NATIONAL ADVISORY COUNCIL ON MIGRANT HEALTH
Meeting
November 18-19, 2008
Sheraton New Orleans Hotel

• printer-friendly minutes from November 18-19, 2008 meeting

Council Members:

Rosita Castillo Zavala (Vice-Chair)
Frances Canales
Susana Castro
Enedelia Cisneros
Michael DuRussel
Jose Manuel Gaytan
Roberto Gonzalez
Jose Lopez              
John McFarland
Christina Ramos
Diana Sanchez
Emma Segarra-Gonzalez

Council Members Not Present:

Federal Staff: 

Presenters:

Public:                                                

Hilda Bogue, National Center for Farmworker Health
Brittany Collins, Salud Family Health Center
Guadalupe Cuesta, Migrant Head Start
Klara Foltyn, Salud Family Health Center 
Brian Jakes, Jr., Southeast Louisiana Area Health Education Center
Heather McLimore, Salud Family Health Center
Evan Mulvihill, Salud Family Health Center
Stephanie Suarez Del Real, Salud Family Health Center

TUESDAY, NOVEMBER 18

CALL TO ORDER AND WELCOMING REMARKS

• Rosita Castillo Zavala, Vice- Chair

Rosita Castillo Zavala called the meeting to order at 9:04 a.m. She informed the Council that Rogelio Fernandez, Robert Nimmo, and Andrea Weathers were unable to attend the meeting and conducted a roll call to confirm that all other Council members were present. Following the roll call, Ms. Castillo welcomed Council staff and guests to the meeting.

Council members reviewed the agenda for the meeting. Diana Sanchez moved to approve the agenda. The motion was seconded by Roberto Gonzales and passed unanimously.

The Council reviewed the minutes of the May 2008 meeting. Frances Canales noted that the sentence on page 19 stating that there are “no male workers” at her packing plant should read that there are “few” male workers. John McFarland moved to approve the minutes, as corrected. Christina Ramos seconded the motion, which passed unanimously.

The Council discussed whether to draft a letter of recommendation at this meeting, given the change of administration. Susana Castro stated that the Council should continue to develop recommendations, because the Council does not meet very often. Dr. Gòmez recommended the Council to move forward with recommendations. She noted that the Council reports to the Secretary of Health and Human Services. She also pointed out that the Council’s recommendations impact the internal work of the Health Resources and Services Administration and the Bureau of Primary Health Care. For example, BPHC is currently drafting a new Policy Information Notice (PIN) for outreach services in response to recommendations submitted by the Council last year.

Michael DuRussel noted that health care would be a priority for the new administration and suggested that migrant health clinics might serve as a model. Dr. McFarland stated that it would be important for the Council to provide the new Secretary with a summary of key issues in order to keep migrant health on the agenda. Ms. Castillo noted that change does not happen quickly and urged the Council to continue to be a strong, consistent voice for clinics and communities. She then welcomed the guest speakers and turned the floor over to them.

WELCOME TO NEW ORLEANS

• Tonya Pollard, Health Disparities Coordinator, Louisiana Primary Care Association
• Linda Sharpless, Chief Executive Officer, The Multipractice Clinic, Inc. (TMC)

Tonya Pollard welcomed the Council to New Orleans and provided an overview of farmworker health issues in Louisiana. She informed the Council that Louisiana is a largely rural state, and most parishes have agricultural industries. Southwest and upper southeast Louisiana have significant populations of migrant and seasonal farmworkers (MSFWs). Following Hurricane Katrina, many refugees and transient populations (largely Latino) came to assist in the rebuilding efforts in lower southeast Louisiana.

Ms. Pollard noted that Louisiana has the second highest poverty rate in the United States and has ranked 50th in healthcare for 15 of the past 17 years. Twenty percent of Louisiana residents lack health insurance. Many of the uninsured are working, often at low-wage jobs in the service sector; either they cannot afford insurance premiums, or their employers do not offer health insurance.

Ms. Pollard informed the Council that the Louisiana Primary Care Association (LPCA) was established in1982 to promote accessible, affordable, quality primary health care for the uninsured and medically underserved populations in Louisiana. Its network of 23 Federally Qualified Health Centers (FQHCs) operates 65 delivery sites that are the major safety net providers in the state’s primary health care system. Four of Louisiana’s FQHCs receive Federal grants to provide health care to special populations, including homeless, public housing residents, and MSFWs. 

In 2007, Louisiana FQHCs served more than 149,000 patients, including 793 MSFWs. The most recent farmworker enumeration study estimated that the number of MSFWs and their dependents in Louisiana increased from 7,357 in 1993 to 12,349 in 2000. Ms. Pollard noted that MSFWs rarely have access to workers compensation, disability compensation, or medical insurance and have limited cash to pay for out-of-pocket expenses. As a result, they have significantly higher rates of infectious diseases, diabetes, hypertension, tuberculosis, anemia, infection, mental health issues, substance abuse, and dental problems compared to the general population. The infant mortality rate among MSFWs is estimated as being 25 to 125 percent higher than the national average. MSFWs are also at special risk for sexually transmitted diseases, and HIV/AIDS infection rates are 10 times the national average.

Ms. Pollard acknowledged that MSFWs are reluctant to miss work to seek health care. As a result, farmworkers often postpone health care until the condition becomes so severe that they cannot work, at which point they must rely upon expensive emergency care. Ms. Pollard stated that the LPCA and Louisiana FQHCs were determined to make a difference in migrant health care. She informed the Council that Louisiana’s newest FQHC, The Multipractice Clinic (TMC), was leading the effort and introduced the Clinic’s CEO, Linda Sharpless.

Ms. Sharpless welcomed the Council to New Orleans and introduced herself to the group. She noted that although TMC was Louisiana’s newest FQHC and the only Migrant Health Center (MHC) in the state, the clinic had been providing health services to MSFWs in a five-parish area for ten years. Approximately 1,500 MSFWs and their families migrate to the area during the growing season. The number of MSFWs seeking services at TMC has grown by 30 to 40 percent each year.

