staff:

Patients’ fear of medical examsUnfamiliar with medical systemLimited concepts of preventive careAppointments take 30-50% longerExpectations placed on refugee patients without providing explanations about system of care

Hearing from Saint Alphonsus Medical Group

Focus Groups with Women’s Health Providers:Women’s Health

“Pelvic exams can be terrifying for refugee patients depending on the culture and the trauma and abuse a patient has experienced.”

“I needed to stay with one women holding her hand for 45 minutes and gently reassuring her before and during the exam.”

Frequently Asked Questions Due to Unfamiliarity with Western Healthcare System

Valid Questions from PatientsWhat is a prenatal exam?Why do I have to have an exam?Why do I have to pee in the cup?Why are you taking all my blood?

CARE Clinic Years in the Making withCommunity Collaboration

Goals of CARE ClinicAddress and decrease health disparities

Provide quality prenatal and postpartum care to linguistically and culturally diverse populations

Create a model of care that adapts to the needs and strengths ofour patients

Create a safe, supportive, empowering environment for women and their babies

Influence the greater system of care at Saint Alphonsus by strengthening provider’s cultural awareness and sensitivity

Strengthen advocacy for patients in overall healthcare system

CARE Maternal/Child Prenatal Clinic

C – CulturallyA – AppropriateR – ResourcesE – Education

CARE Program Design: Creating Safe, Supportive, Empowering Environment

Pre-appointments for paper work, insurance verification, and educational video

Verify Medicaid eligibility prior to NOB appointmentReduces financial stressors

Opportunity to build rapport with clinic staff prior to first prenatal appointment

Schedule ultrasound at Maternal Fetal Medicine

CARE Program Design: Creating Safe, Supportive, Empowering Environment

Pre-Appointment VideoKnow what to expectDecrease anxiety about prenatal exam

CARE Program Design: Creating Safe, Supportive, Empowering Environment

Patient ID BadgeSupplying the correct interpreter for the patientAddress and phone number for taxi or bus driverImproves patient safety and access to appropriate care

AsmaaPreferred Language:

Arabic

CARE Program Design: Creating Safe, Supportive, Empowering Environment

Same time and location for every group appointment

Saint Alphonsus Family CenterWednesdays

Consistent greeters, medical assistants and providers

Patients are familiar with administrative staffSame Providers, Patient Service Representatives and EducatorsOpportunity to develop trustKnow what to expect

CARE Program Design: Creating Safe, Supportive, Empowering Environment

Group Model of Care and Education

Group education – multiple languages in each groupMedical interpreters present for each language groupEstablishing group ground rules, and confidentialityConfidential interviews regarding specific concerns

CARE Program Design: Creating Safe, Supportive, Empowering Environment

First hour Vitals

Weight and blood pressureEducation

Patients rotate vitals while listening to various topics by Women’s and Children’s Educator such as nutrition for pregnancy, comfort measures, breastfeeding, and baby care

Prenatal exams take place behind partially closed wall with female continuity medical provider (CNM)

CARE Program Design: Creating Safe, Supportive, Empowering Environment

Individual concerns shared during prenatal examOften report shared concerns of other group membersPatient is asked permission for provider to anonymously share concern/question with group

CARE Program Design: Creating Safe, Supportive, Empowering Environment

Second hourPre-Natal Education by CNM

Question and Answer SessionBirth Control/Child SpacingGestational DiabetesMedicationsVariations of laborPsychoeducation

Impact of trauma and resettlementAntepartum and Postpartum depression and anxiety

CARE Clinic Curriculum for Group Prenatal Care

Week # 1

First Hour (RN)Welcome and IntroductionsGround Rules – ConfidentialityReview clinic scheduleNeeds Assessments

Topic PreferencesTrue/False

Second Hour (CNM)Welcome and IntroductionsReinforce ground rules and safetyImportance of sharing common questions with groupProvider Topic

Identifying when to call the provider and when to go to the hospitalImportance of Prenatal Vitamins and what to do when they run out

Interpreter and Health Advisor –A New ParadigmInterpreter – serves as a voice for provider and the patient repeating what each of them says without adding additional information.Health Advisor - Provides case coordination to increase access to maternal/child health and family services, assist in increasing healthcare providers’ capacity to deliver culturally appropriate care and assist in improving the health status of refugee mothers and infants

Our Health Advisors(Arabic, Burmese, Farsi, French, Kirundi, Kizigua, Maay Maay,

Nepali, Russian, Somali, Swahili, Uzbek)

Health Advisors – Provide insight into the communities

Improve cultural competence of providers

Curriculum Design

Knowledge of both provider and patient cultures

Help the providers understand the diversity of skin color, language, culture, religion, class, skill level, knowledge, life experiences, and personality

Health Advisor Role ContinuedHelp with paperwork and medical historyAct as “case coordinators”Help pregnant refugee women “navigate” through the American Healthcare SystemAct as patient advocate when neededHelp to identify strengths, needs, and concerns within their communities

Presenting Culturally Sensitive Topics

Actively engaging in the contentBuilding on their own experienceLearning new techniques and contentApplying the new content for immediate learning and relevance.Taking away new knowledge and using for skill buildingHealth Advisors – curriculum consultantsExchange of knowledge between providers and clients

AnchorAddApplyAway

Dialogue EducationPractice teamwork and small group work effectively while integrating ideas (cognitive), feelings (affective) and actions (psycho-motor) domains in learning tasks using a variety of art medium.

