Collaboration in the provision of health care to low socioeconomic people of New Orleans

Collaboration in the provision of health care to low socioeconomic people of New Orleans

Jeanfreau, Scharalda G

The mention of the words “New Orleans” often brings to mind images of the French Quarter, southern mansions, Mardi Gras, world renowned restaurants and food, and a laissez faire way of life. At the heart of this montage is a unique culture comprised of numerous subcultures such as, but not limited to, French, Spanish, African-Americans, Native Americans, Caribbean, Creoles, and of course, the Cajuns. Despite many exciting advantages of this cultural “gumbo,”1 the New Orleans community also experiences problems similar to other cities of comparable size and composition. One such problem is the provision of health care to the poor and medically underserved communities. Many organizations have diligently worked to lessen this problem. This article will describe one collaborative effort undertaken by the Daughters of Charity Health Center (DCHC) and Louisiana State University Health Sciences Center (LSUHSC) to address health care problems of the poor and medically underserved in the New Orleans community.

COLLABORATIVE EFFORT

Lamb and Napodano (1984) define collaboration as the integration of the perspectives and skills of each team member, and a process of complex problem solving. Collaboration implies the generation and evaluation of new problems and plans which result directly from the integration of individual contributions rather than simply the coordination of individual ideas (p. 26).

The collaborative efforts undertaken by DCHC and LSUHSC epitomizes the integration of a faith-based private agency and state supported school of nursing and medical school to address primary health care and obstetrical needs of medically underserved lower socioeconomic residents in New Orleans, Louisiana.

HISTORICAL BACKGROUND

Initial development of LSUHSC-SON began in 1929 in Baton Rouge, Louisiana when several courses in nursing for registered nurses were introduced into Louisiana State University’s (LSU) summer session. The Daughters of Charity at Charity Hospital, New Orleans suggested that a permanent program for the preparation of registered nurses be located in New Orleans; courses began at Charity Hospital in 1931. This early program evolved into diploma programs at Charity Hospital and Hotel Dieu. The LSU System approved a program leading to a Bachelor of Science in Nursing Education degree in 1933 (LSUHSC-SON, 2002). In line with nursing education trends, the diploma programs are no longer in existence; the present LSUHSC program includes baccalaureate, masters, and doctoral programs. Consistent with this early history, the relationship between the Daughters of Charity and the university program prevailed.

The Daughters of Charity order (DCSNO) has a long and historic involvement with health care and nursing education in New Orleans. The Daughters of Charity have contributed to the health care of Louisiana citizens for over 200 years. As changes in the health care industry evolved, their role has also evolved. However, a constant has been the Daughters’ interest in the health care of the New Orleans poor residents and nursing education. After the sale of the historic Hotel Dieu Hospital to the state of Louisiana and an extensive community assessment, the Daughters of Charity Health Center was established in 1997 to provide primary health care to the poor in the Carrollton area, “a city within a city.”

New Orleans has been described as an “inland island” as water and swamps surround the city. Due to geographical barriers, distinct sections, or faubourgs2 developed (Leavitt, 2000). These neighborhoods developed into distinct communities with unique characteristics often representative of the culture of that area. The Carrollton area is one such neighborhood community. Carrollton was originally part of a large sugar plantation that was used as a temporary campground during the Battle of New Orleans. Eventually and as a result of growth, largely due to the railroad, Carrollton was incorporated into New Orleans in 1874 (Hubbard, 1991). Over time the Carrollton area evolved into a conglomerate of smaller sub-neighborhoods and subcultures inhabited by people of various ethnicities and socioeconomic strata. The Daughters of Charity Health Center is located in the midst of three of these smaller Carrollton sub-neighborhoods: Dixon, Gert Town, and Hollygrove. These neighborhoods are generally perceived as being populated by disadvantaged and disenfranchised individuals (see Table 1). As a result, the Daughters of Charity Health Center population reflects these sub-neighborhoods (see Table 2). LSUHSC School of Nursing (LSUHSC-SON) is located in the Medical Center District in a nearby neighborhood. Students at LSUHSC-SON participate in clinical experiences in the Daughters of Charity Health Center Clinic. A nursing student had this to say about the general milieu of the clinic:

The clinic is fairly new and I was impressed by how nice it was on the inside. There was beautiful handcrafted artwork on the walls of each hallway that added such life and color to the clinic. For anybody who may feel uncomfortable in a doctor’s office, this artwork may have helped provide a sense of peace and tranquility since it doesn’t look like your average clinic – dreary and cold.

MISSIONS AND VALUES:

Different With Common Themes

Despite separate and distinctly different governing bodies, the DCHC and LSUHSC-SON demonstrate true collaboration, sharing their individual mission and vision to provide clinically relevant teaching, learning, and practice in culturally diverse settings. DCHC, a private Catholic health center, serves to improve the health and well-being of their community, and to be a presence of the love of Jesus in the lives of all whom they serve and partner. Whereas, LSUHSC-SON, a state academic health center, serves the community through the art of education, research, and practice. Both institutions share philosophical beliefs that a person is a holistic being with dignity and rights. Furthermore, similarities in values demonstrate a commonality in their respective approaches to the provision of health care (See Table 3).

