NATIONAL ADVISORY COUNCIL ON MIGRANT HEALTH (NACMH)
San Antonio, TX -May 21-22, 2006
Council Members Present: Wenceslao Vasquez (Chair); Robert H. Scott, J.D. (Vice Chair); Rosita Castillo Zavala; Susana Castro; Enedelia Cisneros; Edward Colon-Quetglas, M.D.; Rogelio G. Fernandez, M.D.; Anne Kauffman Nolon; Guillermo Martinez; John W. McFarland, D.D.S; Robert S. Nimmo, Jr.; Gilbert Walter; Karen Watt
Federal Staff Present: Marcia Gomez, M.D., Designated Federal Official (DFO); Gladys Cate, Support Staff
Call to Order and Opening Remarks
Wenceslao Vasquez, Chair
The Chair called the meeting to order and welcomed everyone to the meeting. Individuals re-introduced themselves to the group.
Agenda and Minutes Approval
The Chair asked if there were any changes in the agenda. Marcia Gomez noted some suggested changes to the agenda before approving, minor rearrangements to allow for adequate travel time to the hearings in Uvalde, TX. She went on to explain that Robbie Scott would join the Council on the next day and Diana Sanchez will not be able to attend this meeting because she is in California receiving an award for her work as a Family Assessment Worker.
Anne Kauffman Nolon announced that there would be a reception held on Monday evening to honor the Council. All are invited and encouraged to attend. The reception will be held from
5:30 p.m. - 7:30 p.m. There will be a short program, a trio, and a brief history of the work of the Council.
Guillermo Martinez made a motion to approve the agenda with noted changes to the schedule. Enedelia Cisneros seconded the motion. The motion was approved unanimously.
With
regard to the minutes from the last meeting
in Washington, DC, Ms. Castro noted a
correction to the last bullet on page
3. Health centers should read 'satellites'
of Community Health Partnership of Illinois.
Dr. McFarland made a motion to approve the minutes with noted change. Bobby Nimmo seconded the motion. The motion was approved unanimously.
BPHC Update
Dr. Gomez reminded the group that minutes are not posted online until they have been approved by the Council.
Dr. Gomez noted that there had been a recent change in Leadership at the Health Resources and Services Administration (HRSA). Ms. Michelle Snyder has been asked to lead the Bureau of Health Professions, and Mr. Jim Macrae, who has been part of HRSA for a long time, will take Ms. Snyder’s place at the Bureau of Primary Health Care (BPHC). Mr. Macrae started as an intern and has most recently headed HRSA’s Office of Performance Review. Mr. Neil Sampson and Dr. Donald Weaver are there to assist Mr. Macrae.
Dr. Gomez reminded the group that although the Council is thought of as an external body that advises the Secretary, members are Federal employees during the time of the meetings. DHHS has been evaluating programs and how to handle these issues over the last four years, so part of that evaluation has resulted in the fact that advisory council members are no longer able to be considered as outside of government. They need to adhere to Federal Government staff rules during the period of the Council’s meetings.
The government wants to streamline things. Gladys has handled the majority of the logistics because “we no longer have a logistics coordinator; we don’t have anyone dedicated to that task, so we depend on you to keep us informed of the things that we need to do”.
Dr. Gomez reported to the Council that the letter of recommendations sent to the Secretary had been received and was going through the proper channels. She noted that Tab 8 of the meeting packet contains a copy of the letter sent in January. The response has not been received yet. Discussion regarding the timeliness of the letter and the subsequent response ensued. Ms. Nolon asked if Dr. Gomez could pinpoint the exact stage of the letter. Dr. Gomez responded that it has been received by the Office of Migrant Health for comments, and then sent back to the Secretary with comments. Dr. Gomez provided some clarification around the timing of submission of recommendations; historically, it has been once a year. The consensus of this Council during the January 2006 meeting was to send letters as often as needed. She noted that this is the Secretary’s only Advisory Council on Migrant Health. Gil Walter and Ms. Nolon noted that a list of Council recommendations from the last five years had been compiled.
