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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| October 11-14, 2000 | |
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V. Conference Plenary Presentations
Featuring the core conference themes, general plenary sessions highlighted national leaders speaking on the latest trends, practices, and policies in culturally competent health care. Fourteen speakers addressed conference participants during plenary sessions throughout the conference. Summaries of these presentations follow. Opening remarks for the conference were given by conference presenters Julia Puebla Fortier and Dennis Andrulis, PhD; Warren Furutani, consultant to the California Assembly Speaker; and Nathan Stinson, Jr., PhD, MD, deputy assistant secretary for minority health, US Department of Health and Human Services (HHS). Julia Puebla Fortier, director of Resources for Cross Cultural Health Care, welcomed the attendees to the conference. She mentioned the appropriateness of holding the conference in California, as it is a leader in terms of demographic trends as well as policy and activism in delivering high-quality health care services for culturally diverse populations. Ms. Fortier explained that the conference was intended to include interaction, dialogue, and networking to allow participants to benefit from the diverse perspectives represented by the conference participants and speakers. Dennis Andrulis, PhD, research professor at the State University of New York Downstate Medical Center, recognized the growing number of conference attendees (six hundred) and the wide variety of places and distances from which they had traveled (33 states and 3 countries). He pointed out that sponsorship of the conference was also diverse: nineteen organizations representing "all walks of life." Dr. Andrulis presented these facts as an indication that the value of cultural diversity is expanding. He described this conference as "furthering the work of the first meeting by moving beyond identifying the community and health care landscape for cultural competence, to drawing attention to innovations and emerging ideas to improve the health and responsiveness of our health services to the needs of an increasingly multicultural society." Dr. Andrulis emphasized the importance of integrating many experiences and perspectives, and underscored the joint responsibility of health-related professionals and organizations, government, private sector, and health educators working in collaboration with their communities to improve access to high-quality health care for culturally diverse populations. Warren Furutani, consultant to the California Assembly Speaker, welcomed the participants to Los Angeles. He described some of the major events occurring around the time of the conference such as the Los Angeles County worker strike and the Democratic National Convention. Noting that the conference was being held just after the 2000 Olympics, Mr. Furutani discussed the contribution of diversity to the strength of American teams. He pointed out that the ethnic composition of the Olympic teams also reveals a challenge: swimmers are mostly white, ping-pong players Chinese, and the track team is mostly African-American. He felt that this trend was changing but needed attention. Mr. Furutani observed that as the population becomes more and more diverse it is more and more difficult to define "the public," and therefore more difficult to determine how to serve that public. He mentioned the importance of considering what kind of public health systems immigrants have come from in their mother countries. "What do they bring with them as they come to and become a part of our community?" Deputy Assistant Secretary for Minority Health Nathan Stinson, Jr., PhD, MD, was introduced by Dr. Andrulis, who thanked the Office of Minority Health (OMH) for their role in bringing about the conference. Dr. Stinson thanked all the sponsors of the meeting and reiterated the importance of the conference. He brought greetings from then Secretary of Health and Human Services, Donna Shalala, and US Surgeon General David Satcher, mentioning that they have made cultural competency a priority for HHS over the past year. Dr. Stinson also mentioned the importance of advocates for cultural competence within the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services (CMS)). He stated that OMH was looking forward to hearing the recommendations coming out of the conference and that the organization felt strongly about reviewing outcomes of programs and activities they were involved with to glean action steps or recommendations. He also emphasized the importance of getting the information back to the communities and disseminating it "very, very broadly to other aspects of the health care environment." Dr. Stinson pointed out that the chairs at the conference were full and
some of the "pioneers" in work on cultural competency were in
attendance. He mentioned that early in the movement there were only a
few people working on this issue, but now it has begun to gain momentum
and an increased awareness of its importance. He illustrated the strength
of diversity in the United States through an example of the unique contribution
of the Navajo code-talkers to national security during the Second World
War. Dr. Stinson explained that cultural competence is really about quality
of care. As the country becomes more and more diverse, the ability to
