Public health and health professional education at a tribal college: a collaborative immersion program in rural North Dakota.

INTRODUCTION: Native Americans have some of the worst health outcomes of any minority group in the USA, and are severely under-represented in the health professional workforce. From 2009 to 2015, partners from a tribal college in rural North Dakota and academic institutions in New York collaborated to create a program wherein non-Native health professionals traveled to the reservation to teach a summer course to Native students. This study assessed the impact of the program on both the Native students who took the course and the non-Native health professionals who taught the course. METHODS: Focus groups composed of former students in the program were held in Spirit Lake, North Dakota. Non-Native student teachers were surveyed using an online survey tool. Focus group data were analyzed using grounded theory methodology. Survey data were analyzed using descriptive statistics. RESULTS: Fifteen former students participated in the focus groups. Participants stated that their experiences in the course increased interest in health professions and knowledge of public health issues. Participants also described barriers to entering health professionals for Native students and the benefits of close interaction with non-Native individuals. Eighty-six percent (24/28) of former course teachers responded to the survey. Survey respondents stated their experiences in North Dakota increased their understanding of underserved populations and their interest in working in rural areas. CONCLUSION: This study assessed the successes and limitations of a collaborative, interprofessional immersion program in rural North Dakota. Similar programs may increase the number of Native Americans in health professions and increase non-Native health professional interest in and engagement with rural communities.

Positive and negative spillovers of the Health Disparities Collaboratives in federally qualified health centers: staff perceptions.

INTRODUCTION: Quality improvement (QI) interventions are usually evaluated for their intended effect; little is known about whether they generate significant positive or negative spillovers. METHODS: We mailed a 39-item self-administered survey to the 1256 staff at 135 federally qualified health centers (FQHC) implementing the Health Disparities Collaboratives (HDC), a large-scale QI collaborative intervention. We asked about the extent to which the HDC yielded improvements or detriments beyond its condition(s) of focus, particularly for non-HDC aspects of patient care and FQHC function. RESULTS: Response rate was 68.7%. The HDC was perceived to improve non-HDC patient care and general FQHC functioning more often than it was regarded as diminishing them. In all, 45% of respondents indicated that the HDC improved the quality of care for chronic conditions not being emphasized by the HDC; 5% responded that the HDC diminished that quality. Seventy-five percent stated that the HDC improved care provided to patients with multiple chronic conditions; 4% signified that the HDC diminished it. Fifty-five percent of respondents indicated that the HDC improved their FQHC's ability to move patients through their center, and 80% indicated that the HDC improved their FQHC's QI plan as a whole; 8% and 2% indicated that the HDC diminished these, respectively. DISCUSSION: On balance, the HDC was perceived to yield more positive spillovers than negative ones. This QI intervention appears to have generated effects beyond its condition of focus; QI's unintended effects should be included in evaluations to develop a better understanding of QI's net impact.

Insurance status and quality of diabetes care in community health centers.

OBJECTIVES: We sought to compare quality of diabetes care by insurance type in federally funded community health centers. Method. We categorized 2018 diabetes patients, randomly selected from 27 community health centers in 17 states in 2002, into 6 mutually exclusive insurance groups. We used multivariate logistic regression analyses to compare quality of diabetes care according to 6 National Committee for Quality Assurance Health Plan Employer Data and Information Set diabetes processes of care and outcome measures. RESULTS: Thirty-three percent of patients had no health insurance, 24% had Medicare only, 15% had Medicaid only, 7% had both Medicare and Medicaid, 14% had private insurance, and 7% had another insurance type. Those without insurance were the least likely to meet the quality-of-care measures; those with Medicaid had a quality of care similar to those with no insurance. CONCLUSIONS: Research is needed to identify the major mediators of differences in quality of care by insurance status among safety-net providers such as community health centers. Such research is needed for policy interventions at Medicaid benefit design and as an incentive to improve quality of care.

Development and Testing of the Provider and Staff Perceptions of Integrated Care (PSPIC) Survey.

