Refugee & Migrant Health Care: Best Practices ISTM - PDF document

Refugee & Migrant Health Care: Best Practices ISTM INTERNATIONAL CONFERENCE ON MIGRATION HEALTH ROME, OCTOBER 2018 “Principle: set the bar high, at the ideal, then TSEGANESH SELAMEAB, MD, FACP spend decades working towards these goals” DIRECTOR, HEALTHPARTNERS CENTER FOR INTERNATIONAL HEALTH Dr. Patricia Walker Menomonie, Wisconsin Circa 1972 Minnesota? 1

Primary Refugee Arrivals to MN by Region of World 1979‐2016 Foreign‐born Persons in Minnesota 7% of MN population #1 nationwide for refugees and asylees (23% ‐vs‐ 17% nat’l ave) Largest Somali populations in US, second largest Hmong population. Now seeing Bhutanese Nepali, Karen Burmese, Syrians and Iraqis *First resettled in Minnesota Refugee and International Health Program CIH History Established in 1980 at public hospital in St Paul to deal with SE Asian refugees Center for International Health Began as a response to multiple problems: o Clinicians without knowledge providing poor quality care o Dissatisfied providers and systems(racism?) o Dissatisfied patients/cross cultural conflicts Expected to close within 5 years “when the refugees stop coming and people acculturate” CIH Today 2017 1980 o 6 internists, 1 family medicine o 1 internist,1 psychiatrist MD, 2 psychiatrists, 2 o 100% European American staff psychologists, 1 advance Health Equity & Disparities practice provider, 12‐14 resident o 4 volunteer interpreters MDs o Support staff 100% bilingual/ bicultural, Providers 66% o System wide: >100 professional interpreters, all languages, $US17M budget 2

Addressing health inequities in Minnesota would save: 766 lives $2.26 each year billion annually https://www.centerforpreventionmn.com/newsroom/press-releases/addressing-health-inequities-in-mn Best Practice: Data Collection Our Work “ Effective data collection is Pediatric Immunizations the linchpin of any comprehensive strategy to eliminate racial and ethnic Breast Cancer Screening disparities in health.” Tom Perez Colorectal Cancer Screening Courtesy of Getty Images Unequal Treatment Institute of Medicine,2003 HPMG: Integrated care delivery system (7 hospitals, 1,500 clinicians,50 clinics, insurance provider) in the Upper Midwest US 3

Disparities in Breast Cancer Screening Rates HealthPartners 2009 Breast Cancer Screening by Race HPMG GAP is 12.9% GAP is 7.3% points points Interventions Same day access Same day access HEDIS 2017 National 90 th Percentile = 79.8% Centralized outreach Centralized outreach Disparity data deep Disparity data deep dive dive Steps to reduce health disparities Colorectal Cancer Screening Disparities – Dec 2017 1. At the first level, fundamental to understanding patient populations, health care organizations learn for whom they are caring by utilizing demographic data collection 2. The second level of cultural competence involves analyzing health care disparities by demographic group. Know how you are doing in caring for patients. 3. At their most sophisticated health care organizations know for whom they are caring, know how they are doing in terms of patient satisfaction and quality measures by key demographic groups, and also have designed and implemented effective interventions to reduce health disparities. Amer J of PH, 2006 State of Minnesota Immigrant Health Task Force Best Practices Best practices are for refugees and migrants irrespective of country of resettlement Full report available at: www.health.state.mn.us/refugee 4

Eight Key Action Steps to Eight Key Action Steps to Improve Immigrant Health Improve Immigrant Health #1 1.Provide equal access to care for all, regardless of immigration or insurance status. Provide equal access to care for all, regardless of 2.Assess patients’ language preference, and healthcare organizations’ capacity to provide appropriate care. immigration or insurance status. 3.Recognize different costs of healthcare for recent immigrants and provide equitable payment. 4.Develop clinical guidelines and best practices orders for immigrant healthcare. 5.Diversify the workforce 6.Use trained interpreters 7.Use bilingual and bicultural community health workers. 8.Train healthcare providers and educate immigrant patients. Source: Patricia Ohmans, Action Steps to I mprove the Health of New Americans. I n: Walker PF and Source: Patricia Ohmans, Action Steps to I mprove the Health of New Americans. I n: Walker PF and Barnett ED, editors. I mmigrant Medicine. Philadelphia, PA: Saunders Elsevier, 2007; pp.27-35 Barnett ED, editors. I mmigrant Medicine. Philadelphia, PA: Saunders Elsevier, 2007; pp.27-35 US Uninsured US Uninsured and ACA Minnesota Uninsured US Uninsured Citizenship  Citizen: 7% percent  Naturalized citizens: 9.5% percent  Non-citizens: 26.2 percent. 5