provide quality care is dependent on the ability of providers to engage
with different cultures. The critical aspect of delivering patient care
is communication and the provider/patient interaction. In closing he stated,
"The bottom line is that this is a quality care issue that all of
us need to be involved with." Keynote Address: Reed V. Tuckson, MD Reed Tuckson, MD In his keynote address, Dr. Reed Tuckson identified the challenges ahead. "We need to vigorously examine and reassess our strategies and tactics, we must stimulate the continued development of new approaches, and we must take a fresh look." He acknowledged that the struggle was too often frustrating and expressed hope that the conference would give people an opportunity to "recharge their batteries." He outlined the issues he considered critical to progress. Issue One: Develop a shared vision for health for all America. He pointed out that American culture is connected to the rest of the world through its technology, economy, popular culture, symbols, and imagery. He cited as an example the Olympics in Australia, where the advertising was the same seen all over the world, offering an image of "the good life." He described a Millennium New Year’s Eve telecast that stopped in one country after another at midnight, and in each place, the music was played to the same two-four beat. Yet often people don’t see that connection. The person living in a gated community in Los Angeles might not see why he should care if the public health clinics close because of a budget crisis. As Dr. Tuckson said, he could prove scientifically that "the tuberculosis bacilli could just about squeeze through" those gates. "If we’re to be successful, it requires leaders with a vision who are prepared to grapple with difficult, complex, protracted, and interconnected problems, who are focused more on what unites us than on what divides us. We are all in it together," he said. "If we are to be successful, we need a unifying vision that attracts new skills and creative talents to the struggle." He lamented the cuts in public health departments’ budgets that make it impossible to cover even basic services, never mind leaving room for innovation. He said that what was needed was the kind of inspiration that someone at Nike showed in an ad that focused on the "beauty of really dark, rich, black skin. I want to hire that person." Dr. Tuckson quoted Toni Morrison, whose words he felt cut through the barriers between communities: "She imagined a brightness that could be carried in her arms and distributed, if need be, into places as dark as the bottom of a well." Issue Two: Manage the transition from a disease-oriented, pathogenic-based, organ system-centered, individually-focused system to a health promotion, disease prevention, comprehensive person-centered, population-based model. He believes that once the whole person is treated, in the context of their family and community, the number of premature deaths in ethnic groups–numbering about 75,000 in the African-American community–will decline. For this to happen, the challenge is to find "the underlying causes of the underlying causes." One problem is making sure people are getting all the information they need. In AIDS prevention programs, for example, it’s not enough for public health programs to make condoms available; they have to address the issue of resistance to using the condom. Access to information is a problem when "communities are struggling just to get the phone, much less the phone line connected to the Internet." Issue Three: Develop a shared vision for our communities. Health care organizations can no longer engage in strategic planning for the community when nobody from the community is there. Members of the community must be there from the beginning. "And that means we’ve got to have humility, taking the time to listen and learn." The skill of listening is something that doctors must have in order to take an accurate history from a patient. Without knowledge of the community, a doctor in the South wouldn’t know that a black woman who is pregnant may have anemia because she has eaten clay, or that a woman who repeatedly visits an emergency room in L.A., with no apparent injuries, may turn out to have been abused, if the doctor knows enough to look in her ear for a popped tympanic membrane. With community organizing, this type of information can come back to the providers and make them better diagnosticians. He warned against paternalism, a mistaken attitude that he had at one time when he set up a health fair in public housing where only five people showed up. He came to understand that unless he engaged and trained local people as his deputies, and showed them how to set up a fair, he would never get the kind of participation that would bring change. Issue Four: Manage the implications and consequences of the molecular biologic, genetic, and technological revolution. This means gaining the trust of the community so that people are open to new treatment possibilities. There is a great fear of studies of particular ethnic groups, fear of discrimination based on the findings. The possibilities raised by increasing knowledge of the human genome make it even more critical that these complex concepts are explained clearly, and that people understand any test they are given. Issue Five: Improve the clinical interaction with medical care providers and delivery organizations. This involves helping patients recognize symptoms, sensitizing doctors to a patient’s