Improving Health Outcomes in Vulnerable Populations: The Medical-Legal Partnership-Colorado's Experience.

Medical-legal partnerships (MLPs) add legal professionals, trained specifically to tackle health-related social needs (HRSN), to the health care team. We evaluated the impact on health outcomes and health care utilization of a MLP housed in a large federally qualified health center in Colorado (MLP-CO). Clients screened for I-HELP (Income, Housing, Employment, Legal status, Personal stability) needs were surveyed at baseline and six months post-enrollment. Reasons for legal aid were legal immigration status (46.5%), income (30.8%), personal/family stability (14.8%), housing (4.8%), and education (1.2%). Overall, 61.4% attributed great/moderate improvements in their health care experience to the MLP-CO. Statistically significant improvements were noted for days with poor physical/mental health, and feelings of stress/worry. There was a reduction in emergency department visits, hospitalization days, and missed appointments, but only the latter was statistically significant. In conclusion, MLPs are a promising innovation to achieve the Institute for Healthcare Improvement's quadruple aim.

Assessment of biases against Latinos and African Americans among primary care providers and community members.

OBJECTIVES: We assessed implicit and explicit bias against both Latinos and African Americans among experienced primary care providers (PCPs) and community members (CMs) in the same geographic area. METHODS: Two hundred ten PCPs and 190 CMs from 3 health care organizations in the Denver, Colorado, metropolitan area completed Implicit Association Tests and self-report measures of implicit and explicit bias, respectively. RESULTS: With a 60% participation rate, the PCPs demonstrated substantial implicit bias against both Latinos and African Americans, but this was no different from CMs. Explicit bias was largely absent in both groups. Adjustment for background characteristics showed the PCPs had slightly weaker ethnic/racial bias than CMs. CONCLUSIONS: This research provided the first evidence of implicit bias against Latinos in health care, as well as confirming previous findings of implicit bias against African Americans. Lack of substantive differences in bias between the experienced PCPs and CMs suggested a wider societal problem. At the same time, the wide range of implicit bias suggested that bias in health care is neither uniform nor inevitable, and important lessons might be learned from providers who do not exhibit bias.

Accuracy of primary care clinicians in screening for diabetic retinopathy using single-image retinal photography.

PURPOSE: Diabetic patients with limited access to ophthalmologists have low screening rates for diabetic retinopathy. We evaluated a diabetic retinopathy screening program in a community health center using single images taken with a nonmydriatic retinal camera and primary care clinicians trained to read retinal images. METHODS: This study was conducted from 2001 to 2004 in a multisite community health center staffed by family physicians, advanced practice nurses, and physician's assistants. The clinic serves a primarily low-income, Hispanic population. Clinic clinicians were trained to read the retinal photographs. All images were overread by an ophthalmologist. Patients were referred to eye care specialists for severe diabetic retinopathy, unknown or other abnormality, or inadequate photographs. We analyzed agreement between the clinicians and the ophthalmologist in recognizing diabetic retinopathy and in determining which patients needed referral. We also analyzed overall screening rates based on clinic access to the camera. RESULTS: One thousand forty diabetic patients were screened for diabetic retinopathy at the health center. One hundred thirteen (10.9%) were found to have diabetic retinopathy, 46 severe enough to warrant referral to an ophthalmologist. The clinicians failed to refer 35 (10.2%) of the 344 patients the ophthalmologist believed needed referral. Most cases of missed referral were due to failure to recognize an inadequate photograph or for abnormalities other than diabetic retinopathy. Screening rates were better in the clinic with a permanent camera. CONCLUSIONS: Primary care clinicians trained to read single images from a retinal camera have acceptable accuracy in screening for diabetic retinopathy. Further training may be necessary to recognize other common abnormalities.

Stress, coping, and health: a comparison of Mexican immigrants, Mexican-Americans, and non-Hispanic whites.

Mexican immigrants, Mexican-Americans, and non-Hispanic white Americans all face different stressors. Stress-coping strategies may vary for each group as well. We compared relationships among perceived stress, stress-coping strategies, and health-related quality of life (HRQL) in a rural sample of Mexican citizens living in the United States, Mexican-Americans, and non-Hispanic whites. Health-related quality of life and stress-coping styles varied among the three groups. Mexican citizens reported significantly better physical functioning than did non-Hispanic whites or Mexican-Americans. Mexican-Americans reported significantly better mental health functioning than did non-Hispanic whites or Mexican citizens. Mexican citizens were more likely to use positive reframing, denial, and religion, and less likely to use substance abuse and self-distraction, as stress-coping strategies. Stress-coping style may be a potentially modifiable predictor of physical and mental HRQL, and may account for part of the Hispanic health paradox.

A program to improve access to health care among Mexican immigrants in rural Colorado.

CONTEXT: Migration to the United States from Mexico is increasing every year. Mexican immigrants tend to be poor, uninsured, monolingual Spanish speakers without adequate access to appropriate medical care. As a further barrier, many are also undocumented. PURPOSE: This article describes a program developed to improve access to health care among Mexican immigrants in northern Colorado. METHODS: The program was implemented by a migrant/community health center in rural northern Colorado based on findings from an in-depth health needs survey of the target population. The program consists of community outreach services vertically integrated into the main medical clinics, which comprise Salud Family Health Centers. A mobile unit went to nontraditional areas identified by community workers as gathering places for Mexican immigrants. Services provided included preventive health care (screening for diabetes, hypertension, mental health problems, dental problems, and HIV); education; and primary care for acute problems. Patients were referred to a health care home for ongoing care. RESULTS: In the first 6 months, 1,553 Mexican immigrants were seen on the mobile unit. Hypertension and psychosocial problems were the most common problems in this population. Thirty-five percent of patients who received consultation in the mobile unit have visited any of the clinics for follow-up within the following year. CONCLUSIONS: A community-based mobile outreach program targeted toward Mexican immigrants can be effective in uncovering medical and mental illness and in directing patients to a health care home. This is an important first step in eliminating health disparities among this population.