Taraqi Dehendai Sehat: Addressing Health Disparities in the Afghan Community Presented by: Raymond Grimm, Ph.D. Human Services Department City of Fremont, CA November 15, 2017

A brief Introduction to Afghan Refugees War affected for past 40 years 2.7 million refugees and immigrants traumatically displaced Over 1 million lives lost, many sons, daughters, husbands and wives of residents living in the U.S. 12,000 reside in Fremont and the San Francisco Bay Area

Identified Needs High utilization of emergency rooms “Doctor shopping” and collection of multiple medications High rates of multiple chronic conditions, both health (chronic pain, diabetes, hypertension, arthritis) and mental health (e.g., 75 % of women affected by PTSS, anxiety, depression, insomnia) Due to language and economic barriers, inability to access health, social and other community services resulting in significant health disparities Social isolation, especially among women

Afghan Elderly Association (AEA) – A brief history Early 90’s Najia Hamid, assists in documenting needs of Afghan elders. 1995 Najia Hamid, establishes AEA and becomes AEA Executive Director 1998 AEA receives non-profit status; grows from 8 women to over 500 participants by 2008. 2000 receives funding to launch weekly Healthy Aging Program, includes socialization, exercise, health education and a healthy meal. 2006 with funding from Alameda Area Agency on Aging and Alameda County Public Health, AEA in partnership with COF public health nurse launches the Taraqi Dehendai Sehat (TDS) program.

AEA Early Successes Health Promotion (HP) training developed, 5 Afghans recruited and receive 100 hours of training. HPs provide accesses to social services, promote fall prevention, provide health education, chronic disease and medication assistance. Results were 18% increase in exercise, 25% reduction in falls, 21% decrease in ER usage, 14% increase in Medi-Cal access and 81% of clients obtained health care services.

AEA programs Healthy Aging Program Mission: Implement a culture-based chronic condition self- management and care management program that utilizes peers to promote health, wellness and community access to older refugees and immigrants. Healthy Aging Program Tarqi Dehandai Sehat (TDS) Four components: The Happy, Healthy Me Program: utilizes The Flinders Program© Linkages Medication Assistance Community Health Education AEA’s TDS (Health Promotion) Program has four components The Happy, Healthy Me Program: utilizes The Flinders Program© and Partners –in-Health assessment. Health promoters (HP) and participants collaboratively identify and prioritize health goals used in the development of a personalized wellness plan. Linkages: HPs assist participants to accessing health, social service, housing and other community resources. Medication Assistance: HPs and nursing students provide medication review and education, falls awareness and home safety education. Community Health Education: TDS offers Matter of Balance and Tai Chi for Falls Prevention and the Stanford Chronic Disease Self-Management Program programs in Dari.

Why Flinders? Federal mandate that all federally funded programs must be ‘evidence-based’ Best fit for Afghan community through the use of modified use of My Health Story program Incorporates outcome and and change measures. Use of Motivational Interviewing and Structured Problem-Solving.

Flinders Implementation - Challenges Federal approval of Flinders as an ‘evidence-based’ program. Formalized use of program format (questionnaires, measures, forms) not previously utilized in Afghan community or by health promoters. Need to translate Partners-In-Health scale Health Promoters (HP) not previously trained in either Motivational Interviewing or Structured Problem-Solving. Used to telling clients what needed to be done. Other cultural factors: Religion – life is written before birth; current health is God’s wish Priority on services, not health Assessment is viewed as unnecessary “You are the professional, tell me what I should do” client expectations

Movement 2015-16: 2016-2017: Health Promoters trained in Flinders Translation of PIH and inclusion of Afghan images (approved by Flinders). 2016-2017: Implementation of Results-Based Accountability includes Flinders scales Gaps in HPs use of scales and wellness plans identified Need to integrate HHM program and Linkages program for funding and accountability

Movement 2017: National Council on Aging approves Flinders as an evidenced- based model Development of Chronic Conditions Self-Management Strategies Wheel as summary of PIH scales Clients and HPs found this useful as a tool used for a holistic overview of their health and decision-making tool. Development of HP supplementary manuals Chronic conditions outcomes Measurement Wellness Plan – Revised for Flinders Peer Case Management Outcome Measures

Supplementary Manuals Chronic conditions outcomes measurement wellness plan – Revised for Flinders – 12 Domains 1. Knowledge of Condition(s) 5. Accessing Services 9. Managing Impact of Condition(s) on Personal Care and Physical Activity 2. Knowledge of Medications and Treatment 6. Attending Appointments 10. Managing Impact of Condition(s) on Emotional Well-being 3. Medications and Treatment Management 7. Chronic Condition Self-Management 11. Managing Impact of Condition(s) on Social Aspects of Life 4. Empowered Decision Making (Sharing in Decisions) 8. Symptom Monitoring, Response and Management 12. Living a Healthy Lifestyle

Supplementary Manuals

Supplementary Manuals Peer Case Management Outcome Measures – 19 Domains 1. Activities of Daily Living (ADL)/ Independent Activities of Daily Living (IADL) 8. Sensory Deficits 14. Health Insurance 2. Nutrition 9. Cognitive Status 15. Legal Issues 3. Fall Prevention 10. Psychological Status 16. Abuse/Exploitation 4. Medical/Health 11. Housing 17. Immigration 5. Medication Management 12. Transportation 18. Family/Caregiver 6. Pain Management 13. Finances 19. Socialization 7.Language Barriers

Supplementary Manuals

Sample of 2016-2017 Outcomes 161 immigrant/refugee clients served 84 clients received medication education 45 clients developed wellness goals 132 clients assisted with accessing services 58 clients participated in health education 2016-17 Outcomes 2016-17 Outcomes and Satisfaction

Future Directions Ongoing training for HPs in development of Wellness Plans, MI, problem-solving, self-management of chronic conditions Utilization of electronic data base Refinement of supplementary manuals Improve outcomes Expansion of program to other ethnic communities (next up is our Mandarin- speaking community).

Questions Contact Information Raymond Grimm, Ph.D. Senior Project Coordinator Aging and Family Services Division, Human Services Department City of Fremont, CA, USA (510) 574-2063/rgrimm@fremont.gov