Assessing Refugee Utilization of Healthcare Systems

The state of Utah does not systematically evaluate refugee healthcare programs and utilization. Two organizations in the Greater Salt Lake City Valley, Utah provide critical healthcare education and healthcare access to refugees. These two institutions do not have the means to assess the functionality of education delivery or the demographics of the population being served. The purpose of this project was to create a tool to appraise the efficacy of refugee education provided by a resettlement agency and to explore opportunities to strengthen software for refugee-specific health data collection at an academic medical center. To evaluate the efficacy of a refugee healthcare education program, a pre- and post-learning assessment tool was developed for the Health Mentor Program. Assessment results and recommendations were shared with key stakeholders. Healthcare employees were introduced to and appraised of the purpose and functionality of the electronic medical record Refugee FYI flag. The modified flag report captured additional refugee demographics and utilization for analysis. Descriptive statistics were used to summarize all collected data. The learning module assessment revealed that participating refugees felt more confident after receiving mentor education. The Refugee FYI flag captured data about refugee demographics within the academic medical center and holds promise to be helpful. The typical refugee is a 33-year-old female who speaks either Arabic, Somalian, or Swahili. Refugee Urgent Care visits account for 12% of all refugee encounters whereas refugee Emergency department utilization is only 3% of refugee encounters. Of refugee emergency department visits, 18% result in a hospital admission. The pre- and post-learning assessment tool as designed was functional for the mentor/mentee pairs, but the questions should be revisited to enable statistical analysis. The availability of interpreters may limit the effectiveness of mentor teaching. The results of the Refugee FYI flag provided valuable baseline information about the 1,000+ refugees accessing care at an academic medical center in the Greater Salt Lake Valley. The needs and opportunities for refugee healthcare initiatives merit additional investment.

Assessing Refugee Utilization of Healthcare Systems Erica Kueneman The University of Utah College of Nursing 1 Abstract Background: The state of Utah does not systematically evaluate refugee healthcare programs and utilization. Two organizations in the Greater Salt Lake City Valley, Utah provide critical healthcare education and healthcare access to refugees. These two institutions do not have the means to assess the functionality of education delivery or the demographics of the population being served. The purpose of this project was to create a tool to appraise the efficacy of refugee education provided by a resettlement agency and to explore opportunities to strengthen software for refugee-specific health data collection at an academic medical center. Methods: To evaluate the efficacy of a refugee healthcare education program, a pre- and post-learning assessment tool was developed for the Health Mentor Program. Assessment results and recommendations were shared with key stakeholders. Healthcare employees were introduced to and appraised of the purpose and functionality of the electronic medical record Refugee FYI flag. The modified flag report captured additional refugee demographics and utilization for analysis. Descriptive statistics were used to summarize all collected data. Results: The learning module assessment revealed that participating refugees felt more confident after receiving mentor education. The Refugee FYI flag captured data about refugee demographics within the academic medical center and holds promise to be helpful. The typical refugee is a 33-year-old female who speaks either Arabic, Somalian, or Swahili. Refugee Urgent Care visits account for 12% of all refugee encounters 2 whereas refugee Emergency department utilization is only 3% of refugee encounters. Of refugee emergency department visits, 18% result in a hospital admission. Conclusions: The pre- and post-learning assessment tool as designed was functional for the mentor/mentee pairs, but the questions should be revisited to enable statistical analysis. The availability of interpreters may limit the effectiveness of mentor teaching. The results of the Refugee FYI flag provided valuable baseline information about the 1,000+ refugees accessing care at an academic medical center in the Greater Salt Lake Valley. The needs and opportunities for refugee healthcare initiatives merit additional investment. Keywords: Refugee, healthcare, utilization, emergency, urgent care, mentor, mentee, health literacy 3 Introduction Problem Description The number of humanitarian refugees is surging, as is their healthcare needs, including in the state of Utah. The United Nations High Commissioner for Refugees (UNHCR) reports that 70.8 million individuals have been displaced by geopolitical factors, and 29.4 million of these are refugees and asylum seekers (IRC, n.d.). Each year the United States (U.S.) determines how many UNHCR identified individuals will be allowed to enter and resettle within its borders. According to the Utah Department of Health, Utah presently is home to upwards of 60,000 refugees, with the majority of these individuals residing in Salt Lake City or the Greater Salt Lake Valley (Utah Department of Health, 2018). Two resettlement agencies provide most Utah refugees with reception, resettlement, and access to direct and supplemental services. The principal agency, the International Rescue Committee (IRC) in Salt Lake City, UT, was founded in 1994 and is one of 22 IRC resettlement agency offices in the United States (International Rescue Committee, n.d.a; Utah Department of Health, 2018). Its mission is to resettle individuals with refugee status as identified by the United Nations High Commissioner for Refugees. Healthcare support from professionals is critical not only for refugees but also for community public health. A positive interaction between refugees and the healthcare systems is essential (Mangrio & Sjögren Forss, 2017); however, refugees rarely receive adequate health information and too often are invisible partners in their healthcare. A 4 lack of appropriate information tools, poor baseline data, and the resultant disconnect between diverse refugee healthcare initiatives all contribute to inefficient and inappropriate utilization by refugees of healthcare services, especially emergency and urgent care resources (Guess, et al., 2018; Mahmoud & Hou, 2012). The IRC has worked closely with a large academic medical center for many decades to establish collaborative healthcare initiatives to better address the needs of displaced people resettled in the Greater Salt Lake Valley. In 2008, the Occupational and Recreational Therapies program at the University of Utah began working with the IRC in a fieldwork program to assist refugees resettling in Utah (University of Utah, College of Health, n.d.). In 2009, a Medicine-Pediatric Residency program of a large academic medical center partnered with the IRC to develop Child Health Classes for the delivery of health education to refugees in the community with small infants (IRC, 2017). In 2019, the University of Utah's College of Nursing began collaborating with the IRC via the Health Mentor Program. This program partners Doctor of Nursing Practice (DNP) students with IRC clients to deliver education to cover topics such as healthcare navigation, emotional wellbeing, health and hygiene, nutrition basics, and physical fitness to refugees in the first year of their arrival (IRC, 2019). Available Knowledge Despite the collaboration, support, and community investment in refugee health, data regarding refugee health utilization after resettlement are woefully incomplete, and not well researched or well documented (Guess, et al., 2018; Watts, Friedman, Vivier, Tompkins, & Alario, 2012). Inconsistencies in refugee utilization of healthcare services 5 vary among the few existing studies. Findings are influenced by: diverse