Second National
Conference on
Quality Health Care for Culturally Diverse Populations:
Strategy and Action for Communities, Providers, and a Changing Health
System
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Second National
Conference on |
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III.
Conference Conclusions
The following section summarizes themes and conclusions synthesized from
the second national conference presentations and discussions. This summary
is intended to highlight key points from the sessions and identify select
program initiatives. It also attempts to capture the dynamics around the
conference themes that bring to light additional strategies and questions. Cultural competence must be seen as integral to the health and well-being of all individuals: a "shared vision of health for all America," that honors, recognizes, and reaches people where they work and live. In stating this fundamental tenet, Reed Tuckson, MD, then Senior Vice President of the American Medical Association, stressed that "to be effective means extending into job training, banking, the corporate world," reaching those who do not understand that improving and assuring health involves communities in the broadest sense. At the core of this challenge is the need to move from a disease-oriented health care system focused on the individual to a community-based, holistic model. Health care services will not work on a "build it and they will come" model. The community must play a leading role, in partnership with the health care system. Ultimately, as Dr. Tuckson reinforced, the health care system must learn "to deal with the whole person who lives as a member of a family in the context of a community, [in order] to understand preventable deaths and understand the culture." This context should inform all aspects of health care services, including marketing, which must generally appeal to the group it is targeting. The importance of community involvement extends to health professions education as well; school executives must use feedback from local consumers in the development of curriculum. As Sara Axtell, PhD, of the University of Minnesota Medical School, stated, schools must be willing to "engage local communities to figure out what they want us to know." Further, it is critical to recognize, and where possible address, problems arising from medical legacies that may significantly taint the way individuals from diverse heritage see the health care world. Medical revolutions occurring in the fields of genetics, microbiology and technology, especially the human genome, heighten concern for communities that are already distrustful of the health care system. Many health care executives see a compelling case for the integration of cultural competence into their organizational mission based on several internal and external pressures: increasing need for primary care sites to accommodate increased volume; requests for better information technology to assist health professionals in caring for culturally diverse enrollees; greater demand for interpreters; and state and federal health plan requirements. CEOs from Los Angeles, Portland, and Boston area health systems expressed similar sentiments regarding the importance of cultural competence:
Leadership that makes cultural competence a priority also recognizes the changing demand from the community. By establishing priorities and targeting financial investment, the executive sets direction and creates model behavior within the health care organization and the community. CEOs build workforce and community trust by these measures. As Mark Finucane commented, "People pay extraordinary attention to where the CEO spends time and money, and that’s how people will decide what’s important to the organization." In this way, seemingly simple actions, like formally scheduling cultural competence meetings and discussions, can have an impact on the organization. Moreover, concrete actions, such as conducting cultural competence reviews, increase the visibility of the issue within the organization and can lead to the involvement of individuals who otherwise may go unheard. As noted by one executive, "Cultural competence should be like clinical quality improvement–it must be in everything you do." Initiatives and actions vary greatly and depend in large measure on patient needs, communities being served, type of health care organization, workforce, and other factors. At the same time strategies are likely to include several common points, including:
Actions to integrate the community into creating a culturally competent health care system include:
As Dr. Tuckson suggests, "Communities can teach health professionals to be good diagnosticians." He raised the following scenario to make his point: a hospital emergency room received a number of cases in which women presented with no apparent injury. Through interaction with the community, medical providers learned that being hit on the side of the head was a form of spousal abuse that did not leave any visible signs, but damaged the tympanic membrane. This kind of exchange demonstrates the possibility for enhanced communication, engendering trust and improving care. Knowledge and involvement of the community is important because, as Irene Ibarra, JD, CEO of Alameda Alliance for Health, points out, "Health care isn’t just about whether or not you get in to see a medical provider. It’s about how you live, it’s about how safe your environment is, how your community is, whether or not you’re able to provide for your family." The California Endowment has crafted a grantmaking program, CommunitiesFirst, on the premise that the role of the community is central to health. The Endowment’s chief executive officer, Bob Ross, MD, delivered an inspirational address at the conference highlighting the multicultural health vision of The California Endowment, which includes the belief that inclusion, partnership, and community ownership are critical to addressing local issues successfully. Kaiser Permanente provides another model for working with the community to offer improved service access and clinical care. In addition to the many programs mentioned in section G below, Kaiser has created community-focused staff associations that link their workforce with specific racial/ethnic groups in the community to sponsor health fairs, conduct immunizations, provide scholarship programs, recruit new staff, and provide middle management mentorship.
