A Population in Peril


FEATURING: Thomas Buckley, MPH, RPh, Associate Clinical Professor of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut

Theanvy Kuoch, Executive Director, Khmer Health Advocates, West Hartford, Connecticut


A Team Effort

The Cambodian American community that arrived in the United States in the late 1970s as refugees of war, torture, and genocide are now among the highest risk persons in the country. The estimated 140,000 survivors have the same health care costs as a community of 3 million people due to extraordinary rates of chronic disease, including depression, post-traumatic stress disorder (PTSD), diabetes, cardiovascular disease, and stroke.i

Thankfully, Connecticut-based Khmer Health Advocates’ (KHA) mission is to treat the health needs of this unique patient population and their families. Founded in 1982 by a Cambodian holocaust survivor and three American nurses who worked in refugee camps, KHA was one of the first programs for torture victims in the United States, and remains the only Cambodian health organization in the country. The group provides patient-centered care to people in Connecticut and Western Massachusetts, and provides support and training for similar torture trauma groups nationwide.

At KHA, patients are treated by multidisciplinary, cross-cultural teams on which pharmacy plays an integral role. Dr. Thomas Buckley at the University of Connecticut School of Pharmacy conducts comprehensive medication therapy management (MTM) sessions at the center. These medication reviews are critical to improving the health of the Khmer people, as well as improving the efficiency of care delivery by other workers. Students in their fourth year at the pharmacy school also provide MTM at the center.

“When a pharmacist can help manage a patient’s medications, it means that the psychiatrist can provide his or her services directly, without having to also do medication reviews,” Thomas said. “The Khmer people are very complicated because they’re getting their medications from many different places, while also going to many different providers.”

Cultural Complications

Medication reviews are just one part of the comprehensive, coordinated care provided by KHA. Community health workers, who are trained by Thomas and other staff, also screen patients for depression, PTSD, and diabetes, oftentimes visiting patients in their homes to perform such services. They also evaluate social determinants of health, such as access issues, transportation roadblocks, and food and housing components of a patient’s lifestyle.

“We look at the whole person,” Thomas said. “When we do risk assessments, we want to know, What’s the risk of everything they have? Are they at risk of having poor access to care? Do they have translators? Are they seeing a Cambodian faith healer? Cultural competence plays a major role.”

But access doesn’t always equal positive health outcomes, a new study reveals. Together with researchers from the University of Connecticut School of Social Work, Harvard Program in Refugee Trauma, and University of California Los Angeles, KHA surveyed 136 Cambodian American refugees living in Connecticut and Western Massachusetts about their health. More than 70 percent reported fair or poor health status and nearly two-thirds stated that they felt hopeless and/or depressed despite seemingly successful access to healthcare.ii

“This study challenges the perception of healthcare access,” says Theanvy Kuoch, KHA executive director. “It reinforces the definition of culturally and linguistically appropriate care to include care coordination and risk assessment based on the context of the whole person, including a detailed trauma history, evaluation of patient resources and their ability to utilize those resources.”

Coming Up Short

Dramatic slashes to federal funding mean KHA can barely keep its doors open. Specifically, a continuation of the five-year, $5 million Centers for Disease Control and Prevention (CDC) Racial and Ethnic Approaches to Community Health (REACH) grant was discontinued due to sequestration in 2013, and an additional two federal grants were initially approved but not funded. As a result, KHA was forced to eliminate many vital administrative functions necessary to keep KHA open and serving patients. Community health workers were also laid off, forcing KHA to triage their efforts by treating patients with acute problems first and delaying comprehensive services to those with chronic issues.

While it is widely accepted that preventive care is better care for people with chronic conditions, KHA simply does not have the staff to meet the demand for these services due to recent budget cuts. KHA’s recent work with high-risk patients shows that comprehensive care can utilize between 40-60 hours of staff time per year. Since the implementation of sequestration, cuts to their federal funding have meant a 75 percent reduction in the size of their community health worker staff, dramatically decreasing the number of patients KHA will be able to serve. “We can’t do this without the community health workers,” Thomas says. “They are the cultural link.” The effects of delaying comprehensive care to the patients will not be known for years to come. However, with the high precedence of diabetes and stroke in this population, it is not unlikely that a delay in care will lead to further increases in early disability and mortality.

The organization receives some funding through Connecticut’s Department of Mental Health and Addiction Services, but it’s a small amount and isn’t enough to keep the doors open, Thomas said. He hopes to receive additional support from a state innovation model grant, but stresses that the need for torture treatment services remains strong. “In a perfect world, we wouldn’t be surviving with grants.”

American Association of Colleges of Pharmacy

i Continuing Health Crisis in the Cambodian Community. White Paper, Khmer Health Advocates, National Cambodian American Health Initiative, 2013.

ii Berthold, S. M.; Kong, S.; Mollica, R. F.; Kuoch, T.; Scully, M.; Franke, T.. (2014). Comorbid Mental and Physical Health and Health Access in Cambodian Refugees in the US. Journal of Community Health. Page 5.