Latinos face many barriers to health care, including language differences; complex and confusing documents and processes; lack of knowledge of available services; unreliable transportation; and fear of using government services. One way to increase health equity among Latinos is to remove these barriers. Rocio Muñoz, community health navigator at Benton County Health Department (BCHD), in partnership with the school district, worked to embed bilingual, bicultural health navigators into elementary schools in Corvallis, Ore. (7.4% Latino), to address these identified barriers. The partnership resulted in a model where health navigators are placed in schools to coordinate with students, parents and teachers regarding students’ health records in order to boost access to health resources and services available through state Medicaid, as well as other school and community resources.
Awareness: Rocio Muñoz was born to be a health navigator.
Raised in a city with extreme racial/ethnic health and economic disparities, Muñoz recognized the challenges her family experienced to access resources and services needed to live a healthy, productive life.
Muñoz acted as a health navigator for her family and friends in order to help them navigate the often complex health care system and connect them to resources and services. Being bilingual and bicultural allowed Muñoz to bridge these gaps to services on behalf of her family and friends to access health care services.
She then formally became a health navigator for the Benton County Health Department in Oregon.
Muñoz said the current healthcare services were not addressing Benton County’s income inequalities or health disparities and were not keeping up with the growing Latino population.
Indeed, Benton County has two faces.
On one side, the median annual income in the county is higher than the national average, and the proportion of Benton County residents who earn more than $100,000 a year is the highest of any county in the state (6.6% of the population).
On the other side, proportion of Benton County residents who earn less than $10,000 a year is also the highest in the state (at 34.5%), as is the proportion of county residents who live in poverty or extreme poverty.
A closer look into this data reveals that these inequities are greater in certain segments of the community, particularly in the Latino population. In Corvallis, Benton County’s largest city, Latinos’ median household income is 17% lower than the national level and 33% lower than Benton County’s level.
The county’s Latino population was getting bigger, too, doubling from 2000 to 2010, reaching 7% in 2014, and expected to grow another 185% by 2020. When combined with income data, it is clear that Latinos will constitute a growing segment of the economically disadvantaged community.
Income and language barriers affect the ability of people to obtain adequate health care.
Muñoz and other public health officials recognized that trends in both income inequality and the Latino community meant that Latinos would need better support to access healthcare services.
Learn: Elementary students in this region get vision, dental and hearing screenings in schools.
However, schools do not have the staff or expertise to follow-up with parents and discuss what the results mean. This leaves many families unable to interpret the results or access appropriate services, even if they are eligible, due to language barriers and complex medical forms.
Teachers often try to assist Spanish-speaking parents set up eye appointments for students, but they don’t always have the time, expertise, or resources to properly help all families. Even among the insured, many families didn’t know how to use their state Medicaid benefits or were unable to access them, explained Claudia Bouvier, operations assistant at Garfield Elementary School in the Corvallis School District.
“Families were not familiar with how to apply for some health benefits and what programs were available,” Bouvier said. “An example is for immunizations: for some of them, it was pretty complicated for them to go through that because they have to make sure they have all the requirements first and then go to the doctor and do their appointment.”
How could schools bridge this gap and guide parents toward health resources and equity?
Frame Issue: Muñoz, aside from being a county health navigator, also coordinated the local Healthy Kids, Healthy Communities (HKHC)/Creciendo en Salud program. She said the program’s funding drove changes and conversations around health disparities and equity, and spurred her own professional development and her efficacy to advocate on behalf of Latinos.
She spent years working with a variety of community partners, such as the Parks and Recreation department, transportation department, city council, non-profit organizations, Latino families, low income families, and numerous other community members. She also assisted in nurturing the development of a coalition of Latinas—Organización de Latinas Unidas affiliated with Casa Latinos Unidos de Benton County (CLUBC)—to specifically address Latino health needs.
All this community interaction generated big ideas for healthy change.
For example, based on findings from a community assessment of the education achievement gap in Corvallis, CLUBC suggested mimicking a neighboring city’s school welcome center model, which created a central place and contact point for Latino families to find academic support. Schools have strong potential as locations to emphasize support services, because they are culturally and historically a safe place for families to convene.
