Background and Community Problems To a Addressed: The Cambodian population of Lowell, Massachusetts, at 25,000, is the second largest in the United States, following Long Beach, California; it is said to be the third largest in the world. In addition, there are an estimated 5000 Lao and 1500 Vietnamese living in Lowell, which has a total population of just over 105,000. Cambodians came to this country having suffered severe trauma during the Khmer Rouge years (1975-79), and Laotians and Vietnamese also fled their home countries as a result of war and tremendous difficulty. This geographic displacement alone can be very traumatic, with both nuclear and extended family units fragmented in the process. Southeast Asians (SEAS) have had to face the predictable problems encountered by virtually all newcomers, including the challenge of learning English; "culture shock"; locating safe, affordable housing; finding employment and educating their children, and dealing with the loss of their homeland, family and friends. Closing of schools under the Khmer Rouge resulted in limited educational opportunity (Men received an average of 7.2 and women an average of 3.1 years of schooling in Cambodia, according to a local survey) and limited literacy in both Khmer, the Cambodian language, and English.

The Khmer Rouge, headed by Poi Pot, produced misery, murder and repression on a massive scale and caused Cambodian people to live in prolonged fear and hopelessness. A deliberate and systematic effort was made to replace traditional relationships and structures resulting in families being separated, extreme mental and physical abuse, and a "total violation of human dignity" (Gonsalve, Torres, Fischman, Ross, and Vargas, 1993, p. 352). More than 90% of Lowell Community Health Center's (LCHC) Cambodian patients (currently 22% of patients seen at LCHC) suffered torture at the hands of the Khmer Rouge, including forced dislocation, witnessing atrocities such as executions, starvation, forced labor, combat and rape. Approximately two million people were killed.

Poverty is an additional barrier for this population. According to a survey completed in Lowell (Cambodian Community Health CCH 2010, Community Behavioral Risk Factor Survey Results, 2002), almost 25% of respondents (adult Cambodians 25 or older residing in Lowell) indicated an annual household income of less than $15,000. Over 40% live below the federal poverty level according to the U.S. Census, The stigma of mental Illness prevents many from seeking care. Health status Indicators show higher rates of cardiovascular disease (CVD) and diabetes as well as hepatitis B and tobacco use than in the general population, Adequacy of prenatal care among Cambodian women is among the lowest in Massachusetts. Cambodians in Lowell are at disproportional risk for morbidity and mortality due to CVD and diabetes. The vast majority of Cambodian adults report their health as being fair or poor, according to a recent community survey in Lowell (65% for those 50 and older) as well as an earlier study in Lynn, Massachusetts (93%). Given the Khmer Rouge experience, one must marvel at the strength and resiliency which has enabled some Cambodian refugees to heal and successfully rebuild their lives and communities in the U.S. However, many have not been able to do so. Numerous researchers have documented high incidence rates of depression and PTSD (post traumatic stress disorder). Even after 20 years in the U.S., Cambodians in California demonstrated high rates of past-year PTSD (62%) and depression (51%) (Marshall, Schell, Elliott, Berthold, Chun, 2005). The CCH 2010 Survey reveals a quarter of respondents were symptomatic for depression; the rate rose to 43% among women 50 and over.

The Program’s Approach:  Metta Health Center (MHC), was established in November, 200 as a new Lowell Community Health Center site in order to address these needs and the ethno cultural and institutional barriers to health and mental health care for Lowell’s Cambodian and Laotian communities.  These barriers included the complex U.S. health care system, limited provider understanding of health and culture, patterns of limited use of health services except in cases of severe illness, limited transportation options, the appointment system, and literacy limitations. "Metta" is a Buddhist Sanskrit word meaning "love and compassion". The Center's "West Meets East” approach builds on the strengths of the culture that Southeast Asians carried with them to Lowell. To improve access and make clients feel more comfortable, the Center is located in the Cambodian Mutual Assistance Association (CMM), which houses social service programs as well as a Buddhist meditation center. The Center's program model is built on four integrated service delivery components to provide access to care: two western based services - primary health care and mental health services, and two Southeast Asian based services for both physical and mental health needs - traditional healing consultation and alternative medicine, The success of the Center relies on the use of any of the components as gateways to the comprehensive array of services available at this and other LCHC sites; the presence of staff who are either Cambodian, Lao, or other ethnicities with extensive experience working with SEAs; and inclusion of significant patient input into program design.

