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Podcast: Work as a Social Driver of Health — How La Casa Family Health Center Identifies Farmworkers

The latest episode of NACHC’s podcast, Health Centers on the Front Lines, takes us behind the scenes at a health center and its partner network as they change the culture around disclosure of occupation among patients. We talked to experts from the Health Choice Network, a health center-controlled network based in Miami, and their partners at La Casa Family Health Center in New Mexico, about a high-risk group of essential workers who received care at La Casa, the dairy farm workers.

It is not always clear to the Community Health Center care team what a patient does for work. Occupation is one of the most important social drivers of health, affecting patients’ health and access to healthcare in many ways, but patients are often reluctant to disclose information about their employment, and staff themselves may not have a good understanding of how this information is used.

Related resources: View our occupational data for health explainer and this resource from NIOSH (National Institute for Occupational Safety and Health), A Guide to the Collection of Occupational Data for Health: Tips for Health IT System Developers | NIOSH | CDC.

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Podcast Guests

Katherine Chung-Bridges, MD, MPH

Director of Research, Health Choice Network

Daniel Parras

Research Data Scientist, Health Choice Network

Yvonne Armijo

Director of Operations/Information System Analyst, La Casa Family Health Center

Giddel Thom, MD

Chief Medical Director, La Casa Family Health Center

Episode Transcript

Alexandra Walker: Hello and welcome to Health Centers on the Front Lines, a podcast of the National Association of Community Health Centers. I’m your host, Alex Walker. For the past year on this podcast, we’ve told the stories of health centers making public health history and their response to the COVID-19 pandemic. With today’s episode, we are shifting our focus a bit to look at another key role health centers are playing in providing care to essential workers. Among so many other things. The COVID pandemic taught us that the workers who pick, raise, or process our food are truly essential, and they’re often affected more directly than anyone else when a new outbreak or health emergency begins. Yet health care providers often don’t know where their patients work or what they do, so they don’t know who is an essential worker. If they did, they could provide care in ways that could be more protective. Especially when we consider that occupation is a social determinant of health or social driver of health, as we’re starting to say here around NACHC. We’re here today to share some insight into why it’s important for care teams to know about patients’ work and what type of data about occupation health centers should be collecting. I’m so pleased that we have some amazing experts from the Health Choice Network, a health center-controlled network based in Miami, and their partners at La Casa Family Health Center. So let’s begin with Dr. Giddel Thom, chief medical officer at La Casa Family Health Center. Could you please start by telling us the story of a high-risk group of essential workers who received care at La Casa, the dairy farm workers?

Giddel Thom: Thank you, Alex. Just for a background. New Mexico ranks ninth overall in the United States in milk production. And we have New Mexico with over 130 dairy farms and in 2020, these farms produced over 8 billion pounds of milk.

This is essentially for the entire country. Texas and New Mexico combined produce about 10% of the milk that we have in this country. So we have a huge operation going on in terms of dairy and dairy workers here in New Mexico.

Employees come here from different cultural and linguistic backgrounds. Some of them have limited or unknown education, and especially they might not be trained in the position that they’re given the job in. And for some of them, even worse, they might not have been around animals previous to having that job. And so there is not necessarily it’s not necessarily a skilled-based work. It’s a willingness job. You want the job. And so these people, these workers are very, very essential to us.

So are these essential workers? Of course, they are. And so we know that they’re essential workers. And just based on the scale of what we’ve seen and what they’ve been doing now, it’s they are very important. And they come to us and we don’t know that these workers even exist until we start collecting data with the help of, you know, Dr. Chung Bridges. And it’s a young team. We went into this project to start identifying essential workers. And so we start identifying these workers, and we realize that you know, these workers they have. Different exposures, for example. Dairy farming now has become so compartmentalized that, you know, their people are employed to be feeders, feeders of the calves, feeders of the cows, to work in the milk parlors, to clean the stalls. So there are a number of jobs that are involved. And these put the workers at risk for several different things. For example, there are accidents relating to cows and machinery. And we see that, there are a number of. Biological, you know, exposures and the toxin and we see acute diarrheal illnesses. But outside of that, we also see some of these workers having issues with respiratory issues. And so when you look at, you know, the dairy workers and taking that information, it just drew the, you know, remove that that veil, as it were so that you can now see entire population, a group of people and some of the exposures that there have been, you know, and concrete and just because of their job.