Ms. Sharpless described TMC’s comprehensive health care services, which include a specialist in internal medicine, a pediatrician, a family practice nurse practitioner, a psychiatrist, a psychiatric nurse practitioner, two licensed clinical social workers, a licensed professional counselor, a podiatrist, an opthamologist, and an obstetrician/gynecologist who just joined the staff. TMC is very proud of its dental department, which consists of seven dental operatories. Through a collaborative agreement with the Louisiana State University dental school, four dental students do their final clinical rotation at TMC. This enables the clinic to provide affordable dental services to 35-55 patients per day.   

TMC has many other collaborative partners. Migrant Education Training (MET) provides vocational training to assist MSFWs in qualifying for better-paying jobs and is an integral part of TMC’s outreach effort.  The Area Health Education Center (AHEC) and the Stop Smoking Coalition provide educational materials; the Stop Smoking Coalition also provides smoking cessation programs for parents of children with asthma. The Mary Bird Perkins Cancer Center provides free mammograms and prostate cancer screenings at TMC four times per year. The Xavier University School of Pharmacy provides a licensed pharmacist and a bi-lingual medication educator.

Ms. Sharpless stated that language barriers are a major problem in rural Louisiana. TMC has a Spanish-speaking staff member in every department, including the medical and dental check-in desks. TMC also provides interpretation services to outlying facilities (by speakerphone, if necessary) and at area hospitals, as needed.

The clinic’s promotoras provide outreach and education to inform MSFWs of the services that are available at the clinic and to assist them in arranging follow-up care. TMC has extended hours on Monday through Friday; the clinic is also open on Saturday.

Ms. Sharpless informed the Council that TMC had developed innovative strategies to maximize grant funds. The clinic has multiple collaborations with partners that provide some services at no cost, and the State of Louisiana tuition reimbursement program helps to cover physician salaries. The resulting cost savings have enabled TMC to offer transportation to all patients for 10 years.

Ms. Sharpless acknowledged that most MSFWs are not able to pay for expensive diagnostic tests, such as MRIs. TMC is trying to obtain equipment to provide sonograms and other diagnostic services in house.

Ms. Sharpless opened the floor for questions. Ms. Castillo noted that her MHC faced challenges with recruitment and retention of professional staff in rural areas and asked if TMC had encountered similar difficulties. Ms. Sharpless responded that FQHC status enabled the clinic to hire J-1 visa doctors and to participate in federal tuition repayment programs.

Jose Lopez asked how TMC was able to provide transportation. Ms. Sharpless replied that TMC had been in business for 10 years, and had always provided transportation. In addition, TMC provides mobile dental services in some locations. Ms. Pollard added that some LPCA members provide services in outlying areas through mobile units.

Dr. Gòmez thanked both speakers on behalf of OMSP and the Council. She asked them to speak about lessons learned regarding provision of services to special populations during and after natural disasters. Ms. Pollard responded that LPCA has good relationships with growers and makes every effort to provide transportation so that MSFWs can get to shelters. FQHCs have generators so they can continue to provide care during hurricanes. Ms. Sharpless added that during Hurricane Gustave, four FQHCs provided medical services in locations near shelters.

Michael DuRussel noted that hurricanes also impact MSFWs in other states. Following Hurricane Dolly, many farmworkers in Michigan had to return to Texas to check on their homes.

Ms. Canales thanked the speakers for their devotion to migrant health issues. Ms. Castillo thanked the speakers and adjourned the meeting for a break.

BUREAU OF PRIMARY HEALTH CARE (BPHC) UPDATE

• Marcia Gòmez, M.D., Office of Minority and Special Populations (OMSP), Bureau of Primary Health Care (BPHC), Health Resources and Services Administration (HRSA)

Dr. Gòmez presented an update of the Bureau’s activities on behalf of Capt. Lopez, who was unable to attend the meeting. The presentation focused on the mission of the Bureau, recent BPHC initiatives to support the success of FQHCs and to strengthen the HRSA/grantee partnership, and importance of demonstrating the effectiveness of the Bureau’s programs.

Dr. Gòmez reminded the Council that BPHC’s mission was to improve the health of the Nation’s underserved communities and vulnerable populations by assuring access to comprehensive, culturally competent, quality primary health care services. Noting that collaboration was essential, she stressed that the Council plays a critical role in fulfilling the Bureau’s mission for MSFWs.

Dr. Gòmez provided an overview of the Health Center program for calendar year 2007. Overall, the Bureau’s 1,074 grantees served 16 million patients. About 827,000 MSFWs were seen at MHCs; an additional 50,000 MSFWs received services at other FQHCs. Dr. Gòmez noted that special populations (homeless individuals, MSFWs, and public housing residents) represented nearly 20 percent of the patients served by FQHCs. Federal funding—including FQHC grants, Medicaid, and Medicare--accounted for about 60 percent of total health center revenues.

Dr. Gòmez provided detailed data on the Health Center workforce, which had a total staff of nearly 105,000 in 2007. She informed the Council that the program faces serious challenges in recruitment and retention of clinicians. This issue must be addressed in order to have sufficient capacity to meet the need.

Dr. Gòmez stated that there are currently 156 Migrant Health Centers, compared to 131 four years ago. This expansion was funded through the Presidential Initiative; the challenge will be to ensure that these centers remain viable going forward. Dr. Gòmez reminded the Council that the Bureau provides training and technical assistance to health centers through six national Cooperate Agreements grantees.

Dr. Gòmez then presented results of the 2008 BPHC Grantee Satisfaction Survey. Overall, the survey findings showed improvement from the previous year, especially in some key areas. The survey also identified areas that need attention, especially technical assistance related to grant applications. In response, the Bureau has increased its efforts to ensure that grantees are aware of the technical assistance that is available.  