MHC is one of four main sites of Lowell Community Health Center (LCHC), a non-profit, 501 (c) (3) JCAHO accredited Health Center, and Lowell's largest provider of primary medical care and mental health services to SEAS, As an exemplary leader and partner in the provision of community health services, LCHC and MHC have available a culturally and linguistically competent Health Benefits Coordinator to assist patients with the complex issues of Medicaid coverage and in applying for other health coverage programs. These services are critical to the vast majority who are in working families (81 %), but with jobs that are low paying in small firms, service and trade occupations and less likely to offer health benefits.

Program Objectives and Actions: Metta Health Center 's primary objective is to increase access to the health care delivery system for this population by overcoming barriers and implementing effective and sustainable ways to improve the medical and mental health status of the Cambodians and Laotians in the greater Lowell area. The Metta Center strives to serve as the family doctor for those Cambodians, Laotians and others who, otherwise, might not seek or receive consistent, good quality health care; and its services are accessible to everyone. While providing easily accessible primary medical care for all ages, its services also include refugee health assessments, nutrition counseling, mental health services, the Multicultural Connections for Health program for torture survivors, traditional healer and Buddhist monk consultation, meditation, acupuncture, massage therapy, and community health referrals.

Actions taken to offer improved access to the SEA community are multi-pronged and include placing the Metta clinic within the familiar CMAA building, the heart of the Cambodian community, to address transportation barriers. The location was selected for its walking accessibility for a majority of the Community. At Metta, patients are encouraged to have appointments, but the center is set up to accommodate both walk-ins and appointments, since many patients are unaccustomed to appointments Checklist for organizing.

The physical set-up of the Metta Center was carefully designed to be culturally accessible; to make the patients feel welcome and at home. Inside the facility, all signs are written in English, Laotian and Khmer, the official language of Cambodia. Asian music emanates from the television in the waiting area. The overhead lights and ceiling fan are replicas of those found in Cambodia. A Cambodian stringed musical instrument and statues hang on the wall behind the registration desk. Art throughout the center is from Cambodia and reflect attention to the Cambodian culture.

In addition to providing primary medical care and mental health services, Metta also recognizes the importance of traditional healing and alternative medicine methods such as seeing an herbalist or traditional healer, and has a Buddhist monk and a Kru Khmer (traditional healer) volunteer as consultants to educate providers about traditional methods.

Cultural awareness and sensitivity is incorporated into every aspect of the Metta Center, including the careful selection and training of all staff members.  The Metta Health center Director is a Cambodian refugee and is bilingual, speaking Khmer and English; he has designed culturally sensitive approaches to caring for the health and well being of the center’s patients.  The staff is highly experienced in bridging cultural and language gaps, and trained medical interpreters are available for staff who do not speak Khmer or Laotian.

The Cambodian Community Health 2010 (CCH 2010) Program, a collaborative of which LCHC is the lead agency, works closely with Metta staff in addressing disparities in diabetes and cardiovascular disease. According to the CCH 2010 Comm* Health Survey, 78% of Cambodians prefer to receive health information in Khmer when given a choice. Brochures about the services of Metta Health Center in both Khmer and English are distributed in the community, and Metta utilizes the print and audio educational materials produced by the CCH 2010 program. Audio materials are important because of the low literacy rates in the community. Staff also present health topics on Khmer radio and TV.

Unique Nature of Program's Innovation and Creativity In Solving Community Problems: The success of LCHC's Metta Health Center was responsible for LCHC being named in a 2004 report commissioned by the U.S. Department of Health and Human Services, as one of the top five Health programs in the country for its cultural competence and commitment to services for minority populations. The increasing use of Metta, one of the nation's first fully integrated West meets East health centers, is an outstanding demonstration of what happens when the best of t vo cultures, one from the East and another from the West, come together and work mutually for the benefit of the community Behind the scenes of a successful meeting Metta Health Center staff provide the community with high quality, culturally appropriate health care services and programs. One primary indicator of the local need for services and Metta's success in addressing that need is the utilization of the Metta Health Center which currently serves as the primary care or behavioral health provider for almost 5,000 Cambodians, Laotians and other Asians. This wonderful center has become a national model and is frequently referred to throughout the country, as a successful example of true cultural competence coupled with high quality health and mental health care.

