Boosting Preventive Care Access in Immigrant Patient Populations

For the mostly immigrant population Silvia Posada sees at her organization, Essen Health Care, patient access to care—particularly preventive care and chronic disease management—isn’t a given.

Many of these patients don’t just walk into their regular, yearly physicals, and they aren’t always detecting chronic illness and keeping up with management, Posada, Essen’s senior vice president of network development, said. Immigrants face serious patient care access barriers, she emphasized, ranging from socioeconomic issues to health literacy to English language proficiency.

“Most of the Latinos that are in our community are immigrants and they come here and they right away enter into survival mode,” Posada said in an interview with PatientEngagementHIT. “How do I make enough money in order to be able to feed my family and at least have a roof over their head? That takes precedence over educating themselves on the opportunities and the access that is available in terms of getting care.”

According to Posada, a lot of immigrants don’t access medical care, especially primary and preventive care, because that just wasn’t the standard in their home countries. Healthcare was expensive over there, she said, and so when immigrants arrive in the United States it’s reasonable to assume healthcare access will be equally as cost-prohibitive.

In fairness, healthcare access can be extremely cost-prohibitive in the United States. People living in the US are more likely than those in any other similarly developed nation—mostly European countries and Australia and New Zealand—to forgo care because of high out-of-pocket costs.

But the image is starker in the less-developed nations many of the immigrant patients visiting the Bronx-based Essen come from.

“If you don't have money, you don't get to see a doctor,” Posada said. “It's not a secret people die, either because they can't get access to care—they can't afford it—or they live in remote areas where they come from, so they can’t get healthcare. So, they come to the US with the same mentality and although the care is available, a lot of them don't think that it's not.”

“The idea of going to the doctor when I'm fully healthy, when nothing is hurting me, just to make sure that I can do blood work and see my provider and make sure I'm not borderline anything or to further get educated on what else I could do to remain healthy is almost nonexistent,” she added.

Essen is working to turn that paradigm on its head through tailored patient outreach and education. The healthcare provider has set a goal of ensuring every single patient receives direct messaging from Essen encouraging them to schedule their annual wellness visit. On average, Essen sends between six and eight educational outreach messages, Posada said.

The healthcare organization also puts a strong emphasis on comprehensive screening assessment during these visits to ensure providers can catch any emerging chronic or acute illnesses. The Latino population is at higher risk for diabetes, Posada said, so the organization always puts in blood orders to detect the illness.

Additionally, the organization highly prioritizes cancer screenings, particularly cervical cancer screenings. Essen’s internal data shows that most of the cancer diagnoses it makes are for late-stage cervical cancer.

But the challenges lay deeper than getting patients into the clinic; health payer coverage among even the legal immigrant community is hard, she said.

According to figures from the Kaiser Family Foundation, 31 percent of legal immigrants are eligible for Medicaid, and another 50 percent are tax-credit eligible. This comes even as nearly a quarter of lawfully present immigrants do not have any sort of health payer coverage. By comparison, only 8 percent of citizens have no health insurance.

But according to Posada, connecting even legal immigrants to health coverage is hard. There’s a lot of misinformation about how signing up for Medicaid can impact immigration status, she said, with many of the folks she sees fearing they’ll lose their immigration status if they sign up for Medicaid or other federally subsidized health coverage.

This likely stems from public charge policies from the previous administration, which instructed immigration officials to consider the social welfare services an individual will access when considering their immigration status. In other words, if the person will use Medicaid, an immigration official could theoretically deny them legal immigration status.

Data has shown that the public charge rule, which is not currently in effect, led to decreases in Medicaid and other public payer enrollment.

In reality, getting a legal immigrant on a public payer is somewhat simple, at least in New York City, where Posada’s organization is.

“The ones who do qualify, the process is very easy,” she said. “In New York City, downstate, there is a tremendous effort by the health plans that offer many of these government-sponsored programs. And there is a significant amount of community outreach. Here at Essen, we partner with them. We contract with every one of these health plans.”

Essen leaders encourage legal immigrants to explore those coverage opportunities by leveraging the deep trust they have in their communities. Community and kinship are important to immigrant populations, Posada said, and many of those folks who visit Essen have deep ties to them. Through community health partnerships, Essen uses those ties to spread messaging about insurance coverage and healthcare access.

“We also try to work with the leaders in those communities, whether it's from a religious organization or a community organization,” Posada explained. “And as patients are able to see that we've helped other individuals—that they qualify for the program and it has not affected their immigration status, that it has not affected them financially, that they don’t have to pay it back—you start gaining trust.”

That nod to community and culture has taken Essen far in the clinical encounter, too, Posada said. The organization prioritizes training a culturally competent healthcare provider workforce. When patients feel seen and respected, it increases the odds they will continue to engage in their care and with their providers, Posada said.

Ideally, healthcare would have a provider workforce who reflects the diverse communities they serve. Studies indicate patients have better experiences when they visit with a provider who looks like them and speaks their language. And although the industry is tipping its focus to diversifying medical student classes, that’s a long process and cultural competency training will be critical in the meantime.

“We're creating a lot of sensitivity training around these becoming aware of what works with each culture,” Posada said. “For the providers and the staff, to be able to instantly adapt once they're able to identify where the patient culture is, their background is, then it's very critical. And for them to be aware in their day-to-day, as they are delivering the service, it's also very important.”

Providers should consider more than just the single patient presenting in the exam room; culture affects an entire family and can ultimately affect how they engage with their own health at home.

“What are the behaviors that are triggering the developing of these chronic conditions?” Posada queried. “How can we have a more in-depth and longer-term impact in improving not only the health of the patient in front of us but also the family that they're educating and that they're taken care of?”

For example, the carbohydrate-rich diets of many Latino families could be contributing to patient health, and when it’s discussed with the parent it’s going to impact children at home.

Cultural competency or responsiveness means considering those dinnertime traditions and giving realistic alternatives to families. That level of wraparound care, in which Essen trains its providers, is what will spark meaningful health improvement.

“We're trying to really submerge ourselves into the underlying reasons of the chronic conditions and trying to understand how we can become an ally,” Posada said. “How do we become part of their cultural understanding so that we're able to make basically more impact?”

All of this is a long road to what is ultimately a simple goal: improving access to preventive care and chronic care management services. But given the complexity of the population served at Essen, taking nontraditional routes that lean on patient outreach and community engagement is key.

“Prevention is key,” Posada concluded. “And the more that we focus on that theme and the more that we're able to get people to become more interested in the term, that is what's going to get us to the finish line or at least to get us to the beginning of the finish line in terms of approving healthcare outcomes for the Latino community.”