Dennis Andrulis Center for Health Equality Drexel University Philadelphia, PA 19102

1. INTEGRATING DISPARITIES REDUCTION, CULTURAL COMPETENCE AND LANGUAGE ASSISTANCE INTOEDUCATION INITIATIVES FOR DIABETES MANAGEMENT2009 CMS Health Disparities Quality Improvement Meeting Washington, DCMay 22, 2009 Dennis Andrulis Center for Health Equality Drexel University Philadelphia, PA 19102

2. PurposeTo present a care model-based self management framework and template of action for addressing the educational needs of racially and ethnically diverse patients with diabetes.

3. Defining Cultural Competence “Cultural Competence is a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups.” Cultural competence also focuses its attention on population-specific issues including: • Health-related beliefs and cultural values (the socioeconomic perspective), • Disease prevalence (the epidemiological perspective), • And treatment efficacy (the outcome perspective).” Source: Cross, et. al. 1989

4. Lessons From Chronic Care Model of Disease Management • “…Posits that better outcomes result from productive interaction with medical care in which patients receive assessment, support for self management, optimization of therapy, and follow up…” • “Management [also] requires an appropriately organized delivery system linked with complementary community resources…” Rothman, A. & Wagner, E. Chronic Illness Management: What is the Role of Primary Care? Annals of Internal Medicine. 2003 v138, p. 256-261

5. Care Model characteristics • Eliciting and reviewing data on patients and other information affecting management of condition • Helping patients set goals and solve problems for improving self management • Applying clinical and behavioral interventions to maximize disease control and patient well-being • Ensure continuous follow up Sources: Wagner, E. et al. Improving Chronic Illness Care: Translating Evidence into Action. Health Affairs, 2001 v20, p. 64-78

6. Wagner, E. H. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998; 1(1): 2-4.]

7. Disproportionate Prevalence of Diabetes by Race/ Ethnicity • 24% of Mexican-Americans and 26% of Puerto Ricans between the ages of 45 and 74 have diabetes. Source: National Diabetes Fact Sheet, CDC, 2005. • Diabetes rates of Asian Americans are 60% higher than that of Whites (BMI adjusted). Source: McNeely, M. & Boyko, E., Diabetes Care, vol. 27, Number 1, p. 66-69, 2004).

8. Compared with White patients, Latinos are more likely to believe that… • Insulin therapy may cause long term complications • Were more concerned that they could not master the demands of insulin therapy • That it would restrict their lives • The introduction of insulin indicated a personal failure at managing their disease Sources: Caballero, A. Ethnicity & Disease, 2006, p. 559-569; Tripp-Riemer, T. et al. Diabetes Spectrum, vol. 14, 2001, p. 13-22.

9. Compared with White patients, Indians are more likely to believe that… • Diabetes was introduced by Whites • Results from imbalance linked to too much sugar, food, alcohol or immoral behavior • Heaviness is related to health Sources: Caballero, A. Ethnicity & Disease, 2006, p. 559-569; Tripp-Riemer, T. et al. Diabetes Spectrum, vol. 14, 2001, p. 13-22.

10. Compared with White patients, Chinese Americans are more likely to believe that… • Extra weight is a blessing related to wealth • Hot (yin) illnesses like diabetes can benefit from cold (yang) remedies such as Ginseng Sources: Caballero, A. Ethnicity & Disease, 2006, p. 559-569; Tripp-Riemer, T. et al. Diabetes Spectrum, vol. 14, 2001, p. 13-22.

11. Compared with White patients, African Americans are more likely to believe that… • “Sweet blood” is caused by sugar and starchy food • Diabetes is made worse from worry and stress • Common treatments are trust in God, use of bitter foods and herbs (i.e. garlic & lemon juice) Sources: Caballero, A. Ethnicity & Disease, 2006, p. 559-569; Tripp-Riemer, T. et al. Diabetes Spectrum, vol. 14, 2001, p. 13-22.