The School of Nursing Dean and the DCSNO Chief Executive Officer facilitated the current partnership between DCHC and LSUHSC-SON in 1998 with a nurse practitioner faculty member performing an advanced clinical preceptorship at the clinic. This preceptorship evolved into a volunteer faculty practice. After approximately eighteen months of volunteerism a collaborative faculty practice was initiated for general nurse practitioner services. This initial practice evolved into a joint assignment between the two agencies. Forthcoming contracts were instituted to provide for graduate and undergraduate clinical experiences, nurse-midwifery services, and additional family nurse practitioner faculty practices.

COLLABORATIVE PROGRAMS

Collaborative programs between the DCHC and LSUHSC-SON include a family nurse practitioner who administers a disease state management (DSM) program and a certified nurse midwife (CNM) coordinates the obstetrical and gynecological services. The nurse practitioner and the certified nurse midwife are faculty members with joint assignments to the health center.

Disease State Management

Disease state management (DSM) programs provide an organized and structured approach for the comprehensive management of chronic conditions such as Type 2 diabetes. In general, DSM programs are guided by evidence-based clinical guidelines that are geared for the improvement of patient outcomes and lower overall health care costs (Jeanfreau & Beare, 2002). The DCHC-DSM program was implemented for the comprehensive management of type 2 diabetes. Each team member uses the DSM program that is based on a simplified approach to behavior modification designed to maximize patient behavioral changes necessary for successful self-management. A modified transtheoretical model (Prochaska, Johnson & Lee, 1998) allows the provider to quickly assess an individual’s readiness to change specified self-management behaviors. Essential elements of the DCHC program include:

* Active participation and involvement of all team members: physicians, nurse educators, pharmacy; social services, support staff and consultants;

* Flow sheets to facilitate communication between team members and standardize activities;

* Computerized patient registry with longitudinal tracking of visits, screening, and control indicators;

* Individually tailored patient education and interventions; and

* Assistance with obtaining medications through the clinic pharmacy or indigent care programs.

The DSM services are provided by a management team, comprised of a family practice physician, registered nurse, pharmacist, behavioral psychologist, podiatrist, optometrist, counselor, and social workers, and are coordinated by a family nurse practitioner faculty member who provides education and health care to the patients with type 2 diabetes enrolled in the program.

With consideration to cultural and financial capabilities, behavior stage-based educational and behavior change interventions are provided to assist in the achievement of patient selected goals for behavior change and self-management. Depending on the patient’s level of readiness to change, educational interventions are provided on an individual and/or a group basis. Frequency of individual instruction remains dependent on patient needs. Monthly group meetings focus on discussion topics including, overall behavior change, self-management topics, issues, or concerns, and spirituality as related to diabetes. Additionally, each patient is screened for depression and referred for counseling as needed. A caremap is utilized to guide the provision of care over time. Clinical parameters are tracked on a flow sheet that assists clinic staff to adhere to American Diabetes Association guidelines.

DCHC provides care to over 400 patients with diabetes per year with averaging 110-120 patients monthly; 30-35% of these people are enrolled in the DSM program. Adherence by clients to the DSM clinical parameters exceeded expectations; clinical results were better than recommended status by the American Diabetes Association. Over 200 patients with hypertension are treated monthly; approximately 30% of patients with diabetes also have hypertension. Roughly, 40% of patients managed in the diabetes program, also experience depression. Patient satisfaction remains high with “caring” reported as a strength of the program. As patients in the DSM program are instructed, “What we do today is geared toward helping you have a healthy future”, the greater the services and changes made with this disadvantaged population, the healthier their future will be.

Obstetric/Gynecologic Services

Currently over 4000 CNMs practice in the United States (ACNM, 2001). In Louisiana, there are only 26 CNMs with eight practice sites (ACNM, 2001). Outcome evidences of rates for premature and low birth weight infants are below the national average for clients managed by CNMs. Further, according to ACNM (2001), CNMs are cost effective and over two-thirds of their clients are categorized as “vulnerable.” In Louisiana, only 1.2% of births are attended by CNMs, compared to 7% nationally.

The obstetric services at DCHC are provided by a LSUHSC-SON faculty certified nurse-midwife (CNM). The partnership includes a mutual collaboration with the Louisiana State University Health Sciences Center (LSUHSC) School of Medicine, Department of Obstetrics and Gynecology. The faculty CNM is encouraged and supported, through the philosophy and values of both partnering institutions, to promote the midwifery philosophy of care (Table 4).

