Partnering Through the Pandemic: Keystone Health Agricultural Worker Program’s Fight Against COVID-19

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Earlier this year, Melanie Finkenbinder, MD, shared the best practices [2] that Keystone Health, a health center in Chambersburg, Pennsylvania, was using to fight COVID-19 in migrant agricultural worker camps. Six months later, after Pennsylvania’s main agricultural seasons have come to an end, and most migrants have either returned to their country of origin or moved southward for more agricultural work, Dr. Finkenbinder, Medical Director of the health center’s Agricultural Worker Program, shares the partnerships they have built and the lessons they have learned.
        

Pennsylvania Department of Health: An Important Partner

“We have a great relationship with our Health Department here,” noted Dr. Finkenbinder. Her health clinic, located in south-central Pennsylvania, has the highest concentration of migrant agricultural workers in Pennsylvania who come for the fruit planting and harvest season throughout the late spring, summer, and fall. Staff from Keystone’s agricultural worker program has worked closely with the Pennsylvania Department of Health throughout the pandemic, especially Adams County Health Department’s bilingual nurse, Fred Oberholtzer  who works with migrant programs throughout Adams, Franklin, and Cumberland counties, to coordinate COVID-19 outbreak care at migrant agricultural camps. 

Describing their relationship, Dr. Finkenbinder explained the interactive process they used to keep communication open about COVID-19 cases, to swiftly prevent the growth of migrant camp outbreaks. 

When encountering a migrant worker infected with COVID-19, Dr. Finkenbinder’s team immediately contacts the camp’s farm owner . Due to the close quarters in the living arrangements of many worker camps, the agricultural worker program usually recommend that everyone who works or lives around the worker be tested. However, before testing takes place, the agricultural worker program contacts the health department to make Oberholtzer aware of the testing, and to ask his advice on whether additional groups at the camp should be tested. After test results return from the lab, the agricultural worker program distributes them to the farm owner and Oberholtzer. When there are negative results, Dr. Finkenbinder’s team contacts the farm owner, and then mails or hand delivers copies of the test results or a lab letter to the worker. Dr. Finkenbinder then discusses the results and the next steps with Oberholtzer. 

The agricultural worker program also contacts any infected patients and provides them with education on COVID-19. During this visit, they inform the patient that their health department contact will be reaching out to them as well. Following this visit, Oberholtzer reaches out to the patients and completes a case investigation and initial contact tracing. If he finds more workers who are showing symptoms, he contacts Dr. Finkenbinder, who follows up with a telemedicine visit. Following the investigation, Dr. Finkenbinder meets again with Oberholtzer to discuss, and come to an agreement, about a recommended date for the agricultural workers to return to work, as well as whether additional testing needs to be completed. Explaining the importance of this step, Dr. Finkenbinder said, “we were sending a consistent message … it’s very important to the workers and the [farm owners] what day everybody can go back to work.” 

On the impact of the health department and health center’s partnership on local farm owners, Dr. Finkenbinder said she felt that the knowledge that they knew one another and were working closely together to make decisions, even if they played different roles, helped to obtain local farm owners’ confidence in them and improved effectiveness in engaging with them. Additionally, the fact that both the program’s staff and the nurse from the health department speak Spanish aided in gaining the confidence of farm owners. Dr. Finkenbinder noted that in other states, where a lack of collaboration could lead to differing recommendations, farm owners could lose confidence in their advisers’ expertise, or in the importance of the recommendations they are being provided. Additionally, Dr. Finkenbinder feels that her team and the health center having had bilingual staff helped gain trust between them and their patients and allowed workers to ask more questions and gain better clarifications than they may have otherwise obtained. Additionally, she felt like their partnership with the health department may make the health department seem safer to workers, if any concerns were previously present.

“It is a really great partnership. I think we were really effective.” Dr. Finkenbinder concluded. Contemplating their process, she said, “We were able to take care of quite a few outbreaks in that way and I think we were really successful in stopping the spread that was going on.”

While their partnership with the Pennsylvania Department of Health was instrumental in successfully combating COVID-19, the partnership had a little help getting started. Years prior, Fred Oberholtzer was the Director of the Keystone Agricultural Worker Program before moving to the health department. When COVID-19 hit, Dr. Finkenbinder consulted Oberholtzer, and the two realized they should be working together to efficiently combat COVID-19 in their community. Prior to the partnership, Dr. Finkenbinder explained that there did not seem to be a predetermined process at the health department that would successfully group positive cases of migrants from the same camp. “It really makes more sense to [support] them as a group, to have the same person do all of the contact tracing for the group,” she said. Oberholtzer discussed this realization with his supervisor who arranged that he focuses on assisting migrant camps with contact tracing. “I don’t know that we would have ended up in this situation without having had a relationship before but I think it’s a model … that other programs could use in trying to talk to their county health departments about a coordinated response to outbreaks,” said Dr. Finkenbinder.
      

