GEORGIA FARMWORKER HEALTH PROGRAM PROGRAM HEALTH SERVICES NEEDS ASSESSMENT 2019 1|Page Left Intentionally Blank 2|Page Assessment of the Need for Health Services among Farmworkers in Georgia Patsy Whaley Hodge, Executive Director Tiffany Hardin, Program Director Tina Register, Program Operations Specialist Georgia Farmworker Health Program State Office of Rural Health Georgia Department of Community Health Prepared by Ashley Walker, PhD, CHES Bettye A. Apenteng, PhD Charles Owens, MSc Angela Peden, MPH Jiann-Ping Hsu College of Public Health Georgia Southern University 3|Page CONTENTS TABLE OF FIGURES ........................................................................................................................................................................... 5 TABLES .................................................................................................................................................................................................... 5 EXECUTIVE SUMMARY................................................................................................................................................................. 7 BACKGROUND AND METHODOLOGY ................................................................................................................................ 8 PURPOSE ............................................................................................................................................................................................ 8 METHODOLOGY............................................................................................................................................................................ 8 CHARACTERISTICS OF THE GEORGIA FARMWORKER POPULATION ........................................................... 9 DEMOGRAPHIC CHARACTERISTICS .................................................................................................................................... 9 SOCIOECONOMIC AND CULTURAL CHARACTERISTICS ........................................................................................... 9 EMPLOYMENT CHARACTERISTICS ...................................................................................................................................... 9 HEALTH STATUS AND ACCESS ............................................................................................................................................. 10 MIGRANT CLINICS IN GEORGIA ......................................................................................................................................... 11 MAP 1. GEORGIA FARMWORKER PROGRAM CLINIC SITE AND COUNTIES SERVED..........................11 MAP 2. FARMWORKER ESTIMATES BY CLINIC SITE AND COUNTIES SERVED ....................................... 12 MAP 3. FARMWORKER AND DEPENDENT ESTIMATES BY CLINIC SITE AND COUNTIES SERVED .......................................................................................................................................................................................................... 13 UTILIZATION OF MIGRANT CLINIC SERVICES IN GEORGIA ............................................................................ 14 DEMOGRAPHIC CHARACTERISTICS .................................................................................................................................. 14 GENDER ...................................................................................................................................................................................... 14 AGE ................................................................................................................................................................................................ 15 RACE .............................................................................................................................................................................................. 17 INCOME ....................................................................................................................................................................................... 18 WORKER CLASSIFICATION ................................................................................................................................................ 19 HEALTH SERVICES UTILIZATION....................................................................................................................................... 20 HEALTH INSURANCE............................................................................................................................................................20 SERVICES ..................................................................................................................................................................................... 20 STAFFING ........................................................................................................................................................................................ 22 DIAGNOSES AND CLINICAL OUTCOMES OF FARMWORKERS SEEN AT CLINIC SITES...........................24 COMMON DIAGNOSES.........................................................................................................................................................24 CLINICAL OUTCOMES .......................................................................................................................................................... 