Over the last several years, federal, state, and local policymakers have made significant progress in articulating the importance of cultural competence in broad-reaching policy initiatives. Two months prior to the Los Angeles conference, President Clinton issued an executive order requiring federal agencies to address the needs of individuals with Limited English Proficiency (LEP). The U.S. Department of Health and Human Services (HHS) released a guidance to its federal funding recipients on how to ensure equal access to health and social services in the context of language barriers. Then HHS Office for Civil Rights (OCR) Director Thomas Perez, JD spoke eloquently about the process of developing the guidance and the ways OCR would work with health care providers to assess, meet, and track the needs for interpretation and translation services. Michael Hash, Acting Administrator for the Health Care Financing Administration (HCFA) at that time, put the impact of the guidance into the context of Medicare, estimating that about twelve million of the thirty-nine million beneficiaries are at risk for culturally based barriers to care, with an even larger proportion in Medicaid and State Child Health Insurance Program (SCHIP), where the risk population is even larger. "The executive order firmly places our responsibilities under Title VI of the 1964 Civil Rights Act. It requires that the activities of all of our partners, our contractors, be they health plans or contractors administering our traditional fee-for-service Medicare program or the managed care programs or the states who are administering the Medicaid and the SCHIP programs, that these partners, these contractors, make sure that their activities are tailored to the needs of a culturally diverse beneficiary population, particularly with respect to limited-language beneficiaries," he said. Mr. Hash also spoke of other initiatives HCFA, now the Centers for Medicare & Medicaid Services (CMS), has launched related not only to limited-language populations, but also other population groups that are at risk in their access and outcomes in health care. There are more Spanish-speaking customer service representatives on staff at CMS and at the 1-800-MEDICARE toll-free information line. The new Medicare handbook, along with other written guidances, such as a guide to supplemental private health insurance, are available in Spanish. Other program materials are also found online, and regional office staffs have been producing some of these materials in a number of other languages, including Italian, French, Russian, Korean, Chinese, and Tagalog. The Horizons Project is working with community-based organizations to develop appropriate messages and is taking information in Medicare materials about managed care organizations and converting it into culturally and linguistically appropriate formats designed to meet the needs of African-American, Asian-American and Pacific Islander, and Hispanic and Latino populations. Through QISMC, quality improvement system for managed care, CMS has implemented a cultural competence standard for all managed care plans that are contracting with the Medicare or Medicaid programs. That standard will require that all plans assess the needs of their enrolled populations and the populations they are seeking to serve. They must demonstrate that they have educational and training programs for their staff about the unique beliefs, attitudes, practices, and communication patterns of these populations. They must have developed and implemented formal programs and culturally sensitive educational materials. And they must work to reduce racial and ethnic disparities in outcomes from health care, no matter what the enrollee's first language may be. These goals are set in the context of requirements for active involvement in quality assurance and performance measurement programs that demonstrate improved outcomes. As Mr. Hash stressed, "Culturally and linguistically appropriate services means providing information that people need and want in ways that they can understand and use. It’s of course not just about language, it’s about attitudes, it’s about behaviors, it’s about skills, it’s about policies that need to be in place…. When we succeed, of course, we promote access, we reduce disparities and, most importantly, we improve the outcomes of our beneficiaries who need health care services." In addition to the plenary presentations of Hash and Perez, there were several other reports of federal initiatives on cultural competence. Guadalupe Pacheco, MSW from the HHS Office of Minority Health (OMH), and Julia Puebla Fortier, from Resources for Cross Cultural Health Care, reported on the OMH’s national standards for culturally and linguistically appropriate services (CLAS), published in the Federal Register in December 2000. Based on an analytical review of key laws, regulations, contracts, and standards currently in use by federal and state agencies and other national organizations, these standards were developed with input from a national advisory committee of policymakers, health care providers, and researchers. Each standard is accompanied by commentary that addresses the proposed guideline's relationship to existing laws and standards, and offers recommendations for implementation and oversight to providers, policymakers, and advocates. Representatives from the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC) also presented on programs to reduce health disparities among racial and ethnic minorities. State policy advances were also well represented in the program, with
updates from Washington, New Jersey, and California’s Medicaid and
mental health programs on the long-term challenges of implementing detailed
