Bridging Communities and Clinics in Utah 2012

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Br i d g i n g Co m m u n i t i esan d Cl in ics

Pi l o t Sum m ary and O u tcom es

November 27, 2012

Jake Fitisemanu, Outreach Coordinator

Utah Department of Health

Office of Health Disparities


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Br idg ing Com m un i t ies and Cl in i cs

Pro j ect Overv iew

The Utah Department of HealthOffice of Health Disparities beganplanning the For Me, For Us:Bridging Communities and Clinicsoutreach model in December 2011,with expected implementation ofa pilot program between April andOctober 2012.

The Bridging Communities andClinics (BCC) model was designedto address the demonstratedinadequacies and ineffectiveness ofthe traditional health fair approachto community health outreach.

Moving beyond distribution ofbrochures and basic health indicatorscreenings, the BCC employsevidence-based best practicesto address themes of access tohealth care, preventive wellnesspromotion, and cultural competencyby providing (1) a trained, diverseOutreach Team comprised ofclinical outreach assistants; (2)clinically relevant screening tests

for blood glucose and cholesterol,hypertension,BMI, and healthrisk factors at nocost; (3) individualreferrals to free,reduced-cost, orincome-basedprimary careservices throughlocal clinics; and(4) post-screeningfollow-up toassist participantswith schedulingappointments, basichealth questions,language barriers,etc.

Targeted demographics withinthe service population includedcommunities affected by significanthealth disparities and groupshistorically identified to be athigh risk for obesity, unfavorablebirth outcomes, and barriers tohealth care access includingthe uninsured/underinsured,low-income populations, AfricanAmericans, Hispanics/Latinos, andNative Hawaiian/Pacific Islanders.

At the conclusion of the outreachstage of the pilot program inOctober 2012, the BridgingCommunities and Clinics model had

been successfully implemented in24 outreach events coordinatedthrough a dynamic network of 12referral clinics and 22 communitypartners in Salt Lake, Summit,Utah, and Weber counties.


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Out reach Team

The BCC Outreach Team wascomprised of eight clinical studentinterns who were tasked withimplementing the BCC outreachmodel through the 24 outreachevents mentioned before. Theobjective of forming an OutreachTeam was to ensure that outreachevents were conducted by adiverse group of skilled, trainedpersonnel who would adhereto consistent protocols andprofessional standards. OutreachTeam interns received over 15hours of in-person, online, and

community-based training inclinical screening procedures,culturally competent medical care,transcultural communication,medical interpreting, and culturallyand linguistically appropriate servicestandards. During the course of theBCC pilot, individual interns eachprovided between 32 and 72 hoursof screening services and preventivehealth promotion in diverse

communities.

As a central component of theBCC model, the Outreach Teamwas shown to be highly effectiveand efficient in conducting BCCoutreach events. The standardizedtraining of Outreach Team internsas a cohesive team facilitated thesuccessful implementation of theBCC program in an efficient andconsistent manner throughoutthe duration of the pilot. At eachoutreach event, one or two internsacted as coordinator overseeing thesetup, takedown, and operationsof the event. Outreach internsassisted participants in filling outpre-screening questionnaires

and reviewing potential riskfactors (such as smoking andfamily medical history), as wellas assessing health care accessneeds (such as insurance coverageand length of time since previoushealth checkup). Interns providedscreenings for blood glucose,total cholesterol, blood pressure,and body mass index (BMI), andreferrals to BCC clinical partnerswere offered to any participantwhose screenings warranted furthermedical follow-up.1 Participantswere given a Health Passport totake with them, which containedtheir results and an explanation of

their screenings as well as usefulinformation on finding affordablehealth care resources and freeinformation.

Outreach Team interns were alsoresponsible for following up withreferred participants by placingtelephone calls (or sending emails ina few cases) 15 days after receivingthe referral; if a participant was

unable to make an appointmentor required further assistance(including non-English languageassistance), interns would act toremedy the situation and make afurther follow-up call at 30-dayspost-screening.

1. Screening thresholds for clinical referrals followedguidelines published by the National Institutes ofHealth (NIH)


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Com m un i t y Hea l t h Work e rI n v o l v e m e n t

This pilot demonstrated that usinglay community health workers(CHW) had a significant impact on

the success of outreach events inquantitative and qualitative terms.CHWs were involved in six outreachevents, primarily fulfilling roles ason-site navigators who personallyinvited attendees to participatein screenings, assisted with fillingout pre-screening questionnaires,and facilitated participanttransitions between pre-screening,screening, and referral/follow-up

stages. Several CHWs were alsoinstrumental in providing linguisticinterpretation and cultural brokeringassistance.

The mean average screeningfrequency2 of each outreach eventwas 3.0 screenings per intern-hour; all six of theevents coordinatedwith the help of

CHWs were shownto be more time andcost efficient, withindividual interns ableto conduct an averageof 4.7 screeningsper hour (and at oneevent, as many as6.5 per hour) with theassistance of CHWs.

