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Bridging
Cultures and Enhancing Care:
Approaches to Cultural and Linguistic Competency in
Managed Care
For
downloading or printing: Bridging
Cultures and Enhancing Care (PDF file - 513 KB)
May
30, 2002
Chicago, Illinois
Sponsored
by:
Health
Resources and Services Administration (HRSA)
and
American Public Human Services Association (APHSA)
This
conference summary reflects the information provided
by and the opinion of the conference presenters/participants
and is not that of the American Public Human Services
Association, the Health Resources and Services Administration,
or the U.S. Department of Health and Human Services.
Dear
Colleague:
The
Health Resources and Services Administration (HRSA)
is pleased to share with you the enclosed publication
entitled, Bridging Cultures and Enhancing Care:
Approaches to Cultural and Linguistic Competency in
Managed Care. This publication highlights the
events of a national conference that was sponsored by
the HRSA Center for Health Services Financing and Managed
Care in cooperation with the American Public Human Services
Association (APHSA). This conference program covered
the core information that will enable participants to
define and assess the cultural and linguistic competency
of their organization and provider network.
Hopefully,
this publication will serve as a valuable resource as
your organization moves toward becoming more culturally
competent. Copies of this publication may be downloaded
from the HRSA Center for Health Services Financing
and Managed Cares web: www.hrsa.gov/reimbursement
or ordered from the HRSA Information Center,
1-888-ASK HRSA, www.ask.hrsa.gov
Table
of Contents
INTRODUCTION
CULTURAL
COMPETENCY: The Basics
SUCCESSFUL
PRACTICES IN MANAGED CARE
PLENARY
SESSION: An Interactive Session Opportunity to Discuss
Challenges in Delivering Culturally and Linguistically
Competent Health Care
INTRODUCTION
On
May 30, 2002, representatives from State Medicaid agencies,
managed care organizations (MCOs), state and local health
departments, Ryan White Care Act HIV/AIDS providers,
public hospitals, family support groups, state mental
health agencies, and others convened in Chicago, Illinois
for a conference to discuss the special issues related
to providing culturally competent healthcare for patients
with diverse cultural backgrounds. The one-day conference
Bridging Cultures & Enhancing Care: Approaches
to Cultural & Linguistic Competency in Managed Care
was sponsored by the Health Resources and Services Administration
(HRSA) Center for Health Services Financing and Managed
Care in cooperation with the American Public Human Services
Association (APHSA).
The
conference began with opening remarks from Gregory A.
Vadner, Director, Division of Medical Services for the
Missouri Department of Social Services in Jefferson
City, Missouri. After general introductions and administrative
announcements, the objectives for the meeting were set
forth.
Conference
Goals and Objectives
Program
Goal:
To
motivate and increase the ability of participants
to enhance the cultural and linguistic competence
within their managed care organization and their
provider network(s).
Program
Objectives:
Program
participants will gain an understanding of:
- The
contribution of cultural and linguistic competence
to improved health outcomes
- The
business and clinical perspectives for developing
culturally and linguistically appropriate organizations
and services
- The
contribution of culturally and linguistically
appropriate services to clinical practice and
health outcomes through improved provider/patient
communication, adherence, early diagnosis, and
improved prevention
- Developing
and implementing culturally and linguistically
appropriate organizations and services
- The
fundamental elements of culturally and linguistically
appropriate organizations and services
- Policies,
programs, and services which have been developed
by managed care organizations and/or their provider
networks in support of cultural and linguistic
competency for adaptation and/or incorporation
- How
to implement strategies used to develop cultural
and linguistic competence in the delivery of
healthcare services
|
CULTURAL
COMPETENCY: The Basics
The
essential elements of cultural competency were commented
on throughout the program by all speakers. Felicia
Batts* and Josepha Campinha-Bacote** provided comprehensive
information about the fundamental aspects of cultural
competency. Here, Drs. Batts and Campinha-Bacotes
comments have been synthesized and summarized in a simple
format as a foundation for the remainder of this report.
* and ** indicate which speaker
provided the information.
What
is Cultural Competency?*
There
are as many definitions of cultural competency as there
are diverse perspectives, interests and needs. However,
the following is a broad, generally accepted definition:
A
set of congruent behaviors, attitudes, and policies
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.* |
Cultural
competency is based upon the concept that cultural differences
extend beyond race and ethnicity. Cultural variations
include*:
Where
does Cultural Competency in healthcare begin?*
Cultural
competency occurs in both clinical and non-clinical
arenas.
In the clinical arena, cultural competency is based
on the patient-provider interaction.
In the non-clinical arena, organizational policies
and interactions impact the delivery of culturally
competent services.
Why
is cultural competency important?
When
health care services are delivered without regard for
cultural differences, patients are at risk for sub-optimal
care. Patients may be unable or unwilling to communicate
their healthcare needs in a culturally insensitive environment,
reducing the effectiveness of the healthcare process.
Understanding the fundamental elements of culturally
and linguistically appropriate services is necessary
when striving for cultural competency in healthcare
delivery.
Four
Rationales for Cultural Competency in Healthcare Delivery**
-
To
respond to demographic changes
-
To
eliminate disparities in the health status of people
of diverse racial, ethnic, and cultural backgrounds,
especially in particular medical conditions: cancer,
cardiovascular disease, infant mortality, diabetes,
HIV/AIDS, and child and adult immunizations.
-
To
improve the quality of healthcare services and health
outcomes
-
To
gain a competitive edge in the healthcare market
and decrease the likelihood of liability/malpractice
claims. Healthcare is a business, and as such
is influenced by the same force driving all big
businesses today, including market competition,
consumerism, organization restructuring, information
service technology, and customized care.
What
are some obstacles to culturally competent care?*
-
Stereotypes,
Biases and Assumptions
-
Viewing
Culture as Them, Not Me
-
Confounding
Race, Culture and Ethnicity
-
Differing
Health Belief Models
-
Patient
Exploitation and Oppression
-
Pseudo-explanatory
Models
-
Cultural
Mismatches
-
Language
and Communications Barriers
-
Misdiagnosing
Ethnic-specific Medical Concerns
-
Cultural
Clashes
What
are the Pros and Cons of Cultural-Specific Information?*
Cultural-specific
information is one aspect of cultural competency that
is important but controversial. It can be useful, but
misused as well.
Benefits
of Cultural-Specific Information*
-
Can
illustrate important differences among cultures
-
Serves
as a starting point for cultural assessment
of patients
-
Opens
mind to alternative viewpoints and treatments
-
Helps
avoid egregious errors
Cautions
Regarding Cultural-Specific Information*
-
Tends
to promote stereotyping
-
May
fail to fully recognize diversity within
groups
-
Sometimes
creates cultural value scale
-
Can
give providers false sense of confidence
The
Effects of Race and Ethnicity on the Delivery of Quality
Health Care
Nathan
Stinson, M.D.
Deputy Assistant Secretary for Minority Health
Office of Minority Health
U.S. Department of Health and Human Services
Rockville, Maryland
Nathan
Stinson, Jr., PhD, MD, MPH began the presentations by
providing a broad and comprehensive overview of how
race and ethnicity affect healthcare delivery nationwide.