study design, refugee population at the time of the study, location, and the ability of the medical system to capture and make accessible national, regional, and local healthcare data. Assessment strategies designed to describe refugee health and refugee healthcare utilization are limited in the United States, which has a system that is highly fractured and pay dependent (Guess, et al., 2018). Efforts have been made to evaluate refugee healthcare utilization across the United States and internationally. Researchers in Rhode Island have studied refugee children's healthcare utilization patterns (Watts, et al., 2012), Walden and Sienkiewicz (2019) evaluated practice recommendations for refugee clients in North Carolina, and Kohlenberger et al., (2019) investigated refugees' access and barriers to healthcare in Australia. However, no published research efforts have occurred in Utah regarding refugee health needs, utilization, cost, and outcomes, and no data regarding refugee utilization are available in the academic medical center. The following quality improvement project is an incipient effort to address the lack of tools to assess these data and provide information for stakeholders in Utah. Rationale Theories help explain human behavior by identifying the factors driving behavior and the influential motivators of behavior change. The Health Belief Model (HBM) was developed in the 1950s by the United States Public Health Service to attempt to describe why individuals fail to participate in programs designed to improve health (Glanz, Rimer, & Viswanath, 2008). The HBM theory has been broadened to include evaluation of 6 individual responses to health conditions that focus on constructs of an individual's understanding of and responses to disease and health conditions via perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy (Glanz, et al., 2008). The HBM very closely aligns with the principles of the IRC and the Health Mentor Program, which are to promote "self-reliance, integration, and citizenship" (IRC, n.d.). In order to help individuals achieve self-reliance in health behaviors (i.e., when to seek emergency care, preventative care, and utilize self-efficacy), targeted individuals need to understand how aspects of health are related to them, and they need the confidence to enact self-promoting health behaviors (Glanz, et al., 2008). The Health Mentor Program, under study here, is designed to help refugee clients achieve selfefficacy/self-reliance though the adoption of positive health behaviors in the topics covered by the Health Mentor Program, including when to seek professional assistance and care. In keeping with the HBM, refugee health services and health promotion must take into account modifying factors such as, age, sex, ethnicity, education, personality, and knowledge (Glanz, et al., 2008). Therefore, a formal baseline assessment of refugee health demographics and utilization via the electronic healthcare record (EHR) at an academic medical center will contribute to quality care improvement for refugee health in the HBM model. Specific Aims The purpose of this quality improvement project is to provide the University of 7 Utah College of Nursing, the IRC of Utah Health Mentor Program, and an academic medical center with specific recommendations to improve refugee health access and utilization. The project objectives are to a) pilot efficacy of an evaluation tool for the health promotion program directed by the IRC of Utah and the College of Nursing, b) provide the Health Mentor Program with specific feedback and recommendations based on mentor/mentee data collection, c) improve an academic medical center's ability to assess refugee health demographics and Urgent Care and Emergency department (ED) utilization through EHR development, and d) facilitate the education of healthcare staff about refugee-specific EHR tools. These four aims have been assigned to two distinct objectives, Objective I - Health Mentor Program and Objective II - Refugee FYI flag in the EHR of an academic medical center. These objectives are healthcare interventions designed to provide crucial partners in refugee resettlement with relevant, specific, and current data. The interventions of evaluating a health promotion program with a health assessment tool, making program recommendations, obtaining baseline refugee data in a large academic medical center, and educating healthcare staff will occur through multiple modalities, including data collection and synthesis, education, subjective feedback, and recommendation reports. 8 Figure 1. Theory of change for reefugee systems improvement Methods Context This quality improvement project occurs in an urban environment of the Greater Salt Lake Valley, Utah with collaboration among a refugee resettlement agency, recently resettled refugees, Doctorate of Nursing (DNP) students, and an urban academic medical center. DNP students at the university volunteer to engage in a refugee healthcare partnership with IRC of Utah through the Health Mentor Program (Objective I). An academic medical center participates in modifications to EHR data collection practices to better assess refugee demographics and utilization (Objective II). 9 Objective I - Health Mentor Program Context The IRC of Utah designed and developed the Health Mentor Program to help empower refugees to participate actively in their own health management. In Salt Lake City, this program is coordinated by a DNP faculty advisor and the IRC Health Promotion Program coordinator. The Health Mentor Program includes eight student volunteers and an equal number of IRC clients identified by the Health Promotion Program coordinator. DNP student inclusion criteria require volunteers be willing to commit 50 hours, approximately 2 hours per week, for 6 months. The Health Mentor Program is open to DNP students in the Adult/Gerontology-Acute Care Program, Family Primary Care Nurse Practitioner Program, and Psychiatric/Mental Health Nurse Practitioner Program. Mentors are expected to be responsible, reliable, open-minded, and respectful to become a friend, teacher, and cultural healthcare broker to the refugee mentee. Ideally, mentor/mentee pairs cover 24 module topics that fall under the headings of healthcare navigation, emotional wellbeing, health and hygiene, nutrition basics, and physical fitness. Refugee clients are selected by the Health Promotion Program coordinator, who targets individuals with chronic but stable health conditions, who have been in the United States at least 6 months, and who are willing to participate in a voluntary health education program. Objective II - Refugee FYI flag Context At an urban medical center, the electronic healthcare record (EHR) is based on Epic software. The Epic platform has an FYI function to flag healthcare staff when individuals present with specific conditions. One identifier available in Epic is the 10 Refugee FYI flag. This highlight in the patient chart alerts staff to this socioeconomic dimension of specific clients. The Refugee FYI flag can also be part of filter criteria to run data reports on these individuals accessing healthcare services in the Epic system. Initially, the Refuge FYI flag report was created to support the Refugee Program Coordinator at one of the ambulatory clinics, also a liaison between refugee resettlement agencies in the Salt Lake Valley and the academic medical center. The Refugee FYI flag report, however, had not been widely distributed or utilized beyond one ambulatory center in the academic medical network. Education provided to the nursing and communication departments of the medical center about the purpose and function of the tool would improve organizational utilization, and the introduction of additional data points would increase understanding about the refugee population and allowed for better analysis. Interventions Objective I - Health Mentor Program Intervention Initially, a health mentor contact confirmation form was created in Google Forms to verify contact information and enhance understanding of the Health Mentor Program intervention (Figure 3). The Health Mentor evaluation tool for Health Mentor Module I "Navigating the Healthcare