Alexandra Walker: Thank you. I’d like to turn it to Dr. Katherine Chung Bridges, who’s the director of research for the Health Choice Network. To talk a little bit more broadly about what is occupational data? How does it affect health care? And why does that data help us serve patients?

Katherine Chung: So, you know, it’s just so interesting how it all happened, this connection where we learned about these dairy farmers. So the La Casa team has been amazing in collecting this occupation and industry data. In fact, they have been capturing this data on most of their patients. Our HCN team was speaking with the La Casa team about this rich database that was developing that could help their team to better understand the occupational health risks of their patient population. We started talking about the dairy farmers and realized that this was a population that we could query further because there was suspicion of health issues associated. So our research data scientist, Daniel Parras did some exploratory analysis of the data and found a high rate of respiratory issues among these patients. There were 63 cattle farmers and 31 of them, or 49%, had a diagnosis of the respiratory tract or asthma issues. Daniel then stratified the population by demographic factors to get at who these individuals are, and they were mainly middle aged, about 46%, between 40 to 60 years old. They were males, about 75%. Spanish speakers, about 67% preferred Spanish, and Hispanic or Latinx at about 92%. So basically, this information helps providers and staff at the health centers to understand better who these patients are. And that definitely helps when it comes to deciding on an intervention that best meets the needs of the individuals identified.

So then we can see clearly, as you’ve explained, why it’s valuable to have all that data to understand the whole person behind the patient that you’re treating. But how difficult is it to collect the data? We have Yvonne Armijo from La Casa. She serves as the director of operations and information systems analyst. Yvonne, you have direct experience, right? Collecting occupational data for health?

Yvonne Armijo: Yes. Good afternoon, Alex, and thank you for having us here today.(10:24) So in the beginning, we had many patients who were reluctant to share that information with our front desk team. Patients were not clear as to why the organization needed to identify essential workers. To them, it felt that La Casa was violating their personal information, and they noted it very clearly that it was none of our business. And they also believed that providing this information could or would affect the sliding fee discount that la casa offers. Therefore, we had many patients again refusing, in the beginning. To assist with that misconception, HCN did provide a script to our front desk staff to use in explaining the importance of providing the essential worker information and why we are collecting this data. Once our staff understood the reasoning for collecting the data themselves, they in turn were able to simplify and educate patients with the importance of collecting information and the potential impact of health risk exposure, and the time available to access preventative care services. (11:36) So for the most part, the front desk staff are currently successful with patients freely providing that information. And I’m sure Mr. Daniel will share the information data-wise of what we’ve collected with our patients that we’ve seen.

Alexandra Walker: Thanks for setting that up. Yes. Daniel Parras is the data scientist for Health Choice Network. Can you talk about the challenges with integrating occupational data for health into electronic health records and what your experience has been, especially as other health centers or health center-controlled networks are considering doing so themselves?

