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Service Delivery Innovation Profile

Culturally Competent Outreach, Services, and Education Improve Access to Insurance, Primary Care, and Immunizations for Hispanic and Portuguese Children


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Snapshot

Summary

Salud Para Niños provides low-cost (and on some occasions free), culturally competent outreach, primary care, insurance assistance, and education to Spanish- and Portuguese-speaking children in southwestern Pennsylvania. The program is designed to reduce health disparities among Latino populations by addressing cultural or linguistic barriers, lack of health insurance, and limited transportation. The program has increased access to health insurance, primary care services, and immunizations and increased compliance with car seat safety standards.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the volume of services provided, including patients served, children connected with health insurance, car safety seat checks conducted, and car seats replaced.
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Developing Organizations

Children's Hospital of Pittsburgh of UPMC (University of Pittsburgh Medical Center)
Pittsburgh, PAend do

Date First Implemented

2002
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Patient Population

Vulnerable Populations > Children; Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Non-english speaking/limited english proficiency; Urban populationsend pp

Problem Addressed

As the Hispanic/Latino population in the United States continues to grow, lack of health insurance, limited English proficiency, and transportation issues are barriers to receiving preventive and routine health care.1-5
  • A growing population: Between 1990 and 2000, the Hispanic/Latino population in the United States grew from 21.9 million to 35.2 million1 and between 2000 and 2010 grew to 50.5 million.2 In southwestern Pennsylvania, the Hispanic population grew by 44 percent from 1990 to 20001 and by 72 percent between 2000 and 2010.2 Approximately one-third of the Hispanic/Latino population in this area are children.3
  • Disproportionate number of uninsured: Approximately one-third of Hispanic/Latino individuals are not covered by health insurance as compared with 10.4 percent of the non-Hispanic White population.4
  • Less access to prevention and routine care: Individuals who are uninsured are less likely to have routine checkups than those with insurance (42.8 vs. 17.8 percent, respectively). Uninsured individuals are also more likely than insured individuals to report that they could not see a physician when needed due to cost (26.8 vs. 8.2 percent, respectively).5
  • Other barriers to care: In addition to lack of insurance, many Hispanic/Latino individuals face language and transportation barriers to accessing health care.3,4 More than three-fourths of the Hispanic/Latino population speak a language other than English at home.1

What They Did

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Description of the Innovative Activity

