NURS FPX 6618 Assessment 2 Mobilizing Care For An Immigrant Population

Name

Capella university

NURS-FPX 6618 Leadership in Care Coordination

Prof. Name

Date

Mobilizing Care for an Immigrant Population

The development of a Care Coordination (CC) program tailored to serve undocumented Hispanic immigrants is a deeply personal and professional endeavor for me as the Director of CC at St. Mary’s Hospital (SMH). This initiative is designed to dismantle the numerous barriers that hinder this population’s ability to access healthcare, including linguistic challenges, financial instability, and pervasive fears of deportation. By prioritizing culturally responsive care practices and trust-building within the community, the program aims to create a supportive environment that promotes equitable healthcare delivery and improves outcomes for individuals who often exist in the margins of our healthcare system.

Central to the success of this program is a strong emphasis on culturally competent communication and service accessibility. Many undocumented immigrants forgo preventive services or delay treatment due to systemic and societal fears. To combat this, our strategy involves integrating bilingual professionals and culturally aligned health education. These efforts not only help to navigate language and trust barriers but also establish long-term engagement with healthcare services, ultimately reducing hospital readmissions and costly emergency interventions.

In addition, the CC program recognizes that empowering individuals with information and assistance is critical. By connecting patients with social resources, financial aid, and legal support, we aim to relieve some of the pressures that discourage them from seeking care. These coordinated efforts are more than just logistical solutions—they represent a commitment to equity and justice in healthcare.

Rationale for Focusing on the Healthcare Needs of a Particular Immigrant Group

The Hispanic population represents a substantial demographic in the United States, with 57.8 million individuals as of 2016, making up nearly one-fifth of the total population (Perreira et al., 2020). Among this population, undocumented Hispanic immigrants face a unique combination of healthcare barriers that place them at heightened risk. These include fear-based avoidance of medical facilities, limited English proficiency, and prohibitive healthcare costs due to lack of insurance coverage. Addressing their healthcare needs is not just a clinical priority but a social and ethical imperative.

Undocumented Hispanic immigrants are disproportionately affected by chronic illnesses such as Diabetes Mellitus (DM), Hypertension (HTN), and mental health challenges, particularly those stemming from immigration-related stress and trauma (Wright et al., 2024). Many avoid routine check-ups and necessary treatments due to fear of being reported to immigration authorities. This results in late-stage diagnoses and emergency-based interventions that are both financially and medically inefficient. SMH recognizes the urgency of redirecting this trend by providing targeted interventions.

Focusing our efforts on this specific immigrant population allows for a more refined and impactful deployment of resources. By tailoring healthcare delivery models to the cultural, linguistic, and socio-economic realities of this group, we can ensure higher engagement and better health outcomes. This community-centered approach helps fulfill SMH’s mission of inclusive, community-responsive healthcare.

Evaluating Healthcare Needs

A robust and structured methodology is essential to accurately assess and address the healthcare needs of undocumented Hispanic immigrants. The Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) framework has been adopted to guide strategic improvements in care delivery at SMH.

Define

At this stage, the focus is on identifying key challenges such as limited access due to immigration status, fear of deportation, language barriers, and economic constraints (Ornelas et al., 2020). These challenges not only delay care but also compromise chronic disease management (CDM) and mental health support. The goal is to address these barriers while fostering community trust.

Measure

Effective interventions must be based on data. Through patient surveys, EHR analysis, and collaboration with local outreach partners, SMH will gather demographic insights and healthcare utilization data. These findings will help quantify the prevalence of chronic illnesses like DM and HTN within the population and highlight trends in service underutilization (Funk & Lopez, 2022).

Analyze

This phase involves identifying the root causes of disparities using tools like Fishbone Diagrams and Pareto Analysis. Key issues typically include a 34% uninsured rate, economic hardship, and systemic language barriers (Kronenfeld et al., 2021). Identifying these factors is critical for designing interventions that can effectively dismantle access barriers.

