South East (46803, 46806)

Meet Southeast residents addressing the social determinants of health in their neighborhoods

Maria Diaz and Amber Ramsey are Community Health Workers for Parkview's Safety PIN program in Southeast Fort Wayne.

As a Burmese refugee living in Fort Wayne for the past 12 years, Amber Ramsey knows what it’s like to not have access to important information.

When her family moved to the U.S. from Thailand, they found it difficult to assimilate to Northeast Indiana’s culture. None of the local news was in their native language, few people understood their cultural background, and it was difficult to know who they could trust.

But as Ramsey learned English in school, she excelled in her studies and graduated in the top five of her class at Woodlan High School in Woodburn. After going on to earn her bachelor's degree in Business Management and becoming a manager in her job at Panda Express, she and her husband decided to have their first baby. In the process, they discovered a whole new system they were unfamiliar with: Local healthcare services.

“When I was pregnant, I didn’t know about any resources in the community,” Ramsey says. “I paid out of pocket, and I did everything on my own because I never had those community connections.”

Amber Ramsey is a Burmese refugee who works as a Community Health Worker for Parkview Health's Safety PIN program.

It was this experience of having to self-navigate her first pregnancy that inspired Ramsey to pass on the knowledge she gained to her fellow Burmese community members—and to anyone facing lingual, cultural, financial, or other barriers to healthcare in Allen County.

When Ramsey’s baby was two months old, she became one of eight Community Health Workers hired by Parkview Health in 2017 for a four-year Safety PIN program, funded through the Indiana State Department of Health’s Safety PIN grant. The goal of the program is to reduce Allen County’s Infant Mortality Rate (IMR) by taking a grassroots approach to the issue, particularly in the 46805 and 46806 zip codes where infant mortality is the highest.

In the 46806 zip code of Southeast Fort Wayne near where Ramsey lived, the IMR in 2017 was 15.4, which is about three times the national average and the fourth highest in the state. So as someone who has personal experience assimilating to local culture, Ramsey wanted to help other families navigate gaps in culture, language, trust, and resources that may be preventing them from receiving effective maternal and infant care.

“When I heard about Parkview’s Safety PIN program, I was excited because I know what a struggle it is to come here from a different culture,” Ramsey says. “You don’t know what you don’t know, and you’re not always sure what to ask for. So I thought it would be nice if there were people who knew our culture who could tell us about the resources here.”

Data from the Indiana State Department of Health.

After going through training and earning a certification with Parkview’s partner, HealthVisions Fort Wayne, Ramsey and other Community Health Workers often find themselves being that one-stop, trusted voice of guidance for the families they serve. It’s all part of a mission to go beyond the traditional bounds of healthcare to meet families where they are at, says Safety PIN Project Manager Gwen Masterson, who oversees Parkview’s Community Health Workers.

Masterson explains that when it comes to reducing the state’s IMR, it’s not only the education barrier that many families face; it’s also the structural and social barriers that are preventing them from receiving effective care.

“Poverty is at the root of many of the physical, mental, social, and financial challenges that cause infant mortality in our community,” Masterson says. “People in financial need face many barriers when it comes to accessing transportation, nutritious food, housing, healthcare, education, and even emotional support during their pregnancies. So our work is all about bridging those gaps and getting supplies and resources to people. Sometimes, that means literally just being that support system for them.”

When it comes to serving multiple, multicultural families with different needs, Community Health Workers have to be flexible with their schedules. Under normal conditions, they are often working in the community at public events and churches or by making house visits to check in on their clients. But health and safety procedures for the COVID-19 pandemic are changing the way they operate, Masterson explains.

“We’re doing a lot of virtual visits,” she says. “We’re also operating like a ‘Ding Dong Deliver’ service for moms, making sure they still have access to all the resources they need during the pandemic.”

HealthVisions Midwest of Fort Wayne is located at 2135 S. Hanna St.

Since there are many organizations working to reduce Allen County’s IMR, and since so much information is changing week-by-week during the pandemic, Community Health Workers are the ones navigating these changes for families. Along with delivering supplies like diapers, breast pads, COVID-19 masks, fresh produce, and hygiene products to their clients, they also find themselves acting as many families’ first line of defense when it comes to surviving the financial fallout of the pandemic.

Ramsey says that she usually connects families to resources, like Brightpoint, for financial services, but when COVID-19 began and shut down many service organizations, she started getting more involved in the process. With Parview’s permission, she stepped in to help her clients fill out paperwork for Medicaid and unemployment benefits.