Salud Para Niños provides low-cost (and on some occasions free), culturally competent outreach, primary care, insurance assistance, and education to Spanish- and Portuguese-speaking children in southwestern Pennsylvania. The program is designed to reduce health disparities among Latino populations by addressing cultural or linguistic barriers, lack of health insurance, and limited transportation. The program includes the following key components:
  • Culturally competent outreach services: Salud Para Niños reaches out to community members by sponsoring and/or attending programs that are of interest or targeted to specific cultural groups. Health care and other health-related services are offered during these events.
    • Safety and wellness programs: To address low seatbelt and car seat usage in the local Hispanic community, Salud Para Niños provides free car seat safety checks twice a year. In partnership with the American Academy of Pediatrics - Pennsylvania Chapter, Pennsylvania Traffic Injury Prevention Project (Pennsylvania TIPP), and the Team Educators for Child Safety (TECHS), certified car seat safety technicians conduct car seat safety inspections for Spanish-speaking or Portuguese-speaking families. Local students from Carnegie Mellon University and the University of Pittsburgh and community volunteers provide translation services during the car seat inspections. The technicians also speak with families about the importance of using seatbelts and proper child restraints in automobiles, as well as the Pennsylvania occupant protection laws. Inadequate or broken car seats are replaced free of charge. Families who attend the car seat checks also have access to free health services provided by the Children's Hospital's Ronald McDonald Care Mobile, which is available at these events. Services focus on preventive and primary care, including well-child visits, acute care medical examinations, and immunizations.
    • Free monthly mobile clinic: A free pediatric clinic is provided on a monthly basis through Children's Hospital Care Mobile, which parks in front of the Salvation Army’s free clinic for adults (a central location on the south side of Pittsburgh that is easily accessible by public transportation). Families do not need to have health insurance or to make appointments to receive services.
    • Multicultural health fairs: Program staff regularly participate in free fairs and other local events related to health promotion and prevention. Since 2002, Salud Para Niños has participated and coorganized the annual health fair, "Al Servicio de la Comunidad" (Serving the Community).
  • Multicultural, multilingual clinic: Salud Para Niños operates a permanent clinic 3 days a week (two mornings and one evening) at the Children's Hospital's primary care center in Oakland, a central location that is easily accessible by public transportation. During clinic hours, the program's multilingual and multicultural medical staff (Spanish, Portuguese, and English) provide well-child and acute care visits; sports and school physicals; immunizations; screenings for lead, vision, and hearing; health education; specialist referrals; and other primary care services. To receive services, families must have insurance and schedule an appointment.
  • Culturally sensitive care: Staff ask patients and their families questions to understand culture-based beliefs that may impact their health or medical care and share their own cultural background and beliefs to show respect and find common ground. For example, some Latino cultures believe that babies are susceptible to evil eye and have infants wear shakiras or plastic bracelets to reduce this susceptibility. Staff show respect for cultural beliefs while raising concerns that such bracelets can pose a choking hazard. Staff work with patients to find common ground such as moving the bracelet from the infants' arm to their ankle. Other examples of culturally sensitive care include adapting items on developmental tests as needed to reduce cultural bias. For example, staff would check with families to see if they have concerns about putting their infant in front of a mirror before assessing an infant's development based on a question related to whether the infant recognizes his or her reflection.
  • Online immunization support: Staff at any clinic facility or event have access to the Pennsylvania Department of Health's online immunization system, thus allowing them to check on any child's immunization status using a wireless laptop, and provide immunizations as needed.
  • Insurance screening and enrollment assistance: Every family that seeks medical services at any program facility or event is screened for health insurance needs. Salud Para Niños partners with a local agency, the Consumer Health Coalition, to help uninsured families apply for health insurance.
  • Bilingual marketing and education: Children's Hospital's pediatric clinic offers health promotion literature in multiple languages. Focus groups were conducted to ensure that translations are meaningful to patients and families from a wide array of countries. For example, the Spanish translation for the term bottle may be pacha, mamila, tetero, or bebiron depending on the family country of origin. Focus groups were used to establish a full range of terms for inclusion in documents such as the Newborn Guide for Families. The clinic also operates a Spanish phone line with recorded announcements about upcoming mobile clinics, health fairs, car seat safety checks, and other events. A bilingual (Spanish and English) medical assistant regularly checks incoming messages left on the line and routes calls to the appropriate staff person to respond. The program also provides bilingual (English and Spanish) books to children 6 months of age and older who come in for medical visits. The books, which are based on the national Reach Out and Read6 model, seek to increase reading skills among children of all ages and to encourage parents to read with their children while improving their own English skills. A wide variety of books are available, including those that reflect the families' home cultures.

Context of the Innovation

Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center is a 260-bed clinical, teaching, and research facility that is one of 20 hospitals operated by the center. Located in the Oakland area of Pittsburgh, Children's Hospital is the only hospital in western Pennsylvania solely dedicated to the care of infants, children, and young adults. The hospital handles more than 500,000 visits per year at its inpatient facility and many neighborhood locations. The development of Salud Para Niños was spearheaded by a pediatric resident at the hospital in response to the dearth of primary care services available for the growing Hispanic population in the Pittsburgh area.

Did It Work?

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Results

Post-implementation data suggest that the program has increased access to health insurance, primary care services, and immunizations and increased compliance with car seat safety standards.
  • Better access to services and insurance: During the first 12 years of operation, Salud Para Niños has served more than 950 children through approximately 1,500 visits per year (updated January 2014). In addition, more than 100 children have been enrolled in health insurance programs. Many of these previously underserved children would have been unable to access these services in the absence of Salud Para Niños. 
  • More immunizations: A chart review of all Salud Para Niños patients showed that influenza immunizations increased by 81 percent between the 2005 to 2006 and 2006 to 2007 flu seasons.
  • More properly installed car seats: Since the program's inception, 492 car seat safety inspections have been conducted, and 224 car seats have been replaced free of charge during 19 Hispanic/Latino car seat inspection events (updated January 2014).

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the volume of services provided, including patients served, children connected with health insurance, car safety seat checks conducted, and car seats replaced.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Concept creation and approval: During his pediatric residency, the program champion approached hospital leadership with a proposal to develop a clinic and other services dedicated to the area's growing Hispanic and Portuguese population as an adjunct to the hospital's existing pediatric clinic services. The idea was approved by hospital leadership.
  • Community outreach: The program champion spoke at many churches and other local community venues to generate awareness and support for the new program.
  • Partnership development: To obtain necessary resources, partnerships with several key groups were established, including the Ronald McDonald House Charities - Children's Hospital Care Mobile; American Academy of Pediatric - Pennsylvania Chapter, TIPP; TECHS; Children's Hospital Primary Care Center; Children's Hospital pediatric residency program (which provided volunteer medical staff); Carnegie Mellon University; and the University of Pittsburgh (which provided student volunteers to serve as translators).
  • Continued enhancement of communication tools: Information provided in November 2011 indicates that the program's newsletter and Web site (www.chp.edu/spanishclinic) are now available in three languages (English, Spanish, and Portuguese). 

