SummaryThe Culturally Appropriate Resources and Education (more commonly known as CARE) Maternal/Child Health Clinic provides comprehensive, culturally competent prenatal and well-baby care to refugee families at a dedicated site within the Saint Alphonsus Family Maternity Center. Open 1 to 2 days each week and operating out of welcoming space, the clinic offers a precare visit to ease stress and build rapport with the patient, group-based discussion and education, regular examinations based on established protocols, peer health advisers who serve as advocates and educators, real-time interpreters, and incentives to promote healthy behaviors during pregnancy. The program has enhanced access to culturally responsive care, social services, and education; reduced anxiety levels among expectant mothers; and increased attendance at scheduled appointments.Moderate: The evidence consists of pre- and post-implementation comparisons of anxiety among expectant mothers and no-show rates for appointments, along with post-implementation data on the number of patients receiving various types of program services.
Developing OrganizationsSaint Alphonsus Regional Medical Center
Date First Implemented2009
Gender > Female; Vulnerable Populations > Immigrants; Women
Problem AddressedExpectant refugee mothers who have lived in refugee camps, rural communities, and countries with little or no Western medicine face many obstacles to accessing care in the United States. Fear and anxiety associated with unfamiliar medical practices and interactions with medical providers not able to respond to their cultural needs compound these obstacles.
- Many obstacles to care: Expectant refugee mothers face numerous obstacles to accessing care, including transportation difficulties, not understanding the importance of keeping scheduled appointments, lack of insurance coverage and other assistance (often due to a lack of information about how to apply for such programs), and language barriers exacerbated by a lack of interpreters who speak the mother’s preferred language.1
- Fear and anxiety with unfamiliar medical practices: A lack of exposure to Western medical practices, combined with histories of physical and emotional trauma, make many refugee women extremely fearful of physical examinations and anxious about medical screenings and tests that use unfamiliar equipment.1
- Limited provider knowledge of culturally diverse populations: Many medical providers have not had cross-cultural training or exposure to individuals from diverse cultures. As a result, they often remain ill-equipped to address the cultural and emotional needs of expectant refugee mothers. In addition, time constraints during office visits limit their ability to effectively serve refugees.
Description of the Innovative ActivityThe Culturally Appropriate Resources and Education (CARE) Maternal/Child Health Clinic provides comprehensive, culturally competent prenatal and well-baby care to refugee families at a dedicated site within the Saint Alphonsus Family Maternity Center. Open 1 to 2 days each week and operating out of welcoming space, the clinic offers a precare visit to ease stress and build rapport with the patient, group-based discussion and education, regular examinations, peer health advisers who serve as advocates and educators, real-time interpreters, and incentives to promote healthy behaviors during pregnancy. Key elements include the following:
- Warm, welcoming space: To create a safe, welcoming environment, the clinic operates in a separate, dedicated space with examination rooms, a waiting area, and rooms for meetings and classes. The clinic operates 1 to 2 days each week.
- Precare visit to ease stress, build rapport: All new patients have a precare appointment designed to reduce patient stress and build rapport between patient and staff before the first prenatal appointment. During this visit, clinic staff work with the patient to fill out relevant forms, obtain a patient identification badge listing preferred language, verify insurance and Medicaid eligibility (and assist with the application process if necessary), and ensure availability of an appropriate interpreter. Staff also provide the patient with information on transportation and schedule the first prenatal examination. At the end of the visit, the patient watches an educational video about the first prenatal examination.
- Group education and support: During clinic hours each week, expectant mothers participate in discussion groups where they ask questions and discuss concerns. Led by the provider, registered nurse educator or health adviser/educator (see bullet below), the group education consists of three to six language groups. All patients attend these sessions in tandem with the regularly scheduled medical visit, with some also attending on days they do not have a visit scheduled. Some sessions feature a formal presentation followed by a question-and-answer session, while others consist primarily of discussion on topics raised by the women themselves. Sessions address numerous aspects of maternal health, such as medications, childbirth, postpartum depression, and anxiety. The clinic also offers parenting sessions for fathers. If patients have specific concerns that arise during these sessions, they can arrange for a confidential interview with their provider.