25 CLINICAL MEASURES ............................................................................................................................................................ 26 FARMWORKER ACCESS TO HEALTH SERVICES ......................................................................................................... 29 RECOMMENDATIONS................................................................................................................................................................. 32 4|Page TABLE OF FIGURES Figure 1. Gender Distribution of Patients, 2015-2018 ......................................................................................................... 14 Figure 2. Gender Distribution of Patients: Georgia and National Comparison ...................................................................... 14 Figure 3. Age Distribution of Patients, 2015-2018 .............................................................................................................. 15 Figure 4. Age Distribution of Patients, 2015-2018: Females................................................................................................ 15 Figure 5. Age Distribution of Patients, 2015-2018: Males................................................................................................... 16 Figure 6. Age Distribution of Patients: Georgia and National Comparison ........................................................................... 16 Figure 7. Race/Ethnicity Distribution of Patients with Known Race/Ethnicity, 2015-2018 ................................................ 17 Figure 8. Race/Ethnicity Distribution of Patients with Known Race/Ethnicity: Georgia and National Comparison ............. 17 Figure 9. Income Distribution of Patients with Known Income, 2015-2018........................................................................... 18 Figure 10. Income Distribution of Patients with Known Income: Georgia and National Comparison ..................................... 18 Figure 11. Worker Classification, 2015-2018...................................................................................................................... 19 Figure 12. Worker Classification: Georgia and National Comparison................................................................................... 19 Figure 13. Types of Service Provided, 2015-2018 ................................................................................................................. 21 Figure 14. Types of Services Provided: Georgia and National Comparison ............................................................................. 21 Figure 15. Staffing Trends, 2015-2018 ................................................................................................................................ 23 Figure 16. Medical Visits by Provider: Georgia and National Comparison ........................................................................... 23 TABLES Table 1. Gender Distribution of Patients ............................................................................................................................... 14 Table 2. Age Distribution of Patients.................................................................................................................................... 15 Table 3. Race Distribution of Patients with Known Race/Ethnicity ...................................................................................... 17 Table 4. Income Distribution of Patients with Known Income ................................................................................................ 18 Table 5. Worker Classification.............................................................................................................................................. 19 Table 6. Types of Services Provided ........................................................................................................................................ 20 Table 7. Number of Visits by Service .................................................................................................................................... 20 Table 8. Staffing.................................................................................................................................................................... 22 Table 9. Selected Diagnoses ................................................................................................................................................... 24 Table 10. Selected Clinical Outcomes..................................................................................................................................... 26 Table 11. Selected Clinical Measures ..................................................................................................................................... 27 5|Page Left Intentionally Blank 6|Page EXECUTIVE SUMMARY The Center for Public Health Practice and Research (CPHPR) with the Jiann-Ping Hsu College of Public Health at Georgia Southern University, in conjunction with the State Office of Rural Health (SORH) and the six Georgia Farmworker Health Program (GHFP) sites completed the 2019 assessment of needs of the Georgia farmworker population. The assessment includes demographics of those served by the six sites, description of most frequent diagnosis for the farmworkers and their dependents, assessment of the health services provided to farmworker population, and recommendations to improving access to care and services provided. Recommendations are summarized here and detailed on page 30. Data was collected from all six migrant farmworker clinics: Colquitt County Farmworker Clinic Decatur County Farmworker Clinic East GA Healthcare Centers Migrant Farmworker Clinic Phoebe Sumter Farmworker Program/Ellaville South Central Primary Care It is recommended that the GFHP and service sites pursue the following strategies to improve delivery of needed health services within the service area: Increase number of staff trained to assist with outreach clinics. Identify support for additional specialty services such as dentistry, optometry, etc. Expand professional development opportunities for site coordinators and staff. Consider community health worker model for all clinic sites. 