cultural and linguistic competence requirements for health providers contracting
with the state. Bonita Jacques, MSW from the Washington State Department
of Social and Health Services, reported on the state’s comprehensive,
multimillion dollar approach to translating government documents across
all health and social services programs and reimbursing certain health
providers for the cost of providing interpretation services. Ernest Winsor,
LLB from the Massachusetts Law Reform Institute, described the efforts
of advocates from his state over many years to secure legislation requiring
hospitals to provide interpreter services, which finally resulted in a
law being enacted in 2000. Other civil rights and immigrant rights advocates
discussed the strategies communities and activists could use to ensure
that individuals from diverse communities receive the full range of health
and social services to which they are legally entitled. The case for increased diversity and cultural competence in the health professions workforce is evident in light of the rapid changes in the population across the United States. Between 1990 and 2000 the white, non-Hispanic population increased by four percent. Over the same period, the American Indian/Eskimo/Aleut and black populations each increased by fourteen percent, while the Hispanic and Asian populations grew by forty-five and fifty percent respectively. Several cities and states no longer have a majority white population and this demographic shift will continue to occur in many more areas over the next decades. Creating a representative health professions workforce has been a particularly difficult challenge. Historically, there has been significant underrepresentation of minority groups in the health professions. Efforts to address this underrepresentation have been thwarted by recent legal challenges to affirmative action programs. While goals such as the Association of American Medical Colleges’ (AAMC) 3000 by 2000 remain elusive, policymakers and educators have expanded the repertoire of initiatives to advance their objectives. These efforts occur in the context of AAMC President, Jordan Cohen, MD, asserting that AAMC’s primary objective is to build a health professions workforce appropriate to the needs of society–and that mandate requires developing a workforce that is representative by race and ethnicity. Leading organizations such as AAMC in Washington, D.C., and the California-based Center for Health Professions have supported and joined with efforts of individual providers and schools to create new opportunities to improve representation, curricula, and education overall. Both AAMC and the Center are undertaking complementary initiatives to improve diversity in the health professions through research and action programs in the field. Each provides a leading example of innovation at the national and state levels. The Association for American Medical Colleges has undertaken numerous programs to increase diversity and training of the health professions workforce. One of AAMC’s key action areas has been promoting the development of academic skills in preparation for higher education through a focus on pre-college curriculum. The Health Professions Partnership Initiative, sponsored by the Robert Wood Johnson and W.K. Kellogg Foundations, has been established at twenty-six sites to promote health professions as a career by linking K—12 local school districts with health education schools, including medicine, pharmacy, nursing and public health. A second program, the Minority Medical Education Program (MMEP), is a six-week summer enrichment program to expose students to the clinical experience; develop test-taking skills; assist pre-college students in preparing for the medical college admissions test; and promote student networking. Addressing underrepresentation also has revealed the need to create a "marketing strategy for the health professions," as Vanessa Northington Gamble, MD, PhD, of AAMC, stated, because diverse groups may not be aware of the opportunities in the health professions or may have been told they cannot succeed in the field. The Center for Health Professions has instituted the California Workforce Initiative (CWI), sponsored by the California HealthCare Foundation and the California Endowment. The CWI was created as a means of addressing the changes in the health care system that are linked with and are influencing the health care workforce in the state. The broad range of issues considered by the CWI include supply and distribution of professionals, workforce diversity and skill base, utilization of the workforce, consumer and public understanding, regulatory issues and changes in health care delivery. Its activities include research on projecting health care workforce needs using economic, health-industry, and demographic trends; creating community-based health care leadership networks to assist leaders in meeting workforce challenges; improving diversity in nursing; and developing and disseminating best practices for physician training. The CWI’s core objective is "to explore, promote, and advance reform within the California health care workforce." Notwithstanding these efforts and other strategies–for example nurturing junior minority faculty and reassessing workforce needs based on demographic changes–other areas need much greater attention. For example, health professionals must work more effectively with communities, including faith-based organizations. Promising initiatives include developing relationships between schools and hospitals and mentoring programs between health care organizations and community institutions, such as schools and churches. Innovative strategies should consider how individuals make and maintain career decisions in the context of family, work ethic, and discrimination. Continued innovation will be required to move the diversity agenda ahead
