Mobile Care Successes and Struggles in Pennsylvania ... Fall 14_ff LR.pdfof poverty, migration and health. To commemorate our 30th anniversary, we have launched 30 Clinicians Making

Volume 20, Issue 3 • Fall 2014

streamlineThe Migrant Health News Source

Editor’s Note: This year, Migrant CliniciansNetwork is celebrating 30 years of working to create practical solutions at the intersectionof poverty, migration and health. To commemorate our 30th anniversary, we have launched 30 Clinicians Making aDifference, in which we chronicle the work of 30 individuals who have dedicated theirlives to migrant health, of which the three profiles in this issue are a part.

Mary Englerth, PA, the Pennsylvania StateDirector of the Migrant Health Programat Keystone Health, can find herself

reflecting on her patients during her off-hours.“Anytime I’m in the Giant and I pick up a piece of fruit, I think, ‘Who picked this?’” sheadmitted. Englerth has spent much of the last 30 years working with migratory and seasonal agricultural workers in Pennsylvania at Keystone Health, coupled with years of

health work in the highlands of Peru andGuatemala as a physician assistant andMaryknoll Sister, a Catholic religious order ofwomen devoting their lives to service overseas.

From Peru to PennsylvaniaEnglerth first entered the field of migranthealth after returning from Maryknoll service

Mobile Care Successes and Struggles in Pennsylvania: Profile of Mary Englerth, PAJillian Hopewell MPA, MA, Director of Education and Professional Development, Migrant Clinicians NetworkClaire Hutkins Seda, Staff Writer and Editor, Migrant Clinicians Network

continued on page 3

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Just an hour’s drive from the bustle ofNew York City is the Black Dirt region ofthe Hudson Valley, an area named after

its rich, volcanic soil, and a region equally asrich in its agricultural history. For KathyBrieger, RD, CDE, MA, the administrator ofthe Alamo Farmworker Community Center --one of the many hats she wears at HudsonRiver Healthcare (HRHCare) -- the region’sagricultural workers have become more thanjust her patients. “Working with the farm-workers in this area [has been] one of thebiggest gifts in my life,” Brieger said.“[They’ve] been woven into my life, the peo-ple of this black dirt.”

Adventures in mobile careBrieger first learned about agricultural work-er communities and their unique struggleswhen at age 17 she became a UFW organiz-er. By college, Brieger found herself drawn tonutrition studies. “It was something I wantedto spend my life in, especially in areas ofpublic health, and [in] trying to help people

who had food security [issues],” Briegerrecalled. She was just starting as a dieticianat a health clinic in the region more than 30years ago, when a pregnant agriculturalworker with gestational diabetes was unableto make the trip to the health center whereBrieger worked. “I asked my CEO at the timeif it was possible to go out and visit her.Here I was, a dietician, and I just went outand [made] a home visit, and that’s whatstarted the whole thing.”Within a few years, “a lot of the work was

really done out of our cars,” explainedBrieger. As the local health center expanded,so did services to its patients, many ofwhom were migratory and seasonal agricul-tural workers. Her health center eventuallybecame one of the 20 locations of HRHCare,which serves the 10 counties of the HudsonValley and Long Island. HRHCare offers extensive services beyond

primary care, including mental health care,nutrition services, transportation, and bene-fits counseling. Brieger notes that the many

resources the health center provides, like apottery class and an art therapist, a home-work help group, and hot meals in the win-tertime, are often volunteer-run and paid forby donations, but always driven by theneeds of the patients. “We really try to havethe farmworkers tell us what they’re interest-ed in,” Brieger noted. She is inspired by thehigh level of community involvement shewitnesses; a recent homework help groupbrought out one retired principal, ten retiredteachers, and two teenage boys as volun-teers. The health center continues to find ways

to improve the lives of agricultural workers.One recent program brought together farm-ers and agricultural workers for a five-yeartraining program on eye safety, sponsoredby the Centers for Disease Control andPrevention (CDC) and the New YorkAgricultural Center for Agricultural Medicineand Health. Brieger found the program to

Care in the Black Dirt Region: Profile of Kathy BriegerJillian Hopewell MPA, MA, Director of Education and Professional Development, Migrant Clinicians NetworkClaire Hutkins Seda, Staff Writer and Editor, Migrant Clinicians Network

continued on page 10

Photo courtesy of HRHCare

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in Peru for several months in the mid-80s,when her mother fell ill and needed herassistance. While back in the states, shefound out about services provided to migra-tory and seasonal agricultural workers by Dr.Ed Zuroweste – now MCN’s Chief MedicalOfficer – as part of his private practice inNew York. “I remembered going into that office and I

said, ‘I’m a bilingual PA – can you use me?’”laughed Englerth. “That’s when I reallybecame aware of the migrant’s problems andchronic disease.” She returned to Peru, butwas brought back again for family reasonsand joined Dr. Zuroweste at his new work atKeystone Health in the early 90s. In 1995,Keystone Health received a federal grant tostart a migrant health program in 15 coun-ties of rural Pennsylvania. Englerth assisted insetting up the requirements for the migrantprogram, before she again returned to mis-sionary service. She provided primary careservices in Guatemala from 2003 to 2007.When she returned to the states, she foundthat her old job was waiting for her. “I actually stepped back into the same job

as when I left and we really went full force,”said Englerth. The program has expanded to30 counties. “Next year we’ll hopefully beexpanding into a new county, so it’ll be 31,”out of a total of 67 in Pennsylvania, Englerthsaid. The program is notable for its focus onoutreach. “We have five sites throughout thestate,” explained Englerth, noting each sitecovers between five and 10 counties. Eachsite has a site coordinator and a group ofnurses who go out to the camps for migra-tory and seasonal agricultural workers, threenights a week. Englerth noted that muchwork is completed in the field, like healthassessments, immunizations, and screenings.For those who need further assistance –“which of course, there are many” – eachclinic runs slightly different. At her clinic inAdams County, they have an evening clinicevery Tuesday. In more remote areas awayfrom one of their clinics, they haveMemorandums of Agreement with differenthospitals, clinics, and health centers to carefor patients.

Continued struggles“We provide transportation for those whodo not have it,” Englerth explained, buttransportation continues to be a struggledue to the large coverage area and the lackof funding to cover growing transportationcosts. “Right now, we have four men that…desperately need to get to one of our inter-nal medicine doctors over in Chambersburg,and they just don’t have a way,” to getthere, offered Englerth as a common exam-ple. The group is instead doing outreach to

local churches and others who may be will-ing to volunteer to provide transportation tothe patients. The van for the clinic in hercounty, she said, is only able to cover one-third of the county per clinic night, leavingtwo-thirds of the county for a future clinicnight. “If it’s really serious, one of the nurseswill volunteer to go out and [bring] them in,or at times I have gone too… but trans-portation is a big problem,” Englerth said.

Collaboration plays a roleEnglerth’s greatest challenge continues to bemigrant patient follow-up, which she hopesMCN’s Health Network will help solve, asher clinics begin to register all migrantpatients with ongoing health conditions inthe network. A common scenario withmobile patients of any sort is the patient’simpediments to continued care once he orshe has moved on to a new location. “Youget the blood pressure [and] the glucose,never under control, but at least better, andthen they go back and do not follow up,and they come back the next year and it’sworse than what it was the previous year,”Englerth explained. “That’s really the mainchallenge, is the follow-up.” In addition torelying on MCN’s ability to encourage andsupport follow-up, Englerth hopes that fur-ther peer-to-peer connection will enable bet-ter care. She envisions a world where “clini-cians could get together to get a formularyto use the same medicines up and down thecoast… a generalized formulary,” to providecontinuity of care for migrant patients.