State Bureau of Laboratories: Test Results Within 24 Hours

Another partnership Dr. Finkenbinder brought to light was with the Department of Health’s Bureau of Laboratories’ State Laboratory. “They were able to do 24-hour turnaround time for us on tests for a lot of the year,” said Dr. Finkenbinder. “Being able to count on that short of a turnaround time really improved our ability to be effective in mitigating an outbreak and be able to separate all of the asymptomatic positives from everybody else.” If possible, Dr. Finkenbinder recommends working with the state Bureau of Laboratories, “Especially if they are able to prioritize testing for high-risk populations,” she added. After asking their local health department what to do about the long testing turnaround times they were encountering, they were advised to check with the state lab. “So, we talked to them and they agreed to do it, and it wasn’t a big deal… it was all free for us too. They just sent us all of the supplies that we needed,” including testing kits and a courier to pick up the test, she said. 
     

Pennsylvania Farm Owners: Improved Relationships

Dr. Finkenbinder said she thinks the agricultural worker program’s relationships with farm owners have improved during their fight against COVID-19. She feels the direct contact and increased conversations around COVID-19 have helped, and even attributes the pandemic to rebuilding a poor relationship with one farm.

“Being able to provide education services and being able to provide testing services were the keys to building and improving our relationships with [farm owners],” she said. Dr. Finkenbinder stressed that the main, and probably most valuable, services they provided with their outreach to farms was COVID-19 education. While providing farm owners with CDC guidelines and other advice, they would ask them if there was any special COVID-19-related emphasis they would like them to add to their usual health education classes. For example, they could emphasize wearing masks properly if the farm owners noticed workers not wearing masks, creating tailored visits to each group of agricultural workers.

Dr. Finkenbinder attributed some of their improved relationships to the farm owners’ need for assistance with cultural and language barriers that were not as apparent before COVID-19. Typically, farm owners feel they can sufficiently communicate the basic messages they need to ensure workers can do their jobs. However, “this year, that divide and not being able to communicate directly with the workers brought a lot more anxiety for the [farm owners], especially for the ones who did everything that they could to prevent an outbreak,” Dr. Finkenbinder said. Those farmers “really wanted to make sure that [the workers] got that education.” It was something they could not do themselves, and something they depended on the health center to provide.
     

The Past Six Months

Since MCN last spoke to Dr. Finkenbinder in June, Keystone’s agricultural worker program continued with their new plan of best practices for caring for workers through COVID-19, aside from some minor alterations. 

 “We couldn’t bring a lot of patients into our clinic at one time” because of COVID-19, Dr. Finkenbinder explained. So, they utilized their no-contact outreach model. “We dropped the things that required close contact and emphasized the things that didn’t,” she explained, allowing them to help workers who were displaying symptoms access care while minimizing risk to their staff. This change was made following the CDC’s guidelines. Those needing more medical care were cared for in their health clinic, out in the field through field clinics, through scheduled telehealth visits, and, most notably, through an office-hours-style approach to telehealth, where Dr. Finkenbinder and other clinicians at the clinic remained on call when their outreach team was at the camps. The no-contact outreach model “ended up being a good model for us,” noted Dr. Finkenbinder and reduced the use of limited PPE. 

In June, Dr. Finkenbinder had discussed their piloted open-access telemedicine program, in which an agricultural worker could rip off a scan code from flyers placed around agricultural worker housing, and if they scanned the code, they would automatically go to a virtual waiting room. However, she explained that the program did not work as well as expected. One reason is that the workers may not have felt comfortable using the telemedicine platform. Another might have been technical issues. Dr. Finkenbinder explained that after a few failed attempts, “we didn’t push it too hard.” She observed that the platform was largely unknown and might take some training to use properly. She said one option is to switch to platforms other programs are using such as WhatsApp and similar platforms that workers may be more familiar with.
     

Plans for Next Year

In preparation for next year, Dr. Finkenbinder explained they are staying updated on the distribution of COVID-19 vaccines so they know what their part may be in assisting migrant workers with getting vaccinated. She hopes her program will be able to better prepare the community to work together in anticipation of workers arriving in the spring. Testing upon arrival, and available space for isolation and quarantine housing will help prevent large outbreaks like the ones they encountered this year. Additionally, Dr. Finkenbinder wants to make sure workers have everything they need and are entitled to. She explained that if legislation was renewed or created that requires workers to be paid for sick leave, she wants to educate farm owners in order to make sure they are aware the legislation applies to them and some of their agricultural workers, something not all farm owners were aware of this year when legislation, which expires at the end of the year, went into effect. “That is something I hope we would be able to advocate better for this coming year,” she noted.

Aside from testing migrant workers who are waiting on a negative COVID-19 test to go home, most of the migrant agricultural workers have migrated out of south-central Pennsylvania. Instead of enjoying the lull, Dr. Finkenbinder is hoping Keystone Agricultural Worker Program will begin to focus its efforts on farmworkers who stay in Pennsylvania year-round pruning in the orchards or working in poultry processing plants -- especially since she fears COVID-19 will get worse for these workers during the winter months.

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