7|Page BACKGROUND AND METHODOLOGY PURPOSE The purpose of this study was to assess the need for health services among farmworkers in Georgia. The findings would assist the Georgia Farmworker program in health services planning and improvement efforts. METHODOLOGY A mixed methods approach was used for the study, which included the analysis of quantitative secondary data and qualitative data from key informant interviews. Secondary Data Analysis. Data were obtained from the 2013-2016 Department of Labor's National Agricultural Workers Survey and 2018 data from the Bureau of Labor Statistics' Quarterly Census of Employment and Wages. Together, these data were used to estimate the number of farmworkers and dependents in Georgia (following a methodology previously described). 1 2 The National Agricultural Workers Survey was also used to describe characteristics of the farmworker populations in the region. Analysis of Aggregate Clinic Data. Aggregate clinical data were obtained from the state Uniform Data System (UDS) report for 2015-2018. Each farmworker clinic also provided aggregate clinical information to help the researchers complete any gaps. Key Informant Interviews. Qualitative data were obtained during key informant telephone interviews with clinic site program directors, outreach coordinators, and their staff. Each site identified 1 Abernathy, L (2010). The Need for Farmworker Housing in Florida. Retrieved on July 11, 2017, from http://www.shimberg.ufl.edu/publications/RMS_FW_w_cover.pdf 2 Georgia State Office of Rural Health (2017). Assessment of the Need for Health Services among Farmworkers in Georgia. 8|Page at least one representative to participate in the interview. A total of 8 clinic staff participated in the interviews, which were audio-recorded and transcribed. Review of the transcripts was conducted to identify common themes. All findings from this assessment are reported by state level and not by site to protect the confidentiality of the site representatives. CHARACTERISTICS OF THE GEORGIA FARMWORKER POPULATION In 2018, there were an estimated 93,039 seasonal and migrant farmworkers and dependents in Georgia (41,603 farmworkers and 51,437 dependents). DEMOGRAPHIC CHARACTERISTICS State-specific demographic and socioeconomic data on the farmworker population is sparse. However, data from the 2013-2016 National Agricultural Workers Survey indicates that the 71% of farmworkers in the Southeast Region of the country (which includes Georgia), are male with an average age of 37 years. Most are married (54%) and are parents (55%). About two-thirds of farmworkers (65%) in the region are Hispanic. In terms of race, the breakdown is as follows: 31% White, 15% Black/African-American and 54% other race. Foreign-born individuals make up the majority of farmworkers in the Southeast region (62%). About one out of two farmworkers (48%) in the Southeast was born in Mexico. SOCIOECONOMIC AND CULTURAL CHARACTERISTICS According to the 2013-2016 NAWS, two out of three farmworkers in the Southeast region (70%) have less than a 12th-grade education, and a third (39%) have family incomes below the poverty level. Approximately a quarter (23%) do not speak English at all and two-thirds (63%) are most comfortable speaking a language other than English. EMPLOYMENT CHARACTERISTICS According to the 2013-2016 NAWS, farmworkers in the Southeast Region have been employed in the US agricultural industry for an average of 14 years; they had worked with their current employer for an average of 6 years. On average farmworkers started working in the US agricultural industry at age 23 years. Most (98%) are employed by growers, and the rest (2%) are employed by contractors. On average, they work 40 hours a week and 35 weeks in a year. A little over half (55%) engage in field work; 39% work in nurseries; 4% in packing houses and 2% engage in other farm-related activities. 9|Page Migrant workers made up 18% of the farmworker population in the Southeast Region; 82% of workers were seasonal workers. Accompanied farmworkers (i.e. farmworkers living with a spouse, children, or parents, or minor farmworkers living with their siblings) made up 28% and 58% of the migrant and seasonal farmworker populations, respectively. HEALTH STATUS AND ACCESS One out of four farmworkers (23%) from the Southeast region who completed the NAWS reported having at least one chronic condition. The most common chronic condition reported was high blood pressure (10%). Five percent reported having diabetes; 2% and 1% reported a history of asthma and heart disease, respectively. Over half (60%) of farmworkers in the Southeast region reported that they had used healthcare in the US within the last two years. Among those using healthcare services in the US, most had sought care at private physician offices (42%), community health centers or migrant clinics (26%), dental clinics (15%), hospitals (14%), emergency rooms (2%) or other health care services (1%). Compared to seasonal farmworkers, migrant farmworkers were more likely to seek care at community health centers/migrant health clinics (25% (seasonal) versus 34% (migrant)) and less likely to seek care at private medical doctor's offices (44% (seasonal) versus 20% (migrant)). About a quarter of farmworkers in the Southeast surveyed in the 2013-2016 NAWS (27%) reported that they had health insurance for themselves. Seasonal farmworkers were more likely to report having health insurance for themselves, compared to migrant workers (31% (seasonal) versus 8% (migrant)). Almost half of all surveyed Southeast farmworkers (45%) reported that they had paid out of pocket for their most recent health services visit. A higher proportion of migrant farmworkers (71%) reported paying out of pocket for care, compared to seasonal workers (42%). Among those needing healthcare services, the most commonly cited barriers to healthcare access included cost (30% of farmworkers in Southeast region identified it as a barrier to healthcare access); language (4%); undocumented status (3.2%) and transportation (1%). These findings are similar to those previously reported from the 2011-2014 NAWS3 and also corroborate findings from previous studies on the migrant farm worker population. Notably, language and transportation barriers were more pronounced for migrant farmworkers than they were for seasonal farmworkers (language: 8% 3 Georgia State Office of Rural Health (2017). Assessment of the Need for Health Services among Farmworkers in Georgia. 10 | P a g e migrant farmworkers reporting as a barrier vs. 4% seasonal; transportation: 3% migrant farmworkers reporting as a barrier vs. 0.5% seasonal). MIGRANT CLINICS IN GEORGIA There are six federally funded migrant clinic grantees under the Georgia Farmworker Health Program serving farmworkers in Georgia, serving a combined 21 counties (Map 1). Maps 2 shows estimates of farmworkers by county served by the clinics, while estimates of farmworkers and dependents are provided in Map 3. MAP 1. GEORGIA FARMWORKER PROGRAM CLINIC SITE AND COUNTIES SERVED 11 | P a g e MAP 2. FARMWORKER ESTIMATES BY CLINIC SITE AND COUNTIES SERVED 12 | P a g e MAP 3. FARMWORKER AND DEPENDENT ESTIMATES BY CLINIC SITE AND COUNTIES SERVED 13 | P a g e UTILIZATION OF MIGRANT CLINIC SERVICES IN GEORGIA DEMOGRAPHIC CHARACTERISTICS GENDER There were 14,794 and 13,349 patients seen across the six migrant clinics in Georgia in 2017 and 2018, respectively. In both years, and consistent with past trends, about two out of three patients with known gender were male (Table 1 & Figure 1). In comparison with the nation, migrant clinics in Georgia saw relatively more male patients in 2018 (Figure 2). Table 1. Gender Distribution of Patients Female Male TOTAL 2017 # Patients 3,896 9,415 13,311 % 29.3 70.7 100.0 2018 # Patients 3,476 9,287 12,763 % 27.2 72.8 100.0 Figure 1. Gender Distribution of Patients, 2015-2018 % % 34.1 31.6 29.3 65.9 68.4 70.7 2015 2016 2017 Male Female Figure 2. Gender Distribution of Patients: Georgia and National Comparison 27.2 72.8 2018 27.2 72.8 GEORGIA, 2018 Male Female 53.2 46.8 USA, 2018 14 | P a g e AGE In 2017 and 2018, and consistent with past trends, the majority of patients seen at the clinics were between the ages of 18 and 64 years (Table 2 & Figure 3). Children and elderly made up less than 10% and 3% of the patient population, respectively (Table 2). Compared to males, a higher proportion of females seen at Georgia's migrant clinics were children (Figures 4 & 5). In comparison with the nation, migrant clinics in Georgia saw relatively fewer children in 2018 (Figure 6). Table 2. Age Distribution of Patients < 18 years 18-64 65 years and above TOTAL 2017 # Patients 1,016 13,378 400 14,794 % 6.9 90.4 2.7 100.0 2018 # Patients 1,120 11,909 320 13,349 % 8.4 89.2 2.4 100.0 Figure 3. Age Distribution of Patients, 2015-2018 3.1 3.4 2.7 2.4 % 83.5 89.6 90.4 89.2 12.6 2015 Children (<18 years) 7.0 6.9 8.4 2016 2017 2018 Adults (18-64 years) Adults (Age 65 years and over) Figure 4. Age Distribution of Patients, 2015-2018: Females % 5.2 4.6 3.8 3.4 76.7 84.6 85.7 82.7 18.1 2015 Children (<18 years) 10.8 10.5 13.9 2016 2017 2018 Adults (18-64 years) Adults (Age 65 years and over) 15 | P a g e Figure 5. Age Distribution of Patients, 2015-2018: Males 3.2 2.9 2.2 2.0 % 87.0 91.9 92.6 92.0 9.8 2015 Children (<18 years) 5.2 2016 5.2 2017 6.0 2018 Adults (18-64 years) Adults (Age 65 years and over) Figure 6. Age Distribution of Patients: Georgia and National Comparison % 2.4 5.1 59.5 89.2 8.4 GEORGIA, 2018 35.4 USA, 2018 Children (<18 years) Adults (18-64 years) Adults (Age 65 years and over) 16 | P a g e RACE In 2017 and 2018, Hispanics/Latinos made up at least about eight out of every ten farmworkers in Georgia (Table 3 & Figure 7). The race/ethnic distribution has been consistent across years, except for 2017, when the proportion of "other race/multiple race" increased significantly, likely due to changes to data reporting. In comparison with the nation, migrant clinics in Georgia saw a higher proportion of Blacks/African-Americans in 2018 (Figure 8). Table 3. Race Distribution of Patients with Known Race/Ethnicity Hispanic/Latino Non-Hispanic Black/African-American Non-Hispanic White/Caucasian Other Race/ More than One Race TOTAL 2017 # Patients % 10,862 78.4 1,159 8.4 379 2.7 1,454 10.5 13,854 100.0 2018 # Patients % 11,477 86.0 715 5.4 1,137 8.5 20 0.1 13,349 100.0 Figure 