In California's High Desert region, Laurie Roberts and Sr. Lisa Turay, CSJ, are a determined team. Heading community health efforts at St. Joseph Health's St. Mary Medical Center in Apple Valley, Calif., they help the poor and vulnerable across 2,000 square miles of the vast but sparsely populated San Bernardino County. With countless mileage on their vehicles, theirs is a journey that addresses many complex, contemporary challenges. It also is one that ties them to a legacy begun hundreds of years ago by the health system's founders, the Sisters of St. Joseph of Orange, who dedicate themselves to serving the Dear Neighbor without distinction, no matter where he or she has come from.
Indeed, the needs of the Dear Neighbors that Roberts and Sr. Turay support are as sizable as the area they inhabit. Many residents are recent immigrants lacking documentation. As such, health care reform will not improve their access to care. In fact, the access to health care will worsen if preventive care is not made available to all.
In the New England Journal of Medicine article, "Stuck Between Health and Immigration Reform — Care for Undocumented Immigrants," Benjamin Sommers, MD, Ph.D., wrote, "The cumulative effects of these systematic limitations on insurance for undocumented immigrants, combined with low household incomes, are major disparities in health care access between this population — particularly Latino immigrants — and U.S. citizens. Less than 60 percent of undocumented Latinos report having a regular medical provider, and they receive recommended preventive care at far lower rates than citizens."
And, as Sommers observed, the problems increase over time. He noted that most immigrants are healthier than the U.S.-born population, but within one or two generations they become, on average, less healthy than nonimmigrants, most likely due to the adoption of unhealthy American lifestyles combined with systematic access disparities that prevent appropriate care of chronic disease.
For many of these families, Catholic health care not-for-profit organizations like St. Joseph Health have been a staunch advocate. St. Joseph Health's vice president of advocacy, Ron DiLuigi, said, "St. Joseph Health continues to advocate for comprehensive immigration reform. Our advocacy efforts have been carried out in partnership with numerous other Catholic health systems, including the Catholic Health Association and national interfaith immigration reform groups. The position we have carried to our elected leaders is: We advocate for comprehensive immigration reform which offers an achievable pathway to citizenship for our nation's undocumented immigrants, and any measure must offer an achievable pathway to citizenship for the greatest number of undocumented immigrants, with a focus on keeping families together."
He added, "Through reform, and subsequent naturalization, it is our hope that more individuals and families will be able to benefit from fruits of the Affordable Care Act by gaining access to basic health care."
St. Joseph Health, a 16-hospital health system serving California, West Texas and eastern New Mexico, is headquartered in Southern California. The system does not have a formal program specifically dedicated to serving the undocumented. It has, however, developed many avenues for addressing the needs of the vulnerable who often are new immigrants.
Chief among these efforts is the St. Joseph Health Community Partnership Fund, which provides grants to community organizations serving those most in need. The fund was founded in 1986 with the intent of furthering St. Joseph Health's commitment to neighbors in need, reaching beyond the walls of its health care facilities and transcending traditional efforts of providing free acute care. As a commitment to this effort, all system hospitals return 10 percent of their net income to the community partnership fund to improve the health and quality of life of the most vulnerable.
The fund's grant-making efforts focus on partnering with like-minded organizations. Many of the investments focus on activities that integrate immigrants into the local community, which ultimately strengthens society as a whole. These efforts may range from setting up a mobile clinic to supporting a recreation facility in an underserved neighborhood. The intent is to follow the Sisters of St. Joseph of Orange's tradition of serving where needs are greatest and partnering with people who can help to create change.
One key undertaking is a community-building initiative that focuses on developing the skills of local residents so they may continue to positively effect change. For example, the initiative funded a local organizing committee in Loleta, a Humboldt County, Calif., community where 12.4 percent of the population is foreign-born compared to 4.5 percent in the rest of the county. A group of non-profits and concerned residents came together to form the committee to work on increasing community cohesion through creating and enhancing public spaces such as parks and school grounds. As a result of their collaborative effort, they have increased resident engagement in school board and community chamber activities by 70 percent in the first year. Furthermore, community residents are developing advocacy, public speaking and community engagement skills.
The Loleta Organizing Committee continues to seamlessly collaborate with a wide range of community groups, policymakers, media partners, educational institutions, service providers, a church and St. Joseph Health-Humboldt County.