- Scheduled examinations based on consistent protocols: Patients receive scheduled examinations according to established protocols. As noted, patients often attend the group education sessions and medical examinations in tandem, typically leaving the group when it is time for their visit and often returning to the group afterward. Physicians from the medical group affiliated with Saint Alphonsus Regional Medical Center provide care in the clinic, supported by nurses, nurse practitioners, physician assistants, and other professional and administrative staff from the Family Center or Women's Health and Federal Way Clinics. (Physicians bill separately for their services through the medical group.)
- Peer health advisers to support, educate patients: Eight trained health advisers from the patient’s own culture of origin are available during clinic hours to help refugee families navigate the local health care system, access available resources, and adjust to new cultural norms. Under contract with the clinic, they also advocate for patients, offer guidance to providers on culturally appropriate care, lead group educational sessions, and provide individual counseling on a variety of topics, including infant nutrition, proper bathing techniques, and parenting skills.
- Real-time interpretation services: The clinic calls on hospital-based interpreters as needed, providing coverage in approximately 15 languages. If necessary, the clinic can access additional interpreters via telephone through an interpreter service.
- An incentive store: Parents obtain "points" from health advisers for demonstrating positive behaviors, such as attending classes, taking their prenatal vitamins, and healthy eating. They can use these points at a small store in the clinic to get free infant items, including blankets and small toys.
Context of the InnovationSaint Alphonsus Regional Medical Center is part of Trinity Health, the third largest Catholic health care system in the United States. The Family Maternity Center has been providing culturally competent prenatal maternity services to refugee patients in Boise, ID for many years. In 2009, with start-up funding supplied by Trinity Health, the Family Maternity Center opened the CARE maternal/child clinic, to provide specialized prenatal and pediatrics care for refugee families. The Saint Alphonsus CARE Clinic was developed in response to a community needs assessment in 2005 in which Saint Alphonsus Medical Group providers, Saint Alphonsus Family Center leaders, Boise Refugee Agency leaders, Idaho Office for Refugees, and other community and refugee leaders came together to list the barriers to health care access for refugee patients. Many expectant mothers had complex medical needs associated with malnutrition, physical violence, and limited access to health care, along with limited English proficiency and little understanding of maternity care in the United States. As a result, they were often fearful of medical exams, required additional time for appointments, and frequently missed appointments. In addition, many Saint Alphonsus Medical Group providers had little exposure and a limited understanding of the cultural backgrounds of the women. Recognizing the imperative to create a culturally competent environment in which these women could receive high-quality medical and educational services, Family Center leaders submitted a proposal to Trinity Call to Care to plan and create the clinic.
ResultsDuring its first full year of operation, the program increased access to culturally responsive care, social services, and education; reduced anxiety levels among expectant mothers; and increased attendance at scheduled appointments.
Moderate: The evidence consists of pre- and post-implementation comparisons of anxiety among expectant mothers and no-show rates for appointments, along with post-implementation data on the number of patients receiving various types of program services.
- Increased access to care, education, and social services: A total of 105 individuals, representing nearly all eligible patients in the service area, received prenatal care at the clinic. In addition, at least 660 parents and caregivers attended classes, receiving 76 hours of instruction. Finally, all eligible patients working with a health adviser enrolled in Medicaid, WIC (Women, Infants, and Children supplemental food program), and/or food stamps. Prior to launch of the program, only about half of refugee clients reported even being aware of Medicaid.
- Reduced anxiety: Before participating in this program, 85 percent of expectant mothers reported anxiety related to examinations. After viewing the clinic's educational video, only 20 percent remained “a little worried.” Anecdotally, providers report that patients now exhibit much less apprehension during appointments.
- Fewer missed appointments: Only 3 percent of patients have failed to show up for scheduled appointments in the first year, well below the 25-percent no-show rate among refugees at the Family Center before implementation. In addition, parents attended 100 percent of recommended well-child examinations and vaccination visits for their infants (birth to 12 months of age).
Planning and Development ProcessKey steps included the following:
- Conducting research: Program developers conducted extensive qualitative program evaluation to gain an understanding of the requirements and challenges in providing culturally competent services. This research included focus groups and interviews with individuals from various refugee groups receiving medical care at Saint Alphonsus, unofficial community leaders (e.g., wise women), religious leaders, medical providers, and resettlement agency staff.
- Obtaining corporate buy-in and funding: Program developers obtained support from the corporate operating officer and director of women and children services at Saint Alphonsus to develop a proposal for Trinity Health requesting funding for the clinic.