This article discusses development and testing of the Provider and Staff Perceptions of Integrated Care Survey, a 21-item questionnaire, informed by Singer and colleagues' seven-construct framework. Questionnaires were sent to 2,936 providers and staff at 100 federally qualified health centers and other safety net clinics in 10 Midwestern U.S. states; 332 were ineligible, leaving 2,604 potential participants. Following 4 mailings, 781 (30%) responded from 97 health centers. Item analyses, exploratory factor analysis, and confirmatory factor analysis were undertaken. Exploratory factor analysis suggests four latent factors: Teams and Care Continuity, Patient Centeredness, Coordination with External Providers, and Coordination with Community Resources. Confirmatory factor analysis confirmed these factor groupings. For the total sample, Cronbach's alpha exceeded 0.7 for each latent factor. Descriptive responses to each of the 21 Provider and Staff Perceptions of Integrated Care questions appear to have potential in identifying areas that providers and staff recognize as care integration strengths, and areas that may warrant improvement.

Sustaining quality improvement in community health centers: perceptions of leaders and staff.

The Health Disparities Collaboratives are the largest national quality improvement (QI) initiatives in community health centers. This article identifies the incentives and assistance personnel believe are necessary to sustain QI. In 2004, 1006 survey respondents (response rate 67%) at 165 centers cited lack of resources, time, and staff burnout as common barriers. Release time was the most desired personal incentive. The highest funding priorities were direct patient care services (44% ranked no. 1), data entry (34%), and staff time for QI (26%). Participants also needed help with patient self-management (73%), information systems (77%), and getting providers to follow guidelines (64%).

The perceived financial impact of quality improvement efforts in community health centers.

We administered surveys to 100 chief executive officers (CEOs) of community health centers to determine their perceptions of the financial impact of the Health Disparities Collaboratives, a national quality improvement initiative. One third of the CEOs believed that the HDC had a negative financial impact on their health center, and this perception was significantly correlated with centers having a higher proportion of uninsured patients. Performance-based payment incentives may improve care but may also add new financial burdens to facilities that treat the uninsured population. As such, a provider's payer mix may need to be considered in the design of QI programs if they are to be sustainable.

Provider perceptions of limited health literacy in community health centers.

OBJECTIVE: To examine techniques used by community health center (HC) providers to care for patients with limited health literacy (LHL). METHODS: Survey mailed to 803 HC providers in 10 Midwestern states. Response rate was 47.5%. Associations between variables were examined using generalized estimating equations (GEE) models to account for clustering of respondents within HCs. RESULTS: The average provider estimates of LHL prevalence among English- and Spanish-speaking patients were 41+/-24% (mean+/-S.D.) and 48+/-30%, respectively. Those with training in health literacy were more likely to have patients repeat instructions back to check understanding (OR=2.05 and p=0.04) and were more likely to give out health education materials designed for patients with LHL (OR=2.80 and p=0.0002). Providers differed by type in encouraging patients to bring friends or family members to appointments (p=0.02). CONCLUSION: Providers estimate LHL to be highly prevalent in their HCs, and use various techniques to assist patients. PRACTICE IMPLICATIONS: Training in health literacy is associated with increased usage of evidence-based techniques to assist patients with LHL. Providers at all levels would likely benefit from LHL training. Most providers believe providing health education materials designed specifically for patients with LHL would be very helpful.

The use of prayer by Hispanic migrant farmworkers with type 2 diabetes.

Praying for issues related to health can be a very important aspect in peoples' lives. Since research on this practice is limited, a qualitative study was conducted that explored the use of prayer in Hispanic migrant farmworkers diagnosed with type 2 diabetes. Eighteen farmworkers were interviewed and asked two specific questions with multiple probes to elicit information regarding their religious practices and prayer. Responses regarding religious practices were extremely limited whereas the farmworkers expounded on the question relating to prayer. Three main themes emerged: 1) Farmworkers used prayer in their daily lives; 2) Farmworkers prayed for themselves and their family; and 3) Farmworkers recited prayers specifically for their diabetes.

Diabetes lay educator case study: one woman's experience working with the Hispanic migrant and seasonal farmworkers.

