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/financeMC
or ordered from the HRSA Information Center,
1-888-ASK HRSA, www.ask.hrsa.gov
For more information:
Please call the HRSA Center for Health Services Financing
and Managed Care at 1-301-443-1550 or email us at FinanceMC@hrsa.gov
To obtain information on other Managed Care and
Health Services Financing Technical Assistance Center
workshops and conferences, please contact:
Managed Care and Health Services Financing Technical
Assistance Center
1616 North Fort Myer Drive, 11th Floor
Arlington, VA 22209-3100
Phone: 1-877-832-8635
Fax: 703-528-7480
E-mail: hrsamctac@jsi.com
Web: www.jsi.com/hrsamctac
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*:
- race
- country of origin
- native language
- social class
- religion
- mental or physical abilities
- heritage
- acculturation
- age
- gender
- sexual orientation
- other characteristics that may result in a different
perspective or decision-making process
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
SCHIP 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 SCHIP 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 (SCHIP) 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)
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)
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, SCHIP, 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:
- Health Advocates
- Hospitals
- Managed Care Organizations
- Community Clinics
- Academia
- Legal Aide Society
- Immigrant Rights Organizations
- State Health Programs
- Provider Organizations
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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