CHWs were highlyeffective in promotingparticipation amongattendees by providinga familiar facedegree of familiarity and relativityto outreach events that directlyresulted in reported increases inparticipant and intern satisfaction,

as well as the effectivenessand efficiency of the screeningprocess. This was appreciablyevident in outreach events amongAfrican American and Hispaniccommunities, where socioculturaland linguistic barriers wereeffectively bridged and mitigatedwith the help of community-basedCHWs.

It has been demonstrated thatthe integration of CHWs into theBridging Communities and Clinicsmodel is correlated with observedincreases in screening frequency2and procedural efficiency, as well

as increased success in outreachingto underserved and diversecommunities. Increased utilizationof CHWs as community promoters,on-site navigators, and referralfollow-up assistants is projectedto significantly increase outreachefficiency, reach, and effectiveness.

2. Screening frequency was calculated for each eventby dividing the total number of participants by thenumber of Outreach Team interns conducting thescreenings and the hourly time frame of each event.


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Outcomes

Total screenings conducted: 833

Total referrals for follow-up: 178 individuals referred for clinical follow-up

Follow-up contact rate: 35.4% of referrals received telephone follow-up

Clinical encounter rate: 56% seen in clinic within 30 days

Demogr aph ic Da ta 3

Gender

Date o f Bi r t h

3. Obtained from Pre-Screening Questionnairecollected by all screening participants.


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Br idg ing Com m un i t ies and Cl in i csHow do you iden t i f y your sel f? ( Check a l l th a t app ly )

All of the ethnic and racial communities that were targeted by theBCC approach were reached through outreach events, with over halfof all participants self-identifying as Hispanic (all races, alone-or-in-combination). Compared to US Census 2010 data, African Americans,Asians, and Native Hawaiians & Pacific Islanders were all overrepresented

among BCC participants, as was initially expected. Participants couldindicate any combination of races/ethnicities, either alone or incombination.


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Br idg ing Com m un i t ies and Cl in i csWhat i s you r p re fe r red l anguage?

Because the BCC program was intended to reach underserved populations,limited-English proficiency (LEP) considerations were anticipated;pre-screening questionnaires and Health Passports were translated andmade available in English and Spanish, while Outreach Team interns andBCC community partners were capable of providing language assistance

in other languages including Portuguese, Russian, Samoan, Tongan, andVietnamese. Participants who selected the Other primary languageoption indicated a preference for languages such as Chinese, Armenian,Fijian, and Vietnamese.4

4. Vietnamese was consequently calculated as its own category, as shown in the graph Language Preference.


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Br idg ing Com m un i t ies and Cl in i csFam i ly Size ( Paren ts and dependen t s l i v ing a t hom e)

Since multiple families may often reside in the same household/residence,information regarding family size was collected. Nearly 75% of BCCparticipants came from families comprising three or more persons, with21.1% reporting a family size of six or more persons. The average Utahhousehold in 2011 consisted of 3.1 persons.

5. US Census Bureau, 2011 American Community Survey.


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6. At the request of one community partner, this question was omitted in 23 pre-screening questionnaires.7. US Census Bureau, 2011 American Community Survey.

Annua l Fam i l y I ncom e6 ( Paren ts and dependen t s l i v ing a t hom e)

For 2011, the median household income in Utah was $55,869.7 Pre-screening questionnaires requested information on estimated familyincome (rather than household income), revealing that BCC outreachevents were largely attended by individuals with considerable financialdisadvantages. More than 85% of respondents declared an annual family

income of $50,000 or less, with 30% indicating family income of less than$10,000 a year.


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Br idg ing Com m un i t ies and Cl in i csDo you have hea l th insur ance?8 ( I nc lud ing Med icaid , Med icare ,PCN, et c.)

The proportion of Utahs total population that is uninsured was estimatedto be 13.4% in 2011.9 The uninsured rate among BCC participants wasmore than four times the overall uninsured rate for the state of Utah.

When w as t he l as t t im e you had a p reven t i ve checkup?

Pre-screening questionnaires revealed that more than half of participants(55%) had not had a medical checkup within the 12 months prior to beingscreened at a BCC outreach event. More than 11% reported never having

a received a checkup before.

8. At the request of one community partner, this question was omitted in 23 pre-screening questionnaires.

9. Utah Department of Health, Utah Behavioral Risk Factor Surveillance System, 2011..


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Br idg ing Com m un i t ies and Cl in i csWhere d i d you ge t you r l ast p reven t i ve checkup?

The vast majority of those who reported having a previous preventivecheckup were seen at a clinic or private providers office. Responseswritten under the Other category included traditional/alternativemedical practices, workplace screenings, foreign countries, militarymedical facilities, etc.

