Advisory Committee on Interdisciplinary, Community-Based Linkages Meeting

• Membership
• Leadership
• Working Groups
• Annual Reports
• Future Meetings

Membership

Ten nominees have been invited to join the Advisory Committee.  Those that accept will be in attendance at the next (February) meeting.  The following members’ terms have expired: Charles Cranford, Estela Estape, Katherine Flores, Dodie Harper, Lawrence Harkless, Ricardo Perez, Joseph Scaletti, Sabra Slaughter, Charles Spann, and Richard Wansley.

There are seven remaining original members, along with four members who joined the committee in 2003.  HRSA is preparing a package of nominees to submit to the Department for the replacement of the seven remaining original members.

Members encouraged the Advisory Committee and BHPr to provide an orientation for new members at the February 2004 meeting.  Specifically, it was suggested that time be allotted at the meeting for members to talk about their professional expertise and experience (approximately five minutes each).  Also, it was suggested the BHPr provide new members with resources on the Title VII programs so that they can familiarize themselves with these programs.

Members did share concerns with BHPr about the transition of members—a large influx of new members could impact the work of the committee.  BHPr should consider staggering future departures, if possible.   

The departing members asked that BHPr continue to inform them about committee business including:

• Newly appointed members;
• Copies of annual reports; and
• Meeting agendas.

The Advisory Committee’s web site will also serve to keep departing members informed on the committee’s activities.

Departing members expressed an interest in attending future meetings, which they are permitted to do as members of the public.   In addition, they asked BHPr to explore the possibility of holding a conference in the future (3-4 years) addressing best practices for community-based, interdisciplinary health professions education.

Departing committee members stated that there are benefits from the committee beyond the recommendations that are developed.  The committee members gain a greater appreciation and understanding of the programs represented and, in turn, take this understanding back to their communities and institutions. 

BHPr thanked the departing Advisory Committee members for their service over the past three years.

Leadership

The committee was asked to approve Robin Harvan’s succession to Committee Chair.  Originally, Dr. Harvan represented allied and rural health on the committee.  As of July, Dr. Harvan has been serving as interim director of the Colorado AHEC system, which means she is representing a different grantee program than when she was named vice chair.  The advisory committee was asked to elect Dr. Harvan as chair of the committee.

Motioned and seconded: elect Dr. Harvan as the chair of the advisory committee.  Passed unanimously.

The committee will wait until the February meeting to elect an additional vice chair so that new members can participate in the election.

Subcommittees

Two subcommittees have been established by the committee.

• Planning Subcommittee – develop meeting agendas and identify speakers
• Writing Subcommittee – draft recommendations, reports, and other products to disseminate advisory committee recommendations

Subcommittee Assignments

• Status of the Second Annual Report

The second annual report, completed in early 2003, is still under review. 

• Merging of Second and Third Annual Reports

The committee discussed the possibility of merging the second and third annual reports.  In the event the two reports are merged, the second annual report, currently under review, will be withdrawn.  The merger was suggested to reduce confusion that could arise from two annual reports being reviewed and released within a short timeframe.  Concerns about the merger included: it could slow the release of the second annual report; it may be more work to write a combined report; and it may dilute the impact of the recommendations.  Members supporting merging the two reports felt that recommendations in both reports are related and releasing them simultaneously might strengthen their impact.

The committee voted on whether to merge the reports.  Twelve members (12) supported submitting two separate reports.  Four members voted for combining the two reports in a single publication.

• Concerns about Delays in the Review Process

Committee members expressed concern about the delay in the release of the second annual report, which may reduce the relevance and timeliness of the recommendations.   It also may create the appearance that the Advisory Committee is not meeting its mandate.  Member discussed possible strategies for expediting the release of the second and future annual reports, such as requesting a Congressional inquiry into the delay.  It was also suggested that the committee explore other vehicles, such as letters to Congress and the Secretary detailing the committee’s recommendations following meetings, to disseminate information.  The committee asked the Chair and BHPr to work together to explore ways to expedite the review process and identify alternative dissemination methods.

• Recommendations for the Third Annual Report

The third annual report will address bioterrorism and performance measures and outcomes.  The committee finalized recommendations in each of these areas.

Bioterrorism

Members noted that some of the recommendations have already been acted on and that this should be noted in the overview of the report and other sections, where appropriate.  In addition, the text of some of the recommendations should be modified to reflect that action has already been taken.  Specifically, recommendations 2 and 3 should be changed to state, “recommends continued funding.”

• Meeting Process

In 2004, Advisory Committee meetings will be extended by one day to allow members more time to develop recommendations.  The Advisory Committee will travel on Sunday and the meeting will start Monday morning and adjourn Wednesday afternoon.

The establishment of the planning subcommittee will facilitate the process of organizing meetings in a timely manner.  The subcommittee will develop a draft agenda at least two months prior to the meeting.  The final agenda must be published in the Federal Register 45 days before the meeting.

Some committee members expressed concern about the time commitment required by the extended meetings.  It was suggested that an evaluation mechanism be built into the meetings to help ensure that the time is used efficiently (Did we stay on task?  Did we meet our goals?).

Future Topics

Committee members were provided a list of 12 topics for consideration at future meetings.  The topics were proposed at past meetings.  In addition, committee members were asked to submit topics by e-mail.

1. Linkage

At multiple levels - across Federal agencies (NIH, CDC), HRSA (intra-agency), Title VII programs, and health care disciplines

2. Self Sufficiency
3. Legislation and Reauthorization
4. Department of Labor Revision of Health Profession Categories
5. Health Disparities
6. Health Professions Manpower Crisis (Workforce)
7. Faculty Shortages
8. Funding of Health Professions Education

Challenge of keeping programs viable

9. Establishment of National Commission on Health Care Workforce by Congress
10. Interdisciplinary Health Care

Support for interdisciplinary approach as a core competency (NAS/IOM reports and recommendations, accreditation).

 Explore other countries approach to interdisciplinary health care (Canada, UK). 

Interdisciplinary model of care for serving rural and underserved populations. 

