Meeting the needs of immigrant patients

Agency program wins kudos from JCAHO

The San Francisco Bay area has some 100,000 immigrants from eastern Europe, about 40,000 of whom are senior citizens. Numbers like those led to the creation of InCare in 1996, a home care agency that specializes in meeting the needs of this emigrant population.

Along with catering to a growing niche, the 11-nurse agency has been able to build in the kind of quality improvement programs, administrative, and clinical excellence that won the agency commendation from the Joint Commission in its first survey earlier this year.

Yana Leveton, the managing director of the agency, says one of the biggest problems the agency has had to overcome has been the lack of education many of her patients have on basic issues, such as what diabetes is and how to control it.

"We have to start with the basics, like the signs of the disease with our patients," she says. "We probably have twice the educational materials as other agencies."

The material has to be in Russian and English, too, notes clinical director Vadim Markovich, PA, RN. "JCAHO loved that," he says. The materials have had to be customized to fit the Russian mentality, as well. For instance, the agency had to create a brochure on how to cook traditional Russian food with less fat and sodium.

Much of the educational material has been developed with or borrowed from other community resources and institutions that work with the immigrant community, Markovich adds.

This kind of networking has enabled InCare to build a reputation of premium customer service. A local pharmacy, for example, provides Russian-speaking drivers to deliver medications to InCare patients. "It’s an added value," he says. Nurses also accompany patients to appointments with physicians who don’t have Russian language skills. This was another thing that the JCAHO surveyors liked. "They said one of our strongest assets was this bond between nurses and patients, and their extended family."

If nurses didn’t go the extra mile, says Markovich, there is a danger that the traditional accommodating nature of Russian patients would cause medical problems. "They want to provide the right answer that causes the least trouble," he explains. "They don’t understand that they might be jeopardizing their health if they say they are taking their medications but are not. Our nurses have to be investigators to work with these patients."

Staff building

Finding this kind of staff has been difficult. "Language skills are just not enough," Markovich explains. "You really have to know and understand the culture to provide the best health care."

The nurses are matched, as often as possible, to patients from the same area. Along with the nursing staff, there are also two physical therapists and two occupational therapists. InCare also has the only speech therapist in a 60-mile radius who is a native Russian speaker. She travels from the south Bay area one or two days a week to deal with InCare patients, and Leveton says they often get referrals from hospitals just because she is part of the team.

In a way, the difference in culture is one of the biggest headaches for InCare, says Leveton. "In Russia, if you call 911, you get a doctor or a PA coming to your home to give them help there. Here, they get a paramedic who can take them to a hospital, but can’t make critical decisions. That is both more than they wanted and less than they needed."

"Our nurses have to provide high-quality health care at home to people who don’t understand Western-style health care," adds Markovich. "They are the intermediary between what they had before, and what they get now."

Leveton says nurses have to be experts at getting information from patients. "The patients often have little pharmacies of homemade remedies or medicines sent to them from Russia. We have to be able to find out everything they are taking."

The staff are all licensed in California, and all documents must be completed in English, including nursing notes, says Leveton. "We have some problems in grammar and spelling, but in the end, these documents have to satisfy Medicare, state surveyors, and the Joint Commission."

Often nurses spend half an hour on documents that might take others five or 10 minutes, adds Markovich. "They think very carefully about what they are writing and how they are translating. I think that makes the quality a lot higher."

Indeed, the JCAHO surveyor said the strongest point in the records was the clear communication, he says. "We check their records carefully. We spend hours on them."

Currently, the agency is 100% Medicare, which makes complete computerization financially impossible. "We are very lean, and we survive because of our niche. Even as we diversify, it will be some time before we have our nurses on laptops."

Better than expected

Although Leveton was confident the agency would do well in a survey, she didn’t leave anything to chance. For a year, they prepared by going through the JCAHO manual "page by page" says Markovich. "That was a great exercise. Our quality improvement program is in great shape now." Many of the forms were changed to make them more user-friendly. For instance, many were expanded to include more room for notes at the suggestion of the nursing staff.

Mock survey does its job

One major change that the agency made in the run up to the survey was a change in the medication profile. "We found out that when we received change orders for medications, we would send it to the physician for a signature before it was entered in the computer," says Markovich. "But entering it in the computer is what generates the new patient education materials. It could be up to a week before we get the signed order, and all that time, the patient doesn’t have that education."

The process was altered so that the change is entered in the computer as soon as the change order is received verbally. "The nurse is then in the home with the medications and teaching materials from the start," he says.

In going through past charts, he adds there were about a dozen cases where drug interactions could have been an issue. "It was important to get that right," Markovich adds.

InCare also paid for a mock survey before the real one, which Markovich says provided some additional insights.

Leveton says the surveyor was so impressed with organization of the charts and extensive documentation that she told them she thought they would make a nice example for other agencies. In all, the surveyor only had a page of comments for the agency.

While going through the manual and conducting a mock survey certainly helped InCare to fly through the first survey, Markovich says it is as important to concentrate on finding "real ways to help people. In almost every weekly staff meeting, I say that the nurses should ask themselves, Is there something more they can do for the patient?’ All the standards and legal requirements are finally addressing the same issue of regulatory guidelines. But what you really are here for is the patients."

Leveton says her future planning is all geared toward looking at the whole patient. "We want to see the big picture," she says. "The nurses have to approach each patient as if they are developing a story. The way they write their notes is more than putting facts on paper. When you read the documentation, you need to get a clear picture of this person."

By the end of the year, Leveton hopes to expand her business into temporary staffing and private pay, reducing Medicare to about half of her business. That way, she thinks she can bring her agency’s way of meeting the special needs of patients to a wider community.


Yana Leveton, Managing Director, Vadim Markovich, PA, RN, Clinical Director, InCare, 675 Geary Blvd., Suite 500, San Francisco, CA 94118. Telephone: (415) 673-8989.