Dennis Andrulis Associate Dean for Research Director, Center for Health Equality School of Public Health Drexel Universi

1. Opportunity and Promising Practices for Advancing Cultural Competence in Health Care CULTURAL COMPETENCY: HEALTH CARE MEETING THE CHALLENGE OF DIVERSE SOCIETIESThe New York/Jerusalem Dialog ProjectExperts ExchangeWednesday, May 16, 2007 Dennis Andrulis Associate Dean for Research Director, Center for Health Equality School of Public Health Drexel University Philadelphia, PA

2. “[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

3. Growing importance of cultural competence, disparities reduction and language assistance in care management and improving quality of care.

4. 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

5. Elements from Cultural Competence Definitions • Practitioner capability, awareness and relatedclinical standards/policies • Improving outcomes, meeting goals for quality and efficiency • Involving organizations • Overcoming communication barriers • Consumer focus/community participation • Training and professional development

6. RESEARCH

7. POLICY AND PROGRAM RECOMENDATIONS

8. POLICY AND PROGRAM RECOMENDATIONS

9. USDHHS/OMH National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards) Fourteen Standards Issued in 2001 address • Culturally Competent Care • Language Access Service • Organization Supports for Cultural Competence

10. NIH PROGRAMS

11. CONFERENCE LEADERSHIP

12. “…health care systems cannot effectively move their QI goals forward without specifically addressing the embedded problem of racial and ethnic disparities in treatment.” Risa Lavizzo-Mourey Robert Wood Johnson Foundation

13. Why is Cultural Competence Gaining Importance? • Meeting the needs of an increasingly diverse society • Reducing health disparities and improving health care quality • Tailoring health care delivery to meet population and individual needs • Meeting federal and state requirements • Increasing treatment compliance, patient safety; and reducing medical error • Supporting organizational business strategies and objectives • Growing accreditation interest – JCAHO, NCQA

14. The Consequences of Discrimination and Racism • Tuskegee and health system mistrust in Black communities • A national survey of Latinos found that almost one-third had experienced discrimination and that 80% felt it was a problem. • Black women with less than a college education who reported they have experienced discrimination in house or in other ways were more likely to have premature births, likely due to related stress they undergo. • Blacks saying they experience discrimination were less likely to get kidney transplants.

15. 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.

18. “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.’”Source: Paul Schyve, JCAHO, 2002

19. Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot Study Patients with Limited English Experience More Serious Errors “…LEP patients were more likely than English-speaking patients to experience an adverse event that caused some physical harm…a greater proportion of adverse events among LEP patients resulted in moderate or severe harm.” Source: Divi C, Koss RK, Schmaltz SP, & Loeb JM. International Journal for Quality in Health Care. ( April, 2007)

20. Recommended actions for reducing racial and ethnic disparities.

21. Points of intervention • Education About the Patient • Language • Service Setting • Information System • Workforce and Community • State Initiatives

22. A. Education About the Patient • Identify beliefs regarding health and illness (e.g., fatalism) • Determine how family members fit contribute to medical decisions. • Recognize and understand other factors that can affect treatment adherence such as gender issues in care, treatment conflicts.

23. Language • For interpretation, acknowledge the value of language concordance and its association with higher ratings of physical and emotional well being (Perez-stable et. al.), and possibly better outcomes (Tocher et. al.) • Acknowledge the value of professional interpretation in the health care encounter

24. Examples of best practices undertaken by US hospitals focused on language needs • Conducting a system wide assessment of language access needs and offering a set of programs that include on site interpreter staff, advocacy for interpreter needs, translation of written materials, formation of diversity and language access committees, partnerships with community based programs for language services • Developing family and patient education committees to promote understanding among LEP patient regarding general consent to treatment, anesthesia consent, use of educational materials for specific care and discharge instructions

25. Service Setting • Developing service initiatives including diversity training modules on cultural competence and group-specific health care “handbooks” • Instituting policies to promote diversity in hiring, retention, promotion, mentoring • Diversifying board memberships and developing program wide diversity initiatives • Developing market strategies for diverse patients through targeted strategies that match culturally competent care, data and growth in diverse markets. • Linking actions to outcomes measurement • Creating a diversity curriculum task force it identify and address factors affecting successful medical encounters

26. “Practice-site policies to promote cultural competence, the use of reports to clinicians, and access and continuity predicted higher quality of care for children with asthma in managed Medicaid.” Source: Lieu, et. al. Pediatrics. 114; 102 (2004).

27. Conducting Cultural Competence Organizational Assessments

28. The 4 cornerstones of cultural competence for providers and health care settings • The organization’s relationship with its community • The administration and management relationship with staff—organization policies • Interstaff relationships at all levels of the organization—training, education, communication • The patient/enrollee-practitioner encounter

29. Information System • Identifying specific issues for diverse populations: Health literacy, interpreter needs, preferred language; family role. • Linking racial/ethnic information to patient satisfaction, grievances and complaints filed. • Developing bilingual staff availability and test consistency bilingual staff • Offering information guidance to clinicians regarding predisposition to certain conditions and drug dosage sensitivity association with racial/ethnic heritage (e.g., high sickle cell anemia rates)

30. Workforce and Community • Use community health workers as a way to increase racial/ethnic access to health care and to serve as a liaison between health care providers and communities • Lay workers can help with care coordination and continuity and help assure adherence to medical regimens, and can increase awareness of screening for conditions (Bird et. al. and others) • Consider using multidisciplinary teams for addressing risk reduction and for related health priorities such as smoking and obesity.

31. State Initiatives • 43 states have language access laws • Comprehensive • Targeted (e.g. emergency room, hospital) • NJ, CA and WA have laws requiring cultural competency continuing education for health professionals • Some states moving towards health care interpreters certification • 13 states provide Medicaid reimbursement