Dr. Gòmez turned to a discussion of program requirements to support the success of a health center. Based on input from Project Officers, the Bureau identified four key areas for evaluating health center performance: need, services, management and finance, and governance. The Bureau expects and requires every FQHC to meet clear standards in each area.

Dr. Gòmez described BPHC’s efforts in recent years to ensure that all health centers can submit applications and reports electronically. She noted that electronic submission enables the Bureau and Project Officers to track activities and support programs.

Dr. Gòmez reviewed the PINs that were announced in 2008:

• New Scope of Project and Policy for Requesting Changes: This PIN defined key elements of scope and described a new electronic process for requesting a change in scope
  
  
• Baseline Scope Verification: This PIN represented a major effort to develop an electronic database on the scope of project for all health centers, including services, sites, and other activities
  
  
• New Federal Tort Claims Act (FTCA) Deeming/Redeeming Application: This PIN addressed risk management/quality assurance/quality improvement systems, credentialing and privileging policies and procedures, and review of professional liability history and corrective actions.

Dr. McFarland commented that the electronic database on project scope could potentially help the Bureau answer questions from the Council, such as the number of migrant health programs that provide dental services or transportation.

Ms. Castillo commented on the criteria for evaluating FQHCs. She noted that new health centers can be reluctant to provide information on their shortcomings, but over time they learn that the Project Officers are there to help. Dr. Gòmez replied that BPHC wants health centers to understand that the purpose of evaluation is to strengthen health centers to ensure that they are effective.

Mr. DuRussel asked what percentage of the grant funds was allowed for administrative costs. Dr. Gòmez replied that there is no specific cap, but each proposed expenditure must be justified. Mr. DuRussel also noted that the increasing cost of fuel would impact the ability of health centers to provide transportation services. Dr. Gòmez noted that an increasing number of MSFWs do not have their own vehicles and rely on public transportation to get to clinics. She noted that some health centers have found creative ways to bridge this gap.

Dr. Gòmez presented a list of forthcoming PINs:

• Target Population (August 2008)
• Specialty Care (August/September 2008)
• Institutional Care (Draft for comment, Fall 2008)
• Governance (Draft for comment, Fall 2008)
• FQHC Look-Alike Application (Draft for comment, August 2008)
• FTCA (Draft for Comment, Winter 2008)

Dr. McFarland clarified that the FTCA provides liability coverage for clinicians practicing in FQHCs.

Dr. Gòmez described three key areas in which health centers would be evaluated for performance improvement. The areas and their associated indicators are:

• Outreach/Quality of Care (entry into prenatal care; childhood immunizations, PAP tests)
  
  
• Health Outcomes/Disparities (low birth weight; blood pressure control; diabetes control)
  
  
• Financial Viability/Costs (total cost per patient; medical cost per medical encounter; change in net assets to expense ratio; working capital to monthly expense ratio; long-term debt to equity ratio)

Dr. Gòmez noted that the objective of this assessment is to identify baseline data and improvement benchmarks for each health center, not to compare one to another. Four of the performance indicators correspond to federally mandated services (prenatal care, childhood immunizations, blood pressure control, and diabetes control).

Dr. Gòmez stated that, for the first time, health centers would be required to utilize a web-based electronic reporting system to submit their 2009 health care and business plans and their 2008 Uniform Data System (UDS) data.

Dr. Gòmez presented an extensive list of projected Health Center Program grant awards for fiscal year 2008:

• New Access Points ($25 million for 42 awards)
• Expanded Medical Capacity ($10 million for 20 awards)
• Service Expansion ($30 million for 60 mental health awards, 60 oral health awards, and 40 pharmacy awards)
• Planning Grants ($2 million for 25 awards)
• Primary Care Association Workforce Planning ($2.5 million for 50 awards)
• Health Information Technology ($12 million for new awards)
• Base Adjustments ($40 million for all eligible grantees)

Dr. Gòmez noted that a 1.747 percent rescission was applied to all Health Center Program grants for fiscal year 2008. The President’s budget for Fiscal Year 2009 includes a $26 million increase for New Access Points and Planning Grants in High Poverty Areas.

Dr. Gòmez stated that HRSA and BPHC are committed to enhancing partnerships with grantees. To that end, BPHC is increasing the number of site visits to assist Project Officers in applying program requirements and performance improvement measures within the state and local context. HRSA and the Bureau are also working to improve coordination of technical assistance and training among grantees with national cooperative agreements and Primary Care Associations.

Dr. Gòmez informed the Council that the Health Center Program was rated “Effective” in the Office of Management and Budget (OMB) Program Assessment Rating Tool for 2007. She noted that this is the highest possible rating; only 18 percent of all Federal programs received this score.

Dr. Gòmez reported that the Bureau is in the process of developing a Patient Satisfaction survey, which will include MSFWs. The survey will be conducted by an independent agency, with a financial incentive for patients who participate. Dr. Gòmez noted that the Bureau’s efforts to demonstrate the effectiveness of the Health Center Program emphasize a balanced approach that looks at all perspectives, including grantee satisfaction, employee satisfaction, and the quality, timeliness, and impact of the services that are provided.

Ms. Castillo thanked Dr. Gòmez for her informative presentation and opened floor for the Council to discuss priority issues.

COUNCIL DISCUSSION

Dr. Gòmez reviewed Council’s activities during Fiscal Year 2008, including meetings, membership, recommendations, milestones, and challenges. She noted that the process for the New Members Nomination Package this year was moving slowly. As a result, Council members whose terms were due to expire were notified in early November that they may need to serve for an additional 120 days.

Dr. Gòmez presented a chart summarizing the recommendations submitted by the Council from 2003 to 2008. Council members expressed their appreciation for this information.

Enedelia Cisneros noted that TMC offers the full range of services that MSFWs need and asked what could be done to ensure that all MHCs provide these services. Mr. Lopez observed that TMC works with many collaborative partners who receive funds to provide those services at no cost. Dr. McFarland added that FQHCs are funded to provide primary care. Once a patient needs specialty care, all health centers face the same problem.

