Bridging Cultures and Enhancing Care:
Approaches to Cultural and Linguistic Competency in Managed Care

For downloading or printing: Bridging Cultures and Enhancing Care (PDF file - 513 KB)

May 30, 2002
Chicago, Illinois

Sponsored by:

Health Resources and Services Administration (HRSA)
and
American Public Human Services Association (APHSA)

This conference summary reflects the information provided by and the opinion of the conference presenters/participants and is not that of the American Public Human Services Association, the Health Resources and Services Administration, or the U.S. Department of Health and Human Services.

Dear Colleague:

The Health Resources and Services Administration (HRSA) is pleased to share with you the enclosed publication entitled, “Bridging Cultures and Enhancing Care: Approaches to Cultural and Linguistic Competency in Managed Care.” This publication highlights the events of a national conference that was sponsored by the HRSA Center for Health Services Financing and Managed Care in cooperation with the American Public Human Services Association (APHSA). This conference program covered the core information that will enable participants to define and assess the cultural and linguistic competency of their organization and provider network.

Hopefully, this publication will serve as a valuable resource as your organization moves toward becoming more culturally competent. Copies of this publication may be downloaded from the HRSA Center for Health Services Financing and Managed Care’s web: www.hrsa.gov/reimbursement or ordered from the HRSA Information Center, 1-888-ASK HRSA, www.ask.hrsa.gov

Table of Contents

INTRODUCTION

CULTURAL COMPETENCY: The Basics

• The Effects of Race and Ethnicity on the Delivery of Quality Health Care

• Building Cultural Competence in Organizations: Focus on Promoting and Sustaining Change

• Cultural Competence and Linguistically Appropriate Services in the Clinical Setting
  - Promoting Cultural Competence in Clinical Practice: The Patient-Provider-Interaction
  - Linguistic Services: Translation and Interpretation Issues

• California’s Approach to Ensuring Culturally Competent HealthCare Services in Medicaid Managed Care and SCHIP Health Plans

SUCCESSFUL PRACTICES IN MANAGED CARE

• Arizona Health Care Cost Containment System (AHCCCS) Plans and Provider Pocket Guide

• A Culturally Conscious Approach to the Delivery of Healthcare Services

• Model of Cultural Competency for Working with African American Patients with HIV

• Enhancing Family-Centered Care in Managed Care Organizations

• Addressing Cultural and Linguistic Diversity in the Community Health Center Environment: The Sunset Park Family Health Center Network

• Project Street Beat, Planned Parenthood of New York City

PLENARY SESSION: An Interactive Session Opportunity to Discuss Challenges in Delivering Culturally and Linguistically Competent Health Care

INTRODUCTION

On May 30, 2002, representatives from State Medicaid agencies, managed care organizations (MCOs), state and local health departments, Ryan White Care Act HIV/AIDS providers, public hospitals, family support groups, state mental health agencies, and others convened in Chicago, Illinois for a conference to discuss the special issues related to providing culturally competent healthcare for patients with diverse cultural backgrounds. The one-day conference “Bridging Cultures & Enhancing Care: Approaches to Cultural & Linguistic Competency in Managed Care” was sponsored by the Health Resources and Services Administration (HRSA) Center for Health Services Financing and Managed Care in cooperation with the American Public Human Services Association (APHSA).

The conference began with opening remarks from Gregory A. Vadner, Director, Division of Medical Services for the Missouri Department of Social Services in Jefferson City, Missouri. After general introductions and administrative announcements, the objectives for the meeting were set forth.

CULTURAL COMPETENCY: The Basics

The essential elements of cultural competency were commented on throughout the program by all speakers. Felicia Batts* and Josepha Campinha-Bacote** provided comprehensive information about the fundamental aspects of cultural competency. Here, Drs. Batts’ and Campinha-Bacote’s comments have been synthesized and summarized in a simple format as a foundation for the remainder of this report. “*” and “**” indicate which speaker provided the information.