Dr. Gomez reminded the group that there are six member openings for the NACMH next year, and that there is a strong need to recruit within the next month. The group discussed the dynamics and impact of their work on the status of migrant health, and the importance of participation on the part of each member. This Council is being taken very seriously by the BPHC, and while their knowledge and recommendations might be from a regional standpoint, the impact will be National. Group discussion around impact of Council’s recommendations continued and the suggestion was made to push for responses to the issue of the Portability Study conducted by CMS which has not been released.
Migrant Health Funds FY 06:
Dr. Gomez reminded the Council that because of budget constraints, there would be no money for New Access Points (NAP) but that there would be a second round for Expanded Medical Capacity (EMC) grants. These funds were for special populations (migrant and homeless). Those EMC applications were due March 31, 2006 and the response has been significant. The announcement of awards will not be until late summer or early fall, but they are currently being reviewed. The Council might consider how to best ensure that if there are new funds, how to make sure the migrant population is requesting these funds. The estimation is that 20% of the migrant population is currently being seen in a Federally funded health center, so Dr. Gomez asked: How can we increase that number? How do we reach the other 80%?
Dr. Gomez also reminded the group that this is the year of reauthorization of the 330 programs, so she recommended taking a look at the legislation closely and considering possible recommendations, especially from a service perspective. Ms. Nolon asked if the reauthorization was something that needed to be revisited by this group as a whole and whether the Council needs to recommend that there be an opportunity for applications for migrant health to be reviewed separately from the other 330 applications in order to increase access. Dr. Gomez recommended that the Council look at the re-authorization in its entirety and pointed out that this body has not made any recommendations regarding the migrant voucher programs, which exist in the regulations, but not in current legislation.
Mr. Walter noted that the grants management system at HRSA awards the funds to the best written grants, but not necessarily to the areas of most need. He further suggested that our resource allocation policy has nothing to do with farmworkers and their needs and more to do with good grant writers. Mr. Walter further suggested that BPHC needs to be able to identify the geographic areas of unmet need and place priority on funding those areas, either through NAPs or EMCs.
ACTION ITEM: Mr. Walter called for a tool to help provide an idea as to where the farmworkers are located.
There was a discussion on mapping farmworkers. Work which has been done by Dr. Alice Larson and National Center for Farmworker Health (NCFH) on 11 states currently covers what is believed to be 85% of where farmworkers reside. Dr. Larson is currently working on two more states.
Ms. Watt noted that the Council must be cognizant of the definition of farmworkers when attempting to map their geographic locations. She further noted that a lot of people come to migrant clinics for service, and even though they don’t fall under the definition, they are part of the population.
Ms. Ryder from NCFH stated that a legal definition had been used for the Larson enumeration process and was applied uniformly across all states with the exception of California, where two reports were provided in order to accommodate the differing state definition in regard to packing and canning. Ms. Nolon noted that the Council should be educated about the changes taking place within agriculture as well.
Enedelia Cisneros noted that understanding geographic representations of the location of farmworkers does not necessarily mean that they are accessing care. A discussion on geographic representation further clarified that the reports do not reflect penetration because it was difficult to obtain numbers uniformly. Health center specific UDS data reporting the numbers served for the service areas is currently available and can be applied to derive a county by county which can in turn be graphically depicted in relation to the 11 state Larson enumeration study.
ACTION ITEM: Council members agreed that there should be a presentation on the work done by Dr. Larson and NCFH on the Enumeration Study, in a future Council meeting.
Dr. McFarland remarked that there were an estimated 5 million Farmworkers and family members around 25 years ago, and 500,000 were being served by PHS 330 health centers. Now the number of farmworkers is estimated to be 3.5 million. Has there been a drop in the numbers? The Council discussed the fact that there is an estimated 3.5 to 5 million farmworkers. It is not believed that there are significantly fewer than there were 25 years ago. At this present time the most conservative number usually used is 3.5 million. The Council continued discussion around the frustration with being able to accurately estimate the number of farmworkers in the nation, as well as the penetration rate.
David Duran (public) made two comments. The first one was on the substantial increase and blending of financial resources juxtaposition to the relatively small increase in the number of MSFWs receiving health care at PHS funded centers. The second comment was on the immigration legislation that is currently being discussed, if passed, health centers will become criminals. He posed the question of how to deal with immigration to the Council. The Council suggested the need to point out those types of issues and formulate recommendations. They summarized some of the questions that had surfaced such as where is the Farmworker population located in relation to the allocation of resources and that the funding level has nearly doubled, but the numbers have only slightly increased.
