Resettled refugees represent a relatively small population, but their health and illness patterns can have a great effect on the larger community health picture if their needs are not met. The epidemiology of refugee illness is extraordinarily complex. From a public health point of view, the potential for communicable disease transmission warrants comprehensive surveillance, detection and treatment upon arrival. Furthermore, due to the cultural barriers to accessing care most refugees face, at least initially, the risks of chronic disease are vast. For all these reasons and more, health programs specifically tailored to refugee health are not only a cost-savings in the long run, but ethically mandated. However, it is virtually impossible to develop a program comprehensive enough to provide the type and level of care to meet all the needs. We believe the best efforts can be made through an outreach model, drawing on several community components in a coordinated, "team," approach. This section:
Building the Program
The East Dallas Health Center (EDHC) began in 1981 as the East Dallas Health Coalition (EDHCO), a grassroots, community-based clinic and health program developed with a primary purpose of serving the rapidly growing Southeast Asian refugee population in the East Dallas area. As the program grew through the 1980s, East Dallas demographics began shifting from primarily Southeast Asian refugees to a more heterogeneous mix of Latino (American-born and Mexican and Central American) and Southeast Asians. For a variety of reasons, the EDHCO board reached agreement with the Parkland board, the county hospital, to transfer control of the program to Parkland in 1989. After the transfer, there was, for several years, a decreased focus on refugees and some loss of connection with refugee communities. In fact, the County Hospital emergency room was becoming the source of primary care for many of the newly-arrived refugees. Simultaneously, resettlement of refugees was beginning to occur in areas other than East Dallas.
In 1991, EDHC staff noted that Kurdish refugees who had previously been brought to the clinic by caseworkers had ceased to come to the clinic. Follow-up by Baylor nursing students showed that a large, underserved Kurdish community existed in North Dallas. Attempts to connect the Kurds with the EDHC were unsuccessful because of cultural barriers and transportation issues. EDHC responded by sending a physician and refugee program coordinator, an anthropologist, to the Kurdish community one day/week. The Midpark Place Apartments "rec room" was the first outreach clinic site and has served as an enduring model for this work. An aside:
Hence the outreach model to serve the primary health care needs of refugees in Dallas County began at this time, but lacking was an integrated screening program for new arrivals. In 1995, with funding from the Texas Department of Health as well as internal funding, the East Dallas Health Center (Parkland Hospital COPC) and the Dallas County Health Department established a cooperative refugee screening and follow-up program. The goal of the program has been to link the screening procedures with the primary, ongoing treatment and care for the refugee patient, in a flexible and culturally-appropriate manner. The traveling team presently operates out of three outreach sites in the Dallas area (Oak Lawn, Pineland, and East Dallas). The sites are determined in coordination with the Voluntary Agencies, who are responsible for the initial resettlement, and also where there are significant numbers of refugees with unmet health needs and continued difficulty accessing care. (Basic issues in refugee health - such as access - are discussed in the section on "Health" and are not covered here.) Other providers/cooperating organizations are the Vietnamese Mutual Assistance Association (VMAA) and Baylor University School of Nursing.
Outreach sites include apartment "recreation rooms," vacant apartments, and an "interactive community police" building. Funding for the temporary sites is from various sources. Some are donated by apartment management (as they have a vested interest in maintaining a steady stream of new refugees as tenants) or in one case, the police department (which grew out of a relationship with Baylor University School of Nursing's Community Care program). In another scenario, the cost is of an apartment is shared with an existing ESL program sponsored by Catholic Charities. In all cases, the clinic is located in a local facility centered in the refugee community. While none of the sites is ideal as a health care facility, each has the enormous counterbalancing qualities of being:
Services provided include:
In addition to the outreach clinics, the Team also arranges and participates in special refugee community events, such as a health fair at the Cambodian temple during New Year festivities. Team members also regularly conduct educational seminars on refugee health issues to area service providers.
Medically, the program closes the loop between positive screening findings and on-site treatment (including medication delivery when indicated) and hence dramatically improves compliance and outcome. We eventually work the patients into more permanent primary care facilities, such as the East Dallas Health Center, after half a year or so, when they are more adapted to the medical system.