Because of the range of services available at MHC, individuals can seek mental health treatment without feeling the shame often felt when going to a specific mental health agency. To address the limited number of Cambodian credentialed mental health professionals, MHC uses a co-therapy model by partnering licensed American trained social workers, psychiatrist, and clinical nurse specialist with experienced Cambodian bilingual, bicultural mental health specialistslcase managers to deliver mental health treatment.

In primary care, success can be seen in the growth from having no patients to having almost 5000 registered. Over 250 Cambodians and Laotians have been seen for mental health treatment, with 70% receiving medication treatment. There is typically a waiting list of about 25 for Metta mental health services. Additionally, LCHC's Cambodian addiction treatment services have provided care to 100 patients annually. Of patients seen for mental health services, 95% were torture survivors. A similar proportion, 99%, of substance abuse clients were torture survivors.

Impact on Local Health Status and Gaps Program Fills: As mentioned previously, there is a high incidence of cardiovascular disease and diabetes within the Cambodian community. To counter these issues, the Metta Center works with the CCH 2010 project to increase awareness among Cambodians and the clinicians who treat them. Cambodians' attitudes in regard to exercise have improved tremendously. Within the past two years, over 60 Cambodians have become regular participants in the exercise programs of the Lowell Senior Center; previously there were none.

Cultural competency and linguistic capabilities are far from becoming readily accessible at the local hospitals, This segment of the community would remain isolated from the area's overall health care system without the Metta Health Center. Over its years of existence, the Metta Health Center has been responsible for a quadrupling of the number of Southeast Asian patients being seen at LCHC and a greatly improved understanding of the needs and strengths of this community. Health outcomes are described in section 3.

Although it is one of the newest sites of Lowell Community Center, the Metta Health Center clinc has also become in may ways a model for the other older Lowell Community Health Center sites.  The lessons learned from Metta are now being applied at other sites including strategies to achieve appropriate staffing through targeted recruitment and retention of bilingual, bicultural staff; culturally specific decorations and signage; effective outreach and education, creating the same friendliness and warmth that emanates from MHC, and many gateways to service in the same location. The unique Metta model is now being replicated and adapted to provide health services for the Latino, African immigrant, and Brazilian communities of Lowell and elements of the Metta model are being replicated throughout the country.

Health Care Needs

The Metta Health Center populations present with complex health care needs; as described above, and high levels of acuity, The patients have major health care needs that are further complicated by the complexity of their medical histories, cultural and linguistic barriers, a lack of consistent medical care, chronic addiction and mental illness and socio-economic status. The center seeks to alleviate barriers to accessing affordable health care via convenient hours and locations; multi-lingual, multi-cultural staff; culturally comfortable environment of care; enrollment in a comprehensive and consistent primary care system that employs preventive care and disease management; and the provision of supportive social, behavioral and community based services including case management, medication assistance, and culturally competent approaches, Specific needs are described in Section 2, and outcome measures will be described for diabetes and cardiovascular disease.

Diabetes and Cardiovascular Disease

Among Cambodians in Lowell, a disproportionate share of adult deaths (age > 45 years) are attributable to stroke (15.9%) and diabetes (13.4%), when compared with all MA residents (6,5% and 2.5%, respectively). When heart disease, stroke, and diabetes are combined, the proportion of deaths attributable to these is 48,9% for Cambodians, compared with 42.1% for all Massachusetts adults (MA DPH, Bureau of Health Statistics, 1999). Health disparities related to diabetes and cardiovascular disease are addressed through the Metta Health Center and the Cambodian Community Health 2010 program; providing social and clinical case management services for Cambodians with diabetes and cardiovascular disease. Five peer support groups are provided monthly for adult Cambodians with diabetes and/or CVD, Numerous outreach efforts, including blood glucose screenings, are on-going in the Cambodian community.

The profile of risk factors for CVD and diabetes in Cambodians confirms the increased risk for these conditions. Cambodians have low awareness of hypertension, low medication treatment levels, and low control rates (Stavig, 1998). Diets high in sodium and fats are typical. Smoking rates among Cambodian males are extremely high (71%) even in comparison to other Asian groups, (Asian American and Pacific Islander Journal of Health, 1997). Strengths, such as the support of families and temples, have been revealed anecdotally, and the CCH 2010 community behavioral risk factor survey provides positive data, e.g., relatively high rates of vigorous exercise, fruit and vegetable consumption, focus on the family, and declining smoking rates.