Challenges Faced by Health Advisors

Health AdvisorFaced with challenge of remaining neutral while dealing with own thoughts and opinions

Also are aware of community’s frustrations with the health care system and/or providers

Impact of Historical trauma/injustice as well as own personal trauma history

Increased opportunities for projections

Expanding Role of Health Advisor:Health Educator

Health EducatorSomeone who provides education directly in target language without the use of an interpreter or through an additional providerEmpowers Health Advisors to provide direct serviceAcknowledges expertise of Health Advisors

Additional Education: Cooking ClassesOpportunity to enjoy learning from other cultures

Increase familiarity with WIC foods

“ I feel important about myself because the teacher asks if I have any special recipes to share with the rest of the class. I feel that each culture has something to share.”

Health Educators to facilitate

Creating a Safe, Supportive, Empowering Environment

Consistency: Know what to expectFemale Interpreters and Health AdvisorsProviders take time to listen and learn from patientsStrengths Based approach to careTrauma informed practiceRestoration of Dignity and RespectGenuine provider compassion can be felt despite language barriersShared sense of community within CARE ClinicCounseling and supportive services available during each group appointment

CARE Clinic Partnering with Family Maternity Center/Labor and Delivery and NICU

Development of discharge DVD to save RN time at the bedside Health All patients view DVD prior to dischargeDevelopment of picture menu to improve accessibility

Example of Picture Menu

Lessons Learned by ProvidersProviders have realized that it is “US” that needed to adapt

System and provider need to adapt to provide quality care

Recognizing need for providers to be aware of personal bias

Ethnocentric ways of thinkingBelief that Western Medicine is superior

Lessons Learned by ProvidersCaution: Seeing their knowledge as a deficit rather than seeing strength of knowledge

Limited understanding of healthcare system does not mean limited knowledge or ability

A little “cultural competence” can be more dangerous than none at all

Impact of Provider assumptions on care providedMay stereotype individual vs. seeing their unique strengths and needs

Cultural Competence

“To be culturally competent doesn’t mean you are

an authority in the values and beliefs of every

culture. What it means is that you hold a deep

respect for cultural differences and are eager to

learn, and willing to accept, that there are many

ways of viewing the world.” - Okokon O. Udo PhDIntegrative Health and WellnessNorthwestern Health Sciences University

Cross Cultural Health Care Program All Rights Reserved Copyright 2010 41

Reviewing Reasons for IncreasingCultural Competence

To meet governmental regulatory (OMH) and accreditation mandates (TJC)To respond to demographic changesTo address health disparities

To improve the quality of services and outcomesTo enhance the workplace environmentTo reduce healthcare costs and increase efficiencyTo do the right thing

CARE Maternal/Child Health ProgramPrenatal Clinic Outcomes

Increased trust in care, providers and hospitalIncreased trust in Western medicineGreat improvement in “no-shows” - From approximately 25% to 4% resulting in greater efficiency and reducing healthcare costsImproved Health OutcomesIncreased numbers of women accessing mental health services

Program EvaluationHow do we know they know?

RefugeeIdentified

Needs

DEVELOPPROGRAM

ASSESS

Is thisprogram

being practiced?

YES

NO

ASCERTAIN ROOT CAUSE

ADDRESS ROOT CAUSE WITH HEALTH

ADVISORREASSESS

Focus Group: Physician Offices

Focus Group: Refugee Community

Community Assessment Survey

CARE Maternal/Child Health Well Baby Clinic

Well Baby ChecksImmunizationsUnderstanding the importance of those well baby checkups

CARE Well Baby Clinic

Education in a group settingTaking baby’s temperature How to read a thermometerHow to measure medication

CARE Well Baby Clinic Education

Developmental Milestones Importance of play and reading to baby

Infant Safety Happiest Baby On The Block

Encourage Breastfeeding and Lactation Support

Carseat Checks

CARE Steps – Incentive StoreEarn “points” by engaging in healthy behaviors, keeping appointments, providing transportationEncourage self sufficiencyShop for needed baby items

CAREStepsCAREStepsCARE Maternal/Child Health Clinic

and Incentive Program atSaint Alphonsus Family Center

900 N. LibertySuite 100

Boise, Idaho (North of Emerald, on Liberty Street. Liberty

Medical Park Building)

Participant #

BABY’s Date of Birth:

BABY’S NAME:MOTHER’S NAME:Address:

Phone: CARE (Culturally Appropriate Resources and Education)

Maternal/Child Health Clinic and incentive program for any pregnant refugee women and their families regardless of race or religion, whose goal is to promote healthier pregnancies,

babies & families.