Ms. Nolon pointed out that the profile of the worker is changing as well and suggested that the resources needed to improve the health of a Farmworker are being underestimated. The resources that are required are extraordinary on a per person basis causing tremendous strains on the programs. For example, Hudson River Health Care had to close their voucher program before the end of the season.
Dr. Gomez commented that the BPHC has demonstrated commitment to support efforts to better MSFWs health. There were a total of 63 applications received in the last five years, and 32 of those were awarded. She continued that the BPHC can only go by the applications received and what the Council recommends. Ms. Nolon inquired about awards in the last two years. Ms. Gomez responded that those numbers included only New Access Point applications and did not include Expanded Medical Capacity applications and awards. Of 89 total applications received, 51 grants were awarded for EMC’s over the last five years.
Dr. Gomez summed up the barriers discussed: documentation of law enforcement / immigration; transportation; hours of service; costs; clinic locations; language; health literacy; cultural competency of health workers; patient knowledge of services available; need for support services (i.e. outreach, continuity of care), slow growth in the number of patients seen. The Council’s job is to recommend solutions to the problems that have been identified.
Three year findings
Ms. Nolon made a motion to consolidate our three year findings of the public hearings and produce a consolidated report for publication and distribution to migrant health constituents, including the Secretary. Mr. Martinez seconded the motion. The motion was unanimously accepted.
The Council discussed possible distribution and/or sharing of findings from hearings with other Federal, State and Local health organizations.
ACTION ITEM: Consolidate the 2004, 2005, 2006 Public Hearings into a single document.
Preparation for Committee Work
The Council reviewed a list of items that were previously tabled during the January 2006 meeting in Rockville, MD to be further discussed at this meeting to determine if they needed to be addressed as a recommendation to the Secretary. Dr. Gomez instructed committees to revisit these issues, so that when the Council meets again the following day, it can decide on most the important ones and move forward. Group discussion ensued about a change to the agenda, moving committee meetings to the following day, pending any important issues and/or information to be gained from the afternoon’s hearings.
Ms. Ryder spoke to the Council about the hearing scheduled for later that afternoon and the different panels that would be participating.
- First panel is Providers, including three physician assistants, a dentist and a psychiatrist.
- The Farmworker panel: with representatives from Uvalde, Crystal City and Eagle pass.
- The last panel includes a variety of Community Leaders.
Ms. Ryder addressed some of the logistical issues of travel to Uvalde. Dr. Gomez reminded everyone that they are there as Special Government representatives.
Mr. Vasquez recessed the meeting at 1:30 p.m. for lunch and travel to Uvalde for the hearings.
NOTE: The meeting was re-convened in Uvalde at 5:30 p.m. in order to proceed with the hearings, the transcript for which is available in a separate document.
MONDAY, MAY 22, 2006
Mr. Vasquez re-convened the meeting at 8:55 a.m. in order to begin presentations on Migrant Health.
Programmatic Issues
Ms. E. Roberta (Bobbi) Ryder, CEO of the National Center for Farmworker Health, Inc. presented a summary document from a session at the Midwest Stream Farmworker Health Forum in South Padre, TX in November 2005. Ms. Ryder explained that the purpose of the workshop had been to gather information by asking representatives from the health centers and the field what their experience had been with the first five years of the Presidential Initiative (PI). The discussion was preceded by a presentation from Dr. Gomez on the experience of the BPHC in receiving and processing applications during the PI. A few focus questions were posed to the group. Seventeen people participated, represented by administrative, clinical, outreach, and BPHC Migrant Health Program’s Central Office Grantees. Three questions were asked:
1) “If you did not apply for new funding under the PI, what influenced your decision not to do so?”
2) “If you applied, what were your experiences?”
3) “Is there any validity to the concern from the feds that the limited number of applications received reflects a lack of need or a decrease in the population?”
Ms. Ryder indicated that the group’s discussions led to five basic categories:
1) need in the field;
2) process of applying;
3) BPHC policy issues;
4) HRSA leadership and accountability issues; and
5) need for national organization and MHC leadership and accountability.
Ms. Ryder indicated that other issues also addressed by this group included:
• MUP designation
• maintaining proportionality
• unmet need and penetration
• GIS mapping.