Baylor University School of Nursing operates the Baylor Community Care program every Thursday and Friday in a medically underserved Latino and Asian refugee neighborhood in East Dallas. Home base for the program is the East Dallas Police Storefront. Cooperating organizations are the East Dallas Health Center (EDHC) Refugee Outreach Program, Dallas County Health Department, Vietnamese Mutual Assistance Association (VMAA), Dallas Police, and Common Grace Ministries. The program is based on community needs and because support and funding is broad-based and in some cases internal (e.g., Baylor), the program is able to respond to changing community circumstances. Program components can be broadly divided into (1) individual and family-oriented services and (2) community-oriented services.
Individual and Family-Oriented Services
As noted earlier, outreach is door-to-door through the apartments in the district. Students, volunteers, and lay health promoters carry flyers in English, Khmer, Spanish, and Vietnamese about clinic services. Standard procedure for each contact is to talk with people about health problems, check blood pressures, vaccination records, medications, and address any other health issues that arise during the contact. Always, as much as is possible, problems are addressed on the spot.
Language is often an issue. The primary languages spoken in this district (in descending order) are Spanish, English, Vietnamese, Khmer, Laotian, Somali, and Arabic. Currently there are translators about 70% of the time for the first four non-English languages. The program has not always had this current high level of language support.
Language barriers are often a problem in providing refugee and immigrant health services. However, had the program waited for the right translators, thousands of opportunities to serve this community would have been missed. Depending on the right translators would have meant cancer untreated, hypertension undetected, births without prenatal care, vaccinations undone, food stamps benefits lost, and on and on and on.
Primary Care, Case Management, and Home Health Care
When people are found with health or related problems, nursing students or other persons involved with the program help find appropriate resources, help clients access the services and follow-up on the care given to be sure that clients understand treatments and medications, and finally, provide further follow-up to determine if treatments were effective and if any new problems develop. The primary care component of services underwent several changes in the spring of 2000, including the loss of pediatrician and family nurse practitioner services and the dissolution of partnership with Church Health Ministries (CHM). However, Community Care has maintained medical services throughout. Currently, Community Care is in partnership with the Agape Clinic at Grace United Methodist Church (and in continued partnership with the County, Dallas Police, Common Grace Ministries, and other organizations). Community Care provides Friday morning clinic services as a part of the Agape Clinic (also open Saturdays). The Friday clinic is coordinated by students.
Common individual problems encountered in the community include clients having difficulty obtaining and understanding:
Often nursing students or others accompany patients to appointments and thus provide essential advocacy and/or teaching services. In all cases, a goal of care is increasing patient independence so that ultimately the patient is registered with a provider such as the East Dallas Health Center, knows how to make appointments, and is able to recognize the need to seek health care. This goal is not always possible to achieve. There is also a continuity component built into the care so that different aspects of the care, e.g., hospital and home, are connected; and the care is connected among different students and across different semesters.
Community services currently underway include community assessment, immunizations taken into the community, women's health services, parish health, and community development. These are ongoing community care activities that, over time and with reinforcement and repetition, change lives. Each is summarized below.
Assessment of the community is services-based. In other words, the community and its resources are assessed through the process of delivering services. Biostatistical data, but to a lesser degree than direct experience in the community.
In going door to door in the community, the immunization status of every child encountered is assessed. Immunizations are given every Friday at the clinic the Dallas County Health Department. Influenza immunizations are given in the fall. In the areas receiving care 1996-98, 85% of children less than five years of age were within a month of being current with immunizations. We no longer are able to offer the intensive effort necessary to maintain this level of compliance.
In addition to the already described outreach and assistance with family planning and prenatal care, students plan and implement cancer screening events in which a portable mammogram unit is set up in the Police storefront and women who otherwise would be highly unlikely to ever receive a mammogram come in for free screening. Along with mammograms, students teach breast self-exam one on one with the women, screen all participants (and anyone else who comes in the door) for other health problems (e.g., diabetes, hypertension, colon cancer, HIV), and provide follow-up care for all problems. Except for operating the mammogram unit and HIV testing, students are responsible for all aspects of the screening.
The ethnic breakdown of women screened (>200 to date)
African-American 10% Anglo 5.5% Khmer (Cambodian) 21% Hispanic 25% Laotian 14% Native American <1% Vietnamese 23%
In areas receiving care 1996-98 more than 80% of women desiring birth control obtained and understood viable means of preventing pregnancy, i.e., the women were compliant with oral contraceptives or other effective means of birth control; and more than 75% of pregnant women received prenatal care by the second trimester of pregnancy.
