Health district, Catholic Charities defend nurse-conducted examinations
LAS VEGAS — Refugees from around the world come to Southern Nevada, often from countries with diseases not commonly seen in the native U.S.-born population.
How sound is the medical screening refugees receive? Are they getting adequate medical care?
According to the U.S. Office of Refugee Resettlement, more than a thousand refugees annually relocate to Las Vegas with federal assistance. The top countries of origin, says ORR, are Cuba, Iraq, Eritrea, Bhutan and Ethiopia.
Because the refugees often come “from regions of the world with high rates of certain diseases,” notes the federal agency, “refugees face special health challenges.” They thus must first undergo medical screening overseas to ensure they are medically eligible for the U.S. Refugee Program. Then, after arriving in the U.S., they are directed to undergo more in-depth medical examination.
One purpose of the U.S.-based screening, says ORR, is to protect the public health of U.S. citizens. A second purpose is to “provide refugees with a level of health and well-being required for and supportive of successful resettlement in the U.S.”
Since 1994, ORR’s partner in Nevada for refugee services has been Catholic Charities of Southern Nevada (CCSN). For fiscal year 2010-11, the nonprofit administered some $6.7 million in federal refugee funds. CCSN not only serves as ORR’s designated State Refugee Coordinator, but also operates the local refugee resettlement office.
The Southern Nevada Health District, under contract to Catholic Charities since at least 2008, conducts the federally required medical screenings for the refugees — including their health histories and physical examinations.
The refugee medical screenings conducted by SNHD over the last five years, however, do not appear to conform to federal standards.
ORR guidelines state that the refugee medical “screenings should be performed by a qualified licensed health care professional." And by such a professional, ORR means — as demonstrated through ORR’s use of federal billing codes — either a physician, a physician’s assistant, or a nurse practitioner.
SNHD’s contracts with Catholic Charities, however, only state that the district will have “a Community Health Nurse” do “a complete history and physical” on refugees.
All of the district’s community health nurses are registered nurses (RNs), according to the Nevada State Board of Nursing, and none are nurse practitioners (NPs), also called, in Nevada, advanced nursing practitioners (ANPs).
The health district’s use of RNs for such work would also appear to violate the Nevada Administrative Code’s regulations governing nurse practice.
NAC 632.255 states one must at least be certified as an advanced nursing practitioner before "recording medical histories and performing physical examinations" are within one’s scope of practice.
Touro University Nevada’s School of Nursing, which trains both nurses and nurse practitioners, makes a similar distinction:
The Family Nurse Practitioner Track prepares the graduate to work as a nurse practitioner in a variety of settings. S/he will be able to perform health histories and physical examinations, order and interpret diagnostic tests, diagnose and manage acute and chronic diseases, prescribe medication and treatments, provide patient and family counseling and education regarding lifestyle behaviors. (Emphasis added.)
So, are the refugees sent to Southern Nevada by the federal government getting substandard medical screenings? Could Southern Nevada residents be at greater risk of foreign disease than they know?
Nevada Journal asked both Catholic Charities and SNHD about the apparent discrepancy between Nevada law and CCSN’s contract with SNHD.
“Well, it’s always been our understanding that we are in compliance with any medical screening guidelines, in terms of having community nurses conduct the screenings,” said Carisa Lopez-Ramirez, CCSN’s vice president for immigration and migration services.
“It is our understanding that what [the RNs] are performing, is basically asking questions related to medical history. But in terms of the actual physical examination, [the RN] is being monitored by a medical director that oversees that whole program.”
Lopez-Ramirez was referring to the part of the agreement with the health district that calls for the “Program Medical Director” to perform a “review of clients' history, physical and laboratory results”
SNHD director of clinics and nursing services Bonnie Sorenson also cited the review provision in SNHD’s contract with Catholic Charities.
