Action Steps to Improve the Health of New Americans

CHAPTER 4 Action Steps to Improve the Health of New Americans



Patricia Ohmans



Introduction


One in 10 Americans is a first-generation immigrant, according to the US Census. Since the earliest days of our nation, when European settlers joined the native population, immigrants have helped make America a more vibrant and productive place to live.


Sadly, many immigrants to the United States are poorly served by national and local health and social service programs, depending on their legal status, their education, their assets, and whether or not they have health insurance. This poor service results in health status disparities between immigrant and non-immigrant populations. The problem is manifested in a variety of ways, among them:


Incomplete screening and treatment: Immigrants and refugees need screening and treatment for infectious diseases, chronic conditions such as diabetes, high blood lead levels and depression. Often, they do not get them. As a result, there are higher rates of some illnesses among immigrants and refugees than among non-immigrant groups.


Inadequate insurance coverage: Lack of insurance and confusing payment systems discourage many immigrants from seeking the healthcare they need. Blocked from access to healthcare or insurance, many immigrants seek care only in emergency situations. Higher healthcare costs result, for what would have been preventable conditions if they had been treated earlier.


Lack of cultural and linguistic competence: Healthcare providers – most from very different cultures than their immigrant patients – may not be aware of significant communication barriers with the people they treat. The distinctly different clinical and social needs of immigrants are often minimized or misunderstood, resulting in lower rates of comprehension and adherence to doctors’ orders by immigrant patients.


Shortage of bilingual and bicultural providers: Highly trained, bilingual, and capable immigrant healthcare providers are not being integrated into our current healthcare workforce. A waste of human capital occurs, as former physicians and nurses are retrained for other work.


This chapter describes eight important action steps to reduce the barriers to immigrant health described above. The chapter provides a template for broad changes within the healthcare system, with policy and program recommendations to be undertaken by healthcare providers and administrators, policy makers, academic researchers and educators, and immigrant advocates.


These recommendations were developed by the Minnesota Immigrant Health Task Force, a 2-year citizen advisory group to the Department of Health and Department of Human Services, consisting of healthcare providers, academics, policymakers, and immigrant advocates. Patricia Ohmans, MPH, served as the Task Force coordinator; Patricia Walker, MD, DTM&H, was its chairperson.


The Task Force recommendations address barriers to full health for immigrants in Minnesota, but are applicable nationally, and have been amplified and annotated here to fit a national context (Box 4.1). Some of the recommendations are addressed more thoroughly in other chapters of this text. These are noted.



Box 4.1 The Task Force on Immigrant Health recommends these eight action steps to improve immigrant health



1. Provide equal access to care for all, regardless of immigration or insurance status.

2. Assess patients’ language preference, and healthcare organizations’ capacity to provide appropriate care.

3. Recognize different costs of healthcare for recent immigrants.

4. Develop clinical guidelines and best practices orders for immigrant healthcare.

5. Diversify the healthcare workforce to include more immigrant and minority providers.

6. Use trained interpreters.

7. Use bilingual and bicultural community health workers.

8. Train healthcare providers and educate immigrant patients.

Sponsored by the Minnesota Department of Health and the Minnesota Department of Human Services, the Minnesota Commissioners’ Task Force on Immigrant Health consisted of over 80 representatives from the state’s public, private, nonprofit academic, and healthcare sectors, many of them also first-generation immigrants to the state.


The Task Force met every 2 months from July, 2002, to July, 2004, with the following mission: ‘To promote quality, comprehensive and culturally competent healthcare for all recent immigrant communities, by effecting change in statewide health delivery systems.’ The Task Force utilized two reports from the Institute of Medicine as the framework for its deliberations: ‘Crossing the Quality Chasm: A New Health System for the 21st Century’ (2001) and ‘Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care’ (2003), Available at: www/iom.edu. The complete report from the Minnesota Immigrant Health Task Force is Available at: www.health.state.mn.us/divs/idepc/refugee/immigrant



Action Steps



1 Provide equal access to care for all, regardless of immigration or insurance status


The United States is the only developed nation in which healthcare is not universally guaranteed. Nearly 47 million Americans are uninsured and many immigrants are among them. Non-citizens are 7% of the population, but 21% of the uninsured. Their lack of access to healthcare affects us all.1


Access to healthcare can be crucial to achieving full health. People who lack insurance are less likely to be offered screening and treatment of many kinds. They are also less likely to benefit from medical advances, even common ones. Use of the latest treatment technology is lowest among the uninsured.2 Differences in access to care between immigrants and non-immigrants exacerbate these and other health disparities.


Leaving people uninsured is not cost-effective. Uninsured people make greater use of emergency rooms and sometimes delay getting care until they are desperately ill.3


Those suffering from infectious and communicable diseases who do not receive early screening and treatment can present a threat to an entire community. Decisions to cut healthcare benefits for immigrants can have unintended and more expensive results, especially when benefits to young children are cut (Box 4.2).



