Good article on cultural humility--basically the groundbreaking one used to propose the term

Journal of Health Care for the Poor and Underserved; May 1998; 9, 2; Research Library
Melanie Tervalon; Jann Murray-Garcia 

Introduction

In August of 2005, the North Carolina Division of Public Health, Occupational and Environmental Epidemiology Branch (OEEB) was notified that three women who had worked on farms in North Carolina owned by Ag-Mart had delivered infants with birth defects.  All three births took place in Florida where the women also worked on Ag-Mart farms and lived near each other.  This report summarizes the OEEB’s investigation and assessment of the pesticide exposures likely experienced by these women while in North Carolina. 

Are you PCMH certified?

Is your health center certified as a Patient-Centered Medical Home?

Health centers that are designated as Patient Centered Medical Homes aim to connect primary care, private practice providers, specialists, hospitals, outreach, and behavioral health, along with relevant community-based organizations, to not only deliver care but to support healthy lifestyles and safe environments for the community. Studies suggest that implementing an effective Patient Centered Medical Home framework will increase patient acceptance and satisfaction while reducing the total costs. In one study, PCMH recognition was associated with 4.9 percent less total Medicare spending per beneficiary. Another study concluded that the longer a practice had been transformed, and the higher the risk of the patient pool in terms of comorbid conditions, the more significant the positive effect of practice transformation, especially in terms of cost savings.

Visit HRSA Accreditation and Patient-Centered Medical Home Recognition Initiative webpage to get started.

Download HITEQ’s PCMH Self-Assessment Tool to gauge your health center’s readiness for meeting the NCQA 2017 PCMH Requirements.

Are your clinic sites that serve special populations like mobile agricultural workers also PCMH certified?

The majority of health centers have achieved PCMH at one or more of their sites. Many health centers, however, have not brought PCMH to the clinics that serve their most vulnerable, and at times most challenging, patients. Yet, these patients, like mobile agricultural workers, may benefit the most from PCMH processes, if the processes are adapted for the barriers the patients may face. 

Here are some resources to get you started:

Read “Approaches for Establishing a PCMH for Mobile Patients,” an article from MCN’s in-print quarterly clinical publication, Streamline.

MCN’s PCMH for Mobile Patients webpage, which includes a recent poster presentation.

The Patient-Centered Primary Care Collaborative 2017 evidence report, “The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization,” found that “the longer a practice had been transformed, and the higher the risk of the patient pool in terms of comorbid conditions, the more significant the positive effect of practice transformation, especially in terms of cost savings.”

Does your health center clearly identify the occupation of your patients including mobile and agricultural worker patients through your intake process?

Patient-centered means knowing who your patient is and what health risks they may encounter. Simple and effective adjustments to intake methods and a health center’s EHR can assure that you understand the special needs of all your patients and that high risk patients such as agricultural workers and their family members are being correctly identified.

Here are some resources to get you started:

Identifying Migratory and Seasonal Agricultural Workers in Your Clinic: MCN’s resource, in English and Spanish, to guide your intake process.

Ag Worker 2020

Do you identify the social determinants of health that your agricultural workers face such as chemical exposure, poor housing, mobility?

Through a robust PCMH, a comprehensive care team forms to provide coordinated care for patients. By identifying the social determinants of health among a patient population and for an individual patient, care teams can plot a path to health that makes sense for the patient. In general, agricultural workers face numerous obstacles to a healthy life that your overall patient population may manage to avoid. Agricultural workers may suffer health issues or lose health access because of pesticide exposure, mobility, language and cultural differences, transportation issues, and more.

Here are some resources to get you started on identifying and addressing social determinants for agricultural worker patients:

Read the WHO’s page on social determinants and how to address them at “A Conceptual Framework for Action on the Social Determinants of Health.” 

MCN’s Environmental and Occupational Health Screening Questions for Primary Care (available in English and Spanish) is EHR friendly.

Read how one health center used MCN’s Centers of Excellence program to integrate environmental and occupational health into its medical practice.

MCN and Farmworker Justice teamed up to create Clinician Guides for Farmworker Health and Safety Regulations. 

Not all agricultural workers face the same social determinants. Read the summary of 2017 research to hear how subgroups of agricultural workers face different barriers: Recent Research on Agricultural Workers’ Social Determinants of Health and Health Outcomes.

National Association of Community Health Centers PRAPARE Implementation and Action Toolkit

Visit the Medical-Legal Partnership’s SDOH Academy.

Does your health center practice comprehensive team-based coordinated care with these social determinants findings in mind?

Read “Behavioral Health Integration: Obstacles & Successes,” an article by the Patient Centered Primary Care Institute on how Yakima Valley Farmworkers Clinic has built its PCMH to meet the unique needs of its largely agricultural worker population, with a strong emphasis on behavioral health and addressing the social determinants of health.

Has your health center established relationships with community-based organizations to further address barriers to care?

Community-based organizations can help mobile agricultural worker patients tackle many health concerns outside of the clinic’s walls. 

Consider gathering these types of resources for your area

• Transportation resource
• Food resource
• Legal services?
• Migrant head start?
• Housing Shelter resources

Here are a couple of resources to get you started 

Assistance with Transitional Housing 

Homeless Shelter Directory

Does your health center have systems in place to serve a patient who intends to leave the service area before care can be completed?

Health Network, MCN’s bridge case management system for mobile patients, was specifically designed to assure continuity of care for patients who will be leaving the service area. Patients with any ongoing health concern may be enrolled. Clinicians enroll patients for free, after which MCN’s Health Network Associates contact the patient to arrange for the continuation of care and records transfer in the patient’s next location, following the patient for as long as that patient is mobile and in need of care.

Health Network and PCMH together can assure better care for mobile patients. 

Read how MCN’s Ed Zuroweste, MD, Co-Chief Medical Officer, developed a version of PCMH that worked for mobile patients in his practice.

Here are some additional resources:

Open Access Scheduling for PCMH

Standing Lab Orders for Migrant Patients

Does your health center regularly evaluate your systems to assure program effectiveness?

A comprehensive evaluation of interventions to improve the provision of PCMH for mobile patients should include a systematic review of four areas that are critical to performance improvement.

1.       Identifying the social determinants of the patient

• Who are they 
• What do they do 
• What are their needs

2.       Employing comprehensive, team based coordinated Care

• Integration of behavioral health 
• Continuity and Follow up

3.       Establishing clinical-community relationships

4.       Evaluating the value

• Impact 
• Quality
• Return on Investment

Here are some evaluation resources to assure your efforts continue to meet the needs of your community while best utilizing the center’s limited finances.

A Guide to Real-World Evaluations of Primary Care Interventions: Some Practical Advice

Measuring Population Health Management Return on Investment from HITEQ Center

Data for Population Health Management from HITEQ Center

Provides information and educational outreach on cancer-related legal issues to people with cancer and others impacted by the disease. A program of the Disability Rights Legal Center. https://thedrlc.org/cancer/clrc-intake-form/