By ELLEN FUTTERMAN
TRINITY HEALTH
Alem Lingerh, who grew up in Ethiopia, came to the U.S. from Beirut, Lebanon, a little more than three years ago with her husband and two young sons.
The family was settled in Boise, Idaho, one of this country's refugee resettlement cities. She and her husband wanted another child in their new homeland, but Lingerh suffered three miscarriages in a row. When she became pregnant for the fourth time, a fellow refugee told her about the CARE
Maternal/Child Health Clinic at Saint Alphonsus Regional Medical Center in Boise. (CARE stands for Culturally Appropriate Resources and Education.) Operating since May 2009, the clinic provides maternity and well-baby care specifically for refugee women and their infants until their first birthdays.
"It was like a whole world opened for me," said Lingerh, 35, who delivered a healthy baby girl in May 2012. "The first time I came here, all the workers, from the receptionist, to the nurses, to the doctors, made me feel so welcome. This is a safe place. You can ask any questions you want and they answer you as much as you need."
A profile on the CARE clinic published in the Agency for Healthcare Research and Quality's "Innovation Exchange" makes note of the emotional, physical and financial barriers that may keep refugees from accessing prenatal care. Some women come to the U.S. with little appreciation of the benefits of prenatal care. And refugees who have suffered trauma may fear physical examinations, especially when a practitioner uses unfamiliar equipment. But prenatal care can be especially important in this population as some refugee women suffer lingering health issues caused by malnutrition and limited lifetime access to health care.
Peer health advisors at the CARE clinic are sensitive to these issues, perhaps having experienced them personally, and they quiet patients' fears as they build trust and rapport, often by conversing in the patient's first language. The health advisors assist clinical staff in teaching the expectant mothers about behaviors that contribute to healthy pregnancies and abouttheir responsibilities as patients — such as showing up, and on time, for scheduled appointments.
Recognizing need
"We were seeing a large influx of refugees from different countries arriving at the family maternity center at Saint Alphonsus and not prepared for the birth of their babies," explained Judith Hobbs, manager of the CARE clinic, which has a dedicated site within the Saint Alphonsus Family Maternity Center at Saint Alphonsus.
She said that Saint Alphonsus made refugee health care a priority after meeting with representatives from the Boise field offices of three refugee resettlement agencies — the Agency for New Americans, the International Rescue Committee and World Relief. Saint Alphonsus administrators also explored the health needs of the refugee community with the Idaho Office for Refugees, local social service agencies and in focus groups drawn from various refugee communities.
"A big part of our mission and ministry as a Catholic-based hospital is care for the poor and the underserved. It is one of our core values," said Hobbs, who is a registered nurse. Trinity Health of Livonia, Mich., the parent system of Saint Alphonsus Health System, awarded a $524,000, three-year grant to launch the CARE clinic.
Today, three family physicians rotate through the infant clinic, which sees between 75 and 100 newborns a year. In addition, three certified nurse midwives and two registered nurses take care of the roughly 35 to 40 refugee maternity patients at any given time, said Hobbs. An on-site mental health counselor assists refugee patients who have experienced trauma or abuse prior to coming to the U.S.
Most newly arriving refugees receive Medicaid coverage for eight months; if a woman becomes pregnant that coverage is extended throughout the pregnancy and six to eight weeks beyond delivery (afterward, with some exceptions, they must qualify under the same guidelines as any U.S. citizen). Their newborns also are insured through Medicaid until they are at least a year old. Idaho has more generous family income standards for covering children under Medicaid than it does for parents or single adults.
Wise women
The CARE clinic employs about a half-dozen or so settled refugees as paid health advisors. Many of these women are multilingual, which is useful because, according to the Idaho Office for Refugees, there are over 60 languages spoken among the refugee populations in Boise.
"These health advisors are really key to the program," said Hobbs. "Most of them have been through our clinic. We look for someone who is a natural mentor and who is highly respected within her refugee community. Others must trust her, and she must respect patient confidentiality as well. That is a huge piece."
