1. Refugee and Immigrant Health in a Residency Continuity Clinic Presenters: Daniel Kortsch, MD Thomas J. Staff, MD MPH Katherine Wiegert, MD MPH September 11, 2014

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Drs. Kortsch, Staff & Wiegert have indicated that they all are physicians that treat immigrants and refugees within Denver Health and thus their salaries are both partially paid through this care. Beyond this self evident disclosure, they have no relevant financial relationships to disclose.

3. 3 War’s Human Cost. UNHCR Global Trends 2013. http://www.unhcr.org/5399a14f9.html http://www.unhcr.org/5399a14f9.html

4. Where do our refugees come from? 4 Refugees and Asylees in the United States. Migration Policy.org http://www.migrationpolicy.org/article/refugees-and-asylees-united-states

5. Where refugees live 5 War’s Human Cost. UNHCR Global Trends 2013. http://www.unhcr.org/5399a14f9.html

6. Where refugees and asylees live in the U.S. 6 Refugees and Asylees in the United States. Migration Policy.org http://www.migrationpolicy.org/article/refugees-and-asylees-united-states

7. State of Refugee Care Major Immigrant Categories –Diversity green card –Domestic asylee –Refugee –Refugee parolee –Special immigrant VISA –Unaccompanied minor –Undocumented immigrant 7

8. Health Screening Domestic Screening –History and Physical –Hepatitis Screening –HIV Infection Screening –Immunizations Guidelines –Intestinal Parasite Guidelines –Lead Screening Guidelines –Mental Health Screening Guidelines –Malaria Guidelines –Nutrition and Growth Guidelines –Sexually Transmitted Diseases Guidelines –Tuberculosis Guidelines 8 Summary Checklist for the Domestic Medical Examination for Newly arriving Refugees. U.S. Department of Health and Human Services. http://www.cdc.gov/immigrantrefugeehealth/pdf/checklist-refugee-health.pdf

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10. National agencies involved in refugee care Colorado Department of Public Health and Environment & Office of Refugee Resettlement Volunteer Agencies (VOLAGs) Legal NGOs Faith Based Organizations 10

11. Denver Health & Hospital Authority Main campus 11

12. 04- 09- 201 3 12 Denver Cares Correctional Care Denver Health Medical Center 911911 Family Health Centers Regional Poison Center & Nurseline Denver Health Medical Plan School- based Health Centers Rocky Mtn Center for Medical Response to Terrorism Public Health Rocky Mtn Regional Trauma Ctr

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14. Lowry Family Health Center

15. –Opened 1995 when Lowry AFB decommissioned –Site of DH track of University of Colorado FM residency. 4 residents per year. –2014 remodel as an educational health center 28 exam rooms (60% expansion in capacity) Teaching and educational administrative spaces Dental Clinic and WIC services Pharmacy Refugee screening services –Capacity: 3000 new patients by end of 2014 –Fully staffed: 35,000 to 40,000 Visits per year.

16. Lowry Clinic: 2009 Patients (6,432 total patients) Denver County Outside DHHA PSA Lowry Primary Service Area - Outside County Lowry Primary Service Area - Inside County Unduplicated Patients—2009 Lowry Clinic

17. University of Colorado Family Medicine Residency: 1997-2014 Ten residents a year –6 at University Residency Practice site (AF Williams) –4 at Denver Health Track in a CHC (Lowry Health Center) –PCRE grant expanded residency in 2010 23 graduates since 2001: –14 in underserved practices 8 currently working as faculty at DCHS, 3 more to start in 2014 2 in other Colorado Community Health Centers 4 in out of state CHC’s or other rural practice sites

18. Kelly Arnett Tufts University SOM UH Track Lisa Asamoto University of Cincinnati COM UH Track Sara Foster Fabiano Wake ForestSOM of Wake Forest Baptist Medical Center DH Track William Kim University of Cincinnati COM DH Track Hayley Marcus Tufts University SOM DH Track Rebecca Mullen University of Kansas SOM UH Track Roxanne Radi University of Texas Medical Branch SOM DH Track Alexander Sable-Smith University of Missouri- Columbia SOM UH Track Alison Shmerling Tufts UniversitySOM UH Track Emily Spencer University of Florida COM UH Track University of Colorado Family Medicine Residency Class of 2017

19. Refugee arrivals by alien status * Other includes overseas and domestic asylees, special immigrant visas, unaccompanied minors, parolees, and victims of trafficking.

21. Refugee arrivals by country of birth * Other includes up to 43 different countries and those with missing information.

22. Refugee screenings by site NOTE: In 2009 and 2010, 105 and 573 refugees were screened at Colorado Alliance for Health Equity and Practice (CAHEP) and these are included in the 'Other' category.