System" (Figure 4) was also built using Google Forms and distributed via email to eight health mentors in the Fall 2019 cohort. The assessment tool included multiple choice and short answer formats. Mentors were asked to summarize mentee responses to one of the levels of healthcare identified in the Levels of Healthcare form (Figure 3). The Health Promotion Program coordinator reviewed and approved the 11 pre- and post-assessment questions. Information regarding this evaluation tool was presented and distributed to mentors during an orientation meeting. Once the health mentor contact confirmation form was received, the Health Mentor pre- and post-learning assessment tool (Figure 4) was distributed to the Health Mentor volunteers in August and September of 2019. The preand post-learning assessment was sent in one form to simplify the process. The prelearning assessment consisted of a 12-question survey (Figure 4), including multiplechoice and short text entries. The mentors took the following steps: a) arrange for an IRC interpreter to help translate the questions to the appropriate preferred language, if necessary and possible; b) complete the pre-learning assessment with their client; c) review the Health Mentor Module I "Navigating the Healthcare System"; d) fill out the Levels of Healthcare form, (Figure 4); and d) complete the 12-question post-assessment at the end of the visit. Objective II - Refugee FYI Flag Intervention The objective was to create a reporting tool that could be utilized by diverse professional healthcare and social care experts within the academic medical center health system. In order to implement Objective II, a multidisciplinary team consisting of the Refugee Program Coordinator, the internal medicine pediatric resident, the informatics medical assistant, and the senior business intelligence analyst, reviewed the EHR tool to ensure tailoring better assessed health needs of the refugees and expanded information access to the healthcare teams. The tool was originally designed to capture 10 data points but was expanded by this initiative to include information about Urgent Care and 12 Emergency department (ED) utilization and other demographic information (Figure 2). Medical staff education about the Refugee FYI flag report modifications was delivered to the Ambulatory Nursing Practice Council and to the Guest Communications department. The Refugee Program Coordinator and the author of this paper presented staff with education via in-person meetings using a PowerPoint presentation. The content and workflow presented were approved by department managers. Study of the Interventions Objective I - Health Mentor Program Study of the Intervention Evaluation of the Health Mentor Program intervention included a pre- and postknowledge assessment, where objective data described the impact and efficacy of the Health Mentor Module I "Navigating the Healthcare System." Subjective data from the mentors regarding their experience and recommendations were also collected following the intervention. At the end of the first mentor/mentee training refugee mentees received a hard copy of the "Levels of Healthcare" handout (Figure 4) to supplement their recent direct training exposure. A summary of the findings and subjective mentor feedback was provided to the IRC with possible recommendations for improvements to the learning objectives, learning materials, and the learning delivery process for Module I (Figure 5). Objective II - Refugee FYI Flag Study of the Intervention The Refugee FYI report from Epic was analyzed to describe refugee demographics and healthcare utilization with objective and descriptive data. Following the report modifications, refugee healthcare utilization and demographics can now be tracked in a reporting tool with de-identified client data. This approach allows for 13 information to be shared with involved parties, for analysis of and impact on the overall academic healthcare delivery system serving refugees. Measures Data collections for Objective I - Health Mentor Program and for Objective II - Refugee FYI flag were completed in December 2019 and February 2020, respectively. The data were analyzed in March and April and summaries and recommendations were distributed to relevant parties in April. The measures are designed to address both objective areas. They were selected as feasible means to obtain pilot information on Objective I and Objective II. The measures were endorsed by the academic medical center and the refugee resettlement agency to provide baseline data and guidance for further improvement of refugee healthcare systems. Details are provided below. Objective I - Health Mentor Program Measures A tool was developed to evaluate the efficacy of the Health Mentor Module I "Navigating the Healthcare System" in the Health Mentor Program and provide the refugee resettlement agency with specific feedback and recommendations for improvement. The intervention chosen was a pre- and post-assessment tool based on data collected from the mentees and mentors in a Google Forms survey. Google Forms provided a free and secure format for objective quantification of refugee learning. Mentor feedback via emailed comments and notes generated subjective qualitative data for consideration. A synthesis of all information enables triangulation for assessing the efficacy of the program for the first module, "Navigating the Healthcare System". The pre- and post-learning assessments were each 12 questions with six identical 14 questions for direct comparison, three multiple choice and three short-answer. Since the pre- and post-learning process as well as the module content was under review, there was no effort to evaluate for statistical difference in the number of correct answers between the pre- and post- learning. The total number of participants, 6 mentor/mentee pairs, was too small for meaningful statistical analysis and three of the six questions were short answer and not easy for direct comparison. This pilot appraisal is included to comment on the feasibility of the approach for future scaling. Objective II - Refugee FYI flag Measures The collection of objective baseline date was accomplished through modification of the EHR report tool. Baseline data were improved by inclusion of patient age, gender, primary language, and visit diagnosis. The enhanced baseline is essential to appraise current needs and probable modifications in health support to refugees as data change over time. Analysis Each study objective, Objective I - Health Mentor Program and Objective II - Refugee FYI flag had a unique set of parameters and analysis points. Quantitative and qualitative data were collected and analyzed. No statistical comparisons of pre- and postintervention data were performed. Objective I - Health Mentor Program Analysis Quantitative data from Health Mentor Module I "Navigating the Healthcare System" pre- and post-assessment too are used to probe the effectiveness of the Health Mentor Program. The average number of correct responses for multiple-choice questions 15 is calculated and recorded. Short-answer survey results from the tool are grouped by category according to mentor and author judgment. Written feedback from mentor experiences, their perceptions, and their thoughts are synthesized for Module I. Survey results, comments, and recommendations based on the data collected were sent to the refugee resettlement Health Promotion Program coordinator (Figure 5). Objective II - Refugee FYI flag Analysis The activities with the aim of providing education to healthcare staff were not recorded or analyzed. Multiple new data points were added to the original Refugee FYI flag tool to enable tracking of critical data. Specifically, three data points (gender, age, visit diagnosis/encounter) were used to assess and supplement refugee health records. Urgent Care and ED encounters in the academic medical system were documented by discharge diagnosis code. Diagnosis codes were grouped by system type and ranked by frequency. Ethical Considerations Several ethical issues were considered in designing this multidimensional project. The related, but diverging project objectives (Objective I and Objective II) required