in the coming years. The erosion in progress reinforces this need: in
the mid-1990s underrepresented minorities accounted for 12.4 percent of
all applicants to medical school. By 2000, that proportion had dropped
to 10.7 percent. And recent court actions do not bode well for policies
promoting diversity in health education programs. A federal district court
struck down the University of Georgia’s policy that emphasized diversity
in the student body, while the AAMC has been required to accept all students,
rather than only those students from underrepresented minority groups,
into their Minority Medical Education Program in Washington State. D. New curricula and training requirements for health professionals integrate cultural competence into the eductional environment. Training programs for the health professions historically have paid little attention to cultural diversity and the skills that affect cultural competence. As a result, there is general recognition that this neglect has left many new practitioners ill-equipped to meet the needs of the increasingly diverse patient population. Recent research presented by Glenn Flores, MD, of Boston University School of Medicine, found that only about one-third of U.S. medical schools address cultural issues of the largest minority groups in their state as part of the curriculum. As an audience member confessed, "It has become painful for me to go to a continuing education course and see diseases presented as abstractions without seeing how they play out across different populations." New requirements in health professions training seek to address this matter directly. AAMC’S Deborah Danoff, MD, described the process of developing core competencies for specific residency requirements. These competencies include effective communication, ability to obtain essential and accurate patient information (including spiritual and cultural history), and the capability to demonstrate caring and respectful behavior in the patient-provider encounter. Related state requirements are being considered as well. For example, a New Jersey senate bill proposes that physicians be required to participate in cultural competency training as a condition of licensure by the state board of medical examiners. The Joint Commission on the Accreditation of Health Care Organizations has also taken an interest in identifying standards on cultural competence training. Similarly, professional associations are placing new requirements on practitioners to address cultural diversity. For example, the American Board of Medical Specialties is developing a template for competency in providing patients with the information necessary to understand their illness, share treatment decisions, and give informed consent. This includes a mechanism for evaluating communication and interpersonal skills and for assessing the practitioner’s ability to provide culturally competent care. Several specific initiatives have been developed to address these issues. One of the goals of AAMC’s Medical School Objectives Project (detailed at www.aamc.org) is to assure that physicians understand the meaning of patients’ issues in the context of family and culture, with communication in medicine as a major theme. Francis Lu, MD of University of California - San Francisco (UCSF), who was the lead author on the project’s chapter, "Issues in the Diagnosis and Assessment of Culturally Diverse Individuals," noted that the information is cast in the context of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), which now considers "cultural formulation" as part of the clinical responsibility. Medical schools have continued to integrate cultural competency training models into their curricula. For example, Robert Like, MD, at the Robert Wood Johnson Medical School in New Jersey, has developed an extensive program for residents, as have Joseph Betancourt, MD, and colleagues at Cornell Medical Center. (Dr. Like’s model appears in the 1998 national conference proceedings.) Similar efforts are underway at the University of Minnesota and other schools. The University of Minnesota Medical School has developed a curriculum program to meet students’ cultural competence needs. The program focuses on the development of related skills needed for the clinical encounter rather than the memorization of facts about a specific culture. To avoid "marginalization" of the content, this initiative, reported on by Sara Axtell, PhD extends beyond the "one course" model to integrate issues of culture throughout the curriculum. Innovative training for residents and physicians is also being developed. Jeffrey Ring, PhD of the Family Practice Residency Program at White Memorial Medical Center, encourages the use of literature and poetry to facilitate increased self-awareness, improve one’s understanding of a wide array of human experiences, and help health professionals grapple with their own biases in an effort to address the challenges of providing and teaching culturally competent care. Distance learning programs are also entering the arena. The Centers for Medicare & Medicaid Services, for instance, has begun investing in distance learning programs aimed directly at physicians. The success of these programs depends on building administrative and faculty support and using community experiences and resources to shape the curriculum. Strategies include presenting information on students’ views of the learning environment and their preparedness to work with diverse populations; convening forums whereby students share experiences with university administrators; and building relationships with community representatives in order to tailor the educational experience to include information on the communities served. Along with commitment and involvement from these key groups, cultural competence education and training must be continuous. Also, to be seen as valuable, the curricula must have direct clinical applicability. In addition, continuing education programs must consider how to reach private practice practitioners in ways conducive to their needs and settings by assessing practitioner strengths and limitations in providing care, then building on strengths and identifying resources to address those limitations. The increased attention to integrating cultural competency into curricula
