Workshop Objectives

1. Cultural and Linguistic Competency & Health Literacy for Primary Health Care Providers Kentucky Primary Care Association October 19, 2010Torrie T. Harris, Dr.P.H., M.P.H. Director, Health Equity Branch, Commissioner of Public Health Office, KY Dept. For Public Health

2. Workshop Objectives • Define Health Disparities and Health Equity • Define Cultural and Linguistic Competency and the rationale for practicing as a culturally and linguistically competent healthcare professional. • Implement/practice strategies for reducing practitioners’ own biases and misconceptions when encountering patients of a differing cultural background

3. Workshop Objectives • Identify when a language barrier is present and an interpreter is needed • Recognize the advantages and disadvantages of trained vs. untrained interpreters • Identify resources to assess individual and organizational cultural and linguistic competency

4. Workshop Objectives • Discuss the link between health reform, cultural and linguistic competency.

5. Resources • Agency for Healthcare Research and Quality • US DHHS Office of Minority Health • MedScape Internal Medicine: Cultural Competency in Healthcare: A Clinic Review and Video Vignettes From the National Medical Association • Georgetown Center for Cultural Competence • Google or Bing it: “Cultural and Linguistic Competence”

6. Background • KY has seen unprecedented growth in the diversity of their demographics. • The rate of population increase is higher for communities of color. • According to the Census from 1990 to 2000 there was a 172.6% growth of the Hispanic/Latino population. • There was a 49.3% growth of American Indian/Alaska Native; 75.1% growth of Asians; and a 76.1% growth of Native Hawaiian and Other Pacific Islanders.

7. Background

8. Background • The African American population grew by 12.6% while the White, non-Hispanic population grew by 6.8%. • In 2000, More than 29,000 Kentuckians had limited English proficiency, and the number is expected to increase. • Gonzalez indicated that U.S. residents will speak an estimated 329 languages, and 32 million will speak a language other than English at home within the next decade.

9. Health Equity Branch KY Dept. for Public Health • Established in Fall 2008 • Funded by the U.S. DHHS, Office of Minority Health and the KY Dept. for Public Health • Overarching Goals: • To eliminate health disparities among racial and ethnic minorities, rural and low income populations in the state of KY. • To promote health equity in the state of KY.

10. Health Equity Branch Activities • Obtained an Administrative Order from Secretary Miller to officially establish the Branch. • Obtained $420,000 over the course of 3 years from the US DHHS Office of Minority Health to focus on: • Cultural and Linguistic Competency • Hispanic Health Programming • Research and Evaluation

11. Health Equity Branch Activities • Cultural and Linguistic Competency Assessment of Local Public Health Depts. in KY. • Promoting Health Equity Mini-Grants • Healthy People 2020 • Infant Mortality Health Disparities • Diabetes/Obesity Collaborative • Environmental Health Disparities • Lex-Fayette Health Equity Network

12. Definitions • Health Disparities or Health Inequalities: Empirically evident differences that exist in the quality of health and health care across racial, ethnic, sexual orientation, and socioeconomic groups. US DHHS sees health disparities as “population-specific differences in the presence of disease, health outcomes, or access to health care. across different social groups in a society (Peter, 2000). • Health Inequities: are a subset of health inequalities or disparities involving circumstances that may be controlled by a policy, system, or institution so that the disparity is avoidable. These kinds of health disparities may include health and healthcare disparities. SOURCE: Center for Health Equity, Louisville Metro Public Health & Wellness, Overview & Key Ideas, Retrieved Januray,12, 2009 online at: www.louisville.gov/Health/equity/

13. Health Disparities & Healthcare • Low socioeconomic status (SES) has been specifically linked to racial/ethnic disparities in access to quality health care. • Agency for Healthcare Research and Quality (AHRQ) 2006 National Health Disparities Report stated that 73% of Afr-Am and 77% of Hispanic received worse quality healthcare than their counterparts or reference groups, partially attributed to provider or health system biases. SOURCE :U.S. DHHS (2005). 2005 National Healthcare Disparities Report. Agency for Healthcare Research and Quality. Rockville, MD. Retrieved online June 25,2009 at http://www.ahrq.gov/qual/Nhdr05/nhdr05.pdf

14. Health Disparities: Infant Mortality Rates* by Race; Kentucky 1993, & 2000-2006**Background

15. Health Disparities in the Leading Causes of Death in Kentucky 2005Age-Adjusted Rate per 100,000 Population WhiteAfrican American Heart Disease 321.5 Heart Disease 382.8 Cancer (all sites) 213.82 Cancer (all sites) 244.13 Stroke 50.0 Stroke 69.0 Diabetes 26.1 Diabetes 51.8

