In addition to the quantitative and descriptive data housed in the Initiative Logic Map, a series of cross cutting themes were identified related to individual participants, partnerships with educational institutions and employers as well as system-level challenges and associated policy strategies. Understanding these themes and their relationships informed the Initiative’s continuous quality improvement processes and shaped recommendations for building replicable Welcome Back models elsewhere in the future.
English Language Proficiency
Participants, educators, and employers alike identified lack of fluency in English as a fundamental obstacle for ITHPs. While the general consensus is that fluency in English is an important predictor of academic success in health professions, it is also acknowledged that certain professions, like health care interpreters, require a much higher degree of fluency than others, such as phlebotomists. It is also not the only predictor of success. Even some programs that historically required college-level English, like the Licensed Vocational Nursing refresher course at City College of SF reported that frequently, students scoring low on English placement exams did as well in class and on the licensure exam as students with higher placement scores.
Participants understood the need to improve their language skills but expressed great frustration with the length and focus of existing “English as a Second Language” (ESL) programs, which typically run from 3 to 5 years and are primarily focused on reading and writing but not on speaking.
Sixty-one percent (61%) of the respondents to the WB survey indicated that their level of English has improved since their involvement with WB. In addition to referral to ESL classes, the encouragement and the opportunity to use and to be exposed to the English language in the context of classes, study groups, presentations, workshops and other activities with peers and Educational Case Managers (ECM’s) appears to have had a positive impact on the participants. Currently, through funding from the California Wellness Foundation and Kaiser Permanente, a specialized English for Health Professionals curriculum was developed for internationally trained health professionals by the San Francisco WB.
Loss of Professional Identity
Among the most challenging aspects of WB’s work with immigrant health professionals was dealing with the emotional sequela of migration, including losses of country, family, professional identity, networks, and social standing along with the underlying reasons for migrating. The selection of a career direction was often done in late adolescence and became part of the individual’s identity in adulthood. Outside of their families, it is through work that many individuals developed social networks and social standing. Immigrant health professionals often faced the loss of professional identity and associated social standing and the challenge of redefining themselves in a new societal context. Participants needed time to adjust to loss of professional identity; this was especially true with physicians, representing the largest group of participants.
The loss of professional identity was compounded by the complexity of the licensure processes. Without appropriate guidance, the participants easily could become lost in a labyrinth and miss details or deadlines resulting in lost opportunities for validating their licenses. In addition, lack of familiarity with the US health system’s structure, the roles and professions that exist in the US, and the US health workplace culture, could prevent them from taking advantage of potential opportunities. The role of the ECM is essential in helping navigate the licensing process and in identifying new and fulfilling roles in the health sector.
Developing a realistic professional strategy for WB participants took time, a comprehensive assessment, and support. For example, at the San Francisco site, an average of 5 encounters with ECMs per participant were generated, and staff reported that this was the typical face-to-face time necessary to begin a physician’s journey towards either pursuing medical licensure in the US or consideration of alternative career paths. Fifty-four percent (54%) of survey respondents stated that WB had assisted them in improving their self esteem; 98% said it was important or very important to have an opportunity to interact with other ITHPs; and 66% of respondents noted that WB has helped them explore new career options.
Lack of financial resources and time to attend classes were consistently identified as barriers to participation. Individuals often did not have the time to go to school because they held two or three jobs in order to support their families. Therefore, efforts to find the time to go to school frequently implied a significant reduction in income. Structuring the hours of operation of Welcome Back Centers with this issue in mind has enabled the participants to take full advantage of the program’s services. An important role of the ECMs was to assist participants in finding potential sources of financial support, e.g., scholarships, and loan forgiveness programs. In some cases, assistance in finding affordable childcare or housing was identified as a key element for participants to succeed.
With these elements of support in place, the outcomes the participants accomplished are impressive. Data from a sample of program participants at the Los Angeles site shows that, on average, participants’ income has doubled upon completion of the plan they developed with their ECM. Also WB participant survey data shows that 35% of the respondents had slight or significant increase in income since they enrolled in WB.