Resources Used and Skills Needed

  • Staffing: Several Children's Hospital employees volunteer their time to the program, including three bilingual physicians, three nurses, and a bilingual physician assistant. The free mobile clinic is staffed by up to five physicians and two nurses, some of whom speak Spanish or Portuguese. Partnerships have been established with three local schools of nursing and with a group of dental students to have both nursing and dental students volunteering their time at the free clinic. While nursing students help to obtain vitals and provide faculty supervised nursing care, dental students assess children's dental health, do referrals for treatment, and complete prophylactic fluoride varnish to all children in the program.
  • Costs: Costs are minimal, as the program makes use of volunteers, existing clinic space, and in-kind donations of supplies and equipment.
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Funding Sources

PPG Foundation; Ronald McDonald House Charities; American Academy of Pediatrics - Pennsylvania Chapter; Children's Hospital of Pittsburgh of UPMC (University of Pittsburgh Medical Center)
Support from the American Academy of Pediatrics - Pennsylvania Chapter was due to funding from the Pennsylvania Department of Transportation for TECHS.

Support was also received from community volunteers and community donors.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Know the local community and develop program accordingly: Because this program serves a diverse and growing community, staff must understand the unique cultural characteristics and needs of that community and recognize the importance of delivering comprehensive, culturally sensitive care. For example, members of Pittsburgh's Hispanic community come from countries where seatbelts and car seats are not a legal or cultural norm. Developing initiatives to address this problem, such as the program's car seat safety checks, not only prevents injuries but also provides an opportunity to provide other needed services.
  • Establish community relationships: This program cannot be successfully launched without community support. Lay the groundwork by introducing the program to a range of community groups and then recruit program staff who come from the community.
  • Develop local partnerships: Take advantage of local partners who can provide expertise and resources, such as a local medical institution that can provide volunteer staff, local agencies that can help with insurance screening and enrollment, or existing programs that have car safety seat experts.

Sustaining This Innovation

  • Make services as accessible as possible: Make it easy for families to use the program by offering services at convenient locations and times (e.g., both morning and evening hours).
  • Sustain your volunteer base: Develop and update a roster of volunteers who can be called on as needed. Ensure that potential volunteers are trained in the program so that if medical staff move on to other activities or locations, new volunteers can step in.
  • Expand services slowly over time: Take time to cultivate the program by making use of current resources and capabilities and slowly expanding services over time to meet long-term goals.

More Information

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Contact the Innovator

Diego Chaves-Gnecco, MD, MPH, FAAP
Salud Para Niños Program Director and Founder
Developmental-Behavioral Pediatrician
Assistant Professor
University of Pittsburgh School of Medicine
Children's Hospital of Pittsburgh of UPMC
3420 Fifth Avenue
Children's Hospital Office Building, 1st floor Office 114
Pittsburgh, PA 15213
Office: (412) 692-7832
Fax: (412) 692-8516
E-mail: Diego.Chaves-Gnecco@chp.edu

Innovator Disclosures

Dr. Chaves-Gnecco has not indicated whether he 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.

References/Related Articles

Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center Web site. Salud Para Niños (Health for the Children) Spanish Clinic. Available at: http://www.chp.edu/CHP/spanishclinic
 
Centers for Disease Control and Prevention. Vaccine information statements (list of available languages). Available at: http://www.immunize.org/vis/vis_english.asp

More information may be found at http://www.chp.edu/saludparaninos.

Footnotes

1 Ramirez RR. We the People: Hispanics in the United States. Census 2000 Special Reports. U.S. Department of Commerce, Economic and Statistics Administration, U.S. Census Bureau; Dec 2004.
2 2010 U.S. Census. Available at: http://www.census.gov/2010census/.
3 Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center Web site. Bilingual Clinic at Children's Hospital of Pittsburgh breaks down cultural barriers to health care for Hispanic communities. Available at: http://www.chp.edu/CHP/022205.
4 The Office of Minority Health Web site. U.S. Department of Health and Human Services. Available at: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=54.
5 Ayanian JZ, Weissman JS, Schneider EC, et al. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284(16):2061-9. [PubMed]
6 Reach Out and Read Web site. Available at: http://www.reachoutandread.org.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 16, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 29, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 27, 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.