7. Race/Ethnicity Distribution of Patients with Known Race/Ethnicity, 2015-2018 % 0.2 10.0 4.5 85.3 0.2 8.4 3.2 87.9 10.5 8.4 2.7 78.4 0.1 5.4 8.5 86.0 2015 2016 Other Race/ More than One Race Non-Hispanic Black/African-American 2017 2018 Non-Hispanic White/Caucasian Hispanic/Latino Figure 8. Race/Ethnicity Distribution of Patients with Known Race/Ethnicity: Georgia and National Comparison % 0.1 8.5 5.4 86.0 GEORGIA, 2018 Other Race/ More than One Race Non-Hispanic Black/African-American 1.9 8.0 2.0 88.1 USA, 2018 Non-Hispanic White/Caucasian Hispanic/Latino 17 | P a g e INCOME In 2017 and 2018, nine out of every ten farmworkers in Georgia lived at or below the federal poverty limit (Table 4 & Figure 9). Between 2015 and 2018, the proportion of Georgia migrant clinic patients who lived at or below the federal poverty limit declined (Figure 9). In comparison with the nation, a higher proportion of patients seen in migrant clinics in Georgia lived in poverty in 2018 (Figure 10). Table 4. Income Distribution of Patients with Known Income Patients at or below 100% of Federal Poverty Guideline Patients at 101 -200% Federal Poverty Guideline Patients above 200% of Federal Poverty Guideline TOTAL 2017 # Patients % 13,497 93.2 857 5.9 120 0.8 14,474 100.0 2018 # Patients % 12,029 91.1 1,010 7.6 172 1.3 13,211 100.0 Figure 9. Income Distribution of Patients with Known Income, 2015-2018 % 10..02 0.4 1.8 0.8 1.3 5.9 7.6 98.8 97.7 93.2 91.1 2015 2016 2017 2018 Patients above 200% of Federal Poverty Guideline Patients at 101 -200% Federal Poverty Guideline Patients at or below 100% of Federal Poverty Guideline Figure 10. Income Distribution of Patients with Known Income: Georgia and National Comparison % 1.3 3.8 7.6 25.7 91.1 70.5 GEORGIA, 2018 USA, 2018 Patients above 200% of Federal Poverty Guideline Patients at 101 -200% Federal Poverty Guideline Patients at or below 100% of Federal Poverty Guideline 18 | P a g e WORKER CLASSIFICATION Two-thirds of patients seen at migrant clinics in Georgia in 2018 were classified as migrant workers, up from a little over half in 2017 (Table 5). Until 2018, the proportion of Georgia migrant clinic patients who were classified as migrant workers was consistently about half (Figure 11). In comparison with the nation, Georgia saw a higher proportion of migrant farmworkers in its clinics in 2018 (Figure 12). Table 5. Worker Classification Migrant Seasonal TOTAL 2017 # Patients 8,003 6,791 14,794 % 54.1 45.9 100.0 2018 # Patients 8,427 4,922 13,349 % 63.1 36.9 100.0 Figure 11. Worker Classification, 2015-2018 45.9 47.4 45.9 36.9 % 54.1 52.6 54.1 63.1 2015 2016 Migrant 2017 Seasonal 2018 Figure 12. Worker Classification: Georgia and National Comparison % 36.9 63.1 GEORGIA, 2018 Migrant 68.2 31.8 USA, 2018 Seasonal 19 | P a g e HEALTH SERVICES UTILIZATION HEALTH INSURANCE All patients seen at migrant clinics in Georgia in 2018 were uninsured in 2017 and 2018. Comparatively, in 2018, only about a third of patients (36%), with known insurance information, seen in migrant clinics nationally were uninsured. SERVICES The total number of visits made in 2017 and 2018 were 42,153 and 40,296 respectively. The majority of visits were made for medical (70.2% in 2017 & 68.9% in 2018) and enabling services (27.3% in 2017 and 2018, respectively). There were no substance abuse services recorded (Table 6). On average each patient made 2.8 visits in 2017 and 3.0 visits 2018 (Table 7). Between 2015 and 2018, the proportion of dental services provided at migrant clinics in the state increased (Figure 13). Compared to the nation, migrant clinics in Georgia provided fewer dental and other services (including vision and mental health/substance abuse services) and more enabling services in 2018 (Figure 14). Table 6. Types of Services Provided Medical Services Dental Services Mental Health Services Substance Abuse Services Vision Services Enabling Services Other Professional Services TOTAL 2017 # Visits 29,584 807 31 0 17 11,494 220 42,153 % 70.2 1.9 0.1 0.0 0.0 27.3 0.5 100.0 2018 # Visits 27,758 1,190 99 0 34 11,018 197 40,296 % 68.9 3.0 0.2 0.0 0.1 27.3 0.5 100.0 Table 7. Number of Visits by Service Medical Services Dental Services Mental Health Services # Visits 29,584 807 31 2017 # Patients 14,794 807 31 Visit per Patient 2.0 1.0 1.0 # Visits 27,758 1,190 99 2018 # Patients 13,349 545 67 Visit per Patient 2.1 2.2 1.5 20 | P a g e Vision Services Enabling Services Other Professional Services TOTAL # Visits 17 11,494 220 2017 # Patients 17 11,494 220 Visit per Patient 1.0 1.0 1.0 42,153 14,794 2.8 # Visits 34 11,018 197 2018 # Patients 34 11,018 197 Visit per Patient 1.0 1.0 1.0 40,296 13,349 3.0 Figure 13. Types of Service Provided, 2015-2018 0.5 0.6 0.6 0.8 29.9 26.7 27.3 27.3 1.8 1.9 1.9 3.0 67.8 70.8 70.2 68.9 % 2015 2016 2017 2018 Medical Services Dental Services Enabling Services Other Services Figure 14. Types of Services Provided: Georgia and National Comparison % 0.8 7.0 27.3 9.8 3.0 19.5 68.9 63.6 GEORGIA, 2018 USA, 2018 Medical Services Dental Services Enabling Services Other Services 21 | P a g e STAFFING Between 2017 and 2018, overall staffing level increased by 2.6 full-time equivalent (64 FTE in 2018 versus 61.4 FTE in 2017). Together with the 4% reduction in the number visits in 2018 (relative to 2017), the increase in FTE resulted in an 8% decrease in the number of visits per FTE in 2018 (630 visits per FTE in 2018 versus 687 visits per FTE in 2017). At the provider level, the total number of visits per FTE decreased for all providers between 2017 and 2018, with the exception