Individual Care to Population Health: Working with Refugees

Bengt Arnetz, Professor and Chair, Department of Family Medicine

It is widely acknowledged that health care is experiencing a major transformation that includes economic, cultural, political, and societal quandaries. As issues in modern medicine have evolved, stakeholders are increasingly invested and involved in the health care sphere, impacting the way physicians and physicians-in-training approach their work.

Bengt Arnetz leads a department at Michigan State University that is focused on integrating education, research, and practice to address the spectrum of care, from individuals to emerging developments in population health.

Family medicine practitioners are critical partners in the well-being of adults and their families. Addressing the challenges facing primary care and family physicians, Arnetz points to the wide range of skills necessary for people entering the medical field today. Doctors are frequently on the front lines, treating illnesses and diseases that touch on biological, environmental, or sociological factors. In short, family physicians are often among the earliest professionals to become aware of what is happening in homes, schools, neighborhoods, and population clusters.

The Team Approach in Today's Health Care

The Family Medicine Residency Network within the Department of Family Medicine is designed so that faculty, staff, and residents can excel by working together and fostering collaborative projects, research, and program resources. There are nine residency programs across the state, including locations in Lansing, Metro Detroit, Midland, Grand Rapids, the greater Flint area, and Marquette.

"Health care has gone to a team approach, but what makes for effective teams?" said Arnetz. "Basically, how can you enhance well-being and energy in the practices? How can you provide data so they can improve treatment? We work with the clinics to assess their practices, provide data, and evaluate their current status so we can ask ‘what can you do to improve it?"

Arnetz wants to see a focus on outcome research, looking at the function of the person rather than the reason the patient came in for treatment. He points out that doctors are reimbursed per patient visit. But what is the outcome? Right now, payment has very little to do with what is actually accomplished, although the industry is trying to shift that model. That means physicians are increasingly expected to address the patient's full well-being, not just what the patient wanted to address when he/she walked in the door.

"I think the biggest challenge is to make a meaningful connection to family medicine system—or health care systems—and really integrate population health with family medicine practices. We need to take all the knowledge and determiners of our population health, and integrate that with all the knowledge in primary care," said Arnetz.

Utilizing that integrated information steers physicians toward not only treating symptoms, but gaining awareness about what is going on in a patient's life. By understanding underlying or root causes, family care practices can apply the team approach for education, prevention, and health management.

Linking Primary Care and Public Health

While there are differences between primary care and public health sectors, Arnetz and his team promote awareness, collaboration, and cooperation as key elements for improving individual health outcomes as well as population health. For instance, primary care providers and family physicians are expected to report information pertaining to infectious disease outbreaks like influenza, measles, or whooping cough. They may observe increases in opiate use, HIV, autism, teenage pregnancies, or any number of other public health concerns.

But what happens when there is a health issue that doesn't have a formal network? Population health can pertain to geographic regions, or it can include groups with similarities such as ethnicity, obesity, company employees, etc. Even more complex, how do you work with communities where citizens are reluctant to report health concerns or seek treatments and services?

Arnetz has a longstanding collaboration with ACCESS (Arab Community Center for Economic and Social Services), an organization founded more than 40 years ago in Dearborn, Michigan, that was created to assist the Arab immigrant population adapt to life in the United States. His connections with ACCESS resulted in university-community engaged research when Arnetz served as chair of Family Medicine at Wayne State University School of Medicine, and they have continued with his position at MSU.

ACCESS is the largest Arab American human services nonprofit in the U.S. and has more than 100 programs serving Metro Detroit for health, educational, social, and economic well-being. For Arnetz, the partnership with ACCESS is an example of how health care and population health intersect in population clusters.

In a recent study led by Arnetz and published in 2017, research found that Syrian refugees who arrived in the United States with post-traumatic stress disorder (PTSD) regulate stress differently than those who don't have the disorder, including those refugees who may have experienced some of the same traumas. The study was funded by the National Institute of Mental Health and the National Institute of Environmental Health Sciences.

A 2015 study that Arnetz participated in assessed the different levels of trauma Iraqi refugees faced and their resource needs and the utilization of those resources over time. The research showed that while many refugees needed mental and physical health services upon arrival, they didn't begin to utilize those services until they had a chance to learn how to navigate their surroundings. The data was beneficial for funding agencies so they could tailor programs more effectively with limited funding and manpower.

Each study offers critical data that can inform decision makers who provide an agglomeration of resources and services that come into contact with refugees. In Metro Detroit, a region where many Arab immigrants reside, the data is useful when collaborating with refugee services organizations, faith-based organizations, law enforcement, primary care clinics, mental health services, schools, social services programs, and nonprofit agencies.

Shifting Changes in Health Care: Integrating Research, Education, and Practice

Research is critical when moving from individual patient treatment to population health impacts.

One example Arnetz points to is the incidence of asthma in the population residing in Dearborn and surrounding communities.

"Asthma is at least 50 percent more common in the Dearborn area, compared to the rest of Michigan. It's a huge problem, and the community is concerned about air pollution. You can't just treat asthma by drugs," said Arnetz.

The asthma project emanated from work that Arnetz and the MSU team accomplished with the refugee studies. "As we interacted more and more with the community, we discovered that asthma was an issue and we were funded to look at asthma specifically in Arab-Americans. That's how it started."

"We are working with the community and putting together a proposal to work with the community on interventions. The research will contribute toward greater understanding," said Arnetz.

How Community Partnerships Evolve

According to Arnetz, establishing university-community partnerships contributes to meaningful advancements in patient care and population health.

"I really believe in reality based research, which is understanding something that goes on in the community and looking at it from a scientific point of view. How does it affect our biology? How does it affect disease processes? We take that knowledge and see if we can do something together. Can you actually improve their well-being? I think that's really exciting," said Arnetz.

"Whatever interventions we do are based on the community's perceptions. Then, we add our structure to it. But, it has to start with the community concerns. Now, for example, they come to us and discuss their concerns. By having this relationship, the community leaders or the healthcare providers bring us things they think need to be addressed," said Arnetz.