Up to the Challenges

Profile of Sue Hagie

“A personal goal for me each day that I go to the camps is to try to manage to have the same energy level and interest in the last patient of the day as I had with the first patient who was seen.”

Summers on the Eastern Shore of Maryland are busy for Sue Hagie, NP. She is the only nurse practitioner providing health care on the farms and at seafood houses for three counties. Until recently, the Choptank Community Health team with which she works had two and a half additional nurse practitioner positions for the migrant program that sat unfilled. Between June and August, she heads out, with an interpreter and sometimes a support staffer, to the camps to provide care for migrant workers across Maryland.

“I cover 21 seafood houses, a couple of nurseries, a cannery, and the farms,” she said, providing care for 39 sites in all. Including the driving — the northern camps require her to drive about 160 miles a day — she clocks in about ten hours a day. “Then, I go home and I work on the scripts and complete the documentation.” She then inputs all the information into the electronic medical record, as internet access is limited at the camps. “It’s a long day.”

Early Experiences

For the last several years, Hagie has tried to do the work that was once done by several providers. The lack of support, in the field and sometimes financially, is not new to Hagie. Previous to moving to Maryland, Hagie worked for the National Health Service Corp in a community health clinic located in the Blue Ridge Mountains of Virginia, until a loss of clinic funding forced the clinic to downsize. That action nearly eliminated the community-based program. “Our staff… dropped from more than 20 workers to three. It was a wonderful clinic and they gave excellent care, but you need to have money to keep health care programs operating,” she admitted.

The high level of need, and the challenges in providing care, are part of the appeal for Hagie. In speaking about the need for more migrant health care providers at Choptank, she notes, “If folks gave it a chance, I think they’d really love it. There’s just no work I can think of where you can find more challenges than working with the migrant population. One just needs to enjoy variety and be flexible.”

Farm Owners Make a Difference

One of her biggest challenges is the issue of denied access to camps. One farm does not give Hagie and her team access to its camp at all, instead permitting the farm’s workers to attend an off-site clinic, which occurs once or twice a summer. Numerous attempts to provide transportation, and to work with the farm owner in advance to assure farmworker attendance, have resulted in limited success, she says. “Unfortunately, these are sites where there are older farmworkers and ones having numerous chronic care issues, such as hypertension, heart disease, diabetes, asthma, hepatitis, and other chronic conditions,” she said.

The schedule is hard on the workers. The workers arrive several hours late to the clinic, but have to return to the camp shortly thereafter — the owner requires them to be back by 9pm. “The workers start at 5 o’clock in the morning, and they haven’t eaten by the time they arrive at 7:30 at night,” Hagie explained. “We always provide food for them there, and it’s a nice air conditioned clinic, but they’re dead tired. They fall asleep in the waiting room.”

Additionally troubling is Hagie’s inability to fit everything into the short time that she has. “You have almost an hour and a half to see ten or 11 people with several chronic issues, acute issues, a bag full of pill bottles, they need blood work — it makes it very difficult,” she admitted.

Continuing care is even more difficult. “If the patient needs blood work done, I am denied access to that worker by the farm owner to discuss his lab results and how to take any of the needed medications. It’s a difficult situation that prevents the workers from receiving needed medical care,” Hagie stated. “This is an ongoing issue where we have not had a very successful outcome. It’s the type of occurrence that one would have expected a hundred years ago, but not in the present day.”

Hagie emphasizes that the majority of migrant employers are fully supportive of the services Choptank provides, and welcome her team to the camps. “We work around their variable schedules and visit where they live, not disrupting their work time,” she explained. Just as farmers are across the map in providing access, they are diverse in the quality of housing they provide. Hagie recalls her first trip to a migrant camp in Virginia, with the state’s health department, to do check-ups on new mothers and their infants. “There would be a house, and twenty people living in it, and there would be no refrigerator or furniture at all, except for maybe a mattress in one room. That would be where the mom and baby would be,” Hagie recalled. In some camps, “they have nice facilities, where they have a place for people to eat, [provide] dorm rooms, and [offer resources for] English as a Second Language…But then you go to the other places, where there are holes in the roof, [and] very deplorable conditions. It runs the whole gamut,” Hagie said.

Migrant Health Plan Makes Access Easier

Hagie praises Choptank’s migrant health program for its yearly program with migrants. “Each year, we charge a $15 flat fee, and that covers my on-site visits, to provide medical care, and the clinic visits,” she explained. Processing of the lab work is provided by Shore Health, a local lab and medical facility. Her migrant team delivers the medications to the patients within about two days, because travel to pharmacies is difficult.

Hagie likes the strong link between her on-site visits and the clinic option; she encourages workers to go to the clinic for services she can’t provide, like dental care, or for urgent care between her visits.

To help to address the increased need due to fewer migrant health care providers in the field, one of Choptank’s clinics extended its hours an additional hour and a half, one or two times a week, to see migrant workers, Hagie noted.

Additionally, the community program hired an assistant to input information into electronic medical records,as double documentation was labor intensive.

“One of the exciting new additions that we are hoping to try this summer is providing on-site dental exams and cleanings with our dental hygienists and mobile dental equipment,” Hagie added. “Dental care is a much-needed offering and it is difficult for the worker who has variable hours to plan three weeks in advance to go to an appointment. When we offer care on-site to where they live, they put their name on the list and we fit them into the time that we have.”

Prevention and Fair Treatment

Hagie likes to emphasize prevention with her patients. “Prevention and lifestyle changes are an integral part of improving one’s health. It’s very satisfying to see the worker attempt those changes to improve his or her health,” she said.

She tries to do her part by providing fair treatment to each of her patients. “A personal goal for me each day that I go to the camps is to try to manage to have the same energy level and interest in the last patient of the day as I had with the first patient who was seen,” she said. “It is a deliberate effort to make that happen.”

Access Affects Farmworkers’ Health

Hagie finds that the health of the workers who she serves varies greatly. The agricultural workers, she says, come to Maryland sicker than the seafood, nursery, or cannery workers. “The people who are in the worst physical condition are the farmworkers. Being here only three months, they can only access our care for three months,” she said. She finds the agricultural workers coming from Florida and Texas have more uncontrolled chronic health care needs. “They tell me that it costs more — they have to pay for their medications,” she noted. “If they have to pay for medications, many times, they’re not going to get them,” even if care for a chronic condition requires regular medication. She suspects that many are coming from areas without an easily-accessible community health center, and perhaps the combination of accessibility and transportation issues, with financial concerns, keeps these workers from care.

Continuity of care is also a problem. “You’ll see these patients with two blood pressure medications of the same category, or they are taking other medications that should not be given together,” she noted, “because there is very little continuity” as they travel.

But such patients with overlapping issues are the most gratifying for Hagie, when she can make a difference. “I really like working with the high-need patients, those who have several chronic conditions and acute problems. When you throw in the low income and the mobile status, that increases the obstacles and makes it even more challenging,” Hagie admitted. “I like to see if we can make some positive outcomes occur — that’s very satisfying.”

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Profile originally published on MCN’s website as part of 30 Clinicians Making a Difference, a project celebrating Migrant Clinicians Network’s 30th anniversary through the life stories of 30 clinicians making a difference in migrant health.