Despite the struggles, Englerth is positiveabout future changes. She works with sec-ond-year PA students from local universities,who join the clinical rotation for several weeksduring the summer, and experience firsthandthe uniqueness of migrant health. “It showsthem the real disparities of health care in theUS,” Englerth believes. “The reason I do [thePA student program] – because it’s a lot ofwork – is because hopefully they will see andnot forget… our poor in our country.”She also enjoys the strong collaboration

Keystone has with Migrant Education inPennsylvania. Her team joins Migrant Edwhen they visit out-of-school youth inmigratory agricultural worker camps, andconducts health screenings, which hashelped Keystone expand into new campsand new counties. They also do outreach fornew patients through Migrant Ed’s winterEnglish as a Second Language (ESL) pro-grams. Englerth notes that the winter collab-oration has allowed Keystone to providehealth screenings for migratory and seasonalworkers who previously had no contact withKeystone, such as women working in thelocal packing houses.Despite her administrative responsibilities,

Englerth still manages to get out to thecamps. She finds the personal connectionrewarding. “[To] have someone to go outinto the communities, and sit, and listencompassionately to their problems,” makes abig difference, Englerth believes. “The grati-tude in people’s eyes for the little bit we cando… it’s reciprocal, it really is.” ■

■ Profile of Mary Englerth, PA continued from page 1

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In 2007, participants in the brand-new pro-gram Hombres Unidos Contra la ViolenciaFamiliar (HU) gathered to learn together

about sexual/intimate partner violence (S/IPV).Over the course of five sessions led by malecommunity health workers or promotores –trained members of the Latino migrant com-munity – participants engaged in role-play,conversation, and guided discussion aboutS/IPV. Migrant Clinicians Network (MCN)launched the program in an effort to preventS/IPV by creating an opportunity for maleLatino migrants to reflect on behavior andbeliefs related to gender roles, definitions ofviolence, and strategies to address violence.Here is one participant’s wife, and herthoughts on the effect of the training on thefamily dynamics in her home, as collected inthe post-program evaluation:

[Before Hombres Unidos,] my husbandwould come back home from work withthe attitude that he had done the day’swork and he was not willing to help mewith the kids or with any of the house-work. So I was left to do everything and itcreated problems between us. But, afterhe completed the Hombres Unidos work-shop that I recommended to him, he hada complete change of heart. After he hadcompleted the workshop, he got a newjob and when he would get back from thejob he would come home, wash dishes,help with other things around the house,and he started helping the children withtheir homework, along with many otherthings. It was a very positive change whichmade me and my whole family, includingmy husband, much happier.

MCN implemented the program with healthorganizations that displayed sufficient organiza-tional readiness. To date, seven migrant healthoutreach organizations across the United Stateshave brought HU to more than 500 partici-pants. The organizations have piloted HU withslightly varying results due to their organiza-tional capabilities. The question emerged: WasMCN’s organizational readiness process suffi-cient in identifying which health centers wouldbe successful in implementing HU? In 2014,MCN set out to retrospectively evaluate theprocess by which the health centers that pilot-ed the program were selected. This researchaimed to address the gap between researchand practice by identifying characteristics oforganizational readiness, which is the capacityof an organization to execute the programwith fidelity to the original design.

About Hombres UnidosBy targeting the general population of maleLatino migrant men instead of the more tradi-tional approach of working with women, thisprogram seeks to prevent S/IPV in these com-munities, rather than assisting victims of trau-ma or addressing the issue with men after vio-lence has occurred, post-adjudicated. MCNidentified all the best practices for a culturallycompetent program design that is heavilybased on group discussions and role play activ-ities led by male promotores. MCN provides HUcurriculum and training for the five-session,male-led, peer-to-peer workshop. Migranthealth outreach organizations may apply toadopt the program and integrate it into theiroutreach services.

Pilot program evaluationWhen MCN first developed the HU curriculum,it created a national advisory committee ofexperts with significant experience in S/IPV,curriculum development, and outreach to menin the Latino migrant community. Workingwith the advisory committee, MCN extrapolat-ed the most important characteristics for anorganization using HU to have: 1) the interest of the organization in continu-ing to participate;

2) the organizational capacity, including thenumber of bilingual male promotores avail-able to do the work, as well as the level ofexperience of these promotores and the larg-er organization in working on similar proj-ects;

3) the need for a S/IPV prevention program inthe organization’s service area; and,

4) the responsiveness and participation of theorganization during the evaluation phase ofthe project.

Three of the organizations represented onthe advisory committee – all of which metthe basic partner checklist criteria andexpressed interest in piloting the program –implemented HU, with high degrees of suc-cess. Additionally, HU has been implementedin organizations that didn’t fulfill all partnerchecklist criteria. While MCN has not com-pleted all of the evaluation, some partners'lack of success in implementing the programmay be due to their absence in meetingsome of the core criteria indicated in thepartner checklist that gauges an organiza-tion's readiness to adopt the program.

Evaluation of the evaluationThis year, with the extensive help of Swetha

Nulu, a MPH Candidate at Tulane UniversitySchool of Public Health and TropicalMedicine, MCN reevaluated its partnerchecklist to assess its efficacy in assuring suc-cessful program implementation. Herresearch into organizational readinessshowed that appropriate site selection laysthe foundation for successful program repli-cation, and is dependent on external andinternal factors, from geographic location toadministrative activities. According toresearch by Elliot and Mihalic,1 the factorsthat are most pertinent to site selectionassessment are: 1) well-connected and respected organization among locals;

2) strong administrative support;3) formal organizational commitments and organizational/staffing stability;

4) commitment of necessary resources;5) program credibility within the community;

6) potential for program routinization, or the ability to assure program sustainabilitythrough the existing budgetary period.

MCN’s original partner checklist to assess organizational readiness (which is summa-rized above in the four characteristics out-lined by the Advisory Committee) identifiesall of these characteristics. It also askswhether the organization has implementedS/IPV programs in the past. Research sug-gests that prior outreach experience specificto the subject matter (in this case S/IPV) isnot an important factor to consider whencompleting an organizational readinessassessment. Thus, an organization unfamiliarwith S/IPV activities and strategies can besuccessful in implementing the programdesign of HU if all other organizational readi-ness competencies are met. A breakthrough finding by Irwin and

Mihalic has identified a statistically signifi-cant association of certain factors of organi-zational readiness with specific characteristicsof program success, such as percentage ofcore program activities replicated, achievedcomponents, dosage ( defined as the abilityto implement intervention at its intendedfrequency), and sustainability.2 Their findingsshows that dose is directly influenced byprogram characteristics, technical assistance(TA) quality and quantity, and staff recruit-ment and retention. Adherence to originalprogram design was influenced by TA quality

Organizational Readiness: Evaluating the Implementation of Hombres UnidosSwetha Nulu, MPH Candidate, Tulane University of Public Health and Tropical Medicine, Department of Global Health Systems and DevelopmentAdrian Valasquez, Family Violence Coordinator, Migrant Clinicians Network

continued on page 6

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Organizational Readiness Survey: Hombres Unidos

ORGANIZATION’S NAME LOCATION DATES OF HU IMPLEMENTATION

YOUR NAME CURRENT ROLE IN HU

Organizational History with Migrant Community 1. When was your organization established? _______________________________________________________________________________2. How long has your organization worked with Latino migrant communities? _________________________________________________3. Has your organization implemented outreach programs in the past? YES NOIf Yes, what was the program? _________________________________________________________________________________________How long was it implemented for? _______________________________ How many participants _______________________________

4. What has your organization done to address domestic violence in your community prior to HU implementation? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Is domestic violence a problem in community? YES NO6. Is your facility accessible to farm workers? YES NO Close to public transportation? YES NO