As our country grows increasingly diverse, health disparities
based on race and ethnicity are becoming more readily
apparent. In 1985, The Task Force Report on Black and
Minority Health reported that minorities have comparatively
poor health, that health disparities have worsened and
that minorities are chronically underserved by the healthcare
system.
The
March 2002 report Racial and Ethnic Disparities
in Healthcare issued by the Institute of Medicine
(IOM) indicates that these issues have shown little
improvement in the past 17 years. The most relevant
new finding from the IOM may be that racial and ethnic
disparities remain even after adjustment for socioeconomic
differences and other healthcare access related factors.
The IOM concluded that racial and ethnic disparities
in healthcare exist and are associated with worse outcomes
in many cases. Further, these disparities in healthcare
occur in the context of broader historic and contemporary
social and economic inequality, and reflect evidence
of persistent racial and ethnic discrimination in many
sectors of American life. The IOM recommended several
actions to address healthcare disparities:
-
Increase
awareness of racial and ethnic disparities in healthcare
among the general public and key stakeholders;
-
Increase
healthcare providers awareness of disparities;
-
Initiate
legal, regulatory, and policy interventions to enact
change.
The
IOM report also called for data collection and monitoring
according to ethnic and racial backgrounds for myriad
purposes (see box).
Why
Collect Racial and Ethnic Healthcare Data?
- Evaluate
and monitor effectiveness of programs
- Understand
etiologic process and identify differences in
performance within a plan
- Design
targeted quality improvement activities
- Develop
cost-effective improvement efforts
- Identify
the need for and deploy resources form the provision
of culturally and linguistically appropriate
sevices
- Monitor
trends over time at local, state, and national
levels
- Help
all parties understand the scope of the problem
of health disparities affecting their clients
and stimulate action
- Empower
consumers to make informed decisions about health
plan choice
- Assure
civil rights
|
However,
collecting racial and ethnic information gives rise
to some practical and ethical issues. There are perceived
legal impediments with respect to confidentiality and
privacy and the potential misuse of data. Further, the
cost of large-scale data collection is substantial.
In
an effort to address the issues of collecting racial
and ethnic information, a meeting was jointly held in
June 1999 by the Office of Public Health and Science,
The Commonwealth Fund, the Agency for Healthcare Research
and Quality (AHRQ) and numerous managed care organizations
(MCOs). None of the MCOs in attendance routinely collected
racial and ethnic information; however, some have obtained
such data from research, state Medicaid programs or
linkages to other databases (e.g, cancer registries,
birth certificates). While MCOs expressed concerns,
the general consensus was that if data were to be collected,
all plans and health insurers should do it.
With
the assistance of the National Health Law Program, Inc.
(NHeLP), a review of state and Federal laws was initiated
to identify laws and regulations that require or prohibit
the collection of racial and ethnic data by health insurers
and MCOs. Two Federal health services programs require
racial and ethnic date collection and/or reporting:
the End-Stage Renal Disease Program and Substance Abuse
and Mental Health Services Administration (SAMHSA) applications
for prevention service activities. Data collection requirements
for Medicaid managed care and CHIP regulations have
recently been finalized. Several public program statutes
also require racial and ethnic data for participation.
Even
when a specific statutory requirement does not exist,
Title VI of the Civil Rights Act of 1964 provides a
legal foundation for the collection of racial and ethnic
data, though it does not specifically mandate or prohibit
such data gathering. This Act protects individuals by
prohibiting discrimination on the basis of race or national
origin in the provision of any services that are supported
with Federal funds. Title VI protection extends to all
programs and activities of any entity receiving Federal
funds, whether or not the particular program has itself
received or benefited from those funds. This would therefore
include any Medicaid MCOs.
State
laws for MCOs and health insurers vary, however. Four
States prohibit the collection of racial and ethnic
data as part of the application process: California,
Maryland, New Hampshire, and New Jersey. Although MCOs
are free to collect data at the point of care or at
some other time after members enroll, it is logistically
more challenging to generate aggregate data this way.
Conversely, one StateSouth Carolinarequires
MCOs and insurers to collect racial and ethnic data,
while anotherTexasrequires collection of
primary language information.
After
identifying the problem of disparity in healthcare,
Dr. Stinson continued to lay the foundation for the
rest of the days discussions by defining cultural
competency, a concept viewed by many as the solution
to healthcare inequity. According to Dr. Stinson, cultural
competency is the ability of health organizations
and practitioners to recognize the cultural beliefs,
attitudes and health practices of diverse populations
and to apply that knowledge in every interventionat
the systems level or at the individual levelto
produce a positive health outcome. He suggests
that culturally competent care has the potential to
improve access to services, reduce medical errors, and
increase the use of preventive services. Furthermore,
cultural competency may improve patient compliance and
patient satisfaction, reduce financial costs and liability
and ultimately facilitate the elimination of health
disparities. In closing, Dr. Stinson explained that
the Office of Minority Health has established 14 national
standards to inform, guide, and facilitate culturally
and linguistically appropriate healthcare services (CLAS).
He ended with an apt quote from Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health
Care, a report from the National Academies
Institute of Medicine: The real challenge lies
not in debating whether disparities exist, but in developing
and implementing strategies to reduce and eliminate
them. Confronting such unequal treatment
will require a broad and sustained commitment from those
who provide care, as well as those who receive it.
Building
Cultural Competence in Organizations: Focus on Promoting
and Sustaining Change
Calvin
Freeman
President
Calvin Freeman & Associates
Sacramento, California
Calvin
Freeman, former Chief of the Office of Multicultural
Health and Head of Disaster Medical Preparedness for
the State of California, addressed the issue of promoting
cultural competence through organizational change. During
Mr. Freemans 25 years of experience in public
health, he has found a broad-based, multi-level approach
to be effective for several reasons. First, organization
leaders are in a position to guide a large group of
people through priority and goal setting. Policies that
impact many patients can be defined and implemented
throughout the organization. Personnel policies and
decisions can be guided by organizational change. Even
the physical design of facilities, which is often integral
to creating a culturally competent setting, can be addressed.
Mr.
Freeman discussed 4 main strategies for improving
cultural competence by initiating organizational change:
-
Be
strategic in your approach to promoting cultural
competence.
-
Build an infrastructure for cultural competence.
-
Recognize the importance of people and relationships.
-
Use the management knowledge and tools you use for
other issues.
According
to Mr. Freeman, being strategic in an approach to promoting
cultural competency begins with accepting a few assumptions.
First, organizations do not change easily because multiple
staffs, units and functions are involved. Second, large
change is built on small stepswe must get away
from the idea that everything must be, or even can be,
accomplished at once. Finally, even failed attempts
at change can be positive, negative, or both depending
on what we choose to learn from the attempts. With an
understanding of these concepts in place, the first
step to promoting cultural competency in a large group
is to assess the status quo. Assessment helps to define
the context and environment, identify assets and obstacles,
and determine readiness to meet patient and community
needs. Assessments also send a message to the organization
and community of the intent to promote cultural competence.
Looking forward, assessments set a baseline for measuring
progress.
Another
component to strategically promoting cultural competence
is increasing readiness for change. Increasing readiness
begins by building internal support for the initiative.