of case workers (Table 8). This reduction was generally driven by an increase in FTE and a decrease in the number of visits between 2017 and 2018. Notably, caseworker FTE decreased in 2018, compared to 2017, despite an increase in the number of visits during the same period (Table 8 & Figure 15). The number of visits completed by case workers and patient/community education specialists has increased since 2016, whereas the number of visits completed by physicians has declined over the same period (Figure 15). Compared to the nation, Georgia's migrant clinics depend relatively more on non-physician clinicians (NPs and Pas) for the delivery of medical care (Figure 16). Table 8. Staffing Physicians Nurse Practitioners/Physician Assistants Nurses Dentists Dental Hygienists Case Workers Patient/Community Education Specialists Licensed Mental Health Providers and Other Mental Health Staff 2017 # FTE Visit per Visits FTE 1449 1.43 1,013 19,381 7.67 2,527 8,754 278 529 1,926 9,568 13.96 0.1 0.5 1.55 2.28 627 2,780 1,058 1,243 4,196 31 0.35 89 # Visits 1,195 21,830 2018 FTE Visit per FTE 2.12 564 9.75 2,239 4,733 610 580 2,421 8,597 11.24 0.5 0.5 1.3 1.59 421 1,220 1,160 1,862 5,407 94 1.25 75 22 | P a g e Figure 15. Staffing Trends, 2015-2018 VISITS PER FTE 7534 3594 4196 5407 1026 857 1235 1553 2015 1145 541 2186 1819 2015 1243 627 2527 1013 2017 1862 421 2239 564 2018 Patient/Community Education Specialists Case Workers Nurses Nurse Practitioners/Physician Assistants Physicians Figure 16. Medical Visits by Provider: Georgia and National Comparison % 2.6 17.1 48.0 78.6 4.3 GEORGIA, 2018 49.4 USA, 2018 Physicians Nurse Practitioners/Physician Assistants Nurses 23 | P a g e DIAGNOSES AND CLINICAL OUTCOMES OF FARMWORKERS SEEN AT CLINIC SITES COMMON DIAGNOSES Table 9 presents information on selected diagnoses across all clinic sites. The most common conditions experienced by farmworkers seeking healthcare at the states' six migrant clinics are overweight and obesity, hypertension, and diabetes. This finding corroborates the findings from the NAWS as well as other literature that show a disproportionate burden of these conditions among the Hispanic population, compared to the general population. Between 2017 and 2018, the number of visits for chronic obstructive pulmonary diseases (COPD) doubled, and the number of visits per patient increased by 34%. Visits per patient also increased notably for hypertension (54%), sexually transmitted diseases (24%), otitis media and eustachian tube disorders (19%), and abnormal breast findings (17%). The total number of visits for abnormal findings of the cervix, declined by 72% in 2018, compared to 2017 (Table 9). Table 9. Selected Diagnoses Selected Diagnoses (all sites) Overweight and Obesity Hypertension Diabetes Mellitus Tobacco Use Disorder Heart Disease (selected) Anxiety disorders including PTSD Depression and other mood disorders Contact dermatitis and other eczema Asthma Other mental disorders, 2017 # # Visits* Patients 9,451 6,075 2,889 2,463 864 1,997 1,003 664 309 154 282 169 270 199 262 238 233 144 103 78 Visit per Patient 1.6 1.4 2.5 1.3 2.0 1.7 1.4 1.1 1.6 1.3 2018 # # Visit Visits* Patients per Patient 9,565 5,667 1.7 3,099 2,891 788 1,395 2.2 1,061 2.7 571 1.4 301 156 1.9 290 176 1.6 313 215 1.5 272 254 1.1 268 159 1.7 101 75 1.3 % Change Visits Visit per Patient 1% 8% 7% 54% 17% 11% -9% 6% -3% -4% 3% -1% 16% 7% 4% -3% 15% 4% -2% 2% 24 | P a g e 2017 2018 % Change Selected Diagnoses # # (all sites) Visits* Patients excluding drug or alcohol dependence Visit per Patient # # Visits* Patients Visit per Patient Visits Visit per Patient Sexually transmitted infections 102 94 1.1 101 75 1.3 -1% 24% Dehydration 88 88 1.0 56 52 1.1 -36% 8% Chronic 72 obstructive pulmonary diseases 60 1.2 148 92 1.6 106% 34% Abnormal cervical 50 findings 41 1.2 14 13 1.1 -72% -12% Abnormal breast 33 findings, female 26 1.3 40 27 1.5 21% 17% Attention deficit 21 and disruptive behavior disorders 13 1.6 17 10 1.7 -19% 5% Exposure to heat 16 or cold 16 1.0 12 11 1.1 Childhood Conditions -25% 9% Otitis Media and 70 61 1.1 71 52 1.4 1% 19% Eustachian Tube Disorders *# visits regardless of primacy. Note. Rounded figures are presented in table for simplicity. Percentage change computations were made with actual figures and not the rounded figures as presented in the table. CLINICAL OUTCOMES There were mixed results in terms of clinical outcomes in 2017 and 2018. A similar proportion of patients with diabetes had poor glucose control in both years (43% in 2017 and 42% in 2018). On the other hand, in 2018, only 57% of patients with hypertension had their hypertension under control, a decrease from 67% in 2017. The proportion of low-birth weight births declined between 2017 (9.3%) and 2018 (7.1%) (Table 10). 25 | P a g e Table 10. Selected Clinical Outcomes Select Clinical Outcomes Diabetes Poor control: Diabetes patients with Hba1c greater than 9% or with no tests performed during the year Hypertension Proportion of patients with controlled hypertension Births Very low birthweight: Proportion of live births less 1500 grams Low birthweight: Proportion of live births 1500 grams 2499 grams 2017 Percent N=990 42.8 N=1,772 66.6 N=54 0.0 9.3 2018 Percent N=1,042 42.0 N=1,320 57.2 N=42 0.0 7.1 CLINICAL MEASURES Migrant clinics in Georgia performed better on clinical quality measures in 2018, compared to 2017. Improvements were noted in all but 3 clinical measures assessed in this needs assessment (Table 11). Opportunities exist to improve processes concerning tobacco use screening, counseling and intervention, colorectal screening, and care for patients with Ischemic Vascular Disease (IVD). Although colorectal screening rates did not change much between 2017 and 2018, screening rate are notably low at approximately 17% (Table 11). 