1. Longoria, Yessenia D. MSN, RN, CMSRN, CCCTM

Article Content

Healthcare entities continually work to develop innovative models to improve the patient experience and population health while reducing care costs. According to the Institute for Healthcare Improvement, population health is the "health outcomes of a group of individuals," often defined by a common factor, such as community, employer, ethnic group, or other category.1 This article discusses how one health system in the Texas panhandle embraced population health and offers information on what nurses and nurse leaders need to know when taking care of refugees in rural America.

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The impact of disparities

As the concept of population health continues to gain attention, identifying health disparities is more important than ever. What is it that helps one group of individuals be successful in their health while another group fails? A common geographic disparity is between urban and rural communities. Data show that living in rural areas has a negative predisposition on healthcare outcomes compared with living in urban areas. Nearly 60 million Americans live in rural communities, with 65% of all US counties classified as nonmetropolitan.2 Residents of metropolitan areas typically have higher quality healthcare and benefit from better outcomes, whereas rural residents continue to struggle with higher rates of injury, suicide, smoking, opioid misuse, obesity, and poverty.2 Even worsening statistics exist when considering racial and ethnic populations.


Healthcare facilities that serve rural communities often combat significant financial obstacles, struggling more every year to keep their doors open. One hundred and twenty-four rural hospitals closed between January 2005 and November 2017.3 These healthcare systems are often challenged with fewer providers per capita and less resources and networking opportunities to help surrounding residents.


Among the residents accessing healthcare in rural communities are a growing number of refugees-individuals who've fled their native country for fear of persecution, war, and/or violence due to race, religion, political views, or nationality, and who usually can't return.4 Initially, many refugees migrate to camps outside their native country, where they may experience malnutrition and only have access to limited, inefficient healthcare.5 Many refugees also struggle to understand a complex Western healthcare system once in America.6 The combination of trauma endured with the struggle of adaptation often leads to sadness and isolation, deepening the health disparity gap.5


As of July 2018, 45,000 new refugees have arrived in the US.7 The concept of population health is especially relevant for refugees because it addresses the needs of a group of people defined by a common factor; in this case, refugee status. When refugees first settle in America, they receive brief assistance in cultural assimilation, translation services, shelter, and job placement. However, they're then left to help themselves with little, if any, familiarity with local resources, especially when moving elsewhere. Despite phone translation, refugees often struggle to understand basic healthcare terminology, such as physician, primary care provider, appointment, vaccinations, prenatal care, and clinic versus ED. Refugees who've lived most of their lives in a camp have limited experience with healthcare.5 With so many levels of access, such as clinics, urgent care centers, and EDs, many families turn to the ED for primary care needs.


Reaching Refugees: A rural community initiative

There are numerous reasons for refugees to migrate to rural areas, including the ongoing search for a familiar culture and community. For example, in 2006, after a large illegal immigration raid, the Swift & Company (now JBS) meatpacking plant needed to fill more than 1,300 job vacancies across 6 facilities, one of which was in Cactus, Tex.8 This led the company to quickly recruit refugees from resettlement communities, bringing in a rapid influx of Burmese refugees to an extremely rural area of the Texas panhandle. There was then a second wave of Burmese refugee migration to the remote area of Moore County, Tex., a community that lacks the assimilation resources for refugees often found in larger cities.


Reaching Refugees is a program implemented at a small rural hospital in the Texas panhandle, with the focus of positively influencing healthcare outcomes. Evidence shows that culturally sensitive platforms have a higher success rate in addressing overall health issues.9 The goal of Reaching Refugees is to provide culturally sensitive basic health education to Burmese refugees when they present to the ED. Teaching basic information is foundational in improving health behaviors. Successful self-care is difficult to achieve without proper understanding of common healthcare terminology.


When nurse case managers continued to witness poor self-management of chronic illnesses and nonadherence to common instructions among the Burmese population, such as keeping follow-up appointments, a nurse-led effort was put forth to create change. An education protocol was set up in the ED through the intraprofessional collaboration of nursing informatics, ED nurses, nurse case managers, transition care nurses, patient educators, and nursing administrators. Utilizing the electronic medical record (EMR), a process was implemented for nurses to receive an electronic reminder and hand out resources to refugee families. The reminders are imbedded within the EMR and pop up for nurses during documentation. The pop-ups are programmed to offer reminders only for patients who meet predetermined criteria. Several nursing specialties contributed to the program.


Nurse case managers gave examples of resources with which refugee families were often unfamiliar. Nurse educators compiled education in appropriate languages and created folders to be given to families when presenting to the ED. Education includes common medical terminology that often overlaps in the English language, such as primary care provider, family doctor, and physician. For example, patients expressed confusion when at the end of their visit, the ED physician would say, "Follow up with your primary care provider in 1 week," but the nurse who reviewed discharge instructions said, "Don't forget to see your family doctor in 1 week." The ED nurses collaborated with the nurse informaticist to create a workflow that was end-user friendly.


Reaching Refugees was implemented in Fall 2017. Within the first 12 weeks, computerized data showed 100% of Burmese children received translated basic health education and information on local resources before discharge from the ED. The program will be expanded to include video/audio education available for patients to watch while they wait in the ED. This effort addresses the needs of patients who can't read even when information is in their own language.


Reaching Refugees is one example of a population health initiative that demonstrated success through intraprofessional collaboration and teamwork. Over time, the program can be further expanded to measure education efficacy, address additional healthcare issues, and include other underserved populations in the county.