The support of decision-makers is crucial as they can
gradually increase acceptance of implementers and mobilize
change agents. Mr. Freeman noted that it is especially
important to manage expectations of staff where change
is concerned because increasing cultural competency
will not happen overnight, and setting expectations
too high and too fast may result in negative backlash.
Credibility is also important and can be gained if decision-makers
are perceived as actively involved in and committed
to the same culturally appropriate behaviors they are
asking of others in the organization. In addition, garnering
external support can improve an organizations
ability to affect change. By engaging a wide mix of
allies, understanding their motivations for being involved,
and encouraging two-way communication, outside groups
such as other MCOs, hospitals, and public agencies can
contribute strength to organizational efforts.
Building
an infrastructure to sustain the cultural competence
development process includes five key elements, according
to Mr. Freeman: knowledge, a planning committee, a point
person, data and resources. As with any large-scale
project, identifying objectives and goals with actions
and timelines will keep the effort on track. Further,
clearly identifying current and future resources will
help assess the sustainability of the efforts.
Mr.
Freeman noted that while financial resources are an
important part of cultural competency improvement, human
resources are just as valuable. Members at all levels
of the organization need to believe that these efforts
are authentic, will promote better delivery of healthcare
services and are important to the overall success of
the group. Praise and recognition are often the strongest
way to gain internal support. Acknowledge those individuals
whose devotion to change is exceptional and unwavering;
others will likely follow their model. Finally, communicating
the strategic plan to the entire organization as it
develops so that everyone remains in-the-loop
will strengthen the process and help avoid internal
conflicts or dissent.
Cultural
Competence and Linguistically Appropriate Services in
the Clinical Setting
Felicia
Batts, M.P.H.
President
Consulting by Design
Fresno, California
Ms.
Batts shared a comprehensive three-part presentation
with the group. The first part, Development of
Culturally Competent Services: The Fundamentals
has been summarized in the introductory section of this
report to serve as primer of basic principles and concepts.
Part Two (Promoting Cultural Competence in Clinical
Practice: The Patient-Provider Interaction) and
Part Three (Linguistic Services: Translation and
Interpretation Issues) of Ms. Batts three-part
session focusing on cultural competence in the clinical
setting are summarized here.
Promoting
Cultural Competence in Clinical Practice: The Patient-Provider
Interaction
Patients
belonging to minority groups face disparities in accessing
and receiving healthcare. Many feel that they have difficulty
communicating with their physicians and that they would
receive better care if they were of a different race
or ethnicity. Ms. Batts explained that healthcare providers
have the power to improve healthcare experiences for
minority patients through culturally competent interactions
that promote the delivery of quality, timely and effective
clinical services to patients of diverse backgrounds.
First,
there needs to be an understanding of the value differences
between the Western approach to medicine and alternative
approaches to which many minorities are accustom. In
Western medicine, the concept that an individual determines
his or her own health is generally accepted; this supports
the preventive medicine approach and low-power distance
between patients and providers with a Western medicine
mind-set. Patients from other backgrounds often view
things quite differently. They may perceive health and
illness as a matter of fate, focusing more on the present
state of health rather that the future. Frequently,
they may believe the physician has the greater power
in the relationship and therefore avoid asking questions
about their own condition. Depending on their particular
culture and past experiences, patients from minority
backgrounds may perceive a physician in unique ways.
Unique
Patient Perceptions of Physicians
- Healer/Miracle
worker
- Expert
- God's
worker
- Shaman
- Confident
or friend of the family
- Authority
figure or recipient of unquestioned respect
- Pill
dispenser
- Last
resort for healing
- Someone
who inflicts pain
- Partner
in making health decisions
|
More
and more, all patients, regardless of background, are
using alternative therapies. Acupuncture and other traditional
therapies are being proven effective, and the spiritual
and mental aspects of disease are receiving more attention
now than ever. Complementary medicine and alternative
health practices are common approaches to maintaining
wellness and treating illness among patients of diverse
backgrounds. One in three people have used these methods;
however, nearly two-thirds do not tell their regular
physician about the use of complementary medicine. This
is a major concern because of potential treatment interactions.
In some cultures, patients may view Western medicine
as a last resort because they feel it is too potent.
Providers should discuss complementary medicine practices
with their patients to gain a better understanding of
their perspectives and to determine how Western and
alternative therapies can be used together to the patients
advantage.
Next,
styles of communication may differ among patients from
various cultural backgroundsbeyond language differences.
Considering all types of communication (e.g., written,
spoken and body language; dialects; and slang) is important
to patient-provider interactions. Some communication
challenges include medical terminology versus common
terms, varying literacy levels, the speed of speech,
culturally inappropriate words or phrases, multiple
dialects, the use and misuse of interpreters and gender-specific
terminology. Ms. Batts conveyed that there is no one
definitive curriculum on culturally competent communication
and that she does not train physicians in culture-specific
methods (e.g., how to interact with Hispanic patients
versus Korean patients). Instead, she emphasized that
those providers who make attempts to learn about and
understand cultural backgrounds of their particular
community of patients are best equipped to engage in
effective culturally competent communications. However,
there are someareas of general concern that can be addressed
by providers trying to improve their interactions with
culturally diverse patients (see table).
Basic
Concern |
Questions
to Help Providers Understand Patients |
Names |
How
are people named? Do given or family names come
first? Are titles used? Do names change? |
History |
Why
did the family immigrate here? Where from? What
are conditions in the home country? What health
problems exist there? What is the work history of
the family? |
Language |
What
language or dialect is spoken? |
Religion |
What
are the spiritual beliefs and do they impact daily
routines? Are there any medical taboos? How does
religion impact care decisions? |
Moral
Beliefs |
What
do patients believe about pregnancy, unwanted pregnancy,
sexually transmitted diseases or similar conditions?
How does this affect care decisions and disclosure
to physicians? |
Food |
What
foods are common? Are there any taboo foods? What
are the social rules concerning food? |
Community |
What
services are available in the community? Is this
a unified or divided community? |
Acculturation |
How
long has the family/individual resided in the US?
To what degree has each individual family member
adopted American culture? |
Understanding
patients family issues also promotes more culturally
competent care. The family structure and make-up, such
as who lives in the household and who are the decision-makers,
can be important when treating patients. Also, a patients
preferred language may be different than that of other
family members; likewise the extent of acculturation
may differ. It is better to get to know each individual
rather than making assumptions about one family member
based on familiarity with another. Also, internal family
conflict may impact the care process; therefore, being
aware of signs of conflict can also guide providers
as they treat multiple members of the same family.
Patients
beliefs may also impact their communication on numerous
health-related issues. Culturally-held attitudes affect
how patients identify a medical problem requiring professional
attention versus self- or home-care. Patients may also
perceive certain topics as taboo and feel uncomfortable
discussing them, especially if the provider is opposite
sex. Describing such a problem to the provider can be
challenging for patients. Further, if patients disagree
with the provider, cultural attitudes may inhibit them
from sharing their concerns.
