Equity in practice: Integrating cross cultural health brokers for culturally safe primary care for immigrants and refugees in British Columbia

Introduction

Access to longitudinal primary care has been shown to improve individual, community, and population outcomes. ¹ The majority of primary care infrastructure in Canada relies on physician-centred models. ² Community Health Centres (CHCs) are a primary care model found across the globe, defined by specific principles. These include not-for-profit organization, community governance, and focus on primary healthcare, social determinants of health, and health promotion. ³ Community health centres provide team-based care, with a range of practitioners adapted to local or population needs, such as social workers, family physicians, nurse practitioners, dietitians, counsellors, and community health workers. Importantly, their governance model ensures they are responsive to the communities they serve. Umbrella Multicultural Health Co-op (Umbrella Co-op) was established in 2010 as a non-profit co-operative CHC serving diverse cultural communities of immigrants and refugees who experience health access barriers. It was awarded a contract by the British Columbia Ministry of Health in April 2020 as part of the provincial primary care strategy. ⁴ Since then, Umbrella Co-op has been growing in response to the local need for culturally and linguistically appropriate care for immigrants and refugees.

Immigrants and refugees face multiple overlapping challenges which in turn shape their health outcomes. These include language and cultural barriers to accessing essential services, social isolation, discrimination, un/underemployment, cultural dissonance, and poverty.^5,6 Umbrella Co-op addresses these barriers by integrating Cross Cultural Health Brokers (CCHBs)—multilingual, multicultural skilled healthcare workers from each of four ethnocultural groups, including Middle Eastern (Arabic-speaking), Iranian/Afghan (Farsi/Pashto/Dari-speaking), Latin American (Spanish-speaking), and Eritrean (Tigrinya/Amharic-speaking). Many CCHBs are internationally trained healthcare providers (e.g., medical doctors, nurses, or pharmacists).

CCHBs are increasingly recognized across Canada as playing a key role in supporting health equity. They function as a bridge between patients and the healthcare system by materially addressing the spectrum of barriers that cumulatively impair immigrant and refugee health, including language/cultural interpretation during visits, complex system navigation, and advocacy with social services. ⁷ CCHBs are not yet a regulated healthcare profession in Canada but receive extensive training in their unique healthcare role.^8,9

Umbrella Co-op built its cross-cultural model to provide equity-oriented primary care for immigrants and refugees, who are often excluded from interprofessional team-based primary care models, ¹⁰ despite being highly likely to benefit from this type of service. ¹¹ Umbrella Co-op weaves CCHBs into every interaction between the team members and patients, and between patients and external health and social systems. With guidance from immigrant and refugee communities at its centre, Umbrella Co-op is uniquely positioned to identify and respond to community-specific needs with the ultimate goal of providing comprehensive, wholistic, and culturally appropriate primary care. To remain responsive and accountable to the immigrant and refugee communities we serve, our board composition is a majority of members with lived experience of barriers to health access due to language or culture.

Umbrella Co-op’s population of immigrants and refugees has complex medical needs complicated by social determinants of health, and addressing them is not possible for a clinician alone. To address this intersection of medical and social complexity, and provide equity-oriented primary care, Umbrella Co-op utilized funding from the British Columbia Ministry of Health starting in April 2020 to expand our lean primary care team. We started out with three part-time family physicians, CCHBs, a medical office assistant, and a social determinants of health worker. By mid-2023, Umbrella Co-op had added a nurse practitioner, registered nurse, social worker, and registered clinical counsellor. However, the team faced challenges in expanding their base team of CCHBs at a comparable rate. This limitation hindered the new team members’ ability to connect with patients, constraining their ability to provide effective and efficient interprofessional services to the community.

With funding from the Team Primary Care initiative, ¹² it enabled the Umbrella Co-op to: (1) hire, train, and integrate additional CCHBs into our primary care team alongside intentional team development activities with the new allied health practitioners; and (2) sustain our expanded team through team development workshops and co-creation of an evaluation framework for ongoing quality improvement. Our goal was to trial and demonstrate learnings from this expansion of a novel interprofessional primary care team model centred on equitable and culturally safe care using CCHBs. Here, we share our learnings about the benefits and challenges of expanding an interprofessional primary care team with CCHBs and the co-development of our evaluation framework.