Training the Facilitators1. Describe the length and duration of the training sessions for the facilitators:Hours per session: ________________________ Days/Weeks of training program: ______________________

2. What were the criteria to select the facilitators? ______________________________________________________________________________________________________________________________________________________________________________________________

3. Did you feel that there was adequate time for the training sessions? YES NO4. How would you rate the quality of training: Excellent Good Fair Acceptable Poor 5. How would you rate the attendance of the trainees? Excellent Good Fair Acceptable Poor 6. What are some recommendations to improve the training design? _________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Staffing 1. How many administration staff members worked with HU? __________________2. How many total staff members were recruited to work on HU? ________________3. How many staff members working exclusively on HU? ___________________4. How many staff members dedicated to HU resigned during the implementation of HU? ___________5. Please rate staff turnover for HU: High Moderate Low6. How would your rate the attendance of administrative staff? Excellent Fair Poor

Technical Assistance 1. Did you have access to technical assistance throughout the duration of HU? YES NO2. Did you experience any technical problems when implementing HU? YES NOIf Yes, how quickly were you able to get support? ________________________________________________________________________Was the support you received effective in resolving the problem? YES NO

Program Replication Success Four elements have been identified for successful program replication:

1) Consistent implementation of program throughout agreed time period (1 year for HU)

2) Percentage of design replicated (Adherence to activities)

3) Dosage (Adherence to 5 sessions)

4) Achieved components (Achieved intended results of each activity) Of the above components, which would you compromise first? ___________________________________________________________Of the above components, which would you compromise second? _________________________________________________________Of the above components, which component are you not willing to compromise at all? ______________________________________

6 MCN Streamline

Editor’s Note: This is the first article in an ongoingseries by MCN on the 19 program requirementsthat a health center must meet in order to receiveor continue to comply with federal fundingrequirements from Health Resources and ServicesAdministration, Bureau of Primary Health Care(HRSA/BPHC). In addition to this article on creat-ing needs assessments, this issue of Streamlinealso features an article on MOUs, the first of sev-eral articles on the requirements that address theclinical aspects of FQHC programs.

Canyonlands Community Health Care(CCHC), headquartered in Paige, Arizona,has what appears to be a daunting task:

accurately portraying the needs of a diversepopulation base over a large service area forCCHC’s needs assessment requirement. Inorder to meet the first of the 19 requirementsand more importantly to understand how todesign a comprehensive medical home for allCanyonlands patients in each of its eight sites,the CCHC staff must analyze a variety of datato create a clear picture of the needs andresources available for the residents of ruraland frontier Arizona, along the northern bor-der with Utah and at the southeastern borderwith Mexico. These populations vary greatlyin their education levels, local industries,unemployment rates, ethnicity, access tohealth care, heritage, and cultural perspec-tives. Collecting and extrapolating such data,however, have been important for Dr.Latham, the Canyonlands staff, and Board ofDirectors.“We do our surveys and questionnaires

biannually,” explained Dr. Latham, duringwhich they collect data on patient needs andsatisfaction. “It is a standard process for us—it’s not something we do special for the needsassessment. It’s something we’re doing con-tinuously.”“We hand them out to patients as part of

our PCMH process,” Dr. Latham continued,referring to patient-centered medical home, amethod of organizing primary care to betterserve patients through care coordination andcommunication. Patients fill the surveys outby hand, and CCHC inputs the informationinto its database. Every two years, CCHC eval-uates the data to determine shifts in patientneeds and to assure CCHC programs aremeeting expectations and demands. It takesover a year to evaluate the data.To fill out the picture further for the needs

assessment requirement, CCHC then inte-grates statistics for its service area collectedfrom local, state, and national sources, andcreates an extensive narrative on the peoplein its service area. In the last few years,

CCHC’s data points have increased, as a resultof updated census information and expandedneed for survey data internally. This, in turn,has led to the higher specificity of data pre-sented in the needs assessment, and hasincreased the “usability” of the documentinternally, said Dr. Latham. CCHC’s mostrecent assessment was completed at thebeginning of 2014; it ran over 50 pages.Dr. Latham believes that the data is essen-

tial to their programs. “We want a needsassessment that’s going to be a tool that wecan use going forward,” explained Dr.Latham. Grant writers within CCHC canquickly filter the overall data through theirdatabase to pull out figures on specific topicsor populations, without having to go throughthe extensive process of data collection andanalysis. CCHC uses the data to ensure that its serv-

ices are meeting the needs of each of its dif-ferent communities. The data confirm thatCCHC is on track with that goal, and alsoinform CCHC in areas that need improve-ment, said Dr. Latham. For example, recentlyCCHC has provided a greater emphasis oncultural competence for its clinicians servingthe Native American and Latino populations.The need for that change was found throughits needs assessment, Dr. Latham noted. Dr. Latham also reported that the ongoing

needs assessment process allows CCHC to be

more responsive to changes within the servicearea. In the southeast, copper mining is thelargest industry. “With the fluctuation in cop-per prices, the towns will really grow substan-tially,” Dr. Latham said. “In a period of twoyears, one community went from being amining ghost town to booming ... all to dowith the changes in copper prices.” CCHCalready has a small presence in these areas,and their needs assessment evaluations andongoing data collection informed them of theneed to increase their presence as the townsgrew. CCHC can more quickly moveresources due to their needs assessmentprocesses.Despite the wealth of information, Dr.

Latham recognizes the continued struggle tofind relevant and up-to-date data on the dis-parate and unique rural population segmentswithin CCHC’s service area. Often, the urbanareas will collect primary data specific to theirown use, which is not collected in rural areas,noted Dr. Latham. “We just [tell] the story ofthe people we actually serve,” conceded Dr.Latham, and yet the specificity of the data,highlighting each community CCHC serves,leads to a highly compelling and informativeneeds assessment, which in turn is utilizedinternally for grant writing and program eval-uation, and, most importantly, is used to helpCCHC better serve its patients. ■

Needs Assessments at Canyonlands Community Health CareClaire Hutkins Seda, Staff Writer and Editor, Migrant Clinicians Network

and agency characteristics. Community sup-port, TA quality, and inconsistent staffingdirectly influenced percentage of core pro-gram components. Lastly, sustainability waslargely determined by program characteristics. Based on this research, Nulu created an

Organizational Readiness Reflection Surveyfor MCN to analyze the organizational readiness of future clinics interested in implementing HU. The survey addresses fivecategories: organizational history with themigrant community, training quality for thefacilitators, staffing retention and quality, TAquality and reliability, and grading programreplication success. The survey helps identifywhich aspects of program success are mostvaluable for supervisors, and which aspects oforganizational readiness need to be improvedto align with program success goals.

Next stepsThe HU program continues to be rolled outto further its mission of reducing S/IPV. Lastmonth, MCN trained two new facilitators atAmpla Health in Yuba City, California. Their

goal is to have 50 participants in the HUprogram this coming year. Future organiza-tions that would like to implement HU willbe evaluated using the new MCN survey. Forthe organizations adopting HU, attention toidentifying and developing robust organiza-tional components will not only be useful forthe implementation of HU, but can also beapplied to other outreach programs internal-ly. For MCN, partnerships based on theorganizational readiness survey ensure suc-cessful implementation and evaluation. ■

REFERENCES1. Mihalic S, Elliott D. Issues in disseminating andreplicating effective prevention programs.Prevention Sci. 2004;5(1): 47-53.

2 Irwin K, Mihalic S. Blueprints for violence preven-tion: from research to real-world settings -- factorsinfluencing the successful replication of modelprograms. Youth Violence and Juvenile Justice.2003;1(1): 307-329.