Update from the National Association of Community Health Centers, Inc. (NACHC)
John Ruiz, Assistant Director at NACHC welcomed the Council to San Antonio and to the National Farmworker Conference, and expressed his appreciation that the Council had taken the opportunity to network with health centers and front line representatives by holding their meeting in conjunction with the Conference.
Mr. Ruiz discussed several legislative issues related to Community Health Centers and Migrant Health Centers with the Council, including:
• upcoming reauthorization of the legislative authority
• appropriations
• immigration reform
• Ag Jobs.
Mr. Ruiz also touched on some programmatic areas such as the recent EMC opportunity, funding reallocations, conferences, the Need for Assistance Worksheet (NFA) and the Farmworker Study of Medicaid Access. He announced that next year’s Farmworker Conference will be held in Newport Beach, CA and that he hoped the Council meeting could again coincide with that conference.
The Council discussed at length the NFA, and noted that the lack of national data on the Farmworker population should not be a deterrent to applying. Ms. Ryder added that NCFH had produced a TA Brief with data sources. Dr. Gomez reminded the group of the need for data that is independent from health center data gathering conducted by the BPHC (Uniform Data System [UDS]).
The Council also discussed reauthorization and how it might relate to the voucher programs with regard to legislation of the programs. Ms. Ryder commented that voucher programs are a service delivery model, much like a mobile van, and are often confusing if a reviewer does not understand that these models are appropriate solutions for a seasonal migratory population or perceive it as an inferior means of delivering care instead of an effective means. The Group went on to discuss immigration legislation and its potential impact on access to health care services to MSFWs. As the result of this discussion there were no specific recommendations.
Debriefing on Testimonies
The following are Council’s comments summarized about the Hearings from the previous day:
Best hearing so far
Too bad we didn’t have more farmworkers represented, understand that many of them had left for the season
Great to have the past Council Chair (David Duran) there as one of the community representatives
Bobbi did a great job, made us all (panelists and Council) feel very comfortable
Contributions of former farmworkers was a little like driving forward, looking through a rear view mirror
Francis Canales, a farmworker, was amazing
Broad diffusion of population and need for outreach was quite compelling
Providers input from home based state was most interesting for an upstream provider to hear - it works both ways, i.e., send them healthy come back sick
Many behavioral/mental health issues brought up
o There are no behavioral/mental health providers (bilingual) in the areas
o Need to work on information transfer and behavioral health issues
o Mental health is the last frontier – we don’t often address it
Providers and Community reps were very sensitive to the needs of farmworkers, they still feel a passion for their work, need to figure out how to emulate the passion and concern among others, in order to serve them all
Struck by the providers mentioning that there is no effective way of communicating as they travel – starting from scratch
MHCs need to go to the farmworkers and serve them where they are living and working;
The best of the last three Public Hearings with common themes of isolation, lack of transportation, language in all three.
The Council arrived to the conclusion that all Public Hearings have been very inspiring, moving, and motivating. It was interesting to note that so many farmworkers are so far away from the clinic locations in these rural isolated areas and are afraid to go to hospitals because of immigration issues. There was a feeling that things were going backwards instead of forward. Outreach efforts need to be emphasized to ensure people do not go without care. There are no computers there in the field, making it more challenging to ensure continuity of care.
The Council also discussed the fact that compared to previous years there is no longer a strong relationship between migrant education and migrant health. The Council also noted that the domestic violence issues for new population from Mexico were missing from the testimonies given.
They concluded that there is so much to do, so little time to do it but the Council felt invigorated by the testimony.
Welcome to Texas
Fernando A. Guerra, M.D., M.P.H., Director of Health, San Antonio Metropolitan Health District,
welcomed the Council to San Antonio and provided a PowerPoint presentation that shared some observations of work regarding immunizations, as well as some emergency preparedness and Avian Flu issues. He emphasized the continued change in the demographic patterns in the population of this country.
The Council thanked Dr. Guerra for his presentation and time spent with them.
