In addition to the quantitative and descriptive data housed in the Initiative Logic Map, a series of cross cutting themes were identified related to individual participants, partnerships with educational institutions and employers as well as system-level challenges and associated policy strategies. Understanding these themes and their relationships informed the Initiative’s continuous quality improvement processes and shaped recommendations for building replicable Welcome Back models elsewhere in the future.
English
Language Proficiency
Participants, educators, and employers alike identified lack of fluency
in English as a fundamental obstacle for ITHPs. While the general consensus
is that fluency in English is an important predictor of academic success
in health professions, it is also acknowledged that certain professions,
like health care interpreters, require a much higher degree of fluency than
others, such as phlebotomists. It is also not the only predictor of success.
Even some programs that historically required college-level English, like
the Licensed Vocational Nursing refresher course at City College of SF reported
that frequently, students scoring low on English placement exams did as
well in class and on the licensure exam as students with higher placement
scores.
Participants understood the need to improve their language skills but expressed
great frustration with the length and focus of existing “English as
a Second Language” (ESL) programs, which typically run from 3 to 5
years and are primarily focused on reading and writing but not on speaking.
Sixty-one percent (61%) of the respondents to the WB survey indicated that
their level of English has improved since their involvement with WB. In
addition to referral to ESL classes, the encouragement and the opportunity
to use and to be exposed to the English
language in the context of classes, study groups, presentations, workshops
and other activities with peers and Educational Case Managers (ECM’s)
appears to have had a positive impact on the participants. Currently, through
funding from the California Wellness Foundation and Kaiser Permanente, a
specialized English as a Second Language course is being developed for internationally
trained health professionals by
the San Francisco WB.
Loss of Professional Identity
Among the most challenging aspects of WB’s work with immigrant health
professionals was dealing with the emotional sequela of migration, including
losses of country, family, professional identity, networks, and social standing
along with the underlying reasons for migrating. The selection of a career
direction was often done in late adolescence and became part of the individual’s
identity in adulthood. Outside of their families, it is
through work that many individuals developed social networks and social
standing. Immigrant health professionals often faced the loss of professional
identity and associated social standing and the challenge of redefining
themselves in a new societal context. Participants needed time to adjust
to loss of professional identity; this was especially true with physicians,
representing the largest group of participants.
The loss of professional identity was compounded by the complexity of the
licensure processes. Without appropriate guidance, the participants easily
could become lost in a labyrinth and miss details or deadlines resulting
in lost opportunities for validating their licenses. In addition, lack of
familiarity with the US health system’s structure, the roles and professions
that exist in the US, and the US health workplace culture, could prevent
them from taking advantage of potential opportunities. The role of the ECM
is essential
in helping navigate the licensing process and in identifying new and fulfilling
roles in the health sector.
Developing a realistic professional strategy for WB participants took time,
a comprehensive assessment, and support. For example, at the San Francisco
site, an average of 5 encounters with ECMs per participant were generated,
and staff reported that this was the typical face-to-face time necessary
to begin a physician’s journey towards either pursuing medical licensure
in the US or consideration of alternative career
paths. Fifty-four percent (54%) of survey respondents stated that WB had
assisted them in improving their self esteem; 98% said it was important
or very important to have an opportunity to interact with other ITHPs; and
66% of respondents noted that WB has helped them explore new career options.
Economic
issues
Lack of financial resources and time to attend classes were consistently
identified as barriers to participation. Individuals often did not have
the time to go to school because they held two or three jobs in order to
support their families. Therefore, efforts to find the time to go to school
frequently implied a significant reduction in income. Structuring the hours
of operation of Welcome Back Centers with this issue in mind has enabled
the
participants to take full advantage of the program’s services. An important
role of the ECMs was to assist participants in finding potential sources
of financial support, e.g., scholarships, and loan forgiveness programs.
In some cases, assistance in finding affordable childcare or housing was
identified as a key element for participants to succeed.
With these elements of support in place, the outcomes the participants accomplished
are impressive. Data from a sample of program participants at the Los Angeles
site shows that, on average, participants’ income has doubled upon
completion of the plan they developed with their ECM. Also WB participant
survey data shows that 35% of the respondents had slight or significant
increase in income since they enrolled in WB.