Lingerh from Beirut, and Bhima Adhikari, 25, a Bhutanese refugee who came to the U.S. from Nepal, both serve as health advisors. Like Lingerh, Adhikari initially came to the clinic for prenatal care; she gave birth to a healthy boy in January 2011.
"We help remind the women about their appointments; we are with them at the clinics, often riding the bus with them. We make sure they are following doctors' directions, like not to eat too much rice and getting enough rest," said Adhikari.
Hobbs calls the health advisors the "wise women from the community. They really give voice to maternity patients who are new to this country, and often shy or not used to speaking up. Western medicine is not what they have been used to.
"Health advisors give us a true picture of the patient's medical and social needs, as well as improving the cultural sensitivity of the CARE clinic providers and staff. They really help the CARE clinic team understand how we can better serve these women and help them navigate through our complex medical system."
Group education
The CARE clinic makes the most of the time and effort patients make to keep appointments with doctors and midwives. "We felt education was very important," said Hobbs. "Instead of waiting for the appointment in a waiting room, we meet in a large room altogether to educate about medications, how to get WIC food (a government nutrition program for women, infants and children), weighing fruits and vegetables in pounds rather than kilograms, why we take their blood and have them urinate in a cup and other procedures related to their pregnancy. We do have medical interpreters, but the health advisors are also there for support and to help explain procedures."
The CARE clinic also runs an educational incentive program, called CAREsteps, in which mothers can earn points by choosing healthy habits such as increasing their consumption of fruits and vegetables, being on time for appointments and attending group educational sessions. They redeem the points for items in an on-site store. "We get a large amount of community donations of clothes and other items that mothers need for their newborns," said Hobbs. "The Catholic schools in Boise also collect and donate pennies, which help us to buy diapers, car seats and other necessities."
"In one small place, the CARE clinic, you can get medical treatment, education and supplies for your baby. You don't have to search all through Boise to get what you need," said Lingerh. "It's like one-stop shopping."
Saint Alphonsus brings care to refugees
The CARE Maternal/Child Health Clinic isn't the only refugee health care program the Saint Alphonsus Health System oversees in Boise, Idaho. Its Saint Alphonsus Ð Federal Way Clinic also is dedicated to delivering quality medical services to newly arrived refugees while respecting and honoring their cultures of origin.
Along with seeing refugee patients weekdays at its clinic, a few times each month the Saint Alphonsus Ð Federal Way Curbside Care Mobile Health Unit brings a family practice physician directly to the communities where refugee patients reside. The vehicle has an exam room, vitals monitoring and laboratory drawing services; and it improves care access.
"The RV has made such a difference in being able to deliver care to our refugee population at their doorstep," said Jordan Augustine, Federal Way Clinic manager.
In addition to its three family practice physicians who take care of patients from a year old and up, the Federal Way Clinic employs a full-time licensed counselor and two part-time behavior specialists. Their charge is to help arriving refugees with transition challenges as well as any lingering effects from emotional or physical traumas they may have experienced.
"We are committed to a holistic approach to care for our patients," said Augustine. "We have a social worker to help our refugee patients deal with issues that go beyond specific health problems, as well as help them reapply for Medicaid and other kinds of assistance to alleviate some of their stress."
Of the 700 to 850 patients the Federal Way Clinic sees each month, roughly 70 percent to 80 percent are refugees, Augustine said. He added that about 60 percent of the clinic's patients receive Medicaid, 15 percent to 20 percent are covered by Medicare and 15 percent to 20 percent are charity cases. Because of this payer mix, the clinic consistently loses money, he said.
"Our doctors are committed to providing quality, equity care of people of all races and religion regardless of their financial and socioeconomic class," said Augustine. "This is the right thing for us to be doing and is so in line with Saint Alphonsus' mission to take care of those in need. Our clinic is losing money, but we are supported by the rest of the system because our mission is so important."
— Ellen Futterman
Copyright © 2013 by the Catholic Health Association of the United States
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