In collaboration with other local funders, the St. Joseph Health Community Partnership Fund helped create the Orange County Naturalization Initiative Collaborative. Orange County, Calif., has about 220,000 permanent legal residents who are eligible for citizenship but, for a variety of reasons, have not applied. This is a very vulnerable population, and while cost is a barrier for many to apply for citizenship, some also fear working with government entities and are afraid to trust an attorney. The collaborative has effectively helped promote the integration of legal residents who are already here.
In addition to the community partnership fund efforts, there are other community outreach programs led by the St. Joseph Health hospitals themselves. Although the following are just three of many, they are telling examples of how programs flourish when there is a long-term commitment, a focus on services that are truly needed, a community that seeks creative solutions and dedicated individuals like Roberts and Sr. Turay.
As director of community health at St. Mary Medical Center, Roberts can count several successes in bringing much-needed care and preventive education to immigrant families, after more than a decade of continuous outreach efforts. One example began several years ago, when the hospital emergency department experienced a spike in the number of patients with diabetes.
It became clear that many of these patients were undocumented and had put off medical care for fear of having their immigration status discovered. In response, a mobile health unit was established to go out into the neediest communities and provide screening and education that would address problems long before they became medical emergencies. Today, that effort has resulted in more than 150 individuals who have learned to effectively manage their disease. Also, many of these patients have become health advocates, teaching others about adopting healthy lifestyles.
Sr. Turay said she and Roberts take a holistic approach. "We assess the entirety of a family's needs," she said. "If immigration issues are contributing to the family's ill health, we will help them get the resources they require. Or, she added, sometimes an entire community needs a holistic transformation, as did the city of Adelanto. There, the immediate need wasn't for health clinics but for access to fresh foods and recreational areas. "We advocated in partnership with the community and helped open a grocery store and revitalized a swimming pool," she said. "I like to say we adopted that entire city."
Roberts and Sr. Turay said their type of success doesn't come about quickly. They have learned that to help the most vulnerable, programs must be well integrated into the communities and supported by bilingual and culturally attuned team members. "Trust is huge," said Sr. Turay. "When you're scared and undocumented, you seek out people you can trust. You know when people are truly making a commitment to helping."
One senses that neither woman would consider doing her work any differently. "People say the communities are unsafe, but we've been there for almost 15 years helping to make them better," Sr. Turay said. "We feel not just safe, but essential, when we are out in these areas. In fact, it feels like the community protects us."
A HOLISTIC VIEW OF HEALTH
Ensuring a healthy community begins with engaging the entire family. This has been the case with the Paso a Paso (Step by Step) program, begun as a prenatal education class at the health system's St. Joseph Health-Humboldt County, Calif. Today, the program works not only with new mothers, but entire families who learn skills together to integrate into their new community. The staff of six bilingual health educators, all of whom are immigrants, help Humboldt County community residents feel supported and empowered.
Paso a Paso classes began in July 2001, with Carol Cruickshank, CNM, and Elvia Saavedra teaching pregnant mothers the basics of prenatal care. They were a well-matched team: Saavedra, a recognized leader in the Latino community, had considerable experience interpreting for certified nurse-midwives, and Cruickshank was an experienced certified nurse-midwife with both clinical and teaching experience in the United States and Latin America.
At first, they thought their singular focus would be helping expectant mothers prepare for childbirth. Not long after starting, Cruickshank and Saavedra recognized that they needed to do more to facilitate women's participation. Mobilizing available community resources, they began providing transportation, food and child care. They also pared a six-week course down to four weeks, noting that this greatly reduced stress for women already subject to grueling work hours and many transportation challenges.
As the classes grew in attendance, participants helped identify additional curriculum topics. This soon necessitated expanding the program and having the educators demonstrate admirable flexibility. Of particular concern was the students' inexperience with seemingly everyday tasks such as fitting infants into car seats. In response, Saavedra decided to pursue certification as a Child Passenger Safety Technician and, later on, as a doula to better serve her community.
For all classes, emphasis has always been on the practical and the useful: Understanding how to read a prescription and giving the appropriate amount of medication to a sick child; obtaining a bicycle helmet for an active son or daughter; how to contact a women's shelter, if needed. Time is spent on the details: how to call the OB provider; how to get to the hospital; how to call an ambulance; where the hospital is located; and what to do if a child is sick.