3 Stall R, Kilbourne AM, Neumann MS, Pincus HA, &Bauer MS. Implementing evidence-based interven-tions in health care: application of the replicatingeffective programs framework. Implementation Sci.2007;2(42).

■ Evaluating the Implementation of Hombres Unidos continued from page 4

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Skin cancer is less prevalent in people ofcolor than among non-Hispanic whites.That widely held belief happens to be

true, and it may partially explain a secondfact: When skin cancer does occur in self-defined people of color, it tends to bedetected at a more advanced stage and isassociated with greater morbidity and mor-tality than in whites.1 Thus, it’s extremelyimportant that Hispanic outdoor workersunderstand the risks of sun exposure and themeasures they can take to protect them-selves, said board-certified dermatologistAbel Torres, MD, professor and chair of thedepartment of dermatology at Loma LindaUniversity. “These patients need to be awarethat, yes, they don’t get skin cancer verycommonly, but when they do get it, it canlead to significant deformity or death,” henoted in a telephone interview in July 2014.In addition to sun protection, “it’s importantthat we educate our patients to do skinchecks and self-exams, and to see a doctor ifthey notice a changing mole or a spot thatjust doesn’t want to heal. Primary care physi-cians who see these patients can also play animportant role by emphasizing the impor-tance of sun protection and self-exams, and

referring the patient to a dermatologist if asuspicious lesion is spotted by either thephysician or the patient.”physician or thepatient.”

Pilot program in four sunny statesIn an effort to mitigate the skin cancer riskamong this vulnerable population, theAmerican Academy of Dermatology (AAD)has launched a pilot program targetingHispanic outdoor workers in California,Arizona, Texas and Florida. The program isfunded by a grant from Stiefel. An out-growth of the AAD’s existing SPOT SkinCancer public education program, the out-reach effort brings volunteer dermatologistsface to face with outdoor workers atMexican consulates in two locations withineach state. The AAD coordinates withVentanillas de Salud (VDS) to offer free skinexaminations within VDS’s broader healthscreening and education events at the con-sulates. In addition, the dermatologists pro-vide instruction about effective measures forsun protection (eg, seeking shade, wearinghats and long-sleeved clothing, applyingsunscreen) and explain how to perform skinself-examinations. For patients requiring fol-

low-up care, VDS locates dermatologists inthe area who have agreed to provide treat-ment at reduced or no cost. “Coordinatingfollow-up care is a key part of the program,”said Dr. Torres. “The screenings are impor-tant, but they’re not as helpful if you can’tconnect people with some kind of serviceafterwards. The AAD’s partnership with VDSstrives to help ensure that as many of thesepatients as possible who have suspiciouslesions, are able to see a dermatologist fordiagnosis and treatment.”At a recent screening event in the Miami

area, three AAD members and two physicianassistants screened 61 field workers workingin avocado and mango farms, and detectedbasal cell carcinoma in one person, who wasreferred for follow-up care. In addition toproviding free screenings, a Spanish-speak-ing dermatologist who volunteers for VDSconducted educational sessions on skin can-cer in the waiting room, demonstrating howpatients should apply the free samples ofsunscreen which were provided for this pro-gram. In addition to sunscreen, the AAD dis-tributes Spanish-language educational

American Academy of Dermatology Outreach TargetsHispanic Outdoor Workers for Skin Cancer ProtectionJan Bowers, American Academy of Dermatology

continued on page 9

8 MCN Streamline

Editor’s Note: This is the second article in anongoing series by MCN on the 19 core pro-gram requirements that a Federally QualifiedHealth Center (FQHC) must meet in order toreceive federal funding from Health Resourcesand Services Administration, Bureau of PrimaryHealth Care (HRSA/BPHC). This article onMOUs is the first of several articles specificallyaddressing the requirements that relate to theclinical aspects of FQHC programs.

Health centers are expected to have anumber of assurances in place thatdemonstrate they are providing com-

prehensive primary care to the underservedpopulations in their service area. Things likea community-majority board of directors, asliding fee policy with nominal fees for thevery poor, and the availability of interpretersfor those who have limited English proficien-cy are hallmarks that distinguish patient-cen-tered care in a community health centerfrom that in other sectors of health care.Health centers not only provide top-qualitycare, they provide evidence of that qualitythrough the 19 program requirements thatdistinguish a federally-funded program. One of the federal program requirements

that may be unfamiliar to clinicians is theneed to have established written arrange-ments, such as a Memorandum ofUnderstanding (MOU) or a Memorandum ofAgreement (MOA), with other organizationsor individuals who are providing care to thehealth center’s patients. Specifically, anMOU/MOA is necessary when any of the“required services” are not directly availablethrough the health center. Frequently, prena-tal and obstetrical services, dental services,and behavioral health services are not direct-ly provided in small centers, but instead arearranged through referrals. Migrant voucherprograms arrange almost all of their carethrough referrals. When patients are referred elsewhere, it is

easy to lose track of them. For example,pregnant women referred elsewhere for pre-natal care may have many choices ofproviders. How do we as clinicians knowthey are getting timely prenatal care if wedon’t provide it? Health centers are responsi-ble for reporting the birth outcomes ofpatients, even if they get prenatal andobstetrical care through referrals. This isbecause the federal requirements assumethat the health center is responsible formonitoring the quality of care and healthoutcomes of patients for all basic required

Clinical Services Connection: Why Bother With an MOU?Jennie McLaurin, MD, MPH, Specialist in Bioethics, Child and Migration Health, Migrant Clinicians Network

continued on the next page

© earldotter.com

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services. What about the dental needs ofpatients when there is no dental program atthe center? These patients are entitled todental access through the health center’sarrangements. Again, without formalarrangements in place it is difficult to knowif care is being provided. An MOU helpsassure high quality care when referrals takeplace. It also allows the center to communi-cate its vision of community-based, patient-centered care for all patients in need, to thepartnering medical community.An MOU is a document that broadly

describes the working relationship betweentwo parties. It is not a legal contract, but itformalizes practices that are often createdthrough verbal agreements or those thathave been ongoing without any documenta-tion as to each group’s expectations andresponsibilities. Federal program require-ment expectations of the contents of theMOU are very specific, and many healthcenters have asked for help in establishingappropriate MOUs. Here, we briefly outlinethe necessary contents in order to documentthe spirit of patient-centered care as well asthe technical components of an agreement.For required services that are provided

indirectly (not via the health center itself),the following components are necessary inan MOU to meet federal program require-ments:• The manner by which the referral will bemade and managed, and the process for

referring patients back to the center forappropriate follow-up care;

• The availability of the service to all healthcenter patients, regardless of ability topay;

• The availability of a sliding fee discountschedule for all health center patients witha minimum provision of discounts avail-able based on income and family size forindividuals at or below 200% of the cur-rent Federal Poverty Guidelines, and pro-visions of no charge or only a nominal feefor individuals at or below 100% of thecurrent Federal Poverty Guidelines;

• The assurance of a mechanism for thehealth center to track patients and pro-vide follow-up care.

Additional components typically include: thename of the health center; the name of thepartnering organization or individual; theservice being provided; the rationale for theagreement; the contributions of both partiesto the oversight of the quality and provisionof services; the hours or dates the service isavailable; and the duration of the agree-ment. It is preferable that MOUs havedefined time limits, such as two years, withreview of terms at the conclusion of the timelimit. MOUs should be signed and dated bythe responsible lead personnel of all partiesin agreement. MOUs must be presented tothe health center’s board for recognition and

approval.At times, a health center has been obtain-

ing required services without an MOU, andwhen an MOU is requested in order to com-ply with requirements, the other party doesnot wish to sign a document, even thoughthey are willing to continue service provi-sion. In this case, all attempts to obtain anMOU should be well documented.Additionally, a formal MOU should be drawnup, even if not signed. Board minutes shouldreflect that the health center’s board hasapproved the unsigned MOU and hasattempted to obtain the second party’s sig-nature. MCN provides a number of resources to

support health centers in meeting HRSArequirements for FQHC funding, includingtwo example MOUs to help health centersestablish written arrangements. Visit ouronline toolbox at http://www.migrantclini-cian.org/tools-and-resources/toolbox_intro.html and click HRSAGrant Requirements to view the followingtwo documents.