Parish Health and CoMadres
One of the underutilized resources identified in community work were churches in the community. Students made contact with Pastor David Thorp at Emanuel Lutheran Church and obtained his agreement to work with the program one day/week. At the same time this relationship was being established, contact was initiated with Dallas Theological Seminary, a heavily academically-oriented seminary near the community. From the seminary contact, several faculty and student volunteers emerged. Thus there were available sources of spiritual care in a community that in many respects is spiritually bereft. The seminary students and faculty have also been enormously helpful in transportation and related activities.
As a result of work with David Thorp, a relationship was developed with a group of Hispanic women, the "CoMadres" at one of the elementary schools in the community. With the CoMadres, a lay health promoter curriculum was developed and implemented in a series of weekly teaching sessions with the CoMadres and later, a group of CHM lay health promoters. Currently, the curriculum is being refined and offered at the Brady Center, a Catholic Charities center serving primarily Hispanic clients.
In all aspects of working in this community, whether with individuals or as part of community care, students affirm and strengthen the community's ability to grow and care for itself. Many referrals to people in need come from people with whom students have worked in the past and who have learned basic health measures through the program. There is a growing corps of volunteers and a strong network of concerned individuals whom the program helped equip to reach out and help their neighbors. Students also developed a comprehensive community resources guide and regularly distribute copies to community agencies.
Challenges and Problems
Follow-up and evaluation is a constant challenge. For example, follow-up and measurement of proficiency and compliance with BSEs consistently shows a low level of compliance. Despite extensive cultural orientation, it is sometimes difficult for students and clients to reach across vast cultural and experiential differences. The greatest structural problem we face is coverage during summer months when the community health course usually is not offered.
Beginning in 1999, students began following-up on all patients seen in the primary care clinic or identified on outreach with chronic illnesses on which intensive services can impact "preventable admissions." These include diabetes, hypertension, congestive heart failure, and asthma. Approximately 50% were found to be noncompliant with treatment or to have signs or symptoms indicating treatment failure. All who were willing were assisted back into the system and received further follow-up. We estimate about 50% of these came into compliance or signs or symptoms indicating treatment failure were resolved.
Building the Program
Community Care began in Fall 1981 with work with Cambodian refugees placed in a "cluster resettlement" in East Dallas. Initially, services consisted of one clinical group of eight nursing students + one faculty from Texas Woman's University (TWU) working door-to-door in the Cambodian community. Health and other problems were found in virtually every apartment. Although problems were documented and included in a community assessment, students and faculty never simply documented the presence of problems. Instead, they went to work on solving the problem(s) as they were encountered. There also was a policy of not simply referring problems to other providers. In addition to identifying and intervening in many problems, the students were able to build a credible services-based community assessment that showed in a dramatic manner, the terrible conditions in the Cambodian community and the great difficulties the Cambodians had in obtaining services.
Refugee agencies tended to ignore or barely tolerate the presence of the students. Only the smallest agency (Church World Service) was interested and supportive of the student's efforts.
Along with continued work with individuals and families, the community assessment developed by the first group of students was further expanded in Spring 1982. The community assessment was then used as the basis for a grant proposal to a large reform synagogue, Temple Emanu-El, for the social action committee of the synagogue to work with students and others to develop a clinic and health program for refugees. The grant was approved and a partnership formed with Church World Service. That partnership evolved into the East Dallas Health Coalition (EDHCO), which with additional grant and services support opened a clinic in 1983. Originally the clinic was open one evening/ week in donated space in a school with one paid nurse and volunteer physician services. Over time, the clinic increased time of operation and was able to pay for physician and other services.
Nursing students, faculty, and volunteers provided home care and outreach services. As discussed in the section on the East Dallas Health Center Refugee Outreach Program, EDHCO eventually became one of the Dallas County Hospital District's Community-Oriented Primary Care (COPC) health centers.