11. Role of Community-based, Interdisciplinary Learning in Safety Net Services
12. Impact of Title VII Programs on Health Disparities and Workforce Development

Telling our story well – need data on impact of Title VII programs

Motioned and seconded: the following topics will be addressed by the committee:

1)  Health Disparities (February 2004)

2)  Health Professions Manpower Crisis including Department of Labor health professions categories, workforce development, and faculty shortages (May 2004)

Amended to include:  Role and Support for Interdisciplinary, Community-based Health Care as the third topic to be addressed by the committee.

Passed Unanimously. 

The committee noted that the topic of Health Professions Manpower Crisis may require two meetings to address.

For each of the three topics, the Advisory Committee identified questions/issues to be addressed at the meetings.  The planning subcommittee will use these questions to further define the focus of the meeting.

Health Disparities

• What is the relationship between health disparities and underserved/unserved populations (relation to geographic area, economic status, etc.)?
• What is the impact of health disparities on the Title VII programs?
• What is the impact of health disparities and access to care?
• What is HRSA doing to address health disparities?
• What are the Title VII programs doing to address health disparities (what are the best practices)?
• What are the challenges to Title VII programs in adopting best practices that will lead to the elimination or reduction of health disparities?
• Are best practices cost effective (saving States money in health care costs)?
• How can Title VII programs work with Medicaid and other state and local initiatives to alleviate health disparities?

Health Profession Workforce Issues

• What is the relationship of Title VII programs to pipeline development programs?
• What is the current status of kids into health careers and other pipeline development initiatives?
• How early do we start the process of building the workforce (elementary, high school)?
• What is the impact of Title VII programs on workforce development?
• Link between workforce issues to health promotion and disease prevention (obesity program in TX)
• Do pipeline programs address the significant barriers faced by minorities in terms of pursuing a career in health care?
• Explore the whole spectrum of health professions represented by Title VII in terms of workforce development – focus on all disciplines represented by Title VII programs and the interdisciplinary approach to care
• What is the role of faculty in workforce development (role modeling)?
• How does faculty development and recruitment impact workforce development?
• What do Title VII programs need to improve their work in this area (resources, linkages, etc)?

Additional Notes:

• Need to include services for geriatric populations in addressing the topic of workforce development.
• Incorporate Department of Labor categories into this topic.
• HRSA’s Division of Health Careers Diversity and Development should be at the meeting as a resource.

• Do we need an interdisciplinary, community-based faculty fellowship program (role of role models)?
• What do Title VII programs do to provide infrastructure for the delivery of safety net services?
• What is the value of interdisciplinary, community-based care in the health care system (cost effectiveness, cost saving)?
• What are the regulatory and licensure processes that inhibit or support interdisciplinary education, accreditation and evalution?
• What are the Title VII grant programs doing in the area of interdisciplinary, community-based healthcare?  Are there models available? 
• (PACE program for the elderly in DC)
• What are the best practices for regional approaches and barriers to regional approaches?
• How can community-based, interdisciplinary programs reinforce the public health workforce (at State and local level)?

Linking with Other Advisory Committees

The committee has expressed interest in holding joint meetings with other HRSA advisory committees, such as COGME and NACNEP, as well as other advisory committees convened by NIH and CDC that are working on similar topics.  If joint meetings are not possible, the possibility of having representatives from other advisory committees at meetings should be explored (and sending representatives from this committee to other advisory committee meetings).

One of the challenges of holding joint meetings is that the other advisory committees’ schedules are set for the next year or more.  A more feasible option may be to bring representatives from advisory committees together to plan a larger meeting.

• Motioned and seconded:  approval of June Conference Call minutes.  

Passed with six abstentions.

• Two Advisory Committee members, Estele Estape and Richard Oliver, provided information on the Allied Health Reinvestment Act, a House Resolution that calls for new funding to support education and training for allied health professions.  The legislation is supported by the recommendations in the Advisory Committee’s second annual report.

• Recommended Reading on Cultural Competence (from Richard Oliver)

Anne Fadiman.  The Spirit Catches You and You Fall Down: A Hmong Child, her American Doctors, and the Collision of Two Cultures.

II. Cultural Competence and Diversity

Final Recommendations

1. Include legislative language applied uniformly that requires programs funded under Title VII, Part D, Section 756 to address cultural competency. 

For rationale:

• Recommend that Congress and the Secretary incorporate the national standards and definitions for cultural and linguistically appropriate service in health care into the Title VII programs.
• HRSA should direct applicants to OMH resources in the guidance.
• More examples are necessary of best practice for demonstrating impact of cultural competence, including case studies and teaching-specific models.

2. Recommend that Title VII, Part D, Section 756 grantees focus attention on faculty development across health professions disciplines and/or in partnership with students in cultural competence.

For rationale:

• Risk management
• Linking with student efforts such as AMSA

3. HRSA reporting requirements should include, where appropriate, collection of qualitative and quantitative data with regards to cultural competence efforts of Title VII, Part D, Section 756 programs.

For rationale:

• National Study of Culturally and Linguistically Appropriate Services in managed CARE Organizations (CLAS in MCOs Study)

4. Provide, where appropriate, that Title VII, Part D, Section 756 grantees provide evidence-based approaches that health care outcomes are improved through the inclusion of cultural competence efforts in health profession education and training.

Did not revise:

5. To provide funding incentives for education and training programs for health professions learners and practitioners for health promotion and disease prevention which is culturally relevant to diverse unserved, underserved, vulnerable and disadvantaged populations.

6. Encourage linkages and collaboration with other DHHS, HRSA, Bureau and national advisory committees and national commissions that are addressing cultural competency and diversity.

7. Encourage partnerships with the community (providers at the state and local level) to prepare a culturally competent and diverse workforce.

Additional suggestions:

• Include a recommendation that addresses the international importance of cultural competence, especially in relation to emerging issues such as bioterrorism and SARS.

Motioned and seconded: approve recommendations that have been revised by the committee.  The writing subcommittee will revise the remaining recommendations and submit them to the committee for approval.            

Unaimously passed.

To develop the recommendations, the Advisory Committee members divided into three work groups and identified findings and suggested recommendations on cultural competency and diversity, based on the testimony at the meeting and resources provided by BHPr.

Findings

Group 1:

• Cultural competence is of value and increases access to services.
• Despite the fact that there are no specific requirements, Title VII programs are engaged in teaching cultural competence and diversity in various ways (flexibility allows for different, community-appropriate approaches).
• True interdisciplinary models demonstrating cultural competency education were not presented—efforts seem to be discipline specific.
• No demonstrated models for faculty development and role modeling for cultural competency and diversity were presented.