MOU Example 1: The first demonstrates anMOU that meets program standards accord-ing to minimal standards.

MOU Example 2: The second exampleshows the possibility for infusing the healthcenter mission into the language of anMOU, embracing the spirit as well as the law of the arrangement. ■

brochures about skin cancer and sun protection at the events. The AAD conducts free skin cancer

screenings throughout the year for the general public through its SPOT me™ program. Individuals who cannot attend one of the VDS screening events can find a free skin cancer screening atwww.spotme.org.

Beliefs drive behaviorTo develop its Hispanic outreach program,the AAD reviewed existing research and conducted its own focus group withHispanic immigrants from Mexico to guideits decision-making process.The AAD’s Hispanic outreach program is

in keeping with the findings of Agbai et al,1who cite a survey by the Skin of ColorCenter in New York, in which black andHispanic respondents “self-reported low sun-screen use, secondary to misconceptionsthat it is unnecessary to use sun protectionto prevent photoaging or skin cancers. Ifused at all, sunscreens were generally insuffi-ciently applied and not reapplied frequentlyenough.”2 Fortunately, other studies indicatethat education does have a positive impact.

The authors describe another study3 inwhich the participants (15 percent of whomwere Hispanic) were instructed how to iden-tify potentially abnormal moles during skinself-examination. The participants also com-pleted questionnaires evaluating their atti-tudes, practices and beliefs before, immedi-ately after, and three months after theinstruction. The educational intervention wasshown to improve knowledge about the risksand the signs of melanoma. Moreover,“practices such as performance of monthlyself-skin checks, particularly of palms, soles,and periungual skin, dramatically improvedafter the intervention.”

Primary care physicians play essential role Sun protection is likely not a top priority foroutdoor workers because “they know theyhave to be out there since it’s how they earna living, and they also don’t think they’re athigh risk, as some other individuals [are],”said Dr. Torres. “Primary care physicians canpartner with dermatologists to help educatetheir patients about the importance of skincancer detection and prevention.” He noted another issue: “People think

skin cancer isn’t that big a deal; they thinkit’s more of a nuisance. Well, most skin cancer is a nuisance, but if it’s left alone long enough it can cause significant defor-mity and can kill.” He noted melanoma,squamous cell carcinoma, and basal cell carcinoma can all cause morbidity and mortality. “Most skin cancers are treatable,[and] most cause more morbidity thandeath, but a significant number can be very serious, and the paradox is that theindividuals who are less likely to get skincancer are the ones who are at higher risk of having a more serious problem withskin cancer,” Dr. Torres stated. ■

REFERENCES1 Agbai ON, Buster K, Sanchez M, et al. Skin cancerand photoprotection in people of color: A reviewand recommendations for physicians and the pub-lic. J Am Acad Dermatol. 2014; 70(4): 748-62.

2 Buster KJ, You Z, Fouad M, Elmets C. Skin cancerrisk perceptions: a comparison across ethnicity,age, education, gender, and income. J Am AcadDermatol. 2012; 66: 771-9.

3 Kundu RV, Kamaria M, Ortiz S, West DP.Effectiveness of a knowledge-based interventionfor melanoma among those with ethnic skin. J Am Acad Dermatol. 2010;62: 777-84.

■ AAD Outreach Targets Hispanic Outdoor Workers for Skin Cancer Protection continued from page 7

10 MCN Streamline

Minimize Opioid Abuse and Prescribe SafelyThe University of Washington School ofMedicine is offering a new, online courseabout safe opioid prescribing called COPE(Collaborative Opioid Prescribing Education)for REMS.The COPE-REMS course is unique in that

it allows you to experience patient-prescribervideo vignettes on how to handle tough situations and refresh your knowledge ofclinical pharmacology. The CME courseresponds to the FDA REMS (Risk Evaluationand Mitigation Strategy) for extended-release and long-acting opioids by beingfully REMS-compliant. Participants can view interactive, audiovisual content andreview guidelines for safe prescribing, thereby increasing their knowledge and confidence when treating patients withchronic pain.

Learn more at www.coperems.org. Formore information, contact [email protected]

AccreditationThe University of Washington School ofMedicine is accredited by the AccreditationCouncil for Continuing Medical Education toprovide continuing medical education forphysicians.The University of Washington School of

Medicine designates this enduring material

for a maximum of 4 AMA PRA Category 1Credits™. Physicians should claim only thecredit commensurate with the extent of theirparticipation in the activity.

AcknowledgementThe COPE-REMS educational activity is supported by an independent educationalgrant from the ER/LA Opioid Analgesic REMS Program Companies. Please seewww.er-la-opioidREMS.com for a listing ofthe member companies. This activity isintended to be fully compliant with theER/LA Opioid Analgesic REMS educationrequirements issued by the US Food & Drug Administration. Previously, COPE was supported by CME grants from Pfizer Inc.; Mallinckrodt, Inc., a CovidienCompany; and Endo Pharmaceuticals.Copyright© 2013 University of Washington.All Rights Reserved. ■

COPE (Collaborative Opioid Prescribing Education) for REMS

Announcing Free CME Training for Treating Chronic Pain

have positive outcomes beyond work safety,as the farmers and agricultural workersworked together. “The adversarial relation-ship,” that sometimes exists between agri-cultural workers and their employers “does-n’t get us anywhere,” she noted. Sheenjoyed watching the two groups “worktogether to make something good happen.”

Continuing issues for agriculturalworkersDespite the increase in services, Brieger rec-ognizes the ongoing struggles for agricultur-al workers as the region changes. “There’s alot more mechanization,” on farms, saidBrieger, leading to a decline in the need formigratory and seasonal agricultural workers.“People are really scrambling for otherwork,” she has noticed. “More people arestaying. There’s not as much movement,” asagricultural workers settle into other perma-nent jobs in her region. Those remaining in the agricultural sector

face new problems, compared to the work-ers of 30 years ago. Many farmers havestopped providing housing for seasonalworkers. As a result, explained Brieger,“farmworkers have now had to get apart-ments, and share apartments, sometimestwo families or three families” per apart-ment, and are often far from their rural jobs.Transportation to the farms is extremelychallenging, she added.Immigration reform is another hardship for

migratory and seasonal agricultural workers,as it “impacts everything [from] having trans-portation, being able to get to and from theirjobs, and health services, [to] after-schoolactivities for their kids,” Brieger said. “Thereis so much animosity, with this immigrationissue, that people are feeling vulnerable. Ithink that really overshadows everything,including many aspects of their health.”