Commitment to the Safety Net
The intent of the WB program was to strengthen the safety net by contributing
to the creation of a health workforce that better reflects the demographics
of California and is willing to serve medically underserved communities.
The program’s initial plan was to require that, upon completion of
WB, individuals who had received services would volunteer to work 200 hours
in medically underserved areas (when possible, with their
communities of origin) in symbolic “payment” for the services
received. Shortly after the program began its services, it became apparent
that this plan would be difficult to carry out. Time is a prime commodity
for the participants who often juggle more than one job and family responsibilities
even before they attempt to go to school. In this light, 200 hours of volunteer
service represent a cost that participants cannot afford to pay.
Nonetheless, the ECMs continued to encourage and assist participants in
obtaining volunteer placements, as these often resulted in valuable hands-on
experience and letters of reference for future jobs. In addition, the program’s
activities and classes consistently highlight the issues of disparities
in health, barriers to access to health services, and the role of the safety
net. However, when a participant states that he/she is unable to commit
to a volunteer job, the issue is not pursued further.
While participants are highly motivated to work with their communities of
origin, the realities of the marketplace prevail when job opportunities
arise: the private sector can and does offer better salaries than the safety
net. When presented with the option of a job
with a significantly higher salary and sign-in bonuses, participants are
highly likely to take it. The broader contextual issues related to the financial
viability and structural security of the safety net influence WB’s
ability to provide a pipeline of health workers to safety net providers.
The commitment remains to increase the pool of workers available and to
find innovative, realistic strategies to contribute to the medically underserved
communities of California.
The program’s expectation is that as it contributes to increase the
pool of culturally and linguistically diverse health workers, both the safety
net and the private sector will be
able to find qualified staff to deliver services.
Flexible Career Pathways
The program’s approach to developing a career strategy with the participants
started by understanding where the participant was in the spectrum of options
available to him/her. This flexible pathways approach, is a non-linear,
non-“one-size-fits-all” service model featuring a menu of options
and client flow pathways. Participants had different needs at different
points in time and to be successful, the program was required to be flexible.
Typically, early steps in this process included setting both short-term
and long-term goals. For example, if a person’s long-term goal was
to obtain a nursing license, she might begin by enrolling in a phlebotomy
course. Upon completion of the course, she could obtain a job in the health
sector and thus improve his/her familiarity with the US health workplace.
At the same time, she could be enrolled in a customized English as a
Second Language program and have started the process for obtaining her transcripts
from her country of origin. On a monthly basis, she would meet with the
ECM to check in on the status of the entire process, obtain information
about upcoming events, for example an interviewing skills workshop.
Movement in a positive direction in the spectrum of goals and outcomes was
always a function of time. In the best-case scenario, a participant could
take a minimum of one semester to obtain a basic phlebotomy or CNA certificate.
But as the goals became more ambitious, the amount of time required increased
substantially: it usually took several
months to obtain transcripts from other countries; six to 10 months to have
transcripts reviewed by the Nursing Board; one to two years to complete
the prerequisites to a Physician’s Assistant or Dental Hygienist program;
up to four years to complete a residency training program. And all these
scenarios assumed that the participant had the required level of competency
in English to enroll in these programs.
In order to expedite part of these processes, the WB Initiative Director
worked with educational and licensing entities as well as with professional
associations to explore the feasibility of creating accelerated programs
that met all the licensing criteria and at the same time builds on the participants’
previous professional experience. As an example, the Board of Registered
Nursing (BRN) broke ground in California by agreeing to pilot an accelerated
Associate Degree in Nursing (ADN) program, developed for international
medical graduates (IMGs). In fourteen months, the program will graduate
35 IMG participants from the San Diego WB center. While most nursing curricula
are based on a two-year format, the new accelerated ADN curriculum gained
the BRN’s approval because it builds upon the medical training and
experience of these internationally training health professionals.
In addition, several hundred participants have completed license preparation
courses, thousands have received assistance in validating their foreign
credentials, and hundreds more have attended the classes developed by WB.
For a complete description of all the individual participant outcomes see
the Initiative Logic Map under the puzzle piece and pathways arrow.