communication style, applying clinical epidemiology that comes from an understanding of a given population, and using this information to make better diagnoses. A doctor cannot edit the options he offers a patient based on a biased idea of what he thinks the patient can afford or understand. Using technology to make this wealth of information about various communities available to health providers and patients is the next frontier. Issue Six: Find fair and accurate methods to evaluate and assess clinical care outcomes. Pressure is mounting to obtain hard data on whether patients associated with a given provider live or die. Assessments must take into account the population that doctors are dealing with, if, as Dr. Tuckson said, "The people are coming to see you half dead in the first place. You can be doing great work, but it may not come out." This type of disparity calls for very accurate records of such factors as case mix, severity of illness, health status of patients, among other things. He described requirements for competency developed by the American Board of Medical Specialties (ABMS). Among the questions they ask is, "Do you provide culturally competent care?" He encouraged the audience to help the ABMS define the term. Dr. Tuckson concluded by encouraging continued efforts to get more minorities
into the health care professions, to make cultural competency part of
every medical school curriculum, and to keep up the fight to translate
policy into action. Michael Hash Mr. Michael Hash reported on the Health Care Financing Administration’s (HCFA) progress toward cultural competence and described the federal mandates and guidelines that drive HCFA’s work. In August, 2000, an executive order mandated that HCFA partners’ activities meet the needs of their culturally diverse beneficiary populations. The Office for Civil Rights of the Department of Justice published broad government-wide guidelines regarding limited English proficiency, a framework that was intended to be customized by other federal agencies. In response, the Department of Health and Human Services (HHS) issued guidelines through its Office for Civil Rights outlining the elements of success that are common to limited-English-proficiency programs. Four elements were considered integral to success:
Mr. Hash emphasized that the federal guidelines do not imply a "one size fits all" approach; their intent is to make it possible to measure results so that access and outcomes improve. Additional efforts to draft national guidelines on culturally and linguistically appropriate services are ongoing in other organizations, including HHS Office of Minority Health and another conference sponsor, Resources for Cross Cultural Health Care. This work will provide a "common agenda." While he affirmed HCFA’s commitment to ensuring health care access to the one in four Americans represented by its more than 75 million beneficiaries, he expressed concern that access is still not adequate. Of the 39 million people entitled to Medicare, it is estimated that 12 million are at risk for "culturally based barriers." An even larger percentage of the 36 million Medicaid beneficiaries and the 2.5 million children who are entitled to benefits through State Children’s Health Insurance Program (SCHIP) are at risk of getting less than the health care they need. One in six Medicare beneficiaries–6.2 million people–and more than half of those receiving Medicaid are in a managed care plan. HCFA is aiming to publish managed care regulations. All managed care contractors will be required to demonstrate that they have programs underway to address each of the four elements listed in the HHS Office of Civil Rights guidelines mentioned above. HCFA has dedicated many resources to improving translation of administration materials and is sensitive to the difference between translation and "trans-creation," described by Mr. Hash as the "context for communicating information." If translation is too literal, it can create complete misconception. He wants HCFA documents to capture the comprehensive message, to make it relevant to the reader, and to be sensitive to the nuance of meaning, not publishing a brochure in a color that a given culture associates with death, for example. Mr. Hash described some of the new initiatives HCFA has launched over the last few years to improve access to care and reduce health disparities:
In conclusion, Mr. Hash indicated that the funding stream is not secure at HCFA and that there is a gap between resources and opportunities. He said that HCFA can be "not just a payer of bills, a processor of claims, but ... an advocate...and a leader in improving the accessibility, the quality, and the outcomes of health-care services" for its beneficiaries. He acknowledged the importance of feedback from the audience, especially those representing community-based organizations and providers of health plans, whom he considers partners and the "face of our program." During the Q&A period, it was pointed out that there are additional beneficiaries of HCFA’s programs: teaching hospitals and other federally qualified health center programs. As for the future, he described a 2002 national project that would target
improvement of services to patients with a particular disease through
culturally appropriate measures. Funding decisions will then be linked
to these outcomes. Also, there will be more effort to make sure translation
services are available and that funding is earmarked for that purpose.