12. Compared with White patients, Hmong are more likely to believe that… • Discussing a health problem before it occurs may bring on the illness • Fat is essential for vitality Sources: Caballero, A. Ethnicity & Disease, 2006, p. 559-569; Tripp-Riemer, T. et al. Diabetes Spectrum, vol. 14, 2001, p. 13-22.

13. Diabetes & Diversity: Challenges to Care and Patient Education “A lack of cultural competence may result in barriers with respect to communication of pertinent information about diabetes care and insulin therapy… and potentially compromise clinical outcomes.” Source: Caballero, A. Ethnicity & Disease, p. 562, 2006.

14. “[If you] ask staff to describe patients or families they like and do not like, they usually like patients or families who are grateful or people from the same culture or who speak the same language, but beyond that the attributes of popular patients and families become pretty grim. The most popular patients never ring their call lights, never ask for help, never ask questions or challenge their nurses and doctors, and never, ever read medical books or use the Internet for help. Their families are not present, and they do not have friends. In fact, they are as close to dead as possible.” Source: Healthcare Quality Book, 2005

15. Diabetes Self Management for Racially and Ethnically Diverse Populations Premise: To develop effective patient self management education requires knowledge of culturally specific factors that influence decisions, affect continued adherence to treatment and are critical to patient-practitioner relationships

16. Identifying beliefs regarding health and illness New York Times; October 7, 2004

17. Encouraging practitioners to work within belief systems • Fatalism may play a significant role in Hispanics’ perceptions of their health conditions (Flores, 2000) • Asians stress the communal over the individual (Yamashiro et al, 1997)

18. Hospitalized Minority Patients Report More Problems with Respect for Their Preferences Percent of hospital patients reporting more problems* in dimensions of patient experiences * More problems defined as highest quintile of problem scores in each dimension. SOURCE: L. S. Hicks et al., “Is Hospital Service Associated with Racial and Ethnic Disparitiesin Experiences with Hospital Care?” American Journal of Medicine, May 2005 118(5):529–35.

19. Addressing alternative treatments and considering who may play key roles in those treatments • Over one in four for whom English is a second language reported using herbal medicine compared with 13% of English speaking respondents (MacKenzie, 1999)

20. The New York Times; January 3, 2006

21. Determining acceptable levels of formality and interaction The role of family in medical decisions and treatment • Mexican-American and Korean Americans tend to favor family involvement in patient condition and treatment more than European-and African-Americans • Refugees from repressive countries may hesitate to disagree with authority figures • Respect for older individuals in some cultures may confound interactions with an older practitioner • Having a married woman seen by a male physician is taboo for some patients from Middle Eastern cultures

22. Understand cultural/linguistic barriers to care and help navigate system

23. Assessing language and literacy needs • 50% of Hispanics and 40% of African Americans have reading problems (Kirsch et al, 1993) • Diabetic patients scoring lowest on health literacy tests had worse glycemic control and higher rates of retinopathy (Schillinger et al 2002) • Latino patients diagnosed with hypertension or diabetes reported better scores on functioning and well being if their primary care practitioners spoke Spanish (Perez-Stable, Springer, Miramontes, 1997)

24. Assessing language and literacy needs (continued) • Educate and train practitioners on interpreter choices and importance of signage “…A physician who apparently knew some Spanish and liked to deal directly with the patient…ends up eliciting from her that she’s having some trouble sleeping and so he said ‘Well, I can give you some sleeping pills’. At which point the patient immediately breaks into tears and the doctor…turns to the interpreter and says ‘What’s going on here?’ ‘Well, the patient had just told you that she is very depressed and had been saving up her sleeping medication to kill herself and so you told her you’d give her some sleeping medication’”. (Paul Schyve, JACHO, 2002)

25. Recognizing the importance of racism and other contextual factors • “Institutionalized Racism in Health Care.” Lancet. 1999; 353:765.

