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Best Practices in Mobile Team Outreach

By Claire Hutkins Seda, Writer, Migrant Clinicians Network and Managing Editor, Streamline

Best Practices in COVID-19 Mobile Team Outreach: Questions to Consider

Pre-Arrival: Contact the grower to determine:

Schedule: When do farmworkers arrive? Can the health center team provide testing immediately on arrival?

Precautions: What precautions and standards of practice are in place to protect farmworkers:
o On the job? 
o In farmworker housing? 
o During transportation to work?
o If a worker exhibits symptoms of COVID-19?
o If a worker’s test returns positive?
o When in isolation?

Resources: Does the grower need more education or resources (signage, PPE, handwashing stations) to implement precautions before farmworker arrival? To communicate these precautions once farmworkers have arrived? 

Logistics: Is there a suitable outdoor area where the health center team can facilitate testing?

Arrival and Testing:
The mobile team must determine:

Safe travel: How will the mobile team maintain distance while in transit to/from the farm? 

Testing protocol: Develop and practice an in-field testing process including:
o Donning and doffing PPE;
o Administering swab tests;
o Preparing the tests for transport to the testing facility; and,
o Returning to the farm to provide results.

Farmworker Education

Training: What farmworker education can the mobile team provide?

Materials: What handouts, signage, other resources can be provided?

What do farmworkers need to know if they feel ill? What are the steps to getting care and what are their rights as essential workers?

Just west of Portland, Oregon, thousands of acres of orchards, vineyards, and berry bushes stretch out across fertile plains. Every June, these fields are closely tended and harvested by migrant and seasonal agricultural workers who have arrived from around the country and throughout the Western Hemisphere. But 2020 is different: the COVID-19 pandemic has hit this region hard, with Washington County, at the heart of this agricultural region, experiencing the second-highest rate of infection in the state by late April.  Even more concerning is the disparity in infection.  While Latinos accounted for around half of those tested for COVID-19, they were roughly 20 times as likely as other patients to have the virus.  “[Latinos] represented 97 percent of our positive cases,” said Eva Galvez, MD, a family doctor at Virginia Garcia Memorial Health Center, which serves this agricultural worker community, and a member of MCN’s board of directors. “My concern is that, as we get more farmworkers coming in, the numbers could get higher, so I want to do more prevention.”  

Virginia Garcia has quickly mobilized to address the spread by taking a proactive approach to protect the agricultural worker community from COVID-19: it's mobilizing its clinics to provide testing at the farmworker camps as workers arrive. Every year, Virginia Garcia provides outreach to arriving agricultural workers by sending teams out to the farms that provide housing for their workers, but they have adjusted their strategy.  “We’re going to start to test people, and my hope is that we can test them before they begin work,” Dr. Galvez explained. “We want to find people [who are COVID-19 positive] before they are living and working together, so we can decrease the risk of spread.” 

Health centers have a critical role to prevent further spread among those who grow, harvest, and process food, who, despite the increase in attention from news media as “essential” workers, continue to lack worker protections afforded to other worker categories.  The COVID-19 pandemic has exposed these worker health protection disparities, particularly among meatpacking plants where close worker proximity, poor ventilation, rapid line work, and cold environments have accelerated infection rates.  “We’re seeing the impact when you don’t have [sufficient] regulations, and [workplaces] are unprepared,” Dr. Galvez noted. She was a critical actor in pushing Oregon’s Occupational Safety and Health Administration to adopt emergency regulations to protect agricultural workers during the pandemic.  Even with the guidelines in place, workplaces will need health centers to assist in health and implementation education as well as testing, and Dr. Galvez is thrilled that her health center is filling that role.  

“This is a public health issue,” she warned. “Wherever you have essential workers, we need to keep them as safe as we can by trying to prevent illness. So, let’s go out there and start testing, identify possible cases, and isolate them – otherwise we’ll continue to see these pockets” of outbreaks related to essential workplaces, she said.  