23. Refugee arrivals by gender

24. Refugee arrivals by age group

25. Refugee Clinic History Previously housed at Denver Health Lowry Clinic –Run by CDPHE Contract ended 2012 –Lowry remodel Refugee Clinic moved to Aurora –Refugee Wellness Center –Refugee resource center remained at Lowry (temporary) ORR decided to contract with FQHC’s to do screenings Refugee Wellness Center closed 08/29/2014 09/11/2014

26. Patient Centered Medical Home NCQA level 3 accreditation, 2011 Challenges with 2014 Training leaders in Family Medicine QI –PDSA cycles –LEAN philosophy 26

27. Longitudinal Exposure to QI --thanks to Corey Lyon, DO 27

28. Examples of QI projects Resident led, voluntary dinner talks “Nepali Women Pain Group” Group Prenatal Visits, common language Complicated Patient Case Management –CMMI grant NENS Focus Groups –Top 5 languages, HCAHPS Orientation/Access Videos (in development) 28

29. Mortar between the bricks Communication and coordination are the keys Shared drive “dynamic document” Continue QI projects over the year Residents who choose an FQHC for a training site, who choose the refugee population, have a special sense of Professionalism 29

30. Curriculum: The Early Days Needs Assessment: Focus group with current residents in late 2012 Resident and faculty survey in early 2013 Current curriculum inventory & clinic population mapping Input from resident and faculty stakeholders, literature review, and interview with national experts led to the creation of: a curriculum “purpose” five (5) summative goals thirty nine (39) competencies

31. PURPOSE empower our residents to address the social, environmental and political determinants of health while facilitating resource-efficient, evidence-based interventions that enable our patients to live healthier, happier lives both domestically and abroad.

32. SUMMATIVE GOALS 1.Demonstrate the ability to practice medicine effectively in a cross-cultural and underserved context with cultural humility and sensitivity to sociocultural and health literacy. 2.Understand the issues surrounding the social determinants of health & health equity as related to access-to-care, culture, socioeconomic status, education, health policy, lifestyle, and life-stage. 3.Understand the components of health care and public health needs of communities and make evidence-based decisions about resource allocation and the delivery of population health services. 4.Tailor health outreach and clinical encounters by taking into consideration cultural influences, politics, health disparities, and socioeconomics. 5.Create treatment plans based on knowledge of cultural influences utilizing resources that include local, state, federal, and international agencies as applicable.

33. 5 goals will be evidenced by these competencies:Applicable Milestone Educational Format TimelineSetting Community Focus 3.1 Use established community assessment protocols in a resource-poor area or community group PC2 & PC3Small group learning & presentation & lecture PGY 1-3 & lecture 3/2014 Longitudinal Community Assessment Project & Wed didactic w/ Dr. Insel & 3.2 Model resource allocation in a resource-poor settingSBP1Demonstration with feedback on performance & lecture PGY 1-3 & lecture 8/2014 Wed didactic w/ Drs. Wilson & Insel & Continuity Clinic 3.3 Understand public health approaches to affect population health services in high impact areas PC2 Integrated into Community Medicine Curriculum 3.4 Grasp the importance of sustainability of health care delivery in low- resource settings SBP1 & SBP3 3.5 Advocate for systems change to improve the health of the community in which the family physician practices PC3Small group learning & presentation PGY 1, 2 & 3Longitudinal Community Assessment Project 2.3 Recognize the role of culturally specific health perceptions and differences within health and illness PROF3Lecture & Video Review 1-2x/yearPatient Centered Observation Form – Cross-Cultural Version *Patient Care (PC), Medical Knowledge (MK), Practice-Based Learning (PBL), Interpersonal Communication Skills (ICS), Professionalism (P), System-Based Practice (SBP) **Other components of this curriculum can be found in MedHub under Dr. Daniel Kortsch

35. EVALUATION 1.Longitudinal Clinic Encounters (in-process) 2.Video Assessment (in-process) 3.Community Assessment Projects (in-process) 4.Journal Club (in process) 5.Standardization of International Elective Summary and Self-Reflection (in-process) 6.Resident Survey (second survey due this month) 35

36. Enhancement Cultural M&M (pilot 10/2014) Refugee Health Elective (pilot 10/2014) 36

37. References U.S. Department of State. FY13 Refugee Admissions Statistics. http://www.state.gov/j/prm/releases/statistics/228666.htm Summary Checklist for the Domestic Medical Examination for Newly arriving Refugees. U.S. Department of Health and Human Services. http://www.cdc.gov/immigrantrefugeehealth/pdf/checklist-refugee- health.pdf War’s Human Cost. UNHCR Global Trends 2013. http://www.unhcr.org/5399a14f9.html Refugees and Asylees in the United States. Migration Policy.org http://www.migrationpolicy.org/article/refugees-and-asylees-united- states 37

38. Contact us Daniel Kortsch, MD –daniel.kortsch@dhha.org Thomas J. Staff, MD MPH –thomas.staff@dhha.org Katherine Wiegert, MD MPH –katherine.wiegert@ucdenver.edu 38