and training programs has generated heightened interest in accountability
and outcomes. There is interest not only in what was learned, but more
important, in determining how it correlates with higher patient satisfaction
and outcomes. AAMC’s Graduate Medical Education Outcomes Project
evaluates residency programs to determine resident competencies and there
are plans to develop accreditation criteria for core competencies. Still,
evaluation of cultural competence training programs remains a new field
that could benefit from the parallel work in organizational assessment,
including research performed by Tom Delbanco, James Mason, Calvin Freeman,
and Leo Morales. (Please refer to section H below.) E. The success of the clinical encounter often depends on an understanding of the patient’s culture. Pharmaceutical interventions among culturally diverse populations face challenges similar to medical interventions, with efficacy and successful adherence to treatment significantly influenced by communication across cultures, patient preferences, and medical history. However, cultural factors that influence effective use of medications also represent unique issues, which may not always be obvious. For example, translating instructions and labels into the patient’s native language may seem like an adequate method of addressing language barriers. However, one pharmacist noted, "I had a mom who spoke Spanish but could not read Spanish so even if I typed the label in Spanish, it wasn’t going to do her any good, so we ended up having to color code...and you still don’t know for sure." Even when language barriers do not exist or are addressed, less obvious cultural factors may decrease the likelihood that patients adhere to treatment regiments. For example, as noted by Osbourne Blake, MD, of Southern California Permanente Medical Group, "Patients born in Mexico or Central America are not used to taking medications when they feel well, so they stop taking the medicine." For these and other populations, taking medications is a sign of poor health, in which case the patient may equate good or improved health with no longer needing medication. This poses particular challenges for prescribing medications such as antibiotics, which must be taken for the full length of the prescription even if the patient feels better sooner, and daily maintenance medications for chronic conditions. Pharmaceutical interventions require the health professional to pay special attention to the way that the medication is taken and how it interacts with alternative therapies, which can often be culturally based. Sharon Youmans, MD, of UCSF, described a case in which a parent called to ask if it was okay to give rattlesnake powder to a child. Pharmacists need to research such cultural practices to make sure that "it's not something that's going to interact or cause more problems or side effects...masking a fever or even causing bleeding or GI problems." Furthermore, some sensitivities to medications are specific to certain cultures. For example, according to Michael Winter, MD, from UCSF, "It was observed early on that there were significant differences between Asians, Chinese specifically, and Caucasians in how they responded to beta blockers used either for blood pressure or to control heart rate." He explained, "Genes can change the receptors that the drugs bind to and modify how you’ll respond to the drug...making the drug either more toxic if it’s a toxic receptor or less therapeutic if it’s a therapeutic receptor." He mentioned that these genetic differences exist not only between different ethnicities but that there are also differences within them. For example, about thirteen percent of Caucasians and three percent of African Americans lack the enzyme that gives codeine its analgesic effect. "In this case, there is a genetic code that sets you up for a metabolic process that means the drug won’t work for you." Therefore, it is important to be aware of the patient’s background and not work based on assumptions. As one bypass patient who was African-American and Native American stated, "Some of these medications may be contraindicated by my heritage. You’re assuming [my background] because of my skin color. . . you do not know anything about me." Health care systems and professionals are beginning to address these challenges in the health care setting and at the community level. One model program at Kaiser Permanente uses a "group appointment" model to educate patients with chronic conditions in the predominantly African American and Hispanic area of West Los Angeles. In the group model, while still supporting one-on-one appointments, health professionals will see twenty patients for two hours once a month to discuss medications, diet, exercise, and other critical aspects of treatment and self care. Early results have demonstrated greater satisfaction, more effective education, and more appropriate use of medications. This model also has created a normative environment for many of the manifestations of the conditions these patients face, and has educated professionals on culture-specific patient issues. Another chronic care program at Kaiser Permanente for sickle cell disease
