1. Initiating and Sustaining an International Health Clinic AAFP Global Health Conference September 7, 2012 Sandhya Tagaram, MD, PGY2, Stephanie Youd, MD, MPH, & Bruce Kenney, DO, Central Maine Medical Center Family Medicine Residency

3. US census – 2010 Demographic Profile White - 98.4%(1,264,971) Black or African American - 1.2%(15,707) Asians – 0.9%

4. Our City Lewiston total population: 36,592 Whites - 86.6%, Black: 10.9% (the majority of whom are Somali refugees) Asians - 1% Other races- 2.6% Hispanics -2%.

5. What is a refugee? The U.S. Citizenship and Immigration Services defines a refugee as "a person who has fled his or her country of origin because of past persecution or a well-founded fear of persecution based upon race, religion, nationality, political opinion, or a membership in a particular social group.”

6. History of Somali Refugees 1800s -1990 - Somalia gained independence in 1960. Siyad Barre takes over Somalia's government in a coup.

7. History of Somali Refugees (Cont) 1991 - 2001 - Siyad Barre's government falls. Civil war engulfs the country. Militias attack sedentary farmers for labor and food. Thousands flee to refugee camps in Kenya. The US agrees to grant Somali Bantus persecuted minority status and resettle 12,000 in the US. Since 2003, the Somali Bantu refugees began arriving to US. In 2005,the Somali Bantu refugees begin secondary resettlement in Maine

8. . Challenges: -Adjustment issues -The horrors of the refugee camps, -The fast pace of the large American cities in which were initially resettled. Refugees voluntary agencies assisted the refugees with their initial needs during their first three months in the United States.

9. “But if you're asking my opinion, I would argue that a social justice approach should be central to medicine and utilized to be central to public health. This could be very simple: the well should take care of the sick.” -Paul Farmer

10. Goals and Objectives Provide culturally competent care for newly arrived immigrants, including, but not limited to screening for communicable diseases found in developing countries, providing immunizations. To train residents in providing culturally competent care to people from other cultures, and to educate them on the healthcare problems associated with refugees. Create a patient centered medical home specifically designed to meet the needs of newly immigrated populations. Work with other community organizations to meet the needs of the refugees beyond providing primary health care: work programs, mental health issues.

11. High-need Individual PCMH Practice Maine PCMH Pilot Community Care Teams Transportation Workplace Environment Food Systems Shopping Income Heat Faith Community Literacy Coaching Physical Therapy Hospital Services Specialists Outpatient Services Medication Mgt Housing Care Mgt Behavioral Health & SA Family Schools

12. Cultural Competence Respectful care that meets the cultural health beliefs and practices in a preferred language. Diverse staff Ongoing training Interpreters Signage in preferred languages Know your area/Know your patients Use community resources Outreach

14. Common Presenting Health Problems and Conditions Among Refugee Patients Mental health Undiagnosed chronic conditions Pain conditions

15. Mental Health Adjustment disorder Depression/anxiety Post-traumatic stress disorder Social isolation

16. Undiagnosed chronic conditions  Anemia  Asthma  Chronic obstructive pulmonary disease  Diabetes mellitus  Dyslipidemia  Hypertension  Vitamin D deficiency

17. Pain Conditions Abdominal pain Back pain Pelvic pain Headache Neck pain

18. “I alone cannot change the world, but I can cast a stone across the waters to create many ripples.” -Mother Theresa

19. Organizing an International Med Clinic in a FM Residency 1.Organize a team: a. Identify nursing, front desk, social worker, MH practitioner, resident(s) and faculty-clinician(s) “champions”. b. Enlist a committed clinical director. c. Training of all residency & clinic staff. d. Schedule regular team meetings.

20. Organizing an International Med Clinic in a FM Residency (Cont) 2.Informative and clinical materials in minority languages in clinic 3.Lists of community minority resources 4.Outside lines for translator phone lines

21. “It takes a village…” 5.Advisory board a.Immigrant heath care consumers b.Minority community leaders c.Clinic employee or champion d.Resident e.Faculty

22. New Immigrant Examination Requirements Tuberculosis screening Routine labs History Physical examination HIV testing Intestinal parasites