Have you ever been d iagnosed w i th . .. ? ( check a l l th a t app ly )

The most commonly self-reported conditions among BCC participantswere high cholesterol, hypertension, and diabetes; these were also the

most frequently reported conditions among participants immediaterelatives.


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D oes anyone i n you r im m ed ia te f am i l y ( pa ren t s , g randpa ren t s,s ib l i ngs) have a h is to ry o f . .. ? ( check a l l t ha t app ly )

H ow sat i sfied w e re you w i t h you r sc reen ing?

All but two participants who provided evaluation of their screeningexperience reported that they were either satisfied or very satisfiedwith the quality of the screenings.


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Br idg ing Com m un i t ies and Cl in i csDid the screen ing inc rease your aw areness abou t y our h ea l th r i skfac to rs?

The vast majority of respondents indicated that their screening experience(including explanation of results and discussion of potential risk factorswith outreach interns) raised their level of awareness regarding healthconditions for which they may be at-risk.


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Out reach Team Eva luat ionand Feedback

Outreach Team internsprovided online feedback of theBCC program through an online

survey intended to evaluatethe pilot in terms of logisticconsiderations, coordination andorganization, procedural efficiency,and the quality of training received.Successful facets of the programthat were identified includeduser-friendly screeningquestionnaires and efficientscreening procedures. OutreachTeam members also thought highly

of the quality and applicability ofthe trainings (clinical skills, culturaland linguistic competency, medicalinterpreting, etc.) that were offeredthroughout the course of the pilot.When asked about the relevanceof outreach events to their futuremedical careers, all of the internsstated that the real-word, hands-onexperiences they gained throughthe outreach program were highlyrelevant and beneficial to theiracademic and professional goals.Some areas of improvement werealso identified, such as the need formore on-site language assistanceand clearer communication betweencommunity partners.

Pi lo t Eva lua t ion andRecommenda t i ons

The RE-AIM model of public healthprogram evaluation was utilized asan external framework to assess the

reach and effectiveness of BridgingCommunities and Clinics. Qualitativeand quantitative analyses were alsoutilized to determine whether initialobjectives of the pilot program weresatisfied.

Reach:

The pilot program was effectivein reaching the intended

target populations, specificallyindividuals and families without

health insurance coverage, theeconomically disadvantaged, andethnic/racial minorities. Over 85%of participants had an annualfamily income of less than $50,000,compared to the average householdincome10 in Utah of $56,330 peryear in 2011.11 Whereas 13.4% ofUtahns were not covered by health

insurance in 2011,12 over 60% ofparticipants reached through BCCoutreach events reported beinguninsured by any private, group,or governmental insurance policy.Ethnic and racial minorities in Utahbear disproportionate burdensof health conditions and the BCCpilot was shown to be effectivein reaching individuals fromunderrepresented communities;self-identification of race andethnicity collected from screeningquestionnaires revealed that 87%of responses indicated a non-White,minority background.

10. Household income and family income are not equivalent as multiple families may reside in one household.Bridging Communities and Clinics participants were asked to state family income rather than householdincome.11. US Census Bureau, 2011 American Community Survey.12. Utah Department of Health, 2011 Utah Behavioral Risk Factor Surveillance System; US Census Bureau2011 ACS estimates Utahs uninsured rate at 15.3%.


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Br idg ing Com m un i t ies and Cl in i csEf fec t iveness:

Outcome measures were assessedin terms of scope (how manyscreenings were conducted), followup (how many referrals werecontacted post-screening), and

compliance (how many referrals ledto clinical visits). The initial goal ofproviding 1,000 free screenings wasnot met, although 883 screeningswere provided, yielding an 88%attainment rate. Clinical referralswere offered to 178 participants,and attempts were made tosubsequently follow up with allreferrals via telephone and/or

email within 30 days of screening.Accounting for wrong/disconnectedtelephone numbers, unreturnedvoicemails/personal messages,and unanswered attempts, 63participants (35% of those whoreceived a clinical referral) werereached for follow up. Of thoseparticipants, 34 (56% of contactedreferrals) were reported to havevisited a medical provider in relation

to the screening they receivedthrough the BCC.

Adoption and Implementation:The BCC model was piloted in 24different venues in a variety ofsettings including, a neighborhoodblock party, cultural celebrations,faith-based activities, and screeningbooths on-site at health clinics andethnic supermarkets. The integrity

and working framework of the BCCmodel was consistently maintainedin all venues and settings, withminor adaptations implemented asneeded. Overall, the BCC model wasobserved to operate successfully atall outreach sites and with a varietyof diverse community partners andclinical agencies.