After an approximately three year period of markedly decreased involvement in refugee health, the faculty involved in the startup moved from TWU to Baylor and began again working in the East Dallas refugee community. The focus of services provided by students shifted from East Dallas (Cambodian) to North Dallas (Kurds). When outreach by EDHC to Kurdish refugees was in place in 1992, Baylor shifted its efforts back to East Dallas and began working on a district health model.
The district health model ("Community Care") focused on the community as a whole rather than a specific population within the community. The reasons for this shift were:
In essence, the Community Care program took responsibility for providing health care to a culturally diverse (primarily Asian refugee and Hispanic) inner-city low-income community with significant needs/problems.
As with previous work in this area, students became primary providers and links to health services. Students operated out of the East Dallas Police Storefront and worked door-to-door uncovering and solving health problems. Students also initiated health promotion and disease prevention activities, including mammograms and other cancer screening.
Effective interventions and documentation of patient and community problems led to a successful proposal for the EDHC to provide physician (pediatrician) services at the Police Storefront one morning/week. The Dallas County Health Department provided refugee screening services. The partnership of nursing students with physician and supporting services led to increased volunteer participation in the program. A Lutheran church, Presbyterian mission, and other faith-based organizations also became involved. Baylor faculty worked with the VMAA to write a successful grant proposal for Asian caseworker services. Work with a new parish health program, Church Health Ministries (CHM) of East Dallas led to a second morning of physician (internal medicine) services at the storefront. Volunteer services continued to increase and beginning in Fall 1998, TWU students began working with the program. Neither CHM nor TWU are currently involved with the program. However, both continue to provide similar services.
Notes on coalitions and collaboration: Characteristics of effective community coalitions include:
If the coalition evolves into a nonprofit 501(c)(3) organization it is important to involve knowledgeable people in the organization. Information given below under "Steps to Forming a Nonprofit Agency" provides an outline for organization. Tip: The vice-chair or treasurer should be (1) president elect and (2) responsible for fund-raising. Structuring leadership in this way means that the president elect has primary responsibility for insuring the financial health of his or her term of office.
This program was designed and has evolved for the specific purpose of addressing the health care needs and problems of a community that - despite the relatively near presence of several health and social service providers - remained significantly underserved. The program is driven and defined by human needs. Through meeting the needs and priorities of the community, it is possible to gradually introduce services directed to health promotion and disease prevention and early detection. Rather than students coming into the health care system and working as students (whose work would be done whether the students were there on not), students in this program provide services that would not otherwise be provided.
1. Provide real services to people: As noted below, too many people spend too much time planning and talking. Face it. Most of us have good ideas. Few grants are awarded on the basis of a good idea or even a need. Granting organizations want to know if you have the ability to provide services that make a difference in people's lives.
2. Explore the problem and resources: This includes:
This is not a literature review, but rather a problem and a dynamic community assessment that is only the first step in the planning process. Too often, the first steps in planning are to decide on a model or plan. Deciding on a plan of action before the problem is understood in its entirety is a mistake. The community assessment is modified as new data emerges and new funding sources arise. Throughout the planning process . . . (see #3 below)
3. Identify funding sources and begin planning the project. Researching potential funding sources is an ongoing effort throughout planning and writing. Funding sources to research should include foundation, corporate, religious, civic, individual, and government (federal, state, and local). See later discussion of identification of funding sources.
Plans must address the needs of the client population and the desires of funding source(s). Cooperation with other providers is a hallmark of successful proposals in the 1990s. Internally, plans must fit with organization funding development plans. Externally, plans must sometimes be adapted to funding organization constraints. Be flexible! Please note that plans are not yet set.
Write the proposal/finish planning. Creative, effective proposals evolve from a strong understanding of the problem, the community, and a lot of hard work. Proposals/plans must be clearly written, responsive to all requirements of funding sources, show the organization as businesslike and well-managed, and at the same time, be creative. Note that to be taken seriously by sophisticated funding bodies, interventions to improve health should always include plans to address the (1) knowledge, (2) attitudes, and (3) behaviors of the target population. If guidelines are given, plans must be responsive to the guidelines. Using evaluation criteria as a format for the proposal is sometimes possible.
4. Start over again. Rest for a few days and begin again. Successful research, planning, and writing are part of an ongoing process.
Characteristics of Successful Grant Proposals
Commonly Needed Supporting Documents for Grant Proposals (Start a file NOW - establishing a file of these is part of grantsmanship)
Steps to Forming a Nonprofit Agency: Sometimes you have to start your own agency to create a needed program.