offers continuity of care in difficult transition periods from childhood
to adolescence to adulthood, with the team working across departments
to educate other hospital staff about specific population characteristics
in the treatment of the disease. Hospital-based pharmacists, who may have
access to more resources than others in their profession, have worked
with professionals in outpatient settings and in the community to inform
them about culture-specific issues in treatment and the role of family. F. Cross-cultural communication in health care settings is making strides toward quality. Medical interpretation services in the United States, while not ubiquitous, have achieved a high level of quality and penetration in key regions of the country. Both community and health care organization interpreter service directors are in high demand for their expertise in setting up comprehensive programs that serve thousands of clinical encounters a month. Demand is likely to grow with the advent of federal guidance on the interpretation and translation obligations of health and social services providers. Representatives from Virginia, Illinois, Wisconsin, Maine, and Minnesota described in detail the complexities of setting up and running interpreter programs, including securing administrative, clinical, and financial support; recruiting and training interpreters; developing data-tracking systems; and monitoring quality. Assuring quality interpretation, and making the link between good interpretation and clinical outcomes, was the theme of most interpretation presentations. Representatives from medical interpreter associations in California and Massachusetts, as well as from the newly formed National Council on Interpretation in Health Care (NCIHC), discussed ongoing efforts to organize and professionalize the field of medical interpretation. Both the California and Massachusetts organizations provide regular opportunities for interpreters to meet and discuss issues related to service delivery, training, and advocacy for interpretation. NCIHC has recently launched a listserv and Web site aimed at linking medical interpreters across the country to share information about best practices and promote quality interpretation. Maria-Paz Beltran Avery, PhD from the Educational Development Center, discussed her efforts with interpreter organizations in Massachusetts, California, and New York to develop an accreditation process for medical interpreters, based on the Massachusetts Medical Interpreters Association standards of practice. Dr. Avery discussed the challenges of developing a certification process that establishes basic entry-level competencies in medical interpreting, accuracy, and completeness; provides a standard of quality that can be expected from interpreters who successfully complete the medical interpreting assessment for certification; and provides interpreters with an assessment of their performance in the areas in which they need to continue their professional development. She anticipated five areas that will be in the battery of tests:
The work to develop this certification process is only minimally funded at this point, which will impact how quickly the final product will be widely available for use. Workshop participants in this session discussed the benefits of developing a national model or process for certification rather than waiting for individual states or organizations to take action. In the roundtable discussion on translation initiatives for large organizations, participants heard about new web-based strategies for making translated documents available. Pioneered by the Multicultural Health Communications Service in New South Wales, Australia, www.mhcs.health.nsw.gov.au this medium is valued by both local and international users and is cutting costs for their health service by reducing the need to print large numbers of documents that are inefficiently distributed and go out of date quickly. The model has been replicated by a consortium of public and private health organizations in Vancouver, Canada, with the additional dissemination of standards for the translation of health materials www.multilingual-health-education.net. Participants, among them a representative from the Centers for Medicare & Medicaid Services (CMS), discussed the challenges of translating large numbers of documents for many different language groups, the costs and management issues related to translation and regular revision of documents, and the potential that a web-based clearinghouse might hold for large payers like CMS and state Medicaid agencies, or for managed care organizations and health systems. Cross-cultural communication also features the growing field of health
literacy. The National Library of Medicine defines health literacy as
the degree to which people can obtain, process, and understand the basic
health information and services that they need to make appropriate health
decisions. An estimated fifty percent of U.S. residents have difficulty
understanding how to navigate the health care system. This lack of understanding
affects a broad spectrum of individuals including, those who are low literate,
individuals from diverse racial/ethnic heritage who encounter language
or cultural barriers that affect their understanding of treatment regimens
or provider systems, and older individuals with complex health care needs.