23. Requirements (Cont) Lead levels Malaria Nutrition STIs Viral hepatits

25. References Eckstein, B. (2011). Primary Care for Refugees. Am Fam Physician, 83(4):429-436.Eckstein, B. (2011). Primary Care for Refugees. Am Fam Physician, 83(4):429-436. Reavy, K., Hobbs, J., Hereford, M. & Crosby, K. (2012). A new clinic model for refugee health care: adaptation of cultural safety. Rural and Remote Health 12: 1826.Reavy, K., Hobbs, J., Hereford, M. & Crosby, K. (2012). A new clinic model for refugee health care: adaptation of cultural safety. Rural and Remote Health 12: 1826. The Somali-Bantu Experience: From East Africa to Maine. (2012). Retrieved August 2012 from: https://wiki.colby.edu/display/AY298B/HomeThe Somali-Bantu Experience: From East Africa to Maine. (2012). Retrieved August 2012 from: https://wiki.colby.edu/display/AY298B/Home United States Census Bureau. (2010). The Foreign-Born Population in the United States: 2010. Washington, DC: Author. Retrieved from: http://www.census.gov/prod/2012pubs/acs-19.pdf.United States Census Bureau. (2010). The Foreign-Born Population in the United States: 2010. Washington, DC: Author. Retrieved from: http://www.census.gov/prod/2012pubs/acs-19.pdf. U.S. Department of Health & Human Services. (2001). National Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC: Author. Retrieved from: http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf.U.S. Department of Health & Human Services. (2001). National Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC: Author. Retrieved from: http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. U.S. Department of Health & Human Services. (2012). General Refugee Health Guidelines. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/general-guidelines.html.U.S. Department of Health & Human Services. (2012). General Refugee Health Guidelines. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/general-guidelines.html. U.S. Department of Health & Human Services. (2012). Guidelines and Discussion of the History and Physical Examination.. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/guidelines-history-physical.pdfU.S. Department of Health & Human Services. (2012). Guidelines and Discussion of the History and Physical Examination.. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/guidelines-history-physical.pdf U.S. Department of Health & Human Services. (2012). Guidelines for Evaluation of the Nutritional Status and Growth in Refugee Children during the Domestic Medical Examination.. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition- growth.htmlU.S. Department of Health & Human Services. (2012). Guidelines for Evaluation of the Nutritional Status and Growth in Refugee Children during the Domestic Medical Examination.. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition- growth.htmlhttp://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition- growth.htmlhttp://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/nutrition- growth.html

26. References (Cont) U.S. Department of Health & Human Services. (2012). Guidelines for Mental Health Screening During the Domestic Medical Examination for Newly Arrived Refugees. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/mental-health-screening- guidelines.htmlU.S. Department of Health & Human Services. (2012). Guidelines for Mental Health Screening During the Domestic Medical Examination for Newly Arrived Refugees. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/mental-health-screening- guidelines.html http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/mental-health-screening- guidelines.html http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/mental-health-screening- guidelines.html U.S. Department of Health & Human Services. (2012). Guidelines for Screening for Tuberculosis Infection and Disease During the Domestic Medical Examination for Newly Arrived Refugees. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/tuberculosis- guidelines.htmlU.S. Department of Health & Human Services. (2012). Guidelines for Screening for Tuberculosis Infection and Disease During the Domestic Medical Examination for Newly Arrived Refugees. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/tuberculosis- guidelines.html U.S. Department of Health & Human Services. (2012). Lead Screening during the Domestic Medical Examination for Newly Arrived Refugees.. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/lead.pdf.U.S. Department of Health & Human Services. (2012). Lead Screening during the Domestic Medical Examination for Newly Arrived Refugees.. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/lead.pdf. U.S. Department of Health & Human Services. (2012). Intestinal Parasites Guidelines for Domestic Medical Examination for Newly Arrived Refugees.. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/intestinal-parasites-domestic.pdfU.S. Department of Health & Human Services. (2012). Intestinal Parasites Guidelines for Domestic Medical Examination for Newly Arrived Refugees.. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/intestinal-parasites-domestic.pdf U.S. Department of Health & Human Services. (2012). Screening for HIV Infection during the Domestic Refugee Medical Examination. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/screening-hiv-infection- domestic.htmlU.S. Department of Health & Human Services. (2012). Screening for HIV Infection during the Domestic Refugee Medical Examination. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/screening-hiv-infection- domestic.html U.S. Department of Health & Human Services. (2012). Screening for Sexually Transmitted Diseases during the Domestic Refugee Medical Examination. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/std.pdfU.S. Department of Health & Human Services. (2012). Screening for Sexually Transmitted Diseases during the Domestic Refugee Medical Examination. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/std.pdf U.S. Department of Health & Human Services. (2012). Screening for Viral Hepatitis during the Domestic Refugee Medical Examination. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/viral-hepatitis-screening.pdfU.S. Department of Health & Human Services. (2012). Screening for Viral Hepatitis during the Domestic Refugee Medical Examination. Retrieved from: http://www.cdc.gov/immigrantrefugeehealth/pdf/viral-hepatitis-screening.pdf Walker, P., & Barnett, E. (2007) Immigrant Medicine. China: Saunders.Walker, P., & Barnett, E. (2007) Immigrant Medicine. China: Saunders.