SummaryThe Salud Mobile Outreach Program is designed to reduce health disparities among Mexican immigrants, many of whom are poor, uninsured, and monolingual with limited education, by providing medical and dental care, referrals, and patient education primarily in rural areas of northern Colorado. The program is enhancing access to needed medical care and education in a population that has no other means of accessing such services. Information provided in February 2012 indicates that the program has been expanded to service refugees, asylees, and parolees arriving in the northern Colorado area by becoming their first medical contact in the United States of America. Also as part of the program's expansion for mental health center patients who are in need of medical consultation and do not have a primary care provider, Salud's Mobile Unit offers medical services and serves as bridge to incorporate these patients into a Salud clinic and establish a primary care provider.Suggestive: The evidence consists primarily of post-implementation data on patient volume and program usage, with the underlying assumption being that in the absence of the program those served would not have had access to these services.
Developing OrganizationsSalud Family Health Centers
Administrative offices for Salud Family Health Centers are located in Ft. Lupton, CO.
Date First Implemented2003
Patient PopulationInformation provided in February 2012 indicates that 90 percent of the patient population is Hispanic/Latino-Latina and 10 percent is Black/African American and Asian.Race and Ethnicity > Hispanic/Latino-Latina; Vulnerable Populations > Illiterate/Low-literate; Immigrants; Impoverished; Medically uninsured; Non-English speaking/Limited English proficiency; Racial minorities; Rural populations; Transients/Migrants; Insurance Status > Uninsured
Problem AddressedLack of health insurance, inadequate access to preventive care, and language/cultural barriers are associated with poor health outcomes among Hispanics, especially Mexican immigrants.1,2
- Less access to care: Mexican immigrants are less likely than U.S.-born Mexican Americans and non-Hispanic Whites to access preventive care services, due in large part to a lack of health insurance and access to regular primary care.1 In 2000, nearly one-half (45 percent) of Mexican immigrants between the ages of 18 and 64 years did not have a regular source of primary care, whereas more than one-half (58 percent) did not have health insurance.1
- Immigrant men less likely to seek care: In Colorado, most Mexican immigrants are men, who are less likely than their female counterparts to seek health care. A review of patient data conducted before the mobile unit program began found that most patients who visited Salud clinics were women and children.2
Higher rates of diabetes and associated complications, death:
Hispanics are 1.5 times more likely to be diagnosed with diabetes and to seek initial treatment of end-stage renal disease related to the diabetes.3
Disparities are even greater among Mexican Americans. Nationally, Mexican Americans are two times more likely to have diabetes and 50 percent more likely to die of the disease as compared to non-Hispanic Whites.3
Challenges are particularly acute for those arriving from a refugee camp: Refugees who arrive in this country must undergo a series of physical and medical screenings. However, refugees as well as new arrivals to the United States do not have the knowledge to enable them to seek out the proper medical attention as required by United States Citizenship and Immigration Services (USCIS), a division of the U.S. Department of Homeland Security.
Description of the Innovative ActivityThe Salud Mobile Outreach Program provides medical and dental care, referrals, and patient education to Mexican immigrants through a mobile unit that travels to convenient, often frequented locations, primarily in rural area of northern Colorado. The program aims to reduce health disparities among the target population, many of whom are poor, uninsured, and monolingual with limited education. Key elements of the program include the following:
- Mobile medical unit: The cornerstone of the Salud Mobile Outreach Program is a mobile medical unit, staffed by bilingual and bicultural medical personnel, outreach workers, and volunteers. The unit is dispatched four evenings per week to locations identified as gathering places for immigrants. The unit provides a variety of services to Mexican immigrants who otherwise would have very limited access to care. Information provided in February 2012 indicates that the program has been expanded to serve refugees, asylees and parolees.
- Site preparation: Teams travel to rural communities to scout out times and locations where Mexican immigrants gather (e.g., farms, migrant camps, grocery stores, apartment complexes). The goal is to identify places and times that are most convenient to their schedules, thus increasing the likelihood that they will come to the mobile clinic. Once a promising site is found, the teams approach local authorities to get permission and appropriate approvals to park the mobile medical unit and provide services at specific, agreed-to dates and times. Information provided in February 2012 indicates that the program has also designated prearranged places to meet with the refugees, making it easy for them to adhere to USCIS regulations and complete their medical screenings per United States law.
- Participant recruitment: Once dates and locations are set, Salud outreach workers put up flyers to notify the immigrants in the surrounding rural communities about the mobile outreach program dates, times, and locations. Information provided in February 2012 indicates that the refugee program patients are scheduled in advance in Fort Collins or Fort Morgan, depending on their demographics; case managers are informed of the schedule in advance so they can arrange transportation for patients. Professional interpreters are contacted prior to the visit day to arrange for translation services for patients.