Continue (1) documenting outcomes and (2) writing proposals and otherwise raising funds.
http://www.granted.org/ Listing of foundations is broken down into categories, e.g., national, state, local, corporate, areas of interest (health, community development, art, etc.). A good starting site.
http://fdncenter.org/ The Foundation Center: Clearinghouse site. Philanthropy Digest on-line. Books for sale. Click on Grantmaker Info for and excellent listing of "Private Foundations on the Internet" and "Corporate Grantmakers." Also check out On-Line Library's "Proposal Writing Course" and other very helpful guides. Connects to other foundation centers.
http://www.foundations.org/ Has less extensive listing of foundations than the Foundation Center.
http://web.fie.com/cws/sra/resource.htm A gateway page to other sites/resources. Well worth a look.
http://www.aasianst.org/ Association for Asian Studies. Some grants available.
http://www.weri.org/main.htm World-wide Education Research Institute. Small ($1,000) grant-making organization. Why apply for a small grant? The money can be used for services (sometimes unique); and the more funding sources and the more varied funding sources, the better.
http://www.nsfre.org/ National Society of Fundraising Executives.
http://www.special-event.com/ Links and information on special events. The Foundation Center Cooperating Collections are likely to have more extensive information on special events (at no charge) than this site. Why special events? Special events are excellent ways to raise money and promote an organization. Requires a social person who enjoys calling and talking with people. Take advantage of different attributes of the people involved in your organization.
http://www.nonprofits.org/ Internet Nonprofit Center. More on nonprofit organizations than grants.
http://www.clark.net/pub/pwalker/ Nonprofit Resources catalogue. Huge. Easy to use.
http://www.rwjf.org/ Robert Wood Johnson Foundation - when you're ready for the major leagues.
http://www.pewtrusts.com/ Based in Philadelphia, but funds programs of national interest.
http://www.cof.org/dateline/resources.html Resources for international grants.
http://www.sai.com/adjunct/nafggrant.html The At-a-Glance Guide to Grants. Many resources. Some out-of-date links.
http://www.winona.msus.edu/Grants/private.htm Large data base of links to foundations and corporations.
http://www.philanthropy.com/index.html The Chronicle of Philanthropy - has set the standard for years.
http://www.philanthropy-texas.com/ On-line magazine: Philanthropy in Texas.
http://www.philanthropy-journal.org/ Philanthropy Journal Online.
http://www.go-ahp.org/ The Association for Healthcare Philanthropy (AHP) is a
not-for-profit organization of more than 2,700 hospital and health care fund raisers.
http://www.tdh.texas.gov/funds.htm Texas Department of Health information on funding. From this page go to TDH Funding Information Center @ http://www.tdh.texas.gov/hrs/support/rls/fic/fichmpg.htm
Funding Directory @ http://www.tdh.texas.gov/hrs/support/rls/fic/fichmpg.htm), and related sites.
http://www.nih.gov/grants/ National Institutes of Health "Funding Opportunities" start page. Huge - not the easiest to navigate. NIH Grants Administration is at http://web.fie.com/htdoc/fed/nih/any/any/text/any/nihtga01.htm
http://www.nih.gov/ninr/ National Institute for Nursing Research.
http://www.cdc.gov/nchswww/about/grants/grants1.htm Minority Health statistics Grants Program - research, not service.
http://www.health.gov/statelocal/comp_grants.html Availability of health-related grants at state and local government levels. Use this site.
http://www.os.dhhs.gov/progorg/grantsnet/index.html US Department of Health and Human Services GrantsNet.
http://www.hrsa.dhhs.gov/grants.htm More DHHS grants (primary care, related).
http://www.cdc.gov/od/pgo/funding/funding.htm Centers for Disease control and Prevention grants.
http://www.nhirc.org/ National Health Information Resource Center (NHIRC): NHIRC provides direct assistance in building, enhancing, and using health information systems.
http://www.gsa.gov/fdac/queryfdac.htm Search the Catalog of Federal Domestic Assistance.
http://www.nonprofit.gov/ Nonprofit Gateway page.