However practical and useful, a Paso a Paso class can be stymied by an unexpected cultural challenge — as Saavedra found when she couldn't get women to attend a breast-feeding support group for new mothers. She learned that the local population of Latino families observes cuarentena, a 40-day postpartum rest period for a mother and her new baby. Though there are regional variations in specific cuarentena customs, the families generally view the rest period as a fragile time during which it is harmful for the mother and infant to leave the home.
Saavedra's enthusiasm and advocacy are credited with encouraging women and their spouses to even consider coming to breast-feeding classes during cuarentena. Later, word-of-mouth recommendation from the participants themselves served as an important community outreach marketing effort.
Paso a Paso has been well received by the local hospitals, medical staff, community clinics, social service agencies and the Humboldt County community as a whole. Staff members work closely with these other groups to coordinate efforts and refer clients. They also are looking at other needed services to help families thrive, including mental health programs. Said Saavedra, herself once a newcomer to the U.S., "I can relate to the women we serve. I was a single mother, new to the community and without resources. I have been in their situation, and I know how important it is to build respect and trust among them."
PARENTS HELPING PARENTS
Also in Northern California, St. Joseph Health has helped foster a program focusing on the success of young students and their newcomer parents. Napa Valley Parent University offers parents new to the U.S. public education system an opportunity to learn the best way to navigate and participate in their children's schooling.
"For some immigrant parents, teachers are seen as an authority figure, not necessarily a partner in their children's educational and physical development. The problem is that parents may be intimidated and shy away from important conversations with their children's school administrators and teachers," said Dana Codron, executive director of community outreach for St. Joseph Health's Queen of the Valley Medical Center, which provides a full-time employee to support the program and help in the creation of a parent-school engagement curriculum.
Napa Valley Parent University focuses on helping parents achieve four key goals: becoming an effective volunteer in the classroom and at school events; becoming an effective school consumer and advocate; understanding leadership development; and raising a healthy child (which includes knowing how to access health services). Typical classes include walking participants through an effective parent-teacher conference, learning computer literacy (including setting up an email account for communicating with teachers), encouraging healthy eating and preventing obesity.
The free classes are extremely popular: there are more than 860 current participants. Lessons are taught in Spanish or English, and parents may take as many classes as they wish. Child care is provided for all classes offered in the evenings.
Many who have taken the classes become volunteer teachers. Additionally, site coordinators, parents and school teachers often provide instruction. "People are extremely enthusiastic about this program," said Codron. "We have no shortage of community partners."
The program also has a graduation ceremony in which parents completing at least 20 credits receive special recognition. Although it's not a recognized degree, the certificate is a source of pride. Children especially enjoy seeing their parents celebrate the classes' completion.
Whether or not they complete enough courses toward graduation, the parents exhibit more confidence in working with teachers, they become much more engaged in helping their children succeed in school and sometimes even find a lifelong passion themselves. Codron tells of one mother who began the classes unconvinced that she would expand her parenting skills. She quickly became a highly engaged advocate. Today she has a paid position with the school, helping other parents navigate the school system.
"This is the type of program that lives up to the goals of the Affordable Care Act," Codron said. "We need to look at new ways to promote the health of the community. For us, by addressing issues such as poverty and academic achievement, we're turning immigrant parents into partners for their children's future."
As the people of St. Joseph Health see it, this is just another example of what the legacy of the Dear Neighbor and the health system's mission call them to do. The healing ministry of Jesus had a particular focus on bringing people into community and reaching out to the others in our midst. St. Joseph Health continues this call to ministry by reaching out in service to the vulnerable immigrant communities that, by choice or to escape injustice, have taken a leap of faith to build a better tomorrow for themselves and their families.
By supporting these families and individuals, St. Joseph Health stays true to its mission and builds a stronger foundation for everyone.
GABRIELA ROBLES is executive director, St. Joseph Health Community Partnership Fund, St. Joseph Health, Irvine, Calif.
VERÓNICA F. GUTIÉRREZ is manager, community benefit, St. Joseph Health, Irvine, Calif.
GEORGE B. AVILA is director, mission integration, St. Joseph Health, Irvine, Calif.
Copyright © 2014 by the Catholic Health Association of the United States
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