Group 2

• There is no uniform definition of cultural competency and no specific legislative language in Title VII defining cultural competence, diversity of workforce, or diversity of the population.
• There is no specific reporting requirement for quantitative or qualitative data related to cultural competency and diversity activities.
• There is evidence to support that a diverse workforce improves patient access, trust and compliance and the health status of communities.
• There is a lack of health promotion and disease prevention education and training for health professionals that is culturally relevant.

Group 3

• We do not have a culturally competent workforce and efforts to increase diversity in the workforce have reached a plateau.
• There are a number of commissions and organizations addressing these issues.
• Language and cultural characteristics are barriers to providing culturally competent health care.
• All Title VII programs are encouraged to address cultural competency but it is not required.
• While the goal is to have a health care workforce that reflects population diversity, all providers should be culturally competent.
• Ensuring access and cultural competency may require expanding the definition of the health care workforce (community health workers, interpreters).
• Increasingly, accreditation standards reflect the need for care to be delivered in a culturally competent manner.
• Although there are a number of activities in this area being conducted by Title VII programs, the impact of Title VII programs on health disparities and cultural competence has not been adequately reported. 

Suggested Recommendations:

Group 1

• While the workforce should reflect population diversity, all providers should be culturally competent.

• Include legislative language for Title VII programs about demonstrating their responsiveness to providing cultural competency education.  (should be broad and flexible)
• Title VII programs should be properly evaluated for their cultural competence activities.
• Faculty development in cultural competence in needed and should be incorporated into risk management.  Faculty development in this area should also be linked with student-initiated efforts, such as AMSA.
• Title VII programs should develop linkages with leading centers of cultural competence for development of strategies and approaches.
• More examples of best practice for cultural competence are needed, including case studies and teaching-specific models.
• More clearly define cultural competence across populations and along the continuum, including self assessment of cultural competency.
• Congress and the Secretary should incorporate the national standards and definitions for cultural and linguistic competence in healthcare into the objectives of the Title VII programs.

Group 2

• Diversity of population and diversity of the workforce should be addressed in the legislative language related to Title VII programs.
• HRSA programmatic requirements should include collection of qualitative and quantitative data related to cultural competence and diversity activities.
• Provide, where appropriate, that programs provide evidence of improved health care outcomes by the inclusion of cultural competence and diversity efforts in health profession education and training.
• Provide funding incentives for education and training programs for health professions learners and practitioners for health promotion and disease prevention, which is culturally relevant to diverse unserved, underserved, vulnerable and disadvantaged populations.
• Encourage linkages and collaboration with other DHHS, HRSA, Bureau and national advisory committees and national commissions that are addressing cultural competency and diversity.
• Encouraging partnerships with the community (providers at the state and local level) to prepare a culturally competence and diverse workforce.

Presentations

• “Cultural competence is a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups.”

Cross et. Al. 1989 and Lavizzo-Mourney and Mackenzie 1996 as cited in Cultural Competence: A Journey, Bureau of Primary Health Care, HRSA, DHHS, n.d.)

• “Cultural competence also focuses its attention on population-specific issues including: health-related beliefs and cultural values (the socioeconomic perspective); disease prevalence (the epidemiological perspective); and treatment efficacy (the outcome perspective).”

(Cross et. Al. 1989 and Lavizzo-Mourney and Mackenzie 1996 as cited in Cultural Competence: A Journey, Bureau of Primary Health Care, HRSA, DHHS, n.d.)

• improve the recruitment, distribution, supply, quality and efficiency of personnel providing health services to populations having demonstrated serious unmet health care needs;…”; and ·  “prepare individuals to more effectively provide health services to underserved area or underserved populations…” HETC programs are directed by legislation to address: ·  “the persistent and severe unmet health care needs in States along the border between the United States and Mexico and in the State of Florida, and in other urban and rural areas with populations with serious unmet health care needs;…”; and ·  “training in health education services, including training to prepare community health workers…” The Allied Health Special Projects Program, administered by the Allied, Geriatrics and Rural Health Branch, DSCPH, BHPr, has a funding priority based on the President’s Executive Orders 12876, 12900, 13021, and 13125, which state that grantees must: “provide community-based training experiences designed to improve access to health care services in underserved areas; these applicants include Asian-American and Pacific Islander Serving Institutions, Hispanic Serving Institutions, Historically Black Colleges and Universities, Tribal Colleges and Universities serving American Indians and Alaskan Natives, or an institution that collaborates with one or more of the above institutions.”  

Activities Addressing Cultural Competency

At the programmatic level, Title VII programs are carrying out numerous activities addressing cultural competency.  Of the 49 AHEC programs, 23 programs listed cultural competence as a topic covered in their programs for providers and 19 programs participated in managed care presentations regarding cultural competence.  The AHECs carried out various activities to address cultural competence.

The following are examples of grantee activities. 

• Nebraska Medical Center, in collaboration with the Nebraska Minority Public Health Association, developed a cultural competency program for pre-heath professionals.
• North Carolina AHEC offers programs in cultural diversity and cross cultural awareness to area educators, staff, parents, community groups and health practitioners throughout the state
• Alaska has offered a seminar on cultural competency for the past ten years and a new course on cultural competency is being offered at UA-Anchorage, in which 23 students have enrolled.
• University of New Mexico had seven workshops/conferences on cultural competency with 910 participants and trains the entire medical school annually. Case-based tutorials, lectures and panel discussions are used.
• University of Hawaii trained 100 students and 30 faculty in cross-cultural education.
• South Texas AHEC has a significant involvement in culturally competent training of medical and other health professions students.
• New Hampshire provides cultural competency programs for health professions students and faculty in both community settings and in traditional on-campus settings.
• Arkansas AHEC Southwest has a Cultural Medicine rotation at a Migrant Health Center for medical students.
• Idaho AHEC is involved with the Hispanic Wellness Initiative, which provides cultural competency training. A tool to measure cultural competency is currently being developed.
• The Washington AHEC Program provided cultural competency training for multi-disciplinary students as a pre-requisite for community-based service learning projects. The HETC programs have various activities that focus on cultural competence.  HETC programs carried out the following activities.   
• The Health Education and Training Centers Alliance of Texas (HETCAT) has engaged in extensive training of “promotoras” and uses them to improve access to health care for migrant populations in the border region.
• California HETC trains health professionals who provide care to the state’s immigrant Hispanic and other disenfranchised populations in underserved areas. Cultural competency is included in all the training programs. 