He reiterated the necessity of accountability to measurable progress as
key, particularly in regard to making sure state Medicaid programs are
following the national guidelines. HCFA will implement increased training
of surveyors for each of the 50 states to ensure compliance. Irene M. Ibarra Ms. Irene Ibarra described how, over its four-and-a-half-year lifetime, the 75,000-member Alameda Alliance for Health has evolved to serve its diverse population. The Alliance, a licensed local health plan in California, is a public/private partnership comprised of safety-net traditional providers and private practitioners. Ms. Ibarra feels that this mix of providers increases the Alliance’s success in reaching diverse patient communities. She outlined five strategies to which her organization is committed: increasing access to quality health care; reducing disparities in health status; improving quality of care and health outcomes; creating a culturally competent organization; and satisfying patients. To achieve these goals the organization has taken several steps:
Increasing access is the Alliance’s number one priority. Ms. Ibarra pointed out, "If you do not have access to health care on a regular basis you do not receive preventive care." Alameda Alliance for Health is working with community clinics to do outreach and education about Medicaid and SCHIP, with the goal of improving access. The Alliance has partnered with Asian Health Services and La Clinica De La Raza on these projects through grants from the W.K. Kellogg Foundation Community Voices Project. A key factor in increasing access is affordability of coverage. Studies have shown that members of non-white racial or ethnic groups are more likely to be uninsured. Focus groups in Alameda County that included uninsured families showed that those who are uninsured are most likely never to have been insured. They lack employer-based coverage or cannot afford the family premiums that are offered. Compounding the problem, some families do not qualify for Medicaid, have family members who do not qualify, or have a child who is not eligible for SCHIP. When the Alliance conducted focus groups in the community to see what people wanted, they found community members wanted what most people want: "the most comprehensive package for the least cost." In response, the Alliance decided to offer products tailored to working families, including uninsured immigrant and undocumented children and adults who do not qualify for public programs. Family Care offers comprehensive health and dental coverage, with "full preventive and acute care, as well as acupuncture and chiropractic services." The Alliance partnered with Delta Dental and offered low copays for dental care. Membership is steadily increasing and members are paying their premiums on a monthly basis. Ms. Ibarra’s belief is that "if insurance is offered, explained, and made affordable, families will sign up." Currently, the Alliance has funded a random telephone survey to explore
the characteristics of the uninsured in Alameda County with a particular
emphasis on these ethnic communities: African-American, Latino/Hispanic,
Chinese, Vietnamese, and Korean. Once complete, the information will help
Alameda Alliance for Health better serve the uninsured. How Do We Achieve Cultural Competence in the Health Professions? Josepha Campinha-Bacote, PhD, RN, CS, CNS, CTN, FAAN Dr. Josepha Campinha-Bacote, president and founder of Transcultural C.A.R.E. Associates, a health care consulting firm, stated that the skills needed to address cultural competence in the clinical setting are critically different from those needed to address cultural competence in the workforce setting. In addition to understanding a colleague's or patient's values, beliefs, practices, and lifeways, health care professionals must possess knowledge in the field of biocultural ecology. Biocultural ecology includes such areas as ethnic pharmacology, diseases prevalent in specific cultural and ethnic groups, and anatomical and physiological differences found among ethnically diverse populations. She mentioned that these are but a few examples of the knowledge needed by health care professionals to provide quality care for culturally diverse populations in a clinical setting. Her session aimed to provide health care professionals with a model of cultural competence that they can use to improve outcomes. Dr. Campinha-Bacote described a model of cultural competence called "The Process of Cultural Competence in the Delivery of Healthcare Services," which is used in several schools of nursing, medicine, social work, pharmacy and other allied health professions as a conceptual framework for educating undergraduate and graduate students. The model's constructs of cultural awareness, cultural knowledge, cultural skill, cultural encounters and cultural desire can be directly applied to the clinical setting. She mentioned that operationalizing one of the constructs of this model–cultural desire–has been a challenge. Although the model provides health care professionals with a conceptual definition of cultural desire, an operational definition has not been established. Similar to "the art of caring," cultural desire is a subjective construct. However, many health care professionals feel that cultural desire, like caring, is a critical component of cultural competence. She hopes that those health care professionals who already possess cultural desire will take the lead in developing an operational definition for this construct. Dr. Campinha-Bacote stressed that in applying any model of cultural competence to the clinical setting, health care professionals and educators must understand that cultural competence is a journey, not a destination; a process, not an event; dynamic, not static; cyclic, not linear; and finally a process of "becoming" culturally competent, rather than "being" culturally competent. As she asked the audience to remember, "People don't care how much you know until they first know how much you care."
