MIDDLEBURY — When Alicia Rodríguez discovered she was pregnant in 2005, she did not know where to go for medical care. She and her husband worked on a dairy farm and neither spoke much English. She went to Porter Medical Center, and had to navigate using an interpreter over the phone to understand her doctors and nurses.
While she said that access to remote interpretation is better than nothing, it was frustrating. She was in pain, and her interpreter was a non-native Spanish speaker with a heavy accent.
“There came a moment when I said, ‘I don’t want to use the translator anymore, my husband and I can communicate with the doctor and nurse with our limited English,’” Rodríguez told this reporter in an interview, which was conducted in Spanish.
After she gave birth, a nurse told Rodríguez about the Open Door Clinic, located across the parking lot from the hospital. There, Rodríguez could receive free medical care and interact with both Spanish-speaking staff and in-person volunteer interpreters.
The Open Door Clinic is one of the only clinics in Vermont that has developed a program dedicated to serving the local migrant farmworker population. Partnering with other members of the statewide Bridges to Health consortium, and in collaborating with Middlebury College, the clinic is uniquely positioned to offer health care, translation services and case management to a group that is often overlooked.
The clinic was founded in 1991, and for the first two years it provided medical services town-by-town in a blue school bus. The clinic’s free-standing site opened in 1993 in Middlebury, and a second site was added in Vergennes in 2010.
“It was a real kind of grassroots organization that launched the Open Door Clinic,” said Heidi Sulis, the executive director. “In many ways we have evolved in the last almost 30 years but our mission hasn’t shifted a lot. We’re still committed to increasing access to care and serving the uninsured and underinsured. That really hasn’t wavered.”
Access for Spanish-speaking patients
Staff at the Open Door Clinic share a belief that everyone deserves access to medical care, and they have spent more than a decade working on how to best provide medical care to migrant farmworkers. Several factors contributed to the development of the clinic’s program, starting with the high concentration of Spanish-speaking migrants in Addison County.
“Everywhere else in the state, farmworkers are really geographically dispersed,” said Naomi Wolcott-MacCausland, the migrant health coordinator at UVM Extension. “There’s really not a large number of farmworkers in any other county that would allow for a large percentage of a patient population to be Spanish-speaking.”
Without a high concentration of Spanish-speaking patients to serve, Wolcott-MacCausland said, clinics do not have the resources to develop a language access program.
Wolcott-MacCausland works with the Open Door Clinic through Bridges to Health, and over the last decade has participated in developing a model for migrant medical care access. Their work has been supported by a series of federal grant from the Health Resources & Services Administration. The grant has contributed $45,000 annually to the Open Door Clinic’s budget since it was renewed for its fourth three-year cycle in 2018.
In addition to federal grant money, the Open Door Clinic is funded through a series of local and state sources. In 2018, its operating budget was more than $372,000, with the majority of the funding coming from the state Legislature (32%), community fundraising (20%) and private grants (19%). The rest of their funding came from a grant from United Way of Addison County, contributions from individual towns and patient donations.
According to Sulis, the legislative funding is allocated to free clinics with the intention that they will help connect Vermonters to affordable insurance options.
“In a perfect world we would see people once or twice and then move them onto a permanent medical care home,” she said.
However, migrant workers, many of whom do not have legal status in the U.S., are not eligible for health insurance. This means that migrant workers often rely on the clinic more regularly and for longer than other patients.
According to the Open Door Clinic’s records, this year the clinic has seen an equal number of English and Spanish-speaking patients, but the Spanish-speaking patients account for more than 60% of its health care interactions. Julia Doucet, the clinic’s outreach nurse, said that while these numbers are not perfect — some migrant workers are categorized as speaking English, for example — the statistics represent a larger trend.
According to Doucet, the clinic’s migrant medical care model begins with effective outreach.