Commitment to the Safety Net
The intent of the WB program was to strengthen the safety net by contributing to the creation of a health workforce that better reflects the demographics of California and is willing to serve medically underserved communities. The program’s initial plan was to require that, upon completion of WB, individuals who had received services would volunteer to work 200 hours in medically underserved areas (when possible, with their communities of origin) in symbolic “payment” for the services received. Shortly after the program began its services, it became apparent that this plan would be difficult to carry out. Time is a prime commodity for the participants who often juggle more than one job and family responsibilities even before they attempt to go to school. In this light, 200 hours of volunteer service represent a cost that participants cannot afford to pay.
Nonetheless, the ECMs continued to encourage and assist participants in obtaining volunteer placements, as these often resulted in valuable hands-on experience and letters of reference for future jobs. In addition, the program’s activities and classes consistently highlight the issues of disparities in health, barriers to access to health services, and the role of the safety net. However, when a participant states that he/she is unable to commit to a volunteer job, the issue is not pursued further.
While participants are highly motivated to work with their communities of origin, the realities of the marketplace prevail when job opportunities arise: the private sector can and does offer better salaries than the safety net. When presented with the option of a job with a significantly higher salary and sign-in bonuses, participants are highly likely to take it. The broader contextual issues related to the financial viability and structural security of the safety net influence WB’s ability to provide a pipeline of health workers to safety net providers. The commitment remains to increase the pool of workers available and to find innovative, realistic strategies to contribute to the medically underserved communities of California.
The program’s expectation is that as it contributes to increase the pool of culturally and linguistically diverse health workers, both the safety net and the private sector will be able to find qualified staff to deliver services.
Flexible Career Pathways
The program’s approach to developing a career strategy with the participants started by understanding where the participant was in the spectrum of options available to him/her. This flexible pathways approach, is a non-linear, non-“one-size-fits-all” service model featuring a menu of options and client flow pathways. Participants had different needs at different points in time and to be successful, the program was required to be flexible.
Typically, early steps in this process included setting both short-term and long-term goals. For example, if a person’s long-term goal was to obtain a nursing license, she might begin by enrolling in a phlebotomy course. Upon completion of the course, she could obtain a job in the health sector and thus improve his/her familiarity with the US health workplace. At the same time, she could be enrolled in a customized English as a Second Language program and have started the process for obtaining her transcripts from her country of origin. On a monthly basis, she would meet with the ECM to check in on the status of the entire process, obtain information about upcoming events, for example an interviewing skills workshop.
Movement in a positive direction in the spectrum of goals and outcomes was always a function of time. In the best-case scenario, a participant could take a minimum of one semester to obtain a basic phlebotomy or CNA certificate. But as the goals became more ambitious, the amount of time required increased substantially: it usually took several months to obtain transcripts from other countries; six to 10 months to have transcripts reviewed by the Nursing Board; one to two years to complete the prerequisites to a Physician’s Assistant or Dental Hygienist program; up to four years to complete a residency training program. And all these scenarios assumed that the participant had the required level of competency in English to enroll in these programs.
In order to expedite part of these processes, the WB Initiative Director worked with educational and licensing entities as well as with professional associations to explore the feasibility of creating accelerated programs that met all the licensing criteria and at the same time builds on the participants’ previous professional experience. As an example, the Board of Registered Nursing (BRN) broke ground in California by agreeing to pilot an accelerated Associate Degree in Nursing (ADN) program, developed for international medical graduates (IMGs). In fourteen months, the program will graduate 35 IMG participants from the San Diego WB center. While most nursing curricula are based on a two-year format, the new accelerated ADN curriculum gained the BRN’s approval because it builds upon the medical training and experience of these internationally training health professionals.
In addition, several hundred participants have completed license preparation courses, thousands have received assistance in validating their foreign credentials, and hundreds more have attended the classes developed by WB. For a complete description of all the individual participant outcomes see the Initiative Logic Map under the puzzle piece and pathways arrow.