Wisconsin
Across the country, as the COVID-19 pandemic picked up speed, health centers have pivoted their efforts to keep patients safe. The Wisconsin Farmworkers Coalition, led by Family Health La Clinica (FHLC), the only migrant health center in Wisconsin, has developed a comprehensive risk mitigation strategy to protect the state’s agricultural workers and to help clinicians determine protocol for on-farm testing and education. The strategy also provides farms with best practices to ensure implementation of a statewide emergency order that outlines specific measures that must be met on farms. A Risk Mitigation Strategy document outlines Family Health La Clinica’s overall approach, including education, communication, and logistics measures, testing results management, post-outbreak support, and other considerations. The Migrant and Seasonal Farmworker Playbook and the Pre‐Arrival Site Visit and Workplace Modifications feature scripts for first engagement with farm owners, arrival at the farm, COVID-19 education on symptoms, testing, safety measures, and test responses. It also includes workflows for farm arrival and testing. A fourth document to round out their approach is Supporting Migrant Seasonal Agricultural Workers: Housing and Workplace Best Practices. This document gives growers and farm owners specific and detailed recommendations for how to implement each safety and health measure delineated in the state’s emergency regulations.

The Wisconsin Farmworkers Coalition is a multi-sector statewide group that typically meets quarterly. During an April emergency meeting, FHLC’s Chief Executive Officer, Laura Waldvogel, MSE, proposed closer collaboration to develop a more cohesive and collaborative approach, to ensure uniform messaging and strategy.  Within two days, a new steering committee had been formed and began meeting.

“It has really blossomed into something far beyond what I had anticipated,” Waldvogel noted. “It includes partners we typically wouldn’t see working together,” like migrant and seasonal agricultural worker employers, migrant and seasonal agricultural worker advocacy groups, Legal Action of Wisconsin, the Wisconsin Department of Workforce Development, a regional Occupational Safety and Health Administration (OSHA) representative, a medical college, and public health department officials from a number of counties, among others. “Both the employers and workers have been incredible,” she added.

The coalition identified gaps in the processes designed to mitigate the spread of COVID-19, and filled them. FHLC’s Chief Medical Officer, Cheston Price, MD, was instrumental in developing the risk mitigation strategy, to get to an endpoint where the health center can engage with growers and agricultural workers in a way that benefits and is supported by all parties. A Wisconsin-based health improvement philanthropy provided a large grant to support their COVID-19 educational efforts, further bolstering the process.

“We started with a survey to find out what resources [growers] might need,” Waldvogel explained. “We go on-site to do a pre-arrival assessment of the workplace and housing – it’s all voluntary – and we do a review and make recommendations. The employers have been incredible.”  

As close as possible to the arrival of agricultural workers, a team from FHLC begins to do on-site testing.  At first, the state of Wisconsin was not advocating for on-site testing on arrival. The coalition was hoping the state would support their position, as “it’s what we really need to do, for this vulnerable population, and employers simply couldn’t quarantine everyone for two weeks,” Waldvogel noted. Their approach, which they pushed forward, is a necessity, as is education. 

“Education is probably even more important than the testing. If you don’t provide the education, many [agricultural workers] have a difficult time understanding the ways they can keep themselves safe, not just in the housing,” Waldvogel said. She also noted that education around testing was also important, to ensure that workers understand the test is only for that moment in time, and not an indicator of or guard against future infection. “Then there’s the results management, follow-up care if primary care is necessary, and outbreak support,” all of which the coalition has mapped out, and FHLC has supported.  

“As we started [providing all these COVID-19 services], we got a lot of attention from the state of Wisconsin, and they asked if we could scale it up,” Waldvogel recalled. “Now we’re partnering with them.” The state has committed funding and the support of the National Guard to support FHLC’s testing and on-site work.

Nationwide
Among communities that lack statewide regulations, health centers may recommend their own best practices and implement strategies to support agricultural workers, when federal and state guidance are lacking. Dr. Galvez in Oregon was instrumental in securing her state’s regulations after partnering with a legal rights organization. She encourages her fellow clinicians at health centers to take part in such a medical-legal partnership because such regulations, as opposed to statewide guidelines or no guidance at all, can have a profound impact on agricultural worker health.  Read more about Dr. Galvez’s medical-legal partnership to secure emergency regulations in Oregon on Migrant Clinicians Network’s blog: https://bit.ly/3dSAcAi.

