Community Health Care: Share the Knowledge and Hold the Plantains

This New York City program tries to eliminate the “white coat effect” by creating trust and ease between health workers and patients in immigrant communities.

A nurse from New York Presbyterian Hospital goes over nutritional information during a free health-screening clinic for New York bodega convenience store workers July 20, 2010 in the Bronx borough of New York. Nurses and technicians from provided the free medical checks for the primarily-Hispanic bodega worker community, many of whom lack health insurance or regular medical care.
National Journal
Margot Sanger Katz
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Margot Sanger-Katz
March 5, 2014, 5:23 a.m.

NEW YORK, N.Y — Ad­ri­ana Mat­iz, a doc­tor who prac­tices in the Wash­ing­ton Heights neigh­bor­hood in north­ern Man­hat­tan, looks a lot like the pa­tients she serves. Her her­it­age is Colom­bi­an, and she speaks flu­ent Span­ish. But after years of prac­ti­cing at a primary-care of­fice here, she still no­ticed that pa­tients didn’t al­ways trust her or take her med­ic­al ad­vice. The prac­tice had been re­tool­ing it­self to try to provide the best care to its com­munity, but it struggled to make an im­pact on im­port­ant dis­eases that were harm­ing its pa­tients. The neigh­bor­hood’s rate of child­hood asthma was triple the na­tion­al av­er­age. And dia­betes and de­pres­sion were also off the charts.

“There was still something that was miss­ing,” says Mat­iz.

Now Mat­iz’s em­ploy­er, the New York-Pres­by­teri­an Health­care Sys­tem, has found a way to help plug the miss­ing piece between its med­ic­al pro­viders and its im­mig­rant com­munity cli­ents. Team­ing up with loc­al or­gan­iz­a­tions, it de­ploys teams of “com­munity health work­ers” in­to doc­tors’ of­fices, and pa­tients’ homes through a pro­gram called the Re­gion­al Health Col­lab­or­at­ive. The com­munity health work­ers come from the neigh­bor­hood and share the cul­tur­al her­it­age of their pa­tients. They don’t have med­ic­al train­ing or wear white coats, but they do have the tools to help fam­il­ies deal with the house­hold roaches and mold that may be trig­ger­ing a child’s asthma, and they have the cred­ib­il­ity to tell them to lay off the plantains and yucca that are caus­ing their dia­bet­ic blood-sug­ar spikes. And along with oth­er changes in prac­tices like Mat­iz’s, they’ve been able to im­prove health out­comes and re­duce health care spend­ing.

Raquel Gar­cia-Guz­man, a com­munity health work­er from the North­ern Man­hat­tan Im­prove­ment Cor­por­a­tion, one of NYP’s part­ners, has been on the job for about a year. She moved to Wash­ing­ton Heights from the Domin­ic­an Re­pub­lic when she was 3, and she’s had dia­betes her­self for more than 15 years. So when she meets a pa­tient for the first time, she’s quick to de­vel­op rap­port. “You can’t ima­gine the switch when you say it,” she says of shar­ing her own health struggles with pa­tients. On a re­cent home vis­it, she stopped by the house of 82-year-old Rosa Ji­me­nez. Ji­me­nez, a Domin­ic­an im­mig­rant who has lived in her apart­ment for 22 years, has mul­tiple health prob­lems, chief among them un­con­trolled dia­betes. Sit­ting in a rock­ing chair be­side a walk­er and an ar­ray of pre­scrip­tion pills, she smiled at Gar­cia-Guz­man’s ar­rival and the two walked through a ques­tion­naire in Span­ish on her pro­gress over the six months they have worked to­geth­er, while a home health aide cooked lunch.

As they dis­cussed Jiminez’s main form of ex­er­cise — walk­ing — her blood-sug­ar test­ing re­gi­men, and oth­er health factors, Gar­cia-Guz­man looked over at the bowl of plain­tains and a box of candy on the kit­chen counter. Ji­me­nez hadn’t ini­tially men­tioned her sweet tooth when dis­cuss­ing her diet, but with a little prod­ding, she ac­know­ledged that she of­ten had candy after a meal.

De­tails like that will help Ji­me­nez’s doc­tors bet­ter treat her dia­betes. Pa­tients, of­ten eager to please their doc­tors with their com­pli­ance, of­ten white­wash their di­et­ary in­dis­cre­tions, Gar­cia-Guz­man said, lead­ing to omis­sions that can skew med­ic­a­tion dosages and hurt their health. Car­men Cruz, a former com­munity health work­er who now helps run the health-work­er pro­gram at NYP, said she saw this “white coat ef­fect” firsthand when she ac­com­pan­ied her moth­er to doc­tors’ ap­point­ments as a girl and heard her moth­er tell the doc­tors what she thought they wanted to hear. “Every older lady in this com­munity is my moth­er, so I know,” she jokes.