Our experience demonstrates that to significantly contribute to the diversification of the health workforce, intense, up front and flexible investment needs to be made. In the long term, this investment can yield important and long lasting results creating a stable workforce from and dedicated to California’s diverse ethnic communities.
WB had extremely dedicated staff at every center, at every level. Many of these individuals were immigrants themselves and/or had worked with immigrant communities for decades. This core was always willing to go the extra mile to assist participants and advocate for the supports they needed. Leadership at every site included immigrant internationally trained health professionals. The staff’s linguistic and cultural competency directly enhanced the centers’ ability to serve a diverse population; it also probably impacted the racial and linguistic mix of participants enrolled in the program.
The fact that the Initiative Director was a Mexican, immigrant physician gave a "real" public face to the WB program, particularly for the media and within the policy arena. After the initial press conference announcing the Initiative, Latino media –television, radio, and print- picked up and followed up on the story well into the program’s third year. The Initiative Director’s professional networks and his ability to navigate the system and establish bridges between diverse constituencies, e.g., key stakeholders, program staff, and WB participants, was an important added value for programmatic success.
Regional Center Variation
Each center evolved somewhat differently because of geographical location, vision of the local leadership, size of the service area, preexisting relationships with local employers and educational institutions, and staffing needs of the regional health sector. Clearly, well-established relationships through the Regional Health Occupations Resource Centers networks helped identify employer partners, particularly in San Diego and Los Angeles. The three centers began within the existing structure of the RHORCs, which had proven track records of success in health workforce development. The RHORCs also had well-established networks that included community colleges and employers. This was not the case for the Fresno center, where new partnerships were difficult to establish. The directors of the RHORCs were essential insiders that knew both the mechanics of the educational institutions and the employer landscape and early on facilitated important
In San Diego local employers were incorporated early on the center’s advisory committee helping to structure policies and provide in-kind assistance. The sheer large size of the participant pool (even with little outreach) in Los Angeles necessitated a modification in the client flow algorithm to accommodate group orientations. The preexisting strong relationships between San Francisco staff and safety net providers gave this center a distinctive character including the incorporation of safety net providers on their advisory committee.
The strong existent relationship between City College of San Francisco Community College and San Francisco State University and institutionalized through Community Health Works, helped pave the way for smooth inter-institutional relationships. Finally, the nursing shortage throughout California provided opportunities for all WB centers to find employment for participants. Additional information about each center demonstrating these regional variations can be found on each center’s website or by examining client level data through the Initiative Logic Map.
The experience of Welcome Back with academic institutions is limited to three of California’s Community colleges and one California State University (CSU). We have found that a key element in the success of the program has been a strong commitment from the host educational institutions. Chancellors, presidents, deans and department chairs each held a key to a particular piece of the puzzle that needed to work collaboratively. As an example, the development of a nursing licensing exam preparation course at the Los Angeles center required the buy-in of the nursing faculty, the chair of the nursing department and the dean of Economic Development of the host college. As “insiders”, these individuals were essential in finding ways to facilitate processes within institutions that were difficult to understand from the outside.
The affordable costs of education and ease of access, make community colleges an ideal setting for the WB centers. Over 70% of program participants in the San Francisco WB have been enrolled at some point as students in a community college, primarily in English as a Second Language Courses. The educational case management services and other activities provided by the WB centers, complement the needs of this particular immigrant population for language acquisition and educational and vocational
For participants the availability of program components outside a conventional 9 – 5 time frame was essential; mechanisms to support night and weekend classes and activities was necessary. While the college administrators were in favor of evening and weekend hours, union contracts and labor agreements made these configurations difficult in some cases. Besides their educational mission, an appealing incentive for colleges and universities to implement the WB program in California was the increase in revenue associated with a larger number of students in classes. However, this incentive disappeared when programs were impacted, i.e. when there were more applicants than the program was able to accommodate, which was the case at Fresno City College.