Perhaps
most important is to establish a level of trust with
patients. Discrimination occurs when trust is absent
from both the patient and provider perspective. Physicians
have limited time to spend with patients, and patients
may perceive that physicians are driven by profits even
if this not actually the case. A basic lack of trust
between patients and providers results in a lack of
trust in the diagnosis or treatment of the medical problem.
Patients may feel they need to do their own research
to validate treatment recommendations and be more proactive
and aggressive in order to get quality care. Providers
need to be aware of trust issues and strive to establish
a connection with patients that will allay their fears.
Linguistic
Services: Translation and Interpretation Issues
Accessible
and appropriate linguistic services are the foundation
of culturally competent healthcare. Eliminating confusion
and achieving clarity with patients is essential for
ensuring effective communication between patients, providers,
and healthcare staff. Linguistic services are comprised
of four main elements: oral services, interpretation
services, written services, and translation services.
There
are numerous reasons to provide linguistics and translation
services. First, language and cultural differences may
result in under-use of necessary services. In addition,
inadequate communication gives rise to concerns about
malpractice liability. There is also the need to comply
with civil rights legislation and pressure from advocacy
groups. Several Federal laws exist to ensure access
to language services for all limited English proficient
persons. These laws include Title VI of the Civil Rights
Act of 1964, the Hill Burton Hospital Survey and Construction
Act of 1946, and the Disadvantaged Minority Health Improvement
Act of 1990.
There
are many options for providing translation services,
though the effectiveness of these options varies. Healthcare
facilities with bilingual and bicultural providers and
staff are best equipped to provide translational services;
next most desirable is the availability of the staff
members hired specifically for interpretation services.
When interpretation staff members are assigned other,
non-translation duties, their job priorities are divided.
Thus, while this may be a financial beneficial strategy,
it is not the optimal one for patients in most clinical
settings. The use of outside interpreters or telephone
interpretation may be required, but again is not the
preferred method. Finally, last resorts include the
use of family members for translation or referring the
patient to another facility; neither strategy is in
the best interest of the patient or the healthcare organization
providing services.
Having
bilingual and bicultural staff allows direct communication
between staff members and patients, which reduces miscommunication
and misunderstanding. However, there is a lack of qualified
providers and staff, even for common languages. Further,
there is no standardized tool to assess language and
cultural skills. Dialects and language differences related
to socioeconomic status may still exist, and translating
medical terminology in the target language can be a
problem. While building a bilingual staff and provider
group is not a perfect solution, it is the best practical
option for serving patients in a culturally competent
manner.
An
Interpretation-Only staff offers several
benefits, as well. These individuals are more likely
to be skilled at medical interpretation, having had
didactic training in the field. Also, this option also
offers flexibility in hiring practices. However, it
works best in a setting with high demand for a single
language versus one with linguistic diversity of patients.
Again, there is a lack of defined standards in this
area, and finally, it can be a costly option.
Hiring
an interpretation staff person with other duties is
a reasonable alternative when the demand is not sufficient
to hire someone full-time. Interpreters can be effective
as caseworkers or family health workers, roles where
communication is essential. However, care must be taken
to avoid conflicts between interpretation services and
other duties so that staffers are not confused as to
work priorities. If the staff person is used only occasionally
for interpretation, costs are reduced and there is someone
on-site in an emergency. But this is really only a contingency
plan, because maintaining accurate lists of employees
who speak particular languages is difficult and it may
be challenging to locate that person when he or she
is needed, especially in larger facilities. This option
also bears the greatest potential for job conflicts.
Using
outside interpreters can be effective when there insufficient
demand for a full-time staff member. These interpreters
can be hired hourly for prescheduled appointments and
can supplement on-staff interpreters as needed. Again,
the lack of standards is an issue, and hourly rates
can be expensive. Further, there is no established relationship
with the provider, and outside interpreters may be difficult
to access on short notice, so they cannot be used in
an emergency.
The
use of telephone interpretation services is especially
appropriate for emergency situations, or if brief or
basic information is needed. But few telephone translators
are medical specialists, so they may lack cultural health
knowledge. Also, body language and similar communication
clues are lost with this method.
Finding
the option that works will be individual for each healthcare
setting and will depend upon numerous factors. But doing
so is crucial because a lack of translational services
or poor translational practices can result in major
dilemmas, such as cultural misunderstandings, incorrect
assessment of patients language ability, and confidentiality
conflicts. The use of family members, especially children,
is highly undesirable because of the potential for family
conflict or the impact of the information being conveyed.
Several
new approaches for selecting an interpretation method
are now available, thanks to research regarding the
impact, effectiveness, and cost-benefits of various
strategies. Also, technology has evolved to allow video
conferencing translation and computer software has been
developed to aid with translation needs.
Californias
Approach to Ensuring Cultural Competent Healthcare Services
in Medicaid Managed Care and CHIP Health Plans
Gregory
A. Franklin, M.H.A.
Chief, Office of Multicultural Health
California Department of Health Services
Sacramento, California
Gregory
A. Franklin, M.H.A., Chief of the Office of Multicultural
Health, discussed how purchasing strategies and the
application of policy have provided the foundation for
the delivery of culturally and linguistically appropriate
healthcare services in Medicaid and State Childrens
Health Insurance Program (CHIP) managed care organizations
(MCOs) in California. Mr. Franklin began by reviewing
the definition of cultural competency (see Introduction),
and by discussing a framework for health. Personal health
begins with the individual at the center of many other
interactive variables (see figure). Policymakers have
not only the ability, but also the responsibility
to contribute to this process in a positive manner.
Chart:
Determinants of Health (d-link)
![Chart: Determinants of Health](figure1-chart.gif)
The
ethnic and racial composition of Californian residents
is rapidly changing; therefore, cultural competency
will play a large role in the process of determining
health. While the white, African American, and Native
American populations are decreasing, the number of Hispanic
Americans and Asian or Pacific Islanders is growing
simultaneously (see figure).
Graph:
The Changing Ethnic and Racial Composition of California
(d-link)
![Figure 2 Graphic](figure2-graph.gif)
Source
of statistics:
* 1990 statistics are from California Department of
Finance 1990 Census Data.
** 2000 statistics are from U.S. 2000 Census Data.
*** 2040 statistics are from California Department
of Finance Census Projection Data 1990.
Medi-Cal,
Californias Medicaid Managed Care, includes a
significant portion of this diverse population. As of
April 2002, Medi-Cal enrollment was nearly 2.6 million,
of which 45% of members are Latino/Hispanic, 18% African
American, and 10% Asian/ Pacific Islanders. The Healthy
Families Medi-Cal for Children program, CHIP, includes
an additional half-million members with a slightly different
ethnic and racial make-up: Latino (66.7%), white (15.9%),
Asian Pacific Islander (13.4%), and African American
(2.9%). The larger portion of Latino and Hispanic children
enrolled through S-CHIP reflects the recent growth of
this group.
To
ensure culturally competent, quality health services
are delivered to these members, Medi-Cal has partnered
with a range of organizations to enhance care. These
groups include:
Mr.
Franklin noted several important policy considerations
that can support efforts to improve healthcare for California
residents. First, the concept of health
itself should be broadly defined in positive terms in
order to stimulate proactive, preventive interventions.