In the year 2000, Migrant Health Services, Inc. began utilizing Diabetes Lay Educators (DLEs) as a way to improve the health status of Hispanic migrant farmworkers with diabetes. The purpose of this case study was to provide insight into the perceptions of one DLE and characteristics she needed to achieve positive client outcomes. These characteristics included a strong internal desire to help this population, a knowledge base, and advocacy skills needed to work between two cultures.

Developing capacity for the American Indian health professional workforce: an academic-community partnership in Spirit Lake, North Dakota.

BACKGROUND: American Indians/Alaskan Native (AIAN) populations experience significant disparities in health when compared to the average US population who are under-represented in the health care professional workforce. Current research suggests that racial concordance between patients and providers has a positive effect on patient care. OBJECTIVE: We describe a successful academic-community partnership between a tribal college, a local state academic center, an urban public health institution, and an urban academic center all aligned with the goal to increase AIAN health care professional capacity. METHODS: A tribal college course and youth education program were developed with the intent to expose AIAN youth to the health care professions and encourage entry into health professional career tracks. Evaluation using a pre- and post-survey design is underway to assess the impact of the intervention on participating AIAN attitudes and career intentions. CONCLUSION: We believe this model is one way of addressing the need for an increased AIAN health care professional career force.

Meeting the health care needs of a rural Hispanic migrant population with diabetes.

CONTEXT: There is a need for models of health care that provide accessible, culturally appropriate, quality services to the population of Hispanic migrant farmworkers at risk for or diagnosed with diabetes. PURPOSES: The purposes of this study were to describe the Migrant Health Service, Inc (MHSI), Diabetes Program, the conceptual model on which it is based, and 4 types of outcomes achieved over a 3-year period. METHODS: Types and amounts of medical services and education were studied. Qualitative data obtained from program records and documents were analyzed to determine the nature of the program. Quantitative data were used to measure outcomes of the program. FINDINGS: The multiplecomponent MHSI Diabetes Program is addressing economic, cultural, and language barriers experienced by the target population. The program provides a continuum of health services and education that meet American Diabetes Association (ADA) Clinical Practice Recommendations on diabetes. The program exposes regional health care professionals and university students from numerous academic disciplines to Hispanic farmworker culture. CONCLUSIONS: Evidence-based program management, patient care, and program evaluation are traits of this program, which offers accessible, culturally appropriate, quality health services and education to Hispanic farmworkers. The multicomponent program model has high potential for positively impacting the health of the target population.

Community health center access to resources for their patients with diabetes.

Community health center providers and staff access to resources for their Latino and non-Latino patients with diabetes is unknown. We analyzed survey data from 577 community health center providers and staff who manage diabetes from 85 sites across 10 Midwestern states. Respondents were labeled as high proportion (HP) providers if >25 % of their site's diabetes population was Latino. HP providers were more likely than non-HP providers to have access to physician's assistants (71 vs. 58 %) and certified diabetes educators (61 vs. 51 %), but less access to endocrinologists (25 vs. 35 %) (p < 0.05). HP providers had greater access to Spanish-speaking providers (48 vs. 26 %), on-site interpreters (83 vs. 59 %), culturally tailored diabetes education programs (64 vs. 26 %), and community outreach programs (77 vs. 52 %) (p < 0.05). Providers at HP sites reported greater access to a range of personnel and culturally tailored programs. However, increased access to these services is needed across all sites.

Community health center provider and staff's Spanish language ability and cultural awareness.

Many community health center providers and staff care for Latinos with diabetes, but their Spanish language ability and awareness of Latino culture are unknown. We surveyed 512 Midwestern health center providers and staff who managed Latino patients with diabetes. Few respondents had high Spanish language (13%) or cultural awareness scores (22%). Of respondents who self-reported 76-100% of their patients were Latino, 48% had moderate/low Spanish language and 49% had moderate/low cultural competency scores. Among these respondents, 3% lacked access to interpreters and 27% had neither received cultural competency training nor had access to training. Among all respondents, Spanish skills and Latino cultural awareness were low. Respondents who saw a significant number of Latinos had good access to interpretation services but not cultural competency training. Improved Spanish-language skills and increased access to cultural competency training and Latino cultural knowledge are needed to provide linguistically and culturally tailored care to Latino patients.