Foundation Center Cooperating Collections in Texas
Go to http://fdncenter.org/, On-Line Library, and click on "Cooperating Collections" for listings in other states. An asterisk (*) denotes the presence of private foundation information returns (IRS Forms 990-PF).
Print Sources of Information on Foundation, Corporate, Government, and Other Grant Monies
There is no single all-inclusive source of information. If buying a directory or other fundraising materials, be sure to examine before purchase. There are good and bad deals available. Following are internet and print resources (internet resources include URL because some people will read this on paper and some on the internet).
The Foundation Center Cooperating Collections Network. In all 50 states and in most large cities, the Foundation Center helps libraries through a national network of library reference collections for public use. Most collections will have more materials than can be used. Centers in Texas are listed below. Current foundation, corporate, government, etc. Directories (which cost $50 up) are available; as well as books, periodicals, and announcements. To find the locations nearest you, call toll-free 1-800-424-9836.
The Chronicle of Philanthropy is published bi-weekly and contains all the latest on nonprofit and philanthropic activity, including limited information on some grant deadlines. While valuable to anyone seeking money, it is most relevant to the big-money arena. Two weeks is a long time in the world of grant deadlines.
The Grassroots Fundraising Journal is published bi-monthly and is intended for persons working in small and medium-sized organizations. It is a good choice for anyone new to fundraising. The cost is $32/year and it can be ordered from P.O. Box 11607, Berkeley, CA 94712. Phone 510.704.8714.
The Grantsmanship Center Whole Nonpofit Catalog is published quarterly and is free. This catalog serves as a means of advertising Grantsmanship Center workshops, but also has worthwhile articles. Order from 650 South Spring Street, Suite 507, P. O. Box 507, Los Angeles, CA 90014.
Corporate foundation directories include the Taft Corporate Giving Directory, the Corporate 500 Index, the Corporate Foundation Profiles, the National Directory of Corporate Charity, and the Foundation Center Source Book Profiles. The business sections of public and university libraries usually have good sources of information on corporations. Directories of corporations include: Standard & Poors Corporate Descriptions, Reference Book of Corporate Managements, and Dun & Bradstreet's Million Dollar Directory.
The business sections of most daily newspapers publish at least monthly summaries of the financial status of local corporations. These summaries tell you who may be in a position to invest in a program and who is not.
Foundation directories include: the Foundation Grants Index, the Foundation Directory, the National Data Book, the Source Book Profiles, and many others. State and local foundation directories are available in most areas. Libraries or local nonprofit assistance or volunteer centers are good places to begin the search for these. Because funding is so often focused locally, purchase is often worthwhile.
The Federal Register is published on weekdays (other than holidays) by the federal government. Announcements of federal grants, regulations, proclamations, and much more are contained. The Register can be ordered from the Superintendent of Documents, U. S. Government Printing Office, Washington, D.C. 20402. It can be read free at most public, university, or other large libraries.
The Commerce Business Daily summarizes available grants, contracts, and applications. It is available from the same address as the Register or can also be read free as above.
The Federal Grants and Contracts Weekly provides information on "project opportunities in research, training, and services."
The Catalog of Federal Domestic Assistance or "Big Book" is published annually and contains information on government funding sources. For example, the Catalog cites most agencies that fund HIV prevention, family planning, primary care, etc. Once this information is obtained, it is necessary to contact the individual agencies (CDC, NCI, etc.). Reading is recommended, purchase is not.
State registers are published several times each week by all state governments for about $100/year (prices vary). Using one's own state directory and aggressive contacts with all state agencies that might have an interest in a particular effort will result in some good opportunities.
Religious and Civic organizations
Area denominational offices and large or socially conscious churches and synagogues can be contacted directly.
Women's civic groups such as the (local branches of) Junior League and National Council of Jewish Women are excellent sources of professional volunteers, funding, and program validation. Getting these organizations involved is an unmistakable seal of approval.
Men's civic organizations such as Lions International, Rotary, etc. tend to already be well-committed.
Society organizations require significant political and social acumen and connections to access.
Specific Interest Directories
Directories of foundations, etc. with a history of funding specific areas (women, aging, minorities) broken down by state are available. Careful examination of some of these will show that they are mostly listings of the larger foundations in each state.
Copyright 1998-2000: Lance Rasbridge & Charles Kemp