Culture Begins Within:

1. Culture Begins Within: Self-Reflection and Systems for Partnering with our Diverse Patients Jeffrey Aalberg Mary McDonough Debra Rothenberg

2. Goals • Increase the participants' awareness of patients' cultural and ethnic needs at the point of care • Discuss some system level solutions to addressing patients' cultural and ethnic rights

3. Agenda • Overview of the current cultural/ethnic diversity in Southern Maine • Systems: approaches and challenges • Cultural competency

5. Changes in Portland’s demographics • 1970-1980-- Vietnam and Cambodia • 1980’s-- Eastern Europe, former USSR, Afghanistan and Iran • 1990-present-- Africa (especially Somalia, Sudan, Congo) and the former Yugoslavia • Currently-- family reunification, secondary migration, and increasing numbers of persons identifying as Latino/Hispanic.

6. Ten-Year ELL Enrollment–Portland Schools

7. Primary Home Languages Other Than English: 2007-08 *

8. Interpreter Services at MMC In 2003, Maine Medical Center provided patients, who are Limited English proficient (LEP), with 11,000 interpreter encounters or 8,000 hours of interpreter services in 62 languages at a cost of $320,000.

9. Top Interpreted Languages at MMC in 2003 • Somali 22% • Vietnamese 14% • Spanish 14% • Russian 11% • Khmer 8% (Cambodia) • Serbo-Croatian 6% (Yugoslavia) • Arabic 6% (Mideast and Islamic Africa) • Chinese 4% • Farsi 4% (Persian/Iran)

10. Systems for Partnering with diverse populations Technologies: • EMR: • Powerful tool to collect report and track data • Ethnicity/Race • Numbers of patients • Paper charts: many will be moving to Maine health Epic. If not, tracking tools can be developed, web based or paper • Multiple technical systems—do they talk to each other? • Internet • E-Mail • Phone systems

11. Challenge: searching for diversity • Language • Social history, patient stories • Patient satisfaction

12. Questionnaire In order to better understand and care for our patients, we are requesting you to fill out the answers to the following questions about your race/ethnic background, and the language you speak at home. The care you receive in this office will NOT be affected by your response or your choice not to respond. THANK YOU for helping us to take better care of all our patients.

13. Please define your race/ethnicity, checking as many boxes as you feel are appropriate: • American Indian • Asian • Black or African American • Franco-American • Hispanic or Latino • Native Hawaiian or Other Pacific Islander • White or Caucasian • More than one race/ethnicity • Other _______________________

14. What is the primary language you speak at home? • Acholi • Arabic • Cambodian (Khmer) • Chinese • English • Farsi • French • Russian • Serbo Croatian • Somali • Sudanese Arabic • Swahili • Spanish • Vietnamese • OTHER:_________________

15. Resources for Partnering with diverse populations • Health literacy • Community Libraries • Community groups • Web based information • Maine Health Learning Resources • Interpreters • Accessing; hospital interpreter services phone based services • Affordability? can an office afford not to… • CHOWs (Community health Outreach Workers) partnering with the city of Portland

16. Community Supports • Public Health Agencies • CHOWs • MH Learning Resource Centers • Area Agencies on Aging • Living Well Programs( Maine Health’s Partnership for Healthy Aging)

17. Community Supports • Libraries & the Internet • Colleague networks: Prism 5 • State of Maine: Office of Multicultural Affairs- http://maine.gov/dhhs/oma/Statewide resources

18. A Model that supports partnering with diverse populations Patient Centered Medical Home: • Partnership between patients, a specially trained primary care provider and integrated team. • Information and education to assist patients in making informed decisions, while offering support and help to patients and families. • Empowers patients and their families to have a greater voice in their care • Supports patients’ self management. • Shared commitment to work together

19. Racial and ethnic differences:access to needed medical care

20. Partnering with patients, families & community • Patients and community should have a voice in local delivery of health care • Medical practices benefit from alliances, and knowledge, of/from their community ___________________________________________ An answer: Advisory Councils • Selecting people for a patient-family advisory board • A broad interest in local delivery in health care • Ability to listen and hear other points of view • Ability to connect with people • Ability to share medical stories in ways that others may benefit from

21. Confronting Barriers • Customers should face no barriers when seeking care: • Attitudes • Time • Language • Lack of organizational guiding vision • Organizational culture • Office cultural changes

22. SELF AWARENESS: Where you stand determines what/how you see. . .

23. Peds Crossing

24. Left vs. Right

25. to make accessible the normally unexamined assumptions by which we operate and through which we encounter members of other cultures. EXERCISE: CLOSE YOUR EYES

26. Cultural Humility • a lifelong process of self-reflection and self-critique. • does not require mastery of lists of "different" or peculiar beliefs and behaviors supposedly pertaining to certain groups of patients. • encourages development of a respectful partnership with each patient through patient-focused interviewing, exploring similarities and differences between provider and patient's priorities, goals, and capacities. • the most serious barrier to culturally appropriate care is not a lack of knowledge of the details of any given cultural orientation, but the providers' failure to develop self-awareness and a respectful attitude toward diverse points of view. Tervalon M, Murray-Garcia J: “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education, “Journal of Health Care for the Poor and Underserved 1998; 9(2):117-124.

27. Clinical Cultural Competence To be culturally competent, it is not to be an expert in every culture. It is to build one’s capacity for self-awareness, new learning, and sensitivity to human diversity. These qualities guide the health care provider in determining how to adjust communication style, ask better questions, and function effectively and respectfully within the cultural context. • Boris Kalanj, Children’s Hospital, MN

28. Guidelines for Health Practitioners: LEARN L : Listen with sympathy and understanding to the patient’s perception of the problem. E : Explain your perceptions of the problem. A : Acknowledge and discuss the differences and similarities. R : Recommend treatment. N : Negotiate agreement. From: Berlin EA, Fowkes WCJr: “A Teaching Framework for Cross-Cultural Health Care,” Western Journal of Medicine 1983, 139:934-938.