specific measures of consideration. The involvement of multiple organizations attending to health and welfare of a vulnerable population, along with diverse and crossdisciplinary interests, made considerations of ethical, legal, and moral parameters essential in this quality intervention initiative. Objective I - Health Mentor Program Ethical Considerations In July 2019, prior to clearing the Health Mentor pre- and post-learning 16 assessment tool questions with the refugee resettlement agency, the project details were submitted to an internal review board (IRB). The IRB deemed the project to be health care improvement exempt from requiring further oversight. To protect client safety and data, the refugee resettlement agency maintains very strict policies about what client data can be collected, studied, and analyzed. Only non-demographic client assessment questions for the Health Mentor Module I "Navigating the Healthcare System" were approved for a pre- and post-learning assessment tool. For example, age, gender, and primary language were considered demographic data and off limits per the IRC for Objective I. Objective II- Refugee FYI Flag Ethical Considerations The Refugee FYI flag did not need IRB review since it was already in effect. Ethical and legal concerns were raised by communication department management regarding the Refugee FYI flag data collection practices, verbiage being used, and legality. These concerns were explored by the Chief Compliance Officer and the Billing Compliance department. No ethical or legal findings of concern were noted, so employee education for ambulatory nursing care and the communication department was provided by the Refugee Program Coordinator and the author of this paper on several occasions. Results Quantitative data from Objective I - Health Mentor Program and Objective II - Refugee FYI flag are summarized in the tables included in the Appendix. Additional information is included in figures 6, 7, and 8. Objective I - Health Mentor Program Data 17 Objective I - Health Mentor Program data are summarized in Tables 1-4 (see Appendix). The pre-assessment had 12 questions, but only questions in the preassessment that are not part of the post-assessment are summarized in Table 1, with an N of six pairs of mentor/mentees. Two questions from the pre-assessment were excluded from the analysis, the mentor's email, and the date of the mentor/mentee meeting. Table 2 is a comparison of the six identical questions in the pre- and post-assessment which allowed for easier direct comparison between the pre- and post-learning data, although no statistical analysis of refugee answers was evaluated given (N = 6 pairs). Table 3 includes refugee and mentor responses to the six unique questions in the post-assessment (N = 6 pairs). Table 4 is a summary of mentor feedback rates (N = 5). Objective II- Refugee FYI flag Data Data from this intervention are presented in Tables 5-7 (see Appendix) as well as Figures 6-8. Table 5 shows average rates of utilization for clients with the Refugee FYI flag accessing health care within the academic medical center system. Table 6 is a compilation of Urgent Care encounters grouped by system complaints and Table 7 includes refugee utilization of the Emergency department (ED) based on final discharge diagnosis. The 10 languages most commonly noted by refugee patients are identified in Figure 6. Figure 7 reflects the refugee gender breakdown, and Figure 8 is a bar-chart of refugee age demographics by decade. Discussion Summary 18 Insights from the pilot Health Mentor Program evaluation tool, addressed in Objective I, strongly suggest the merit of expanding this approach of learning and support activities. Such an expansion in turn, will likely be a positive spin-off for broader public health issues and management. Similarly, enhancement of the Refugee FYI flag, along with awareness raising across healthcare teams indicates meaningful opportunities for improving health services to refugees. The synergistic combination of data from the Health Mentor Program and the Refuge FYI flag brings new energy for addressing refugee healthcare opportunities. Objective I - Health Mentor Program Summary The Health Mentor Program initially began in August, 2019 with 8 refugee mentor volunteers. One volunteer withdrew in November. Of the remaining 7 volunteers, 6 completed the pre- and post-learning assessments with a mentee, and 5 of those 6 mentors returned feedback about the experience. Even with the limited number of participants, the pilot initiative strongly suggests that the Health Mentor Program Module I can improve refugee knowledge of and confidence in accessing the healthcare system. Additional follow-up studies and support for this kind of approach is merited. Objective II - Refugee FYI flag Summary The Refugee FYI flag report modifications were completed, discussed, and available for analysis in February 2020. The report captured data from the inception of the reporting tool, September 18, 2018, through December 31, 2019. Data points related to Emergency department (ED) and Urgent Care services, as well as age (without date of birth) and gender, were successfully added to the original report structure. Information 19 from 1,802 patients with the Refugee FYI flag was obtained for review and analysis. Interpretation The evaluation of a refugee Health Mentor Program and the assessment of the refugee population generated new questions and opportunities for further investigation. The pre- and post-learning assessment tool proved effective for the mentors and mentees. Information collected provided insights into the refugee resettlement agency for future efforts to simplify content, increase the amount of translated materials, and improve interpreter services. The report modifications for the academic medical center generated a new understanding of the refugee patient. Objective I - Health Mentor Program Interpretation Review of Table 1 data from the pre-learning assessment indicated that 50% of volunteer and client pairs had an interpreter available for the first Health Mentor module and the pre- and post-learning assessment. Two individuals reported they had no interpreter, and one mentor had a family or friend available for interpretation. Five of six (83%) of the mentees reported that they did not need an appointment before seeing a doctor in their country of origin, and the same percentage indicated they understood individuals in the United States should have health insurance for healthcare services. Two-thirds (4 of 6) of the refugees did not know or understand if medical payment was required before emergency care; however, a third of respondents knew emergency medical care did not require pre-payment. Table 2 shows how respondents answered questions that were identical in the preand post-assessment surveys. The first three questions had a multiple-choice option 20 followed by an open-ended format. Following the teaching, 100% (6 of 6) of the refugees identified that a family doctor or PCP provided treatment for chronic conditions, up from 67% (4 of 6) in the pre-assessment. There was no change in the number of respondents who knew an appointment was necessary to see a PCP; however, 83% of refugee clients were able to verbalize that address/location was critical for 9-1-1 calls, up from 50%. On the pre-assessment, 83% of respondents identified that home care or a family physician appointment would be appropriate treatment for an injured wrist without deformity as well as for symptoms of a respiratory illness. In the post-assessment, 100% of respondents listed home or PCP care as appropriate for an injured wrist, but there was no change in their response to the respiratory symptom question. The sixth and final question on both the pre- and post-assessment related to emergency activation and emergency services. In the preassessment, 83% of refugee mentees felt that 9-1-1 or the Emergency department was appropriate for an individual who was not responsive and breathing poorly, but this number rose to 100% in the post-assessment. The six questions unique to the post-assessment survey are listed in Table 3. To evaluate learning connected to the role of the family provider or PCP, mentees were asked to list information necessary for a scheduled appointment; 67% knew to get the date of the appointment, and 83% knew to note the time of the appointment. However, only 17% (1 of 6) included location of the appointment as pertinent information. Furthermore, 83% of refugees knew to re-schedule their PCP appointment if they could not make the original appointment and knew to call 9-1-1 for someone who was having trouble speaking. 