“We’ve been going above and beyond what we would normally do because families need it,” Ramsey says.

Community Health Workers connect families to service organizations like A Hope Center.

Parkview’s Safety PIN program works with families from the time they are pregnant until one year after their baby is born. Families are connected to the program primarily through Parkview’s OB Nurse Navigators, who screen every new mother at their initial prenatal visit. New clients also come from self-referrals, or referrals from friends, family members or other agencies.
While Community Health Workers connect families to pregnancy-specific resources, their work focuses more broadly on the social determinants of health, like access to healthy food and transportation, which impact infant mortality, too, Ramsey explains.

“Transportation is a big issue for the Burmese community,” she says, noting that many Burmese mothers do not drive and are afraid to use services like medical taxis since they are unfamiliar with the local language and culture.

“They don't know the drivers, they don't know the language; they don't know the area,” she says. “All of these factors become issues.”

Ramsey’s fellow Community Health Worker, Maria Diaz, says this brings to mind another important aspect of their work: Building relationships based on trust and shared cultural experiences.

Whereas Ramsey is a multi-lingual Burmese and Thai speaker, Diaz is a bilingual Spanish speaker, and she sees the value of having critical information available to her clients in their native tongue.

“A lot of times, my Spanish-speaking moms have told me they go to places and try to get involved, but they don’t have the information in their language, so that makes them feel like less of a person,” Diaz says. “It really makes a difference.”

Maria Diaz is a Community Health Worker in Southeast whose family immigrated to the U.S. from Mexico.

Living and working in the same area as their clients adds another layer of trust to the equation. Diaz has lived on the Southeast side of Fort Wayne since she moved to the city when she was eight-years-old. Like Ramsey, she has personally overcome several barriers to assimilating to local culture since her family immigrated to the U.S. from Mexico.

When she first moved to Fort Wayne in elementary school, she only spoke Spanish, and she had to learn English quickly to avoid ridicule from her peers.

“I learned how to speak English in six months because I went through a lot of bullying when I didn’t speak well,” Diaz says.
After graduating from South Side High School with scholarships, Diaz worked two jobs to put herself through college at Ivy Tech, where she earned her Associates Degree in Human Services.

“It’s a two-year degree, but I earned it in six years because I had to pay out of pocket, I had no transportation, and my father was not involved in our family, so I had no support or anything,” she says. “It was very difficult.”

Despite these challenges, she graduated with honors and established many connections in the Fort Wayne community through her various jobs and volunteer roles.

One of her jobs was working as the Office Manager for El Mexicano News for seven years, where she built many relationships in the Fort Wayne community, at-large. As a result, she often found herself acting as a bridge between the city’s Hispanic community and its broader community. So when she learned that she could make her passion for helping people a full-time career at Parkview, she jumped on the opportunity to earn her certification as a Community Health Worker.

“Before I had my clients, I was giving this kind of information to my friends and family when they would ask me, so I’ve been doing this for a long time now,” Diaz says. “As Community Health Workers, we live here, so we know the struggles and concerns of the community, and we are able to help.”

Along with the cultural sensitivities that she and Ramsey bring to their roles, they have the added benefit of being recent mothers themselves. Diaz’s two children are ages three and five, and Ramsey’s baby is two-years-old. So when they provide health and language services to their clients, they often find themselves speaking from personal experience, mother to mother, Ramsey says.

“We can relate to these moms, so not only do we educate them about what they need to know on paper, but also we can tell them what our own experience was like,” she says. “We still always recommend that they talk things over with their doctors, but we can provide information that's not in the books.”

In her time working for Parkview, Ramsey says she’s learning about so many resources and services she never knew existed in Fort Wayne before. She sees one of the main values of her work as simply letting families know what’s out there and letting them know that they’re not alone.

“When I became a Community Health Worker, I was surprised that I didn't know about so many of these resources even though I had lived in Fort Wayne for 12 years,” Ramsey says. “A lot of people just don’t know what resources are available to them.”

This Special Report was reviewed and made possible by Parkview Health.
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Gwen Masterson
Gwen Masterson
Safety PIN Project Manager
Parkview Health

In 2016, Parkview Health received $3.6 million to implement strategies to combat infant mortality in Allen County, as part of the Indiana State Department of Health’s Safety PIN grant.