What is Cultural Competency?*

There are as many definitions of cultural competency as there are diverse perspectives, interests and needs. However, the following is a broad, generally accepted definition:

Cultural competency is based upon the concept that cultural differences extend beyond race and ethnicity. Cultural variations include*:

• race

• country of origin

• native language

• social class

• religion

• mental or physical abilities

• heritage

• acculturation

• age

• gender

• sexual orientation

• other characteristics that may result in a different perspective or decision-making process

Where does Cultural Competency in healthcare begin?*

Cultural competency occurs in both clinical and non-clinical arenas.
In the clinical arena, cultural competency is based on the patient-provider interaction.
In the non-clinical arena, organizational policies and interactions impact the delivery of culturally competent services.

Why is cultural competency important?

When health care services are delivered without regard for cultural differences, patients are at risk for sub-optimal care. Patients may be unable or unwilling to communicate their healthcare needs in a culturally insensitive environment, reducing the effectiveness of the healthcare process. Understanding the fundamental elements of culturally and linguistically appropriate services is necessary when striving for cultural competency in healthcare delivery.

Four Rationales for Cultural Competency in Healthcare Delivery**

1. To respond to demographic changes

2. To eliminate disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds, especially in particular medical conditions: cancer, cardiovascular disease, infant mortality, diabetes, HIV/AIDS, and child and adult immunizations.

3. To improve the quality of healthcare services and health outcomes

4. To gain a competitive edge in the healthcare market and decrease the likelihood of liability/malpractice claims. Healthcare is a business, and as such is influenced by the same force driving all big businesses today, including market competition, consumerism, organization restructuring, information service technology, and customized care.

What are some obstacles to culturally competent care?*

• Stereotypes, Biases and Assumptions

• Viewing Culture as ‘Them’, Not Me

• Confounding Race, Culture and Ethnicity

• Differing Health Belief Models

• Patient Exploitation and Oppression

• Pseudo-explanatory Models

• Cultural Mismatches

• Language and Communications Barriers

• Misdiagnosing Ethnic-specific Medical Concerns

• Cultural Clashes

What are the Pros and Cons of Cultural-Specific Information?*

Cultural-specific information is one aspect of cultural competency that is important but controversial. It can be useful, but misused as well.

Benefits of Cultural-Specific Information*

• Can illustrate important differences among cultures

• Serves as a starting point for cultural assessment of patients

• Opens mind to alternative viewpoints and treatments

• Helps avoid egregious errors

Cautions Regarding Cultural-Specific Information*

• Tends to promote stereotyping

• May fail to fully recognize diversity within groups

• Sometimes creates cultural value scale

• Can give providers false sense of confidence

The Effects of Race and Ethnicity on the Delivery of Quality Health Care

Nathan Stinson, M.D.
Deputy Assistant Secretary for Minority Health
Office of Minority Health
U.S. Department of Health and Human Services
Rockville, Maryland

Nathan Stinson, Jr., PhD, MD, MPH began the presentations by providing a broad and comprehensive overview of how race and ethnicity affect healthcare delivery nationwide. As our country grows increasingly diverse, health disparities based on race and ethnicity are becoming more readily apparent. In 1985, The Task Force Report on Black and Minority Health reported that minorities have comparatively poor health, that health disparities have worsened and that minorities are chronically underserved by the healthcare system.

The March 2002 report “Racial and Ethnic Disparities in Healthcare” issued by the Institute of Medicine (IOM) indicates that these issues have shown little improvement in the past 17 years. The most relevant new finding from the IOM may be that racial and ethnic disparities remain even after adjustment for socioeconomic differences and other healthcare access related factors. The IOM concluded that racial and ethnic disparities in healthcare exist and are associated with worse outcomes in many cases. Further, these disparities in healthcare occur in the context of broader historic and contemporary social and economic inequality, and reflect evidence of persistent racial and ethnic discrimination in many sectors of American life. The IOM recommended several actions to address healthcare disparities:

1. Increase awareness of racial and ethnic disparities in healthcare among the general public and key stakeholders;

2. Increase healthcare provider’s awareness of disparities;

3. Initiate legal, regulatory, and policy interventions to enact change.

The IOM report also called for data collection and monitoring according to ethnic and racial backgrounds for myriad purposes (see box).