21 Overall, the learning module appeared to be well received and appreciated. 5 of 6 (83%) of refugee mentees reported they felt more comfortable accessing different levels of healthcare after Module I - "Navigating the Healthcare System" learning and only one individual indicated the teaching made no difference to their comfort level. Additionally, 83% of mentors completed the Levels of Healthcare handout with their mentee, a critical document in the refugee resettlement Health Promotion program. Two thirds of mentors indicated that the results of the pre-test affected what content they covered in the Navigating the Health System module. Health Mentor feedback (Table 4) reflects the response rate from the mentors about the experience of the Google Form pre- and post-assessment and module content. Data were collected from 5 of the 6 Health Mentors who completed the pre-and postassessment. The responses included email, notes taken during the lesson, and documents translated by the mentors for the client. Mentor suggestions related to Emergency and 9-1-1 teaching included: adding resources for parents to teach children about 9-1-1 calls, providing mentees with directions and addresses of closest emergency rooms, and practicing calls for the mentee to be able to clearly state preferred language, address, and what kind of help they require during a rescue call. Several mentors found that practicing sharing information in different scenarios was an important exercise for the mentee, as role-playing helped solidify concepts. Some mentors found the concepts, questions, and scenarios too complicated for their mentees, whereas others felt the examples were appropriate. No mentor mentioned that the concepts were too basic or over-simplified. One mentee synthesized information about the levels of healthcare from the 22 learning module into four unique documents regarding Home Care, Family or Primary Care, Urgent Care, and Emergency Department. She translated these documents into the primary language of her mentee for easy review. She felt this was beneficial because she could make concise points and focus on important information and leave the documents with the Levels of Healthcare for her mentee. Objective II - Refugee FYI Flag Interpretation The scope of the Refugee FYI flag report is to identify healthcare utilization and demographics for the Utah Refugee community accessing care at a large academic medical center. Tables 5-7 include information about utilization, and Figures 6-8 include demographic data. Each year since the Refugee FYI flag was created (2018), over 20 but less than 30 employees utilized the tool to identify an individual as refugee within the EHR system Overall, the refugee utilization data available for 2018 and 2019 appeared stable. In both years, 12% of all refugee encounters within the academic medical center were Urgent Care visits and 3% were Emergency department related. The remaining 88% and 97% of refugee encounters were for scheduled procedures and appointments. Refugees visited five Urgent Care locations within the academic medical center system during the reporting period. A total of 2,025 visits were flagged. A slight variation from the refugee summary of utilization (Table 5) was not investigated as it represented less than a 2% variation. Urgent Care encounters at one specific location accounted for a 1,976 or 98% of all documented Urgent Care visits. The remaining 2% occurred at the other Urgent Care locations. Unique diagnoses codes were grouped by major organ systems for clarity. 23 Most complaints were related to ears, eyes, nose, and throat (EENT), followed by gastrointestinal, respiratory, musculoskeletal, and integumentary concerns (Table 6). Emergency visits took place at two emergency departments during the report data extraction period (2018 through 2019). Less than 1% of all visits occurred outside the main academic center ED. All remaining emergency encounters occurred at the large ED where refugees received 266 unique diagnoses codes. These diagnoses were again grouped by major systems (Table 7). The five most common complaints in the ED were related to gastrointestinal diagnoses followed by cardiac, pregnancy, neurologic, and respiratory. Of the 507 ED visits, 89 resulted in an admission, or approximately 18%. Thirty-seven languages plus "Other" were identified by refugees as primary. The top 10 languages are listed in Figure 6, in which the group "Other" encompasses all the languages not listed. Arabic was the most common language identified (18%), followed by Somalian (16%) and Swahili (14%). The gender breakdown of the refugees identified by the Refugee FYI flag revealed that 60% of individuals were female and 40% were male (Figure 7). The average age of the refugees in the Epic system was 33 years old, with 19% of refugees falling between the ages of 31 and 40 (Figure 8). Females were on average one year younger than males, and 82% of all refugees had a reported age of less than 50. Limitations As the project progressed, implementation, method, and interpretative challenges emerged in both objectives. Due primarily to the limited sample size, the results were suggestive but not conclusive in Objective - I. A broader survey from the public health 24 department or repeated surveys from the academic medical center would be appropriate. Overall, the largest limitation of this project is that although it tries to describe and relate to health services for the refugee population in Utah, it captures information about only a unique subset of individuals, refugees accessing the academic medical center who are also appropriately flagged. This project does, however, serve as a pilot study to guide a more robust survey when resources are identified. Objective I - Health Mentor Program Limitations This was the first use of a pre- and post-assessment tool in the Health Mentor Program and the greatest limitation was the size of the study. The pre- and postassessment tool should be repeated with the next cohort of participants to see if the findings are consistent and if the feedback changes with different groups or remains the same over time. The question and answer format was selected carefully, but may not be the most effective tool for assessing learning. Half (3) of the pre- and post-assessment questions (Table 2) were open-ended scenario-based questions regarding appropriate levels of care. This type of question required the mentor to summarize and characterize the mentee response since the mentee was supposed to respond without prompting. This approach created two problems. First, it is impossible to verify if the mentor accurately interpreted the refugee's response, and second, the summarization misses the fuller assessment of health literacy achieved by allowing refugees to describe what they would do, i.e., some mentees were able to describe performing CPR in addition to seeking Emergency Medical Services (EMS). Simplifying all the answers into multiple choice may fail to 25 show true health literacy but would be more likely to allow statistical analysis of the effect of the learning. To better assess if the learning in Module I - "Navigating the Healthcare System" improved understanding about the levels of healthcare in the Utah, simpler scenarios, multiple-choice questions, and a larger sample size are needed. Additionally, issues with the situational questions illustrated that the teaching module was perhaps not effective in helping the mentees distinguish between ED care and activation of EMS. The module may not have made the distinction clear since emergency room and 9-1-1 seemed to be used interchangeably in the open-ended questions. Going forward, it may be better to emphasize the distinction