Our experience demonstrates that to significantly contribute to the diversification
of the health workforce, intense, up front and flexible investment needs
to be made. In the long term, this investment can yield important and long
lasting results creating a stable workforce from and dedicated to California’s
diverse ethnic communities.
Dedicated Staff
WB had extremely dedicated staff at every center, at every level. Many of
these individuals were immigrants themselves and/or had worked with immigrant
communities for decades. This core was always willing to go the extra mile
to assist participants and advocate for the supports they needed. Leadership
at every site included immigrant internationally trained health professionals.
The staff’s linguistic and cultural competency
directly enhanced the centers’ ability to serve a diverse population;
it also probably impacted the racial and linguistic mix of participants
enrolled in the program.
The fact that the Initiative Director was a Mexican, immigrant physician
gave a "real" public face to the WB program, particularly for
the media and within the policy arena. After the initial press conference
announcing the Initiative, Latino media –television, radio, and print-
picked up and followed up on the story well into the
program’s third year. The Initiative Director’s professional networks
and his ability to navigate the system and establish bridges between diverse
constituencies, e.g., key stakeholders, program staff, and WB participants,
was an important added value for programmatic success.
Regional Center Variation
Each center evolved somewhat differently because of geographical location,
vision of the local leadership, size of the service area, preexisting relationships
with local employers and educational institutions, and staffing needs of
the regional health sector. Clearly, well-established relationships through
the Regional Health Occupations Resource Centers networks helped identify
employer partners, particularly in San Diego and Los Angeles. The three
centers began within the existing structure of the RHORCs, which had proven
track records of success in health workforce development. The RHORCs also
had well-established networks that included community colleges and employers.
This was not the case for the Fresno center, where new partnerships were
difficult to establish. The directors of the RHORCs were essential insiders
that knew both the mechanics of the educational institutions and the employer
landscape and early on facilitated important
working relationships.
In San Diego local employers were incorporated early on the center’s
advisory committee helping to structure policies and provide in-kind assistance.
The sheer large size of the participant pool (even with little outreach)
in Los Angeles necessitated a modification in the client flow algorithm
to accommodate group orientations. The preexisting strong relationships
between San Francisco staff and safety net providers gave this center a
distinctive character including the incorporation of safety net providers
on their advisory committee.
The strong existent relationship between City College of San Francisco Community
College and San Francisco State University and institutionalized through
Community Health Works, helped pave the way for smooth inter-institutional
relationships. Finally, the nursing shortage throughout California provided
opportunities for all WB centers to find employment for participants. Additional
information about each center
demonstrating these regional variations can be found on each center’s
website or by examining client level data through the Initiative Logic Map.
Educational Partnerships
The experience of Welcome Back with academic institutions is limited to
three of California’s Community colleges and one California State University
(CSU). We have found that a key element in the success of the program has
been a strong commitment from the host educational institutions. Chancellors,
presidents, deans and department chairs each held a key to a particular
piece of the puzzle that needed to work collaboratively. As an example,
the development of a nursing licensing exam preparation course at the Los
Angeles center required the buy-in of the nursing faculty, the chair of
the nursing department and the dean of Economic Development of the host
college. As “insiders”, these individuals were essential in finding
ways to facilitate processes within institutions that were difficult to
understand from the outside.
The affordable costs of education and ease of access, make community colleges
an ideal setting for the WB centers. Over 70% of program participants in
the San Francisco WB have been enrolled at some point as students in a community
college, primarily in English as a Second Language Courses. The educational
case management services and other activities provided by the WB centers,
complement the needs of this particular immigrant population for language
acquisition and educational and vocational
counseling.
For participants the availability of program components outside a conventional
9 – 5 time frame was essential; mechanisms to support night and weekend
classes and activities was necessary. While the college administrators were
in favor of evening and weekend hours, union contracts and labor agreements
made these configurations difficult in some cases. Besides their educational
mission, an appealing incentive for colleges and universities to implement
the WB program in California was the increase in revenue associated with
a
larger number of students in classes. However, this incentive disappeared
when programs were impacted, i.e. when there were more applicants than the
program was able to accommodate, which was the case at Fresno City College.
