underservedpopulations

Who are the medically underserved?

A farm in the countryside surrounded by lush green fields. This question continues to be debated by communities, municipalities and agencies at both the state and federal level. This edition of our newsletter is not intended to debate the definition of this term, but rather to create a personal context for the medically underserved by highlighting the work of our programs and connection to real people and conditions in North Carolina. The Center of Excellence for Integrated Care is working with sites to help overcome barriers this population faces to behavioral healthcare and Rural Forward NC is helping those affected recover from the aftermath of Hurricane Matthew, whose appearance on October 8, 2016 brought the fragility of the communities in the affected counties front and center. It seems that until a crisis like Hurricane Matthew arises, we tend to discuss the issues related to individuals who are vulnerable with less urgency and as policies, not people.

North Carolina is fortunate to have the North Carolina Institute of Medicine, whose work highlights the services and needs of our state. Two of their publications are important to share, as they provide some assistance and perspective regarding the underserved and what we can all do to help. First, is a manual intended to help communities identify unmet health care needs and develop or expand on safety net organizations, which typically have a mission or legal obligation to provide health services to underserved populations. Second is a more recent brief, which highlights new opportunities to expand health insurance access to low income North Carolinians.

At the end of the day, it’s important to remember that there are a tremendous amount of people out there living with unmet healthcare needs. Ask any healthcare provider volunteering for “pop-up” one-day medical clinics about their experience and they are likely to tell you they did not realize that the needs they see in these communities could be possible in the United States. They are. So, the next time a person asks for help or passes you on the street and you think you know their story, take a second glance and ask yourself if that person or family was always in their present circumstances. How did they get there? During such uncertain times, we all deserve a second “look.”

Susan Martin has always been passionate about children’s health. A strong believer that no child should be left without access to care, she has opened both her heart and home to the issue. She spends the majority of her time volunteering for organizations, sitting on various committees and boards, and has previously served with her late husband as a foster parent for newborns with special needs.

“I’m just a normal person who has a strong faith, believes in family and that good health is just our human right,” Susan tells us. “I believe we have a responsibility to a fellow man, woman or child, to give them the opportunity to live a healthy productive life.”

This past October, at the 11th Annual Jim Bernstein Health Leadership Dinner, the Foundation received a generous donation from Susan to support the Bernstein Fellows program. We are extremely grateful for her contribution that will help to support the work being done to advance community health in North Carolina.

What first brought the Fellows program to Susan’s attention was Dr. Steve North, a previous Bernstein Fellow and current Foundation board member. Also passionate about children’s health, Dr. North used his fellowship to develop the Health-e-Schools school-based telemedicine program. He has continued work with this program as the founder of the Center for Rural Health Innovation, an organization focused on applying innovative technologies to improve access to health care in rural communities.

[box] “I have a great deal of admiration for Steve North,” Susan said. “Knowing his story, I wanted to get a better understanding of the other people involved.” [/box]

Impressed by what she learned about other Fellows and their projects, Susan decided to give the program more support. “I really like all the things I’ve read about,” she reflects. “The work they’re doing just makes sense, especially for our rural areas.”

To learn more about the Bernstein Fellows program, click here.

Suffering from a mental health or substance abuse disorder is not uncommon. In the U.S., approximately 1 in 5 adults, or 18.5% of the adult population—experiences mental illness or a substance abuse problem in a given year. Given their complex nature, successful treatment for a behavioral health issue often requires regular access to services and support. But for many, especially underserved populations, these services are unavailable or underutilized. Immigrant populations in particular, who possess unique risk factors attributed to their migration experience, face many barriers to this type of care because of their cultural and linguistic differences.

COE, a program of the Foundation for Health Leadership & Innovation, works to help to connect these underserved patients with the primary care and behavioral health services they need –and also identifies and trains medical practices on how to provide integrated behavioral health services. One of the sites they work with, as part of an effort led by the Cone Health Foundation, is the Center for New North Carolinians at the University of North Carolina at Greensboro (CCNC). CCNC specifically helps to serve immigrant and refugees families’ healthcare needs in Greater Greensboro through the Immigrant Health Access Project (IHAP), which aims to eliminate language and cultural barriers, two of the main issues that prevent the immigrant community from receiving health care. From coordinating outreach efforts to providing interpretation and translation services to running workshops on how to navigate the health system, the IHAP helps to ensure that this underserved population receives the quality care they need and deserve.