However, collecting racial and ethnic information gives rise to some practical and ethical issues. There are perceived legal impediments with respect to confidentiality and privacy and the potential misuse of data. Further, the cost of large-scale data collection is substantial.

In an effort to address the issues of collecting racial and ethnic information, a meeting was jointly held in June 1999 by the Office of Public Health and Science, The Commonwealth Fund, the Agency for Healthcare Research and Quality (AHRQ) and numerous managed care organizations (MCOs). None of the MCOs in attendance routinely collected racial and ethnic information; however, some have obtained such data from research, state Medicaid programs or linkages to other databases (e.g, cancer registries, birth certificates). While MCOs expressed concerns, the general consensus was that if data were to be collected, all plans and health insurers should do it.

With the assistance of the National Health Law Program, Inc. (NHeLP), a review of state and Federal laws was initiated to identify laws and regulations that require or prohibit the collection of racial and ethnic data by health insurers and MCOs. Two Federal health services programs require racial and ethnic date collection and/or reporting: the End-Stage Renal Disease Program and Substance Abuse and Mental Health Services Administration (SAMHSA) applications for prevention service activities. Data collection requirements for Medicaid managed care and SCHIP regulations have recently been finalized. Several public program statutes also require racial and ethnic data for participation.

Even when a specific statutory requirement does not exist, Title VI of the Civil Rights Act of 1964 provides a legal foundation for the collection of racial and ethnic data, though it does not specifically mandate or prohibit such data gathering. This Act protects individuals by prohibiting discrimination on the basis of race or national origin in the provision of any services that are supported with Federal funds. Title VI protection extends to all programs and activities of any entity receiving Federal funds, whether or not the particular program has itself received or benefited from those funds. This would therefore include any Medicaid MCOs.

State laws for MCOs and health insurers vary, however. Four States prohibit the collection of racial and ethnic data as part of the application process: California, Maryland, New Hampshire, and New Jersey. Although MCOs are free to collect data at the point of care or at some other time after members enroll, it is logistically more challenging to generate aggregate data this way. Conversely, one State—South Carolina—requires MCOs and insurers to collect racial and ethnic data, while another—Texas—requires collection of primary language information.

After identifying the problem of disparity in healthcare, Dr. Stinson continued to lay the foundation for the rest of the day’s discussions by defining cultural competency, a concept viewed by many as the solution to healthcare inequity. According to Dr. Stinson, cultural competency is “the ability of health organizations and practitioners to recognize the cultural beliefs, attitudes and health practices of diverse populations and to apply that knowledge in every intervention—at the systems level or at the individual level—to produce a positive health outcome.” He suggests that culturally competent care has the potential to improve access to services, reduce medical errors, and increase the use of preventive services. Furthermore, cultural competency may improve patient compliance and patient satisfaction, reduce financial costs and liability and ultimately facilitate the elimination of health disparities. In closing, Dr. Stinson explained that the Office of Minority Health has established 14 national standards to inform, guide, and facilitate culturally and linguistically appropriate healthcare services (CLAS). He ended with an apt quote from Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, a report from the National Academies’ Institute of Medicine: “The real challenge lies not in debating whether disparities exist, but in developing and implementing strategies to reduce and eliminate them. Confronting such ‘unequal treatment’ will require a broad and sustained commitment from those who provide care, as well as those who receive it.”