Secondly, patients and providers need to recognize that
the health is determined by sociocultural and economic
issues as well as physical factors. And as previously
noted, Californias changing demographics will
have long term effects on policies that impact healthcare
delivery.
With
these considerations in mind, Medi-Cal has developed
and disseminated numerous policy letters for providers
and provider groups in the Medi-Cal network. The policy
letters address issues such as linguistic services,
translation of written informing material, Community
Advisory Committees, and needs assessments. To meet
the needs of a culturally and linguistically diverse
population, Medi-Cal has identified threshold
languages (languages common to a significant portion
of the patient population) and requires that written
material and oral translational services be available
in these languages. Members have been informed of these
services. Medi-Cal groups have been asked to establish
a Community Advisory Committee for recruiting membership
and identifying the groups function. For translation
of written informing materials, healthcare groups are
required to create linguistically accessible documents
and/or timeline for the creation of such materials.
Despite
these efforts, some challenges still exist in delivering
culturally competent care. There is no one size
fits all solution for every provider or practice
in the Medi-Cal system. Though enforcement and accountability
are important, practical issues sometimes impede required
activities. Other obstacles include competing priorities
(i.e., the will of health advocates vs. State policy),
access issues, and lack of dedicated funding.
Still,
the future of quality healthcare depends on continued
efforts to overcome these obstacles and bring culturally
competent care to every Medi-Cal member throughout the
State. Medi-Cal plans to incorporate policies throughout
the State health department and make policies and processes
available to other State agencies. As they continue
to refine existing efforts in managed care, Medi-Cal
would also like to develop fee-for-service models for
enhancing culturally competent care. Finally, the organization
plans to step up its efforts to monitor for compliance
with these important policies.
SUCCESSFUL
PRACTICES IN MANAGED CARE
Arizona
Health Care Cost Containment System (AHCCCS) Plans and
the Provider Pocket Guide
Georgia
Hall, Ph.D., M.P.H.
Executive Director
Institute for Health Professions Education
Phoenix, Arizona
Philip
Nieri, MPA
Director of Compliance
Schaller-Anderson, Inc.
Phoenix, Arizona
Georgia
G. Hall, PhD, MPH and Philip Nieri, MPA discussed how
Arizonas Medicaid program (AHCCCS) developed a
cultural competency provider-education initiative in
conjunction with its many contracted health plans throughout
the State. AHCCCS subcontracts with health plans owned
and/or managed by Catholic Healthcare West, CIGNA, United
Health Care, Schaller Anderson, Inc. and various hospital
based health care companies (e.g. IASIS Healthcare and
Vanguard). These companies help manage services provided
to 650,000 members in all Arizona counties. Members
choose a plan and PCP to act as their medical
home.
Because
of the many separate entities involved in serving the
AHCCCS patient population, the challenge was to create
a plan that would improve provider awareness of cultural
competency issues across the entire network. By believing
that culturally appropriate care improves health outcomes
and helps eliminate health disparities, AHCCCS and its
subcontractors met that challenge head on. AHCCCS requires
its health plans to participate in quality improvement
efforts in both clinical and non-clinical areas that
would be expected to have a beneficial effect on health
outcomes and member satisfaction. One of these areas
is cultural competency of services.
AHCCCS,
with its subcontractors, established a framework for
a cultural competency workgroup to coordinate compliance
with cultural competency program requirements, including
those imposed federally and by the State. The workgroup
helped coordinate the development of annual cultural
competency work plans and methods for reporting outcomes
from the Cultural Competency Quality Improvement Project.
The workgroup includes representatives from all AHCCCS
health plans and program contractors from various sectors
including compliance, quality management and operations.
By engaging in discussions on compliance and by sharing
best-practices ideas, the workgroup identified
a strategy for action. The core idea was to reduce redundancy
of culturally competent activities, particularly training
and outreach to physicians, and develop new efforts
to supplement existing training/outreach resources.
A sub-committee was subsequently created by those health
plans and programs contractors who volunteered to help.
The
sub-committee focused on development of a cultural competency
pocket guide to be distributed to every
provider in an AHCCCS health plan. A consultant was
hired to gather information about educational needs
in providing culturally competent care and to ensure
that information in the guide reflected AHCCCS requirements.
The sub-committee also coordinated the printing/distribution
of the guide for participating provider offices. Though
it required significant coordination between the State
and many individual health plans, the project presented
a unique opportunity to jointly develop a useful resource
for providers, proving that collaborative projects can
workin spite of competition and other perceived
barriers.
A
Culturally Conscious Approach to the Delivery of Healthcare
Services
Josepha
Campinha-Bacote, PhD, RN, CS, CNS, CTN, FAAN
President
Transcultural C.A.R.E. Associates
Cincinnati, Ohio
Josepha
Campinha-Bacote, PhD, RN, CNS, BS, CTN, FAAN, President
of Transcultural C.A.R.E. Associates, shared with the
group the ASKED model of cultural competence, which
she developed and published in 1998. According to Dr.
Campinha-Bacote, cultural competency is the process
in which the healthcare provider continuously strives
to achieve the ability and availability to effectively
work within the cultural context of a client (an individual,
family, or community). Emphasizing the process
aspect of her model, she states that cultural competence
is a journey, not a destination; it is cyclic not linear.
The
process of Cultural Competence involves interrelationships
between five elements:
Cultural
Awareness
Cultural Skill
Cultural Knowledge
Cultural Encounters
Cultural Desires
Hence, the ASKED model.
Cultural
awareness requires self-evaluation of ones
own prejudices and biases towards other cultures. [It
is] the process of cultural humility.[1]
It is also a willingness to explore ones own cultural
and ethnic background. Basically, says Campinha-Bacote,
cultural awareness means knowing yourself. On a broader
level, this concept entails asking the question, Is
there racism in the delivery of healthcare services?
Dr. Campinha-Bacote cited several evidence-based studies
that confirm that such racism does in fact exist.
Cultural
knowledge includes obtaining a sound educational
foundation concerning the various world views of different
cultures. Within the field of healthcare, it also means
obtaining knowledge of biocultural ecologybiological
variations, disease and health conditions and variations
in drug metabolism related to ones background.
Dr. Campinha-Bacote warns, though, that it is necessary
to be wary of intra-ethnic and intra-cultural variations;
even within cultural groups, many differences exist.
Cultural
skill is the ability to collect culturally relevant
data regarding a clients health history and current
medical problem. This is done using a cultural assessment
tool. Conducting a culturally-based physical examination
is also part of cultural skill in healthcare. These
assessments should be conducted in a culturally-sensitive
manner. Dr. Campinha-Bacote reminded the audience that
everyone should be given a cultural assessment. Only
conducting an assessment with patients who look
like they might need one is a culturally bias
practice itself. A cultural assessment tool is available
in Dr. Campinha-Bacotes book, The Process of
Cultural Competence in the Delivery of Healthcare Services.[2]
The ultimate goal of a cultural assessment is to determine
appropriate culturally responsive interventions, which
ask providers to recognize the differences in individuals,
but build upon similarities to others.
Another
element of the process is the cultural encounter.