26 | P a g e Table 11. Selected Clinical Measures Selected Clinical Measures Children 2 years of age who received age appropriate vaccines by their 2nd birthday Female patients aged 23-64 years receiving Pap smear Patients aged 50-75 years with appropriate colorectal screening Children and adolescents 3-17 years with documented BMI, nutrition, and physical activity counseling Adult patients with documented BMI and appropriate follow-up plan documented if BMI is outside of normal parameters Patients aged 18 years or older who were screened for tobacco use one or more times in the measurement year or prior year and (2) those found to be a tobacco user received cessation counseling intervention or medication 2017 # # Patients % Patients Receiving Eligible Vaccination/ Screening/ Counseling 37 10 27.0 3,515 1,937 930 12,585 7,400 640 18.2 327 16.9 434 46.7 7,566 60.1 4,651 62.9 2018 # Patients Eligible 38 # Patients % Receiving Vaccination/ Screening/ Counseling 20 52.6 2,704 1,600 1,042 1,276 47.2 264 16.5 836 80.2 4,659 3,846 82.5 10,230 5,921 57.9 Improvement /Decline 2018 Compered to 2017 Improved Improved Stable Improved Improved Declined 27 | P a g e Selected Clinical Measures Patients 5 -40 years with persistent asthma who have an acceptable pharmacological treatment plan Patients 18 years of age and older with a diagnosis of coronary artery disease who were prescribed a lipid lowering therapy Patients 18 years of age and older with a diagnosis of IVD or AMI, CABG, or PCI procedure with aspirin or another antiplatelet Patients 12 years of age and older who were (1) screened for depression with a standardized tool and, if screening was positive,(2) had a follow-up plan documented 2017 # # Patients % Patients Receiving Eligible Vaccination/ Screening/ Counseling 44 31 70.5 146 78 53.4 87 46 52.9 12,721 6,109 48.0 2018 # Patients Eligible 40 # Patients % Receiving Vaccination/ Screening/ Counseling 39 97.5 115 89 77.4 105 51 48.5 10,548 8,913 84.5 Improvement /Decline 2018 Compered to 2017 Improved Improved Declined Improved 28 | P a g e FARMWORKER ACCESS TO HEALTH SERVICES Eight representatives from the six clinics participated in semi-structured phone interviews during the months of September and October 2019. Each of the interviews were audio-recorded and transcribed verbatim. The transcriptions were reviewed for recurring themes concerning Georgia's migrant farmworkers' top health issues and the assessment of health services in which they received. Based on the analysis of the transcriptions, the top health issues reported by the site coordinators and staff are cardiovascular disease (high blood pressure and high cholesterol) and diabetes. Obesity was mentioned by most of the participants as a precursor to the major health issues and linked to the farmworkers' diet. Mental health, specifically depression, was identified by one clinic as a top health issue even though most identified it in 2017. However, the lack of services to treat mental health/illness was identified as barrier to providing adequate care to their clients. We live in a very rural area, and psych is a major issue down here. They closed the facility in [city name], so the closest facility is gonna be [city names], and that's only, like, for emergent things. I do know that a couple of other hospitals, they're not in our service area, but they are looking into trying to have some psych available. Similar to findings from 2017, a common theme emerging as a barrier to care was patient compliance. Interview participants noted that migrant farmworkers will often receive their initial screenings but are not as likely to return for regular appointments. In addition, the farmworkers are not compliant with managing diabetes, hypertension or hyperlipidemia. Compliance with proper diet and provider follow-up appointments is difficult for the farmworkers. The most prominent barriers identified were cultural practices, transportation, clinic hours, and worker schedule. Transportation was mentioned by all participants as the top barrier for this population. Transportation and Compliance The proper treatment and maintenance of the top health issues identified by the clinic site supervisors and staff are impeded by the inability of the farmworker to remain compliant. Non-compliance is not directly linked to farmworker motivation, but more likely related to other issues such as lack of transportation, cultural influences, and low wages. Lack of transportation was the most noted barrier to providing care to the farmworkers. Among the six clinic sites there is variation in clinic service hours. Clinic hours were also identified as an influencing factor to patient compliance in 2017. Most of the clinics provide their care at the work 29 | P a g e site or the living barracks because it is difficult to get the farmworkers to come to the clinic. Transportation impedes follow-up care, but clinic hours do not complement the long work days. Migrant workers are not likely to miss time from work to attend a clinic appointment. ...the next thing is transportation, and getting them there and getting them back. Because most of them, they're not gonna they're gonna work. They're gonna work all day long, and then you have to see them later in the day or whatever. Because if they're not