In 2001-2002, 1,192 health professions students in 200 sites were trained in cultural competence.  In addition, a medical Spanish program was implemented at UC San Diego.  Three family practice residencies have adopted cultural competency as part of the entire training program, which graduate about 25 family physicians each year who return to underserved communities to practice.   In FY 2003, the Geriatric Education Centers Program funded 46 Geriatric Education Centers Projects (GECs).  All addressed cultural competence and diversity.  

Examples of these activities include:

• Implementation of interdisciplinary faculty development programs that include topics on cultural competency related to older adults in community-based care;
• Recruitment and education of minority students;
• Increased diversity of faculty;
• Development of education programs on ethnicity;
• Development of educational offerings on cultural assessment of older adults;
• Training of  faculty, providers, and students to recognize and manage dementia and depression associated with diabetes among American Indian, Mexican American, African American, Japanese American, and Chinese American elders and caregivers in culturally appropriate ways; and
• Development and dissemination of four types of curricula on bioterrorism and infections designed to sensitize providers to the special health care needs and concerns that older adults of different cultures have in times of crisis. In addition, BHPr funded the development of an ethnogeriatrics curriculum by the Stanford Geriatric Education Center, which is designed to serve as a basic curriculum in ethnogeriatrics.  The goals of the curriculum are to increase health care providers’ awareness of the effects of race, culture, and ethnicity on the health and health care of older adults and to increase the ethnogeriatric competency of health care providers.  The curriculum consists of five modules: introduction and overview; patterns of health risk; fund of knowledge; assessment; and health care intervention, access and utilization.  There are 11 ethnic-specific modules.   Other activities include the Geriatric Training Program for Physicians, Dentists, and Behavioral Mental Health Professionals, which in FY2003 funded 12 projects.  The projects are designed to recruit minority fellows and faculty members, provide clinical training for minority elders, and integrate ethnogeriatrics into the curriculum.  The Geriatric Academic Career Awards (GACA), of which there were 71 in FY2003, are designed to provide: 1) training in community-based settings, in addition to hospital and medical school-based training; 2) culturally competent care to diverse elders; and 3) interdisciplinary team training that includes cultural competence.   The Quentin N. Burdick Program for Rural Interdisciplinary Training funded 23 projects in FY2003, of which 19 projects address cultural competence and diversity.  Projects recruit minority students and faculty; establish innovative models of culturally-sensitive, interdisciplinary health sciences education; partner with community/migrant health centers to augment delivery of health services to Latinos and other minority groups; develop culturally sensitive/competent curricula focusing on needs of Latinos and other minority groups; develop culturally sensitive health professionals who will function as part of a interdisciplinary team to deliver care in rural communities; and increase availability of diverse, culturally sensitive heath professionals.   The Allied Health Program funded 44 projects in FY2003.  The projects recruit, admit, retain, and graduate minority students; recruit minority faculty; provide clinical training with diverse populations; and integrate cultural competence into the curriculum.  Specific activities include: development of three multimedia case studies, each with text, audio, and video components to enhance curricular content on aging and cultural diversity; and development of a web site that provides health care professional education programs on interdisciplinary care of elders from diverse cultural, ethnic, and socioeconomic backgrounds.   Finally, HRSA has established a cross-agency work group on community health workers, an emerging discipline as targeted populations become more diverse.  The work group is currently working to identify the Agency’s activities in this area. Resources on Cultural Competence ·  The Provider’s Guide to Quality and Culture Link from Bureau of Primary Health Care (BPHC) < http://bphc.hrsa.gov/quality/default.htm >·  Cultural Competence Compendium (AMA) < http://www.ama-assn.org/ama/pub/category/2661.html >·  Cultural Competence: A Journey was published October 1999 < http://bphc.hrsa.gov/culturalcompetence/ >·  BPHC Quality Center < http://bphc.hrsa.gov/quality/Cultural.htm >

• Responsiveness to current and projected demographic changes;
• Elimination of long-standing disparities in health and mental status;
• Improved quality of services and outcomes;
• Meeting of legislative, regulatory and accreditation mandates;
• Achievement of a competitive edge in the market place;
• Reduction in the risk of liability/malpractice;
• Historical issues related to why people cannot get care;
• Promotion of workforce diversity as society is growing increasingly diverse;
• Improved formal education of staff and faculty;
• Improved institutional practices; and
• Promotion of the institution’s best interests.

Current and emerging demographic trends point to the importance of cultural competence.   The United States is becoming more and more diverse and there have been significant changes to immigration patterns over a relatively short period of time.  In 1990, the top five countries of origin for migrants to the U.S. were Mexico, the Philippines, Canada, Cuba, and Germany.   By 2000, this had change and the top five countries of origin were Mexico, China/Taiwan, the Philippines, Cuba and the Dominican Republic.   In 2001, over 200,000 people came to the U.S. from Mexico.  Over 70,000 immigrants came from India, over 55,000 came from China, 53,000 from the Philippines, and 35,000 from Vietnam.

Data from the 2000 census indicates the increasing complexity of the data collected by the U.S. Census Bureau.  Almost one-third of the U.S. population is from ethnically and culturally diverse groups and 2.4 percent of people describe themselves as belonging to more than one race.  The single largest multiracial category is Caucasion and “some other race.”  There is also a discrepancy between the data and those who self-identify with a specific race/ethnicity.  For example, there are approximately 2.5 million American Indians and Alaskan Natives in the U.S.  However, a total of 4.1 million people self-identify as having American Indian and Alaskan Native ancestry.

One of the most significant changes is the increase in the number of Hispanics in the United States.  The nation’s Hispanic population has doubled since 1980 and now, there are 37 million Hispanics in the U.S., which is 13 percent of the population.  Hispanics now outnumber Blacks.  There is diversity within this population:  three out of five Hispanics were born in the United States; there are 1.7 million Hispanics who are Black; and Hispanics come from many different countries, each with a unique cultural identity.