Dr. Gòmez called the Council’s attention to the issue of the penetration rate. She noted that MHCs are only serving 800,000 of the estimated three million MSFWs in the US , which leaves 2.2 million without services. Mr. DuRussel suggested that younger, healthy workers do not seek health care. Dr. Gòmez responded that workers who are otherwise healthy are still exposed to pesticides. Ms. Canales stated that some MSFWs might not seek services because they know they need specialty care, which they cannot afford. She noted that this is a problem for all uninsured individuals, not just migrants, and especially those between the ages of 18 and 64 who do not qualify for Medicaid or Medicare.

Dr. Gòmez noted that she had spoken with the Council Chair, Dr. Fernandez, who hoped that Council would identify key issues for a recommendation letter, which could be developed by a subgroup. She urged the Council to concentrate on issues that are relevant to MSFWs and go beyond those that affect the general population. When drafting a letter, she suggested that the Council should focus on submitting a request or identifying a problem, rather than prescribing a solution.

After some discussion, a subgroup comprised of Diana Sanchez, Susana Castro, John McFarland, Jose Lopez, and Rosita Castillo agreed to work on drafting the recommendations from this meeting.

Important Areas for Recommendations

Ms. Castro noted that the Council had repeatedly addressed the issue of ancillary services, such as outreach, case management, transportation, mobile services, and interpretation. Dr. Gòmez advised the Council that BPHC was drafting a PIN to address this issue.

Dr. McFarland outlined a number of key issues, including 1) access to care, 2) defining, standardizing, and implementing the primary care scope of services, 3) specialty care, 4) health issues unique to MSFWs (e.g. pesticide exposure; housing and sanitation; and higher than average morbidity in all categories) 5) primary care workforce, and 6) other services, such as pharmacy.

Ms. Castillo felt that increasing access should be the top priority. While it is important to improve services, it is essential to get people to utilize them. Christina Ramos pointed out that in Michigan, public health nurses provide preventive services and health education in the migrant camps.

Emma Segarra stated that it is important for health educators to address domestic violence.

Roberto Gonzalez felt that prevention was the most critical issue for MSFWs, especially in the area of pesticide exposure. He stated that in California, many farmers send MSFWs into areas that should be closed due to pesticide application; they use contractors to get around liability issues. Ms. Castro stated that this goes beyond prevention to include enforcement of rules. Jose

Gaytan emphasized the need for more education to help MSFWs understand the health risks of pesticide exposure.

The Council broke into subcommittees to discuss these issues in more detail.

SUBCOMMITTEE REPORTS

The Council reconvened for a presentation and discussion of the issues identified by each subcommittee.

The subcommittee identified the following issues related to access:

• Accurate identification of the MSFW population is an ongoing problem, especially during off-season when migrants do other types of work.
• Outreach services are essential to enrolling MSFWs into programs, but they are not provided by all CHCs.

The subcommittee identified the following issues related to resources:

• Pharmacy services are important, because the cost of medications can make it difficult for MSFWs to follow through with treatment plans.
• There are not enough healthcare personnel to educate and inform patients. Nurses can be effective in encouraging MSFWs to seek care.
• Care stops when patients need specialty care because MSFWs cannot afford expensive diagnostic tests and specialty services.
• MHCs need strategies for workforce development. Collaborations between medical/dental/nursing schools and MHCs should be encouraged. The National Health Service Corps is an important asset and should be fully promoted to health professionals.

The subcommittee opened the floor for discussion. Dr. McFarland described the Advanced Education in General Dentistry (AEGD) program, a one-year residency that helps provide dentists for CHCs. He suggested that the Council recommend promoting closer collaboration between MHCs and schools of medicine, dentistry, and nursing where they exist. Dr. McFarland also stated that it would be helpful to have baseline data on the number of MHCs that have such collaborations. Ms. Castro stated that nursing schools always looking for clinical sites, and collaborations could provide nursing students with more exposure to migrant health programs. Dr. Gòmez described the Practicum Program developed by the Migrant Clinician Network (MCN) that could serve as a model. Dr. McFarland suggested that it would be helpful to find out how many MHCs have such collaborations.

Dr. Gòmez suggested that the Council could benefit from a presentation by former Council chair Dr. Bruce Gould. As Program Director of the Eastern Connecticut Area Health Education Center (AHEC) and Associate Dean of the School of Medicine at the University of Connecticut, Dr. Gould ensures that his medical students learn about migrant health care.

• ACTION ITEM: Dr. Gòmez will invite Dr. Gould to make a presentation on the AHEC program at a future Council meeting.

The subcommittee raised the following issues:

• Coalitions and partnerships within communities are essential to increase access to migrant health services and maximize limited resources
• HRSA could survey MHCs to elicit suggested strategies for reaching a higher percentage of the farmworker population
• Board members, clinicians, and staff of MHCs must have a shared vision.

Responding the second point, Dr. Gòmez informed the Council that the MCN and the National Center for Farmworker Health (NCFH) had received additional funding to study trends in MSFW populations and to develop tools to help health centers gauge the number of migrants in their service areas. Data from this study should be available in about a year. This research was based on recommendations from the Council.

The subcommittee focused on primary care services, access to specialty care, and portability of coverage. It identified the following issues in these areas:

• Primary care services: Need to identify a model MHC program to determine the components that make it successful.
• Access to specialty care: There is a flaw in the system when primary care identifies problems that cannot be treated.   
• Portability of coverage: This issue is unique to MSFWs and their families. The Texas Medicaid case is a start and should be expanded. This would require involvement of the Centers for Medicaid & Medicare Services (CMS).

Dr. Gòmez stated that the recently appointed Assistant Secretary of Health, Dr. Joxel Garcia, was very supportive of Council’s work, although he could not attend this meeting and was unable to make commitments beyond the current administration.

Dr. Gòmez suggested that the Council consider preparing a letter of introduction for the new Secretary and Assistant Secretary of HHS once they are appointed. Council members discussed whether to submit recommendations to the current Secretary, wait until the new Secretary is confirmed, or write two separate letters. The consensus of the meeting was to write two letters.

