Community health care centers adapt to population changes

The face of New Hampshire has changed dramatically in the last decade, with the state’s minority populations doubling in size – from 30,000 to more than 60,000 – between 1990 and 2000. To meet that changing demographic, the state’s federally qualified community health care centers have had to adapt the way they meet the needs of this growing population.

Mariellen Durso, center director for Lamprey Health Care’s Nashua Area Health Center, has seen that doubling in her center’s patient population.

“Five years ago, we saw about 2,200 patients, and about 25 percent were non-English-speaking. Today, we see nearly 5,000, and 50 percent are non-English-speaking,” she said.

At her clinic, located on the campus of the Southern New Hampshire Medical Center in downtown Nashua, she sees predominantly Hispanic immigrants speaking Spanish, with Brazilian-born, Portuguese-speaking patients the next largest segment.

“Our population has changed because Nashua has changed,” said Durso. “We are seeing more new immigrants.”

Kris McCracken, director of operations for Manchester Community Health Center on Elm Street, says Spanish also is the largest language spoken at her facility – about a fifth of the 9,000 patients speak Spanish, she said.

But large portions of her patient population also speak Bosnian and Arabic, with smaller segments speaking French, Cantonese, Mandarin and Somali, among dozens of other languages.

“Our population continues to change at an exponential rate,” said McCracken. “We certainly get several hundred patients a year from refugee resettlement programs, but primarily we see an upward influx of people from Boston.”

Diverse populations

Federally qualified community health care centers were launched in 1965 through the establishment of the Public Health Service Act in response to the disproportionate availability of providers in certain urban and rural settings. These centers receive funding through Section 330 of the act.

In 2004, New Hampshire’s 23 community health centers served some 81,000 people.

Community health care centers treat diverse populations, many of them at risk due to poverty, little or no health insurance, low birth weights and other concerns.

These centers also are different from other medical institutions because 51 percent of the directors on their boards must be consumers of the care they provide.

“This becomes incredibly important in creating the organizational philosophy,” said Durso.

Durso has her own theory, based on decades of experience, of a need for business processes to change when a certain segment of the patient population grows by about 5 percent.

“You start to see cultural impact issues at that point. You know you have to address the changes at 10 percent, but if you wait that long, you’re really behind the eight ball.”

For example, she said, when she saw the population of Brazilian patients grow to about 5 percent, she had documents translated into Portuguese and added translation services.

For the centers in Nashua and Manchester, cultural and language differences are twin hurdles to overcome, both for patients and providers.

Something as seemingly simple as a physician seeing a patient of the opposite sex can be a cultural taboo.

Durso said some of the female patients come from countries where they do not own property, do not attend formal education classes and are illiterate in their own language. Conversely, some patients from Slavic countries are very well educated, and some were even physicians themselves. “So just because they don’t speak fluent English, you can’t assume anything,” she said.

More interpreters

To adapt to its changing population, McCracken said, the Manchester center has added staff interpreters, external interpretation services and has printed its 40 most important forms in English, Spanish and Bosnian.

Five years ago, she had about 40 staff members. Today, the center has over 50. Twenty members of the Manchester center’s staff are bilingual, and the center also has a roster of some 25 independent interpreters.

The interpreters McCracken uses do more than simply speak a patient’s language; they are highly specialized professionals certified in medical interpretation.

“There are well-defined standards for medical interpretation that stipulate where the role ends and begins. An interpreter can’t advocate for the patient as a case manager unless they are in fact a case manager. The role of the interpreter is to omit nothing, change nothing, but not to decide what or when or how something gets said.”

McCracken also is developing an algorithm based on patient populations and other information that can help decide how many translators will be recommended per number of patients. “If it’s less than 0.5 FTEs (full-time equivalents), you can’t really recruit for a position. That’s a part-time job and most people would need to balance that with another part-time job and need benefits,” she said.

Durso also has greatly increased the size of her bilingual, and in some instances trilingual, staff.

Five years ago, the Nashua facility had about five bilingual staff members whose primary job function was something other than translating. Today, she has three contract medical interpreters, nearly half of her staff is bilingual, 20 percent are trilingual and four of her nine providers are bilingual.

The Nashua center also has nearly tripled the amount of interpretation resources spent per year. In 2000, the cost of specialized communication resources was about $35,000. In 2004, it was $100,000.

“In actuality, this cost could have been much higher, but we’re so focused on our patient population’s needs and being proactive it is less than it could be,” said Durso.

At Manchester Community Health Center, about $120,000 is spent on interpretation resources – almost double the amount spent four years ago.

Like Durso, McCracken said the higher cost is not so much because of a growing population, but being more attentive to their population’s needs.

While the challenges at both centers are as diverse as their populations, both directors see a need for multilingual, multicultural health care professionals and providers.

“We are all dealing with the nursing shortage,” said Durso. “Now try and find a trilingual one.”