Building Cultural Competence in Organizations: Focus on Promoting and Sustaining Change

Calvin Freeman
President
Calvin Freeman & Associates
Sacramento, California

Calvin Freeman, former Chief of the Office of Multicultural Health and Head of Disaster Medical Preparedness for the State of California, addressed the issue of promoting cultural competence through organizational change. During Mr. Freeman’s 25 years of experience in public health, he has found a broad-based, multi-level approach to be effective for several reasons. First, organization leaders are in a position to guide a large group of people through priority and goal setting. Policies that impact many patients can be defined and implemented throughout the organization. Personnel policies and decisions can be guided by organizational change. Even the physical design of facilities, which is often integral to creating a culturally competent setting, can be addressed.

Mr. Freeman discussed 4 main strategies for improving cultural competence by initiating organizational change:

1. Be strategic in your approach to promoting cultural competence.

2. Build an infrastructure for cultural competence.

3. Recognize the importance of people and relationships.

4. Use the management knowledge and tools you use for other issues.

According to Mr. Freeman, being strategic in an approach to promoting cultural competency begins with accepting a few assumptions. First, organizations do not change easily because multiple staffs, units and functions are involved. Second, large change is built on small steps—we must get away from the idea that everything must be, or even can be, accomplished at once. Finally, even failed attempts at change can be positive, negative, or both depending on what we choose to learn from the attempts. With an understanding of these concepts in place, the first step to promoting cultural competency in a large group is to assess the status quo. Assessment helps to define the context and environment, identify assets and obstacles, and determine readiness to meet patient and community needs. Assessments also send a message to the organization and community of the intent to promote cultural competence. Looking forward, assessments set a baseline for measuring progress.

Another component to strategically promoting cultural competence is increasing readiness for change. Increasing readiness begins by building internal support for the initiative. The support of decision-makers is crucial as they can gradually increase acceptance of implementers and mobilize change agents. Mr. Freeman noted that it is especially important to manage expectations of staff where change is concerned because increasing cultural competency will not happen overnight, and setting expectations too high and too fast may result in negative backlash. Credibility is also important and can be gained if decision-makers are perceived as actively involved in and committed to the same culturally appropriate behaviors they are asking of others in the organization. In addition, garnering external support can improve an organization’s ability to affect change. By engaging a wide mix of allies, understanding their motivations for being involved, and encouraging two-way communication, outside groups such as other MCOs, hospitals, and public agencies can contribute strength to organizational efforts.

Building an infrastructure to sustain the cultural competence development process includes five key elements, according to Mr. Freeman: knowledge, a planning committee, a point person, data and resources. As with any large-scale project, identifying objectives and goals with actions and timelines will keep the effort on track. Further, clearly identifying current and future resources will help assess the sustainability of the efforts.

Mr. Freeman noted that while financial resources are an important part of cultural competency improvement, human resources are just as valuable. Members at all levels of the organization need to believe that these efforts are authentic, will promote better delivery of healthcare services and are important to the overall success of the group. Praise and recognition are often the strongest way to gain internal support. Acknowledge those individuals whose devotion to change is exceptional and unwavering; others will likely follow their model. Finally, communicating the strategic plan to the entire organization as it develops so that everyone remains “in-the-loop” will strengthen the process and help avoid internal conflicts or dissent.

Cultural Competence and Linguistically Appropriate Services in the Clinical Setting

Felicia Batts, M.P.H.
President
Consulting by Design
Fresno, California

Ms. Batts shared a comprehensive three-part presentation with the group. The first part, “Development of Culturally Competent Services: The Fundamentals” has been summarized in the introductory section of this report to serve as primer of basic principles and concepts. Part Two (Promoting Cultural Competence in Clinical Practice: The Patient-Provider Interaction) and Part Three (Linguistic Services: Translation and Interpretation Issues) of Ms. Batts’ three-part session focusing on cultural competence in the clinical setting are summarized here.

