Meeting the Health Care Needs of an Older Hispanic Population

Community Healthcare Network (CHN) operates 12 federally qualified health centers in some of the most underserved communities in New York City. Each year, the nonprofit provides more than 75,000 people, many who are uninsured, with critical access to basic primary care, mental health services, nutritional counseling, dentistry, and more.

Community-based care is at the core of CHN's mission. The organization believes in offering health care services in locations that are easily accessible to its patients. To better serve those individuals, who are not as likely to visit a health center, CHN offers confidential educational outreach and sexual health services through its medical mobile van weekly throughout Manhattan and Queens. The mobile van also responds to specific health crises as they arise.

During these health care visits, counselors and physicians say they encounter an increasingly aging and diverse population confronting higher rates of obesity, heart disease and diabetes.

"An aging and increasingly diverse population requires that health care organizations and institutions take heed and respond to patients' individualized needs," says Catherine M. Abate, Community Healthcare Network's president and chief executive officer. "It's important that we ensure that all of our patients are health literate so they better understand what questions to ask their doctor, how to address existing health conditions, and how to prevent new illnesses.

"The growth in the Hispanic population of patients should be a signal to all health care providers that they should take steps now, and not wait until it's too late, to improve access and care."

As the country's Hispanic population continues to steadily escalate, medical providers are establishing ways to improve their services, to draw more Hispanics into the health care system and inevitably strengthen access. Hispanics represent the largest ethnic group without insurance in the country.

It's estimated that nearly 1 in 3 Latinos living in the country does not have insurance or has poor access to quality care - the largest "minority" group by far (recent research noted that 1 in 8 white individuals are uninsured, by comparison). Experts further dispel perceptions that undocumented immigrant Hispanics are primarily among the uninsured, pointing out that nearly a third of U.S.-born Hispanics and more than a third of Hispanic American citizens are uninsured.

The debate over access escalated amid the extended period to enroll for insurance under the Affordable Care Act (ACA). In mid-April, the White House reported that 8 million people signed up for private insurance under the ACA, which the federal government maintained would ensure coverage was more affordable and accessible for millions of Americans.

The debate aside, experts agree an aging population that is increasingly Hispanic should warrant long-term efforts to improve the public's understanding about proper health care, and to address issues earlier before they become life-threatening.

According to the federal Department of Health and Human Services (HHS), Hispanics suffer from certain illnesses at disproportionately higher rates than non-Hispanic white Americans. Nearly 32 percent of Hispanics were obese in 2010, compared to just over 26 percent of whites, with a larger gap among women (33.1 percent of Hispanic women compared to 24.5 percent of white women).

Among other troubling concerns: Hispanics face higher rates of the risk factors that can lead to heart disease such as obesity and diabetes; Hispanic women have steeper rates of cervical cancer, which they contract at 1.6 times the rate of white women, according to HHS department reports; and, only 46.5 percent of Hispanics had a colorectal cancer screening in 2010, significantly less than the 59-9 percent rate of non-Hispanics.

"With the Latino community, we know there are access issues," says Yvette Martinez, associate state director of AARP New York, noting cultural and social reasons often driving that imbalance. "Add to that the fact that Latinos have the highest rates of being uninsured, and that there are particular diseases, such as diabetes, which Latinos are at greater risk for, but are hugely preventable."

AARP is just one organization that has recognized the alarming disparity and targeted its education efforts at the older Hispanic community. Last year, AARP launched an "aggressive" outreach campaign, both on national and local fronts, to encourage older Hispanics to sign up for insurance.

"There was massive misinformation, a complete lack of knowledge about what this meant," Martinez said. "There was so much information and fear about what it meant, and people were not enthused about enrolling."

AARP's outreach efforts were designed to infuse a stronger understanding of the benefits of insurance and improved healthcare. "That was a huge part of the campaign," she said. "If people are able to go to a doctor, and get regular checkups so that things that may be treatable are identified early, that keeps health care costs down for everybody."

AARP teamed up with other organizations - such as the nonprofit Hispanic Federation based in New York City - to amplify a media campaign and forge connections with Hispanic communities. One avenue to reaching older adults: connecting with Hispanic youth that enjoy close familial relationships with their elders.

"Latinos are very family-oriented, and many adult children are still living with their parents," she said. "What impacts one member of the family really impacts them all. Getting them information that will help them prevent diabetes or high cholesterol or heart conditions is important."

She added, "Keeping our community educated and healthy is really what's important."

One creative campaign designed to connect with older - and younger - Hispanics was a digital outreach effort in which mothers would email or post on Facebook humorous e-cards aimed at their adult children reminding them to sign up for health insurance.

The National Hispanic Council on Aging (NHCOA), a Washington, D.C.-based nonprofit organization working to improve the lives of Hispanic older adults, their families and their caregivers, reports that Hispanic seniors represent 7 percent of the country's older adult population; by 2050, Hispanics will comprise 20 percent of the nation's older adults.

NHCOA has developed a Hispanic Aging Network of community-based organizations across the country, the District of Columbia, and Puerto Rico that reaches millions of Hispanics each year.

"As the U.S. population grows older, an increasingly larger share of our older Americans are Hispanic," said Dr. Yanira Cruz, president and CEO of NHCOA.

"Through this demographic shift we are confronting several realities that need to be addressed, particularly in the area of health. Hispanic older adults are disproportionately affected by chronic diseases and illnesses. In addition, we know that lack of health literacy is an added burden that impacts Latinos, as well as other Americans."

