Program helps immigrants navigate health system
Program helps immigrants navigate health system
Role of bilingual medical caseworkers expanded
In addition to providing interpreter services for its increasing immigrant population, staff from Harborview Medical Center in Seattle go into the community, helping eligible patients learn to navigate the health care system.
The hospital’s Community House Calls/Case-worker Cultural Mediator Program expands the role of medical interpreters into the role of caseworker cultural mediators and helps overcome linguistic and cultural barriers to health care for patients with limited English, says Bria Chakofsky-Lewy, RN, nurse supervisor for the program.
The caseworker cultural mediators are bilingual, bicultural, and have had the experience of being immigrants themselves. They all have connections with the communities they serve and visit their clients in their homes and in their communities.
"In order to care for people from these communities, we need to hear and see exactly what they need. It wasn’t useful to use the old model of an institution sending out what it believes the population needs. There needs to be a loop where we hear from the community as well as speaking to them," Chakofsky-Lewy says.
The caseworker cultural mediators’ duties include case management services such as advocacy and coordination of care, interpretation, cultural mediation, health education, and assistance in accessing English and citizenship classes.
They visit the patients and their families in their homes, providing case management for families with complex social or medical needs. They teach the families how to make their own clinic appointments and get pharmacy refills. Case-managed families typically have needs for housing, nutrition, education, mental health, and other social services. Those who are refugees often have post-traumatic stress disorder, fear, and depression.
The caseworker cultural mediators work with social workers to assist the families and educate them on how to access the resources available. They develop relationships with ethnic community associations and help their clients access the services those organizations provide.
A key portion of their jobs is to help clinicians understand their patients by providing them with information about their cultural backgrounds, current living situations, and health care practices and beliefs.
"The combination of cultural mediation with case management enables [caseworker cultural mediators] to be extremely effective at addressing the specific health care needs of one of Harborview Medical Center’s largest vulnerable patient populations," she says.
Preventing readmission and ensuring that people use their medical services appropriately is a goal of the Community House Call program.
"If the only access care people know about is visiting the emergency department in a time of crisis, it gets pretty expensive. We follow up to make sure the clients are refilling their prescriptions and making follow-up appointments with their physician," she says.
The caseworker cultural mediators work with the medical center to make sure that patients sign up if they are eligible for reimbursement such as Medicaid or health insurance offered by their employer.
The Community House Calls/Caseworker Cultural Mediator Program at Harborview Medical Center in Seattle was started in 1994 as a pilot program funded by the Robert Wood Johnson and Henry J. Kaiser Family foundations.
The program, now a part of Harborview’s interpreter service department, includes seven caseworker cultural mediators, a nurse supervisor, community advisors, and a medical director. They provide services to patients from the following language groups: Cambodian, Somali, Amharic, Tigrigna, Spanish, and Vietnamese.
"When Harborview initiated the program, we looked at the demographics of our patients and which ones were having the hardest time accessing services. We expanded our interpretation services to include cultural mediation and case management for these patients," Chakofsky-Lewy says.
The medical center brought the elders in each ethnic community together and asked their advice on what the program should provide. The initial caseworker cultural mediators were hired with input from the community.
The majority of patients who are part of the Community House Calls program are referred by social workers, nurses, and physicians at the medical center.
Following up with patients
The needs of the populations served vary from community to community. For instance, one caseworker cultural mediator helped a newly arrived group of refugees from Somalia find housing and take care of other basic needs.
"When people come from refugee camps, they are really lost in the system we have for health care today in this country. A lack of knowledge can easily cause confusion. It’s not the lack of a desire to be cooperative. It’s a lack of understanding or lack of resources," Chakofsky-Lewy explains.
A recent referral is native of Somalia who has been in the United States less than a year, is pregnant with her second child, and is very thin and suffering from nausea. The caseworker cultural mediators assigned to her are acting as advocates for her in the health care system, educating her on caring for her children, and helping her learn self-help skills so she can make her own doctor’s appointments and understands her plan of care.
Another patient missed bringing her child with iron-deficient anemia for doctor’s appointments. Her caseworker cultural mediator is working with her to ensure that the child’s prescription is refilled and that she brings him for regularly scheduled appointments.
The caseworker cultural mediators follow up with some of their clients by telephone, home visits, and at clinic appointments.
"What you can learn in one home visit takes the place of many phone calls. Visiting in person is the best way for the [caseworker cultural mediators] to establish trust with the patients," Chakofsky-Lewy says.
The home visit allows the caseworker cultural mediator to see the family in its own environment and to determine what needs are not being met. Sometimes they work with the housing authority, immigration officials, or community agencies to help take care of the family.
The length of time the caseworker cultural mediators follow their clients depends on what the patient and family need.
"Sometimes it’s a one-time visit. Others are followed for a long time. Our goal is to give the patients the tools they need to be able to navigate the system on their own," Chakofsky-Lewy says.
For instance, a caseworker cultural mediator has been following one patient with cognitive deficits as a result of torture for 11 years, helping with medication compliance and other needs.
One client needed a transplant, and a caseworker cultural mediator was able to identify a transplant among his siblings in Mexico, a challenge made difficult by the fact that the sibling did not have a telephone and the blood had to be transported across borders. "She accomplished it and got a visa for the matching brother, saving the life of a human being who otherwise would be dead," Chakofsky-Lewy recalls.
In addition, the caseworker cultural mediators help the medical staff at Harborview understand the culture of their patients, providing cultural mediation to facilitate clinical encounters that involve cultural differences and making presentations to the staff on a variety of topics including health beliefs, traditional health practices, end-of-life issues, parenting practices, and explaining diagnoses to patients.
"Some of our patients have no insurance. They don’t understand Western medicine, and this frightens them," Chakofsky-Lewy says.
For instance, one man who had a small skin cancer heard the word "cancer" and went home and prepared to die because, in his country, a diagnosis of cancer meant death.
"We think that we have a legal obligation to give a diagnosis directly to the patient. In many cultures, giving bad news to the patient is seen as a way of hastening their demise. When bad news has to be communicated, the [caseworker cultural mediators] coach the provider about the best way to do it," she says.
In a patient satisfaction survey of Cambodian mothers treated at the medical center, those who received caseworker cultural mediator care coordination were able to identify the caseworker cultural mediator as a helpful person who worked in the hospital and could easily be identified. Mothers in the control group were not as likely to identify a hospital staff person they could contact for help with health issues.
[For more information, contact:
- Bria Chakofsky-Lewy, RN, Nurse Supervisor, Community House Calls/Caseworker Cultural Mediator Program, Harborview Medical Center, Seattle. E-mail: [email protected].]
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