Those who reported themselves “Black only” in the 2000 census number 35 million, which is 12 percent of the U.S. population.  An additional 2 million people said they were Black and at least one other race.  Within this group, the most common combination was Black and Caucasian, making up 45 percent of the pairings.  Foreign-born Blacks made up 7.8 percent of the Black population in 2001, up from 1.3 percent in 1970.

This diversity has significance for the delivery of a broad range of services, from education to health care.  According to the 2000 census, more than 10.5 million U.S.  There are reported to be 176 different languages spoken in the U.S.

In addition to race/ethnicity and language, there are cultural factors that contribute to diversity among individuals and groups.  Internal factors (i.e., those relating specifically to the individual) include:

• Cultural/racial/ethnic identity;
• Tribal affiliation/clan;
• Nationality;
• Acculturation/Assimilation;
• Socioeconomic status/class;
• Education;
• Language;
• Family constellation;
• Social history;
• Health beliefs and practices;
• Perception of disability;
• Perception of mental health;
• Age and life cycle issues;
• Gender and sexuality;
• Sexual orientation;
• Religion and spiritual views;
• Spatial and regional patterns; and
• Political orientation/affiliation.

External (i.e., relating to the larger society) factors include:

• Institutional biases;
• Racism and discrimination;
• Community economics;
• Intergroup relations;
• Group and community resiliency;
• Natural networks of support;
• Community history;
• Political climate;
• Workforce diversity; and
• Community demographics.

There are specific cultural influences on beliefs and practices that can have a significant impact on institutions and providers of health care and mental health services.   These include:

• Reliance on traditional remedies and healers;
• Delaying access to care (only seeking care when “really” sick);
• Historic mistrust of health care and social service professionals (e.g., African Americans and the Tuskegee experiments);
• Experiences of racism, discrimination and bias; and
• Cultural and linguistic barriers.

Cultural and Linguistic Competence Frameworks

In Ms. Goode’s presentation, culture was defined as:

“An integrated pattern of human behavior that includes, but is not limited to: thought; communication; languages; beliefs; values; practices; customs; courtesies; rituals; manners of interacting; roles; relationships; and expected behaviors of a racial, ethnic, religious, social or political group.”

Culture is transmitted to succeeding generations and is dynamic in nature.

It can be helpful to visualize culture as an iceberg.  People tend to pay attention to what they can see (what is above the water), which includes dress, age, race/ethnicity, gender and language.  However, there are many, many more aspects that are not visible and these can have an impact on the delivery of health services.  Examples of these include:

• Eye behavior;
• Facial expressions;
• Body language;
• Sense of self;
• Notions of modesty;
• Concept of cleanliness;
• Emotional response patterns;
• Rules for social interaction;
• Child rearing practices;
• Decision-making processes;
• Approaches to problem solving;
• Concept of justice;
• Value of individual vs. group;
• Perceptions of mental health, health, illness and disability; and
• Patterns of superior and subordinate roles in relation to status by age, gender, and class.

The National Center for Cultural Competence defines competence as follows:

“Having the capacity to function within the context of culturally-integrated patterns of human behavior; values, attributes, knowledge and a skill set to work effectively cross-culturally.”

There are many definitions of cultural competence, and sometimes it is necessary to craft a new definition, based on a specific mission.  The definition used by the National Center for Cultural Competence is as follows:

“A congruent set of behaviors, attitudes, policies, structures, and practices that come together in a system, agency or among professionals and enable that system, agency or those professionals to work effectively in cross-cultural situations.”

Five key element of cultural competence at the organizational level are:

• Valuing of diversity (have to show it, not just talk about it);
• Cultural self-assessment (identify strengths and areas for growth);
• Management of the dynamics of difference (acknowledging, addressing and managing cultural differences);
• Institutionalization of cultural knowledge (using an integrated approach, not just stop gap measures); and
• Adaptation to diversity.

Cultural competence must be integrated at all levels of an organization.  This includes the policy, administrative, service delivery, consumer and community levels.  Cultural competence must be reflected in an organization’s attitudes, structures, policies and services.

A continuum can be used when considering cultural competence.  There are various levels that demonstrate an organization’s integration (or lack of integration) of cultural competence.  The continuum runs from cultural destructiveness to cultural incapacity, cultural blindness, cultural pre-competence, cultural competence and finally, to cultural proficiency.  According to Ms. Goode, most health care organizations fall between cultural incapacity and cultural blindness.  In addition, the level of cultural competence can vary from population to population.  For example, many service providers in the South have a history of serving African Americans.  However, increasing numbers of Hispanics have moved to the South.  These organizations may have a significantly higher level of cultural competence with African Americans than with Hispanics.

The definition used by the National Center for Cultural Competence for linguistic competence is:

“The capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who are not literate or have low literacy skills, and individuals with disabilities.”

Specific policies, structures, practices, procedures and dedicated resources are necessary to support linguistic competence and varied approaches are required to share information with diverse populations, including people with cognitive disabilities.  Examples of activities that increase an organization’s linguistic competence include:

• Bilingual/bicultural staff;
• Cultural brokers;
• Multilingual telecommunication systems;
• TTY;
• Foreign language interpretation services;
• Sign language interpretation services;
• Ethnic media in languages other than English;
• Print materials in easy to read and low literacy formats (e.g., picture and symbol formats); and
• Materials in alternative formats (e.g., audiotape, Braille, enlarged print).

Materials that should be translated so they are accessible to various populations include: legally binding documents (e.g., consent forms, confidentiality and patient rights statements, release of information, applications); signage; health education materials; and public awareness materials and campaigns.

Incorporating cultural and linguistic competence into an organization is challenging.  It can be difficult for staff members, in that they have to change their values, attitudes and behaviors (an adaptive challenge) and also challenging technically because training is necessary to bring about these changes in values, attitudes and behaviors.  Managing change is a complex process.  It requires vision, skills, incentives, resources, and an action plan.  If one of these components is lacking, it is unlikely that significant change will occur.