“The individuals we see in our program,” she said, “come to us with a bundle of information that was gathered in an assessment overseas. And all of that is transferred to a nursing assessment form, along with any other additional information collected by the nurse, as well as the screening tests that are done in public health.
“That is all,” said Sorenson, “then forwarded to the physician, who reviews it all, does his own history and physical assessment and treatment and diagnosis.”
However, Sorenson did not answer when asked, “Does the physician actually examine all of the refugees who come through the system?” Instead, she introduced Community Health Nurse Manager Margarita DeSantos, whom Sorenson described as the “manager of the program.”
“What our nurse is doing,” said DeSantos, “is a screening nursing assessment…. If the client presents with any complaint, or, if they happen to bring in their overseas form — which many don’t — and there is something listed as a chronic condition needing follow up, or, um … then she refers them to a physician that takes that particular refugee’s insurance program, and then that physician follows that refugee client under their own practice. All we are doing is a screening nursing assessment.”
That SNHD RNs make the initial, critical medical judgments about the state of each refugee’s health — acting as gatekeepers before refugees see a physician — is also indicated not only by the remarks of Sorenson and DeSantos, but by the health district’s own description of the program in its annual reports.
SNHD’s 2010 annual report states that its staff that year “screened 484 refugees,” with 109 of them requiring “follow-up for possible communicable diseases: 72 for tuberculosis; 13 for hepatitis B; 10 for ova and parasites; and 15 for sexually transmitted disease.” For 2011, the comparable numbers were 492 refugees, 109 receiving follow-up: 72 for tuberculosis; 17 for hepatitis B; 10 for ova and parasites; and 14 for sexually transmitted disease.
The difficulty with such screening by RNs, notes James D. Hook, director of healthcare consulting at the Fox Group, LLC, is that recognizing whether some patient’s condition actually is abnormal may at times require a greater level of medical expertise than even a typically competent RN would have.
Hook agrees with Sorenson that “RNs can certainly do physical assessments, up to a point.” And, he says, “there’s no bright line that says, ‘Below this it’s fine, above this you need somebody with more qualifications.’”
But “[i]n terms of doing a physical,” he told Nevada Journal, “the question always becomes, if you find something that does not appear normal, what do you do then? And are you so well-qualified and schooled, and experienced and so on, that you can tell what’s normal and what isn’t?
“Where it’s not something that the patient can tell you about,” he said, “that’s where the issue of being an advanced practice nurse, or a PA or a physician comes into play.”
Nevada Journal attempted multiple times to interview internist Dr. Antonio Serru Paez, the local refugee program’s medical director, but was unsuccessful.
On Friday, a woman identifying herself as his office manager said the doctor would be available for a short telephone interview Monday afternoon at 4:30 p.m. However, when NJ called at that time, it was stated that Serru Paez was too busy, still seeing patients. Could the reporter call back early Tuesday morning, at 8 a.m., the reporter were asked. However, at 8 a.m. Tuesday, Serru Paez again opted to not come to the telephone. According to his telephone receptionist, Serru Paez was “not yet in the office,” although he “sees patients from 8 a.m. to 5:30 p.m.”
Nevada Journal’s phone number was taken, but no return call was received by publication time.
ORR program spokeswoman Lisa Raffonelli told Nevada Journal that “ORR puts forth general guidelines to states, which then have the flexibility to adapt them to their individual models within the broader ORR program regulations outlined in 45 CFR Part 400.”
The federal Centers for Disease Control — upon which ORR relies heavily for guidance on refugee medical issues — calls “The initial history and physical (H&P) examination … a critically important first step in the assessment of newly arrived refugees. A thoughtful H&P can both assist in identifying disease and help refugees develop a sense of trust in our medical system and in the care being provided” them.
“Depending on their country of origin,” says the CDC, “refugees are at increased risk for many diseases, both infectious and noninfectious, not commonly seen in the native US-born population. Conditions such as tuberculosis and sexually transmitted infections are particularly important to recognize early, given their potential public health consequences.”
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