Daniel Parras: Absolutely, Alex, and thank you for having us. That’s an excellent question. I think one of the first couple of steps to do and some of the advice I would actually give the other networks or health centers is to first determine if additional occupational data aside from employment status can be collected in the EMR. So are there fields for, for example, occupational roles? Are those fields mapped out to some of the standard occupational classification system codes? Are there fields for industry and are those able to be mapped out to the codes used by the North American Industry Classification System? If those are available and can be used for data collection, that’s a great first step if they’re not available. I think the network or the health center has to determine with some subject matter experts whether the earmark is optimized to collect this information. Are there any customizations that can be provided by the vendor to collect this information? And once it is collected, you have to sort of integrate that into the already established clinical workflows. You have to determine whether or not this new data collection is going to impact operations. You can assume that there will be more time than the front desk or registration, well, it would take to collect this information aside from their standard workflow and determine, you know, what kind of efficient workflows can be used to continue collecting this data. Once that is already determined, I think bringing that data to the forefront for clinicians to be able to access is equally as important. You want clinicians to be able to access this information, to be able to assess occupational hazards and exposures that would ultimately make their clinical decisions that much better. Some of the um, I guess, pitfalls we encountered were, you know, being able to search for these additional occupational data points such as occupational role or industry, within the EMR. We came across an issue where we had to implement somewhat of a keyword search into these fields outside of the EMR. And we went around that by providing a searchable list, where the clinic staff have to side by side with the EMR while they’re asking the patient, you know, where do you work? What kind of occupation is it? What kind of industry is it in? They could, you know, search this list, and correlate that into the EMR. And using those codes, they could do a 1-to-1 match. So that’s you know, that’s very important. It makes the workflow much more efficient. And then, you know, I think what’s also important is, aside from just the data collection, is just educating the providers and the staff on the importance of occupational health data. What is it? What’s it useful for and what’s the best way to approach patients? And, you know, in a sincere and healthy manner to collect that data from them.

Alexandra Walker: Thank you. Dr. Chung Bridges, do you have anything to add especially from the perspective of other health centers or health center-controlled networks that might be thinking of?

Katherine Chung: I would add that it’s helpful if EHR companies think through these issues to make sure that the occupation and industry data are collected at a level of detail that’s meaningful, in a manner that’s easiest for staff and takes the least amount of time. As Daniel mentioned, these companies should also be thoughtful as to where the information lives in the E.H.R. so that clinicians and staff can access and act on it. A consistent, unified coding of the data is very important so that data analyses can be done using data spanning different E.H.R systems. You want to be able to combine data from different systems together. That means comparing apples to apples, not apples to oranges. (16:31) So having that uniform unified coding system, Daniel talked about NAICS, the North American Industry Classification System, or SOC, the standard occupational classification system. (16:44) There was one thing I didn’t say earlier that (16:47) I did want to mention in giving the big picture that occupation is one of the most important social drivers of health. (16:56) It exerts its effect in many different ways. Occupation, so, you know, just giving the big picture of why occupation is important. It represents socioeconomic status in the usual sense. So it determines, for example, how much income an individual has and therefore their access to basic needs, such as food, clothing, and shelter. (17:19) But it also impacts another aspect of social class, which is prestige or level of respect in the community and in society. (17:28) Occupation directly impacts on access to health care as it determines whether or not someone has health insurance coverage as well as the quality of that coverage. It can also impact access to care in another way. Certain occupations or jobs give time off to workers so they can go to health care appointments as needed. While other jobs might make it difficult for workers to take time off to seek health care. (17:56) Occupation also has an environmental impact, so people spend many hours at their work and are therefore exposed to different environmental exposures. (18:08) Could be chemical in nature. Some of the risks that Dr. Thom talked about are that these agricultural workers are exposed to, for example, the bio biological exposures, risks of injury, and illness. But there can also be psychological stress due to work conditions or due to power dynamics on the job. For example, a worker who feels undervalued in their job and possibly mistreated and the impact that this can have on their overall health. Finally, occupation impacts on other social drivers of health. For example, it might determine the neighborhood one can live in and therefore the walkability of the neighborhood, access to healthy foods, exposure to crime or overcrowded living conditions, a parent’s occupation or employment status. Whether or not they have a job, for example, can impact the quality of education their child can access and the support that the child can be given by the parents based on the number of hours the parent needs to work or the ability of the parent to take time off to support the child’s activities. So I just wanted to give that broad view to say that occupation is arguably one of the most important social drivers of health because it can impact so many of the other downstream factors. (19:31)

 (19:38)

Alexandra Walker: Thank you. That’s excellent context. Appreciate that. I wanted to just bring it back to the patient and hear first from Dr. Thom. What…how would you describe the difference when you’re meeting a new patient and you’ve got this information about the patient in your record when you’re speaking with them?