• Rosita Castillo-Zavala, Vice Chair

Ms. Castillo reviewed the activities of the first day of the meeting. The informative presentations on migrant health services in Louisiana provided some ideas that Council members could take back to their own clinic, and the update of BPHC activities and summary of previous recommendations were very helpful.

Ms. Castillo noted that access, collaboration, and accountability were recurrent themes in the Council discussions and subcommittee presentations. The task for the second day would be to identify the key issues for the recommendation letter. She emphasized that it would be important to present the recommendations in a way that would capture the attention of the current Secretary as well as the new administration. Dr. McFarland noted that it would be important to acknowledge achievements as well as challenges.

Ms. Castillo provided an overview of the agenda for the second day, after which she adjourned the first day of the meeting at 4:25 p.m.

WEDNESDAY, NOVEMBER 19

RECAP FROM DAY 1

• Rosita Castillo-Zavala, Vice Chair

Ms. Castillo called the meeting to order at 8:35 a.m.

Ms. Castillo reviewed the list of issues that the subcommittees had identified and noted that additional issues would be identified during the testimonies. Dr. McFarland suggested that Dr. Fernandez, as Chair of the Council, and Dr. Weathers should be included in the group that would prepare the letter to the Secretary.

Ms. Castillo reviewed the process for testimonies and noted that the Council would have time in the afternoon to discuss issues presented by the panelists.

PUBLIC HEARINGS

Moderators:

• Bobbi Ryder, Chief Executive Officer, National Center for Farmworker Health
• Erin Sologaistoa, Migrant Health Coordinator, Southeast Region; Florida Association of Community Health Centers, Inc.

Ms. Castillo welcomed the panelists and observers and asked Council members to introduce themselves for the record. Ms. Castillo introduced the moderators and thanked them for their assistance in assembling the panels.

After introducing herself and Ms. Sologaistoa, Bobbi Ryder described the format for the hearings. She emphasized that the Council is the highest placed body in the country for advocating on behalf of migrant farmworkers. 

Ms. Ryder noted that the panelists would be responding to the questions that were used for the hearings in Florida in 2007; the questions would also be used for testimonies on the West Coast next year. The questions asked panelists to identify: 1) the programs or practices at their health center and in their community that have had the greatest positive impact on increasing the health of farmworkers in their area; 2) those “moments” when they feel that their ability to serve farmworkers is compromised; and 3) one solution that would facilitate their ability to provide high quality healthcare to the greatest number of farmworkers.

Ms. Ryder stated that the panelists’ statements would be followed by a question and answer session with the Council. If time allowed, the panelists would take questions from the audience.

NOTE: A court reporter was present to record the testimonies in full. The following summaries highlight the major points.

Administrative/Policy Issues Panel

• Susan Bauer, Executive Director, Community Health Partnership of Illinois
• Josie Ellis, RN, Program Director, Vecinos Inc. Farmworker Health Program, North Carolina
• Lucy Ramirez, CEO, Nuestra Clinica del Valle, Texas
• Linda Sharpless, CEO, The Multipractice Clinic, Louisiana

Question: What programs or practices at your health center and in your community have had the greatest positive impact on increasing the health of farmworkers in your area?

Ms. Sharpless noted that the Multipractice Clinic (TMC) is the only federally funded MHC in Louisiana. The clinic attempts to provide a full range of services in house, because migrants cannot pay for many of those services. TMC has multiple collaborations, which enable it to use grant funds efficiently.

Ms. Ramirez stated that in addition to medical services, Nuestra Clinica del Valle has a promotora component that provides health education in the colonias and rural communities. To address the high prevalence of diabetes in the area, the clinic offers a diabetes prevention program for any patient identified as being at risk. Many patients tell their friends and neighbors about the program, which is an effective marketing tool. The diabetes prevention program incorporates behavioral health, screening all participants for depression and addressing mental health issues in the education component sues. The clinic also participates in the Healthy Start program to promote early prenatal care.

Ms. Bauer highlighted her organization’s promotores program. Most of the outreach workers are male, because most MSFWs in Illinois are men without families. The promotores are an essential part of the continuum of care. They are trained in occupational health and safety issues, and they also conduct research in this area. Ms. Bauer stated that the cooperation of employers is a key element in the program’s success. Promotores are organized by worksite, which helps in developing a closer working relationship with the employer. The goal is for the promotores program to be meaningful for workers and manageable for employers.

Ms. Ellis stated that she started her career in mobile medicine, conducting home visits as a child health nurse. She noted that farmworkers are the only population where health care providers are expected to check with employers and landlords before talking with patients. Other migrant health programs are comfortable working through employers, but her program refuses to do so. Ms. Ellis emphasized the importance of respecting patient privacy and autonomy. She stated that it is unethical and illegal for health care providers to go through a third party and stated that the issue should be addressed at the federal level.

Question: What are those “moments” when you feel that your ability to serve farmworkers is compromised by administrative responsibilities and/or practices?

Ms. Ellis stated that her organization was threatened with legal action for trespassing five times. They challenged it successfully each time, arguing that farmworkers have same legal rights as any tenants.

Ms. Bauer stated that Ms. Ellis had raised an important issue and noted that most farmworker patients face immigration and insurance challenges. Illinois has the most generous States Children’s Health Insurance Program (SCHIP) in the country, but the state is under pressure to remove coverage for undocumented children. Ms. Bauer noted that migrant health programs preceded community health center (CHC) programs, yet they have fewer sources of funding. She recommended that BPHC support redistribution of funding to programs that serve high percentages of uninsured and uninsurable patients.

Ms. Ramirez stated that 82 percent of her clinic’s patients are uninsured, not just migrants. Primary care is never compromised, but the clinic does not have resources to help patients who need specialty care, and local providers are not willing to provide pro bono services.

