Promotoras bridge clinics and community

September 4, 2013

By Callie Shanafelt

Elizabeth Luciano sits in her small office looking compassionately at the young mother complaining of stomach pain. She was undocumented and had no health insurance. They met at a community event a week before and the woman cautiously approached Luciano to see if she knew of anyone who could help with her Medi-Cal application.  Luciano, a former hospital nutritionist in her home country of Columbia, told her it was safe to come to her office at the Pittsburg Health Center.

Luciano is a promotora, a community health worker helping other Latinos understand how to improve their health and access resources in Contra Costa County.

Promotoras like Luciano are playing a critical role in helping patients manage their chronic illnesses. Controlling illnesses like diabetes is key to the preventative approach clinics are increasingly turning to as a way to reduce costs and improve care.

Navigating the health-care system is difficult for many patients, but perhaps the most challenging for patients like Luciano’s young mother – those who are undocumented and only speak Spanish. She had three options – pay out of pocket for care at a clinic that charges on a sliding scale, go to an emergency room, or sign up for emergency Medi-Cal, which is possible for some undocumented residents.

Luciano arranged the last option for her patient, calling a contact at Medi-Cal who promptly enrolled the young woman in the 6-month emergency care program. She left the office after hugging Luciano, a look of relief on her face.

Contra Costa’s promotora program started 9 years ago, when Pittsburg clinic manager Concepcion Trevino James noticed that Latino parents weren’t following instructions from their children’s dentists, which led to rampant tooth decay.  James realized that in the brief time dentists had with the parents they weren’t able to fully train them in how to tend to their children’s oral health. So they established group visits so they could carefully explain to parents how to care for children’s teeth.  Initially the groups didn’t do well, with parents dropping out before the end of the 5-7 week series.  But then they hired a promotora to help parents understand the importance and call to remind them of the appointments, and participation increased to 80 percent.

Following the success of that program James identified diabetes and childhood obesity as the major health concerns among Latinos and decided to have group visits in Spanish with a doctor to educate patients on how to care for themselves and their children. Those groups, however, didn’t attract many patients. So they turned to promotoras to bring the community into the clinic.

Promotora and Pittsburg resident Nuria Jovel has a firsthand understanding of how hard it is to manage chronic illness. She has type two diabetes and over the past eight years she’s worked hard to change her diet and exercise. Eventually, she lost more that 100 pounds and no longer has to take medication for her condition.

Now, Jovel is almost evangelical about what it takes to stay on top of your health. James hired Jovel and another resident already involved in the community to engage patients and keep them in the program. Jovel, a native of El Salvador, had promoted politics in her home country, but had been working cleaning houses and other miscellaneous jobs since moving to the United States.  She was also very involved in Latino community groups.

“Their name means promoters- salespeople right?” James said. “They could get people to stay in the group because they are from the community, they understand the way to package things in a way the Latino community understands. People were surprised.”

Since then Jovel, Luciano and two other promotoras have grown the program. They reach more than 800 people a year. They help residents enroll in public programs, direct them to non-county resources and co-facilitate group patient visits.

The groups involve 5-7 week sessions with 10-15 patients and coaching them how to manage diabetes, fight childhood obesity or prenatal care.  The promotoras partner with a doctor and a nurse to conduct the sessions, but they play a key role in ensuring attendance and interpreting information.

Jovel shares her personal struggle to manage her condition in the diabetes group, encouraging people to exercise more and understand how their body processes food. During a group session she walks around the room demonstrating the right way to walk to increase your heart rate, a skill she says was hard for her to learn.

At first medical staff were skeptical of the benefit of promotoras, James said.

“I think once the doctors understood how they could be utilized they were like ‘I want one,’” James said.

Contra Costa promotoras also meet the community at events and centers, where they field requests for help accessing health care, food stamps, housing and other resources.  They meet with people one on one to explore their options and navigate complex systems that often require English proficiency.

But as health-care reforms ramp up, options for undocumented residents are slimming down.

Undocumented immigrants were left out of expanded Medi-Cal and federal health-care subsidies that will soon go into affect thanks to Obamacare. Contra Costa is one of the state’s 50 counties that are expanding Medi-Cal early through a program called the Low Income Health Plan. So far they’ve enrolled more than 12,000 people, in part thanks to the help of promotoras like Jovel and Luciano.

But the LIHP does not cover the undocumented, as the county’s health plan had in the past.

The county still covers 1,800 undocumented children but could no longer afford to cover primary care for undocumented adults, said Patricia Tanquary of the Contra Costa Health Plan.

“The county lost a great deal in the great recession, we had one of highest foreclosure rates,” Tanquary said.

Instead they refer people to La Clinica De La Raza or RotaCare, clinics that cover the undocumented on a sliding scale.

Many of the county’s undocumented residents are hoping that immigration reform will improve their health-care options. In the meantime, Jovel, Luciano and their colleagues keep advocating for their patients and doing their best to connect them to care.

This article was produced as a project for California Endowment Health Journalism  Fellowships, a program of USC’s Annenberg School of Journalism.

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