Clinician connectionBrieger notes that connection to other clinicians focused on mobile patients canmake a big difference. “When I first started, I really didn’t know who to talk to or whereto go,” for support in migrant health, shesaid. She initially encountered MCN at herfirst East Coast Migrant Health meeting. Sheremembers the thrill of coming together asmigrant clinicians who encountered similarissues, and she recalls thinking, “I’ve foundmy tribe,” she remembered with a laugh. “Itwas my happy day!”“Sometimes the work we do is very chal-

lenging,” she admitted. “It’s exhaustingbecause you try to get whatever help youcan, whether it’s a winter coat, a blanket, oreven food,” but working with other clini-cians addressing similar issues can be inspir-ing, providing perspective, new ideas, andresources. “I think that challenge [of workingwith mobile populations] can really wearpeople out,” Brieger said, “but having thatcommunity support makes all the differ-

ence.” She continues to see a need for moreresources to strengthen the connectionbetween clinicians involved in mobile patientcare throughout the country. “I think thatconnecting other clinicians in the field withpeople who are doing right work remains avery important role that MCN can play,” shesaid. “There are such unique challenges tothe migrant community,” Brieger explained,saying MCN and clinicians both have a dutyto “keep the migrant issues on the forefront.”Meanwhile, Brieger will continue to push

forward programs to support the localmobile population. Over the years, Briegerhas found herself part of the community –attending quinceañeras, weddings, andfunerals, and watching children grow up.She finds the community “giving and kind,”adding, “They embody the best characteris-tics of what I think we should be about inthis country.” Recently, she hosted a poolparty for the teenagers in the health center’sprograms. “[For] at least four of them, I hadknown their fathers or mothers as little kids.No wonder they look familiar!” Briegerexclaimed.“It thrills me, and reminds me why I

came into this line of work – because youcan really make a difference in their lives,and they are so appreciative of everythingyou do for them,” Brieger says of herpatients. “I think I get so much more out of this than they do, and it makes mehappy,” she added with a laugh. ■

■ Care in the Black Dirt Region: Profile of Kathy Brieger continued from page 2

MCN Streamline 11

E N V I R O N M E N T A L / O C C U P A T I O N A L H E A L T H S E C T I O N[The material presented in this portion of Streamline is supported by a grant from the

Environmental Protection Agency, Office of Pesticide Programs, Grant # x8-83487601]

As a young child in Puerto Rico, Jose O.Rodriguez Ramos, MD didn’t havemuch time to daydream; in addition to

attending school, by the age of eight he hadalready started to work to assist his familyfinancially. But he knew he wanted to be adoctor. Recently, Dr. Rodriguez recalled visit-ing the local Hospital de San Sebastian as achild, where he peeked through the win-dows to get a better sense of what went oninside. When needing care himself at thehospital at a young age, he enjoyed watch-ing the dynamics and teamwork of the clini-cians. Despite the economic struggles, Dr.Rodriguez fulfilled his dream, and now worksas a doctor in a rural hospital in Puerto Ricothat serves the local agricultural worker com-munity.

Dissatisfaction with treatment: Earlyexperiences in medicineWith community and family support, youngJose joined a high school program for disad-vantaged students interested in medicalschool. While studying pre-med, he some-times encountered inhumane treatment ofpatients in the emergency room where hewas stationed, and he felt driven to changethat environment in his own future practice.Upon completion of his undergraduate

studies, he received a grant from theNational Health Service Corps (NHSC) tostudy medicine at the University of PuertoRico. After graduating with honors in familymedicine, he completed his residency at theHospital Family Alejandro Otero andManatee Hospital in San Pablo Bayamon,both rural hospitals serving high numbers ofagricultural workers. He found inspiration inworking with low-income people with highlevels of need. During his residency, he wasexposed to the full range of health and well-ness issues in the locals’ lives, from assistingin childbirth to attending the funeral of apatient. The residency was unforgettable forDr. Rodriguez. There, he met his wife,Carmen; he buried his father; he got mar-ried; and his wife gave birth to their firstdaughter, Mayra Alejandra.

Physician at Castañer General HospitalAfter completing his residency in 1990, he

began work as a family physician at CastañerGeneral Hospital, where he still currentlyworks. The rural hospital serves a populationof approximately six thousand inhabitants,of which 80% are agricultural workers, manyfrom the local industries of sugar cane, plan-tains, and coffee. The high number of agri-cultural worker patients keeps the hospital inline with its mission to serve economicallydisadvantaged populations, and the associat-ed funding to serve those populations. Hehas received many awards for his clinicalwork. For six years, he has been the medical

director of the hospital. Interested in issuesaffecting the community, and inspired bythe work of Amy Liebman, the director ofenvironment and occupational health atMCN, Dr. Rodriguez began to implement aneducation program for migratory agriculturalworkers with attention toward protectionfrom and prevention of pesticide poisoning,utilizing some of the program work on pesti-cide exposure developed by MCN. Dr.Rodriguez’s program helps agricultural work-

Dr Jose O. Rodriguez: Providing Care in Rural Puerto RicoIleana M. Ponce-Gonzalez, MD, Senior Advisor for Scientific and Strategic Planning, Migrant Clinicians Network


12 MCN Streamline

[Editor’s Note: This article is the Author’sManuscript. The Version of Record waspublished in the Journal of Agromedicine,Volume 19, Issue 4 (October 2014).]

Diabetes is a set of complexhyperglycemic metabolic disorderscharacterized by dysfunction in insulin

hormone secretion and/or insulin resistanceby target cells.1 Development of the twomajor types of diabetes are distinguished bydestruction of beta cells in the pancreas (type1) or by a combination of insulin resistanceand inadequate compensatory insulinproduction (type 2). Type 1 diabetes isusually immune-mediated and discovered inadolescence or young adulthood. Type 2diabetes is generally diagnosed in middleage, although it can also occur in obeseadolescents. Type 2 diabetes accounts forapproximately 90% of all diabetes cases andis associated with obesity, high caloric diet,physical inactivity, and advanced age.Hyperglycemia is the hallmark of diabetesand is detected by elevated levels of serumglucose or glycosylated hemoglobin (HbA1c) or an oral glucose tolerance test.Intermediate elevation of these markers isconsidered to be indicative of the pre-diabetes phase.In this issue of the Journal of Agromedicine,

Hansen et al2 present findings from acontrolled, cross-sectional study of pesticideapplicators in Bolivia. The study explores theprevalence of pre-diabetes, as determined by

elevated HbA1c levels, and its relationship topyrethroid exposure. This study found aremarkably high prevalence of elevatedHbA1c values (> 5.6%) of 61% amongpesticide applicators who applied pyrethroidsin public vector control campaigns in Bolivia.In contrast, the prevalence in controlscomposed of non-spraying employees of thevector control centers, university students,and “others” was 8%. When pesticide sprayers were compared

to controls, the adjusted odds ratio forelevated HbA1c was very high at 11.8 (95%CI 4.2 – 33.2). This value increased to 18.5(95% CI 5.5 – 62.5) when the analysis wasrestricted to sprayers who had only eversprayed pyrethroid pesticides. Dose-responseto quintiles of spraying duration andspraying intensity did not reach statisticalsignificance, but both raw and adjustedquintiles of spraying duration showed astatistically significant trend for sprayers withexclusive pyrethroid exposure. Worldwide, the age-adjusted prevalence of

diabetes has increased each decade since1980,3 paralleling the increase in theprevalence of obesity.4 However, not all ofthe increase in diabetes can be explained byhigher rates of obesity. Globally, theprevalence of type 1 diabetes has alsoincreased5 and a higher proportion of Asianswith type 2 diabetes are of normal weightcompared to Europeans with diabetes.6These findings have prompted the search forpossible environmental factors that may be

linked to the diabetes pandemic. Persistentorganic pollutants, including organochlorinepesticide residues, have been associated withtype 2 diabetes in epidemiologic studies.7Agricultural workers in particular have hadhigh exposures to many of these organiccompounds. From 1993 – 2003, theAgricultural Health Study prospectivelystudied over 45,000 licensed pesticideapplicators and their spouses in Iowa andNorth Carolina and found an elevatedincidence of self-reported diabetes associatedwith use of organochlorine andorganophosphate pesticides.8Organochlorine pesticides have been

largely abandoned due to environmentalconcerns and use of organophosphates hasbeen reduced dramatically in the US over thepast two decades due to concerns regardingacute toxicity. Pyrethroids have replacedmany of these chemicals in agriculturalapplications and have almost completelyreplaced most other chemicals for non-commercial household pest control.9,10Pyrethroids are a synthetic derivative ofpyrethrins , originally processed fromchrysanthemum flowers. Althoughpyrethroids were shown in one older studyto alter glucose metabolism in rats,11 thepotential for pyrethroid exposure to alterglucose regulation or diabetes onset has onlyrelatively recently been investigated inhumans.