Main tenance :

The BCC pilot has effectivelyestablished a network of communityand faith-based organizations,clinical facilities, medical providers,and civic advocacy groups that

are committed to long-termhealth-related interventions. Thiscollaborative effort was crucial tothe successful implementation ofthe BCC pilot. It is noted that therewas no systematic componentwithin the pilot to monitorparticipants clinical outcomesbeyond the 30-day post-screeningfollow up period. Considerations

for sustainable maintenance ofthe BCC program beyond the pilotstage include recruitment andtraining of highly qualified OutreachTeam interns, sustainable fundingsources, and expansion of the BCCcollaborative network.

Recommendat ions :

Given the demographic background

of the majority of BCC participants,it is strongly recommended thatfuture outreach efforts be closelyintegrated with the Division ofWorkforce Services insuranceeligibility and enrollment personnel.

Community health workers (CHWs,promotoras, etc.) should be utilizedto enhance overall efficiency andeffectiveness of outreach events.

Extending the referral follow-upprotocol (beyond 30 dayspost-screening) will providemore information about theestablishment/utilization of medicalhome services.


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References

Carter-Pokras, O., et al. (2011).Perspectives on Latino lay healthpromoter programs: Maryland2009. American Journal ofPublic Health, 101: 2281-2286doi:10.2105/AJPH.2011.300317

Center for Multicultural Health.(2010). Health status by race andethnicity: 2010. Salt Lake City Utah,UT: Utah Department of Health.

Estabrooks, P., Allen, K. (2012).Updating, employing, and adapting:A commentary on what does

it mean to employ the RE-AIM model. Evaluation and t heHealth Professions, 8 :1-6.doi:10.1177/0163278712460546

Rorie, J., et al. (2011). Usingresident health advocates toimprove public health screeningand follow-up among public housingresidents, Boston, 2007-2008.Preventing Chronic Disease, 8(1):

1-10.http://www.cdc.gov/pcd/issues/2011/jan/09_0103.htm.Accessed February 12, 2012.

Shubert, T., Altpeter, M., Busby-Whitehead, J. (2011). Using theRE-AIM framework to translate aresearch-based falls preventionintervention into a community-

based program: Lessons learned.Journal of Safety Research, 42(6):509-516.

US Census Bureau. (2012). CurrentPopulation Survey, 2012. US CensusBureau.

Utah Department of Health, Centerfor Health Data. (2012, August).Health insurance highlights2011. Utahs Indicator-BasedInformation System for PublicHealth.http://health.utah.gov/opha/publications/2011brfss/Highlights_2011.pdfAccessed December 18, 2012.


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Acknow ledgmen ts and Thanks

Progr am DesignDulce Dez, MPH, MCHES; UDOH Office of Health DisparitiesJacob Fitisemanu, Jr; UDOH Office of Health DisparitiesChristine Espinel; UDOH Office of Health DisparitiesApril Young Bennett, MPA; UDOH Office of Health Disparities

Pro j ect Coord ina t o r , Sum m ary Au thorJacob Fitisemanu, Jr; UDOH Office of Health Disparities

Outr each TeamAmanda Berbert; University of Utah, School of MedicineAdam Bracken; University of Utah, School of MedicineBrynn Dimino; University of Utah, College of NursingEduardo Galindo; University of Utah, Health Promotion & EducationElizabeth Pacheco; University of Utah, School of MedicineKimberly Piteck; Westminster College, School of Nursing

Melissa See, MPA; University of Utah, School of MedicineSamuel Thomas; University of Utah, School of Medicine

Cl in ica l Par tn ers

Sal t Lake Coun tyUtah Partners for Health, Exodus NetworkHealth Clinics of Utah Salt Lake CityIntermountain Lincoln ElementaryIntermountain Rose Park ElementaryIntermountain North Temple

Intermountain Sorenson Center

Utah Coun t yIntermountain Dixon Middle SchoolHealth Clinics of Utah ProvoMountainlands Community Health Center

Sum m i t Coun tyThe Peoples Health Clinic

Weber Coun t y Midtown Health CenterHealth Clinics of Utah Ogden


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Com m un i t y Par tn e rs

Sal t Lake Coun tyLei Aloha o Ka OhanaLincoln Community Learning CenterThe Queen CenterSorenson Unity Center

Community Faces of UtahUnified Vietnamese Buddhist AssociationNational Tongan American SocietyAlliance Community ServicesCalvary Baptist ChurchMidvale City Community Building CommunityHawaiian Cultural CenterSt. Patricks Catholic ChurchRose Park Community CouncilUtah Pacific Islander Interfaith Health Council

MANA Fitness ChallengeBinational Health Week Coalition

Utah Coun t yCentro HispanoCommunity Health ConnectUT Migrant Seasonal Farmworker Coalition

Sum m i t Coun tyHoly Cross Ministries

Weber Coun t yProject SuccessDelta Sigma Theta Sorority

Documents

Bridging Communities and Clinics in Utah 2012