Discussion about Recommendations to the Secretary
Dr. Gomez recommended that the group make a decision as to how wide or far the Council wants to reach in terms of making recommendations. She reminded the Council that there wasn’t much opportunity or funding in the budget for another meeting in the fall. The Council worked to come to a consensus as to the major topics of discussion for the remainder of the afternoon. Those topics included the following:
• mobile units
• voucher programs
• outreach
• transportation
• transfer of information
• adapting the services umbrella
• leadership
The following is a draft created by the Council for recommendations to be submitted to the Secretary:
“The Migrant Health Legislation calls for both mandated services and non-mandated services. This Council recommends that funding policies be directed to the strengthening of the availability of resources to existing MHCs so that they are able to provide the non-required services which are essential to improving the health status of this hard to reach population. This is not to say that new MHCs should not be funded, but that the allocation of resources be adequate to address the pressing need of the migrant farmworker population by strengthening the infrastructure of existing MHCs. Such services must encompass comprehensive primary care services and include outreach, transportation, translation, health education and health promotion, case management, mobile services, and environmental services, thus allowing maximum flexibility to adapt established BPHC expectations in order to appropriately apply them to the migrant health setting.”
The Council broke into subcommittees in order to give each subcommittee the opportunity to more fully develop recommendations based on each committee’s areas of focus. Ms. Watt reminded the Council that honing these recommendations was something that could not wait given the unlikelihood of a meeting in the fall, and reiterated that for some of the Council members, this would be their last opportunity to make an impact.
Once the Council reconvened as a whole, subcommittees began their report backs, with each committee offering a few more specific recommendations in support of the more general recommendation that had been agreed upon earlier.
Public Policy & Advocacy Committee
1) EMC Policy Information Notices (PINs) should be modified to reduce the minimum required threshold of patients in the targeted service area to 500. Due to the dispersion of the current population, and in order to reach more – placing services where they need to be.
2) EMC Pins should be modified to place a priority on flexibility for use of funding to expand access and capacity by recognizing the important of unique service delivery models and enabling services to include voucher programs, promotoras, outreach and mobile services, case management, etc.
Migrant Health Services Committee
MHCs should provide both mandated and non-mandated services.
1) Comprehensive primary care services
a. medical
b. dental
c. behavioral health
d. pharmaceutical
2) Enabling services including…
a. transportation
b. translation
c. health education
d. health promotion
e. case management
f. outreach services
g. mobile services
h. environmental services
Access, Resources, and Funding Committee
Recommend that funding policies be directed to ensure availability of resources to existing centers to provide essential, non-required services. This is not to say that new health centers should not be funded but that the allocation of resources be redirected to address the pressing need of this socially isolated, hard to reach population, by strengthening the services supporting the infrastructure of health centers so that they can provide such non-required services. This Committee concurred with the list presented by the Migrant Health Services Committee.
John McFarland made a motion to accept this last recommendation, and Guillermo Martinez seconded the motion. Karen Watt and Bobby Nimmo had a friendly amendment to include continuity of care as part of the recommendation. Susana Castro seconded the friendly amendment which was accepted by John McFarland. The vote was unanimous to adopt the recommendations as amended.
The Council discussed continuity of care in the MSFW population. Dr. Rogelio Fernandez pointed out that continuity of care for a migrating population cannot mean that each patient always sees the same provider, as it does within individual health centers. In the Migrant Health context, continuity of care focuses on the level of communication between providers in distinct clinics and a recognition that health information needs to be transferable. Dr. Fernandez also described the Mexican program of “Vete Sano, Regresa Sano”. Dr. McFarland observed that the MHP operates within a very loose knit network of Federally funded health centers, but it must be acknowledged that we are not a “system” of care.
Discussion about current and potential projects followed. Dr. Gomez reminded Council to look at what has worked, what is working, and what can be done. Dr. Fernandez shared that there are web-based programs, but data entry becomes the stumbling block because health centers either don’t have the staff or they don’t see it as a priority. Gil Walter emphasized that there are a lot of MHCs that want to connect with each other, but can’t do it without HRSA to help move the project forward, and further commented that the issue of electronic health records may need additional leadership from the BPHC in order to implement an initiative. Enedelia Cisneros pointed out that continuity of care has more to do with the individual, rather than the system or the doctor. Ms. Cisneros went on to explain that continuity of care issues can often be addressed by health education – by informing individuals and encouraging them to take responsibility.