Box 4.2 Access to care: what you can do



If you are a policy maker, you can:


Strengthen access to insurance and care for the poor. Immigrants are disproportionately poor and uninsured.


Increase funding for prevention and treatment of communicable diseases such as TB and HIV-AIDS. Screening and early treatment are cost-effective and protect the community at large from serious infectious diseases.



If you are a healthcare administrator, you can:


Enforce existing mandates and standards such as the standards for Culturally and Linguistically Appropriate Services (CLAS) issued by the US Department of Health and Human Services.


Allow providers to offer creative alternatives for discounted or free care.



If you are an educator or researcher, you can:


Document how cuts in public funding for healthcare affect health outcomes among immigrants and other minority groups.


Document health disparities between immigrants and non-immigrants and their relationship to healthcare access.


Research the impact of equitable access to health insurance and care on health outcomes.



If you are a healthcare provider, you can:


Become familiar with public programs that offer healthcare at free or reduced rates, and recommend these to your patients who lack insurance.


Donate a percent of your work time to volunteer or charity care for immigrant patients.


Work toward a system of universal healthcare.



If you are an advocate for immigrants, you can:


Lobby for a system of universal healthcare. The US is the only nation in the developed world without one.


Help immigrant patients contact legislators or policymakers to stress the importance of healthcare for all.



2 Assess patients’ language preference, and healthcare organizations’ capacity to provide appropriate care


Improvements in care for immigrants cannot be documented without data linking immigrant status with health status. Healthcare facilities should also document their capacity to provide good care to immigrants. Healthcare organizations should collect key demographic data, including race/ethnicity, country of origin, and preferred language for interacting with healthcare providers.


Current data on the connection between im-migration status and health status are inadequate.4 The link between minority status, low income, and health disparities is increasingly clear,5 but there is much missing in our understanding of possible links between health and immigration status or low English proficiency.


Information can be very revealing. Because of screening done by health authorities and researchers, we know immigrants suffer disproportionately from some health conditions, while seeming protected from others. Infectious diseases such as tuberculosis are more prevalent among the foreign born. On the other hand, birth outcomes among recent immigrant mothers are often better than those among other minority group mothers. (For a thorough discussion of the seemingly paradoxical ‘healthy migrant effect’ see Dr. Kathleen Fennelly’s analysis in Chapter 3). More data linking diseases and conditions with immigration status would help explain this paradox.


Collection and reporting of data on race, ethnicity, and primary language are legal, according to Title VI of the federal Civil Rights Act of 1964. No federal statutes prohibit this collection.6 Further, patients agree that it is important for healthcare providers to collect and track data on race, ethnicity, and language. When they know why the information is being asked of them, they disclose it readily to healthcare providers.7


Healthcare organizations can do more to collect and analyze useful data.8 Increasingly, healthcare facilities are expected to assess their capacity to serve diverse patients, including immigrants. In 2000, the US Department of Health and Human Services issued standards for culturally and linguistically appropriate services in healthcare that recommend internal audits and outcomes-based evaluations of cultural competence, as well as data collection on patients’ race, ethnicity, and language preferences.9


The Joint Commission on Accreditation of Hospitals and the National Council on Quality Assurance both recognize the importance of data collection and assessment regarding cultural and linguistic aspects of care in the accreditation review processes.10


A commitment to eliminating health disparities between immigrant and non-immigrant patients should be measurable from the boardroom to the waiting room. Healthcare networks and systems should have written policies about access, language services, provider training, marketing and of course, data collection. They should also have internal quality assurance measures to track goals toward increased cultural competence.11,12


Data collection and assessment leads to rational funding allocations, more cost-effectiveness, better care and ultimately, better outcomes.13 Using accurate information on the race and ethnicity of patients, providers, clinics and healthcare systems can identify health status and service disparities.14 This vital pool of information can serve as a guide in focusing prevention and treatment efforts as well as general expenditure of health dollars (Box 4.3).



Box 4.3 Data and assessment: what you can do



If you are a policy maker, you can:


Establish mandates and expectations regarding data collection by healthcare and social service organizations.



If you are a healthcare administrator, you can:


Explore existing forms of data collection which provide valuable information without the need for new collection; use markers such as ER visits, increases in insured individuals, etc. to measure progress toward better care.


Routinely link organizational key quality measures to demographic data which are collected, and develop organizational responses to the results.


Develop policies and systems within your organization to support data collection at the point of the patient’s first encounter with your system.



If you are an educator or researcher, you can:


Use existing and new data to explore the link between immigrant status and health.


Document ways that healthcare organizations are using data effectively to improve services.

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Aug 11, 2016 | Posted by in INFECTIOUS DISEASE | Comments Off on Action Steps to Improve the Health of New Americans

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