Cultural encounters are the process by which healthcare
providers directly engage in face-to-face, cross-cultural
interactions. The goals of these interactions are to
generate a wide variety of verbal responses (i.e., encourage
patients to communicate openly) and to send and receive
both verbal and non-verbal messages accurately and appropriately
in each culturally different context.[3]
Perhaps
the most vital component of the ASKED model is cultural
desire. This, unlike the other four elements, is
not necessarily a learned behavior; rather, it is based
upon providers internal motivation to engage in
the cultural competency processbecause they want
to, not because they have to. Characteristics
of a provider who has cultural desire include compassion,
authenticity, humility, openness, availability, and
flexibility. Dr. Campinha-Bacote emphasizes that skill,
knowledge, and awareness matter very little without
desire: People (i.e., patients) dont care
how much you know until they first know how much you
care.
One
application of the ASKED model of cultural competence
is the BE SAFE model, a culturally competent model for
caring for African Americans with HIV/AIDS. Following
Dr. Campinha-Bacotes presentation, her colleague
John McNeil, MD, Principal Investigator for National
Minority AETC in Washington, D.C., describe the BE SAFE
model.
Footnotes:
[1]
Tervalon, 1998.
[2] Campinha-Bacote,
J. “Cultural Skill” in The Process of Cultural Competence
in the Delivery of Healthcare Services. 1998, 3rd
edition. OH: Transcultural C.A.R.E. Associates.
[3] Adapted from Sue,
1982.
Model
of Cultural Competency for Working with African American
Patients Infected With HIV
John
McNeil, MD
Principal Investigator
National Minority AETC
Washington, D.C.
John
McNeil, MD, Principal Investigator for the National
Minority Aids Education Training Center (AETC) in Washington,
D.C., discussed cultural competency in a very specific
context: caring for African Americans with HIV or AIDS.
Dr. McNeil noted that people of African decent who reside
in the United States are a hybrid population. Most African
Americans have genetic make-ups that cross African ethnic
groups and other racial groups, primarily European and
American Caucasian, as well as Native American. Caribbean
population mixtures include East Indians, Chinese, and
Indigenous West Indians. Nearly one million individuals
have emigrated from nations in Africa and the Caribbean
since 1994, with Florida, New York and New Jersey being
the most highly populated areas. Within the African
American community, many cultural differences exist,
and recognizing these differences is vital to providing
culturally competent healthcare.
Moreover,
providing culturally appropriate care for African American
patients with HIV requires a unique sensitivity to issues
that transcends race or ethnic background. There are
shared behaviors and issues that create a culture associated
with the disease itself. Patients with HIV/AIDS experience
emotional distress, sexual orientation issues, economic
hardship, and societal discrimination. They may also
participate in high-risk behavior and substance abuse
as part of their daily lives. Understanding and addressing
these issues is vital to providing culturally competent
care.
The
National Minority AIDS Education and Training Center
developed a model of cultural competency for African
American patients with HIV/AIDS. A multidisciplinary
panel comprised of physicians, nurses, dentists, physicians
assistants, and HIV educators was organized; the panel
included a heterogeneous mix of individuals born in
America, the Caribbean, Africa, and Cape Verdean. The
primary aims of the panel were to 1) encourage a deeper
understanding of cultural competency as it relates to
the HIV infected patient, 2) assist clinicians working
with HIV-infected patients to develop their understanding
of intra-ethnic variations, and 3) develop an understanding
of the role HIV plays in values, beliefs, and customs
of a patient. These aims were achieved through the development
of the model and dissemination of information to care
providers.
The
result of the panels efforts was the BE SAFE
model for culturally competent care for African American
patients with HIV/AIDS. The model is based upon the
principles of Josepha Campinha-Bacotes model of
cultural competency. BE SAFE is an acronym for six major
factors that influence the quality of care these patients
receive: Barriers, Ethics, Sensitivity of providers,
Assessment, Facts, and Encounters. Providers are encouraged
to consider all elements of the model in their daily
practice. The BE SAFE model is detailed in the figure
below; each list identifies major issues to consider
during each step of the BE SAFE process of culturally
competent care.
B |
E |
Barriers
|
Ethics |
Prejudices
Socioeconomics
Ethnicity
Stigma
Mistrust
Geography |
Third
Party Notification
Responsibilities
Desire
Humanizing
Confidentiality
Truth Telling
Difficult Patients
Dying Patients
Professionalism
HIV Specific Ethics
Patients Rights |
S |
A |
F |
E |
Sensitivity |
Assessment |
Facts |
Encounters |
Provider
Biases
Stigmas
Self-Exploration
Cultural Imposition
Unpopular Patients |
Physical
Emotional
Spiritual
Social
Mental
Occupational |
Purnells
12 Domains
Values
Beliefs
Practices/Customs
World Views
Biocultural Ecology |
Encounter
Strategies
Case
Presentations/Studies
Language/Communication
Dos and Donts
Establish Cultural Communication |
Enhancing
Family-Centered Care in Managed Care Organizations
Sophie
Arao-Nguyen, PhD
Cultural Competency Consultant
Parents Helping Parents, Inc.
San Jose, California
In
California, a dramatic population shift is occurring:
while the percentage of African Americans remains stable
and the proportion of whites decreases, the number of
Asian and Hispanic Americans is rapidly rising. Further,
the number of recent mixed-race births is also climbing,
with more than 70,500 biracial children born in 1997
alone. Healthcare plans and community groups in this
increasingly diverse state have thus turned their attention
to devising ways of offering more culturally competent
care to its members.
Parents
Helping Parents (PHP), a parent-directed family resource
center, and Kaiser Permanente, a managed care facility,
joined forces to create a national model for introducing
family-centered, culturally competent services for Children
with Special Health Care Needs (CSHCN) into managed
care through a collaborative consumer/provider partnership.
Sophie Arao-Nguyen, Ph.D., cultural competency consultant
and PHP Advisory Board Member, described this exciting
and successful initiative.
In
1994, PHP and Kaiser Permanente received a 4-year SPRANS
grant (Special Projects of Regional and National Significance)
to develop and assess this model. When children with
special needs visited Kaiser Permanentes offices
in Santa Clara and Santa Teresa, California, physicians
referred parents to PHP as a supportive resource. In
turn, PHP hired and trained a parent liaison, working
through Kaiser Permanente, to enroll and support parents
who sought out their services. PHP services include
information and education, mentor parents, support groups
by disability and by language, and translation services.
In addition, PHP trained Kaiser Permanente physicians,
nurses, social workers, and other staff members in seminars
such as Better Ways of Breaking Diagnostic News,
The Modern Art of Caring for Families, and
The Heart of Family-Centered Care.
This
model was so successful that after four years, Kaiser
Permanente decided to fund the program when the SPRANS
grant was complete. Parents reported satisfaction with
the services that were offered by Kaiser Permanente
and PHP. Efforts to replicate this successful model
at two other managed care facilities began in 1998 through
a grant funded by the HRSA Maternal and Child Health
Bureau (MCHB). This grant, which ended in June 2002,
allowed PHP to partner with Good Samaritan Hospital,
a private managed care organization, and Valley Medical
Hospital, a government-run hospital, to enhance family-centered,
culturally competent care. At the time of this presentation,
negotiations for continued funding through Good Samaritan
and Valley Medical Hospitals were on-going. Plans to
replicate this model with other hospitals in the San
Francisco Bay Area are currently being explored.