- Medical services: Medical services provided by the mobile outreach program include: (1) screenings for HIV, hypertension, diabetes, anemia, tuberculosis, cholesterol, and cervical cancer; (2) medical consultations; (3) influenza and tetanus vaccinations; (4) dental screenings; (5) prescription and over-the-counter medications; and (6) referrals for followup medical care. The program provides most services free of charge. Patients can receive most screening results immediately, and program staff are available to explain all results thoroughly in Spanish. Information provided in February 2012 indicates that the medical services and laboratory tests performed for new refugees, asylees and parolees arriving in the area include (but are not limited to) the following: complete blood count, chlamydia, hepatitis B and C, lead, ova and parasites, quantiferon, pregnancy test, urine analysis, pap smear, a complete physical exam, immunizations for children and adults, mental screening and mental education, and a vision test. Since the integration of the refugees, asylees and parolees into the program, translation and interpretation services have been incorporated to offer detailed explanation in the patients' native languages. The program takes special care to expedite the medical care of refugees, asylees and parolees, given that USCIS regulations specify a limited time frame during which they can receive government-subsidized medical care; the program works closely with the case coordinators to ensure that all care is provided within the defined time limits.
- Patient education and other related services: The program provides patient education on a variety of health care issues. Literate patients and/or family members can receive written materials in English or Spanish. In addition, patients receive information and resources to help improve their quality of life, including a "survival guide" for individuals who have recently immigrated. Information provided in February 2012 indicates that the program helps refugees, asylees and parolees integrate in to the American health system by helping them establish a primary care provider.
- Clinic followup: Those who need followup care receive referrals to a Salud Family Health Center or another area facility as appropriate. Staff members use Salud's management information system on a monthly basis to determine how many patients seen in the mobile unit are referred elsewhere and can also track how many actually come to a Salud clinic for a followup visit. Information provided in February 2012 indicates that a third party (medical specialist, dental, mental health, and/or health department) act as refugees' liaisons by coordinating their integration into society as well as coordinating translation services as required.
Contact the InnovatorMiriam R. Diaz, IMG
Migrant Health Director
Salud Family Health Centers – Commerce City Clinic
6255 Quebec Parkway
Commerce City, CO 80022
(303) 286-8900, x3655
Innovator DisclosuresDr. Diaz has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsWhile the health outcomes of patients have not been formally evaluated, post-implementation data on use of program services suggest that the program is enhancing access to needed medical care and education in a population that has no other means of accessing such services.
Suggestive: The evidence consists primarily of post-implementation data on patient volume and program usage, with the underlying assumption being that in the absence of the program those served would not have had access to these services.
- Increased access, especially among men: Since 2003, the program has provided 19,590 visits in primarily rural areas. Of those, 15,647 are not repeat patients. Approximately 6,500 individuals who received services had not previously sought medical care from Salud Family Health Centers, which is the largest health care provider for low-income people within a five county region, and in some locations is the only health care provider for this population. In contrast to the patient population at Salud's existing clinics (which is 70 percent women), the majority (54 percent) of the patients seen by the mobile medical clinic are men.
- Facilitating access to needed followup care: All 1,553 patients seen during the first 6 months of the program were referred to a dentist for serious dental problems. In addition, nearly one in five (19.6 percent) screened positive for a psychosocial disorder (e.g., alcohol abuse, depression, eating disorders) and were referred for followup mental health services. Of those who also received a medical consultation for positive screenings or physical ailments, 35.4 percent reported to a Salud clinic for followup care.
Context of the InnovationSalud Family Health Centers is a primary health care delivery system comprised of 14 clinics across northern Colorado. Established in 1970, Salud is a Federally Qualified Migrant and Community Health Center that provides primary health care services to low-income, minority, and migrant worker populations, the majority of whom (65 percent) are Latino whose primary language is Spanish. Prior to the development of the Salud Mobile Outreach Program, the Salud Family Health Centers had owned a mobile medical unit for several years, although the unit was used only during the farming season. In an effort to maximize the existing resources and opportunities to connect with underserved members of the target population, the Medical Services Director prompted the initial needs assessment described below, which was the impetus for the development of the new Salud Mobile Outreach Program.
Planning and Development ProcessKey steps include the following:
- Initial needs assessment: Prior to implementing the program, Salud Family Health Centers assessed the health needs of Mexican immigrants. Through interviews with 154 Mexican immigrants in rural Colorado, program developers collected medical histories and evaluated respondents for mental disorders and health-related quality of life. In addition, Salud surveyed Mexican immigrants throughout the state who were applying for identification cards. The needs identified in these interviews and surveys helped to shape program offerings.
- Training: All previously untrained members of the mobile medical unit team received training in cardiopulmonary resuscitation, Occupational Safety and Health Administration standards and requirements, and administration of all immunizations and screening services offered in the mobile unit.