between activation of 9-1-1 versus going to the ED. This is an important consideration as most of the clients in the Health Mentor Program are new arrivals and have limited access to transportation. Going forward, it may also be beneficial to separate "I don't know/ I don't understand the question" into two separate multiple-choice answers. The answers "I don't know" versus "I don't understand the question" suggest two different post-assessment outcomes. The first may indicate the teaching content is not effective, whereas the second might be that the assessment question is too complicated or not well written. In addition, the lack of interpreters for some of the module lessons likely negatively impacted the data collected. In the future, it may be better to compare data obtained with an interpreter separately from data collected without an interpreter. Objective II - Refugee FYI flag Limitations The Refugee FYI flag limitations were multifactorial. Initially, one of the original 26 requests was to assess and determine the chief complaint for all unscheduled provider/patient interactions in the Urgent Care centers and the EDs. However, patients interact with Epic in multiple modalities, making these data difficult to obtain with an automatic report. Another aim was to evaluate the most common diagnoses based on the principal diagnose code. However, this approach did not provide meaningful information because the diagnosis codes are so unique that they fail to associate nearly identical conditions. The work-around was to group diagnoses by organ system, which provided a better picture of why refugees were utilizing services. Unfortunately, this work-around narrowed multifactorial diagnoses into one category, and it required a subjective interpretation. In the future, a detailed study of the definitive diagnoses could give a clearer picture of utilization and perhaps better focus education efforts in the Health Mentor Program so that preventable encounters can be avoided. The project presented an opportunity to evaluate utilization of Urgent Care and ED by age group, but the age-based utilization was not consistent with the refugee utilization summary. The exact reason for this discrepancy was not fully understood, so the data were excluded in this review. In future studies, an age-based analysis of healthcare utilization could be very helpful for further efforts at tracking well-child checks, immunization, and other age-based screening recommendations. Finally, Urgent Care and ED utilization rates, 12% and 3% respectively, suggest that refugees using the academic medical center for healthcare are not overly reliant on these services. However, without more robust local, state, or national data available 27 regarding refugee healthcare utilization, it is impossible to make a definitive conclusion. Future research will be necessary for better result definitions to enable the application of appropriate policies. Weak healthcare delivery to refugees has wider direct and indirect implications for the health and economy of all citizens, especially with respect to infectious disease management. Enhancing the interface between curative medicine and preventative public health, including for refugees, merits raising awareness and strategic investment. Also of note, pregnancy related diagnoses were among the most common complaints for ED encounters. Whether this is unique to refugees or a norm of the general population should be determined. This finding may suggest that more comprehensive women's health services could mitigate some ED encounters. Again, additional investigation is warranted. The Refugee FYI flag tool provides information on the refugee population accessing healthcare through the academic medical center but does not necessarily reflect the refugee population in Utah as a whole. The academic medical center and the refugee resettlement agency involved in this project are closely linked, so information can be shared quickly between the two parties. The CCS resettlement agency does not have that same standing relationship with the academic medical center, and so pertinent findings should be provided to local and state organizations working closely with this population. Conclusions At the conclusion of the interventions and analysis there are more questions than answers, in part because of the limited sample size and short time horizon of the study. 28 The pre- and post-learning assessment provided some valuable information to share with the refugee resettlement agency, such as the urgent need to expand interpreter services for the Health Mentor. This process can and should be expanded to evaluate the success of the other 23 learning modules in the Health Mentor Program. The Refugee FYI flag tool is in its inception. Perhaps, more individuals will explore the data and focus refugee healthcare improvement measures in a specific and targeted manner. There is a clear need to invest in larger and longer-term surveillance of refugee-targeted healthcare support. The benefits will go well beyond the immediate improved health of a very vulnerable population. Indeed, this enhancement is not only a moral imperative; it will also have implications for broader economic and public health needs. 29 Acknowledgements I would like to thank Linda Johnson, DNP, AG-ACNP-BC, Keisa Lynch, DNP, APRN, FNP-C, Anna Gallegos, BA, Farah Al-Hamdani, Sheri Vanderhoof RHIA, Brian Head, Romany Redman, MD and the Health Mentor volunteers for their time, energy, feedback, patience, and expertise. 30 References Glanz, K., Rimer, B. K., & Viswanath, K.V. (2008). The Health Belief Model. In Champion V.L. & Skinner, C. S. (Eds). Health behavior and health education: Theory, research, and practice. San Francisco, CA, US: Jossey-Bass. Retrieved October 21, 2019 from https://www.med.upenn.edu/hbhe4/part2-ch3.shtml Guess, M., Tanabe, K., Nelson, A., Nguyen, S., Hauck, F., & Scharf, R. (2018). Emergency department and primary care use by refugees compared to non-refugee controls. Journal of Immigrant and Minority Health, 21, 1-8. International Rescue Committee (IRC). (n.d.). International Rescue Committee in Salt Lake City: Health Mentor Handbook. [Handbook]. Retrieved from U of U residents promote health access for refugees [Announcement]. Retrieved from https://www.rescue.org/announcement/u-u-residents-promote-health-access-refugees International Rescue Committee (IRC). (n.d.a). The IRC in Salt Lake City Utah. Retrieved June 19, from https://www.rescue.org/united-states/salt-lake-city-ut International Rescue Committee (IRC). (2017, November 22). U of U residents promote health access for refugees [Announcement]. Retrieved from https://www.rescue.org/announcement/u-u-residents-promote-health-access-refugees International Rescue Committee (IRC). (2019, February 13). Health mentors open doors as refugees access healthcare. [Announcement]. Retrieved from https://www.rescue.org/announcement/health-mentors-open-doors-refugees-accesshealthcare Kohlenberger, J., Buber-Ennser, I., Rengs, B., Leitner, S., & Landesmann, M. (2019). Barriers to health care access and service utilization of refugees in Austria: Evidence from a cross-sectional survey. Health Policy, 123(9), 833-839. Mangrio, E., & Forss, K. S. (2017). Refugees' experiences of healthcare in the host country: a scoping review. BMC Health Services Research, 17(1), 814. doi:10.1186/s12913-017-2731-0 United Nations High Commissioner for Refugees (UNHCR). (2019, June 19). Figures at a glance. Retrieved October 6, 2019 from https://www.unhcr.org/en-us/figures-at-aglance.html 31 University of Utah, College of Health. (n.d.). OTRT fieldwork/internship. Retrieved October 6, 2019 from https://health.utah.edu/occupational-recreationaltherapies/fieldwork/community-outreach/immigration-resettlement.php Utah Department of Health. (n.d.). Refugee health statistics. Retrieved October 6, 2019 from http://health.utah.gov/epi/healthypeople/refugee/datastatistics/ Utah Department of Health. (2018, October). Utah Refugee Health Program. [Manual]. Retrieved from http://health.utah.gov/epi/healthypeople/refugee/Refugee_Health_Program_Manual_ 2018.pdf Walden, J., & Sienkiewicz, H. (2019). Immigrant and refugee health in North Carolina. North Carolina Medical Journal, 80(2), 84-88 Watts, D., Friedman, J., Vivier, F., Tompkins, P., & Alario, M. (2012). Health care utilization of refugee children after resettlement. Journal of Immigrant and Minority Health, 14(4), 583-588 32 Figures Figure 1. Theory of change for reefugee systems improvement Note. Kueneman, E. (2019). Assessing Refugee Utilization of Healthcare Systems. [Scholarly Project Manuscript]. Figure 2. Interventions Note. Kueneman, E. (2019). Assessing Refugee Utilization of Healthcare Systems. [Scholarly Project Manuscript]. 