In their efforts to achieve cultural and linguistic competence, service providers should explore all aspects of their organization.  This includes:

• Faculty recruitment and retention;
• Student recruitment and retention;
• Workforce management;
• Faculty and staff development;
• Curricula development and/or adaptation;
• Teaching methodologies;
• Research methodologies;
• Telecommunications systems;
• Provision of interpretation and translation services;
• MIS systems;
• Facilities and physical environment;
• Health promotion and health education materials;
• Community engagement; and
• State Title VII Grant programs and other grant applications.

Finally, the process of achieving cultural competence needs to involve the community being served.  Communities must determine their own needs and community members must be full partners in decision-making.  In addition, communities should benefit economically from this involvement.  For example, when possible service providers should hire staff from the community they serve.  Also, when a larger organization is collaborating with a community-based organization, the community-based organization should be compensated adequately for its participation.  There must also be a commitment to transfer knowledge and skills to the community.

Cultural Competence Activities at the Northern Virginia AHEC

            Presenter:  Lynn Hainge, Executive Director, Northern Virginia AHEC

Approximately 1.8 million people live in Northern Virginia.  Minorities make up 35 percent of the population.  Twenty-one (21) percent are foreign born and 11 percent self assess as speaking English “less than very well.”  Over 150 languages are spoken in the region.

The Northern Virginia AHEC (NVAHEC) was established in 1996 and focuses on continuing education and site support.  As a new service provider in the region, NVAHEC wanted to avoid duplication of existing services.  Needs assessments, conducted by NVAHEC and others in the community, indicated that the top three needs were: trained interpreters; translated documents; and cultural competence education.  There is also a strong business case for providing these services since culturally competent care can have an impact on the workforce in terms of competence and diversity; quality of care; patient compliance; risk management; regulation; and cost.

Currently, NVAHEC provides: cultural competence education; interpreter services; interpreter testing and training; consultation; and translation services.  The cultural competence education is tailored to address priority issues for providers, which includes: information on how people from specific cultures may act; how to communicate with patients from different cultures; and how to communicate effectively through an interpreter.  NVAHEC’s consultation services focus on integration of language access services, meeting CLAS standards, and development and implementation of interpreter services.  In addition, NVAHEC is participating in the Robert Wood Johnson Hablamos Juntos initiative.

In FY2003, the NVAHEC conducted the following activities:

• Administered language tests to 315 individuals;
• Trained 169 interpreters;
• Provided cultural competency education to 682 individuals;
• Provided 4300 interpreter hours; and
• Provided over 1,500 consultation hours.

The interpreter services were initiated in 1999, with the support of a private grant.  Currently, over 70 interpreters, speaking 28 languages, serve more than 30 sites.  Forty-five (45) percent of these services are provided on a fee-for-service basis and 55 percent are grant funded.  In addition, NVAHEC conducts interpreter testing and training, for its own interpreters and those from other organizations.   This training also addresses cultural competence. Language proficiency testing is conducted in both languages. 

Providers report that with interpreters, patient interaction is much easier and the communication is more effective, even with complicated diseases.  Others have reported the importance of having trained interpreters, rather than relying on family members or friends, and how the quality of care can be dependent on interpreters.  Patients report that trained interpreters are significantly different than untrained ones.  They are nonjudgemental, do not offer opinions, and place the patient at ease. 

Based on experience working with diverse populations, NVAHEC made the following recommendations:

• Ongoing efforts to build a diverse health care workforce;
• Continued effort to support and expand use of trained interpreters and community health workers (emerging professions);
• Include cultural competence training in health professions curricula and as part of re-licensing;
• Utilize flexible approaches;
• View cultural competence is a continuum, not a set objective;
• Support for reimbursement of interpreter services;
• Some approaches, such as “Medical Spanish,” may appear to be a quick fix but do not sufficiently address the needs; and
• Support funding of programs that provide the necessary education, training and support services.

Role of Community Health Centers

Presenter: Carmen Velasquez, Executive Director/CEO, Alivio Medical Center, Chicago

It is estimated that by 2050, the Spanish-speaking population in the U.S. will make up 25 percent of the population.  In 2002, there were 37.4 million Latinos in the U.S.  Two-thirds were of Mexican origin, 14.3 percent were Central and South American, 8.6 percent were Puerto Rican, and 3.17 percent Cuban.

Alivio Medical Center, which opened in 1989, serves a predominately Mexican, Spanish monolingual population.  Most are uninsured, working poor, and many are undocumented.  Alivio has always been committed to hiring bilingual and bicultural staff—any staff person with direct patient contact has to be bilingual.  This includes physicians, nurses, receptionists, mid-level providers, medical records staff, financial evaluators, case managers, social workers, dieticians, and health educators.  The commitment to hire bilingual and bicultural staff does prolong the hiring process, especially at the professional level.  Adding to the challenge is the incredibly competitive market for health care professionals with these skills.  While this policy may appear to be discriminatory, it is important to have a staff that reflects the population served.

Compounding the difficulty of hiring bilingual and bicultural staff is the relatively small number of Latinos in health care professions.  Of nurses in the U.S., only 2 percent are Latinos.  This is set against the backdrop of the larger shortage of health care providers.  It is estimated that by 2010, there will be a shortage of over one million nurses.

Many see interpreters as the answer to the shortage of bilingual and bicultural health care professionals.  While there are many languages, and in some instances, using interpreters is the most practical solution, for the Latino population, use of interpreters gives policy and decision makers an easy way out and does not confront the real issues of respect, sensitivity and communication.

Alivio has explored various options, in addition to recruiting professionals domestically.  In the past, Alivio has gone outside of the U.S. to recruit.  However, developing countries see recruitment as a threat that can drain their limited professional resources.  One option is to recruit providers licensed in their own countries that are already in the U.S.  The Department of Health and Human Services needs to continue to advocate for options that allow providers to serve patients.  Currently, the J-1 option applies only to physicians.  Can it be applied to nurses and others?

Alivio’s Physician Review Program, developed in 1990, recruited physicians from Spanish-speaking countries.  While the program is no longer in operation, due to lack of funding, 22 physicians were recruited, assisted in identifying resident programs and are now working physicians in the U.S.  A similar model was developed for nurses.  In 2001, Alivio was approached by Mercy Hospital and Medical Center to reestablish the nursing program.  The Chicago/Mexico Nurse Initiative has brought 50 nurses from Spanish-speaking countries, mainly Mexico, to the U.S.   As a result of this work, the Chicago Bilingual Nurse Consortium was developed.  At a roundtable held in June 2003, seven states (Illinois, Michigan, Wisconsin, Indiana, Texas, New York and Oregon) joined together to address this issue.

