Rosemary Cano grew up speaking Spanish and English as her family moved back and forth between Seattle and Lima, Peru. Five years ago, Cano became one of eight “cultural mediators” in Harborview Medical Center’s Community House Calls program; the mediators offer interpretation, case management, and other services to help immigrant and refugee populations navigate the health care system. As part of her job, Cano educates Spanish-speaking patients who have poorly controlled diabetes about their disease and helps them overcome social and logistical obstacles to better health.
Transforming Care: Tell us about the patients you work with and the challenges they face.
Cano: A lot of our Spanish-speaking patients are dealing with day-to-day survival and therefore don’t prioritize chronic disease management until they find themselves in the hospital trying to avoid big consequences like amputation, blindness, or renal failure. Until that point, many think, “Why should I care about this long-term issue when I am more worried about being deported or finding a bed in the shelter or paying my rent and getting a job as a day laborer?”
Transforming Care: With these competing demands, how do you persuade them to take their health more seriously?
Cano: I tell people diabetes is not a life sentence — it is your companion on the highway of health and you need to drive it the way you drive a car, so it doesn’t drive you. I stress that ours is a prevention program where we catch people before they have serious complications. Prevention is a bit of a foreign concept for many. In the countries some of our patients come from, you only go to the doctor when you are really sick.
Transforming Care: What are some of the challenges the Hispanic patients you work with face in managing diabetes?
Cano: One of the most basic is transportation to medical appointments. It’s not just the distance and whether they have to find a babysitter, but also the price of the bus fare or gas. Because of the immigration raids, and the perceived anti-immigrant and anti-Latino atmosphere, I have had several patients tell me they prefer not to go outside. And then there is life stress. One of my patients has a four-year-old daughter who is autistic and needs to go to a lot of medical appointments. She and her husband also have deportation orders and frequent appointments with their lawyer. When she found out she had diabetes, she said I don’t have time for it.
Transforming Care: How might you help someone like her?
Cano: I showed her how to take the light rail, which cut down an hour on her transportation time. I also pointed out that walking to the station will help her manage her diabetes. I have gone with people to the Northwest Immigrants Rights Project to serve as an interpreter, to the food bank, and to the library to help people get their library card so they can have internet access.
Transforming Care: Do those sorts of services help?
Cano: Obviously we can’t do everything that patients need. But I think when they feel trust — and know we don’t share their information with immigration — it helps. We also stress here at Harborview we won’t judge you for not being able to read or write. About 25 percent of my patients are illiterate. Some know a few numbers so they can keep track of phone numbers.
Transforming Care: How do you work around that?
Cano: In my first year, it was by trial and error. I used a lot of pictures for medication instructions: a sun in the morning next to plate of food, that kind of thing. I had one patient from Mexico who was deaf and illiterate. Her parents never sent her to school. We did a lot of drawing. I put a frownie face next to a blood sugar reading of 150 or more and a smiley face for a reading below 150. Also we have 150 to 200 different rubber food models that I take to people’s homes to illustrate different food groups and practice portion sizes.
Transforming Care: What sort of results have you seen?
Cano: We found about a quarter of Harborview’s Spanish-speaking patients with type 2 diabetes have a hemoglobin A1c level greater than 9. When we looked at one cohort of 53 patients who received services from the cultural mediator program, we saw the mean level drop from 9.82 to 9.1 at three months, and then down to 8.86 at six months. At 24 months, the number was 8.99.
Transforming Care: What might it take to improve further?
Cano: It truly does take an interdisciplinary approach — going from the nutritionist to the pharmacist to the social worker to the doctor and the financial counselor may be a winding path, and I can help build some bridges with language and cultural understanding. Paying close attention to the mental health piece including “diapression” and “diabetic distress” can also help providers in their efforts to encourage patients to prioritize their own well being. Educating the care team about the role of a cultural mediator beyond “just an interpreter” is also key.
Transforming Care: How often and how do you communicate with providers? Do you see the information you share changing the course of care?
Cano: On one occasion, I received a message from a provider that one of my patients was about to be discharged from the hospital back to the street. I knew this would be disastrous, having worked with this patient for over a year as he moved in and out of homeless shelters. He was always good-natured and never complained about his circumstances. But due to his memory issues and physical vulnerability he was constantly losing his belongings and was a target for thieves. He would disappear for weeks and develop extremely high blood sugar, which would inevitably send him back to the emergency department. I immediately messaged the entire team to advocate for the patient to stay in a transitional care unit. He was not released back to the street and his care plan has now changed for him to move to a long-term care facility.
Transforming Care: What advice would you give providers working with immigrant and refugee populations?
Cano: I would say try to be cognizant of how hard it is for many of these patients to navigate the health care system, especially those with literacy challenges and limited financial resources. If they get handed a prescription or a referral, will they know where to go? Some may need help coordinating appointments, which can be difficult with the language barrier. Lastly I’d say try to ask patients how far they went in school. It could be the handouts are just wads of paper to them.