Health literacy advocates and researchers, including George Flouty, MD,
of Pfizer Inc, and Mark Williams, MD, of Emory University School of Medicine,
led a lecture session highlighting the need for developing health information
that its intended audience can understand and discussed the challenges
and opportunities of performing health literacy screenings for individuals
in clinical care. As major participants in providing health care, managed care organizations are increasingly being responsive to the needs of culturally diverse enrollees and communities. Recognizing the importance of this role has led to the introduction of federal and state actions (for example, California, Massachusetts, Minnesota, New Jersey) requiring managed care organizations to document their efforts to provide culturally competent care. These population and regulatory pressures are leading many plans to create new initiatives directly targeted at improving the health of and health care for culturally diverse enrollees. Research on barriers to service for diverse enrollees highlights important differences between managed care and other settings. For example, analysis using the 1996 Medical Expenditure Panel Survey, presented by Kathryn Phillips, PhD of UCSF, found greater difficulties in obtaining care and less satisfaction with care for certain diverse populations in managed care settings. These problems reinforce the need for increased action in managed care organizations to improve access to high-quality health care for culturally diverse populations. Alameda Alliance for Health, HealthPartners, and Kaiser Permanente presented their cultural competence initiatives at the conference. Alameda Alliance for Health is a public/private program comprised of traditional safety net providers and private practitioners. Alameda Alliance’s strategies have emphasized improving care for culturally diverse populations through addressing health disparities and enhancing access. Further, concerned with patient satisfaction and health outcomes, Alameda Alliance has integrated measurement components into its programs. The Alameda Alliance has adopted a broad vision of health care. As Irene Ibarra, CEO, commented, health care is also "about how you live, it’s about how safe your environment is, how your community is, and whether or not you’re able to provide for your family." At the same time, the Alliance recognizes the service imperative of cultural competence. "If we don’t have a culturally competent organization at all levels–top management to the frontline person who answers the phone–we can’t reach our members and our population." The Alliance works closely with "community partners" and community clinics to educate individuals about eligibility, benefits, and access, including language access. The Alliance also has incorporated consumers into their programs by using advisory committees to guide strategies. At HealthPartners of Minnesota, the decision was made that once the organization committed to diversity, it had to make significant changes to meet that commitment. HealthPartners’ efforts include adding staff and specific programs addressing the needs of culturally diverse populations, building clinics in diverse communities, printing health section inserts in community newspapers, and emphasizing diversity in hiring that strives to reflect the ethnic composition of the service area. Upon learning that the organization’s standard workforce diversity training tended to isolate groups, HealthPartners modified the design to create a sense of community that cut across racial/ethnic and other categories. As a major managed care organization, Kaiser Permanente has undertaken a number of initiatives to address cultural competence. Their strategy has engaged organizational leadership as well as clinical improvement and service access. These efforts have occurred in the context of community dynamics, clinical quality, and organizational needs, and include:
Kaiser Permanente has established community health clinics targeted at treating chronic conditions that affect diverse populations, such as sickle cell disease, prostate cancer, and congestive heart failure. Further, using the community clinic model, Kaiser has developed a cadre of trained interpreters, to address issues such as signage needs and to set up a related information clearinghouse. Finally, Kaiser has focused extensive attention on overcoming physician resistance, providing practitioners with critical information on enrollees from diverse heritage. This is especially relevant given that cultural competence can be seen as conflicting with health care training that emphasizes treating everybody the same and not knowing the answers is seen as practicing "bad medicine." Initiatives include developing a provider handbook on culturally competent care, instituting a web-based Continuing Medical Education program, providing training videos, and offering cultural competence inserts for staff medical presentations. Kaiser Permanente’s actions are motivated by the need to create
a successful business as well as provide the best care possible. While
many initiatives are not organization-wide yet, there is institutional
support to implement cultural competence-related projects and programs.
As Vince Pasquariello noted, "These issues impact liability. . .