33 34 Figure 3. Health mentor contact confirmation survey 35 36 37 38 39 40 41 42 Figure 4. Health Mentor evaluation tool for Health Mentor Module I "Navigating the Healthcare System" 43 44 Figure 5. IRC Recommendations Figure 6. Top ten refugee languages 45 Figure 7. Refugee by gender Figure 8. Refugee age demographics 46 Appendix Table 1 Pre-assessment Data, N=6 Is there an Interpreter present? N 3 2 1 % (50%) (33.3%) (16.7%) N 1 5 0 % (16.7%) (83.3%) (0%) In the United States, should you have health insurance for healthcare services? Yes No I don't know/ I don't understand the question N 5 0 1 % (83.3%) (0%) (16.7%) If you need to use emergency services (ED) in the United States, do you need to pay ahead of time? Yes No I don't know/ I don't understand the question N 0 2 4 % (0%) (33.3%) (66.7%) Yes No Other Where you come from, do you have to make an appointment before you see a doctor? Yes No I don't know/ I don't understand the question Table 2 Pre- and post-assessment, N=6 Pre-assessment Who provides care for long-term (chronic) health conditions? Family Doctor/ Primary Care Providers (PCP) The Hospital/ Emergency Department An Urgent Care/Clinic I don't know/ I don't understand the question 47 N 4 0 0 2 % (66.7%) (0%) (0%) (33.3%) Post-assessment N 6 0 0 0 % (100.0%) (0%) (0%) (0%) Do you need to make an appointment to see your primary care (family) doctor? Yes No I don't know/ I don't understand the question If you call 9-1-1, what information do you need to have? Your address/location Where you are from Your insurance, how you will pay I don't know/ I don't understand the question You slipped on some ice and your wrist is swollen and painful, but you can move it up and down and it is not crooked. What would you do first? Where would you go for medical care? Home/Home Care Family Doctor/ Primary Care Providers (PCP) Home or make an appointment? I don't know. You wake up and you have a runny nose, a sore throat, are shivering, and don't feel well. What would you do first? Where would you go for medical care? Home/Home followed by appropriate escalation of care Family Doctor/ Primary Care Providers (PCP) Urgent Care The Hospital/ Emergency Department You find someone that is breathing very slowly and you cannot wake them up. What would you do first? Where would you go for medical care? Call 911 Emergency Room I don't know Table 3 Post-assessment data, N=6 48 N 4 1 1 % (66.7%) (16.7%) (16.7%) N 4 0 2 % (66.7%) (0%) (16.7%) N 3 0 0 3 % (50%) (0%) (0%) (50%) N 5 0 0 1 % (83.3%) (0%) (0%) (16.7%) N 3 2 1 % (50%) (33.3%) (16.7%) N 2 4 0 % (16.7%) (66.7%) (0%) N % N % 4 (66.7%) 2 (16.7%) 1 0 1 (16.7%) (0%) (16.7%) 3 1 0 (50.0%) (16.7%) (0%) N 4 1 1 % (66.7%) (16.7%) (16.7%) N 5 1 0 % (83.3%) (16.7%) (0%) What should you always write down when you make an appointment with your doctor? (check all boxes the client is able to name) Date Time Location Gave different information/ Wasn't able to provide any answers What should you do if you have a doctor's appointment, but are unable to make it to the appointment? Call the doctor's office and re-schedule the appointment Send a friend or family member instead Go to the emergency room Find a new doctor Other/I don't know/I don't understand the question N 4 5 2 % (66.7%) (83.3%) (16.7%) 1 (16.7%) N % 5 (83.3%) 1 0 0 0 (16.7%) (0%) (0%) (0%) What number should you call if you see someone who is suddenly having trouble speaking? Call 911 Other/I don't know/I don't understand the question N 5 1 % (83.3%) (16.7%) After completing this lesson, how do you (mentee) feel about accessing different levels of healthcare? More comfortable No change Less comfortable N 5 1 0 % (83.3%) (16.7%) (0%) Did you complete the Levels of Healthcare form with your mentee? Yes No N 5 1 % (83.3%) (16.7%) Did the pre-test results affect what you covered in the Navigating the Health System I module? Yes Understood most of the pre-test before the module N 5 1 % (83.3%) (16.7%) Table 4 Mentor feedback, N = 6 49 Feedback provided Yes No N 5 0 % (83.3%) (0%) Table 5. Refugee rates of utilization Refugees utilization of services within an academic medical center % of % of Urgent Visits that Visits Refugee Total Care are Urgent ED that are Date Count Appts. Visits Visits Care ED < 2018 194 NA NA NA NA NA 2018 1280 8251 1000 12% 248 3% 2019 330 8347 991 12% 260 3% Total 1808 16598 1991 12% 508 3% ED to % of ED to Hospital Hospital Admissions Admissions NA NA 15% 38 20% 51 18% 89 Table 6: Urgent Care Utilization Urgent Care Utilization (N = 2,025) N Diagnosis EENT: Streptococcal pharyngitis, pharyngitis, periapical abscess, nasopharyngitis, otitis media/externa, Candida stomatitis, sinusitis, disorders of teeth and supporting structures, obstructive laryngitis, seasonal/allergic rhinitis, nasal congestion, oral aphthae, viral/atopic conjunctivitis, tonsillitis, impacted cerumen, mastodynia, dental caries, otalgia, gingivitis, laryngitis, foreign body, examination of eyes and vision with abnormal findings, perforation of tympanic membrane, hordeolum externum/internum, pansinusitis, bullous myringitis, sialoadenitis, dry mouth/eye, jaw pain, conjunctiva and 393 corneal abrasion, injury eye/orbit, disorders of eustachian tube, pterygium, conjunctival hemorrhage, cataract, laryngopharyngitis, hemophthalmos, ocular pain, disorders of eye and adnexa, dry eye syndrome, herpesviral gingivostomatitis and pharyngotonsillitis, disorders of nose and nasal sinuses, chalazion, gingiva and edentulous alveolar ridge, dacryocystitis, stomatitis, diseases of lips, lesions of oral mucosa, esophagitis, tinnitus, malocclusion, dysphagia, localized swelling, mass and lump head/neck, 50 Gastrointestinal: epigastric pain, quadrant/periumbilical pain, constipation, gastroesophageal reflux, viral intestinal infection, nausea, vomiting, diarrhea, gastoenteritis and colitis, epistaxis, gastritis, dehydration, constipation, melena, gas pain, flatulence, foreign body of alimentary tract, bacterial intestinal infections, peptic ulcer, dyspepsia, umbilical hernia with obstruction, infarction of intestine, irritable bowel, hemorrhage of anus/rectum, hematemesis, heartburn, Respiratory: acute upper respiratory infection, cough, influenza due to virus, asthma, bronchitis, bronchiolitis, bronchiectasis, shortness of breath, pneumonia, chronic obstructive pulmonary disease, dyspnea, wheezing, hypoxemia, pulmonary embolism Musculoskeletal: pain-low back/thoracic spine/pelvic perineal pain/knee/shoulder/foot/leg, cervigalgia, chondrocostal junction syndrome, strain of muscle, fascia, tendon, strain, lumbago with sciatica, plantar fascial fibromatosis, torticollis, unspecified injury, radial styloid tenosynovitis, enthesopathy, primary osteoarthritis, intervertebral disc degeneration, subluxation of patella, ganglion, myalgia, radiculopathy, medial epicondylitis, bicipital tendinitis, effusion, synovitis, crushing injury, Integumentary: follicular disorder, rash, pruritus, dermatitis, tinea corporis, anesthesia of skin, viral wart, hemorrhoids, herpes viral vesicular dermatitis, urticaria, abrasion, laceration, seborrheic dermatitis, plantar wart, pityriasis rosea, flushing, wound, blister, changes in skin texture, umbilical hemorrhage, paresthesia of skin, puncture, cellulitis, Molluscum contagiosum, dyshidrosis, acne, Tinea unguium, abscess, urticaria, eczema, purigo, Candidiasis, Nummular dermatitis, Impetigo, soft tissue disorders, viral infection characterized by skin and mucous membrane lesions, skin eruption due to drugs/medicaments, melanocytic nevi, Pregnancy: pregnancy related conditions, hyperemesis gravidarum, pregnancy test, hemorrhage, diseases