Combating Obesity at Community Health Centers (COACH): a quality improvement collaborative for weight management programs.

Community health centers (CHCs) seek effective strategies to address obesity. MidWest Clinicians' Network partnered with [an academic medical center] to test feasibility of a weight management quality improvement (QI) collaborative. MidWest Clinicians' Network members expressed interest in an obesity QI program. This pilot study aimed to determine whether the QI model can be feasibly implemented with limited resources at CHCs to improve weight management programs. Five health centers with weight management programs enrolled with CHC staff as primary study participants; this study did not attempt to measure patient outcomes. Participants attended learning sessions and monthly conference calls to build QI skills and share best practices. Tailored coaching addressed local needs. Topics rated most valuable were patient recruitment/retention strategies, QI techniques, evidence-based weight management, motivational interviewing. Challenges included garnering provider support, high staff turnover, and difficulty tracking patient-level data. This paper reports practical lessons about implementing a weight management QI collaborative in CHCs.

Predicting changes in staff morale and burnout at community health centers participating in the health disparities collaboratives.

OBJECTIVE: To identify predictors of changes in staff morale and burnout associated with participation in a quality improvement (QI) initiative at community health centers (HCs). DATA SOURCES: Surveys of staff at 145 HCs participating in the Health Disparities Collaboratives (HDC) program in 2004. DATA COLLECTION AND STUDY DESIGN: Self-administered questionnaire data collected from 622 HC staff (68 percent response rate) were analyzed to identify predictors of reported change in staff morale and burnout. Predictive categories included outcomes of the QI initiative, levels of HDC integration, institutional support, the use of incentives, and demographic characteristics of respondents and centers. PRINCIPAL FINDINGS: Perceived improvements in staff morale and reduced likelihood of staff burnout were associated with receiving personal recognition, career promotion, and skill development opportunities. Similar outcomes were associated with sufficient funding and personnel, fair distribution of work, effective training of new hires, and consistent provider participation. CONCLUSIONS: Having sufficient personnel available to administer the HDC was found to be the strongest predictor of team member satisfaction. However, a number of low-cost, reasonably modifiable, organizational and leadership characteristics were also identified, which may facilitate improvements in staff morale and reduce the likelihood of staff burnout at HCs participating in the HDC.

Living with diabetes: perceptions of Hispanic migrant farmworkers.

This study1 focuses on Hispanic migrant farmworkers and their perceptions of living with diabetes. A phenomenological design was utilized with a sample of 12 participants recruited from 2 local migrant health centers. The interview guide was based on questions from Kleinman's Explanatory Model. Data were explored with regard to etiology, onset of symptoms, pathophysiology, and course of illness. Six themes emerged from the analysis: usualness of diabetes, causes of diabetes, symptoms prior to the diagnosis of diabetes, understanding the chronicity of diabetes, impact of diabetes on daily life, and fear of long-term complications related to diabetes. Based on the analysis of the interviews, the individuals' explanations of this chronic disease are compiled within their own perceptions and cultural beliefs. The results of this study can be utilized by providers to adapt their health care and education methods to better meet the needs of this mobile population. In the Hispanic migrant farmworker population, further research is needed to explore the long-term impact of living with diabetes on a daily basis.

The experiences of migrant health nurses employed in seasonal satellite nurse-managed centers: a qualitative study.

This research study describes the unique experiences of nurses who are employed in migrant health seasonal satellite nurse-managed centers in the upper Midwest. Data were generated through semistructured interviews with 10 seasonal nurses. Phenomenology served as the research method. Four themes were identified including seeking seasonal employment, establishing migrant seasonal satellite nurse-managed centers, learning the culture of Hispanic migrant farmworkers, and referring Hispanic migrant farmworkers for medical care. During their seasonal employment, nurses learned to establish and operate satellite nurse-managed centers. Due to the migrant health nurses' daily contact with their clients, they were able to establish rapport that led to a trusting relationship. This enabled them to provide culturally sensitive and lifestyle appropriate care to the migrant farmworker population.