The Medical School’s annual meeting for minority health policy research, which took place on May 3, set a wide-angle lens on health care disparities, offering a surprisingly broad view of socioeconomic and cultural barriers to high-quality care.
Seven fellows gave practicum presentations whose topics ranged from access to oral care for developmentally disabled children in migrant farm worker families to a comparison of chronic disease self-management in communities around the world. These presenters were joined by three fellowship alumni who also gave talks and by keynote speaker Deborah Prothrow-Stith, HSPH professor of public health practice, who addressed the relationship between violence and disparities. The fellows came from the Commonwealth Fund/Harvard University Fellowship, the California Endowment Scholars Program, and the Joseph L. Henry Oral Health Fellowship.
Commonwealth Fund/Harvard University fellow Ann Kao studied the health care utilization patterns of refugees at MGH Chelsea health care center, specifically exploring whether the center’s refugee intake program led to improved utilization and quality of care in the 24 months following program entry. The U.S. Refugee Act of 1980 standardizes the resettlement services for all refugees, and Massachusetts offers a comprehensive Refugee Health Assessment Program, including two intensive medical visits, social services, and support groups.
Little was known about the long-term effectiveness of the program at Chelsea, which has a total of 100,000 patient visits each year. Kao also asked whether the successful aspects of the program could be extended to other immigrants.
The approach to refugee care has been comprehensively organized at MGH Chelsea for about five years and standardized for the last three or four, Kao explained. The program has a case manager, who is a former refugee, translators, and culturally matched social workers. The health care providers have training in refugee issues.
In observing patient care at the health center and developing her investigation, Kao noticed that the refugee patients did not use the urgent care center as much as other immigrant groups. “There’s something that’s being done right in the primary care clinics,” she realized.
Studying refugees who had begun the intake program between January 2004 and March 2005, Kao looked at the proportion of missed appointments versus scheduled appointments, the number of visits to the emergency room and urgent care center, several basic measures of care quality, and insurance status after 24 months. Most of these refugees come from Africa or central Asia.
Kao found that in the refugee group, adults had an 18 percent no-show rate for appointments and children an 8 percent rate. For all patients at the center, adults had the same no-show rate while children had a 22 percent rate. Further, about 19 percent of adult refugee visits and 6 percent of pediatric visits were to the emergency room or urgent care center. In contrast, 20 to 30 percent of all visits to MGH Chelsea are for urgent care.
After 24 months, 88 percent of the adult refugees and 92 percent of the child refugees were enrolled in some form of insurance. Overall, in the United States, immigrants have a 44 percent uninsured rate, Kao said.
Approximately 97 percent of the adult refugee patients at Chelsea had at least one blood pressure measurement recorded in the period studied, and all of the pediatric refugee patients had immunizations recorded.
“This data does suggest that a comprehensive team evaluation in a refugee population, which is a difficult population to capture and has very low health literacy, really can lead to improved utilization of health care services, decreased emergency and urgent care visits, as well as improved navigation of public insurance programs,” Kao said. She is now studying immigrant control groups and investigating whether the same approach can be extended to them.
In her keynote on violence and disparities, Prothrow-Stith addressed the audience directly, urging them to develop their empathy for people touched by violence. Another person’s experience of violence is easy to discount, she said.
“While I’ve spent 20 years working on violence prevention and handling anger and teaching conflict resolution, I really have underestimated the fear and the anxiety and the stress of the little boy who watches his mother beaten on Sunday, comes to school on Monday, and is expected to behave like all the other children. I think you and I have to very intentionally increase our empathy, our understanding, and probably the best way to do that is get close to the stories, listen to the stories.”
The annual meeting was introduced by Joan Reede, HMS dean for diversity and community partnership, whose office holds the event each year. In addition to the talks on May 3, the program featured poster presentations by Dana–Farber/Harvard Cancer Center junior investigators.