Ms. Sharpless stated that TMC has a large Medicaid population, which enables it to provide more services. They collaborate with as many partners as possible. Access to specialty testing and care is the greatest obstacle to serving farmworkers.

Question: Please name one administrative, management, or policy solution that could be made at the federal level that would facilitate your center’s ability to provide high quality healthcare to the greatest number of farmworkers.

Ms. Ramirez stated that the minimum/maximum number of users is an obstacle to applying for federal grants. Health centers that serve special populations need more flexibility and should not be held to the same standards as other CHCs. Grantees should not be penalized for situations that are beyond their control that make it difficult to meet goals.

Ms. Sharpless emphasized funding for specialty care for populations that do not have coverage.

Ms. Ellis identified the need for a Federal directive mandating that farmworkers be treated same as any other patient.

Ms. Bauer stated that migrant health programs rely heavily on nurses, but the UDS does not include nurse medical encounters when calculating cost per medical encounter. This misrepresents both the actual cost per encounter and the contribution of nurses to patient care.

Questions from Council

Dr. McFarland asked Ms. Sharpless to describe the transportation services offered by TMC, noting that these services are not provided by all MHCs. Ms. Sharpless replied that TMC has three patient vans that provide transportation to and from the clinic for all patients. She noted that transportation, mental health, and dental health are mandated for FQHCs.

Dr. McFarland asked Ms. Bauer whether the base adjustment should be limited to voucher programs, or if it should include all migrant health programs. Ms. Bauer replied that voucher programs have a disproportionately high percentage of uninsured and uninsurable patients and relatively few Medicaid patients. She stated that programs should make every effort to enroll all eligible individuals into Medicaid, but resources should be reallocated to centers where 80 percent or more of the patients are uninsured. Dr. Gòmez noted that the base adjustment was recently reformulated, but HRSA may need to revisit the threshold. Ms. Ryder added that if the Bureau has trouble meeting the targeted number of grant applications for migrant health programs, it may be necessary to look at other ways to meet the threshold.

Mr. DuRussel noted that MHCs only serve about 20 percent of the migrant population and asked where the other 80 percent receive treatment. Ms. Ellis stated that in North Carolina, farmworkers who are not treated at MHCs receive no care, or only emergency care. Ms. Bauer noted that the total population of MSFWs is unknown. In her view, local data provide the only meaningful statistics.

Clinical Issues Panel 

• Maria Heredia, Consumer Representative, Board of Directors, Nuesta Clinica del Valle
• Kristi Jacobson, Chronic Disease Coordinator, Migrant Health Services
• Susan Stiegler, B.S.N., M.P.H., Director, Family Health Clinical Services, Family Oriented Primary Health Care Clinic, Inc.
• Ed Zuroweste, MD, Chief Medical Officer, Migrant Clinicians Network

Question: What programs or practices at your health center and in your community have had the greatest positive impact on increasing the health of farmworkers in your area?

Ms. Jacobson described the “one stop shopping” model at her clinic, which has been successful in helping patients with diabetes. Patients can see multiple providers at one time, including dentists and ophthalmologists, and pharmacy services are also provided onsite.

Dr. Zuroweste stressed the importance of outreach efforts in a comprehensive model that includes promotoras, case management, and clinical services. Electronic medical records help to ensure continuity of care. Dr. Zuroweste suggested that migrant health programs could serve as a national model because they incorporate a team approach on all levels. MCN has helped to establish greater communication at the state and national levels because it helps providers share best practices. He noted that migrant clinicians are often the most innovative, because they have fewest resources.

Ms. Stiegler described a coalition that was developed in her community in response to the growing Latino population in need of health care. The program provides linguistic and culturally competent care and provides outreach services through a mobile medical van and churches. She emphasized that collaboration and coordination are essential to avoid duplication of services. 

Ms. Heredia stated that she became aware of the needs of migrant farmworkers through participating with volunteers in the community. The promotora program at her clinic has a positive impact by educating farmworkers about health risks. Ms. Heredia stressed that legal assistance is important because illegal immigrants are not eligible for Medicaid.

Question: What are those “moments” when you feel that your ability to serve farmworkers is compromised by administrative responsibilities and/or practices?

Ms. Jacobson stated that more than 90 percent of migrant health patients do not have insurance and are not eligible for Medicaid. It is increasingly difficult to find providers who will accept uninsured patients or offer a payment plan. Other challenges include the lack of qualified interpreters in rural areas and limited access to culturally competent mental health services.

Dr. Zuroweste cited the shortage of primary care providers in all categories as the major challenge facing MHCs. He stressed that the team approach to primary care can take care of more than 90% of cases. Dr. Zuroweste also stated that the current immigration policies and anti-immigrant environment are a significant barrier to access to care for MSFWs.

Ms. Stiegler stated that the patient load at her clinic has more than doubled in past four years, without corresponding increase in funds. She also expressed concern about the lack of referral resources and cultural competency issues.

Ms. Heredia emphasized the importance of understanding community needs. Her community urgently needs more specialists and access to medical care for undocumented immigrants.

Question: Please describe one change that, if implemented, would be a solution to the limitations you identified.

Ms. Jacobson recommended that grant funds be provided to continue existing projects. She also cited the need for mechanisms to facilitate coordination among providers in different locations to minimize duplication of work.

Dr. Zuroweste asked the Council to emphasize the urgent need for an aggressive local, state, and federal plan to increase the number of primary care providers who can deliver culturally and linguistically appropriate care for MHCs. He also urged the Council to advocate for an immigration policy that recognizes the contribution of MSFWs and eliminates the health impact of the current policy.

Ms. Stiegler recommended expanding the definition of MSFWs and revisiting the amount of funding per user for special populations. She also noted that there is a shortage of bilingual staff, yet some states do not accept credentials of nurses from other countries.

Ms. Heredia requested low-cost prescriptions, health education provided at schools and strategic locations in the community, and more doctors, nurses, and funding. She also stressed the importance of providing services to children and the elderly.