[and the ability] to take an accurate history, to make the correct diagnosis,…to
assure compliance with the treatment plan and to develop appropriate and
necessary support among the patient’s family and friends. It’s
what allows me to deliver on the promise to provide them with the best
care I can give." H. Data and measurement break new ground for patients, communities, and organizations. As cultural competence gains greater visibility in health care, measurement, quality, effectiveness, and outcomes are concerns for both providers and policymakers. Interest in clinical models is accompanied by an equal interest in determining their ability to reduce unnecessary morbidity and increase adherence to treatment. Likewise, purchasers are intensifying pressure on health plans not to add expenses. While health plans argue that paying for interpreters, for instance, will ultimately lower costs, buyers are not convinced. George Halvorson, president and CEO of HealthPartners, views increased data about outcomes as crucial to changing that attitude. Interestingly, erroneous assumptions about the collection of race/ethnicity-based data must be overcome first. For example, managed care plans have become interested in documenting both beneficiary benefit and "return on investment" for cultural competence interventions. However, many health plans believe that federal, state, or local regulations prohibit them from collecting data on race/ethnicity. These presumed restrictions create a significant barrier to measuring the effectiveness of programs for these populations and their communities. However, HHS’s Tom Perez stated that federal law makes no such prohibition for race, ethnicity, or language-related data. The second national conference expanded the presentation of cultural competence models begun in the first meeting to include discussion of data and measurement issues. Both conferences highlighted the growing number of innovations and practices tailored to specific settings. The programs discussed in the sessions generally focused on either organizational assessment or patient/community level measurement. Selected organization assessment strategies The Maternal and Child Health Bureau of HRSA has been working with the National Center for Cultural Competence to design a tool for reviewing cultural competence in seven state maternal and child health programs. This effort, which uses a model developed by James Mason, PhD of the National Center for Cultural Competence, profiles three areas: policy making and administrative status; practice and service delivery; and consumers. Lessons learned suggest that working with states may be encumbered by such factors as staff turnover, slowness of the process, and degree of investment in the process by the state. The Multicultural Health Unit in Australia has been working with hospital directors to determine organizational readiness for cultural competence. Financial or racial/ethnic problems and other environmental factors are considered in this process. It includes assessment of the effectiveness of hospital departments in addressing priority problems among key populations. The Portland Department of Health has created an "organizational climate survey" that integrates cultural competence issues into benchmarks for addressing health conditions in diverse communities and populations. Patient/consumer/community oriented measures Health systems and research centers have generated designs for tracking or measuring the effect of their programs on culturally diverse populations. The sample of California-based programs cited below reflects only some of the many efforts to assess effectiveness of individual level interventions. Kaiser Permanente has extended traditional measures of efficacy and satisfaction to assess the effectiveness of its initiatives in reaching diverse populations. For example, they have sent a patient satisfaction instrument, the Member Appraisal of Physician Services, to enrollees after appointments. These assessments, however, extend beyond access in general to consider the cultural characteristics of enrollees and utilization. For example, Kaiser has assigned accountability for implementation of language services, with three-year implementation plans being submitted by each of the northern California facilities. The Consumer Assessment of Health Plans (CAHPS) survey instrument has been used by the National Committee on Quality Assurance to measure satisfaction in diverse populations. As described by Leo Morales, MD, PhD, of UCLA and RAND Health Program, the National CAHPS Benchmarking Database surveys patients at thirty-one Medicaid plans and fifty-four commercial plans. It uses four "global ratings," two for health professionals (personal doctor or nurse, and specialist), one for health care and one for the health plan. These ratings are considered within the context of five different domains: access, promptness, communication, courtesy/helpfulness of office staff, and health plan customer service. General findings are that white and black adult enrollees tend to give more positive ratings of care than Hispanics. Such results, however, reflect very low response rates (fifty percent or below), especially among those qualified for Medicaid. The California HealthCare Foundation and the California Pan-Ethnic Health Network sponsored a program assessing the value of using general consumer surveys such as the CAHPS, the Picker Patient-Centered Care, and Physician Value Check to address cultural competence. As part of this effort, researchers and experts in cultural competence review relevant materials to evaluate their usefulness in describing the experiences of diverse communities. Results indicated that generally, these surveys provide useful information on disparities in health care through the experiences of consumers. Their standardized content and administration allow for comparisons between institutions. However, the items in the surveys did not address some crucial aspects of culturally competent service delivery such as translated signage and interpreters. In summarizing the "state of the art" in measuring patient satisfaction, Thomas Delbanco, MD, of Harvard Medical School, noted: "We’re at the absolute Model T stages of measuring patient experiences with care. The sky is the limit." While sophisticated instruments provide valuable information, there is significant merit in bringing together individuals in a particular health care setting to determine what is important to both practitioners and patients in measuring the efficacy of these initiatives. Finally, addressing disparities in health care services will require more comprehensive ethnic/cultural data and information. As expressed by Calvin Freeman, of Calvin Freeman & Associates, "We do need to advocate for policy and practice changes to promote collection and analysis of race/ethnicity data at the organizational level and to promote changes in content, administration, and analyses of consumer surveys to enhance their ability to contribute to measures of cultural competence." |
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essentials | models
and practices | policy |
legal issues | networking |
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Diversity Rx is sponsored by: |
 The National Conference of State Legislatures |
 Resources for Cross Cultural Health Care |
 Henry J. Kaiser Family Foundation |
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