Using Data to Respond to Farmworkers’ Needs across the State

Influencing State-Level Policy on Behalf of Farmworkers

Quantifying Outreach Services Using Relative Value Units

Tracking Farmworkers Using ID Cards

Tracking Effectiveness of Outreach with Incentive Cards

Using Technology to Increase Medicaid Application Process for Farmworker Children

Surveys and Screenings Identify Health Needs

Using GIS to Improve Outreach Services

Assessing Patient Satisfaction

Satellite Link in the Field

Provider and Caseworker Team Visits to Housing Camps

Using MiVia and Telemedicine Technology to Increase Access to Specialty Care

Encouraging Home Gardening through the Raíces (Roots) Program

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Using Data to Respond to Farmworkers’ Needs across the State
2007, North Carolina Farmworker Health Program top

As a statewide voucher program, NCFHP developed a customized data tracking and documentation system, Farmworker Health Administration System Electronic Services (FHASES), in collaboration with a volunteer computer programmer, to ensure consistent tracking of services at its 14 voucher sites—including medical, enabling, and outreach services. Each of the voucher sites uses standardized health assessment and encounter forms during outreach and the data documented on these forms are then entered into the FHASES program. Because FHASES is web-enabled, data are updated immediately and they can be viewed in real time by staff at NCFHP’s office in Raleigh. NCFHP staff use the data to: 1) examine trends in the services being provided at each of the sites; 2) review the needs of each site and its respective farmworker population; 3) plan programs and services with each of its sites; and, 4) develop relevant health education lessons that respond to emerging farmworker health issues.

Because outreach staff can input data into FHASES wherever they have internet access, they have been able to more effectively keep pace with data entry which used to be difficult to manage in a timely fashion. As a result, NCFHP staff has a much truer picture of farmworker and service needs at each of the sites across the state. The program FHASES, which can be used by any organization with multiple sites, allows NCFHP to consistently and effectively track outreach and medical services and make data-driven decisions for increased funding and/or targeted health interventions, including health education that responds to local needs. Data-driven decision-making also facilitates the rationale and effective use of NCFHP’s limited financial resources and ensures that as many farmworkers as possible access health services in North Carolina.


Influencing State-Level Policy on Behalf of Farmworkers
2007, North Carolina Farmworker Health Program top

NCFHP participates in several state-level task forces in order to influence policy and be a voice for farmworker issues. Because farmworkers are not always included on certain policy and programmatic agendas, NCFHP strives to ensure that policymakers are aware of their presence in the state and their unique needs. In 2006, NCFHP made significant contributions to the North Carolina Office of Minority Health and Health Disparities’ (OMHHD) Hispanic Health Task Force and the North Carolina Emergency Management Human Services and North Carolina Department of Health and Human Services Disaster Coordinator's committees.

Through involvement on the Hispanic Health Task Force, NCFHP staff were able to inform the development of a Community Health Workers curriculum used for a Lay Health Advisor Program. Originally, the curriculum only addressed issues affecting Latinos in the state as a whole, overlooking farmworker-specific demographic data and cultural information. NCFHP staff highlighted the unique vulnerabilities of this population and shared information on popular education techniques that are effective with farmworkers. As a secondary and unexpected result of this effort, the OMHHD now collects and disseminates farmworker demographic data and health information on their Latino Fact Sheets.

As a result of increased advocacy and education with the two emergency management and disaster committees, consideration for the state’s farmworker population has been incorporated into emergency response plans. Before NCFHP’s participation on these committees, disaster response agencies were relatively uninformed or unaware about farmworkers and their unique lifestyles and living conditions that impact these organizations’ abilities to respond effectively. NCFHP recently trained state disaster coordinators on issues such as the barriers farmworkers face in accessing emergency shelters, the challenge of communicating with non-Spanish speaking emergency responders and how to provide financial reimbursements to farmworkers during the recovery period when they have already left the area. Though these efforts are relatively new, it is anticipated that the critical discussions started by NCFHP will ensure that North Carolina farmworkers are no longer overlooked when emergencies occur.


Quantifying Outreach Services Using Relative Value Units
2007, Columbia Basin Health Association top

Columbia Basin Health Association (CBHA) has been working diligently to quantify and get credit for the outreach services it performs—a challenge that many health centers face. CBHA has found that the role of these services is often undervalued because it is very difficult to measure. To address this, CBHA has implemented the use of relative value units (RVUs) as a way to quantify individual outreach activities in the same way that clinical interventions are assessed and tracked. In order to modify this system to benefit outreach, CBHA worked with a consultant to assign a code and an RVU to each routinely performed outreach activity. The RVU is determined based on the time commitment and intensity level of each activity. For instance, a 45 minute individual health education session is assigned 1.17 RVUs while 30 minutes devoted to assistance with forms completion is assigned 0.60 RVUs.