Vince Pasquariello, MD Dr. Vince Pasquariello described Kaiser Permanente’s strategies for improving cultural competence at all levels of the organization. He analyzed the successes and the challenges facing various types of programs. Key to these efforts were leadership at the national level; knowledge of the community and needs assessment at the local level; and treating cultural competence not as an add-on, but as integral to quality and good business. Dr. Pasquariello opened by saying that diversity is nowhere more apparent than in California, "the first contiguous state in the United States to be composed entirely of minorities. We have no majority group in this state…" Kaiser Permanente’s 70,000 employees and 7,500 physicians serve six million members in California. The company’s efforts in California were spearheaded by their National Diversity Council, made up of senior leadership committed to these endeavors. Half of this board, by design, was made up of physicians. The council produced two documents: "Diversity and Excellence, Planning for the Year 2000," which makes the business case and the quality case for cultural competence; and "Kaiser Permanente’s Strategic Plan for Diversity," which lays out plans for various groups to use. Dr. Pasquariello described a series of programs that Kaiser Permanente has used.
Dr. Pasquariello acknowledged that any program can meet with physician resistance. Physicians were taught to treat everyone the same, to follow a logical course of treatment that stems from the diagnosis. They may feel as if "they are being told they’ve been practicing bad medicine all these years." Learning how to deal with a constantly changing population can seem overwhelming, but he said that an exploration of strategies must continue. Celebrations of success show an organization’s commitment. Kaiser Permanente celebrated with their 23rd national conference on diversity, a free conference open to all members. They also present the RJ Erickson annual diversity achievement awards to thank and honor individuals, teams, groups, and facilities who have made cultural competence a priority.
Mr. George Halvorson reflected on the root causes of misunderstanding and conflict when organizations serve a multicultural population. He explored "the impact that diversity has on any setting, on any community, on any industry," and specifically on health care. He explained how HealthPartners, one of the largest health plans in the United States, addresses the needs of the increasingly diverse population it serves in Minnesota. "Diversity should create synergy. . . . Ideally, diversity should create learning experiences for us all." The multiculturalism that is evident in our cuisine, music, clothing, vocabulary, science, and our legal system are the result of taking what works from many cultures and leaving the rest behind. As an example he cited the adoption of the concept of common law from Great Britain, giving rights to individuals, while leaving behind the monarchy. This selective and enlightened borrowing of the best features from other cultures creates a synergy that draws people from all over the world to the United States. However, he said, we "often find our behaviors guided by ancient instincts–hardcoded, hardwired into our genes–that cause us to divide the world into us and them, friend and enemy, our clan and your clan. . . . When that kind of behavior is triggered, then diversity creates divisiveness." Understanding the underlying causes of this behavior offers a chance to see how it can undermine efforts in a field such as health care. He compared instincts to programs that reside on the computer but do not run until they are activated. "Instincts require triggers to come forward. And once triggered, the instinct creates a program, and that program interprets data and gives emotional responses to situations. So a triggered instinct creates an intellectual and emotional context," he said. Mr. Halvorson discussed the instinct to mate, to form hierarchies, to be territorial, to protect the young, and to name a chief to lead a group. He quoted Carl Jung, who said, "Human behavior is influenced by instinct to a far greater degree than is generally supposed. Whenever we meet with uniform and regularly recurring modes of action and reaction, we are dealing with instinct, no matter whether it is associated with a conscious motive or not." Mr. Halvorson added, "Even though we are intellectual and enlightened people, we do have instincts that create some of our core drives, and our intellect very often is servant to those instincts." Instinct forms cultures that "are in some cases beautiful, wonderful, productive human inventions." But, he advised, the culture need not define the individual. "There are too many times when cultural rigidity binds people." The tribal instinct that creates "us" and "them" has led to hundreds of ethnic wars and millions of people being displaced because of their ethnicity. Those conflicts are the "result of local diversity that was situationally inflamed into us/them instincts and created a state of armed divisiveness." When those same instincts are triggered in corporations, divisions result: union versus management, caregivers versus marketing, doctors versus hospital administration. Then suspicions arise, and there is mistreatment, lying, and anger. This even gives rise to the feeling that it is traitorous to make friends with someone who is a "them." People are wired by instincts to suspend conscience in dealing with someone emotionally defined as a "them." In health care, the wariness goes both ways. Whichever person is the minority goes on full alert. This is a natural response. Each culture has a list of "shoulds" that another culture is not likely to understand. If a woman believes she should not be touched by any man other than her husband, or if someone believes in a mystical cause for a disease, and if the caregiver is ignorant of these beliefs, then "we won’t be able to heal as well as we should. We need to recognize the key beliefs of other cultures so we can respect and deal with them." Here are some of the steps HealthPartners has taken to fulfill their commitment to serve a diverse population:
Mr. Halvorson explained that the company’s mission is to improve
the health of its members and its community. "We are a healing company.