Com­munity health work­ers are more likely than med­ic­al pro­viders to hear about pa­tients’ sus­pi­cions about medi­cine — that asthma in­halers will ad­dict their chil­dren — or home rem­ed­ies they’re us­ing in place of tra­di­tion­al medi­cine. Loc­al tra­di­tion has it that chamo­mile tea can take the place of in­sulin or that a com­bin­a­tion of cof­fee grounds and pea­nut but­ter can hold asthma at­tacks at bay. The health work­ers also have the time to provide ba­sic edu­ca­tion about pa­tients’ dis­eases, ex­plain­ing which fa­vor­ite Domin­ic­an dishes are good for dia­betes and which should be eaten in mod­er­a­tion. Pa­tients are of­ten also more will­ing to open up about prob­lems they’re hav­ing out­side the med­ic­al realm, with hous­ing, do­mest­ic vi­ol­ence, or oth­er dif­fi­culties that nev­er­the­less have a big im­pact on health. “They have oth­er is­sues,” says Maria Liz­ardo, the as­sist­ant ex­ec­ut­ive dir­ect­or for pro­grams at Up­per Man­hat­tan Im­prove­ment, who said that health work­ers can also help con­nect pa­tients to the bevvy of oth­er ser­vices the or­gan­iz­a­tion provides — ESL classes, tax pre­par­a­tion, debt coun­sel­ing, and oth­ers. “It’s not just asthma or dia­betes go­ing on.” And, as she points out, a fam­ily strug­gling to put food on the table will be less likely to fill that in­sulin pre­scrip­tion.

The com­munity health work­ers are a piece of a lar­ger trans­form­a­tion in how the med­ic­al prac­tices de­liv­er care that’s de­signed to be more re­spons­ive to pa­tient needs and more sens­it­ive to these so­cial and eco­nom­ic factors that may be im­ped­ing pa­tient’s health. In ad­di­tion to em­ploy­ing the com­munity work­ers, the prac­tices have ad­op­ted new elec­tron­ic health re­cords to bet­ter track their pa­tients; they’ve re­or­gan­ized their staff to bet­ter in­clude re­cep­tion­ists, di­eti­tians, and so­cial work­ers in­to their treat­ment routines; and they’ve also trained every­one to be more cul­tur­ally com­pet­ent. They de­scribe their new mod­el as a “med­ic­al vil­lage.”

The pack­age of re­forms has led to some im­press­ive res­ults. In a re­cent Health Af­fairs art­icle, NYP boas­ted of ma­jor re­duc­tions in dis­ease and the pos­sible prom­ise of cost sav­ings. In 2011, a year in­to the pro­gram, the hos­pit­al was able to doc­u­ment re­duc­tions in the num­ber of times pa­tients in the prac­tices were vis­it­ing the emer­gency room or get­ting sick enough to re­quire ad­mis­sion to the hos­pit­al. But even with those prom­ising ini­tial res­ults, so far, health in­surers aren’t pay­ing for the pro­gram. Much of the work is fun­ded through a series of grants — from the state, Columbia Uni­versity, and found­a­tions. That may change as more res­ults come in and in­surers de­vel­op more flex­ible ways of pay­ing doc­tors who want to be part of a more col­lab­or­at­ive sys­tem. “These people are go­ing to be key ele­ments of the health care team and go­ing to have huge im­pacts on guidelines,” says Dr. Joseph Betan­court, the dir­ect­or of the Dis­par­it­ies Solu­tions Cen­ter at Mas­sachu­setts Gen­er­al Hos­pit­al and an as­so­ci­ate pro­fess­or at Har­vard Med­ic­al School, who points to the NYP pro­gram as a mod­el.

The people in­volved in the NYP pro­gram say there’s no reas­on the com­munity health work­er ap­proach couldn’t be widely ad­op­ted around the coun­try in places with strong com­munity or­gan­iz­a­tions. The Wash­ing­ton Heights mod­el is geared to­ward the Domin­ic­an and Pu­erto Ric­an com­munit­ies, but only be­cause that’s who lives there. A sim­il­ar mod­el could work, they say, in a neigh­bor­hood of Chinese, or Ni­geri­an, or Rus­si­an im­mig­rants, as long as the health work­ers had the right skills and re­la­tion­ships. The health chal­lenges for vari­ous groups dif­fer, as do the cul­tur­al norms, tra­di­tions, and at­ti­tudes to­ward medi­cine. “Spe­cificity is one of the key chal­lenges for our city, be­cause we’re so di­verse,” said Ana Gar­cia, the deputy dir­ect­or of health policy at the New York Academy of Medi­cine, a pub­lic-health re­search and ad­vocacy or­gan­iz­a­tion with re­la­tion­ships around the city. Gar­cia said that she’s seen cul­tur­ally tar­geted pro­grams, like the one at NYP, reap be­ne­fits in oth­er places it’s been tried.

Mat­iz agrees. In con­ver­sa­tions with col­leagues, she’s been im­pressed by how quickly they grasp and em­brace the com­munity health work­er mod­el. “People are con­stantly say­ing to me, this looks like something that could work in my com­munity,” she says.

Mar­got Sanger-Katz is cur­rently on leave from Na­tion­al Journ­al to par­ti­cip­ate in the Knight-Bage­hot Fel­low­ship in Eco­nom­ics and Busi­ness Journ­al­ism at Columbia Uni­versity. 

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