Experiences
with the PHP/Kaiser Permanente project provided several
important lessons. First, it is crucial for community
resource groups to build relationships with the managed
care organizations serving the groups members.
Establishing trust and mutual respect through open communication
is key, and can be facilitated by identifying champions
within the managed care system. Secondly, a referral
system that works for both entities is an important
component for success. Establishing an Advisory Board
composed of representatives from the managed care organization
and the parent organization helps ensure that the goals
and needs of both groups are met. Further, reliable
technology and support for gathering quantitative and
qualitative data is necessary to show improved outcomes
in terms of health and/or patient satisfaction as well
as cost-effectiveness. These lessons will provide the
framework for potential models in the future.
Addressing
Cultural and Linguistic Diversity in the Community Health
Center Environment: The Sunset Park Family Health Center
Network
Molly
McNees, Ph.D.
Staff Medical Anthropologist
Sunset Park Family Health Center Network
Brooklyn, New York
Molly
McNees, Ph.D. spoke to the group about Sunset Park Family
Health Center (SPFHC) Network, a group of Federally-funded
community health centers in and around Brooklyn, New
York. The Network grew out of a single community health
center established in 1967. The original OEO Neighborhood
Health Center was based upon the Community Oriented
Primary Care Model and has maintained a long tradition
of assuring quality care by measuring clinical outcomes
since 1990. Today, the vision of Sunset Park Family
Health Center Network is to improve the overall health
and well-being of the communities served by delivering
high quality, culturally-competent primary care and
related services within community-based settings.
The
outcomes for which Sunset Park strives are three-fold:
-
Quality
services that are competitive in a managed care
environment
-
Highly
satisfied patients with improved health and well
being
-
High
levels of staff satisfaction
The
communities that SPFHC Network cares for are generally
medically underserved. In terms of insurance, 30 percent
are enrolled in Medicaid, 25 percent in managed care,
while 13 percent have private insurance, and 10 percent
are covered by Medicare. A full 22 percent of SPFHC
Network patients are uninsured. The patients reside
in an urban, inner city environment. Seventy-eight percent
live below 125 percent of the Federal poverty level.
Twenty-five percent of patients (or 123,000) lost their
Medicaid eligibility in Manhattan and now seek treatment
in Brooklyn. Nearly 700,000 are uninsured Brooklyn residents.
The
current SPFHC Network consists of 8 primary care centers,
over 20 community and provider partnerships, and 13
school-based centers. Patient membership exceeds 90,000
users who make more than 575,000 annual visits. The
ethnic mix of SPFHC Network closely reflects the communities
it serves; 55 percent of patients are Hispanic, 12 percent
Asian and Pacific Islander, 7 percent African American,
and 26 percent white. With a high immigrant population,
40 percent of patients are limited English speakers.
The SPFHC Network has several facilities that primarily
serve patients of specific backgrounds based on the
neighborhood composition.
For
example, the Family Physician Health Center, one of
the eight Sunset Park centers, mainly cares for Hispanic
patients because it is geographically located in a mostly
Hispanic neighborhood. Similarly, the Park Ridge Family
Health Center offers multi-ethnic outreach and provides
an Islamic prayer room, fish tanks (which are an Asian
sign of good health) and complementary medicine services.
There is also a Caribbean American Family Health Center
in the Network. The SPFHC Network has also begun an
Asian Initiative, which includes community partnerships
and a needs assessment. Language access has been addressed
by creating more culturally appropriate signage and
translating written material. Staff development, including
in-service training to staff, a new culturally competent
hiring policy, and foreign nurse training, is another
component of the Asian Initiative. The New Brooklyn
Chinese Family Health Center is the primary care site
for Brooklyns Chinese community. Network-wide
language access strategies have also been instituted,
addressing patients who speak English, Spanish, Chinese
dialects, Arabic, Russian, Haitian, and Creole.
In
addition, SPFHC offers residency for new physicians
training with a curriculum in cross-cultural health
care. Integrated with Family Practice Residencies, this
didactic and experiential curriculum teaches communication
skills, such as patient-centered interviewing and medical
anthropology. SPFHC Network is also engaged in research
related to cultural competency. The Mexican Health Project,
conducted in conjunction with Barnard College at Columbia
University, is a multi-method study examining health
issues and disparities in the Hispanic communities.
Areas of focus are healthcare needs and experiences,
reproductive expectations and experiences, folk medicine
and self-care, and diabetes management. Study methods
include a cross-sectional survey, intensive patient
interviews, ethnography, and focus groups. This study
is supported by United Hospital Fund, CAP and HRSA Disaster
Assistance.
Dr.
McNees concluded her presentation by stating that SPFHC
Network will continue its mission to enhance culturally
competent care in order to meet new State and Federal
mandates, tap new patient markets, achieve quality and
satisfaction for patients and staff, and improve clinical
outcomes.
Project
Street Beat, PPNYC
Daphne
Hazel
Associate Vice-President
Project Streetbeat, Planned Parenthood of New York City
Bronx, New York
HIV
and AIDS are a serious threat to the underserved, culturally
diverse community living on the streets of Bronx, New
York. Daphne Hazel, Associate Vice-President of Project
Street Beat, described this program from Planned Parenthood
that tackles HIV/AIDS on its own turf. Project Street
Beats mission is to reduce the rate of HIV transmission
by empowering communities of color and others to change
risk behaviors and to receive HIV care-related services.
The uniqueness of Project Street Beat is that treatment,
education, and outreach are delivered straight to the
streets of the South Bronx where teens and young adults
are at greatest risk.
Project
Street Beat started in 1988 in the South Bronx, but
now includes consolidated services in Brooklyn, Queens,
Bedford, and Northern Manhattan. The individuals served
through Project Street Beat are predominantly black
(55%) or Latino (43%); the ratio of males to females
is nearly equivalent. Thirty-percent of patients are
between the ages of 14 and 25, with 69% age 25 and older.
The target population is at high risk for HIV/AIDS because
of the nature of their activities: 8% are commercial
sex workers, 52% use intravenous drugs or other substances,
30% are adolescents, and 6% are other hard-to-reach
populations including men who have sex with men, transgender
or transsexual individuals, or parolees.
The
concept behind Project Street Beat is for an outreach
team to establish a presence on the street and offer
practical help on the spot. The outreach teams build
relationships with clients based on trust and develop
a rapport with clients allies, who may include
pimps, drug dealers, abusive partners, family, and friends.
Gaining the support of allies is essential because they
can be influential in promoting or negating the healthy
practices Project Street Beat teaches.
The
Outreach Teams explore the target areas to identify
the hot spots, areas where drug dealing
or sex peddling occurs. Once there, the teams conduct
impromptu focus groups by engaging potential
clients in conversation about what Project Street Beat
is all about. The teams continue to cultivate the areas
by repeatedly visiting and establishing a familiar presence.
Van Outreach and Mobile Medical Unit Outreach offer
various levels of care from oral HIV testing to gynecological
exams and birth control.