Pyrethroid exposure and diabetes?Matthew C. Keifer MD, MPH, Editor, Journal of Agromedicine; David L. McClure PhD, Associate Editor, Journal of Agromedicine


E N V I R O N M E N T A L / O C C U P A T I O N A L H E A L T H S E C T I O N

© earldotter.com

MCN Streamline 13


Babies whose moms lived within a mileof crops treated with widely used pes-ticides were more likely to develop

autism, according to [research published inJune, 2014].The study of 970 children, born in farm-

rich areas of Northern California, is part ofthe largest project to date that is exploringlinks between autism and environmentalexposures.The University of California, Davis

research – which used women’s addresses todetermine their proximity to insecticide-treated fields – is the third project to linkprenatal insecticide exposures to autism andrelated disorders.“The weight of evidence is beginning to

suggest that mothers’ exposures duringpregnancy may play a role in the develop-ment of autism spectrum disorders,” saidKim Harley, associate director of Universityof California, Berkeley's Center forEnvironmental Research and Children'sHealth. She was not involved in the newstudy.One in every 68 U.S. children has been

identified with an autism spectrum disorder– a group of neurodevelopmental disorderscharacterized by difficulties with social inter-actions, according to the Centers for DiseaseControl and Prevention.“This study does not show that pesticides

are likely to cause autism, though it suggeststhat exposure to farming chemicals duringpregnancy is probably not a good thing,”said Dr. Bennett Leventhal, a child psychia-trist at University of California, San Franciscowho studies autistic children. He did not par-ticipate in the study.The biggest known contributor to autism

risk is having a family member with it.Siblings of a child with autism are 35 timesmore likely to develop it than those withoutan autistic brother or sister, according to theNational Institutes of Health.By comparison, in the new study, children

with mothers who lived less than one milefrom fields treated with organophosphatepesticides during pregnancy were about 60percent more likely to have autism than chil-dren whose mothers did not live close to

treated fields. Most of the women lived inthe Sacramento Valley.When women in the second trimester

lived near fields treated with chlorpyrifos –the most commonly applied organophos-phate pesticide – their children were 3.3times more likely to have autism, accordingto the study, published in the journalEnvironmental Health Perspectives.Chlorpyrifos, once widely used to kill

insects in homes and gardens, was bannedfor residential use in 2001 after it was linkedto neurological effects in children. It is stillwidely used on crops, including nut trees,alfalfa, vegetables and fruits.The study also is the first to report a link

between pyrethroids and autism. Applicationof pyrethroids just prior to conceptionmeant an increased risk of 82 percent, andduring the third trimester, the risk was 87percent higher.That finding is particularly concerning

because “pyrethroids were supposed to bebetter, safer alternatives to organophos-phates,” said the study’s senior author, IrvaHertz-Picciotto, an epidemiologist who leadsthe UC-Davis project to investigate environ-

mental and genetic links to autism.Use of pyrethroids has increased in recent

years, both on farms and in the home, dueto bans of other insecticides. Some studiesnow suggest pyrethroids may carry risks fordeveloping fetuses.The autism risk that could be attributed to

an individual pesticide is likely slight, saidAlycia Halladay, senior director for environ-mental and clinical sciences at the nonprofitAutism Speaks. “We need to understand howmultiple exposures interact with each otherand with genetics to understand all that isinvolved in the causes of autism,” she said.But while the risks reported in the

study pale in comparison to some hereditaryfactors, Hertz-Picciotto said they are comparable to other risks for autism, such as advanced parental age or not taking prenatal vitamins.“In any child who develops autism, a

combination of genetic and environmentalfactors are at work. There’s an accumulationof insults to the system. What we’re seeing isthat pesticides may be one more factor thatfor some kids may push them over theedge,” she said. ■

[Editor’s Note: This article is excerpted from Environmental Health News. Please visit their website for the complete article.Konkel L. Autism risk higher near pesticide-treated fields, study says. Environmental Health News. June 23, 2014. http://www.environmentalhealthnews.org/ehs/news/2014/jun/autism-and-pesticides. Accessed October 27, 2014.]

Autism risk higher near pesticide-treated fields, study saysLindsey Konkel, Environmental Health News

14 MCN Streamline


Migrant Clinicians Network (MCN) hasdeveloped a program to improve carein the primary care setting, supported

through a cooperative agreement with theUS Environmental Protection Agency (EPA),Office of Pesticide Programs as part of theNational Strategies for Healthcare Providers:Pesticide Initiative. MCN partners with interested federally-

funded Community and Migrant HealthCenters (C/MHC) in a year-long collabora-tion to develop simple, practical and flexibleadaptations to integrate EOH into the pri-mary care setting. These system changes aredesigned to assist the C/MHC and its clini-cians to reach the following goals:• to improve clinicians’ skills in the recogni-tion and treatment of environmental andoccupational health problems;

• to develop clinical systems that will sup-

port risk assessment, management anddocumentation of EOH issues;

• to support the C/MHC in attaining or main-taining Patient-Centered Medical Home(PCMH) and Meaningful Use recognition byintegrating improvements into the organi-zation’s Electronic Health Records (EHR) andQuality Improvement programs;

• to assist Migrant Health Centers to fulfill theHealth Resources Services Administration(HRSA) expectation that they “deliver com-prehensive, high quality, culturally-compe-tent preventive and primary health servicesto migrant and seasonal farmworkers andtheir families with a particular focus on theoccupational health and safety needs of thispopulation.” http://bphc.hrsa.gov/about/specialpopulations/index.html; and

• ultimately, to improve the health status ofthe health center’s migrant population

through quality healthcare services thatrespond to their unique needs.

Utilizing a performance improvement model,both administrative and clinical staff partici-pates in order to ensure success. MCN worksdirectly with a “clinician champion,” typical-ly the medical director, who is willing tospearhead the clinic-based program, alongwith a team of key staff members. MCN designates a C/MHC partner as

an MCN Environmental and OccupationalHealth Center of Excellence. This project isoverseen by a national advisory committeewith expertise in migrant health, primary careand occupational and environmentalmedicine. Follow this link to find out more about

becoming an EOH Center of Excellence,http://www.migrantclinician.org/files/MCN_EOH_Description.pdf ■

Become an Environmental/Occupational Health Center of Excellence!

© earldotter.com

MCN Streamline 15

Consistent with the findings presented byHansen et al,2 a 2011 study of 3,080 Chineseagricultural workers found that pyrethroidexposures were significantly associated witha 50% increase in the prevalence ofabnormal glucose regulation compared tothose unexposed.12 Notably, the AgriculturalHealth Study did not find an association ofself-report diabetes and pyrethroid use.8The Hansen et al2 study published in this

issue does have some fundamental flaws.The cross-sectional design, while sometimesthe only practical option, is itself is a weak

model to explore such associations asuncontrolled and unanticipated factors maybias results. Additionally, the study groupswere not well-matched. Pyrethroid exposedworkers were older than the largely non age-overlapping control population. This leads toless control of potential confounders inregression modeling and more potential forbiased estimates.13 Exposures were also self-reported with potential for recall bias.13Nevertheless, internal analysis of exposureduration suggested a direct dose responsebetween pyrethroid exposure and odds of

elevated HbA1c, which supports the crossgroup comparison results and should berelatively unbiased. This study juxtaposes two important

trends seen in the US and worldwide, namelyincreasing glucose intolerance and increasingpyrethroid use, and presents the hypothesisthat the two may be causally related. Giventhe importance for world health that thistrend represents, any potential causalassociation should be explored further withmore robust study designs, larger samples,and more objective exposure assessment. ■

■ Pyrethroid exposure and diabetes? continued from page 12


ers learn how to prevent pesticide poisoningby simple measures such as leaving shoesoutside and removing clothing before goinghome. Through this program, he began tovisit and train agricultural workers at thelocal church, community center, and farms.The program is popular, because the ownersof the farms receive a certificate, and partici-pants receive a card that certifies theyreceived education on the prevention of pes-ticide poisoning. This program has helped tosignificantly reduce exposure to pesticides.Agricultural workers are evaluated at leasttwice a year.