working, they're not making money. Primary Care The outreach coordinators and staff at all six sites offer a variety of health assessments to the farmworkers. Most site visits focus on screenings. The clinics provide access to pharmaceuticals to alleviate symptoms of chronic disease and acute conditions. Some sites have more advanced technology to perform more complete health assessments. For example, some sites have mobile units which allow them the ability to perform more invasive screenings compared to other sites that do not have access to a mobile unit. All the sites indicated that they have appropriate capabilities to screen and manage chronic disease like diabetes and high blood pressure. Specifically, with the focus on diabetes management, the clinics have been able to provide more education to the farmworkers to improve patient compliance. One participant noted the ability to provide `home visits' to assist with nutrition education. But we also, in our outreach group, they go to the house. They make house calls to do education on obesity and hypertension and diabetes. So we do a lot of hands-on activities, hands-on education with it as well. Access to mental health care remains an issue for the farmworkers. The cost of specialized care and limited providers that are willing to participate in farmworker health is lacking. In addition to mental health, the sites noted access to dentistry services as another unmet need. ...so by them being self-pay, and then some of them are migrant and seasonal, going to different outside offices is kind of difficult because they sometimes don't accept those patients. And then they don't accept our voucher program, or some don't accept Medicaid. So they, you know, wouldn't accept the Medicaid rate. The clinic staff identified the relationships they have with the crew chiefs, local providers and farmworkers as a major strength when providing care. The staff have good relationships and these 30 | P a g e positive relationships are a boon to the overall mission of the farmworker program. Many of the staff in the clinics have been working with the population and local providers for years and this commitment has helped establish a level a trust that cannot be replaced. Everyone involved in the health of these farmworkers views each other as a partner. Relationships with the Crews We work with the farmers and the crew chiefs, is the main people we work with outside of the clinics. That's our biggest connection to the population. Commitment and Trust Yeah, that's what I was gonna say. Most everybody has been here more than 12 years. There's only a few that have been here, like, five, and everybody else has been here 12, 15 years. And so they have that trust for us, they recognize us in the community when we're there, you know, to speak and say hello. So, I think that that partnership, that relationship, is very strong. The clinics serve several different farms. Funding to increase services is a needed resource along with staff. Because of the limited staff and access to specialty care providers, unmet health needs are more likely. The clinics cannot provide convenient hours when there is not enough staff to manage the clinic. Further, needs beyond primary and secondary care are not treated because it is hard to find local providers that will serve the needs of the population. These concerns are similar to those expressed in the last assessment cycle. 31 | P a g e RECOMMENDATIONS The following are the recommendations which emerged from the needs assessment. Increase number of staff trained to assist with outreach clinics. This continues to be one of the top requests from the six grantees. The clinics are meeting the needs of the farmworkers, but with more staffing, outreach can be provided more often, and clinic hours can be extended to work around the workers' schedules. At this time, clinic hours and provider access vary between clinics depending on current resources. Identify support for additional specialty services such as dentistry, optometry, etc. Outreach coordinators can provide access to most primary care needs and several screenings, but more is needed in terms of eye, oral, and mental health. Most of the specialty services must be referred out and patient follow-up is limited based on access and affordability. Expand professional development opportunities for site coordinators and staff. Continuing education would greatly benefit this population. The trainings specific to the diabetes focus were identified as helpful and useful as staff provide services to the farmworkers. Professional development could assist new and veteran staff learn more about the population and effective ways to improve patient compliance. ...because I just try to broaden my education everywhere I can...websites...free about diabetes and high blood pressure, and how you can try to manage that better in populations that are noncompliant, Consider community health worker model for all clinic sites. One clinic mentioned using a model that mimics a community outreach effort and identified it as a useful model to assist with patient compliance and follow-up. Other participants recommended a lay health worker curriculum as another resource to better meet the health needs of the farmworkers. I think using a curriculum for using lay health workers in the field. A vetted curriculum, medically vetted curriculum that lay health workers can use 32 | P a g e THE GEORGIA FARMWORKER PROGRAM STATE OFFICE OF RURAL HEALTH GEORGIA DEPARTMENT OF COMMUNITY HEALTH 2019 33 | P a g e