 (19:59)

Giddel Thom: Well, basically, it helps you to understand the patient you’re dealing with  because you’re not dealing with someone in a vacuum. Now, you can apply that knowledge to assisting the patient in terms of not only getting over this bout of illness, whatever that is but how to move forward in life in terms of prevention, in terms of how to maximize the situation that you’re in so that you know, you can optimize your health. So having that kind of information really serves the physician in good stead because now you’re looking at more of the patient. You’re not just looking at it. A respiratory illness. You’re looking at it in context. So it’s okay to give that antibiotic or to give that breathing treatment. But they’re then now you’re exposed to more. Now you can look at more. What else can I do for this patient? Because giving him that so-called treatment and sending him back to that environment, then maybe we’re going to be continuing a cycle. (21:16) The physician now can look at how I can break the cycle. How can I help this patient to live a more healthy life given his working conditions? And so I think that this is very valuable information, very useful information. Because now you’re not just looking at, you know, one aspect of the patient. You have more aspects. And the more holistic, the more you see the patient, the better you’ll be able to relate and better you be able to manage that patient.

 (21:46)

Alexandra Walker: And are the dairy farm workers in your service area more comfortable now with sharing that information with your health center, with your clinics?

 (21:58)

Giddel Thom: I think Yvonne mentioned some of the difficulties we had. One of the things included in that…my estimation is that some of these patients are concerned about their immigration status. And so they’re thinking that you know, if I said too much, then, you know, it can be linked. And I don’t want to get involved in that. And so I don’t think it is going to be totally an easy thing to do. There would always be challenges, but that’s why we’re here. We’re here to work with challenges, to work through challenges, and to overcome some of those challenges. I think, you know, the major part of this is education, education, education. The more we can go out there and spend time and educate people about what we’re doing and why we’re doing it and how it’s going to benefit them in the long run, then I think people are going to come over. I don’t think that you know, you might not, we might not get people on the first try, but, you know, the second time they hear it and the third time they hear it, they may say, yeah, you know, this makes sense. And eventually, they’re going to get it.

 (23:03)

Alexandra Walker: I wanted to give you, give people a chance for any closing comments. You don’t have to make them, but I’m going to ask you for them. So I’ll ask a closing question. This has been such an interesting topic today. I really appreciate all of your time. I want to give you if anyone has any closing thoughts that you think it’s important for other health centers or health center control networks to understand about your experience, please share.

Daniel Parras: If I could add just a few more things. You know, I think it’s really important to empower not only patients but also the providers using all the tools that are in the EMR. You can get all this data at their fingertips instantly with the right tools and even optimize the EMR to have patients maybe in the comfort of their homes prior to an appointment. Enter this information using some of the tools where they can access their patient chart and update employment status, update their occupation, their industry, and even link some of the resources to education on what industry and occupation are within that system, within that patient profile can help gather that data efficiently and would give that information to the provider even before the patient is being seen. They can already keep in mind, okay, the patient has exposures or hazards at their job. Let me keep this in mind when I’m making these clinical decisions. So just empowering, you know, patients and providers with these tools are very important.

 (26:41)

Alexandra Walker: That’s a great point. Thank you.

Katherine Chung: I guess I was going to say that, you know, I just feel like a collection of occupational data allows for objective assessment of associations between occupational categories and health outcomes. And as Dr. Thom has so clearly expressed, this helps a physician or a clinician to understand better the risks of their patient and the health of the patient they’re taking care of. But I also think it helps the patient themselves to connect the dots, to understand when talking about occupation and the environment in their jobs, they can connect the dots on how their job is impacting their health, and it can then empower them to work toward improving the work conditions that might not be ideal and seeing what can be done to improve. I think it’s also important for policymakers to understand these associations between jobs, occupation, employment, and health and understand how important it is to make sure that the work environments of our essential workers and others is optimized so that we have a workforce that’s healthy and able to, you know, continue to contribute in the ways that they do.

 (28:13)

Produced by Heartcast media.

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