Promoting Cultural Competence in Clinical Practice: The Patient-Provider Interaction

Patients belonging to minority groups face disparities in accessing and receiving healthcare. Many feel that they have difficulty communicating with their physicians and that they would receive better care if they were of a different race or ethnicity. Ms. Batts explained that healthcare providers have the power to improve healthcare experiences for minority patients through culturally competent interactions that promote the delivery of quality, timely and effective clinical services to patients of diverse backgrounds.

First, there needs to be an understanding of the value differences between the Western approach to medicine and alternative approaches to which many minorities are accustom. In Western medicine, the concept that an individual determines his or her own health is generally accepted; this supports the preventive medicine approach and low-power distance between patients and providers with a Western medicine mind-set. Patients from other backgrounds often view things quite differently. They may perceive health and illness as a matter of fate, focusing more on the present state of health rather that the future. Frequently, they may believe the physician has the greater power in the relationship and therefore avoid asking questions about their own condition. Depending on their particular culture and past experiences, patients from minority backgrounds may perceive a physician in unique ways.

More and more, all patients, regardless of background, are using alternative therapies. Acupuncture and other traditional therapies are being proven effective, and the spiritual and mental aspects of disease are receiving more attention now than ever. Complementary medicine and alternative health practices are common approaches to maintaining wellness and treating illness among patients of diverse backgrounds. One in three people have used these methods; however, nearly two-thirds do not tell their regular physician about the use of complementary medicine. This is a major concern because of potential treatment interactions. In some cultures, patients may view Western medicine as a last resort because they feel it is too potent. Providers should discuss complementary medicine practices with their patients to gain a better understanding of their perspectives and to determine how Western and alternative therapies can be used together to the patient’s advantage.

Next, styles of communication may differ among patients from various cultural backgrounds—beyond language differences. Considering all types of communication (e.g., written, spoken and body language; dialects; and slang) is important to patient-provider interactions. Some communication challenges include medical terminology versus common terms, varying literacy levels, the speed of speech, culturally inappropriate words or phrases, multiple dialects, the use and misuse of interpreters and gender-specific terminology. Ms. Batts conveyed that there is no one definitive curriculum on culturally competent communication and that she does not train physicians in culture-specific methods (e.g., how to interact with Hispanic patients versus Korean patients). Instead, she emphasized that those providers who make attempts to learn about and understand cultural backgrounds of their particular community of patients are best equipped to engage in effective culturally competent communications. However, there are someareas of general concern that can be addressed by providers trying to improve their interactions with culturally diverse patients (see table).

Understanding patients’ family issues also promotes more culturally competent care. The family structure and make-up, such as who lives in the household and who are the decision-makers, can be important when treating patients. Also, a patient’s preferred language may be different than that of other family members; likewise the extent of acculturation may differ. It is better to get to know each individual rather than making assumptions about one family member based on familiarity with another. Also, internal family conflict may impact the care process; therefore, being aware of signs of conflict can also guide providers as they treat multiple members of the same family.

Patient’s beliefs may also impact their communication on numerous health-related issues. Culturally-held attitudes affect how patients identify a medical problem requiring professional attention versus self- or home-care. Patients may also perceive certain topics as taboo and feel uncomfortable discussing them, especially if the provider is opposite sex. Describing such a problem to the provider can be challenging for patients. Further, if patients disagree with the provider, cultural attitudes may inhibit them from sharing their concerns.

Perhaps most important is to establish a level of trust with patients. Discrimination occurs when trust is absent from both the patient and provider perspective. Physicians have limited time to spend with patients, and patients may perceive that physicians are driven by profits even if this not actually the case. A basic lack of trust between patients and providers results in a lack of trust in the diagnosis or treatment of the medical problem. Patients may feel they need to do their own research to validate treatment recommendations and be more proactive and aggressive in order to get quality care. Providers need to be aware of trust issues and strive to establish a connection with patients that will allay their fears.