We’re trying to create a healing environment, and part of that healing
is to heal us." Federal and State Governments Set the Standard for Serving Culturally Diverse Populations Thomas E. Perez, JD Mr. Thomas Perez, while describing the Office for Civil Rights’ (OCR) most recently published guidance on ensuring meaningful access to health care, pointed out that these guidelines are "a subset of the broader issue of eliminating racial and ethnic disparities." He outlined the factors that need to be in place for a successful program and elaborated on the ways in which his agency can help. Any effort to eliminate disparities must look first at the root causes. Mr. Perez acknowledged that some of these causes–economics, geography, genetic predispositions, lifestyle, education–are frequently cited as reasons why "communities of color are behind the curve in terms of a number of health indicators." But his hope is to bring to light other reasons that are less frequently discussed. One of those is discrimination. Mr. Perez described several cases of discrimination that OCR had dealt with. In South Carolina, a hospital had a policy of not administering epidurals to non-English-speaking women during delivery. In a border town in Texas, hospital security personnel dressed in uniforms that closely resembled those of the border patrol. In Connecticut, a home health agency was involved in redlining, denying services to a minority public housing development. He has also heard complaints of managed care organizations bypassing certain zip codes in their marketing. The good news, he said, is that when he has talked with providers about the illegality of these practices, they have in general been anxious to find out how they can comply. To explain how to go about making changes, his agency released the guidance that explains what Title VI of the Civil Rights Act of 1964 is and how to apply it to questions of access to health care. It offers a roadmap to providers as they move toward compliance. The guidance is available on the agency’s website: www.hhs.gov/ocr. He wanted the audience to understand that there are no new requirements in the guidance, but instead an elaboration on what Title VI has been about for 35 years. In essence, the message is, "It is the obligation of the health and human service provider that receives HHS funding to ensure that each and every person who is limited English-proficient can meaningfully access the program or service." While the interpretation of "meaningful access" may vary by organization, there are four factors that are common to successful programs:
OCR is available to help agencies with compliance. They are in the process of gathering promising practices, and they are anxious to share these. Among the keys to building successful programs are: commitment from the top, partnerships with all concerned parties, and the wise use of technology. Mr. Perez encouraged people to bring together hospitals, foundations, medical societies, and state governments to discuss these issues. Discussing the root causes of disparities in health care, Mr. Perez mentioned the issue of fear. Immigrant communities often do not seek health services because they fear that their application for citizenship will be jeopardized if they seek Medicaid or SCHIP benefits. He feels it is critical to educate these communities so that they know their status is not in danger when they apply for benefits. Mr. Perez’s hope is that most compliance disputes can be resolved through this kind of education and negotiation. He also indicated that his agency is involved in self-assessment to make sure they are practicing what they preach. Bonita H. Jacques, MSW Ms. Bonita Jacques encouraged the audience to learn from the experience of the Department of Social and Health Services (DSHS) in the state of Washington even though each state’s challenge is unique. Washington’s DSHS is an agency with 19,000 employees, administering a wide range of services including child welfare, juvenile justice, rehabilitation and disability services, home health, and Medicaid. Her group, called Language Interpreter Services and Translation (LIST), works with all DSHS programs. "The mission of LIST is to provide high-quality language support services... to DSHS programs that serve limited-English-proficient clients in a professional and cost-effective manner to promote equal access," she explained. LIST was started a decade ago to help DSHS staff comply with state and federal laws. Office for Civil Rights complaints and a class action suit forced the department to step up to the plate to serve diverse clients. As they resolved those complaints, they entered into several consent agreements that committed them to translating all major communications into five languages. For other languages, they were required to summarize the material for the client. Today, the