Methods

We used the learning health system ¹³ framework to structure our expansion process for the length of the project (May 2023 to March 2024) and to establish an infrastructure for ongoing learning beyond the project term. The learning health system outlines learning cycles in three phases: data to knowledge, knowledge to practice, and practice to data.

In the data to knowledge phase, from May to August 2023, we started by hiring four new CCHBs with the team (expanding CCHBs capacity in our four main ethnocultural communities and the Umbrella Mobile Clinic serving migrant farm workers) and then reviewing our training materials in order to onboard the new group all together. We took knowledge gained from previous experience and through participation in a national cultural brokering research and curriculum development project, ⁹ and translated this into the orientation of the new CCHBs. We also reviewed relevant literature on evaluation metrics and priorities for CHCs, and met with experts in primary care and team-based care evaluation to consider what frameworks would best fit our team.

In the knowledge to practice phase, from September 2023 to January 2024, we initiated team development workshops where we co-created new clinic workflows in order to simultaneously practice teamwork while developing updated practice guidelines that incorporated new team member roles. Guided by the learning health systems framework, we introduced the concept and practice of evaluation to the team and iteratively built an evaluation framework. We added an hour to our monthly clinic staff meeting and used that time to adapt the TEAM Framework ¹⁴ to Umbrella Co-op’s specific model and context and then generated a working evaluation framework, incorporating priorities from our team, organization, and relevant stakeholders (e.g., Ministry of Health and other funders). We chose the TEAM Framework as our base, since it comprehensively reviews the literature on primary care evaluation frameworks, and outlines 10 dimensions that map onto our values at Umbrella (Box 1). We iteratively reviewed the framework with the entire clinical team and together selected priorities for domains and indicators to start our evaluation process. We prioritized the domains: (1) relationship-based care and (2) capacity and access. We began with the indicator of “third next available appointment (3NAA),” a well-known primary care indicator of access.

OPEN IN VIEWER

Box 1.

Dimensions and aspects of primary care evaluation from the TEAM Framework ¹⁴ that Umbrella Co-op integrated into our evaluation framework.

Dimension	Aspects
Relationship-centred care	Continuity; cultural safety; patient, family and relationship centredness
Patient experience	Patient perception of care, patient empowerment, and activation
Provider experience	Provider experience of work and care
Team function	Team training, communication, and information systems
Quality-of-care process	Care effectiveness, quality improvement activities, and care safety
Capacity and access	Comprehensive services, equitable access, service accessibility, and team capacity
Team-based primary and community care foundations	Care coordination, clinical infrastructure, workforce capacity, education, and funding
Governance and accountability	Evidence-based decision-making, system leadership and management, monitoring and evaluation, and stakeholder engagement
Health of the population	Health outcomes, attachment, and responsive community services
Healthcare costs	Care cost-effectiveness

In the practice to data phase, from January 2024 to March 2024, we undertook a series of consultant facilitated workshops on (1) strategic development in putting our values into practice (equity, racism-free/culturally safe, and trauma-specific) and (2) communication (including feelings/needs, judgement/trust-building, and appreciation/feedback). Through this development work, we drafted a values-based policy development process and policy template that we will trial going forward. We also applied the 3NAA evaluation indicator by collecting it weekly and collaboratively analyzed and interpreted the data. In this phase, two project leads along with a CCHB traveled to the Team Primary Care Summit in Ottawa, where we presented a poster, spoke on a panel, and collaborated in conversations with other projects and stakeholders to receive and share knowledge on best practices and future directions in team-based primary care.

Results

Over the course of our learning cycle, the learnings that emerged from our process, experiences, and data analysis fell into two key areas: (1) team development and expansion, and (2) co-development of the evaluation framework.

