Health Care Disparities & Diversity: Developing Cultural Competence

1. Health Care Disparities & Diversity: Developing Cultural Competence Joseph R. Betancourt, M.D., M.P.H. Director, The Disparities Solutions Center Senior Scientist, Mongan Institute for Health Policy Director for Multicultural Education, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School

2. Outline • Disparities, Quality and Cultural Competence • Provider Perspectives • Lessons from the Field

3. What is the goal of Cultural Competence? To improve the ability of health care providers and the health care system to effectively communicate and care for patients from diverse social and cultural backgrounds Emerged in response to acknowledgement of impact of culture on clinical care, and increasing patient diversity

4. Why Cultural Competence? Disparities in Health Care 2002 Racial/Ethnic disparities found across a wide range of health care settings, disease areas, and clinical services, even when various confounders (SES, insurance) controlled for. Findings: Many sources contribute to disparities—no one suspect, no one solution • Provider-Patient Communication • Stereotyping • Mistrust Rec: Cultural Competence training for all health care professionals

5. How about the impact on quality? The Role of Communication, Cultural Competence, and Care • Safety • Minorities have more medical errors with greater clinical consequences • Effective • Minorities received less evidence-based care (asthma) • Patient-centeredness • Minorities less likely to provide truly informed consent • Timeliness • Minorities more likely to wait for same procedure (transplant) • Efficiency • More test ordering in ED for minorities due to poor communication • Equity

6. …and Payment Reform and Health Care Reform? • ACO’s, PCMH’s and Population Health • Minorities more likely to have ACS admissions; communication about use of services key • Transitions of Care and Readmissions • Minorities more likely to be readmitted with CHF in 30d; communication about what to do, where to go key • Patient Experience • We see variations in HCAHPS by race and ethnicity; communication and service is key

7. Moving from the Margin to the Mainstream:Accreditation and Quality Measures • Joint Commission: Disparities/cultural competence standards 2010-11 • NCQA: Multicultural Recognition and new standards • National Quality Forum: Released cultural competence quality measures, developing disparities measures, incorporating into MAP

8. But where’s the evidence? • AHRQ Meta-analysis • A systematic review of 91 articles in peer-reviewed lit • 64 chosen that evaluated cultural competence training as strategy to improve the quality for minority popn’s • Excellent evidence for improvement in provider knowledge • Good evidence for improvement in provider attitudes/skills • Good evidence for improvement in patient satisfaction • No strong link to clinical outcomes yet, but what do providers say?

9. Residents Preparedness to Care for Diverse PopulationsJAMA 2005 • Residents located in programs affiliated with 160 academic health center hospitals • Final year of training • N=2047 (RR=60%) • Seven Specialties 1) Emergency Med (EM) 2) Family Med (FM) 3) Internal Med (IM) 4) OB/GYN 5) Pediatrics (Ped) 6) Psychiatry (PSY) 7) General Surgery (Surg)

10. Good News – The “Buy-In” is There 97% of residents feel that it is “moderately” or “very important” for physicians in their specialty “to consider the patient’s culture when providing care”.

11. … and, Residents Perceive Consequences for the Health Care System & Patients % of Residents Who Said Cross-Cultural Patient Issues Resulted “Often” in the following consequences

12. Many Residents Feel Unprepared to Deliver Specific Components of Cross-Cultural Care % Very or Somewhat Unprepared “How prepared do you feel to care for [following types of] patients (or pediatric patients’ families)…? General Specific

13. Training Matters: Residents with Little Instruction During Residency Much More Likely to Perceive Low Skill Levels % of Residents with Low Perceived Skill Levels (1,2) by amount of instruction None/ Vy Little Instruct’n A Lot of Instruct’n

14. Problems when Delivering Cross-Cultural Care Percent Saying Each Was a Problem When Delivering Cross-Cultural Care Dismissive Attitudes of Attendings Lack Experience Inadequate Training Lack Role Models Lack Time

15. Physicians Perspectives on Cross-Cultural Care • Online survey of clinicians to get their perspectives on how cultural issues impact health care delivery • Collaboration led by QuantiaMD’s (www.quantiamd.com) Doctor-Patient Relationship Interest Group • 4334 respondents from all 50 states, 2011 • Largest responders: CA, NY, PA, FL, IL

16. Current Approaches

17. Impact of Cultural Factors on Visit Time

18. Why are Providers and Staff Resistant? They want to do the right thing, and understand that if they don’t it impacts quality, but… • They don’t want to be lectured with the assumption they are broken and need to be fixed • They view cultural competence as: • Something that just increases visit time, not a skill set • Soft-science, not a set of skills • They want “just the facts” about cultures

19. Lessons from the FieldOur Experience in Cross-Cultural Communication E-Learning • Developed Quality Interactions in 2003 • Portfolio of e-learning programs • Goal: To improve quality, address disparities, and achieve equity through cross-cultural education • Have trained 125,000 healthcare professionals (clinicians and front-line staff) • Top hospitals, health plans, health professions schools throughout country

20. Model for Cross-Cultural Care: A Patient-Based Approach Awareness of Cultural and Social Factors Elicit Factors Negotiate Models Implement Management Strategies Avoid stereotypes and build trust Tools and skills necessary to provide quality care to any patient we see, regardless of race, ethnicity, culture, class or language proficiency.

21. Model for Cross-Cultural Care:A Patient-Based Approach • Assess Core cross-cultural issues • Explore the meaning of the illness • Determine the social context • Engage in negotiation

24. Key Lessons: What our experience tells us… • E-Learning allows for extensive training of a large group of people in a short amount of time with a set of uniform skills • Messaging is key: generalize, link to quality, value-added • E-Learning needs to be: • Case-based, interactive, and create teachable moments • Provide personalized feedback • Longitudinal (with boosters) and have option for blending • Clinical programs need to be: • Realistic, easy to maneuver • Linked to evidence-based guidelines and peer-reviewed literature • Health Staff Programs need to be: • Interactive yet basic, not overwhelming • Provide skills to communicate with all

25. MGH Provider and Staff Training:It can be done… • Quality Interactions Cross-Cultural Training offered as option as part of MGPO QI Incentive in Q3 2009 • 987 doctors completed; more than 88% said program increased awareness of issues, would improve care they provide to patients, and would recommend to colleagues; average pretest score 51%, posttest score 83% • 3000 nurses and front-line staff being trained with respective programs 1. Available at: http://www.qualityinteractions.org/prod_overview/clinical_program_features.html.

26. Summary • Being inattentive to cross-cultural issues has a direct impact on quality and safety • Improving cultural competence will lead to higher quality care for diverse populations • There are multiple strategies for creating culturally-competent organizations; initiatives need to be strategic, practical, actionable, and messaging and communications are key

27. Thank You Joseph R. Betancourt, MD, MPH jbetancourt@partners.org www.mghdisparitiessolutions.org