DCHC/LSUHSC-SON Obstetrical/Gynecology Data

Indicators of successful perinatal services are poor in Orleans Parish (Table 5). These parish statistics include the Carrollton community. Approximately 18% of women enter prenatal care at greater than three months gestation. About 20% of the pregnant women are less than 20 years old at delivery. Low infant birth weight is considered an indicator of poor prenatal care; any infant born below 5 pounds and 8 ounces (2500gm). Orleans parish continues to have above national and state rates for low birth weight infants. African American newborns are more than twice as likely as Caucasian newborns to be of low birth weight (Louisiana Department of Health and Hospitals (2001). Immunization rates for children under 2 years old remain a concern. Orleans parish and Louisiana still fall short of the 90% rate designated by the U.S. Surgeon General’s office. (See Table 5)

At DCHC, approximately 60% of the women are African-American; 10% Caucasian; and 30% Hispanic or from other ethnic backgrounds. This aggregate reflects the New Orleans community diversity. The average birth weight is greater than or equal to seven pounds. Forty percent of women continue to breastfeed at six weeks. Over 90% of the women return with their newborns for a two week postpartum/newborn visit with the CNM. These clinic visits result in greater numbers of infants receiving their well-baby exams and immunizations. All the clients either receive Medicaid or are uninsured.

Although, women enter the prenatal program from throughout the greater New Orleans area, they become a part of the DCHC community. The diversity of the aggregate illuminates the similarities and differences among clients as well as the health care professionals. Diversity illuminates the core values of each partnering institution, particularly human dignity and respect for all people of any race or faith. Most significantly the DCHC promotes the spiritual awareness that permeates the clinic and helps to create bonding, much like maternal-infant bonding, between the clinic staff and clients.

To empower the served clients at DCHC, the authors propose that there are three major themes contributing to the uniqueness of the DCHC/LSUHSC-SON collaboration. These themes are: listening to women, women empowering women, and compliance with health care. Many clinics must examine and treat large numbers of clients to remain viable; making contacts with professionals brief. This CNM focuses on listening to women, which is an important component of midwifery. The DCHC has been supportive of this practice even if reduced numbers of served clients results. As evidenced based practice, the CNM author collected client statements:

…[midwife] always treated me with respect and made me feel cared about and supported.

…[midwife] is a great midwife. She always answered questions and always showed support.

She was there for me the whole time. . . I really enjoyed the services from the midwifery program. I would recommend it to alot of women. [midwife] makes you feel so safe and secure. I love her for that. She is concerned about all of her patients. She treats all the women the same.

Women have made these positive comments about their experiences at DCHC and the CNM faculty.

Some women have had valid complaints and requests concerning the designated hospital for the delivery. To address these issues, the CNM and school of nursing faculty, in conjunction with the University Hospital’s women services administration, have developed a task force to identify women’s concerns, requests and recommendations to improve obstetrical services. A specific referral form was provided to the CNM to improve and expedite referral/consult services for DCHC clients to the Medical Center of Louisiana OB/GYN clinics. This action facilitated access, which is invaluable for women of diverse cultures.

The CNM promotes a philosophical belief that women have the power to give birth and that breastfeeding is a normal physiological process. Women have 24-hour access directly to the CNM, they have been extremely responsible about calls. Although the CNM finds attending to the birth, it is awesome when the woman attributes the success of the birth experience (whether at risk or not) to her own ability and not the abilities the midwife or physician. The authors feel women become empowered through their innate abilities to give birth.

Finally, adherence with health care is extremely important at DCHC. Women who feel valued are more likely to feel empowered about their health and well being. Very few pregnant women miss their appointments and almost all of the women return for a two week newborn and mother exam. Most of these mothers do a great job with keeping the baby’s well-baby check-ups. Since, DCHC is a primary care clinic, it is “langiappe”4 to be able to watch the adorable infants return to the well baby clinic. These authors overwhelmingly admire these women for their strengths through their own empowerment to come to every clinic visit on schedule. Further more these women give birth in a powerful fashion; successfully breastfeed their newborns; and to learn about their bodies, test results, and preventive maintenance to improve their physical and mental sense of well being. The long term results will be documented in future health statistics.

CONCLUSION

The collaborative effort undertaken by LSUHSC-SON and DCHC has accomplished the goals in the provision of selected health care services to poor and medically underserved of New Orleans. Each collaborative program recognizes the need for improvement and long term expansion of services. The DSM program recommends to: (a) develop a comprehensive information system, (b) increase enrollment of patients with diabetes to 80%, (c) include a dietitian in the DSM management team, (d) obtain Certified Diabetes Educator certification and Recognized Provider status, and (e) offer open access health care.

Obstetric services are evaluated through participation in the annual midwifery benchmarking project to compare clinic data with other midwifery services. These data are then used to guide midwifery practice, negotiate for women-centered care, and promote change of overall childbirth practices in Louisiana. Recommendations to guide the future success of the partnership and practice include: (a) compile statistics of newborn/well-baby care at the clinic; (b) identify barriers to practice and focus on resolutions to improve services; (c) improve obstetric services by identifying resources available to women; and (d) develop programs and services that help empower childbearing women to demand quality health care. Continued and expanded collaborative efforts will bring these recommendations to fruition and impact the health status of this medically underserved population.

Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Winter 2003

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