Struggles and successesin migrant healthDr. Rodriguez’s pesticide exposure preven-tion program initially encountered opposition from farmers, who did not want agricultural workers to be trained

during working hours. But even after farmers got on board, barriers to safetyremain; because Puerto Rico’s pesticides are packaged for the US market, warninglabels are typically only in English. Very few of the workers understand English, leading to the possibility of an increase inpesticide exposure incidents.One of the greatest satisfactions from his

work is the love and gratitude of hispatients, who are often struggling to survive.He points to the recent case of a farmerwhose illness turned out to be caused by atoxin from ingesting snails -- an indicationthat the farmer’s food sources were not suffi-cient. These experiences have motivated himto continue working for agricultural workers,particularly in light of the lack of attentionby some of his colleagues to the problemsfacing agricultural workers, he said.Beyond pesticide exposure prevention,

Castañer General Hospital runs a number ofprojects to battle chronic disease. Dr.Rodriguez is proud that he and his facultyare participating currently in the manage-ment and prevention of diseases such asasthma, diabetes, and hypertension and can-cer prevention with their agricultural workerpopulation. For Dr. Rodriguez, MCN has been an

organization that has supported him in preventing problems from pesticideexposure prevention, to training clinicians.For the future, Dr. Rodriguez hopes MCN can push for a physician exchange,wherein US doctors live and work in a rural Puerto Rican setting. Puerto Ricandoctors, in turn, would spend time in UShospitals: "I wish MCN could also support[physicians] in an exchange of physiciansfrom Puerto Rico, with US doctors, who work in rural areas.” ■

■ Dr Jose O. Rodriguez: Providing Care in Rural Puerto Rico continued from page 11

1. American Diabetes Association. Diagnosis and clas-sification of diabetes mellitus. Diabetes Care. 2014Jan;37 Suppl 1:S81-90. doi: 10.2337/dc14-S081.

2. Hansen et al, WAGR-2013-0148.R1

3. Danaei G, Finucane MM, Lu Y, Singh GM, CowanMJ, Paciorek CJ, Lin JK, Farzadfar F, Khang YH,Stevens GA, Rao M, Ali MK, Riley LM, RobinsonCA, Ezzati M; Global Burden of Metabolic RiskFactors of Chronic Diseases Collaborating Group(Blood Glucose). National, regional, and globaltrends in fasting plasma glucose and diabetesprevalence since 1980: systematic analysis ofhealth examination surveys and epidemiologicalstudies with 370 country-years and 2·7 million par-ticipants. Lancet. 2011 Jul 2;378(9785):31-40. doi:10.1016/S0140-6736(11)60679-X.

4. Finucane MM, Stevens GA, Cowan MJ, Danaei G,Lin JK, Paciorek CJ, Singh GM, Gutierrez HR, Lu Y,Bahalim AN, Farzadfar F, Riley LM, Ezzati M; GlobalBurden of Metabolic Risk Factors of ChronicDiseases Collaborating Group (Body Mass Index).National, regional, and global trends in body-massindex since 1980: systematic analysis of healthexamination surveys and epidemiological studies

with 960 country-years and 9·1 million partici-pants. Lancet. 2011 Feb 12;377(9765):557-67.doi: 10.1016/S0140-6736(10)62037-5.

5. DIAMOND Project Group. Incidence and trends ofchildhood Type 1 diabetes worldwide 1990-1999.Diabet Med. 2006 Aug;23(8):857-66.

6. Chen L, Magliano DJ, Zimmet PZ. The worldwideepidemiology of type 2 diabetes mellitus--presentand future perspectives. Nat Rev Endocrinol. 2011Nov 8;8(4):228-36. doi: 10.1038/nren-do.2011.183.

7. Taylor KW1, Novak RF, Anderson HA, Birnbaum LS,Blystone C, Devito M, Jacobs D, Köhrle J, Lee DH,Rylander L, Rignell-Hydbom A, Tornero-Velez R,Turyk ME, Boyles AL, Thayer KA, Lind L. Evaluationof the association between persistent organic pollu-tants (POPs) and diabetes in epidemiological stud-ies: a national toxicology program workshopreview. Environ Health Perspect. 2013Jul;121(7):774-83. doi: 10.1289/ehp.1205502.

8. Montgomery MP1, Kamel F, Saldana TM, AlavanjaMC, Sandler DP. Incident diabetes and pesticideexposure among licensed pesticide applicators:

Agricultural Health Study, 1993-2003. Am JEpidemiol. 2008 May 15;167(10):1235-46. doi:10.1093/aje/kwn028.

9. U.S. Environmental Protection Agency. Pyrethroidsand Pyrethrins. http://www.epa.gov/oppsrrd1/reevaluation/pyrethroids-pyrethrins.html. AccessedAug 27, 2014

10. Food and Agriculture Organization of the UnitedNations, FAOSTAT. http://faostat3.fao.org/faostat-gateway/go/to/home/e. Accessed Aug 27, 2014.

11. Cremer JE, Seville MP. Changes in regional cerebralblood flow and glucose metabolism associatedwith symptoms of pyrethroid toxicity.Neurotoxicology. 1985 Fall;6(3):1-12.

12. Wang J, Zhu Y, Cai X, Yu J, Yang X, Cheng J.Abnormal glucose regulation in pyrethroid pesti-cide factory workers. Chemosphere. 2011Feb;82(7):1080-2. doi: 10.1016/j.chemos-phere.2010.10.065.

13. Rothman KJ, Greenland S, Lash TL. 2008. ModernEpidemiology. 3rd ed. Philadelphia: LippincottWilliams & Wilkins.

R E F E R E N C E S

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Migrant Clinicians NetworkP.O. Box 164285 • Austin, TX 78716

Non Profit Org.U.S. PostagePA I D

PERMIT NO. 2625Austin, TX

Acknowledgment: Streamline is published bythe Migrant Clinicians Network (MCN). Thispublication may be reproduced, with credit toMCN. Subscription information and submissionof articles should be directed to:

Migrant Clinicians NetworkP.O. Box 164285

Austin, Texas, 78716Phone: (512) 327-2017Fax (512) 327-0719

E-mail: [email protected]

Kristine McVea, MDChair, MCN Board of Directors

Karen Mountain, MBA, MSN, RN Chief Executive Officer

Jillian Hopewell, MPA, MADirector of Education, Editor

Editorial Board — Matthew Keifer, MD, MPH,National Farm Medicine Center (NFMC),Marshfield Clinic Research Foundation,Marshfield, WI; Kim L. Larson, PhD, RN,MPH, East Carolina University, Greenville,North Carolina

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New Haven, CTwww.uniteforsight.org/conference

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Mobile Care Successes and Struggles in Pennsylvania ... Fall 14_ff LR.pdfof poverty, migration and health. To commemorate our 30th anniversary, we have launched 30 Clinicians Making

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