agency publishes every form, brochure, and publication in seven languages, and translates every piece of client-specific documentation regardless of language. In doing so, they have exceeded the requirements of the state statutes and there have been no legal actions since 1991. In providing language support services, Ms. Jacques pointed out that the first challenge is to make sure that all materials are written clearly in English, so that in translation the material can address people at a level they can comprehend. Next is the challenge of finding interpreters and translators for an ever-increasing number of languages. Washington State DSHS has the capability to certify and qualify interpreters in any language and to certify translators in seven languages. They test interpreters/translators at six sites, four days per month, and if there is a large enough group, they will do on-site testing. While the agency can test and certify interpreters, they do not offer them full-time positions as interpreters/translators, so they must compete with other state agencies as well as large corporations who need these services as well. DSHS contracts with language agencies for interpreter/translation services. They pay a consistent hourly or per word rate, which varies slightly by county. It is DSHS policy to make sure that an interpreter understands that he or she is not an advocate for the patient, but is a transmitter of information. This differs from the role interpreters may be asked to fill by other agencies. Ms. Jacques is pleased with the level of service LIST is able to provide. The $5 million spent by Washington State for language services is matched by Medicaid for Medicaid eligible clients and Medicaid eligible services. They also provide Medicaid matching funds for health districts, health departments, the Title V agencies, and the federally-qualified health centers. She noted that the program also covers the costs for doctors’ interpreters. As for future directions and funding, Ms. Jacques supports the use of
technology for remote interpreters, but she has found so far that face-to-face
seems to be the preferred method, particularly for doctors. Her hope for
future funding is that there will be more resources to train interpreters
in skills that will improve the process and the outcomes. She also hopes
to have funding to develop more culturally sensitive tests for certifying
interpreters. Malcolm Williams, Mr. Malcolm Williams advised grant-seekers on how best to approach the diverse world of foundations and encouraged listeners to look to foundations not only for funding but also for help in identifying unmet community needs. Understanding differences in the type, size, organizational/operational structure, and mission of a foundation can streamline the search for a match with a given goal. While Mr. Williams commended the federal government for progress toward its goal of reducing and eliminating racial and ethnic disparities in health, he noted that foundations are capable of choosing issues and offering opinions in ways that the government cannot. To understand whether a particular foundation is the right one to approach, he suggested looking carefully at the following characteristics:
Grantmakers In Health can help people collect this information. The Foundation Center, located in New York City, also is dedicated to making this information available. But once this information is collected, the most important work begins. "The next step isn’t just writing the proposal after you find this all out. It’s developing a relationship with the staff of the foundation. . . .that’s the single most important thing," he said. The staff is generally made up of experts in their field: they can help in the development of programs; they can provide insight into the work of the foundation, the history as well as the recent changes; they can serve as the grant-seeker’s advocate; they can influence the foundation toward change; and they can make it possible to form a true partnership. "A partnership means involving the foundation at all levels of their work," Mr. Williams said. They can and should be active in all phases of the program, including developing ideas for new programs. To illustrate the variety of foundation initiatives in the area of integrating cultural competence into health care, Mr. Williams gave some examples. Some of the work focuses on funding only interpretation and translation. Other foundations have adopted a broader vision in focusing on racial and ethnic disparities. In his concluding remarks, Mr. Williams highlighted the following programs because they emphasize the kind of wide-ranging strategies that are needed to address disparities.
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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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