However, overcoming these barriers does not come without its challenges. Holly Sienkiewicz, the Director of the Center for New North Carolinians (CNNC), tells us from experience that just getting this population to admit they need treatment can be difficult, as mental healthcare is often stigmatized, especially in other parts of the world. “In some cultures, if a certain individual has a mental health or substance abuse problem, it is seen as a bad omen, and the entire family is avoided,” she says. “Because of this, many people do not want to admit their problems in fear that their families will be ostracized from the community.” Many cultures are also much more collective than we are here in the U.S., meaning it’s common to put others first and do what’s best for either the community or your family. It can be difficult to convince people to get treatment for their own problems when cultural norms encourage prioritizing the needs of others.

Language can be another significant barrier to behavioral health for immigrants and refugees, but simply translating is not always enough. A deeper understanding of the culture that patients come from is important, because even simple words that we use every day can have different meanings in other cultures.

“When discussing mental health with a doctor, most of us would have no problem telling a doctor that we feel stressed,” Holly says. “However, some cultures associate the word stress with crazy, and will interpret it that way if you ask.” She notes financial barriers as well- especially with mental health. “These populations often have no insurance or low quality insurance,” she says. “It’s difficult to find insurance for this population that will cover mental health, and finding someone who is willing to work with an interpreter is even more challenging.” It is important to note that these financial barriers also affect many other low-income residents of NC who do not have access to quality insurance coverage.

[box] “It’s difficult to find insurance for this population that will cover mental health, and finding someone who is willing to work with an interpreter is even more challenging.” [/box]

Overall, the members of the IHAP work hard every day to ensure that immigrants and refugees receive culturally and linguistically appropriate services, as this is critical to addressing their behavioral and general healthcare needs. Holly expressed that she is personally impressed with the resilience of immigrants and refugees, who come with a lot of trauma in their lives, yet are still so resilient and hopeful for the future. “I wish there was more understanding and cultural empathy for this population. Working for immigrants and refugees is in no way easy, and people often understandably get frustrated with language barriers and cultural differences,” she says. “But if you just take the time to get to know them and the circumstances they come from, your perception will change dramatically.”

For more information about COE, click here. For more information about the IHAP, click here.

Despite recent drops, North Carolina’s uninsured rate remains among the highest in the nation, at 15.6 percent. Without proper insurance, health care costs can become expensive and unaffordable, deterring many people from seeking the care they need. A recent article by the News and Observer illustrates this problem, telling the story of a hard-working man who after being laid off was forced to live in his car. No longer able to afford health insurance, he didn’t pursue the care he needed and developed poor vision brought on by an undiagnosed case of diabetes. After two car accidents and the eventual loss of his car, he finally received care from a local free clinic, but it was too late. His vision worsened over time, making him unable to ever drive or work again.

Many people in North Carolina, like the man in this story, are often referred to as medically underserved, because they face numerous barriers to receiving preventative health care or treatment for existing conditions. While being uninsured is one of the major roadblocks, being medically underserved can arise from a variety of other factors, including place of residence, transportation, age, race, ethnicity and even language. Most importantly, these barriers can have a detrimental impact on their overall health and well-being.

To get a better understanding of those who are medically underserved, we asked our staff here at the Foundation for Health Leadership & Innovation to describe the population from their own experience. One staff member described the population broadly as “those who are overlooked and fall through the cracks of our world,” while another defined them as simply, “anybody that does not have access to affordable quality healthcare.” It was also pointed out that for this population, “the already complex healthcare system often becomes more complicated” and “focusing on a lack of personal responsibility among this population does not address the root causes.”

It is important to note that the population that faces these barriers is not small. Across the United States, thousands of communities and populations are considered to be medically underserved. Additionally, more than half of North Carolina is considered a medically underserved area. Because of this, it is vital that we increase the level of attention paid to these groups when it comes to healthcare. As another staff member pointed out, these individuals “deserve to have seamless access and get valued and treated in a system that treats the whole person.”