Also, it was important that the partnerships included a four-year educational
institution able to provide additional career pathways. Most WB participants
had an educational equivalent to a Bachelor’s degree, hence the importance
of having the option of accessing master’s level programs, e.g. MPH
program. In addition, the Leadership in Health Series and the Introduction
to the US Health Care System courses were developed by SFSU faculty. By
offering some courses at the 4-year college, participants were exposed to
another educational environment that might be a better fit for some program
participants.
A central strength of the program was access to faculty that could structure
and spearhead
a sophisticated evaluation strategy.
Institutionalizing courses and trainings within the partner institutions
was an essential part of the sustainability strategy. The Introduction to
the US Health System, the USMLE prep course, and the English for Health
Professionals have been institutionalized in San Diego and in San Francisco.
In some instances, college districts were connected to the county’s
civil service program thus hiring processes were inordinately long or cumbersome
for a time-sensitive, grantfunded program.
It became clear during the first year of implementation that a key educational
partner was not at the table, medical schools. The Initiative director,
as part of his policy work, began making contacts with medical schools in
Northern California, as did the Los Angeles Center Director in the Los Angeles
area. These contacts are ongoing and efforts to continue this program need
to involve these key partners.
Employer Participation
As key stakeholders, employers were involved with the three sites in different
levels of support/engagement. They participated in advisory boards, provided
in-kind support (e.g. space), financial support (e.g. covering the cost
of courses), and became policy partners.
Partnering with the public health sector employers enabled the Initiative
to stay true to its mission of developing a workforce to serve the underserved
communities of California. A survey conducted by students in the MPH program
at SFSU documented the need for linguistically competent health professionals
in San Francisco as well as clinic and hospital administrators’ attitudes
and opinions of foreign-trained health professionals. Among other findings,
respondents stated that there is not a large enough pool of
bilingual/bicultural applicants for chronically open positions. Moreover,
administrators stated that retaining bilingual/bicultural clinical staff
is a challenge because they often get recruited elsewhere for better pay.
Many clinics also have difficulty hiring ancillary staff to provide supplemental
support to primary medical care. Also, a concern of administrators was that
ITHPs might not have the necessary English language skills to
communicate effectively with all patients and other staff.
Partnering with the private health sector was an important element of sustainability
for the program. Because of their stronger economic situation, the private
sector has been willing and able to provide financial support to the Centers,
directly and indirectly. Thanks to this support, curricula was developed
and implemented (e.g. Nursing Licensing Preparation Course at Los Angeles
WB, English Health Train at San Francisco WB),
office space for the program was secured (e.g. San Diego WB). In addition,
the enthusiastic support from the private sector lends the Initiative an
important degree of credibility vis à vis other employers, potential
funders, and policy makers.
Policy Environment
WB’s work in the policy arena focused on opening doors and fostering
constructive dialogue with and among the key stakeholders: WB participants,
employers, educators, licensing boards, professional associations, community
advocates, and policy makers. In its planning phase, the Initiative developed
a much better understanding of the interconnected roles of these players
and was able to establish itself as a new partner. By presenting the data
collected in the past three years at numerous meetings, hearings, and conferences,
the program has had ample opportunity to establish the need for and the
value of the WB program and the ITHPs that reside in California.
The Initiative greatly benefited from the professional experience and networks
of its staff. For example, these were essential in the early stages of developing
a collaboration with the Board of Registered Nursing, which lead to the
full support of the Department of Consumer Affairs and on to healthy working
relationships with other licensing boards. The centers’ Advisory Committees
also assisted in establishing relationships with other
entities such as the California Primary Care Association, the California
State Rural Health Association, the Latino Coalition for a Healthy California,
the San Diego Medical Society, as well as with State senators and assemblypersons.
Today, most of the health workforce development discussions in the State
include the ITHPs as a valuable resource to be included in program planning.
This is in large part created by the visibility of the WB program. After
three years in operation, the WB Initiative has developed a meaningful presence
in Sacramento as well as in some areas across the country with significant
concentrations of immigrants. Recent changes in State leadership will require
that the Initiative re-examines and reestablishes relationships with the
new players that might not be as familiar with the work WB has conducted
with ITHPs over the past three years.