We Can Do That! 1

Sarah Miner, RN, MSNStephanie Chalupa, RN, BSN

Piloting a Home Care Intervention for

Refugee Populations

We Can Do That! 2

1. Understand health services offered by professional home health

2. Identify what type of refugee patients may be eligible for and benefit from home health services

3. To assess the impact of a pilot project on meeting refugee health needs

4. Identify challenges and opportunities for incorporating refugee populations into professional home health services

Objectives

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Home care is a branch of community health which includes:– “A range of medical and therapeutic services as well as other services

delivered at a patient’s home or in a residential setting for promoting, maintaining, or restoring health, or maximizing the level of independence, while minimizing the effects of disability and illness.”

Home health has been shown to:– Reduce the rates of hospitalization and ER use– Improve functional outcomes and chronic disease management

Caffrey et al., 2011; National Association for Home Care & Hospice

Home Care

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• Founded In 1978 By CEO, Louise Woerner

• Uses research-based quality improvement and continuing education to provide the highest standard of care possible, gaining National recognition

• Employs a diverse workforce of both internal and field staff

• Large expanding organization – Expansion across Upstate NY began in 2010– HCR provides home care in 19 counties across

HCR Quick FactsEmployees:

690Average Daily Census:

2,215

Accolades • 2011 Home Care Elite - Top 100

Agency– 6 years in Top 500 – One of 42 agencies to achieve this

Nationally

• Winner of the Rochester Business Ethics Award

• “Employer Of The Year” and “Best Places To Work” Awards

• “Breakthrough Award” by the Transcultural Nursing Society

• Publications in translational research

HCR Home Care Background

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HCR’s Services

• Skilled Nursing• Physical Therapy• Occupational Therapy• Speech and Language Therapy• Medical Social Work• Registered Dieticians• Home Health Aides• Personal Care Aides

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• A newly-diagnosed, change, or decline in condition

• Frequent hospitalizations or emergency room use

• Difficulty leaving the home or is ‘homebound’

• Teaching Needs: disease process, injections, I.V. therapy, etc.

• Diabetes: newly-diagnosed, uncontrolled, unable to self-manage, or requiring education

• Therapy Needs: Physical, Occupational, Nutritional, and Speech

• Unsteady gait, falls, or fractures, joint replacement recovery

• Medication management needs

• Unhealed wounds requiring management

Qualifying for Home Care Services

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• Minority groups are disproportionately underrepresented in homecare, despite their need and documented risk for increased complications related to chronic illness conditions

• Nurse leaders at HCR noted health disparities and lack of access to community resources among diverse groups in Monroe county

• Refugees were identified as a sub group of the population at particular risk for marginalization and poor health outcomes, and with needs that could be met by home care

Caffrey et al., 2011;Healthy People 2012; Young, 2003

Background

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• The health and social needs of refugees match closely with the services provided by home care – Few referrals being made despite this documented need

• Home care is uniquely poised to offer community health services to this population– Potential to promote and improve health – Decrease disease burden on refugees as well as healthcare system

• Purpose of pilot project:– To create a home care team using Leininger’s Theoretical Foundation

to better serve the needs of vulnerable refugee populations in Rochester, NY

Significance of Home Care for Refugee Adults

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Building a Team

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• Home care professionals were selected from within the organization

• Grant funding allowed for the creation of a community liaison position

• In-service for homecare providers on refugee health issues

• Outreach with prominent refugee community groups, advocacy organizations and healthcare providers

Building a Team

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Once a referral is made:• Refugee patients assigned to the team

• Community Liaison used to prearrange visits and covisit

• Skilled nurse performs initial assessment and refers in other services, as needed

• Contacts identified at PCP offices to facilitate communication with the provider and assist with planning for MD visits and transportation

• Work with local organizations when appropriate to coordinate other community services

Referral and Admission to Home Care

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Results

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Demographics*(Patient Gender & Insurance)

Quantity (Patients)

Percentage (Patients)

Gender

Male 19 40%Female 29 60%Insurance

Medicaid 43 90%Medicare 1 2%Dually Eligible 4 8%

Demographics*(Age of Patients)

Average Range

62.9 years 37 – 96 years

*Total quantity of patients (n) = 48*Episodes of care from 1/1/13-6/1/14

Demographics* (Length of Episode)Average Range

41.5 days 1 – 120 days

Demographics and Diagnosis

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Services Rendered During Home Care Episode

Service Total

Physical Therapy 25Occupational Therapy 16Medical Social Work 8Home Health Aide 4Dietician 2Telehealth 3

Demographics*(Patient’s Country of Ethnicity)

Quantity (Patients)

Percentage (Patients)

Somalia 19 40%Bhutan 19 40%Ethiopia 1 2%Liberia 3 6%Cambodia 1 2%Burundi 1 2%Burma 2 4%Sudan 1 2%Vietnam 1 2%

Demographics and Diagnosis

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Primary and Secondary Medical DiagnosesDiagnosis Total Quantity

(Patients)Percentage (Patients)

Uncontrolled Hypertension 21 44%Uncontrolled Diabetes 18 38%Uncontrolled Pain 9 19%Wounds and/or Infections 7 15%Respiratory Conditions(ie Asthma, COPD)

7 15%

Atrial Fibrillation 2 4%Congestive Heart Failure 0 0%

Demographics and Diagnosis

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ADL Functions*Outcome Improvement Stabilization Decrease N/A

Toileting 15 (56%) 11 (40%) 1 (4%) 0Ambulation 24 (89%) 2 (7%) 1 (4%) 0Dressing 14 (52%) 11 (41%) 2 (7%) 0Bathing 21 (78%) 5 (19%) 1 (3%) 0Transferring 18 (67%) 7 (26%) 2 (7%) 0Oral Medication Management 18 (67%) 9 (33%) 0 0

Injectable Medication Management

7 (70%) 3 (30%) 0 17

Pain Management 17 (71%) 6 (25%) 1 (4%) 3

*Total quantity of patients (n) = 27

Home Care Outcomes

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Discharge Status*Discharge to Community with Formal Assistance 5Discharge to Community with No Formal Assistance 22

*Total Quantity of Patients (n) = 27 -Data consists of patients with completed episodes through 6/01/14

Three (3) emergency room visitsOne (1) hospitalizationOne (1) death at home

Home Care Outcomes

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• Greetings first

• Want you to share tea or food with them (want to thank you)

• Texting is often more successful than phone calls

• Value children and large families and want them incorporated in their care – Some groups may practice polygamy

• Main issues of care are related to mobility, pain control and chronic disease

Issues Related to Home CareHolding Knowledge

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• Remove shoes in the home

• Prayer is 5 times a day – Will not answer phone, door, nothing when in prayer

• Friday is prayer day (go to mosque Friday afternoons)

• Ramadan– Month of fasting, nothing by mouth during the day

Issues Related to Home Care: SomaliHolding Knowledge

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• Tremendous issues around adapting to U.S. culture and its effect on the family structure

• Social determinants of health (transportation, financial, unsafe neighborhoods)

• Restructuring traditional home health service model

• Coordination of interpretation services

• Same gender preferences (may refuse services if not available)

• Community Liaison position, staff

• Tracking data

Challenges

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• Many of our patients have expressed satisfaction with our services both to us and to their PCP’s

• PCP offices have also expressed satisfaction with our services

• Families are often incredibly supportive and participatory in plan of care

• Have had good home care outcomes

• Continue to grow and accept new patients

• Continue to work with other organizations to employ people from the refugee communities

• We can be a resource, for time and for mental health

Successes

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Questions?