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Service Delivery Innovation Profile

Bilingual, Culturally Competent Community Health Workers Increase Insurance Enrollment, Access to Care, and Self-Efficacy Among Low-Income Latinos


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Snapshot

Summary

Trained bilingual/bicultural community health workers, known as promotores de salud, help to connect low-income Latino families in Fresno County, CA, to insurance and affordable health care services by delivering personalized education and assistance designed to improve participants' knowledge and attitudes about health insurance, health care access, and preventive services. The program increased health insurance enrollment, use of preventive care services and a usual source of care, and self-efficacy among participants.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of self-reported access and self-efficacy indicators at baseline and 3 months after program initiation.
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Developing Organizations

Central Valley Health Policy Institute, California State University, Fresno; Latino Center for Medical Education and Research, University of California San Francisco, Fresno
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Use By Other Organizations

According to information provided in September 2011, program leaders recently worked with the Tulare County Workforce Investment Board to adapt the training program for use as a community college training and certificate program for community health workers. Clinica Sierra Vista, a nonprofit health care corporation, also uses an adapted form of the training program to instruct patient navigators.

Date First Implemented

2007
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Patient Population

Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Immigrants; Impoverished; Medically uninsured; Non-english speaking/limited english proficiencyend pp

Problem Addressed

Latinos have a higher risk of developing and dying from many chronic diseases and are less likely to have health insurance or a usual source of care than are members of other racial or ethnic groups. This disparity is especially profound in California's San Joaquin Valley, where the proportion of Latinos (40 percent) is higher than in California as a whole.

  • Higher risk: Latinos suffer from a disproportionate risk of many chronic diseases. In 2005, Latino adults were twice as likely as non-Hispanic white adults to be diagnosed with—and 1.6 times as likely to die from—diabetes. Similarly, Latino men and women are twice as likely to have and die from liver cancer, while Latino women are twice as likely to have cervical cancer.1
  • Less likely to be insured: Latinos are less likely to have health insurance than any other racial or ethnic group, with 32.1 percent being uninsured in 2007 (compared to 10.4 percent of non-Hispanic whites and 15.3 percent of the overall population).2 In California's San Joaquin Valley, more than twice as many nonelderly Latino adults reported having no health insurance in 2005 than did white nonelderly adults.3
  • Less access to care: Lack of insurance, combined with other barriers such as cultural and language differences, make it difficult for Latinos to access medical care. In the San Joaquin Valley in 2005, a higher percentage of nonelderly Latino adults (24 percent) reported having no usual source of care than did members of any other racial or ethnic group.3

What They Did

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Description of the Innovative Activity

The Central Valley Health Policy Institute trained bilingual, bicultural community health workers, known as promotores de salud, to connect low-income Latino families in Fresno County, CA, to affordable health care services. Promotores delivered personalized education and assistance designed to improve participants' knowledge and attitudes with respect to health insurance, health care access, and preventive service use. Key elements of the program included the following:
  • Recruiting promotores: The project coordinator recruited 17 promotores from six local health and social service organizations: Reading & Beyond, California Health Collaborative, Centro Binacional para el Desarrollo de Indigena Oaxaqueno, Centro La Familia, Companeras en Salud, and Fresno Metro Ministry. All promotores were bilingual and bicultural, had existing relationships with low-income Latino communities, and had experience working in a health advocate role.
  • Training promotores: Two faculty members from the California State University, Fresno, Department of Public Health delivered 16 hours of initial classroom training to promotores. The training provided background information on the health care system, health insurance basics, common barriers to accessing care, and motivational interviewing techniques. In addition to the didactic training, promotores also received 8 hours of small group and individual followup training.
  • Recruiting participants: Each promotora was responsible for recruiting 20 adult and elder participants for the program. Participants were Latino/Hispanic residents of Fresno County older than 18 years with incomes below 250 percent of the Federal poverty level. Both U.S. citizens and undocumented individuals were invited to participate.
  • Culturally competent services: Over the course of a 3-month period, promotores spent from 5 to 10 hours with each participant assigned to them. Most promotores maintained a client load of approximately 20 clients. Services provided included the following:
    • Preassessment: Promotores completed an indepth preassessment interview with each participant, using a survey tool developed for the project. During the interview, promotores gathered information on objective measures (including demographics, insurance status, current use of preventive, primary, and other services) and attitudinal measures (self-efficacy in solving health care problems, experiences of prejudice in seeking health care). Each participant received a $25 gift card incentive after completing the interview.
    • Health care access plan: Using the information gathered during the preassessment, promotores helped each participant develop an individualized health care access plan to address their needs for insurance enrollment, primary care access, and preventive services.
    • Ongoing assistance: Promotores provided ongoing assistance to each participant in carrying out the plan, including helping them to complete health insurance applications, scheduling and providing transportation to medical appointments, making referrals to appropriate health and social service agencies, and providing advice and information on how to navigate the health care system.
    • Followup and postassessment: Promotores conducted several followup calls and/or visits to each participant to provide encouragement and motivation for completing the tasks in the health care access plan. Three months after the initial interview, promotores delivered a postassessment survey to each participant that assessed the following: whether they secured insurance, use of health care services, achievement of preventive health goals, self-efficacy, and unique experiences in implementing the individualized plan. Participants received a second $25 gift card incentive after completing this survey.

Context of the Innovation

The Central Valley Health Policy Institute was established in 2002 at California State University, Fresno, to facilitate regional research, leadership training, and graduate education programs to address emerging health policy issues that influence the health status of people living in Central California. Researchers at the Institute had observed persistent disparities in health care utilization and access to care among Latinos in the San Joaquin Valley and became interested in developing a study to explore the role of promotores in addressing these disparities. Although the Institute had previously examined the use of promotores to assist breast cancer patients in navigating care and improving health behaviors, no systematic exploration had been conducted to determine their value as promoters of health care access.

