Monday, May 18, 2015

Community Health Workers and Home Visits in Navajo Nation

“Next to the mountain. Literally right at the foot of the last mountain to your left.” That’s where she lived. Ms. G was a 60yo lady with diabetes, HIV, and a big heart. While here in Navajo Nation, I’ve had the opportunity to see amazing medicine in the clinic but also outside the clinic. In fact, when you think about it, most of what affects health doesn’t happen within the fours walls of a hospital or doctor’s office, but in a person’s home, among their family. As such, home visits can be a powerful lens for understanding how people live and how their environments contribute to their health in both positive and negative ways.

Yesterday, I was fortunate to travel with HIV community health workers to visit the homes of patients with HIV and make sure that they were being cared for and had their medications. For patient with HIV, adherence to anti-retroviral medications of 95% or greater is essential to rendering the HIV viral load undetectable. For many diseases, adherence of >70% is a victory, but for HIV high adherence means life or death. As such, ancillary support from social work, nursing, and family can be essential. 

After traveling for 1.5 hrs and missing her home multiple times (there are many mountains on the reservation), we arrived at Ms. G’s humble abode - a 2 bedroom converted trailer home. Ms. G profusely apologized for missing her appointment and not answering the phone, but because of the rain and the unpaved roads on the reservation, she was afraid she would get stuck in the wet clay and so was unable to get to her appointment. Regarding the phone, she did not have a landline, and her daughter needed her only cell phone.

In speaking with the CHW, I found that this scenario was not uncommon. ~80% of the roads and driveways on the reservation are unpaved, and only 60% have access to landlines with fewer having access to internet and cell reception. More disturbingly, 9% of households do not have access to clean drinking water and sanitation.

The infrastructure that I take for granted in Boston is feeble at best on the reservation, further exacerbating the poverty and poor health that plague this community. Sadly, the Navajo Nation suffers from unemployment reaching over 50% by some estimates with yearly income 1/3 of the general US and rates of intimate partner violence as high as 39%. In this setting, health and healthcare often take a back seat to food, nutrition, housing, and other goods.

Ms. G was ever the gracious host, offering my companions and I a drink and making us feel welcome in her home. On the kitchen table, I was impressed to see a strict food diary with blood glucose levels and a medication dispenser organized by her daughter. Of course, this victory was hard won and over the past 2 years, Ms. G had been hospitalized for complications related to diabetes and come close to death many times. The CHW was able to re-schedule her appointment using a cellphone, schedule labs that had been missed due to the rain, and provide her with a more organized medication dispenser.

As a medical doctor, I am trained to interpret numbers, look for signs and symptoms, examine the body, and come up with a diagnostic and treatment plan. All too often, the most important elements of a patient’s daily life (i.e. rain, poor infrastructure, no cell phone, domestic violence, economics hardships) are left out of the plan to the detriment of the patient and society’s health. In these cases, we physicians re-double our efforts to treat patients in the ways we know how, but never are we trained to think about the big picture, to think about how access to clean water or to telephones can make an outsized impact on health. It is here that the CHW and the home visit really shine and add impact to a medical team. 

In my next post, I’ll talk more in depth about innovative care delivery models in Navajo Nation.

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