“If you’re new here and you don’t speak the language, and you get sick or hurt and you don’t know what to do, that can be a really scary experience,” Doucet said. “I see the outreach program as a way of assuaging fears, of building trust, of putting a face to our clinic and showing through an understanding of their culture and their language that we are a place that can be trusted.”
Each fall, Doucet and her team go to more than 35 farms in the area to give flu shots and spread the word about the clinic. Doucet visits farms throughout the year, sometimes with other medical providers, offering services from urine tests to birth control shots to dental screenings.
“Sometimes it’s just easier to go to the farm than to have somebody come here,” she said. “We’re basically the liaison between our brick and mortar clinic and the population that we’re trying to reach.”
When patients do decide to make an appointment, the Open Door Clinic does its best to provide linguistically and culturally aware care. According to Doucet, this means more than ensuring a patient can understand a doctor during an appointment.
“Seeing a patient in a room is only a small part of a health interaction,” she said. “It starts with, can the patient call a clinic and make an appointment in their language or be understood to make an appointment? Can the clinic confirm the appointment with the patient? Can the patient show up and fill out the appropriate paperwork?”
In order to recruit the number of volunteer interpreters needed to serve its Spanish-speaking patients, the Open Door Clinic turned to nearby Middlebury College.
“We couldn’t send in-person interpreters to half of these appointments if we didn’t have all the volunteers. I think that is unparalleled in the state,” Sulis said.
According to Rodríguez, who now serves on the clinic’s board and interprets once a month, it can be daunting to rely on a translator in a medical context.
“You have to completely trust that person, and trust that they are saying how you are feeling and passing the message to the doctor correctly,” she said.
However, she said that in her experience Spanish-speaking patients trust the services they receive at the clinic.
“[The clinic] has created a strong bond between the doctors, patients and interpreters,” she said. “We all trust that the interpreters are doing a good job.”
With the help of Spanish-speaking volunteers, the Open Door Clinic sends interpreters to every appointment where they are needed, and also with patients who are referred to specialists.
Beyond language services, Open Door Clinic aims to address other obstacles that might block migrant workers from accessing medical care, scheduling follow up appointments and applying for financial assistance at specialists’ offices. According to Doucet, many of the barriers that migrant workers face are caused or exacerbated by the fact that many do not have legal residency status.
One such barrier is transportation — until a few years ago, when Vermont adopted driver’s privilege cards that allow people to drive regardless of citizenship status, undocumented workers could not legally drive. Even now few have access to licenses or cars. Sometimes, they rely on their bosses for rides to the clinic, and some bosses are better than others about giving workers time off to visit the doctor, according to Rodríguez.
“It makes me mad to know that some bosses do not give workers permission, you shouldn’t need permission to go to the doctor,” Rodríguez said, “However, there are occasions when people cancel because they don’t have a ride or because they can’t get time off work.”
No other clinic in the state has a similarly comprehensive outreach, interpretation and case management model for their Spanish-speaking patients. Migrants in other parts of Vermont often access health care through UVM Extension, where staff help them get in touch with the medical care in their area.
‘You never arrive to where you should be’
According to staff at the Open Door Clinic, and at partner organizations through Bridges to Health, the clinic’s capacity to serve migrant workers stems from a longstanding commitment to their Spanish-speaking patients.
“We had some very innovative, creative and future-minded people on staff who really saw the way that immigration was going and came up with a scaffolding for how to create access to health care in a really professional way,” Doucet said.
Doucet said another important aspect of the clinic’s philosophy is that it is always trying to improve its services.
“You never arrive to where you should be,” she said. “We are always looking at how we can continue to better the services we provide, what wrap around services should we be building in, how can we empower our patients to take control of their own health care.”
For Rodríguez, it has been a joy to find an avenue to serve her community through an organization she believes in.
“We are all enchanted with the services, with the doctors and nurses and therapists,” she said. “I don’t think you’ll find a person who says, ‘I went to the clinic and I didn’t like the attention I received.’ Never.”
Read the story on VTDigger here: Open Door Clinic helps meet health care needs of migrant farmworkers.