In early April, NHCOA launched a new health literacy elearning platform - Portal e-Comunidad - for lay community health workers to promote health literacy among Hispanic seniors with chronic diseases. The platform features five modules of 20- to 40-minute lessons on narrated PowerPoint presentations, including instructions on managing medications at home and how to get the most out of a doctor's visit.

When Hispanics do have access to health care, linguistic and cultural gaps between the health care provider and patient or a lack of cultural competency can result in misunderstandings and poor communication - a driving force behind the health literacy movement.

Dr. Matthew Weissman, Community Healthcare Network's chief medical officer and vice president of medical affairs, stressed the need for health care organizations to incorporate health literacy strategies to provide culturally competent care to Hispanic patients.

Noting the Spanish word "once" for the English word "eleven," he said: "One of the classic health literacy stories is about the medication bottle that says take once a day, but someone with limited English proficiency takes 11 pills instead of one."

While elderly patients comprise about 7 percent of its current patient population, CHN anticipates a growth in that number due to higher life expectancy rates, along with the increasing amount of people who now qualify for affordable health insurance.

Often, he said, elderly patients are receiving care from multiple medical providers, and receiving multiple medications.

"Without the oversight of one qualified primary care doctor, it's very easy for patients to have their health worsen," he said. "And for Spanish-speaking patients, this care model is critical since English is not their first language and they may not know what questions to ask or understand all of the directions for taking medications and improving their own health conditions."

'We want to make sure they follow a provider's directions," he said. "We hire as many bilingual staff as possible. These are people from the community who are able to understand the language and culture of our patients."

Additionally, CHN ensures that it has a language line available so its patients can communicate with translators via phone, and the nonprofit is now readying to launch a video translation service to allow translators to notice nonverbal gestures to better assess conditions.

'We suspect it's going to enhance the translation process, and allow people to see each other, use gestures and read lips," Weissman said.

NHCOA reports that steep costs may often be prohibiting older adults from seeking medical care. While Medicare provides life-saving benefits, it does not provide insurance for all health care expenses. NHCOA notes that Medicare does not help older adults pay for long-term, dental, or vision care, and that the cost of long-term care can be too high for all but the wealthiest families.

For many Hispanic older adults, Social Security is their only income. The average Social Security payment to male Hispanic older adults in 2010 was $12,815, and for female Hispanic older adults, the amount was $9,605. While Medicaid helps with costs, a person would need to live in poverty or near poverty to qualify for the benefits.

In fact, NHCOA reports that Hispanics were the racial and ethnic group most likely to not see a doctor in the past year - because of cost. This has spurred nonprofits to strengthen their efforts to bring greater numbers of older Hispanics into the health care fold.

That trend is evident at the 10-year-old East Harlem House Outreach Partnership (EHHOP), a clinic operated by the students of the Icahn School of Medicine at Mount Sinai, which provides free, confidential primary care to uninsured residents in the surrounding East Harlem community. The New York City Department of Health and Mental Hygiene reported in 2011 that 17.6 percent of East Harlem residents - a heavily Hispanic community - had no insurance, compared with 15.6 percent in Manhattan as a whole, and 44.2 percent had no primary care provider compared with 18.4 percent in Manhattan as a whole. Additionally, a third of East Harlem residents reported their health was fair, or poor, according to EHHOP's 2012 annual report.

Chronic illness, diabetes, high blood pressure, high cholesterol, asthma, and obesity rates were significantly higher in the community as well - and six of the top 10 causes of death in East Harlem resulted from complications of chronic disease.

As a result, the clinic is navigating new initiatives to connect with a community often without access to care earlier. In October 2011, EHHOP launched a Patient Ambassadors Program to advocate for specialty care outside of EHHOP.

Although EHHOP provides comprehensive primary care, some patients require specialty services and before this program was established, these patients encountered a number of barriers to specialty care. Language and health literacy barriers were particularly challenging for many of the most vulnerable patients to overcome - and led to long delays in effective treatment.

Patient ambassadors are medical and graduate students who help patients with the logistics of referral appointments. They walk them to appointments, greet front desk staff, help them sign in and ensure payments proceed smoothly. They also help to coordinate follow-up care.

Jillian Nickerson, a fourth year medical student at Icahn, is the chief teaching senior and chair of clinical care at EHHOP, noted that EHHOP sees patients from their early 20s to their 90s, the majority of whom are Hispanic. "We started out as an urgent care facility where patients came in for an appointment when they were feeling sick, but now we've become a medical home," she said.

EHHOP launched a chronic care program in which thirdyear students are paired with patients with complex chronic disease for one to two years to ensure they have a stable medical provider who can effectively tackle their health needs rather than the discordant care that comes with multiple providers. EHHOP also is regularly staffed with social workers and nutritionists - all in an effort to knit more comprehensive services together.

'We train all of our students at the clinic to be very proactive about educating their patients," said Nickerson, "and to make sure whatever they tell their patients is appropriate and understandable."

Establishing stronger inroads in the older Hispanic community is a key, she said.

"Once people have diabetes or high blood pressure, diseases that could be prevented or improved through earlier lifestyle changes and education, it is harder to treat them," she said. "The main reason we need to focus on this group of people is that they are at high risk. Some of it is genetic, some of it is because of the environment they live in, but there is a lot we can do. This is really important and meaningful to focus on."