In addition identifying providers to meet existing needs, for the long term, it is necessary to focus on directing children to health care careers.  Alivio has worked with the Boys and Girls Scouts’ Health Career Explorers and the Summer Initiative of Job Corp to provide opportunities to students interested in health careers to work at Alivio.  Students also developed a health survey and curriculum that was adopted by the local high school.

From Alivio’s perspective, some methods of training providers are problematic.  Community health centers are frequently asked to partner with universities, hospitals, and other entities that train medical students and residents.  It is very difficult for Alivio to accept these opportunities, especially if the staff of collaborative partners do not speak Spanish.  In the past, Alivio physicians have had to serve as interpreters.

Finally, there are two other issues that affect Alivio’s work in this area.  Many community health centers, including Alivio, are being unionized.  Unionization makes cross-training more difficult and can result in higher personnel costs.  In addition, community health centers are facing issues related to succession of staff.  There are limited resources for pensions, retirement plans, staff development and long-term growth.

Discussion

Committee members expressed some concern about programs that allow foreign-trained health professionals to practice in the U.S.  In particular, there was concern that this could lead to a two-tier system of care.  In addition, committee members shared that in their experience, students who are not bilingual and have trained in centers serving primarily Spanish-speaking patients did not have the same quality experience as the bilingual students.

Cultural Competency and Diversity: AMSA Programs, Advocacy and Legislative Policy

Presenter: Lauren Oshman, MD, MPH, National President, American Medical Student Association (AMSA)

For over 50 years, AMSA has been the independent voice of physicians-in-training.  It is entirely student run and has nearly 40,000 members.  Each year, members contribute over a million hours in community service.  AMSA’s strategic priorities are to: develop physician leaders; create diversity in medicine; eliminate health disparities; transform the culture of medicine; and support universal health care.

AMSA identifies several key elements in the effort to eliminate health disparities.

• Medical education is an important component of an overall strategy to eliminate health disparities.
• Today’s medical students must expand knowledge of different racial and ethnic populations and health care inequities to be able to serve a diverse population.
• Healthy People 2010 advances the goal for elimination of all health disparities in the United States.
• New cultural competency guidelines are widely available.

Health disparities are widely documented by research.  However, what is known about health disparities and how to eliminate them needs to be integrated into medical education.  Several studies document the inadequacy of cultural competency and diversity training.   Results from the 2002 AMSA Health Care System Survey provide insight into student knowledge and attitudes about racial/ethnic disparities in health access.  For example, according to the survey, students believed:

• African Americans and Latinos are “worse off” in terms of having health insurance; and
• The health care system treats people unfairly “somewhat” or “very often” (fourth year students are less likely to believe this).

In addition, 42 percent of fourth year and 37 percent of third year students thought the curriculum is inadequate in this area.

In response to these disparities and curriculum inadequacy, students have initiated various activities including:

• PRIME cultural competency and diversity curriculum (a one year model curriculum to be integrated through at least the first two years of training which includes definitions, background information, practical suggestions and case studies.  Available at: www.amsa.org/programs/diversitycurriculum.cfm );
• Brown bag lunch discussions;
• Orientation activities;
• Participation in global AIDS awareness activities;
• “Demand Diversity” week to focus on diverse populations;
• Development of cultural competency case studies; and
• MD program with the National Coalition Building Institute ((NCBI).

With student-initiated activities, students feel a great sense of ownership.  While students often welcome faculty involvement in their activities, there is sometimes a sense that if faculty members become too involved, the activity will become institutionalized and lose its unique qualities.  Sometimes, however, it is appropriate for student-initiated programs to be incorporated into the school’s overall program.  For example, many activities are driven by the students who initiated them.  When those students graduate, there may be no one to continue them.  In such cases, the school should consider carrying on the activities.

In addition to carrying out specific activities to promote cultural competency, student also engage in advocacy efforts, which include:

• Service-learning activities in the community;
• Students demanding enforcement of LCME standards; and
• Partnering with institutions to improve or create curricula.

AMSA conducts a range of activities addressing cultural competence and diversity.  AMSA holds workshops examining student education and action on health disparities prior to its national convention, which takes place in March each year.  These activities are funded by the Agency for Healthcare Research and Quality.  These workshops help to jump start student initiatives and improve buy in for such activities.  There are also activities addressing diversity integrated throughout the national convention.

In 2003, AMSA received $1.9 million in funding from HRSA’s BHPr to develop the Achieving Diversity in Dentistry and Medicine (ADDM) program.  The four-year program consists of five components:

• Develop a cultural competency curriculum that will be pilot tested in up to 12 medical and dental schools (RFP in January 2004);
• Develop an ethnogeriatrics curriculum that will be pilot tested in up to nine medical and dental schools (RFP in January 2004);
• Develop and offer an annual week-long Primary Care Leadership Training Program;
• Create a plan that helps increase medical and dental student involvement in community health centers; and
• Create a plan that educates underserved middle and high school students about health careers options.

The Primary Care Leadership Training Program, which AMSA has been conducting for eight years, is a week-long institute that explores important issues in primary care, leadership, curricular reform, and health policy.  Each year, it is hosted by a different school.  The tentative theme for 2004 is “Health Disparities and the Health Workforce.”  Topics will include: health care disparities; advocacy/health policy; leadership skills; interdisciplinary work; communication skills; mentoring; and careers in health.

To increase medical and dental student involvement in community health centers, AMSA will collaborate with the National Association of Community Health Centers (NACHC) to create opportunities for dental and medical students to become more involved with community health centers.  A guide on student/community health center collaboration will be developed and successful collaborative models will be showcased at workshops and during poster sessions at appropriate forums.

To educate underserved middle and high school students about health careers options, AMSA plans to:

• Develop a cadre of medical and dental students trained to educate and mentor middle and high school students;
• Provide technical assistance and resources on implementing mentorship programs; and
• Conduct a one-day workshop highlighting accomplishments and successful models.