Using the assigned codes, outreach workers indicate on their encounter forms which activities they performed and the length of time involved. Once this information is in inputted into CBHA’s data management system, the codes are automatically converted into RVU values. The information is reviewed monthly and used to allocate internal resources, determine staffing plans and inform future grant applications.

Even though outreach breaks down the barriers that farmworkers face when trying to access medical care, it can be difficult to maintain support for outreach services. At CBHA, developing a standardized system for tracking outreach activities has been a key step in demonstrating the value of and making a case for the necessity of outreach. By assigning RVUs to various outreach activities and analyzing the data periodically, CBHA’s Program Director is able to measure staff productivity more concretely, gauge the effectiveness of outreach efforts and justify funding for future outreach activities. Perhaps if more farmworker-serving health organizations like CBHA tracked their outreach activities using a standardized system, a stronger case could be made for reimbursable outreach services or increased funding of outreach.


Tracking Farmworkers Using ID Cards
2007, St. Bernadette Catholic Church top

St. Bernadette Catholic Church partners with area non-profit organizations and congregations to meet farmworker needs. St. Bernadette’s offers a screening clinic on Sundays after mass. Farmworkers who need follow-up care are referred to the Wake County Human Services Migrant Farmworker Health Program. During outreach visits to camps, outreach workers provide farmworkers with laminated ID cards, which often serve as the only identification many farmworkers possess. One side of the card includes information for providers: the individual’s name, date of birth, and instructions for accessing the patients’ medical records. The reverse side has instructions for the farmworkers: a welcome note in Spanish that explains the use of the card and that they should call 911 in case of emergency. The ID card also includes the name of the individual’s camp and the date of issue. The cards are linked to a master log sheet referred to regularly by outreach and clinical staff.

The identification card system enables the farmworkers to have a handy telephone number that they can call for assistance, offering a degree of ownership and self-direction regarding their health care. The farmworkers no longer have to wait for an outreach worker to discuss concerns or request an appointment. The master log sheet allows St. Bernadette’s outreach team to easily locate clients for follow-up and appointments. The ID cards have reduced language barriers faced by non-Spanish speaking outreach volunteers in the past. The ID cards provide consistent birthdates and spellings of farmworkers’ names and therefore, do not require that volunteers be able to converse in Spanish with the farmworkers to solicit this information.

The cards have also improved data management by enabling the church to track the types of visits to the clinic and determine if there are clusters of diseases or injuries among or within camps. These epidemiological data have been used in community advocacy efforts and to train volunteers on what they can expect to see at screening clinics and when they do outreach. An unexpected benefit of the ID system has been the calls from growers, emergency rooms, and hospital wards on behalf of the card holders in their care seeking the church’s assistance for their farmworker employees or patients.


Tracking Effectiveness of Outreach with Incentive Cards
2007, Clinicas del Camino Real, Inc. top

Clinicas del Camino Real, Inc. (“Clinicas”) has implemented several strategies for tracking how many patients are brought in as a result of outreach activities. One strategy is to distribute pre-printed incentive cards to potential farmworker patients during outreach. Outreach workers fill out the incentive cards which include the name of the outreach worker, site visited, date, and time. When farmworkers see a provider and present the incentive card, they receive a $5 gift card. The data from the incentive cards returned to the health center are entered into a computer program for periodic analysis. In the case of patients who forget to bring in the incentive cards, the Director is considering administering a questionnaire, asking them about how they learned about Clinicas. These data would be reviewed in the same manner as the incentive card data.

Though this strategy was just recently implemented, tracking data from the incentive cards will allow the Program Director to measure and assess the cost-effectiveness, efficiency, and productivity of outreach activities carried out at Clinicas’ various sites by determining which outreach activities and staff members are generating more clinic visits. The Director believes it will be helpful for making programmatic decisions about the use of human and financial resources; for adjusting outreach methods to achieve optimal effectiveness; and for providing evidence about the outreach program's effectiveness to the head of the health center and potential funders.


Using Technology to Increase Medicaid Application Process for Farmworker Children
2006, La Clinica de Familia, Inc. top

La Clinica de Familia, Inc. (LCDF) Health Promoter Program equips its health promoters with digital cameras and portable scanners to assist in the process of registering farmworker children for Medicaid benefits. The health promoters carry this equipment with them during their home-based care visits and make copies of all key documents necessary for Medicaid applications. They then take the copied information back to health center and submit the applications for the farmworker families in order to expedite their access to financial coverage of health care for their children.