MN Refugee Resettlement Program Minnesota Uninsured Citizenship  US Born: 5.2% All refugees are eligible to apply for health care programs available to residents with low incomes.  Non‐US Born: 18.2 % Refugee Medical Assistance may provide coverage to refugees who do not qualify for Medical Assistance for up to eight months after arrival in the United States. 2017 Minnesota Access Survey Eight Key Action Steps to Best Practice: Data Collected at Improve Immigrant Health #2 HealthPartners Assess patients’ language Language preference, and healthcare organizations’ capacity to Interpreter Needed provide appropriate Race/ethnicity interpretive services Country of Origin Source: Patricia Ohmans, Action Steps to I mprove the Health of New Americans. I n: Walker PF and Barnett ED, editors. I mmigrant Medicine. Philadelphia, PA: Saunders Elsevier, 2007; pp.27-35 Eight Key Action Steps to HealthPartners CIH: Patient Languages June 2009 Improve Immigrant Health #3 Al l other s, 95, 6% Amhar i c, 28, 2% Spani sh, 45, 3% Engl i sh, 400, 25% KaRen, 70, 4% Recognize different Or omo, 75, 5% costs of healthcare for recent Russi an, 82, 5% immigrants and Hmong, 95, 6% provide equitable payment Cambodi an, 110, 7% Somal i , 323, 21% N=1572 Vi etnamese, 249, 16% 6

Eight Key Action Steps to Best Practice: Improve Immigrant Health #4 Consult available resources US refugee health guidelines: Develop clinical www.cdc.gov/yellowbook/RefugeeGuidelines guidelines and best Canadian refugee health guidelines: practices order sets for www.ccirh.uottawa.ca immigrant healthcare 16 EU countries have screening guidelines UK migrant health guidelines: https://www.gov.uk/guidance/assessing‐new‐patients‐from‐overseas‐ migrant‐health‐guide Source: Patricia Ohmans, Action Steps to I mprove the Health of New Americans. I n: Walker PF and Barnett ED, editors. I mmigrant Medicine. Philadelphia, PA: Saunders Elsevier, 2007; pp.27-35 Eight Key Action Steps to Improve Immigrant Health #5 Best Practice: Order Sets Diversify the healthcare workforce to include more immigrant and minority providers. Source: Patricia Ohmans, Action Steps to I mprove the Health of New Americans. I n: Walker PF and Barnett ED, editors. I mmigrant Medicine. Philadelphia, PA: Saunders Elsevier, 2007; pp.27-35 Eight Key Action Steps to Improve Immigrant Health #6 Patient’s ethnicity affects physician satisfaction with clinical encounters, particularly in the delivery INTERPRETER of preventive care and Use trained WORKSHOP chronic disease interpreters TOMORROW management 2PM Courtesy of Medicine Box Films Provider Satisfaction in Clinical Encounters with Ethnic I mmigrant Patients. Source: Patricia Ohmans, Action Steps to I mprove the Health of New Americans. I n: Walker PF and Kamath CC, O’Fallon WM, et al. Mayo Clinic Proc. 2003; 78: 1353-1360 Barnett ED, editors. I mmigrant Medicine. Philadelphia, PA: Saunders Elsevier, 2007; pp.27-35 7

Global Literacy US Literacy  > 30 million adults in the United States cannot read, write, or do basic math above a third grade level.  NAEP 12 Grade Reading Level Assessment (2015) ◦ 46 percent of white students scored at or above proficient ◦ 17 percent of black students scored proficient ◦ 25 percent of Latino students scored proficient CIH primary care – completed visits: What is the Minnesota Experience? LEP patients vs. English‐speakers Limited English‐Speaking Households 2015 2016 2017 UNITED STATES MINNESOTA 4.4% 2.4% Source: Source: U.S. Census Bureau, 2017 American Community Patient Patient does not Survey 1-Year Estimates www.census.gov/acs speaks English speak English HealthPartners/ Center for International Health In Alternative to Live‐ In Person Person Medical Interpreter CyraCom Language Solutions: http://www.cyracom.com Required to have 40 hours of professional training LanguageLine Solutions: http://www.languageline.com Additional assessment of interpreter skills (if MultiLingual Solutions: http://www.mlsolutions.com language is available) Telelanguage: http://www.telelanguage.com Extensive “On boarding” • Standards of profession/ Ethics/ cultural competency • Informal mentorship Maintain annual minimal CEU Tiered compensation for Certified Medical Interpreters 8