Project
Street Beat is built on the premise that culture is
not limited to race and ethnicity; rather, it includes
customary beliefs, shared attitudes, values, practices,
and integrated patterns of behaviors. The staff reflects
the racial and ethnic make-up of the target population
with 18 African-American staffers and 12 Latino staff
members. They also have employees who speak English,
various Spanish dialects, and Creole. The staff is diverse
in their ages, life experiences, sexual orientation,
and professional backgrounds. Project Street Beat also
hires Peer Educators who are former drug abusers or
sex workers living with HIV.
Applying
cultural competence in this environment means understanding
the clients needs and motivations. For example,
because sex is currency in the drug economy of the street,
using a condom can mean making less money or putting
oneself at risk for violence. For this reason, outreach
strategies must be creative, such gaining the acceptance
of a clients pimp or abusive partner or by making
arrangements to meet the client in a safe place. With
adolescents who are often outcast from troubled families
and who are wary and rebellious, cultural competence
means understanding that these clients may not trust
adults. In these cases, outreach may include gaining
the trust of a leader in the group whom other teens
tend to follow.
Project
Street Beat does not act alone; the group collaborates
with numerous community agencies to meet their clients
needs. These collaborators include AIDS centers and
hospitals, detoxification centers, drug rehabilitation
centers, substance abuse programs, community health
centers, maternal/child centers, legal and social services,
housing, food banks, faith-based organizations, and
other community-based organizations.
Project
Street Beats 14-year history is a testament to
its success, as are some of its more recent accomplishments.
In 2001, Project Street Beat made a difference in the
lives of many people living and working on the streets
of New York City, as the following figures reveal:
Project
Street Beat Accomplishments in 2001:
-
Served
24,295 people in need of care
-
4,053
harm reduction counseling sessions
-
1,349
HIV tests
-
719
post-test HIV counseling
-
479
medical exams
-
4,476
referrals
-
422
case management clients
-
240
support groups and presentations to community based
organizations
PLENARY
SESSION: An Interactive
Session Opportunity to Discuss Challenges in Delivering
Culturally and Linguistically Competent Health Care
The
day-long program culminated in a plenary session during
which three panelists (Felicia Batts, Josepha Campinha-Bacote,
and Calvin Freeman) addressed challenging areas identified
by the audience that can arise when developing culturally
and linguistically appropriate services and programs.
In an interactive session, these expert facilitators
led a discussion on approaches that can be used to address
those issues raised by the audience. The audience provided
questions, and panelists facilitated a discussion to
provide answers. The questions and resultant group answers
are summarized in this section.
1.
Please comment on strengths/weaknesses of implementing
cultural competence initiative through a Quality Improvement
(QI) committee.
For
managed care organizations, QI committees are a logical
place to introduce cultural competency initiatives because
these committees have a broad influence on what happens
in the whole organization and because QI committees
focus on measurement and outcomes, so initiatives would
more likely be assessed to show an actual impact on
patient care or organizational processes. Also, implementing
cultural competency through QI guarantees that the high-level
executives at the hospital or MCO will be included in
these initiatives.
The
California Department of Health Services (CDHS) is an
excellent resource for community-based groups looking
for information in this area; CDHS has developed policy
letters that address how to develop a cultural competency
quality improvement initiative. Importantly, access
to accurate racial and ethnic data will be crucial to
the success of QI projects. Health plans may be able
to get this type of data through collaboration with
state agencies.
2.
As a coordinator of a Substance Abuse and Mental Health
Services Administration grant focusing on mental health
disparities in the Russian and Latino community, what
are some suggestions you have for training to encourage
cultural competence of primary care providers?
One
overriding challenge in mental health is that psychiatric
conditions are often viewed as not as important as diagnoses
of physical conditions, such as diabetes or asthma,
when in fact both types of conditions impact one another.
This bias, combined with cultural competency challenges,
poses a significant dilemma for mental health therapists
and their clients. One participant suggested that medical
schools and residency programs are one arena in which
to strive for improvements. Primary care and mental
health specialists who can discuss cultural competency
may be effective as consultants to introduce cultural
competency early in medical education so as to instill
new paradigms in the future healthcare professional
community.
Another
participant responded that in the rural area where she
works, cultural competency issues are not well understood
or accepted by veteran physicians, and finding a cultural
competency consultant is difficult. The HRSA Managed
Care and Health Services Financing Technical Assistance
Center is one resource for providing such training.
Offering Continuing Medical Education (CME) credits
in cultural competency will also draw physicians of
all ages to attend training sessions. Ms. Batts commented
that many physicians need CME credits specifically in
the category of ethics, so as ethics-oriented CME programs
are developed, there needs to be greater focus on cultural
competency.
3.
What is the difference between Hispanic and Latino?
Is one more culturally sensitive or correct? Does one
encompass all people of Spanish descent?
There
was no consensus on this issue. The terms Chicano,
Hispanic, and Latino were discussed.
Though Chicano is used rarely now, the difference
between the other terms was less clear. The preferred
term may vary by region and by individual. It is best
to know the general preference of community you serve,
but to accept that from patient to patient, attitudes
may differ. Self-definition should be respected. More
importantly, if patients know that their providers care
about and respect them, the political correctness of
terms used will most likely not be challenged.
4.
Are certain diseases found more frequently among particular
ethnic populations? What common misdiagnoses exist according
to ethnicity?
Cultural
competency is not just about values, beliefs and attitudes;
there are biological and clinical issues that are relevant.
But there is still considerable controversy about whether
widespread genetic variation exists among ethnic and
racial groups. It is well-established that certain diseases
are more prevalent in certain groups. One participant
expressed concern about misdiagnosis of these diseases.
Certain cultural-bound illnesses, particularly
in the mental health arena, are an example. Dr. Campinha-Bacote
stated that there is national evidence that people of
color are more often misdiagnosed with thought-disorders,
such as schizophrenia, whereas whites are more often
diagnosed or misdiagnosed with mood disorders, such
as depression. In addition, another participant emphasized
that it is important for providers to be aware of diseases
that may be truly be more prevalent in particular populations,
for instance, diabetes in the Latino population.
5.
As a Healthy Start grantee, we provide trained medical
interpreters to providers. Demand for interpreter services
exceeds our resources, yet providers say they cannot
pay for services on a contracted basis. How can Massachusetts
funds be tapped to reimburse for interpreter services?
The
panelists and meeting participants offered several options.
Approaching the legislature for Title IV funds was one
approach suggested. Also, community-based resources
may be available, and community agencies receiving State
and Federal funds are mandated to assist in the area
of translator services. Finally, be creative about partnerships
and alternate funding sources.
Other
Comments:
-
Sonja
Boone, MD, from Northwestern Memorial Hospital commented
that to enhance the awareness and use of the language
line, her hospital had speaker-phones installed
in the emergency rooms and clinical units. In addition,
they developed a formal program for minority physician
recruitment.
-
The group identified the literacy level and legalese
in informing documents as another challenge to culturally
competent services. Readability of language and
visual presentation can limit communication to consumers.
Colors, font size, white space, graphics, and grade
level of textual material should always be considered
and revised if necessary.
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