The scanning service offered during home visits has greatly increased the volume of children getting registered for Medicaid and has freed up the health promoters’ time to do other outreach activities because they no longer go back and forth between clinic and farmworkers’ homes with Medicaid application documents. Farmworker families no longer have to miss work to apply for Medicaid nor do they have to worry about losing or damaging critical documents by carrying them around. When farmworkers return to the area after migrating, they only have to provide income verification to get their children reinstated with Medicaid since copies of their documents are on file at the health center.


Surveys and Screenings Identify Health Needs
2005, Panhandle Community Services, Community and Migrant Health Center top

The staff of PCS actively support many health and research initiatives designed to identify and respond to the needs of their community. In 2003, PCS initiated the Southwest Nebraska Migrant Study, which involved conducting surveys, extensive health screenings, and chart reviews to identify the health needs and barriers to care for the MSFW community. Goals are set by using study results to establish a baseline and are compared against national goals like the Healthy People 2010 goals. PCS used the findings of this study to modify the Migrant Health Program’s strategic planning, functions, and outreach activities.

PCS is using comprehensive needs assessment results to develop a new model of care for migrant and seasonal farmworkers. They have applied for Expanded Medical Capacity and are attempting to build on the local infrastructure rather than trying to develop competing clinics. Although PCS currently works within a voucher system, it is trying to move toward a unified health care model, where all participating providers would maintain farmworker patients’ records in a networked, “paperless” system.


Using GIS to Improve Outreach Services
2005, Panhandle Community Services, Community and Migrant Health Center top

PCS uses multiple methods to identify the needs of the migrant population in the region. One particularly innovative method is the use of Geographic Information Systems to map key geographic barriers to care and to support program planning and funding efforts. By laying local maps over maps produced from the 2002 U.S. Department of Agriculture national census, PCS was able to identify the farms in their region using farmworker labor.

Using the advanced technology of GIS has led to a vast increase in PCS staff awareness of the use of migratory labor in the region and subsequent identification of MSFWs living and working in the region. PCS has been able to reallocate a limited amount of resources and place an outreach worker in the region. It has also added a Mobile Health Clinic that supports direct field screening and limited clinical and laboratory services, thereby significantly increasing access to care for farmworkers in extremely remote locations.


Assessing Patient Satisfaction
2005, Salud Para la Gente top

At Salud Para la Gente outreach staff conduct a quarterly telephone survey and focus group to assess satisfaction with center services in an effort to continually improve services to farmworkers. The survey and focus group ask participants who have visited the health center in the last quarter questions regarding satisfaction with services; the quality of treatment received at the clinic; satisfaction with staff interactions, all the way from the receptionist to the doctor; and for recommendations on how to improve services. The survey is conducted mostly in Spanish with about fifty people each quarter. Results are shared with the Board of Directors, senior staff, and some of Salud Para la Gente’s funders.

Salud Para la Gente has improved upon efforts to evaluate patient satisfaction by conducting organized and quarterly assessments with large numbers of patients. Their efforts give farmworker patients a greater voice in the services they receive at the health center, and help to further build a relationship between the health center and the farmworker community. By sharing results of the survey with the Board of Directors and funders, Salud Para la Gente demonstrates its commitment to applying the information it receives and monitoring the results of any changes in the coming quarters.


Satellite Link in the Field
2005, North County Health Services top

North County Health Services uses a satellite communication system that allows staff in their mobile clinic to have immediate access to patient registration, billing records, and lab results from the health center system from their laptop computers. Using the new communication system, staff in the Mobile Clinic can also remotely complete new patient registrations and create an electronic file for patient records. The Mobile Clinic reaches out to farmworkers everyday in housing camps, nurseries, and in the fields.

In implementing this system, North County Health Services took advantage of the resources they already had in house – a relatively small geographic area and laptop computers on the mobile clinic – and used them to improve services with a satellite link-up. NCHS chose this system over other, more expensive alternatives to linking mobile clinic services to the health center such as using PDFs or other telemedicine alternatives. By implementing the Mobile Clinic’s communication system, North County Health Services enabled outreach staff to network to its central information system, significantly speed up their patient registration process, and improve outreach services NCHS provides to farmworkers in the places they work and live.