Questions from Council

Mr. DuRussel asked if physicians at MHCs are required to have private malpractice insurance. Dr. Zuroweste replied that they are covered by the FTCA, which is very cost effective.

Mr. Gonzalez stated that MSFWs need to see physicians who speak their language because interpretation services create barriers. Dr. Zuroweste replied that it is essential for MHCs to provide interpreters who can provide accurate information.

Mr. DuRussel asked how the Council could address workforce issues in its recommendations. Dr. Zuroweste suggested that the Council join with the National Association of Community Health Centers (NACHC) and other groups in recommending increased funding for the National Health Service Corps (NHSC) and other loan repayment programs. He reiterated the urgent need to develop a culturally competent workforce that includes all health care professions.

Ms. Castro asked Ms. Stiegler to expand on the issue of credentials for foreign nurses. Ms. Stiegler replied that Alabama does not recognize nursing or dentistry degrees from other countries, while other states do allow this. Addressing this obstacle would help to alleviate workforce issues.

Outreach and Health Promotion Issues Panel 

• Mirasol Bravo, Regional Capacity-Building Director, Migrant Health Promotion, Texas
• Christine Flores, The Multipractice Clinic, Louisiana
• Mitch Garcia, Director, Farmworker Services and Health Education, Valley Wide Health Systems, Colorado
• Brian Jakes, Sr., CEO, Southeast Louisiana Area Health Education Center
• Georgia McCormick, Lay Health Promoter, Salud Family Health Center, Colorado

Question: Please describe one aspect of your outreach and/or promotora program that you believe makes the greatest difference to the health of farmworkers in your area.

Ms. McCormick stated that a mobile unit enables her center to provide education and services in the field.

Ms. Bravo stated that the promotora model enables her program to deliver the message directly to farmworkers and their families.

Mr. Jakes cited the patience, persistence, and collaboration that resulted in the creation of a federally funded MHC in Louisiana.

Mr. Garcia stated that his program’s mobile clinic provides comprehensive services, including a full dental operatory and a medical exam room.  In addition, the program responded to the high number of patients with urgent and emergent needs by creating an accessible and affordable emergent care center. 

Ms. Flores cited TMC’s vision, which includes a commitment to outreach and education. She noted that TMC’s integrated service model provides a full range of health services at low cost, and it is the only clinic in the area that provides interpretation services and free transportation.

Question: What are those “moments” when you feel that your ability to serve farmworkers is compromised by a lack of understanding or support for you role as an outreach worker and/or promotora?

Ms. McCormick cited communication barriers for patients who do not speak English or Spanish. She also noted that providers on the mobile unit are reluctant to write prescriptions because they cannot provide follow-up care.

Ms. Bravo noted that her program serves two counties, and resources often change. This makes it difficult for outreach workers to know what resources are available.

Mr. Jakes stated that innovation and creativity are essential in providing care to the migrant population. 

Mr. Garcia expressed concern about the lack of a comprehensive immigration policy, growing anti-immigrant sentiments, and the policy of penalizing employers for hiring undocumented workers. He stated that the situation is especially difficult for families in which some family members are eligible for services, while others are not.

Ms. Flores cited a need for more outreach workers and health educators and the lack of access to lab tests for patients who do not have insurance or documentation.

Question: Please describe one change that could be implemented as a solution to those moments when you feel your ability to serve farmworkers is compromised.

Ms. McCormick stated that the capabilities of the mobile unit should be expanded so that staff could provide follow-up care and educate farmworkers about their rights and health care options.

Ms. Bravo cited a need for additional training for promotoras.

Mr. Jakes stressed the need for the Delta Regional Authority to be engaged in farmworker issues. He noted that the Southeast Rural Child Health program (SEARCH) was an excellent model that saved Medicaid more than $1 million during the pilot phase.

Mr. Garcia requested additional funding for the Central Office Grantees. He also asked the Council to ensure that the new Administration addresses immigration policies.

Ms. Flores recommended comprehensive projects that include education for community leaders and the general community, with funding for health promoters.

Questions from Council

Dr. McFarland asked Mr. Garcia about the dental services on his mobile van. Mr. Garcia described the existing collaboration with a dental residency program and noted that they are working toward full-time staffing.

Mr. DuRussell asked about the impact of immigration policies. Mr. Garcia stated that growers are shifting to less labor-intensive crops and the workforce is changing, with fewer families. Many MSFWs are returning to Mexico .

Dr. Gòmez thanked the moderators and panelists on behalf of the Council, and she assured them that their testimonies were extremely important.

Wrap-Up

Bobbi Ryder assisted the Council in identifying major themes that emerged from the testimonies, based on the three questions:

What is working:

• Provision of multiple, comprehensive services is essential
• Collaboration and relationship building
• Coalitions and outreach
• Transportation systems
• Adequate resources to provide necessary care for the farmworker population
• Dental care provided through collaboration with dental schools
• Passion and vision demonstrated by presenters
• Educating farmworker families
• Comprehensive model and outreach component
• Diversity of services
• Emphasis on outreach, mobile services, and use of promotoras
• Rights of patients recognized by all partners

Moments of compromise:

• Lack of specialty care
• Lack of access to expensive diagnostic testing
• Lack of transportation
• High percentage of uninsurable patients
• Language barriers
• Workforce issues for all disciplines in primary care
• Latinos are real people and have right
• Capacity to take care of all in need
• Ceiling on target numbers for new grant application
• UDS does not reflect care presence of nursing
• Continuity of care and transfer of records among C/MHCs
• Immigration policy (or lack thereof)
• Compromise privacy and respect of patients with patronage system
• Lack of referrals

Proposed solutions:

• Expand and strengthen NHSC
• More funding for clinics
• Expand collaboration with other entities, including foundations
• Do not penalize grantees for reaching target numbers due to issues beyond their control
• Electronic tracking and information sharing of medical records
• Flexibility to serve smaller numbers
• Reduce credentialing barriers for nurses and other providers licensed in other countries
• Expand and strengthen relationships with schools of medicine, dentistry, and nursing
• Review the definition of farmworkers to see if it needs to be updated
• Multi-lingual physicians
• Interpretation by the right person in the right language
• Federal directives to MHCs to not involve growers in confidential patient matters
• Inform patients of tenants’ rights
• More mobile clinics
• Adequate training for educating farmworkers about immigration law

RECAP OF ISSUES PRESENTED BY PANELISTS

Mr. DuRussel noted that the testimonies were consistent with issues the Council identified the previous day. This will be helpful in drafting the letter to the Secretary.

