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Service Delivery Innovation Profile

Health Center Combining Traditional and Western Medicine Enhances Access to Care, Improves Health Outcomes for Southeast Asian Immigrants


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Summary

With a design that reflects Cambodian culture, the Metta Health Center combines traditional Southeast Asian and Western medicine, offering primary care and behavioral health services along with massage, meditation, and acupuncture to a large, local population of Southeast Asian immigrants. Since its founding in 2000, the center has enhanced access to care, increased the setting of self-management goals among patients with chronic conditions, improved outcomes related to mental health and diabetes, and generated high levels of patient satisfaction.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the number of Southeast Asian immigrants served by the Lowell Community Health Center, the number of patients with select chronic conditions who have set self-management goals, and key outcomes related to mental health and diabetes.
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Developing Organizations

Lowell Community Health Center
Lowell, MAend do

Date First Implemented

2000
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Patient Population

Race and Ethnicity > Asian; Vulnerable Populations > Immigrantsend pp

Problem Addressed

The failure to offer culturally sensitive services reduces the quality of care and can create barriers to accessing care, particularly among patient populations, such as Southeast Asian immigrants, that tend to believe in traditional medicine. Programs that combine traditional and Western medicine can increase access to care, yet few exist.
  • Lower quality, reduced access: Minorities frequently receive a lower standard of care than whites, even when income, insurance status, age, and severity of conditions are comparable. Key factors contributing to these disparities include cultural and linguistic barriers within the health care system; greater clinical uncertainty among providers when interacting with minority patients; and beliefs or stereotypes held by providers about the health or behavior of minorities.1 The failure to cater to cultural sensitivities leads some minority patients to resist seeking care in a timely fashion. For example, most Southeast Asian immigrants living in Lowell, MA, did not seek care from the local Federally Qualified Health Center due to language barriers and lack of comfort with Western medicine, even though many of them faced significant physical and psychological health issues (including a high incidence of posttraumatic stress disorder and depression as a result of torture by the Khmer Rouge). Rather than seeking preventive and primary care, most of these immigrants chose to wait until they experienced a significant illness, at which time they sought care in the emergency department.2
  • Unrealized potential of traditional medicine: Most immigrant populations, including many Southeast Asian immigrants, are more comfortable with traditional medicine than with Western medicine. For example, a study of Hmong immigrant experiences in the U.S. health care system found that differences between Hmong traditional beliefs, including shamanism, and Western biomedical beliefs have created a lack of understanding between Hmong patients and Western providers, and that negative experiences with the Western health care system have caused mistrust and fear of Western medicine in the Hmong community.3 Yet, very few health centers catering to immigrant populations have integrated traditional and Western practitioners. In fact, Metta Health Center represents one of very few "East meets West" health centers in the United States; during pre-implementation research efforts, Metta staff identified only one program (for Native Americans) that integrated traditional cultural beliefs and Western medicine.2

What They Did

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Description of the Innovative Activity

With a design that reflects Cambodian culture, the Metta Health Center ("metta" means "love," "compassion," and "kindness" in the Buddhist Pali language) combines traditional Southeast Asian and Western medicine, offering primary and behavioral health services along with massage, meditation, and acupuncture to Southeast Asian immigrants. Key elements of the center include the following:
  • Bilingual, culturally sensitive staff: The vast majority of employees are bilingual (including all those who staff the front desk and/or answer phones), with many being Cambodian. An elderly bilingual volunteer from the Cambodian community greets patients in a traditional way as they enter the center. Those few staff who speak English as their primary language have taken Cambodian language classes, and many nurses have also received formal training as interpreters. When needed (e.g., during the care of Vietnamese patients and a small number of Burmese refugees), the center uses a pool of on-call interpreters or a telephone interpretation service. When English medical terms do not have a corresponding word in the patient's native language, bilingual staff try to explain the meaning to patients as thoroughly as possible. To ensure that staff remain culturally sensitive and enthusiastic, they take part in regular professional development days and wellness clinics and have the opportunity to participate in yoga and dance classes and to receive massage therapy, acupuncture, and other services.
  • Southeast Asian design: The facility looks like a traditional Cambodian health center, with all design elements, including light fixtures, artwork, paddle fans, and furnishings, reflecting Southeast Asian culture. A television shows pictures of Cambodian scenery, making patients feel at home. All signs are written in English, Cambodian, and Laotian.
  • Regular community outreach: The center regularly markets its services to the Southeast Asian community via radio and television programs featuring the program director and through other outreach activities such as health screenings and flu shot clinics.
  • Culturally sensitive Western medicine services: These services include primary care, behavioral health services (for those aged 18 years and older), and nutrition counseling. Primary care and mental health patients sit together in one waiting room to reduce the stigma associated with seeking mental health care, which can be significant in the Cambodian community. Bilingual nurses and medical assistants first bring patients to the examination room to take their vital signs. A bilingual physician then conducts the examination and talks to patients about their physical and mental health needs and about the Western and traditional services offered at the center. When necessary, the center refers patients to specialists who are also culturally sensitive to the Cambodian population. If inpatient care is required, center staff contact the hospital to ensure that interpreters will be available for the patient.
  • Traditional medicine services: The center offers a variety of traditional Southeast Asian healing services, as outlined below:
    • Meditation and related services: A Buddhist monk conducts 2-hour meditation services at the center every Sunday morning. The monk also leads periodic educational sessions (e.g., teaching youth about meditation), traditional healing rituals, and ceremonies and engages in counseling and other discussions with individual patients.
    • Acupuncture and massage: Patients can receive onsite services from a traditional acupuncture practitioner and a message therapist.
    • Counseling for torture survivors: Three specially trained mental health service providers offer counseling to victims of torture. Patients have received torture-related counseling assistance to date.
    • Holiday celebrations: The center hosts traditional holiday celebrations (e.g., for the Cambodian New Year) for the local Southeast Asian immigrant community.
  • Assistance in securing insurance: For patients who lack insurance coverage, staff assist in determining their eligibility for various public programs and in completing the application process for those programs for which they qualify.