Provider and Caseworker Team Visits to Housing Camps
2008, Finger Lakes Migrant Health Care Project, Inc. top

Finger Lakes Migrant Health Care Project, Inc. (FLMHCP) has contracted with a voucher site provider to visit migrant housing camps in the counties that they would normally serve in private practice. The clinical provider sees patients in their homes, observes their living conditions, and meets their family members in order to get a more holistic understanding of the factors influencing the patients’ health. On such visits, the provider is accompanied by a FLMHCP bilingual/bicultural case manager to provide assistance and serve as a patient advocate. The case manager organizes follow-up care including making arrangements for and covering the costs of transportation for patients to be seen in a clinical setting if necessary.

This program gives clinical providers a rare opportunity to experience first hand what the farmworker deals with at work and home. The case manager provides a constant link for the patients so that wherever seen, there is a familiar face. In addition, patients receive care without needing to travel. This is especially important for routine screenings that may not seem worth a trip to the clinic but which often uncover more serious diseases such as diabetes, hypertension, and hepatitis.

Though providing medical services in isolated areas is difficult because doctors often lack access to their patients’ prior medical histories, in this program, a medical chart is created for each patient using MiVia software. MiVia is a secure, web-based, and patient-driven Electronic Health Record program that allows patients to go anywhere in the world and give any provider access to their health records. The in-camp providers bring internet-accessible laptops, in order to look up patients’ previous medical care. This approach prevents the duplication of services, such as blood work and immunizations, that may have occurred at other clinics and it also allows for the tracking of medications.


Using MiVia and Telemedicine Technology to Increase Access to Specialty Care
2008, Finger Lakes Migrant Health Care Project, Inc. top

Finger Lakes Migrant Health Care Project, Inc. (FLMHCP) has teamed up with a major regional hospital to provide access to a variety of healthcare specialists for migrant and seasonal farmworkers using both telemedicine equipment and MiVia software.

Prior to an appointment, a FLMHCP clinical provider enters all of a patient’s vital information as well as notes on past interactions. On the day of the visit, the patient is accompanied by a bilingual case manager into the clinic the farmworker normally visits. By then, the off-site specialist has already accessed the patient’s record using MiVia, and is aware of the patient’s health concerns and important medical information. Using telemedicine cameras and digital diagnostic instruments such as otoscopes, stethoscopes, and cameras, the visit is conducted just as if the specialist were in the room with the patient except that a trained nurse provides the hands-on piece of the exam, under the specialist’s direction.

Thanks to this system, patients do not lose an entire day of work because of a trip to a specialty care center in a distant city, yet they gain access to top specialists. Also, FLMHCP’s case managers are more efficient because they do not have to drive long distances nor spend most of a day with one patient. A new component of the program is the use of a portable camera to transmit video images back to providers in the clinic. The camera will be used in farmworkers’ residences so that they will be able to access specialty care without having to leave their homes. The telemedicine program is effective, but more importantly, it addresses transportation barriers while assuring that patients have access to high-quality health care in a setting with limited providers.


Encouraging Home Gardening through the Raíces (Roots) Program
2008, La Clínica del Cariño Family Health Care Center, Inc. and Nuestra Comunidad Sana, a program of The Next Door, Inc. top

Raíces, a partnership program of La Cliníca del Cariño’s (LCDL) Vida Entera y Sana project and Nuestra Communidad Sana (NCS), encourages farmworker families to reconnect with their cultural roots of growing their own food, adopting healthier food choices, being more active, coming together in community, and taking pride in reconnecting with their history. The objectives of the Raíces program are: 1) to encourage families to grow home gardens using organic methods; 2) to build community, social support, and self-sufficiency through gardening in ways that honor Latino cultural traditions; and, 3) to examine the impact of gardening on eating habits and food security.

Raíces has completed three growing seasons, with a total of 46 families participating and 287 people touched by the program. Participants were first invited to attend an orientation where healthy food was served. The families continued to meet regularly to socialize, and share information, tips, and extra vegetables. Families taught each other canning and freezing methods to battle food insecurity year round. Those without gardening space were encouraged to use the clinic’s community garden or other creative alternatives. A Harvest Fiesta is held each fall with music and a piñata for families to enjoy the fruits of their gardens together.

The dramatic impact of Raíces is demonstrated by data gathered on families before and after having a garden. The number of adults eating vegetables several times a day increased by 140% (117% for children). The number of adults skipping meals because the family ran out of money decreased by 78% (100% for children). In addition, Raíces has helped to: 1) teach children that vegetables are rewarding, delicious, and nutritious; 2) create health promoter families who continue to take leadership in the community; 3) re-establish the cultural norm among Latino farmworkers of growing their own food; and 4) counteract the societal norm of “produce deserts” in poor areas.