California Project to Improve Health of Refugees Sponsor: CA Department of Pubic Health Refugee Health Section Presenters: Patricia Erwin, MPH Sandra Meucci, PhD

Presentation Outline I. Our Challenge II. Role of State Public Health Dept IIA. Role of Local Public Health Dept III. Implementing Infrastructure Change IV. Evaluation Model

I. Our Challenge How can state and local health departments assist refugees in to become and stay healthy; through prevention, early detection and management of chronic conditions?

Top 15 Refugee Groups in California from 2006 – 2009 ( 16,994 refugees of total 18,357) Iran 9221 Iraq 3964 Myanmar (Burma) 785 Vietnam 602 China 587 Ukraine 368 Bhutan 314 Russia 216 Armenia 198 Somalia 194 Moldova 144 Ethiopia 122 Nepal 100 Afghanistan 98 Kenya 81

Top Three Health Conditions of CA Refugees 2006 - 2009 Dental Carries (Mean = 1,388) Essential Primary Hypertension (Mean = 991) Obesity (Mean = 958)

5 Year Project Goal: Promote overall well being, change behaviors for healthy living, and improve self management of cardiovascular risk factors related to chronic health condition for refugees throughout California

II. Role of California Dept of Public Health Provide the Direction and Leadership by: A. Performing Chronic Disease Risk Assessment of newly arriving refugees B. Identifying and subcontracting with local health departments dealing with different refugee groups in different regions of CA.

CA Dept of Public Health C. Providing ongoing technical assistance in two areas: program implementation and evaluation D. Providing Training: Develop a “train the trainer” model for community health workers and develop training for health care providers on chronic care management with refugees from the refugee communities being served

IIA. Role of Local Public Health Departments Implement Infrastructure Changes to improve follow-up with refugees with risk factors for chronic disease (to inform patient of chronic health condition s/he is at risk of, to make referral to primary care, to have information flow to primary care physician, to see that person has kept appointment)

Local Public Health Departments Foster partnerships between clinical assessment and services and community based agencies, mutual assistance agencies, voluntary organizations (to deliver culturally relevant health education and follow-up services)

Local Health Departments Recruit, train and deploy community health workers to liaison between health delivery system and refugee group

III. Designing and implementing infrastructure changes to improve follow-up of identified chronic and other harmful health conditions of newly arrived refugees

Important Consideration How well acquainted are the clinic staff with the culture/customs/language of refugee group and of the chronic care model?

Ways to Improve Cultural Competency of Clinic Services Training of health care providers on the chronic care model specific to the refugee populations in their clinics may be needed. Use of Community Health Worker (either within clinical setting or within local voluntary agencies or Mutual Assistance Associations) to serve as community liaisons; sustain preventive health education and awareness in the community.

Important Consideration How well connected is the local health department (or entity performing initial health assessment of newly arrived refugee) to the primary care physicians who treat the refugees post-health assessment?

Health Department/Primary Care Some public health departments are situated within clinics that have primary care physicians who will see refugees on an ongoing basis after the initial health assessment and others are have no relationship with the primary care physicians in the community who will treat the refugees.

Improve Coordination These different levels of connection between health department and ongoing primary care have implications for the amount of coordination that needs to occur after referral and for ongoing follow-up. Communication between health assessment staff and primary care providers support enhanced follow-up efforts.

IV. Evaluation methods and tools We want to measure changes within different health care environments and among many different refugee groups Objectives (SMART) are developed collaboratively EXAMPLE: By June 30, 2010, 100% of refugees identified with chronic conditions or other harmful conditions (to be defined by the grantee) will be referred to a primary care physician, and 70% of the refugees referred to a PCP will be followed up utilizing a follow-up appointment system to confirm that the refugee kept the first appointment

Evaluation Measures Standardized measurement of changes in knowledge and behavior (eating, exercise, coping with stress, using the medical system) according to trans-theoretical model. This allows for cross-comparisons of programs and changes over time within each program. Evaluation survey is translated into all appropriate languages – still a fee refugees are not literate in any language

Evaluation - Reporting Individual differences are taken into account An individual case study approach is done for each grantee which allows for unique configuration of health delivery system to be described and explored.