“Community health centers can play such an important role in helping our essential workers stay safe on the job,” added Amy K. Liebman, MPA, MA, Director of Environmental and Occupational Health. “In many places they are trusted sources and can help educate workers in a language they understand, using a culturally competent approach.”

FHLC hopes its materials will benefit other health centers; they’ve made their resources and education widely available on a site dedicated to the coalition’s COVID-19 work: https://www.famhealth.com/wi-msaw-covid-19.html. “We make no claims that [the information on the website] is perfect. It’s constantly in evolution, and as soon as we have it out, it’s obsolete because things change,” Waldvogel admitted. “But we put it out there because we want it to benefit everyone.”

 


 

11 Jordan M and RA Oppel Jr. For Latinos and Covid-19, Doctors Are Seeing an ‘Alarming’ Disparity. New York Times. 7 May 2020. Available at: https://www.nytimes.com/2020/05/07/us/coronavirus-latinos-disparity.html?searchResultPosition=1

12 Seda CH. Q&A With Dr. Eva Galvez: How Clinicians Can Protect Farmworkers During the COVID-19 Pandemic Through Partnerships and Advocacy. Clinician to Clinician: A Forum for Health Justice. 6 May 2020. Available at: https://www.migrantclinician.org/blog/2020/may/qa-dr.-eva-galvez-how-clinicians-can-protect-farmworkers-during-covid-19-pandemic-thro

 

Access FHLC’s guiding documents on their website:

Pre‐Arrival Site Visit and Workplace Modifications: https://bit.ly/2TDI4xJ

Supporting Migrant Seasonal Agricultural Workers: Housing and Workplace Best Practices (COVID-19): https://bit.ly/2M1tko4

COVID-19 and Wisconsin’s Migrant and Seasonal Agricultural Workers: Family Health La Clinica’s Risk Management Strategy: https://bit.ly/2X0NzbV

Migrant and Seasonal Farmworker Playbook: https://bit.ly/36uIYlq

 


Health Network and PRAPARE
In 2016, just as PRAPARE was set to launch, Migrant Clinicians Network was beginning to develop its new database to better serve patients enrolled in Health Network, MCN’s bridge case management program. Over the course of the following year, MCN configured the new database to allow for the integration of PRAPARE data, in which one health center’s PRAPARE data can be transferred to the next health center, as a mobile patient moves.
“When we started thinking about that data and [Health Network] case management work, so much of case management isn’t just ‘are you taking your medication every day?’ It’s more about, ‘How can I help you access care and manage your health in general?’” explained Anna Gard, RN, who assisted MCN in the development of the new database. “One piece of this is: ‘Let me help you find a health center.’ But the larger pieces around effective case management are, ‘How are you going to get there? Is there public transportation? How are you going to pick up your medications if you live in a hostile community and you’re afraid of leaving the house?’ PRAPARE gives a structured format to capture [these] data, in a form that’s been tested and validated.”
As more health centers provide case management and chronic care management to address the social determinants of health, Gard noted, integration of the PRAPARE data with Health Network, a virtual case management, seemed to make sense. Now, the Health Network team is working to fit PRAPARE into their own workflow.
Saul Delgado, Health Network Data Specialist, who has been integral in building and launching Health Network’s new case management system, notes that asking such personal questions over the phone, when a patient doesn’t have transferrable PRAPARE data from a previous health center, can be challenging. “When we call, the patient doesn’t know you. They’re very scared to answer these kinds of personal questions, whereas when you go the clinic, you at least see the nurse or case worker face-to-face,” he explained. But he recognizes the utility of the data, and has developed the PRAPARE data screens within the database to be easily accessed from the main patient information screen. With drop-down menus, Health Network Associates can populate the information they hear from patients, like how many people live with them in their household, or if they’re worried about losing their home. The information, either attained from a previous health center or inputted by a Health Network Associate, will be transferred when the mobile patient gets to his or her next destination, just as the basic medical records do.
“Health centers are doing more to integrate social and behavioral determinants of health, and we’re recognizing that all of those things have to be integrated with care management. So we’re on the forefront,” Gard concluded.

MCN Streamline Summer 2020

Read this article in the Summer 2020 issue of Streamline here!

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