The Council formulated a recommendation “to maximize the effectiveness of dollars expended in Migrant Health, we ask the Secretary to identify successful models of communication between health centers which enable Migrant Health Centers to provide continuity of care and improve the health of farmworkers.” Karen Watt made a motion to make this a formal recommendation to the Secretary and the motion was seconded by Susan Castro.
Gil Walter observed that HRSA funds information networks within states (NJ and FL), and suggested that interstate development might be a better goal.
Group votes; motion carries, with Gil Walter dissenting.
The Council re-visited their earlier discussion regarding the need for a geographic analysis of the areas in the country where farmworkers are either unserved or underserved, i.e., an analysis of the penetration rates in existing service areas, and asked that OMSP staff move forward with this analysis and also schedule a presentation of the Larson Enumeration Study for the next Council meeting. This will provide the Council with the information they currently lack and thus allow them to make more informed recommendations regarding the allocation of resources.
ACTION ITEM: OMSP will provide an analysis of penetration rates in existing service areas during the next Council meeting.
Expiring Terms of Council Members
Dr. Gomez announced that there are six positions on the Council that will be available starting in November 2006. She explained that once her office received the nominations, they would prepare recommendations for the Secretary, but in the event that the Secretary did not appoint people to those positions in a timely fashion, incumbents would have to stay on until their replacement had indeed been appointed, but for no longer than 120 days.
Dr. Gomez referred the group to the map in Tab 10 of their books that indicated the geographic representation of the present Council. She noted that the Council will be losing Enedelia Cisneros, Gloria Reyes-Garcia, Diana Sanchez, Guillermo Martinez, Wenceslao Vasquez, and Robbie Scott. When nominating new members, she asked the Council to keep this geographic representation in mind, as well as the mandate that the composition of the Council include 12 board members, of those 12 members, 9 are users, and the other 3 are providers/administrators. The request for nominations was sent on April 2006.
Gladys Cate directed the Council to Tab 9 of the book to review the request for nominations to the Council. Ms. Cate reminded the Council that there are 6 vacancies. The six nominees must be board members of MHCs and at least five must also be users of the MHCs.
Other Issues
Shelley Davis from Farmworker Justice, Inc. spoke to the group about the pending immigration reform legislation and specifically about the Ag-Jobs bill. She pointed out that if Ag-Jobs were to pass, it would put farmworkers on the path to legalization and would create a lot of work in helping undocumented farmworkers process the necessary forms. She indicated the Farmworker Justice would be doing a lot of educating in order to help the process along.
Ms. Davis went on to report on two research studies of particular importance. The first indicated that there is a genetic cause to pesticide susceptibility among farmworkers. The second study indicated that even low levels of pesticide exposure can affect intellectual functioning. Ms. Davis further reported that the EPA would be launching a pesticide reporting function in 2006 in order to prevent exposure and educate the public. MHCs will have to recognize and report pesticide exposure, increasing their role in helping to identify these cases.
Closing Remarks
The Council concurred that the Chair and Vice Chair will draft the letter to the Secretary with discussed recommendations.
ACTION ITEM: The Chair and Vice Chair will draft the letter of Recommendations to the Secretary.
Ms. Cate reminded everyone about the logistics information and reimbursement form that had been sent. She asked the Council members to send forms and receipts (except for meals) to her as soon as possible. Dr. Gomez pointed out that one form is for compensation and the other is for expenses. She asked the Council to safeguard their card and avoid cancellation, because it will not be reissued.
Guillermo Martinez made a motion that a face-to-face meeting be suggested and arranged, citing the important issues at hand. Rosita Castillo Zavala seconded the motion, and it was unanimously approved.
ACTION ITEM: To research possibility for a third Council meeting during the present Fiscal Year.
Meeting adjourned.
NATIONAL ADVISORY COUNCIL ON MIGRANT HEALTH
ACTION ITEMS
1. Mr. Walter called for a tool to help provide an idea as to where the farmworkers are located.
2. Council members agreed that there should be a presentation on the work done by Dr. Larson and NCFH on the Enumeration Study, in a future Council meeting.
3. Consolidate the 2004, 2005, 2006 Public Hearings into a single document.
4. OMSP will provide an analysis of penetration rates in existing service areas during the next Council meeting.
5. The Chair and Vice Chair will draft the letter of Recommendations to the Secretary.
6. To research possibility for a third Council meeting during the present Fiscal Year.
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