Context of the Innovation

The Lowell Community Health Center is a Federally Qualified Health Center located in Lowell, MA, a city with approximately 105,000 residents. The health center provides a range of primary care, behavioral health, women's health, pediatric, and adolescent health services. Due to a heavy influx of immigrants during the 1980s, residents of Southeast Asian descent make up roughly one-third of the area's population, which includes approximately 25,000 Cambodians (giving Lowell the second largest Cambodian population in the country after Long Beach, CA), 4,000 Laotians, and 1,000 Vietnamese. The impetus for building the Metta Health Center came from Lowell Community Health Center staff, who noted that relatively few Southeast Asians came to the center for care, due in large part to the numerous language and cultural barriers outlined earlier.

Did It Work?

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Results

Since its founding in 2000, the center has enhanced access to care for Southeast Asians, increased the setting of self-management goals among patients with chronic conditions, improved outcomes related to mental health and diabetes, and generated high levels of patient satisfaction.
  • Better access to care: The number of Southeast Asian patients receiving care at the Lowell Community Health Center increased from approximately 300 annually before the Metta Center was built to approximately 2,100 in 2009. Much of this increase is likely due to creation of the new center, which reduced many of the aforementioned barriers to care facing Southeast Asian immigrants in the area.
  • Increase in setting of self-management goals: The percentage of patients with depression who have set self-management goals and had these goals documented in their medical records increased from less than 30 percent of patients to nearly 60 percent of patients. Corresponding figures for those with diabetes increased from 0 to 31 percent over the same time period.
  • Better outcomes in mental health and diabetes: For patients with depression, scores on the Hopkins Symptom Checklist Depression Scale (scale of 1 to 4) fell from 3.1 at baseline (initial measurement) to 2.4 after 6 months, and then dropped further to 2.1 after 12 months. For patients who are victims of trauma, average trauma scores as measured by the Harvard Trauma Questionnaire Posttraumatic Stress Disorder Scale (scale of 1 to 4) dropped from 3.2 at baseline to 2.6 after 6 months, and then fell further to 2.1 after 12 months. For those patients with diabetes, Cambodian nurse case management coupled with nutritional assessment and intervention helped improve HbA1c levels for some Southeast Asian patients.
  • High levels of patient satisfaction: Anecdotal feedback suggests that patients have fully embraced the health center. Many in the community refer to it as "our clinic," and some arrive for appointments several hours early (or come when they do not have an appointment) so that they can socialize with other members of the community in the waiting room.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of the number of Southeast Asian immigrants served by the Lowell Community Health Center, the number of patients with select chronic conditions who have set self-management goals, and key outcomes related to mental health and diabetes.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Securing funding: The Lowell Community Health Center, under its Federally Qualified Health Center 330 grant (i.e., funding provided for such centers under Section 330 of the Public Health Service Act), applied for and received additional funding to launch a new site.
  • Determining community needs: The Lowell Community Health Center chief executive officer (who had worked with Cambodian refugees across the state before joining the health center) and other center leaders talked with experts around the country to determine the health and psychosocial needs of Southeast Asian immigrants. They also held local focus groups and spoke with community health and human services workers and Buddhist monks to identify needed services.
  • Developing the center: The aforementioned leaders identified and examined a model that integrated Western-trained primary care and mental health care professionals with traditional healers. They then sought input from a Buddhist monk in the community who provided feedback regarding center development. (This individual continues to provide supervision, input, and advice regarding center operations.) The chief executive officer and two staff traveled to Cambodia to tour health clinics and purchase artwork for the new center, which was created by renovating an existing building in the community.
  • Recruiting staff: Leaders hired a program director for the new center, and this individual took responsibility for hiring other Metta Health Center staff. Bilingual and bicultural staff came from within the community and from other areas with large Southeast Asian populations (e.g., Long Beach and San Francisco, CA; Tacoma, WA; and Philadelphia, PA).
  • Training staff: The health center contracted with Boston University School of Social Work to train all staff about management of psychosocial issues through a series of 13 classes that covered a variety of topics, including domestic violence, substance abuse, working with interpreters, and other issues commonly facing this patient population. Some staff also received training from the Cross Cultural Health Program in Seattle, WA. Mental health providers periodically receive additional training related to torture at the Center for Victims of Torture in St. Paul, MN.