CLUBC also suggested that “strengthening parental involvement needs to be matched by a sustained effort to increase bilingual/bicultural capacity across the school system.”
This culminated in a big idea: Expand the school welcome center model to include health services by embedding bilingual/bicultural healthcare navigators in schools.
Embedding a county-employed, bilingual/bicultural health navigator in a school could provide a central location for parents to gain direct knowledge of available health care services and benefits, while also removing barriers to access care, Muñoz said.
“All of those services and those benefits that families don’t know they have. It’s their right to know and experience health equity in this community,” she said.
Education/Mobilization: Because Muñoz already had already built well-established trust with partners across multiple sectors, she was able to get strong early support for embedding county navigators in schools.
“We know [Corvallis] is going to develop, so why not be a part of that decision-making process to make sure that how it is developed is actually in favor of the community versus isolating the community,” she said.
Muñoz, the local health department and the school district started to explore this idea more deeply.
Debate: Health departments don’t typically provide services in schools.
BCHD had been looking for ways to reach out to low income, minority and rural residents.
BCHD has a state-funded community health improvement plan that seeks to promote access to healthcare, knowledge of available services, and transportation among state Medicaid members.
Meanwhile, Amy Lesan, student services coordinator for the Corvallis School District, worked with BCHD to identify two dual-immersion schools with a large population of English-language learners and free and reduced lunch populations—Garfield Elementary (48% Latino) and Lincoln Elementary (37% Latino)—that could serve as the locations to pilot the school navigator project.
Benton County’s placement of bilingual, bicultural navigators in schools would help ensure that services and outreach are accessible and culturally relevant, while also addressing overtasked, underfunded schools.
Activation: The health department and school district continued to work with various stakeholders to determine how a school-based health navigator program could work.
The challenge, according to Muñoz, is creating the pathway for parents to access services and figure out what fits best for each school, for the space in which they had to work, and for each navigator’s individual work style.
The health department and school administration officials decided to meet monthly to oversee the project. Muñoz and other BCHD staff would attend kindergarten intake meetings at the beginning of the school year to discuss student needs with parents.
Frame policy: For the program itself, BCHD would fund and supervise the navigators, and the Corvallis School District would provide the culturally relevant school locations to reach and serve Latino students and families.
Health navigators would have an office, a phone, and be stationed in the school. They would act as school district employees, with access to student records and health screenings, in addition to the resources of the health department and community health navigators.
Rather than merely signing families up for insurance and sending them on their way, school navigators would assist with health insurance literacy, how to use health benefits, and how to make informed decisions within their health care.
The student would serve as the first step to reach the rest of the family.
“The beauty of being a community health worker is that we have already experienced some of the barriers ourselves, and then also because we are coming from a community organization, we already come with those skills and the knowledge and the connection to the available community resources for our members,” Muñoz said. “Because we are bilingual and bicultural we can navigate and act as service brokers.”
Change: With the planning and preparation complete, the School Navigator Project embedded a health navigator at two schools—Muñoz at Garfield Elementary School and Araceli Mendes at Lincoln Elementary School—at the beginning of the 2014/2015 school year.
Their purpose was to connect families to health insurance, health care services and well child checks, as well as connect students with vision, hearing and dental specialists and other resources.
Implementation: School health navigators access student records and screenings and use existing outlets, such as newsletters, listservs and PTA meetings to reach out to families.
Muñoz and Mendes called parents to follow-up with the screening results. This included asking parents if they were aware of available services and if they needed help accessing those services. The school health navigators identified available providers and encourage a conference immediately to set up an appointment. They used this as an opportunity to ask about other health concerns and family needs such as additional support with other children; other family members; preschool; food security; food stamps eligibility; elderly care; housing and more.
Using student records was a great starting point, Muñoz said.
“It was really just an excuse to pick up the phone and say, ‘Hi, your student was identified for blank. Can I help you with that? Let’s make an appointment right now. Let’s just make a conference call. We can set up language services for your appointment. Do you have a transportation barrier? Did you know that state Medicaid covers that? We can provide a taxi to your home to pick you up and drop you back off. By the way do you have any other children in your house? What about yourself?” So it was really just an excuse to connect,” Muñoz said.