Did It Work?

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Results

Comparisons of data from surveys administered to 313 documented U.S. citizen participants at baseline and 3 months after the intervention began found that the program increased health insurance enrollment, use of preventive services and a usual source of care, and self-efficacy. Data from surveys administered to undocumented participants are forthcoming.
  • Enhanced access to insurance: The percentage of participants enrolled in health insurance plans increased from 55 percent at baseline to 80 percent at followup.
  • Enhanced access to care: Ninety-two percent of participants reported having a usual source of care at followup, compared to 62 percent at baseline. The percentage of participants receiving a physical increased from 35 percent at baseline to 65 percent at followup.
  • Increased self-efficacy: The average level of self-efficacy reported by participants improved from 2.187 at baseline to 3.239 at followup, with rankings based on a scale of 0 (indicating low efficacy) to 5 (indicating high efficacy).

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of self-reported access and self-efficacy indicators at baseline and 3 months after program initiation.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Obtaining initial funding: Project developers at the Central Valley Health Policy Institute worked closely with the Latino Center for Medical Education and Research at the University of California San Francisco, Fresno, to submit an initial study proposal to the Centers for Medicare and Medicaid Services for funding.
  • Establishing relationships with local health and social service agencies: The project coordinator held meetings with key leaders at six local health and social services agencies to explain the project and solicit participation. As a result of these meetings, each agency agreed to allow one or more staff members to serve as promotores.
  • Developing community health resource guide: The project coordinator created a comprehensive community health resource guide to be used by the promotores; the guide lists insurance enrollment agencies, clinics, and transportation services. For each resource listed, the project coordinator identified one or more Spanish-speaking staff members to serve as the point of contact for promotores.
  • Developing and pilot-testing data collection forms: Project developers created pre- and postassessment survey tools and pilot tested them with a group of promotores who provided feedback on content and cultural appropriateness.
  • Adding second phase to study: The scope of the initial study allowed researchers to study only participants who were documented U.S. citizens. Researchers obtained additional funding in the study's second year to add and evaluate 100 undocumented participants.

Resources Used and Skills Needed

  • Staffing: The project employed 1 full-time project coordinator and 17 part-time promotores. Promotores received a fixed amount of compensation per participant recruited and served. In addition, staff members from the Central Valley Health Policy Institute and the Latino Center for Medical Education and Research contributed time to the project as part of their regular job responsibilities.
  • Costs: The project cost approximately $200,000, including $175,000 for the initial study and $25,000 for the addition of 100 undocumented participants.
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Funding Sources

California Endowment; Centers for Medicare and Medicaid Services Hispanic Health Services Grant Program; Kaiser Permanente Fresno
The Centers for Medicare and Medicaid Services provided core funding for the project through a $175,000 grant, with Kaiser Permanente providing an additional $25,000 to include undocumented participants. The California Endowment provided supplemental funds.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Choose a project coordinator who knows the community: The success of a promotora-based intervention depends on hiring a bilingual, bicultural project coordinator with established relationships within the target community. Promotores and partnering community agencies must be able to trust and communicate with the project coordinator.
  • Recruit experienced promotores: Hiring promotores who are already working as health advocates in the community can reduce the learning curve and provide a foundation for establishing relationships with potential participants.

Sustaining This Innovation

  • Provide ongoing support for promotores: The work of a promotora can be difficult and emotionally taxing. Ongoing guidance and supervision from the project coordinator is necessary to ensure that promotores feel supported and encouraged.
  • Emphasize importance of data collection: To prevent a disconnect between the service and data collection roles of promotores, project staff must devote adequate resources to training and ongoing supervision of data collection activities.
  • Advocate for policy change to establish long-term funding: Until there are state and national policies that recognize the need for community health workers for those with health care access limitations, projects utilizing promotores will need to rely on philanthropic funding to maintain services.

Use By Other Organizations

According to information provided in September 2011, program leaders recently worked with the Tulare County Workforce Investment Board to adapt the training program for use as a community college training and certificate program for community health workers. Clinica Sierra Vista, a nonprofit health care corporation, also uses an adapted form of the training program to instruct patient navigators.

More Information

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Contact the Innovator

John A. Capitman, PhD
Executive Director
Central Valley Health Policy Institute
1625 East Shaw Avenue, Suite 146
Fresno, CA 93710-8106
Phone: (559) 228-2157
Fax: (559) 228-2168
E-mail: jcapitman@csufresno.edu

Alicia Gonzalez, MPH
Evaluation & Learning Specialist
Fresno Building Healthy Communities
4949 E. Kings Canyon Road
Fresno, CA 93727-3812
Phone: (559) 244-5710 x 633
Fax: (559) 228-8159
E-mail: agonzalez@unitedwayfresno.org

Innovator Disclosures

Ms. Gonzalez reported having no financial interests or business/professional affiliations relevant to the work described in the profile, while Dr. Capitman has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in the profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

More information on the project, including promotora training manuals, is available on the Central Valley Health Policy Institute's Web site: http://www.fresnostate.edu/chhs/cvhpi/.

Footnotes

1 United States Department of Health and Human Services, Office of Minority Health. Hispanic/Latino Profile [Web page]. 2009. Available at: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=54
2 United States Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2007. Current Population Reports, P60-235. Washington, DC: U.S. Government Printing Office; 2008. Available at: http://www.census.gov/prod/2008pubs/p60-235.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
3 Bengiamin M, Capitman JA, Chang X. Healthy people 2010: a 2007 profile of health status in the San Joaquin Valley. Fresno, CA: California State University, Fresno; 2008.
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Original publication: September 02, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 18, 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.