That’s why at the Foundation, our staff are committed to assuring quality health care for these underserved populations through the work of their programs. Rural Forward NC works hard to support providers, local leaders, organizations, and coalitions that are focused upon improving the lives and conditions of these underserved communities, while the Center or Excellence for Integrated Care helps guides sites in using evidence based practices when working with this population. Additionally, the NC Oral Health Collaborative works to directly address the causes of barriers to oral health care access by looking at the policies that create these inequities, and Practice Sights develops data that is used to both identify and address issues affecting provider retention in the areas where these populations reside.

So whether it’s with oral health, mental health, or basic health needs, it’s clear we all can play a part in ensuring that those who are medically underserved have an equal chance of receiving the affordable, quality healthcare they deserve. As leaders and mentors of the healthcare world, if we don’t step up and take initiative to care for and guide this population, who will?

Rural areas are not the only places for which health care access is a challenge.

In urban areas like Wilmington, North Carolina, access is also an issue, especially for teens and young adults in underserved populations who face barriers like transportation, location, and insurance coverage. Jill Boesel, the Development and Outcomes Director at WHAT, or Wilmington Health Access for Teens, has been a part of closing the gap and bringing health care closer to where teens and young adults are.

WHAT is a community-based nonprofit health care organization that focuses on improving health care access and integrated care for adolescents and young adults between the ages of 11 and 24 in the Wilmington area.

WHAT opened its first school-based health center in 1999 and currently runs centers in three of the four local public high schools in Wilmington. The centers are located on the high school campus, open to students as walk-ins or by appointment. The centers are staffed with multidisciplinary teams that include a primary provider, mental health counselor, and registered dietician at each site.

School-based health centers have several advantages from their location. In addition to overcoming the barriers mentioned above (transportation, geography and insurance coverage), WHAT minimize lost class time for students, as students are able to simply walk down the hall to their appointment. WHAT also minimizes lost work time for parents. Parental participation in appointments is strongly encouraged, but rather than a parent having to pick their child up, take them to the doctor and back to school, parents can simply come to the school for the appointment and then return to work.

In addition to offering health care services to students in the form of one-on-one appointments, WHAT also provides the entire school with ongoing education about the health care needs of students, and WHAT providers work closely with school counselors, social workers, faculty and administration to improve the overall health of students.

Along with the school-based clinics, WHAT also runs a centrally located facility that offers adolescents and young adults, ages 11-24, access to primary care, mental health, nutrition and prevention services. Three-quarters of the population served by WHAT clinics are either publicly insured or uninsured, which provides a fair share of challenges for the clinics, especially in the rapidly shifting health care environment in the country and in this state.

Jill Boesel came to the Wilmington area and to WHAT in 2007, and her primary role focuses on seeking and securing public and private grants and managing current grants. She is also a member of the organization’s leadership team, and believes that the key to her work is communicating very effectively the advantages of having a school-based health center situated conveniently on campus for students and parents.

“The most cherished aspect of my job is having the ongoing opportunity to develop relationships with so many incredibly talented, energetic and committed people—both within and outside of Wilmington—who are working relentlessly to pave the way for a better tomorrow here in North Carolina, despite the often seemingly insurmountable challenges we face in health care today,” Boesel says.

She points out that WHAT is focused on “whole person care”, where the traditionally separated areas of primary care, mental health care, nutrition, and other areas occur within a connected network. This enables the provider in each area to be aware of what is going on in other areas and proactive in connecting the dots when appropriate to give the patient the best overall care possible. By having different types of providers serving patients in a team-based approach in the same location, integrated care works naturally and improves the patient experience and outcome.

Boesel is a current Bernstein Fellow, and her project is very fitting with the true integrity of the Bernstein Fellowship program and the mission of Jim Bernstein: ensuring access to health care for the populations that are most vulnerable in our state. She is exploring how WHAT as an organization can improve the use of data for population health and patient engagement, within the context of an integrated school-based healthcare setting.

Boesel says: “My fellowship has afforded me the unique opportunity to connect with others doing similar work throughout other regions of the state, including my “fellow Fellows” and many others.”

Serving the Underserved: How We Can Make a Difference