Diabetes Case Management Program: At MHC the number of patients with a primary or secondary diagnosis of diabetes grew from 23 in 2001 to 703 in 2005. The Metta Health Center was a participant in a Diabetes Case Management Program of Lowell Community Health Center funded by Blue Cross Blue Shield of Massachusetts; the funding allowed LCHC to improve patient care processes and patient outcomes The project enhanced patients' ability to self-manage their diabetes, empowering patients to manage their own care. The project transformed the delivery of diabetes care and case management and facilitated the development of diabetes education materials in multiple languages, and has also facilitated the development of case management teams. The project results, utilizing the sample 33 enrolled patients, illustrate the effectiveness of the case management model in yielding, successful results for the patients.

Demographics of Patient Cohort:  The Diabetes Case Management Program of LCHC enrolled thirty-three patients during the project year.  Patients were deemed eligible if they had an HgbA1C of ten or above and if the patient demonstrated an interest in taking on self-management plans.  Twenty-one patients were originally enrolled at the Adult Clinic and twelve at the Metta Health Center.  None of the patients at the Metta site discontinued participation during the project.  Of the twenty-one patients in the Adult Clinic who originally signed up, 12 (57%) were Puerto Rican, 3 (14.2%) Portuguese, 3 (14.2%) Caucasian, 1 (4.7%) was Dominican, 1 (4.7%) African, and 1 (4.7%) Brazilian.  At the Metta Health Center, of the twelve patients 8 (66%) were Cambodian, 2 (16%) Laotian, 1 (8%) Caucasian and 1 (8%) Latino.

This sampling based evidence from the Metta Center group demonstrates effective improvement by participating diabetic patients from treatment through the Case Management approach. Utilization of the Case Management program is now being duplicated at other Lowell Community Health Center sites.

Analysis of the Features of the Model: The project has made progress in controlling patients' HgbA1C's. During the six months from November to May, work continued with patients to lower their HgbA1 C's and implement the lifestyle and self-management changes needed to improve health status. This model has been effective in monitoring patients, effectively educating patients, and effectively communicating with patients despite language or cultural differences.

The program, by utilizing a case management approach, has been able to monitor patients more closely than non-case managed patients as demonstrated by the percentages of HgbAl C tests and Micro Albumin tests performed. The Nurse Case Management Team Model, made up by the Nurse Case Manager and bilingual/bicultural Medical Assistant in Adult and the LPN Nurse Case Manager at Metta, has facilitated the provision of culturally and linguistically appropriate education, thus making patients more receptive to education, By having a bilinguallbicultural educator, physician and other staff involved in the project, the cultural gap that may exist is bridged, and an effective exchange of ideas and knowledge between the Nurse Case Manager and the patient is able to occur.

The Group Peer Support sessions are an additional important factor in the success of the project, as patients are able to understand that other community members face the same issues, and are able to develop and work on implementing self-management goals in an environment of support and encouragement with other patients who share similar linguistic and cultural backgrounds, The ability to provide group sessions in the languages spoken by the patient is likely a key variable in our success to date.

Cardiovascular Disease - Community Change

Through the Cambodian Community Health 2010 initiative, the Metta Center and LCHC has been involved with the MA Department of Public Health's Cardiovascular Health Initiative, which encompasses the goals of Healthy People 2010 to increase the quality and years of healthy life and to eliminate health disparities, Specifically, the related objectives identified in the CCH 2010 community action plan are to increase the proportion of community health promotion activities that are culturally appropriate, without environmental barriers, linguistically competent, and encouraging older adult participation. The success of this effort is demonstrated by the numbers of older Cambodians who now attend exercise programs at the Lowell Senior Center, any of whom now participate in other Senior Center activities as well.

New formal collaborations have been developed with the Saint Julie Asian Center to integrate health education about COLD and diabetes into English as a Second Language programs. The City of Lowell Council on Aging has partnered to provide several wellness programs and initiatives for elder Cambodians including weekly physical activity programs, peer support groups and health fairs.

The area pictorial graphs for both the changes in depression and trauma scores demonstrate the tremendous impact on patient outcomes achieved by the culturally sensitive care with the integration of mental health services with primary care provided by the center.  Careful statistical testing shows that the changes n depression and PTSD are statistically significant, despite the small sample size.