Sharing the Stories…
“The health care systems have become more complex and this causes barriers
and challenges for individuals who need to access and navigate their own
health care benefits.” (NASW, 2012)
Needs
Assessment
Rapport/Trust
Community
Resources
Advocacy
Follow Up
/
Consistency
Needs Assessment

Community Health Assessment Tool, developed
by Kent Cova-Suarez, outlines the basic
psychosocial needs of individuals and their
families

Within the assessment are all the basic social
determinants of health

Role of CHW in an integrated medical setting is
to assess the patient/family to inquire about unmet
needs, desires, and goals

Assessments occur by means most accessible to the
patient/family

Assessment is person centered
Rapport-Trust

As is similar in all professional-patient relationships, trust MUST be established for progress to
occur


“When there is no trust it becomes harder to get anything
done”
Person-centered interviewing/assessing allows for the patient/family to share THEIR story and
guides us in identifying what they feel are their highest needs.

If ‘needs’ are subjective it becomes the responsibility and role of the patient to identify those needs while the
professional provides the clinical judgment to either agree or disagree, this also helps the patient build on
their strength of self-determination.

An automatic distrust may be evident when working with patients who have sought refuge in a foreign
country due to trauma, war, persecution, etc. Understanding where the distrust comes from and allowing for
the development of the professional-patient relationship to occur can/will demonstrate to the patient that you
have an invested interest in their care.

Establishing rapport opens the gateways for services to become more effective and efficient.
Community Resources

One of many roles of CHW is to be a constant
‘hub’ for community resources

Patient/family system has arrived in a new
FOREIGN area, they are unfamiliar with the
systems, processes, agencies, and array of
resources

Educating on local resources to meet basic needs

Going further, resources for social needs, spiritual
needs, religious needs, etc.

Actively being the bridge between the patient and
the community resource until they are able to ‘form’
their own bridge/gain independence in accessing
community needs

Needs: Housing, education (school for children),
food supports, employment, financial assistance,
religious facilities, ethnic food stores, transportation,
family supports, etc.
Advocacy

What is advocacy?


The assurance that:

“…guarantee the human services and education needs of all children are met regardless of their or
their parent’s legal status.”

“ensure access to language-appropriate services in the form of interpreters, translated documents, and
other resources as needed.”

“provide refugee resettlement programs adequate in length and substance to include English language
training, trauma and mental health counseling, and job readiness and placement.”
How does one advocate for refugee patients (all patients):

Professional positions have POWER. Recognizing YOUR position, how it relates to that of your
patient, and using your voice (POWER) to help your patient be heard and understood

Assuring needs are met by referrals to community agencies

Listening to needs patient identifies and helping to fulfill those needs

Follow up with agencies and persons/families to guarantee completion of task

Follow up is key in the process. Unmet needs cycle back and usually do so in crisis situations.
Follow-Up/Consistency

Building rapport is on-going. Patient will
continue to trust the working relationship if
they continue to see your support

Consistent with advocacy, follow up on
referrals, services, needs assessment can
eliminate the cycle of unmet needs

Current unmet needs turn into future unmet
needs, future unmet needs adversely affect a
patient’s health both today and in the future

Follow up ensures services and supports that
are in place have a plan for duration,
consistency, and efficacy.
Sharing the Story of ‘Family A’

Family presented to ODHC via an advocate
from a local organization

Father, mother (expecting at the time),
son 12 yoa, son 8yoa , and daughter 2
yoa
Homeless, but living with a community
member or a short-term period

Mother had not yet seen a doctor for her
pregnancy

Son 12 yoa, significant health conditions
as reported by father and mother

Arrived knowing less than 5 people in
the state and unfamiliar with how to
navigate the complex health and human
services system in MN/U.S
No basic needs items except briefcase
with medical records (son’s) and
suitcase with clothing

Lacked healthcare insurance coverage

Financially unstable
Family in crisis situation (having just
left refugee camp in similar conditions)

No plan for children to receive
education (parent’s TOP priority)

Little social supports
Arrived at clinic on 05/29/15

Reportedly arrived in St. Louis, MI on
05/25/15 and moved to MN to be closer
to a family friend (community
connections)

Psychosocial Assessment of Family upon
arrival to our clinic:




‘Family A’

First steps:



Met with father of the family in a
private room with community advocate
also serving as an interpreter

First set of referrals:

Family scheduled same day medical
appointments for mother and son.