Resources Used and Skills Needed

  • Staffing: The Metta Health Center employs 28 individuals; key staff include the program director, 2 full-time and 1 part-time medical providers (physicians and nurse practitioners), 3 registered nurses, 1 nurse coordinator, 1 part-time massage therapist, 1 part-time acupuncturist, 3 mental health specialists, and 1 administrative coordinator. All staff are either Cambodian or have achieved proficiency in Southeast Asian cultural practices; most staff are also bilingual, speaking Khmer or Laotian as well as English. Traditional medicine services are provided on a part-time basis onsite by qualified members of the community. Depending on patient need, patients may be referred to traditional medicine service providers who are not on staff at the center.
  • Costs: Data on program costs are unavailable; the largest ongoing expense consists of salary and benefits for staff, whereas the largest upfront cost involved renovating the existing building to create the new center.
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Funding Sources

U.S. Public Health Service; United Nations
The Lowell Community Health Center received an initial 1-year grant through its Federally Qualified Health Center 330 grant to develop the Metta Health Center; Lowell continues to receive yearly stipends to support Metta under this same 330 grant. In addition, the United Nations provided a grant to allow Metta to provide mental health services to victims of torture, and Metta receives ongoing funding from third-party payers that reimburse the center for services provided to insured patients.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Secure leadership support: Leaders help to shape an organization's culture and hence must be fully supportive of the program. These leaders should seek to foster a family atmosphere so that the program becomes viewed by the target population as a community asset rather than just a health clinic.
  • Collaborate with community leaders: Health center administrators and providers should seek input on the center's design and services from heads of community organizations, city officials, university faculty, and informal leaders within the community.
  • Recruit mission-oriented, culturally sensitive staff: When possible, hire staff from the same culture as the population to be served. Recruit individuals who are empathetic with the population and mindful of and committed to the organization's mission, which often extends beyond the regular 9-to-5 workday. For example, some Metta staff previously lived in refugee camps in Cambodia and personally experienced the devastation perpetrated by the Khmer Rouge. Patients recognize the sincerity of these individuals and often feel a special connection with them.

Sustaining This Innovation

  • Continually seek input from community: Engaging community leaders in ongoing program operations enhances the comfort level of patients and helps make them think of the center as "their" clinic.

More Information

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Contact the Innovator

Mr. Sonith Peou
Program Director, Metta Health Center
Lowell Community Health Center
135 Jackson Street
Lowell, MA 01852
Phone: (978) 322-8755
E-mail: SonithPE@lchealth.org

Diane Trowbridge, RN

Chief, Clinical Operations
Lowell Community Health Center
161 Jackson Street
Lowell, MA 01852
Phone: (978) 322-8532
Fax: (978) 746-3089
E-mail: dianetr@lchealth.org

Innovator Disclosures

Mr. Peou and Ms. Trowbridge have not indicated whether they have 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

More information about Metta Health Center is available at http://www.lchealth.org/Metta.shtml.

RWJF selects Sonith Peou to receive Community Health Leaders Award. The Medical News. October 2009. Available at: http://www.news-medical.net/news/20091008/RWJF-selects-Sonith-Peou-to-receive-Community-Health-Leaders-Award.aspx.

Footnotes

1 Institute of Medicine Web site. Unequal treatment: what healthcare providers need to know about racial and ethnic disparities in healthcare. 2002. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2003/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care
/Disparitieshcproviders8pgFINAL.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Interview with program developers, February 5, 2010.
3 Johnson SK. Hmong health beliefs and experiences in the Western health care system. J Transcult Nurs. 2002;13(2):126-32. [PubMed]
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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: April 28, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 21, 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.