Since infant mortality rates (IMRs) have proven to be effective indicators of community health, Parkview has spent the past three years applying its grant to take a grassroots approach to reaching underserved populations, addressing the social determinants of health that impact pregnancies.

As part of the Women’s & Children’s Service Line and in partnership with its Community Nursing Program, Parkview hired and trained a diverse team of residents who live and work among the people they serve. They’re known as Community Health Workers, and they’re overseen by Gwen Masterson, who was hired in 2017 as the Project Manager for Parkview’s Safety PIN program.

Input Fort Wayne sat down with Masterson to learn more about Parkview’s Community Health Workers serving Southeast Fort Wayne and how they strategically work to reduce the area’s IMR.

IFW: Tell us what Community Health Workers do in the Southeast community.

Community Health Workers are women and men who are actual members of the communities they serve. In many ways, they reflect the neighborhoods they’re working in, whether it’s their personal background or their language, so they’re working to connect their neighbors to services and resources in the Fort Wayne area. They’re trained by Parkview’s partner, HealthVisions Fort Wayne, so they are knowledgeable and certified to provide this guidance to families, but their real expertise is knowing the community and building connections there.

For the past three years of the Safety PIN grant, we have been based in the South side zip codes of Fort Wayne like 46806 where infant mortality rates are among the highest in the state and country. Our goal with the Safety PIN program is to reduce infant mortality by meeting families where they are at and helping them get connected to programs and services that are available to help them.

IFW: How do families get referred to the Safety PIN program?

We work with our OB Nurse Navigators here at Parkview, and they assess every mom at their initial prenatal appointments. That’s where they go over the social determinants of health, and they assess if a family wants or needs a Community Health Worker. Then, after the family agrees, they send a referral over to us, and our assigned Community Health Worker begins the outreach process. Community Health Workers can also refer families to the program if they meet them at an event, or families can reach out to us if they’d like to work with a Community Health Worker. We also get referrals from other organizations in the community. So referrals happen a number of ways.

We currently have eight full-time Community Health Workers for the Safety PIN program, and we’re streamlining the process. We take in about 40-100 new clients per month, working with families from the time they are pregnant until their baby is one-year-old. As a team, we do approximately 250 client visits per month, and prior to COVID-19, most of our visits were in families’ homes.

IFW: How has the Community Health Workers program evolved during COVID-19?

Our program is really based on going to families’ homes and all the places where people tend to congregate. So before the pandemic, we were out in the community, working in South side apartment complexes, participating in giveaways, working with churches, getting involved in local fairs and cultural events.

During the pandemic, we’re finding different ways to meet families’ needs that comply with safety standards. We’re doing a lot of hybrid visits. While most of the education and support is occurring virtually, we’re still providing delivery of educational resources and critical supplies, making sure moms still have access to all the resources they need during the pandemic, like diapers and hygiene products.

Since things are changing so quickly during the pandemic, with new resources becoming available and old resources reopening, we’re constantly navigating all of these changes for families and then linking them to those services.

We collaborate with many community partners to do this work, whether it’s Fort Wayne Housing Authority, Healthier Moms and Babies, Healthier Families, Headstart, or even the Allen County Public Library (ACPL). For example, we recently started partnering with the ACPL to provide age-appropriate books to families and promote bonding through reading together.

The other important aspect to note about our program is that it ends when the family’s baby turns one-year-old, so if families are still needing support after their time with our program ends, our community connections can help them get that ongoing support from another organization that provides it.

IFW: In your work with families, addressing the social determinants of health around infant mortality, what are some of the biggest barriers you are seeing?

Poverty is at the root of many of the physical, mental, social, and financial challenges that cause infant mortality in our community. People in financial need face many barriers when it comes to accessing transportation, nutritious food, housing, healthcare, education, and even emotional support during their pregnancies. So our work is all about bridging those gaps and getting supplies and resources to people. Sometimes, that means literally just being that support system for them.

We’re trying to meet families where they are at, and ask them: What do you need? What can we help you with? So our work looks different for every family, every day.

Our whole goal is to ask the types of questions that put the ball into the family’s court, so they are telling us what they need. That way, they are the masters of their own destiny. We’re just here to help them navigate and let them know that they’re not alone.

IFW: The Safety PIN grant expires in December 2021, so what’s next in the fight to reduce infant mortality rates in Fort Wayne?

Parkview is committed to reducing the infant mortality rate in the region, eliminating health disparities, and improving overall health outcomes for moms and babies. There are still some funding questions up in the air, but we are dedicated to continue serving families.