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An Arizona health center that works with a Navajo population started a diabetes case management program to help patients stay out of the ED and hospital.
A health center that works with a Navajo population in Arizona faced challenges in improving care for people who struggle to overcome cultural and economic barriers to care. The center’s solution combines case management with cultural integration in medical care.
Chinle Comprehensive Health Care Facility in Chinle, AZ, started a program to provide quality, low-cost healthcare to diabetes patients. This population includes people who lack basic living standards, such as clean water and electricity.
“That’s where the Navajo Baa Hózhó Program came from,” says Ruth Finley, RN, BSN, outpatient department nurse improvement specialist at Chinle Comprehensive Health Care. Each patient receives a Baa Hózhó card with a phone number that patients can call weekdays from 7 a.m. to 6 p.m.
After implementing the program, the Chinle area’s ED visits per 100 adult patients began to decline from a peak rate of 60 per 100 patients per year in December 2015 to a rate of about 35 per 100 patients per year in August 2017, according to the health center’s internal data.
“We wanted to work with high-risk, high-cost patients and mainly try to keep them out of the emergency room,” Finley says. “Many of our patients use the ER if they have something wrong. They don’t see primary care providers.”
Patients sometimes live in the mountains without electricity or running water, Finley says. “There are grandmas and grandpas who are herding sheep,” she says. “They heat their homes with wood.”
Most families will take care of their elders, but a few people do not have anyone helping them, she adds. “Transportation is a huge issue because of the remoteness and not having reliable services,” Finley says. “We don’t have paved roads everywhere, and we have a food desert here.”
The nearest Walmart is more than an hour away. Junk food is readily available, but produce is expensive. It is difficult to convince diabetic patients to not eat high-calorie, cheap food that lacks nutritional value, she adds.
It also is difficult to find nurses to work in such a remote area. This is why the health center employs health coaches, including people who are part of the Navajo community. The health center also has hired diabetic health coaches; now, these coaches are part of the Baa Hózhó program.
“Baa Hózhó is a Navajo term that means ‘happy’ or ‘balance,’” says Krista Haven, MSN, RN, CDE, diabetes nurse improvement specialist at Chinle Service Unit Diabetes Program and diabetes case manager at Navajo Baa Hózhó Program.
The program is a patient-centered care plan. This means that if the Navajo patients need help that is outside of Western medicine, they receive it. (See story on how program works in this issue.)
“If a patient doesn’t feel comfortable because of cultural beliefs, then we find a way to get the patient the best care and integrate Western culture along with Navajo culture,” Haven says. “We have Navajo medicine in the clinic, including Navajo medicine men, who do prayers, chants, and ceremonies.”
For example, if a patient presents to the ED because of a snake bite, the ED staff will treat the injury and hold a ceremony for the patient. They also will cleanse the ED by burning sage to clear the room of negativity, Haven says. “The perspective that patients have is different from Western thinking, and you have to allow for cultural barriers and consideration if you are giving care to patients,” she adds.
Cultural considerations are important to many patients. One success story involved a patient with a necrotic foot. Doctors told him that it needed to be amputated. The patient refused the surgery when he learned that he would not be allowed to take the amputated limb home to bury, per his cultural/spiritual tradition, Finley recalls.
“Our case manager and health coach got on the phone with him and talked about how this is a life-threatening situation,” she adds. “They worked it out that he could be transferred back to Chinle to have the operation, and he was able to go home and do his ceremony to bury the amputated foot. He’s been doing wonderful since then.”
In the Navajo culture, healthcare professionals also must be sensitive to how they give information to patients, Haven says. “I wouldn’t go into a room after a Navajo patient’s A1c results are back and tell her, ‘I’m sorry, ma’am, you have diabetes,’” Haven says. “That would be taboo because you just cursed the person.”
Instead, healthcare professionals should present the results in a third-person narrative format, like telling a story. “Say, ‘Sorry, we were able to read your blood results, and some of the readings were high. Some people we know, who had high readings, were able to start on medication. Would you also like to have that medication?’” Haven explains. “Or say, ‘We worked with someone else who had high sugars like you do, and they had a diagnosis of diabetes, and we gave them a medication to bring down their sugars. Can we do for you what we did for them?’”
The patient might ask to go home and think about it. Sometimes, they will return and say their aunt or grandmother told them to not take the medication. The care provider will say, “Can you bring them in so we can talk with them?” she adds.
“Sometimes it takes several visits to be able to give the patient that diagnosis, and sometimes they just take a long time to think about it,” Haven says. “You have to explain what you’re doing because they think about every aspect of the disease.”
Health coaches also help with the language barrier. All of them speak Navajo. “When sitting and talking with patients, we have them speak Navajo,” Finley says. “About 25% of our population lists English as a second language.” Patients often do not understand what their doctor tells them, so the health coach can sit with a patient after the doctor’s visit and explain what was said.
Since health coaches live in the Chinle community, they also provide consistency in patients’ healthcare experience. This builds trust, Finley notes. “Our providers come here for three to four years, and then leave,” she says. “Our population does not trust the health system.”
Now that patients can call their health coach and the health coach stays long-term, there is more stability and trust, she adds.
Financial Disclosure: Author Melinda Young, Editor Jill Drachenberg, Editor Jonathan Springston, Editorial Group Manager Leslie Coplin, Nurse Planner Toni Cesta, PhD, RN, FAAN, and Accreditations Manager Amy Johnson, MSN, RN, CPN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.