16. Examples of Health Disparities SOURCE:

17. Causes of Health Disparities • Multifactoral • Sociocultural • Genetics • Economic • Healthcare delivery systems • Systems of Care • Patient and Communities • Healthcare providers

18. Social Determinants of Health

19. Social Determinants by Populations SOURCE:

20. Social Determinants by Population

21. Definitions • Health Equity: When everyone has the opportunity to “attain their full health potential” and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance. SOURCE: Whitehead M, Dahlgren G. Leveling Up (Part 1): A Discussion Paper on Concepts and Principles for Tackling Social Inequities in Health. World Health Organization. Available at http://www.euro.who.int/document/ e89383.pdf.

23. Strategies for Achieving Health Equity • Awareness: Increase significance of health disparities, their impact on the nation, and actions necessary to improve health outcomes. • Leadership: Strengthen and broaden leadership for addressing health disparities at all levels. • Health and Health System Experience: Improve health and healthcare outcomes for racial and ethnic minorities and for underserved communities. • Cultural and Linguistic Competency: Improve competency. • Research and Evaluation: Improve coordination and utilization of research and evaluation outcomes.

24. Health Reform & Health Disparities • Data Collection • Directs new Assist. Sec of Health Information to • Set standards for data collection • Coordinate analysis of data on health disparities with HHS • Language Access and Cultural Competence • Qualified health plans have appropriate communication and services • Test models and curricula that train health professionals • Require a study on how Medicare can reimburse health professionals providing language services and create a 3 yr grant program to test • Extend matching rates for states that provide language services to for Medicaid beneficiaries not just children. • Workforce Diversity • Permanent advisory committee • Increase funding and scholarships for disadvantaged students, with special consideration to institutions with a track record of training individuals from minority communities.

25. Achieving Health Equity

26. Achieving Health Equity Strategy: Cultural and Linguistic Competency • Workforce Training: Develop and support broad availability of cultural and linguistic training • Diversity: Increase diversity and competency of the healthcare and administrative workforces through recruitment and retention of racially, ethnically, and culturally diverse individuals through leadership by healthcare organizations and systems • Standards: Require Interpreters and bilingual staff providing services in languages other than English to adhere to National Council on Interpreting in Health Care (NCIHC) Code of Ethics and Standards of Practice • Interpretation Services: Improve financing and reimbursement for medical interpretation services

27. Definitions • Cultural Competence: A set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enables effective interactions in a cross-cultural framework. • Linguistic Competence: Providing readily available, culturally appropriate oral and written language services to limited English proficiency (LEP) members through such means as bilingual/cultural staff, trained medical interpreters, and qualified translators. SOURCE: Cross et al. 1998. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.

28. Definitions • Cultural and Linguistic Competency: The ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by the patient to the health care encounter. SOURCE:2 U.S. Department of Health and Human Services, Office of Minority Health. 2000. Assuring Cultural Competence in Health Care: Recommendations for National Standards and an Outcomes-Focused Research Agenda. http://www.omhrc.gov/clas/finalpo.htm Accessed January 17, 2003.

29. Background • In 1994, Congress recognized the need to address the impact of cultural and linguistic competency on health disparities and mandated the Office of Minority Health, USDHHS to develop to capacity of health professionals to eliminate barriers to health care delivery and access to health care for limited English-proficient people.

30. Cultural and Linguistic Competency • As a result of the 1994 legislation, the Center for Cultural and Linguistic Competence in Health care was created. • The National Standards on Culturally and Linguistically Appropriate Services (CLAS) were developed to help guide health care delivery organizations towards a competent workforce.

31. Cultural Competency Joseph Betancourt defines a culturally competent health care system as one that “acknowledges and incorporates-at all levels-the importance of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural knowledge, and adaption of services to meet culturally unique needs. “

32. What does it mean to be culturally and linguistically competent? • Awareness of one’s own cultural worldview’ • Attitude toward cultural differences • Knowledge of different cultural practices and worldviews; and • Cross-cultural skills

33. Cultural and Linguistic Competency: Scientific Studies • Dilworth-Anderson discovered that a provider’s awareness about their own biases has influence on providing culturally appropriate care. • Many studies indicated that physicians tend to display less emotion and communication when dealing with ethnic minority patients, which translated to shorter consultation time and empathy. • Gao, Burke, and Sumkin, et.al discovered in their study of culture in physician patient communication during colorectal screening, that interpersonal relationships were common themes that determined whether or not a patient was referred for screening.