They were both assessed by ODHC
physician within 2 hours of arriving in
the clinic doors
Father identified the families primary
needs as: medical attention for his
pregnant wife, medical attention for his
oldest son, and getting his children
connected with the education system

CHW identified needs as medical
attention for mother and son, applying
for healthcare insurance for entire
family, and finding adequate housing as
their stay with a friend was only going
to be brief in nature
Appointment schedule for following
Monday (06/01/15) with ODHC MN
Sure Enrollment Navigators to
complete healthcare insurance
application

Family connected with local Minnesota
Council of Churches organization for
housing needs/assistance
‘Family A’
(continued)

Second set of referrals:

Connection with Nicollet County Human
Services department for application of food
support/financial assistance programs

Mother: WIC and regularly scheduled OB/PCP
appointments

Son: referral to specialty pediatric provider

Salvation Army contributes household items and
vouchers for additional clothing

Children are connected with local school and
registered for Fall 2015 school year

Father referred to county employment assistance
program for refugee’s and immigrants

Housing


Family moved into own home with assistance of MCC
and local action council on 07/01/15
Altruism in Community Supports

Community members donated household items
including beds, living room furniture, kitchen
items, children’s school supplies, toys for
children, bedding, clothing, bathroom items, etc.

CHW conducts home visit to deliver items and continue
building rapport with the family


Home visits: assessment of home environment to better
identify additional barriers
Father gains employment at local factory, with very
limited understanding of English

First of several jobs over the course of next 2 months

Barriers to secure employment included lack of
transportation, limited understanding of English language,
and additional stressors of living in completely new
environment
Trials and Tribulations

08/01/15 family becoming acquainted with
‘system processes’ including being able to
effective schedule needed medical appointments,
using their local pharmacy for prescriptions,
shopping at local grocery stores, and father
acquires means of transportation via a bicycle to
get to and from employment

Family is still quite isolated in the community,
however, they have connected with some
community members from similar cultural
background, father is able to car pool to and from
work

Oldest son attends specialty appointment on
07/28/15 (transportation and interpreter
arranged). Treatment plan includes multiple
surgeries

Children begin attending school on 08/17/15
Acquaintance with Community
and New Home

09/15/15 all family members have
thoroughly completed Refugee
Health Assessments

At this point family has identified
support persons at ODHC and
routinely call with valid and
informative questions (resources
are disseminated as needed)

Oldest son’s pre-op for surgery is
scheduled

Set backs in medical condition and
education to the family on severity
(or lack there of) push surgery
dates back to 12/15/15
‘Advocacy, to
change “what
is” into “what
should be”’
‘Family A’ in their new home

12/15/15 oldest son completes initial surgery, second surgery schedule for 02/2016

Mother delivers child #4, daughter, on 12/21/15

Children continue to regularly attend school. English has improved significantly for
the 2 school aged children as well as father

Father continues to hold stable employment at local factory

Family routinely schedules needed medical/dental/community health
appointments at ODHC

ODHC ‘see’s less’ of the family these days…why?

Community supports are in place

Family is stable in their environment

They have slowly integrated into their new home and culture

They are educated on resources and ‘where to go for what’
Timeline Process and Team Involved

Met family on 05/28/15, 01/2016 family continues to strive towards integration into their community



Initials goals set with family are still in progress (ex: son’s surgery), however, many of the goals have been met
Community Health Worker’s role in the ENTIRE process is vital

Advocate

Resource ‘hub’

Cultural broker

Coordinator of care

Familiar community agent/trust established

Routine and consistent follow-up
Other professionals/agencies involved in process

ODHC Staff: Medical providers, social workers, CHW, MN Sure Navigators, interpreters

Minnesota Council of Churches

Blue Earth and Nicollet County Human Services

Minnesota Valley Action Council

Mankato Salvation Army

Somali Community Barwaaqo Organization

Gillette's Children's Specialty Clinic

St.Peter Public Schools
Sharing the Stories…
“The health care systems have become more complex and this causes barriers
and challenges for individuals who need to access and navigate their own
health care benefits.” (NASW, 2012)
Needs
Assessment
Rapport/Trust
Community
Resources
Advocacy
Follow Up
/
Consistency
References

National Association of Social Workers. (2015).Social work speaks: 2012-2017
Policy Statements (9th ed.).Washington, DC: NASW Press.

http://www.health.state.mn.us/divs/idepc/refugee/backgrd.html

http://www.who.int/social_determinants/advocacy/health-post2015_sdh/en/