Besides the ADDM program, AMSA is planning other activities to support cultural competency and diversity.  These include:

• Complement ADDM program with support for student-initiated learning;
• Follow-up 2003 National Convention with small grants to support new medical student initiatives to address disparities; and
• Address perceived deficiencies in current curricula.

Separate from, but related to the issue of cultural competence, is the issue of workforce diversity.  Fewer under-represented minorities (URMs) are entering medical school.  URMs made up 23.8 percent of the population in 1997 but only 12.2 percent of new medical students.  Schools are admitting fewer URMs, with enrollment peaking at 13.7 percent in 1995.  In addition, applications from URMs are also dropping.  Some of the barriers to URMs entering medical school, identified by medical school officials, include low MCAT scores, low GPA, poor science preparation, few on faculty reflect URMs, and a lack of role models.  Since MCAT scores and GPA have proven to be poor predictors of future clinical capability, research is needed to determine applicant characteristics that are predictors to later clinical ability.  There is also a lack of representation by URMs, both faculty and student, on admissions committees, which can also impact enrollment of URMs.

In addition to exploring admissions policies that might pose barriers to URMs, support programs are need once these students enter medical school.   URM students are more likely to: require an extra year to finish; fail USMLE exams; fail first-year courses; and leave medical school. Research is needed to further identify the barriers for URM students and ways to better prepare them to enter medical school and support them once they are enrolled.  Some activities that may help create a supportive and healthy environment for all students include: peer counseling and tutoring; adequate student affairs resources; and having minority faculty as guest speakers.  URM students have identified other URM students, URM faculty and mentors, and URM student groups as important sources of support.  Although many schools believe that they have effective programs in place for supporting URM students, URM students report that these programs are not always well-run or designed to meet their needs.

AMSA recommendations to promote workforce diversity include:

• Conduct a national survey of URM students to understand the URM medical student experience;
• Individual schools should collect feedback from students on effectiveness of support programs;
• A large, active URM student and faculty community fosters support for URM students and enhances recruitment and support programs; and
• Schools should encourage and support student-initiated activities and mentorship programs;

AMSA also identified legislative steps that can enhance URM representation in the health care workforce.  AMSA supports restoring funding for Title VII of the Public Health Service Act.  The Title VII programs are designed to enhance minority representation in the health care workforce, which is essential to providing access to care as minority providers are more likely than others to care for underserved populations.  However, better targets for URMs are needed for funded health professions programs.  For example, a target of 40 percent is set for 2004, even though only 12.5 percent of current medical school graduates are URM.

Other pending legislation in this area that AMSA supports include:

• The Healthcare Equality and Accountability Act of 2003, which is designed to address cultural and language barriers, create programs to increase workforce diversity, improve data collection and promote accountability; and
• The Health Care Access Resolution (HCR 99), which calls for Congress to enact legislation by October 2005 to guarantee that all persons in the U.S. have access to health care.

Why should there be a culturally competent and diverse workforce?

Presenter:  Louis W. Sullivan, MD, Chair, Sullivan Commission on Diversity in the Healthcare Workforce

Funded by the Kellogg Foundation, the Sullivan Commission on Diversity in the Healthcare Workforce is made up of 15 members.  Members are highly diverse, with representatives from academia, business and public health.   Bob Dole and Paul Rogers are honorary co-chairs.  The Commission’s charge is to bring about systemic change within health professions education to increase workforce diversity and eliminate health disparities.  The Commission will explore strategies for increasing diversity in medicine, dentistry, and nursing.  While this is a somewhat limited scope, focusing on three disciplines will allow the Commission to address the issue in an in-depth manner and make more specific recommendations.  The Commission will release a report in 2004.  It is holding a series of hearings across the country to hear testimony on the issue and is currently about half way through the process of collecting testimony.  The Commission’s report will be disseminated to a wide audience (Congress, Administration, DHHS, state governments, private sector).  The Commission is exploring the possibility of continuing on an ongoing basis beyond the release of the report.

The U.S. has a world class system for health professions education at both the undergraduate and graduate level.  This has evolved over time.  In the early 1900s, there were few standards for health provider education and it varied widely.  After 1950, there was a dramatic increase in the number of new medical schools and expansion of existing programs.  This was in response to population growth that would result in a shortage of health care providers if training opportunities were not expanded.

The U.S. population is becoming increasingly diverse, which necessitates a more diverse health care workforce.  Efforts to create a more diverse workforce were initiated in the 1960s, which led to some improvement during the 60s, 70s, and 80s, when small gains seemed to plateau.  Today, minorities are significantly underrepresented in health care professions.  For example, in 1997 African Americans made up 13 percent of the population but less than 3 percent of physicians, Hispanics also make up about 13 percent of the population but only slightly more than 2 percent of physicians.    There are numerous factors that contribute to this under-representation, including the inadequacy of inner city, public schools and the lack of counseling directing children toward health careers

Workforce diversity is directly linked to access to care and health status.  Providers who share a patients’ ethnic and cultural background are often able to better communicate with those patients.  Communication leads to the development of trust, which can improve compliance.  In addition, providers who share a common background with patients may have a greater understanding of the challenges confronting that patient.  For example, a provider who grew up in a lower income household may know the barriers that costly prescriptions pose

In looking at the issue of diversity, the Commission will explore the various questions listed below.

• Is it important to have a diverse workforce?
• How does a diverse workforce influence access to care and health status?
• What are the barriers to workforce diversity (financial, geographic, etc.)?
• What programs have worked to close health status gaps and increase access to care?
• Is there a standard definition for cultural competency?
• What is the role of affirmative action in promoting health care workforce diversity?
• What is the role of government (Fed., State, local) in promoting workforce diversity?
• What are the roles of other stakeholders (AMA, etc)?
• How should a health profession education be financed?
• What are the economic implications of disparities in health status?
• What are the implications of workforce diversity in competing (economically) with other nations?
• What are the roles of prevention and health promotion as they relate to access to care and health status?

While just half way through the scheduled hearings, several trends have become apparent to commissioners.  These include the need for more primary care practitioners, more care in medically underserved areas, and more health education and disease prevention activities.  To gain support for efforts to address these needs, advocates need to emphasize the economic impact of improvements in health status—studies have shown that improvement in life expectancy adds to the nation’s economy.