CARESteps program is made possible by a generous grant from Saint Alphonsus Foundation

PHONE208-367-2126

OPEN after clinic and classes

POINTS RECORDDATE POINTS

EARNEDPOINTS SPENT

BALANCEFOR TODAY

BALANCE TOTAL

Date: Car Seat Check-up50 points

Date:B O N U S: All immunizations are completed on time 100 points

12-15 months

6 months4 months2 monthsBirth-2wk

Scheduled Immunizations 100 points each

12 months9 months6 months

4 months

2 months1 month<1-3 weeks

Well Baby Check-Ups 100 points each

Delivered by: (Signature)

LengthWeightWeeks Gestation:

YearDayMonthDueDate:

YearDayMonthBirthday

Baby’s Name:

WELCOME BABY!

Different Phases/Types of Refugee TraumaCountry of Origin or Pre-migration Trauma

Political, Ethnic, Religious Conflict and Persecution

Migration TraumaFlee due to violence, separation from family, survival and insecurity

Host Country/Countries TraumaLong-term impact of life in refugee camps and/or continued discrimination and persecution in urban areas

Resettlement TraumaLanguage and cultural barriers, transportation, unemployment, western amenities, navigating systems, barriers to healthcare, impact ofresettlement on family system

Historical TraumaFamily System Trauma

Refugee Mental HealthCompound Trauma

More than one type of traumaProlonged feelings of insecurity, persecution, physical abuse, sexual abuse, psychological abuse, witnessing of violence, victim of war violence, torture, forced to harm others, natural disasters, etc.

Stages of ResettlementPre Resettlement

Waiting and AnticipationTime spent in camps or resettlementsApplication, interviews, orientationMixed emotions, e.g. goodbyes to loved ones

Initial ResettlementUnknown and Expectation

Anxiety/nervousnessHopefulness for family’s futureMisinformation about resettlement countryFalse expectationsSteep learning curve

Stages of ResettlementActive Case Management

Adrenaline PhaseSurvival SkillsCountless appointmentsStructure and schedulingAcute adjustment stressorsELL and Job Training

Ending of Case ManagementDisillusionment Phase

Alternating from Hope to DespairProjections based on historical traumaSignificant increase in anxiety and depressionImpact of financial and acculturation stressors on family systemReality of family reunification casesIntense feelings of abandonment

Stages of ResettlementPost Case Management

Isolation and InsecurityDifficulty navigating systemsIncreased barriers to servicesIncreased interpersonal tensionsIncreasing familiarity with surroundingsIncreased PTSD symptoms

Acculturation and AdjustmentCultural and language barrier stressors ongoingStrengthening of community OR increased divisionsImpact on family system

Barriers to Accessing Mental HealthStigmaImpact of shame on family systemClose proximity of resettlement groupsDifferent Cultural PerspectivesLack of insurance/limited incomeTransport Limited interpreter optionsDifficulty navigating referral from referral clinic/agency to mental health clinic

Creating Refugee Patient Centered Medical Home

Creating safe, supportive, welcoming environmentProviding holistic health services in primary care settingBuilding strong rapport with patientsMultidisciplinary approach

Working closely alongside medical providers

Creating Refugee Patient Centered Medical Home

Decreases barriers to accessing quality services

Consistency in scheduling transport Patients develop relationship with receptionHealth Advisors decrease language and cultural barriersHealth Advisors assist in navigating systemsMedical and Mental Health providers coordinate services and care

Creating Refugee Patient Centered Medical Home (Continued)

Decreases barriers to accessing quality services

Trauma informed practiceStrengths Based-Multicultural ApproachResources and Materials considerate of linguistically diverse populations and patients who have limited literacy

Group Model of Care: Psychoeducation

# 1-Becoming part of the groupBuilding relationshipsBecoming accepted member of the group

# 2-Introduction to Mental HealthNarrative Story “Bag of Heavy Rocks”Impact of ongoing resettlement and psychosocial stressors

Group Model of Care: Psychoeducation

# 3- PTSDSigns and SymptomsSomatic SymptomsNormalize symptoms for trauma survivorsProvide information on treatment available

# 4 – Depression and Anxiety (antepartum and postpartum)

Signs and SymptomsSomatic SymptomsImpact of limited support system due to resettlement

Group Model of Care: Psychoeducation

# 5-Coping MechanismsDeep Breathing and Relaxation ExercisesStrengthening support systemGoing for walks, Doing activities you enjoyCommunity GardensReligious/Spiritual strengths and resourcesWays to reduce reoccurring nightmaresImportance of asking for help/Providing resources for assistance

Continuity and Follow Up CareClose Coordination with medical providers

Assessment, Counseling Services, Consultation, Referrals

Future Goals for CARE Clinic Mental HealthMental Health screening for each patient as part of careAdditional Group Psychosocial Education

Domestic Violence and Substance Abuse

A letter of appreciation