complicating pregnancy, pre-eclampsia, infections in pregnancy, threatened/complete abortion, incompetence of cervix uteri, maternal care for abnormalities of pelvic organs, intrauterine death, decreased fetal movements, antepartum hemorrhage, disorders of lactation, supervision of multigravida, gestational edema, external causes complicating pregnancy, noninflammatory disorders of vagina, ovarian cyst, Neurologic: headache, dizziness and giddiness, tension-type headache, syncope and collapse, injury of head, concussion, intracranial injury, altered mental status, migraine, benign paroxysmal vertigo, cyclical vomiting, cerebral infarction, epilepsy, injury of face, fatigue, Geniurinary: dysuria, cystitis with hematuria, frequency of micturition, acute pyelonephritis, proteinuria, urethritis, symptoms and signs involving the genitourinary system, renal colic, tubulo-interstitial nephritis, hematuria, polyuria, acute kidney failure, calculus of gallbladder without cholecystitis 51 313 307 249 138 112 104 90 Misc: symptoms and signs involving the circulatory and respiratory systems, general symptoms and signs, general adult/child medical examination, malaise, enlarged lymph nodes, examination of blood pressure, effect of heat and light, idiopathic gout, restless legs syndrome, chronic pain, urethral discharge, localized edema, chills, angioneurotic edema, follow-up examination after completed treatment, obstructive sleep apnea, specified counseling, examination/observation following transport accident, weakness, fatigue, abnormal weight loss, fussy infant, illness, superficial foreign body, adverse effect of drugs, medicaments and biological substances, toxic effect of venom of bees, sexual dysfunction, general counseling/advice on procreation, dietary counseling/surveillance, encountering health services, insomnia, sleep disorder, acute postprocedural pain, vascular complications following infusion, transfusion and therapeutic injection, adverse effect of other vaccines and biological substances, specified symptoms and signs involving the circulatory and respiratory systems, exposure to hazardous, chiefly nonmedicinal, chemicals Cardiac: chest pain, palpitations, pleurodynia, hypertension, hypotension, arrhythmia, cardiomegaly, heart failure, hypertension and CKD, varicose veins, venous insufficiency Infectious/Sepsis: fever, viral infection, exposure to viral communicable diseases, Human immunodeficiency virus (HIV), sepsis, Plasmodium malariae malaria, unspecified malaria, Hb-SS disease with crisis, Enteroviral vesicular stomatitis with exanthem, infection following a procedure, Zoster without complications, fever with conditions, screening for HIV Women's Health: dysmenorrhea, excessive and frequent menstruation with irregular cycle, abnormal uterine and vaginal bleeding, mastitis, amenorrhea, acute vaginitis, surveillance of injectable contraceptive, pruritus vulvae, excessive and frequent menstruation, lump in breast, parametritis and pelvic cellulitis, Candidiasis of vulva and vagina Endocrine: Type 2 diabetes mellitus with hyperglycemia/nephropathy, Type 1 diabetes with ketoacidosis, thyrotoxicosis Contusion: eyelid and periocular area, head, thorax, hip, abdominal wall, foot, shoulder, finger, oral cavity, lip, knee Fracture: Torus fracture of lower radius/tibia, fracture of calcaneus/proximal phalanx/middle phalanx/distal phalanx/fifth metatarsal/nasal bones/rib/tibial tuberosity/lower leg/lateral end of clavicle/second metacarpal Behavioral Health: hallucinations, anxiety, symptoms and signs involving emotional state, major depressive disorder, nightmare disorder Bite: insect bite (nonvenomous), open bite Men's Health: testicular pain, disorder of male genital organs, Burn: burn of second degree of right hand, unspecified site, initial encounter Left AMA: procedure and treatment not carried out due to patient leaving prior to being seen by health care provider Abuse: adult physical abuse, suspected Hematologic: acute embolism and thrombosis of veins, 52 72 65 61 43 20 19 19 5 5 3 2 2 1 1 1 Line, drain, device: encounter for change or removal of surgical wound dressing Table 7: Emergency department utilization Emergency Care Utilization (N = 507) Diagnosis Gastrointestinal: Epigastric pain, quadrant pain, gastro-esophageal reflux, ulcer with hemorrhage, gastroenteritis and colitis, cholelithiasis, diarrhea, nausea, vomiting, hernia, diverticulosis, constipation, perforation of intestine, cholecystitis, cholangitis, fistula, pancreatitis, hematemesis, melena, intestinal infarct, dehydration Cardiac: chest pain, hypertension, hypertension and CKD/HF, arrhythmias, NSTEMI, HF, CAD, pericarditis Pregnancy: hemorrhage, other specified diseases complicating pregnancy/childbirth/puerperium, spontaneous/threatened/missed abortion, tubal pregnancy, pre-eclampsia, vomiting, mental disorder complicating pregnancy, endometriosis following delivery, mastitis Neurologic: Headache, migraine, dizziness and giddiness, cerebral infarction, TIA, epilepsy, AMS, idiopathic normal pressure hydrocephalus, concussion, encephalopathy, conversion disorder, abducent nerve palsy, syncope, head injury, ICH, tremor, weakness, dissociative amnesia, fatigue Respiratory: Acute/chronic respiratory failure with hypoxia/hypercapnia, asthma, shortness of breath, cough, upper respiratory infection, pneumonia, bronchiectasis, respiratory tuberculosis, chest pain on breathing, COPD with exacerbation, pulmonary embolism, influenza Musculoskeletal: Pain in foot/low back/shoulder/knee/arm/finger/pelvic, strain of muscle, fascia and tendon, osteoarthritis, effusion, spinal stenosis, radiculopathy, sciatica, muscle spasm, chondrocostal junction syndrome, cervicalgia, dorsalgia, myalgia, EENT: Streptococcal/acute pharyngitis, dental caries, oral disorders, sialoadenitis, conjunctivitis, tympanic membrane perforation, retinal artery occlusion, sinusitis, tonsillitis, vision loss, swelling/mass/lump, impacted cerumen, otitis media, otalgia, chalazion, dysphagia, epistaxis, periapical abscess Geniurinary: Tubulo-interstitial nephritis, dysuria, UTI, urinary retention, renal calculus, incontinence, pyelonephritis, hydronephrosis, AKI, cystitis, Integumentary: Urticaria, candidiasis, cellulitis, disorder of skin/subcutaneous tissue/soft tissue, anesthesia of skin, laceration, hemorrhoids, residual body Endocrine: Type 2 diabetes mellitus with hyperglycemia/ketoacidosis/polyneuropathy, Type 1 diabetes mellitus with ketoacidosis 53 N ED to Admit 82 14 65 14 61 9 53 9 38 10 29 1 27 1 24 1 17 1 16 6 Women's Health: acute parametritis/pelvic cellulitis, abnormal uterine and vaginal bleeding, mastodynia, pelvic inflammatory disease, vaginitis, corpus luteum cyst, excessing/frequent menstruation Behavioral Health: delusional disorder, anxiety disorder, PTSD, major depressive disorder, OCD, acute stress rxn, anorexia nervosa Infectious/Sepsis: Sepsis due to unspecified organism/Staphylococcus, infection following procedure, fever, viral infection, varicella Misc: acute postprocedural pain, other general symptoms and signs, gout, other specified surgical aftercare, chronic fatigue, issue of repeat prescription Fracture/Dislocation: ribs, lateral condyle of humerus, lateral end of clavicle, dislocation of acromioclavicular joint, intraarticular fracture of radius, femur Line/Drain/Device: Malfunction of tracheostomy, mechanical complication/adjustment of other gastrointestinal prosthetic device, complication of vascular dialysis catheter, change or removal of drains Contusion: thorax, foot, finger, abdomen, leg Other: Procedure and treatment not carried out due to patient leaving prior to being seen by health care provider Drug: Alcohol dependence with intoxication, alcoholic hepatitis, stimulant abuse Malignancy: neoplasm, multiple myeloma, sacrococcygeal disorder Abuse: adult sexual abuse, adult physical abuse Anaphylaxis: Anaphylactic reaction, allergy Burn: Burn of second degree Hematologic: Immune thrombocytopenic purpura, and thrombosis Men's Health: Abnormal level of enzymes in specimens from male genital organs, Inflammatory disorders of spermatic cord, tunica vaginalis and vas deferens 54 15 0 14 2 14 9 9 0 7 3 7 1 8 0 5 0 3 2 3 2 2 2 2 1 1 1 0 1 2 0