26. Recognizing the importance of racism and other contextual factors(continued) • “[Physicians] could hardly be expected to ‘respect’ their patients’ system of health beliefs, since the medical schools they had attended had never informed them that diseases [in the Hmong population] are caused by fugitive souls…All of them had spent hundreds of hours dissecting cadavers…but none of them had had a single hour of instruction in cross cultural medicine” (Fadiman, 1996, p.61)

27. Examples of diabetes disease management best practice programs for diverse patient populations Aetna initiative in diabetes • Objective: to improve rates of preventive service use, especially cholesterol screening and glycosolated hemoglobin testing • Interventions: revise telephone call script to consider language, literacy and numeracy skill issues; targeted mailing to patient’s physician with specific data, patient education materials and information on cultural competence MD training; patient received targeted mailing in English and Spanish with materials emphasizing control of glucose, cholesterol etc and screening needs; follow up call to answer questions/address barriers • Early results: 38% of those who had not received key screening now met goals. Source: Disparities Solutions Center. Aetna’s program in health care disparities, 2007.

28. Examples of diabetes disease management best practice programs for diverse patient populations continued… American Healthways’ Diabetes disease management program • Objective: reach diverse patients using population based information and initiatives to improve self management • Interventions: integrating information on “local market cultural competency” involving local diet considerations, community values, other cultural/social norms • Results: improved adherence to physician plans; delayed onset of complications Source: Pope, J. et al., Health Care Financing Review, Sept.22, 2005

29. CDC Project REACH in Detroit • Targets African Americans and Hispanic-Latinos. • Trains community based “family health advocates” to lead self management training, cooking sessions and physical activities, and helps prepare for health care visits. • Resulted in higher program retention and satisfaction. • Significant drop on A1C. Sources: Heisler, M. Medscape. 2006.

30. Massachusetts Health Center Diabetes Program for Asian/ Pacific Islanders • Uses house parties in Vietnamese and Cambodian communities that includes friends, relatives and bicultural health staff . • Hawaiian health center conducts workshops led by lay leaders with diabetes and a practitioner to provide nutrition and other information and encourages peer to peer sharing of experience and information, building on local traditions. Sources: Heisler, M. Medscape. 2006.

31. Starr County Border Health Initiative • Cultural competent diabetes self management education for Mexican American patients included: three months of weekly instructional sessions on nutrition; self monitoring of blood glucose, exercise and other self care; and six months of biweekly support groups for behavioral change. • Integrated into these interventions were culturally related aspects of language, diet, social emphasis, family participation and incorporation of cultural health beliefs. • Result was that A1C was 1.4% less in this group than a control group. Sources: Caballero, A. Ethnicity & Disease, 2006.

32. Project Dulce • Nurse case management and peer education that was community and culturally related to Hispanics increased understandings of diabetes and self awareness. • Result in an A1C drop of 4% from 12 to 8. Sources: Heisler, M. Medscape. 2006.

33. Preventing lower extremity amputations • Multiple interventions approach involving patient education, use of multidisciplinary teams, and organization around disease management led to a 48% reduction in lower extremity amputations among Native Americans (Rith-Najarian et al, 1998) • Interventions --foot self-examination, appropriate footwear, long-term follow up and other actions as part of a comprehensive prevention program targeting at risk African American diabetic patients-- significantly reduced hospitalizations, foot operations; it reduced foot amputations by 79%.  (Patout et al, 2000)

34. Source: “The Development and Implementation of the Chronic Care Management Programme in Counties Manukau.” Wellingham, J. New Zealand Journal of Medicine. Vol 116, Number 1169.

35. Options for integrating disparities reduction/cultural competence into care teams • Formation of diversity teams • Designating/assigning an individual within the team to assume responsibility for integrating disparities/cultural competence into the initiative • Requiring each team member to include in their responsibility

36. Conclusion • Culturally tailored programs may provide a way to focus actions for diverse patients by using cultural products, practices, living circumstances, social supports, self –efficacy, coping skills-- to create or enhance change for both patients and practitioners (Fisher et al 2007)