- Creating program model: Leaders from the Family Center and Women's Health and Federal Way clinics designed a program model that relied heavily on health advisers and medical interpreters to support patients and their families to provide culturally appropriate care. As part of this effort, they made various decisions designed to maximize the potential for success, including creating a dedicated space for the clinic; limiting clinic hours, in the beginning, to a half-day a week (due to wide fluctuations in the number of expectant refugee mothers); partnering with Women's Health, Maternal Fetal Medicine and Federal Way providers; using Family Center professional educators in the clinic; and contracting for the services of health advisers and interpreters (rather than hiring them).
- Training health care advisers: As natural leaders and mentors, CARE Clinic health advisers are the "wise women" of the refugee communities. Their ability to perform as health advisers often emerged when they received services at the CARE Clinic. Once selected, they receive four 1-hour trainings on cultural competency, professional boundaries, patient confidentiality, safety and other CARE Clinic emergencies, and standard procedures. Weekly meetings/trainings further enhance the health advisers' skill in handling difficult issues, following office procedures, and assisting to develop providers' cultural sensitivity.
Resources Used and Skills Needed
- Staffing: A program manager from the Saint Alphonsus Family Maternity Center devotes 40 percent of her time to direct the program. As noted, other staff include providers in partnership with Saint Alphonsus Women's Health and Federal Way clinics, nurse practitioners, physician assistants, and administrative staff from the Family Center, Women's Health, and Federal Way; health advisers; hospital and telephone-based interpreters; and physicians from the hospital's affiliated group practice.
- Costs: The operating budget for fiscal year 2010 totaled approximately $184,000, excluding approximately $200,000 of in-kind support from Saint Alphonsus to cover compensation for the program manager and administrative staff, space, fundraising efforts, and evaluation activities. As noted, physicians bill separately for their services.
Funding SourcesMarch of Dimes; Trinity Health; Saint Alphonsus Medical Center; Saint Alphonsus Foundation; Sisters of the Holy Cross; Raskob Foundation for Catholic Activities
Getting Started with This Innovation
- Obtain support from community leaders: Support, input, and leadership from each refugee community is essential to develop an effective, culturally responsive program. The developers at Saint Alphonsus made a special effort to obtain the support of women viewed as mentors or wise women within their communities. They also invited male community leaders to open houses to discuss their concerns and hear their suggestions.
- Develop operational budget and fundraising plan: Although hospital systems can likely absorb a good portion of the costs associated with this type of program, developers will need to raise additional funds for full implementation. Saint Alphonsus started its program with a 3-year grant from Trinity Health. Fundraising continues to be an integral part of administrative activities.
Sustaining This Innovation
- Maintain contact with refugee resettlement agencies: As the primary point of contact for new refugees, resettlement staff need to be kept informed of program activities, outcomes, and lessons learned. Sharing this information also may provide insights that can enhance other programs and activities for refugees.
- Remain open to needs of new refugee groups: In spite of similarities across experiences, each refugee group has unique characteristics and needs specific to their culture and experiences. Therefore, program leaders must remain open and responsive to making personal and programmatic adaptations.
- Identify opportunities to collaborate: Look for opportunities to collaborate with other programs serving refugee groups. For example, programs that serve elderly members of the community may want to collaborate on the development of educational classes on nutrition, parenting, and other life skills that support families and help elders adapt to their new environment.
- Continue to pursue funding: As noted, program implementers likely will need to obtain supplemental funding. In addition to private charities, individuals, and in-kind support, consider approaching Federal, state, and local refugee programs as potential funding sources.
- Regularly remind staff to adapt to patient needs: Staff and physicians must recognize their personal biases, be able to view the medical system through the lens of their patients, and be willing to adapt to meet patients’ needs.
References/Related ArticlesA handout about the CARE Maternal/Child Health Program is available at: http://dx.confex.com/dx/10/webprogram/Session1391.html.
1 Widener M, Lipscomb M, Hobbs J, et al. An innovative model of maternity care for refugee populations. A presentation to the Seventh National Conference on Quality Health Care for Culturally Diverse Populations. October 18, 2010. Available at: http://dx.confex.com/dx/10/webprogram/Session1391.html
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Original publication: July 20, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 22, 2012.
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