34. Competent Healthcare Organizations • Clinical (Provider-patient encounter): Interventions that include equipping individual clinicians with the skills to effectively provide care to diverse patient populations. • Organizational (Leadership/Workforce): Recruiting a diverse workforce and leadership that represents the diversity of the community that it serves. • Structural (Processes of care) Developing processes of care that facilitate access for underrepresented communities and cultures.

35. Competent Healthcare Organizations • Diverse workforce reflecting patient population. • Convenient facilities • Language assistance for patients with LEP • Ongoing staff training regarding delivery of CLAS. • Quality of care tracked across racial, ethnic, and cultural subgroups. • Community included in setting priorities and planning, delivery, and coordination of care.

36. Competent Provider-Patient Interpersonal Interaction • Explores and respects patients beliefs, values, meaning of illness, preferences, and needs. • Builds rapport and trust • Establishes common ground • Is aware of own biases or assumptions • Maintains and is able to convey unconditional positive regard • Is knowledgeable about different cultures • Is aware of health disparities and discrimination affecting minority groups • Effectively uses interpreter services when needed.

37. The Impact of Unconscious Bias and Stereotypes • Healthcare providers may: • Lack recognitions of nonverbal cues when dealing with patients of different cultural backgrounds; • Biases; • Stereotypes • http://cme.medscape.com/viewarticle/573591_2?src=emailthis

38. Strategies to Address Unconscious Bias • Awareness training of bias and stereotypes and their effect on clinical decision-making • Self-reflection practices • Individuation vs. categorization • Perspective-taking and affective empathy • Partnership building

39. Patient-Provider Communication • Minority patients report lower satisfactions with medical encounters, less partnership with healthcare providers, and less involvement in medical decision making. • Minority patients also tend to perceive a lack of respect for their preferences compared with similar white patients. • Minority patients may also be distrustful of the healthcare system due to personal experiences or the experiences of people they know.

40. Patient-Provider Communication • Minority patients may feel better with “Setting Talk”: Discussions centers on topics of immediate context, such as the surrounding environment, the clothes one is wearing or daily activities. • Healthcare providers may feel more comfortable with “Categorical Talk”: Openly inquiring about another person’s age, occupations, place of residence-things which may be considered private or personal.

41. Patient-Provider Communication • Differences in Expectations of Treatment and Outcomes • Differences in Expectation • With regard to respective roles • Appropriateness of asking questions and receiving info • Level of family involvement • Differences in Explanatory Models • Understanding the connection between symptoms and the underlying disease process or causes of illness • May lead to poor patient compliance

43. Strategies to Improve Patient-Provider Communication • Explore the respective expectations of an encounter • Open discuss interpretation of nonverbal cues • Use models of cross-cultural communication • Use shared decision-making • http://cme.medscape.com/viewarticle/573591_2?src=emailthis

44. Models of Cross-Cultural Communication

45. Overcoming Language Barriers • Limited English Proficiency Patients are more likely to: • Receive Preventive Care • Have consistent source of primary care • Receive timely eye, dental, and physical examinations • Receive error-free medical care • Visit their clinician • Return for follow-up visits after being an ER patient

46. Overcoming Language Barriers • Gold Standard: Bilingual-Bicultural Provider who is fluent in the patient’s language and culture and who expects patients to communicate their needs in English only if they have adequate English language skills. Provider should also have the necessary communication proficiency and an understanding of the patient’s language to be able to explain medical concepts in lay terminology.

47. Selecting an Interpreter • Title VI of the 1964 Civil Rights Act says that “requiring, suggesting, or encouraging” a patient to bring his or her friends, minor children, or family members to serve as an interpreter infringers on the patients civil rights. It is also considered illegal if the institution receives federal funds.

48. Interpreters • Professionally Trained Interpreters at no cost to patient: • Staff Interpreters • Agency Interpreters • Volunteer Interpreters • Telephone Interpreters • Bilingual staff is Ok, but not preferred • IF patient insists on family member or friend: • please honor the request after full disclosure of options • Have patient sign waiver, releasing institution of liability.

49. Interpreters • Interpreters should be able to do the following: • Be faithful in communicating the patient’s own words to the provider • Maintain confidentiality • Be trained in memory, note-taking, language transposition • Skills that go beyond proficiency in speaking language

50. Friends and Family • Compromise of confidentiality • Family member or friend may filter info • Level of comfort may be lost • Comprehension • Children may lack the vocab. Or be embarrassed to discuss sensitive topics. • http://cme.medscape.com/viewarticle/573591_2?src=emailthis