Improve

Interventions will be implemented to address identified gaps. These include employing bilingual staff, offering medical interpretation, and introducing sliding-fee scales for low-income patients. In addition, collaboration with non-profits will support patient education and advocacy efforts (White et al., 2020). These actions aim to enhance both access and trust.

Control

Sustainability is ensured through continuous monitoring via EHR data, patient feedback, and health outcome tracking. Staff will undergo periodic cultural competency training, and funding streams such as public health grants will be leveraged to maintain program effectiveness (Tsai et al., 2020).

Table 1: Evaluation Framework for Mobilizing Care

Phase	Description	Actions and Strategies
Define	Identify specific barriers to healthcare for undocumented immigrants	Focus on fear of deportation, lack of insurance, and language differences
Measure	Collect relevant healthcare usage and demographic data	Use surveys, focus groups, and EHR analytics
Analyze	Determine root causes of health disparities	Apply Pareto Analysis and Fishbone Diagrams to examine socioeconomic and systemic issues
Improve	Implement targeted healthcare strategies	Provide bilingual services, financial assistance, and community outreach
Control	Ensure sustainable program delivery	Track patient outcomes and provide continuous staff training and quality checks

References

Brown, H. L. (2020). Emergency care EMTALA alterations during the COVID-19 pandemic in the USA. Journal of Emergency Nursing, 47(2). https://doi.org/10.1016/j.jen.2020.11.009

CDC. (2024). National health initiatives, strategies & action plans. Public Health Professionals Gateway. https://www.cdc.gov/public-health-gateway/php/communications-resources/national-health-initiatives-strategies-action-plans.html

NURS FPX 6618 Assessment 2 Mobilizing Care For An Immigrant Population

Doctors Without Borders. (2024). Doctors Without Borders – USA. https://www.doctorswithoutborders.org/

Funk, C., & Lopez, M. H. (2022, June 14). Hispanic Americans’ experiences with health care. Pew Research Center Science & Society. https://www.pewresearch.org/science/2022/06/14/hispanic-americans-experiences-with-health-care/

Hispanic Services Council. (n.d.). Hispanic Services Council. https://www.hispanicservicescouncil.org/

Kronenfeld, J. P., Graves, K. D., Penedo, F. J., & Yanez, B. (2021). Overcoming disparities in cancer: A need for meaningful reform for Hispanic and Latino cancer survivors. The Oncologist, 26(6), 443–452. https://doi.org/10.1002/onco.13729

Ornelas, I. J., Yamanis, T. J., & Ruiz, R. A. (2020). The health of undocumented Latino immigrants: What we know and future directions. Annual Review of Public Health, 41(1), 289–308. https://doi.org/10.1146/annurev-publhealth-040119-094211

Perreira, K. M., Los Angeles Abreu, M., Zhao, B., Youngblood, M. E., Alvarado, C., Cobo, N., … & Giachello, A. L. (2020). A population perspective on health care for immigrant communities. American Journal of Public Health, 110(3), 301–308. https://doi.org/10.2105/AJPH.2019.305491

Tsai, J., Sangalang, C. C., & Gee, G. C. (2020). Discrimination and well-being among undocumented Mexican immigrants: Examining the role of economic, social, and psychological resources. Cultural Diversity and Ethnic Minority Psychology, 26(1), 60–71. https://doi.org/10.1037/cdp0000280

White, K., Yeager, V. A., Menachemi, N., & Scarinci, I. C. (2020). Impact of language barriers on access to healthcare services for Latino immigrants in the U.S. Southeast. Journal of Immigrant and Minority Health, 22(5), 846–854. https://doi.org/10.1007/s10903-019-00942-0

NURS FPX 6618 Assessment 2 Mobilizing Care For An Immigrant Population

Wright, R., Menjívar, C., & Chavez, L. R. (2024). Legal violence and health: Impacts on immigrant Latinos in the United States. Annual Review of Public Health, 45, 89–105. https://doi.org/10.1146/annurev-publhealth-112623-032000