Case Study 1: Providing Culturally Appropriate Services in a Changing Community Our Covenant Health Center is a 17-year old nonprofit clinic in an indigent, multi-ethnic neighborhood of a once-prosperous urban community. Our Covenant was founded as a free pediatric clinic by a consortium of churches after a sharp economic downturn left many area residents without jobs or health insurance. Through the leadership of a retired public health administrator and the volunteer efforts of other church members, the clinic grew steadily. After only a few years Our Covenant had expanded to provide a wide range of medical and social services for which patients paid on a sliding scale based on household income. By its 6th anniversary, Our Covenant had received funding from several private foundations and had hired a full-time administrator and several full- and part-time clinical staff. Our Covenant celebrated its 10th anniversary by moving into a renovated discount store building, which was donated by its owners to avoid a tax foreclosure. The mission of Our Covenant Health Center is to provide community-based primary care for area residents, and the neighborhood has long viewed the clinic and its staff as important community assets. The 10-person board of directors includes 3 long-time community residents, and the community advisory board meets monthly to review operations and take part in planning. Both boards and the administration consider community capacity building to be one of Our Covenant's basic responsibilities. Two lay health workers were recruited from among neighborhood residents, and the veteran social worker/educator lives nearby. All three participate actively in the life of the community, visiting patients in their homes and conducting education and referral sessions. Changing demographics have complicated Our Covenant's community-based efforts over the past few years. When the clinic was founded, the surrounding neighborhood and the clinic's patient population were a roughly equal mix of African-American and white Anglo families; today it is about 95% African American. About 6 years ago, an influx of Mexican and Central American immigrants to the city brought new populations to the clinic. Soon the clinic needed Spanish interpreters to care for the many patients with limited English proficiency (LEP) coming from across the city. The administrator obtained private funding for 2 half-time bilingual clerks, but the availability of language assistance drew more LEP patients to the clinic, and their need for language assistance soon overwhelmed the bilingual staff members' abilities. To date the clinic has not had the money to hire additional interpreters or bilingual staff, and has relied instead on uncertified volunteers to translate. After a month in which almost 60% of the patients spoke little or no English, the administrator concludes that the staff must be reconfigured to meet the clinic's current and projected need for bilingual services. She proposes that the social worker and one lay health workers each be made halftime, and that the clinic use the resulting salaries to hire a part-time bilingual social worker and a parttime Spanish-English interpreter. The board grudgingly agrees but the community advisory board objects. They insist that the social worker, an original member of Our Covenant's staff and neighborhood resident, should not be penalized for not speaking Spanish. The community advisory board points out clinic statistics that show that the majority of LEP patients come from outside the clinic's target population and that a growing number come from out of state. They propose that all patients from outside clinic's designated service area should be referred to other facilities.

Read your classmates' posts and respond to at least two, indicating whether you agree or disagree with their positions, and explaining why you agree or disagree. Keep your responses logical and mission-focused.

Peer one below.

Hi everyone! Ok, so it took me reading this case study a few times to finally come up with a possible ethical response to Our Covenant's growing problem. I believe their response needs to reflect back on their original mission statement which is, "to provide community-based primary care for the area residents." (Jennings. 2003) According to their clinical statistics that show, "that the majority of LEP patients come from outside the clinic's target population and that a growing number come from out of state," (Jennings. 2003) I feel they have no choice but to try to refer them to other facilities. Now, if they feel they need to try to take on the growing number of Spanish speaking patients from out of the area, then their mission statement needs to change to reflect their new "mission." If they choose to refer the new patients out to other facilities however, they may lose a good deal of revenue being that they stated that this population makes up for 60% of their clientele.

If they choose to change their mission statement to incorporate the Spanish speaking community from out of town, then another option other than cutting two employees down to part time in order to hire two Spanish speaking employees, is to look into telephone interpreters. This essentially provides them a three-way conversation between a staff member, the patient, and an over the phone interpreter. Depending on the company they go with, some you can pay a yearly or monthly fee for their services, and some you pay by the minute. This may be more cost effective and more ethical then cutting down the hours of two long time employees. I have used this type of phone interpreter in the ER many of times, as well as a FaceTime interpreter, and it's been an amazing tool when a Spanish speaking employee isn't around. Also, I believe there is even an app on your phone you can use to easily interpret language. Sometimes I wish I took Spanish in school instead of French! Would have served me better J

Peer two below.

The free pediatric clinic, Our Covenant Health Center, has an obligation to support a changing demographic as well as support the existing staff while also keeping in mind the original mission.

As an established public health service, it is their responsibility to continue to meet the ever growing and evolving needs of the patients with limited English proficiency (LEP) within the neighborhood. It is also important that the existing social worker and lay health worker keep the full time positions that they currently possess, as they are also members of the community and active in the lives of those they serve. A connection has been established and key to maintain. By reducing the two positions to part time, the burden might possibly just be shifted another direction.

While the administrator concluded that with the increase in LEP patients a reconfiguring of staff would be necessary to include more bilingual employees to meet the current need, I feel that a more thorough needs assessment is required to present the board of directors and community advisory board with other options. For example, investigating the cost of certifying volunteers and the cost of using a translation telephone service. Even though these two options will incur a cost, they might be a more affordable solution. I would also look into grant funding for these as well.

The case study also stated that the majority of LEP patients came from outside of the clinic's target population and from out of the state. Collaborating with other agencies in the areas beyond their community, is another option to providing the necessary needs of the patients while continuing the original mission of providing primary care to the community and being a vital asset to the local neighborhood and the existing staff.