- Equipping the mobile medical unit: To serve patients, the mobile medical unit was equipped with one examination table, three networked computers with wireless Internet access, one cholesterol testing machine, three glucometers, one urine chemistry analyzer, three blood pressure cuffs, one centrifuge, one microscope, three thermometers, three otoscopes, three ophthalmoscopes, and two hemoglobin monitors. In addition, the unit was stocked with medical supplies necessary to perform procedures such as blood draws, suturing of lacerations, removing foreign bodies from the eye, Pap smears, immunizations, and testing for strep throat, chlamydia, and herpes.
- Program modification based on evaluation: The program asked a select number of patients to fill out surveys providing information about demographics, migration history and utilization of health services. Salud staff used results from these surveys to modify the program to better serve the needs of the target population. Specifically, this evaluation found that more patients were in need of mental health services than previously anticipated, and that mental disorders were more likely to adversely affect the daily lives of Mexican immigrants than were occupational hazards (which represent the focus of many traditional programs serving Mexican immigrants).
- Expansion: Information provided in February 2012 indicates that the Salud Mobile Unit Program was expanded in 2009 to include refugees, asylees and parolees as well as mental health patients, providing a cornerstone for the health and well-being for this population.
Resources Used and Skills Needed
- Staffing: The mobile outreach team typically includes a driver, a physician assistant, a medical assistant, a dental hygienist, two outreach workers trained to conduct medical screenings, and up to three volunteers (e.g., from AmeriCorps and/or the local community). Although physicians, social workers, and registered nurses have served as volunteers, most of the volunteers who are available on a regular basis are premedical students. The majority of mobile outreach team members are bilingual and bicultural, which facilitates communication between service providers and patients, and helps to reduce misunderstandings that could affect quality of care.
- Costs: The 2006 annual operating budget for the program was $145,455, consisting primarily of personnel (84 percent) and travel and fuel costs (10 percent). Other, minor expenses include maintenance and repairs (2 percent), supplies (2 percent), internal equipment (less than 1 percent), and license and operating fees (less than 1 percent). The acquisition cost for the mobile unit and initial set of equipment is not included in these figures.
Funding SourcesNational Center for Farmworker Health; Salud Family Health Centers; Federal 330(e) Migrant Health Center; Colorado Department of Local Affairs; Mexican Consulate (Denver, CO)
Daily operations are funded by Federal 330(e) Migrant Health Center funds (40 percent), Salud Family Health Centers (45 percent), and donations from private sources and foundations. In 2005, the program received a grant from the Colorado Department of Local Affairs to purchase a new, updated mobile medical unit. In 2004, The National Center of Farmworkers' Health provided funding for supplies to administer influenza and tetanus vaccinations. In addition, the program has received some funding in the past 2 years from the Mexican Consulate in Denver to administer vaccinations to Mexican immigrants. Finally, since 2009, Salud Family Health Centers Mobile Unit provides the necessary services to Refugee, Parolees and Asylees arriving to North East Colorado through a contract with the Colorado Department of Public Health and Environment.
Tools and Other Resources
- The Patient Health Questionnaire was used to assess the presence of mental health disorders (e.g., major depression, eating disorders, substance abuse). More information on this instrument is available at http://www.ncbi.nlm.nih.gov/pubmed/10568646.
- The MOS 36-item Short-Form Health Survey (SF-36) was used to measure health-related quality of life. A description of this instrument is available at http://www.ncbi.nlm.nih.gov/pubmed/1593914.
Getting Started with This Innovation
- Conduct an initial needs assessment: Understanding the needs of the target population allows appropriate tailoring of the program to best serve the target population.
- Hire culturally competent staff: To best serve the target population, it is essential to hire culturally competent staff; bilingual and bicultural personnel have contributed to the success of the program.
Sustaining This Innovation
- Actively pursue alternative funding sources: Because public funding can shift with new budget priorities and grant funding is usually time-limited, active pursuit of alternative funding sources, including third-party reimbursement, is essential.
- Build community relationships: The program depends on the cooperation of local agencies and organizations that approve the times and locations for unit operation, thus making it critical to obtain and sustain community support for the program.
- Find a strong organization to support the program: Having an organization with a similar mission and the ability to provide staff, resources, and funding is critical to the ongoing sustainability of this program.
Additional Considerations and Lessons
- Health outreach requires a large initial and ongoing financial investment, including purchase of equipment and the mobile unit. With no external payer source, this program can be quite expensive to operate. However, by providing increased access to health screenings and ongoing care management for difficult-to-reach, high-risk populations, the program reduces the likelihood of acute exacerbations of health problems, thus creating the potential for reduced downstream costs.
Use By Other Organizations
- Valley-Wide Health Systems and Sunrise Community Health Center in Colorado Valley have mobile medical programs that focus on providing services to migrant farm workers during farming season. Representatives from Valley-Wide visited Salud to learn about its mobile unit initiative before setting up the program.
Diaz-Perez Mde J, Farley T, Cabanis CM. A program to improve access to health care among Mexican immigrants in rural Colorado. J Rural Health. 2004;20(3):258-64. [PubMed]
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Service Delivery Innovation Profile
Original publication: January 15, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: May 01, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 13, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.