Also, it was important that the partnerships included a four-year educational institution able to provide additional career pathways. Most WB participants had an educational equivalent to a Bachelor’s degree, hence the importance of having the option of accessing master’s level programs, e.g. MPH program. In addition, the Leadership in Health Series and the Introduction to the US Health Care System courses were developed by SFSU faculty. By offering some courses at the 4-year college, participants were exposed to another educational environment that might be a better fit for some program participants.
A central strength of the program was access to faculty that could structure and spearhead
a sophisticated evaluation strategy.
Institutionalizing courses and trainings within the partner institutions was an essential part of the sustainability strategy. The Introduction to the US Health System, the USMLE prep course, and the English for Health Professionals have been institutionalized in San Diego and in San Francisco.
In some instances, college districts were connected to the county’s civil service program thus hiring processes were inordinately long or cumbersome for a time-sensitive, grantfunded program.
It became clear during the first year of implementation that a key educational partner was not at the table, medical schools. The Initiative director, as part of his policy work, began making contacts with medical schools in Northern California, as did the Los Angeles Center Director in the Los Angeles area. These contacts are ongoing and efforts to continue this program need to involve these key partners.
As key stakeholders, employers were involved with the three sites in different levels of support/engagement. They participated in advisory boards, provided in-kind support (e.g. space), financial support (e.g. covering the cost of courses), and became policy partners.
Partnering with the public health sector employers enabled the Initiative to stay true to its mission of developing a workforce to serve the underserved communities of California. A survey conducted by students in the MPH program at SFSU documented the need for linguistically competent health professionals in San Francisco as well as clinic and hospital administrators’ attitudes and opinions of foreign-trained health professionals. Among other findings, respondents stated that there is not a large enough pool of bilingual/bicultural applicants for chronically open positions. Moreover, administrators stated that retaining bilingual/bicultural clinical staff is a challenge because they often get recruited elsewhere for better pay. Many clinics also have difficulty hiring ancillary staff to provide supplemental support to primary medical care. Also, a concern of administrators was that ITHPs might not have the necessary English language skills to communicate effectively with all patients and other staff.
Partnering with the private health sector was an important element of sustainability for the program. Because of their stronger economic situation, the private sector has been willing and able to provide financial support to the Centers, directly and indirectly. Thanks to this support, curricula was developed and implemented (e.g. Nursing Licensing Preparation Course at Los Angeles WB, English Health Train at San Francisco WB), office space for the program was secured (e.g. San Diego WB). In addition, the enthusiastic support from the private sector lends the Initiative an important degree of credibility vis à vis other employers, potential funders, and policy makers.
WB’s work in the policy arena focused on opening doors and fostering constructive dialogue with and among the key stakeholders: WB participants, employers, educators, licensing boards, professional associations, community advocates, and policy makers. In its planning phase, the Initiative developed a much better understanding of the interconnected roles of these players and was able to establish itself as a new partner. By presenting the data collected in the past three years at numerous meetings, hearings, and conferences, the program has had ample opportunity to establish the need for and the value of the WB program and the ITHPs that reside in California.
The Initiative greatly benefited from the professional experience and networks of its staff. For example, these were essential in the early stages of developing a collaboration with the Board of Registered Nursing, which lead to the full support of the Department of Consumer Affairs and on to healthy working relationships with other licensing boards. The centers’ Advisory Committees also assisted in establishing relationships with other entities such as the California Primary Care Association, the California State Rural Health Association, the Latino Coalition for a Healthy California, the San Diego Medical Society, as well as with State senators and assemblypersons.
Today, most of the health workforce development discussions in the State include the ITHPs as a valuable resource to be included in program planning. This is in large part created by the visibility of the WB program. After three years in operation, the WB Initiative has developed a meaningful presence in Sacramento as well as in some areas across the country with significant concentrations of immigrants. Recent changes in State leadership will require that the Initiative re-examines and reestablishes relationships with the new players that might not be as familiar with the work WB has conducted with ITHPs over the past three years.