The local healthcare system extended efforts beyond Reaching Refugees, creating a more comprehensive partnership with private practices and JBS itself. The network of entities collaborated to hire a nurse care coordinator to assist with access and navigation of the local healthcare system for JBS employees. Although resources are scarce in rural communities as compared with urban areas, the collaboration between the hospital, private practices, and JBS has resulted in success. According to a Gallagher report of total expenses paid between 2017 and 2018, inappropriate ED utilization by JBS employees is expected to decline 41% in the first quarter alone. Meanwhile, local primary care practices continue to report an increase in office visits, demonstrating a positive trend in appropriate access to primary care.


The unique role of rural nurses

Rural nurses are often described as "generalists."10 They're the bedside nurse, the patient educator, the rapid response team member, and the case manager. Rural nurses care for those coming into life and those taking their last breath all in the same shift. It isn't uncommon for the rural nurse to be the informaticist Monday through Friday and the ED nurse on Saturday. These nurses often require experience in several areas of care. How does this environment affect refugees in rural communities?


Although there are limited resources in rural areas, most rural nurses know how to quickly access assistance from close ties that exist within the community and can network to improve care. They're also able to pull from considerable experience when caring for refugees. In a complex healthcare system, sending refugees from place to place creates more confusion and opportunity for error and nonadherence. Often, rather than referring refugees from one department to another, a single nurse can cover a large overview of needs in one setting, and refugees can transition to appropriate areas of care with greater ease.


Rural nurses have a unique role in the health of refugees because their well-rounded knowledge of processes within their institutions creates opportunity for successful patient advocacy. They have the advantage of working in environments that require less navigation through the layers of administration that often exist in large facilities. This often leads to close relationships between clinical nurses, directors, and administrators, increasing opportunities to create change quickly and follow processes thoroughly.


When the nurse case managers recognized a need for change, there wasn't a "build freeze" within the informatics department, as is often described in larger facilities. Administration was easily accessible, and Reaching Refugees was quickly approved and implemented. This eased the process of collaboration between nursing informatics, ED nursing, case management, patient education, and administration. The EMR build was completed within 4 weeks and the accuracy of the process was noted at a 100% success rate within 3 months of implementation.


Lastly, rural nurses are often deeply imbedded within the community itself. The patients for whom they care are typically either someone they know or related to someone they know. A patient in the ED during the day may be standing behind the nurse in the checkout line at a local store the same evening. Nurses in rural communities often have close ties to their patients, which creates an understanding of the cultural context of rural living itself. Rural nurses have a deeper understanding of the challenges patients face when living in isolated communities.3 (See Unique characteristics of rural nurses.)


Implications for nursing practice

Because rural nurses care for patients from infants to older adults and from varying cultures, it's important for them to have a "strong and varied experience base."10 Not only do educational programs need to emphasize strong assessment skills, but they also should include preparation for nursing students in caring for refugees. The curriculum needs to include an adequate history regarding the common characteristics that refugees share, such as experiences, trauma, social needs, and low health literacy levels. Collaboration between nurse educators and hospital administrators can enhance awareness of the local demands that nursing students will need to be prepared for upon graduation and licensure. Educational programs should include information that prepares students for the challenges of rural nursing, such as critical thinking with limited resources and adaptation strategies.


To successfully care for the refugee community, nurses should expand their cultural awareness and properly address language and educational barriers so patients can achieve success in self-care. Rural nurses need to be diligent in maintaining an adequate level of continuing education that includes knowledge about every stage of life and familiarization with the cultural norms and values of their patient population. Regardless of the specialty area, rural nurses should strive to be well-rounded and knowledgeable, including a proper understanding of referral processes and the key team players who can assist patients with additional needs.


As new models of care delivery continue to emerge, nurses can't accomplish population health endeavors singlehandedly. Collaboration efforts need to embrace rural nursing. Educational opportunities specific to rural nurses should be offered, especially at professional conferences. Education should include not only information on caring for refugees, but also lobbying for rural healthcare necessities. Rural nurse leaders often lack the networking resources to advocate for their needs. With fewer collegial networking opportunities than urban areas, rural nurses need to reach beyond the walls of their institutions and beyond county limits. Collaboration between urban and rural nursing administrators can increase networking opportunities and enhance the resource base for rural residents. Furthermore, urban areas will become more knowledgeable about the challenges rural nurses face and the successes that occur through adaptation.


A successful journey

Western healthcare is complicated even for the average American-born citizen. Combined with an environment already lacking in resources, non-English-speaking refugees often struggle to access appropriate health services in rural communities. However, rural nurses have unique strengths that can positively influence the existing paradigm. As demonstrated within one rural hospital in the Texas panhandle, collaboration, coupled with innovative nursing leadership, can lead even the most rural and marginalized population on a successful journey to health.


Unique characteristics of rural nurses10


* Proficient in clinical skills for multiple areas of nursing, such as emergency/trauma, critical care, obstetrics, surgical, case management, pediatrics, and geriatrics


* Well-rounded knowledge of resources within the community


* In-depth awareness of cultural norms and values


* Thorough knowledge of processes across the continuum of health


* Easier access to multiple healthcare disciplines


* Knowledge of one's own area of practice, as well as other disciplines, such as pharmaceuticals, various therapies, and environmental services


* Heightened role on the multidisciplinary team


* Ability to adapt to available resources


* Autonomous, innovative, and able to overcome challenges in areas without major medical centers and with limited supplies and equipment


* Less layers of administration


* Improved collaboration between clinical nurses, department directors, and administrators


* Close ties with the individuals and communities they serve


INSTRUCTIONS Population health of refugees in rural communities



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7. Refugee Processing Center. Admissions and arrivals. 2018. [Context Link]


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10. Daily Nurse. Rural health nurse. [Context Link]