Dr. McFarland noted that Susan Bauer’s position on the total number of MSFWs was relevant to the first issue identified by the Access and Resources Subcommittee. Dr. Gòmez responded that in reality, the denominator is extremely regional and should not be based on a count done at a single point in time. Ms. Bauer’s position was that each state should conduct its own assessment, rather than having a national figure. Dr. Gòmez stated that the National Agricultural Workers Survey (NAWS) was the closest thing to a national enumeration. She pointed out that the studies being conducted by NCFH and MCN would help to clarify population trends, which in turn would assist in determining the types of services that are needed.

Ms. Sanchez expressed concern about families who may be turned away because they do not live within the catchment area. Dr. Gòmez replied that Section 330 health centers are not supposed to refuse treatment. Dr. McFarland: added that most MHCs do not impose boundaries for migrants, but they may establish them for seasonal workers due to capacity limits. 

Noting that MHCs currently provide services to 8 to 20 percent of MSFWs, Dr. Gòmez asked whether they would have the capacity to serve the other 80 percent. Dr. McFarland responded that the current system does not have enough providers to care for that many patients.

Mr. DuRussel asked whether MHCs had a program to recruit retired physicians who may be interested in continuing to practice part time.  Dr. McFarland responded that the FTCA does not cover part-time physicians or volunteers. Dr. Gòmez added that this was linked to licensing issues.

The Council reviewed the list of issues that emerged from the testimonies. Dr. McFarland stressed that it would be important to condense the issues into a manageable number of recommendations. After some discussion, the Council decided that the letter to the Secretary should include three to four recommendations, structured around the subcommittees’ primary areas of focus.

The Council adjourned for subcommittee meetings.

SUBCOMMITTEE REPORTS

The Subcommittees presented their revised lists of key issues, which incorporated input from the testimonies.

• Lack of access to expensive diagnostic testing and specialty care
• Lack of adequate resources to ensure delivery of comprehensive primary care services
• Need to expand collaborative relationships with other entities (foundations, hospitals, etc.) to increase diversity of services
• Need for workforce development

• Primary care services: Need to build on and expand the MHC model and identify and strengthen the components that make it successful, including medical, dental, and behavioral health and outreach components, including transportation, education, prevention, promotoras, translation, case management, and mobile services
• Portability of coverage and records: Portability of coverage is unique to MSFWs and their families; the Texas Medicaid case is a model.

• Ensure that MHC board members, staff, and patients are aware that health care services provided by FQHCs are exempt from the Public Charge law
• Address workforce expansion and collaboration issues for all disciplines in primary care through the NHSC.

Council members noted that the subcommittees had identified some overlapping issues, especially regarding workforce development, collaboration, and comprehensive primary care.

Ms. Castillo noted that there is a national shortage of primary care physicians. MHCs must compete with many other practice settings, while also requiring individuals to have linguistic and cultural competence. Mr. Lopez suggested that a program to promote careers in migrant health to high school students might be helpful.

The notetaker emailed the list of key issues to Dr. Gòmez before the meeting adjourned so that they could forward them to Council members responsible for developing the letter to the Secretary.

• ACTION ITEM: Dr. Gòmez will forward the list of key issues to Council members responsible for drafting the letter to the Secretary.
  
  
• ACTION ITEM: The Council will submit its letter to the Secretary by December 15.

FEBRUARY 2009 MEETING AGENDA ITEMS

The Council discussed the agenda for the February 2009 meeting in Washington, DC and proposed the following items:

• Presentation by Dr. Gòmez on the history of the Migrant Health program
• Presentation by Migrant Clinicians Network
• Presentations by Dr. Duke and BPHC Division Directors

Dr. Gòmez noted that this would be a good time to request a meeting with the newly appointed Secretary. She stated that she would look into the possibility of holding the meeting at the Humphrey Building downtown.

• ACTION ITEM: Dr. Gòmez will try to arrange for the Council’s February 2009 meeting to be held at the Humphrey Building.

COMMENTS BY OUTGOING MEMBER

Dr. McFarland stated that he had enjoyed his three years on the Council and felt lucky to be involved, because the Council does good work. He noted that he began his career in a MHC in 1972. In his view, the multidisciplinary model of CHCs and MHCs provides some of the best health care in the world and deserves to be expanded.

Council members expressed their appreciation for Dr. McFarland’s contributions.

LOGISTICAL INFORMATION

Gladys Cate provided detailed instructions for submitting travel reimbursement forms and guidelines for using government-issued credit cards. She urged Council members to submit their paperwork as soon as possible. Ms. Cate also informed Council members that they should receive their salary payment within one month by direct deposit.

Ms. Castillo called for a motion to adjourn. The motion was made by Ms. Castro, seconded by Ms. Canales, and carried unanimously. The Vice Chair adjourned the meeting at 5:25 p.m.

ACTION ITEMS

• Dr. Gòmez will invite Dr. Gould to speak at a future Council meeting.
  
  
• Dr. Gòmez will try to arrange for the Council’s February 2009 meeting to be held at the Humphrey Building.
  
  
• Dr. Gòmez will forward the list of key issues to Council members responsible for drafting the letter to the Secretary.
  
  
• Diana Sanchez, Susana Castro, John McFarland, Jose Lopez, Rosita Castillo, Rogelio Fernandez, and Andrea Weathers will draft the recommendation letter, which will be submitted to the Secretary by December 15.