In the first month of implementing the school health navigator pilot project, the team received enormous positive feedback from teachers, principals, equity coordinators, student support staff, and superintendents.
One parent, Maria Fragoso, said Muñoz helped Latino parents make doctor appointments, reminded them about upcoming appointments, and found them transportation to the clinic.
At Garfield Elementary, Muñoz’s prior years as a navigator had raised the community’s awareness of her work, and that enabled teachers and parents to be at ease with her presence in school.
Families often sought her help for other things that promoted health equity, like interpreting for a client with a landlord for housing issues.
Muñoz’s services were so popular, she would arrive to work and find four or five mothers lined up at 8:15 a.m. with papers in their hand, she said.
“[Muñoz] really helped with the [immunization] process. If they didn’t have any insurance, she would give the parents options for them and then she would help them fill out paperwork and get it to the point where it becomes an easy process for them,” Bouvier said.
At Lincoln, Mendes was a new health navigator and her role in the school helped to build trust and develop relationships with community members.
A school program, called 100% Lincoln, had previously been established by BCHD at Lincoln Elementary to ensure all students were insured or had health access to the school-based community health center. This program specifically targeted students who did not qualify for state Medicaid because of lack of U.S Residency or citizenship. Therefore, a majority of students at Lincoln were already enrolled in insurance; however, they still faced barriers in utilizing services.
“A lot of initiatives had already happened at Lincoln, therefore the rush wasn’t as sudden or big as it was at Garfield, where no resources and no targeted work had been done in the past,” Mendes said.
Equity: This project specifically aims to increase health equity, Muñoz said.
The student populations at Garfield and Lincoln participate in the federal free and reduced meal program at higher rates, which means they are more than likely to be enrolled in the state Medicaid program.
The school health navigators work to provide support to underserved students and parents to access and use as needed healthcare and other social services.
“We are all here together to help the kids and to make sure that families get what they need,” Bouvier said.
Muñoz noted that decision-makers play a big role. In order to have a positive impact on all community members it is important for decision makers to identify the needs and challenges of our most vulnerable populations. Having cultural humility is a big component of understanding these challenges.
Sustainability: Navigators have documented the entire process and kept excellent records to evaluate process and outcome objectives.
Due to the success of the pilot project, three community health navigators will be embedded in schools for the 2015/2016 school year. Muñoz’s new role will be to provide technical assistance to the project, raise awareness of the project, and continue to foster communication between departments and agencies.
The project is currently funded through a grant from the region’s Accountable Care Organization. BCHD and the school district are looking into Medicaid Administration Claim (MAC) funding to continue funding the program over the long term, with potential expansion to all schools. This is a sustainable funding source that provides reimbursement based on the amount of services delivered. Partners have also been exploring other funding opportunities that are designated for prevention, as well as using the co-placed staffing model in other sectors, such as housing programs.
“Access to safe, affordable and healthy housing is a major social determinant of health,” Muñoz said. “Let’s explore having a health and housing navigator working in conjunction with the homeless student coordinator at the school district.”
This success story was produced by Salud America! with support from the Robert Wood Johnson Foundation. The stories are intended for educational and informative purposes. References to specific policymakers, individuals, schools, policies, or companies have been included solely to advance these purposes and do not constitute an endorsement, sponsorship, or recommendation. Stories are based on and told by real community members and are the opinions and views of the individuals whose stories are told. Organization and activities described were not supported by Salud America! or the Robert Wood Johnson Foundation and do not necessarily represent the views of Salud America! or the Robert Wood Johnson Foundation.
ABOUT THE PROGRAM
Salud America! The RWJF Research Network to Prevent Obesity Among Latino Children is a national program of the Robert Wood Johnson Foundation. The program aims to educate researchers, decision-makers, community leaders, and the public in contributing toward healthier Latino communities and seeking environmental and policy solutions to the epidemic of Latino childhood obesity. The network is directed by the Institute for Health Promotion Research at the University of Texas Health Science Center at San Antonio.
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