Learning #1: Team development infrastructure supported effective expansion and integration of new CCHBs to our primary care team.

We hired and onboarded four additional part-time CCHBs (each 15 hours per week). We chose candidates from our main ethnocultural groups who were internationally trained healthcare workers (e.g., physician, nurse, and pharmacist). The integration process required focused resourcing, as CCHBs accustomed to carrying individual caseloads needed to develop ways to share their caseload with their new counterpart from the same ethnocultural community, while the remaining team needed a shared process to communicate with the CCHB pair about patient care. We approached this need by implementing daily morning team huddles, increasing the length of monthly clinic team meetings, and organizing pragmatic team development workshops where we co-created workflows for clinical issues. For example, we redesigned our workflow for prescription refills by looking at the issue from the perspective of each role on the team, and then rebuilding our workflow collaboratively, with the benefit of modelling and practicing interprofessional team work as part of the workshop process.

Due to a lack of equity-oriented comprehensive primary care for immigrants and refugees locally, and the effectiveness of the CCHBs model, Umbrella Co-op waitlists and community referrals are extensive and growing. Expanding the team required a parallel expansion of team development activities so that both new and existing team members learnt how to work well together toward a common goal that embodies our values. To this end, we worked with consultants on a series of workshops in two essential areas: (1) strategic development for equity, cultural safety/racism-free, and trauma-specific practice; and (2) communication. In our Strategic Development series, we explored how we understand and articulate these practices in our work with patients and with each other—even co-defining our organizational chart and policy development process. In our Communication series, we worked with an expert trainer, through a series of sessions practicing empathy and needs identification, judgement and trust-building, and appreciation and feedback.

Expanding our CCHB team allowed us to expand our number of attached patients, providing comprehensive team-based primary care for 174 (or 20%) more marginalized immigrants and refugees. This expansion required dedicated infrastructure (e.g., protected time and resources) and intentional team development. Team development infrastructure was, and is, essential to improving working relationships, team function, and an appropriate distribution of work that ultimately increased family physician and nurse practitioner capacity to attach more medically and socially complex patients, while maintaining cultural safety and equity-orientation.

Learning #2: Co-development of a team evaluation framework is necessary for quality care and requires protected time.

An essential result of our learning cycle was the development of a process for approaching evaluation as a team. Adjusting our existing infrastructure by adding an hour to our regular monthly team meetings for evaluation work enabled inclusion of all team members. Voting on the dimensions illuminated team and stakeholder priorities and guided us to start evaluating the dimension of Capacity and Access using the 3NAA indicator. Reviewing the purpose of an indicator, defining the 3NAA in our context, and analyzing together at each successive clinic team meeting expanded our collective capacity and skills in evaluation. We learned how this indicator can help us assess both our urgent care access and our attachment capacity, and plan to continue using it ongoing in our evaluation database. We will continue iteratively selecting, defining and implementing other indicators specific to our needs to continuously improve our care. We found that a collaborative team-based approach to the ongoing Umbrella Co-op clinic evaluation takes time but ensures that every team member is engaged in analysis and practice improvement.

Conclusions

A team-based approach that integrates CCHBs can deliver wholistic, culturally appropriate, and equity-oriented primary care for cultural communities, immigrants, and refugees. With a small expansion in the capacity of CCHBs, we successfully provided primary care to 20% more immigrant and refugee patients facing complex social and health issues. This expansion required multiple team development activities and additional infrastructure, including dedicated time, funding, and training resources, crucial for sustaining effective team function. Collaboratively designing evaluation frameworks with the entire team ensured that community priorities and fundamental primary care domains were integrated into our learning health system model. Connection with a nationwide network of team-based primary care models and content experts through Team Primary Care was valuable in connecting us with relevant evidence-based resources and opportunities to learn from innovative practices in multiple diverse communities. Moving forward, primary care policy and funding models seeking to deliver equity-oriented services should incorporate defined roles for community health workers like CCHBs and invest in continuous team development infrastructure.