Linguistic Services: Translation and Interpretation Issues

Accessible and appropriate linguistic services are the foundation of culturally competent healthcare. Eliminating confusion and achieving clarity with patients is essential for ensuring effective communication between patients, providers, and healthcare staff. Linguistic services are comprised of four main elements: oral services, interpretation services, written services, and translation services.

There are numerous reasons to provide linguistics and translation services. First, language and cultural differences may result in under-use of necessary services. In addition, inadequate communication gives rise to concerns about malpractice liability. There is also the need to comply with civil rights legislation and pressure from advocacy groups. Several Federal laws exist to ensure access to language services for all limited English proficient persons. These laws include Title VI of the Civil Rights Act of 1964, the Hill Burton Hospital Survey and Construction Act of 1946, and the Disadvantaged Minority Health Improvement Act of 1990.

There are many options for providing translation services, though the effectiveness of these options varies. Healthcare facilities with bilingual and bicultural providers and staff are best equipped to provide translational services; next most desirable is the availability of the staff members hired specifically for interpretation services. When interpretation staff members are assigned other, non-translation duties, their job priorities are divided. Thus, while this may be a financial beneficial strategy, it is not the optimal one for patients in most clinical settings. The use of outside interpreters or telephone interpretation may be required, but again is not the preferred method. Finally, last resorts include the use of family members for translation or referring the patient to another facility; neither strategy is in the best interest of the patient or the healthcare organization providing services.

Having bilingual and bicultural staff allows direct communication between staff members and patients, which reduces miscommunication and misunderstanding. However, there is a lack of qualified providers and staff, even for common languages. Further, there is no standardized tool to assess language and cultural skills. Dialects and language differences related to socioeconomic status may still exist, and translating medical terminology in the target language can be a problem. While building a bilingual staff and provider group is not a perfect solution, it is the best practical option for serving patients in a culturally competent manner.

An “Interpretation-Only” staff offers several benefits, as well. These individuals are more likely to be skilled at medical interpretation, having had didactic training in the field. Also, this option also offers flexibility in hiring practices. However, it works best in a setting with high demand for a single language versus one with linguistic diversity of patients. Again, there is a lack of defined standards in this area, and finally, it can be a costly option.

Hiring an interpretation staff person with other duties is a reasonable alternative when the demand is not sufficient to hire someone full-time. Interpreters can be effective as caseworkers or family health workers, roles where communication is essential. However, care must be taken to avoid conflicts between interpretation services and other duties so that staffers are not confused as to work priorities. If the staff person is used only occasionally for interpretation, costs are reduced and there is someone on-site in an emergency. But this is really only a contingency plan, because maintaining accurate lists of employees who speak particular languages is difficult and it may be challenging to locate that person when he or she is needed, especially in larger facilities. This option also bears the greatest potential for job conflicts.

Using outside interpreters can be effective when there insufficient demand for a full-time staff member. These interpreters can be hired hourly for prescheduled appointments and can supplement on-staff interpreters as needed. Again, the lack of standards is an issue, and hourly rates can be expensive. Further, there is no established relationship with the provider, and outside interpreters may be difficult to access on short notice, so they cannot be used in an emergency.

The use of telephone interpretation services is especially appropriate for emergency situations, or if brief or basic information is needed. But few telephone translators are medical specialists, so they may lack cultural health knowledge. Also, body language and similar communication clues are lost with this method.

Finding the option that works will be individual for each healthcare setting and will depend upon numerous factors. But doing so is crucial because a lack of translational services or poor translational practices can result in major dilemmas, such as cultural misunderstandings, incorrect assessment of patient’s language ability, and confidentiality conflicts. The use of family members, especially children, is highly undesirable because of the potential for family conflict or the impact of the information being conveyed.

Several new approaches for selecting an interpretation method are now available, thanks to research regarding the impact, effectiveness, and cost-benefits of various strategies. Also, technology has evolved to allow video conferencing translation and computer software has been developed to aid with translation needs.

California’s Approach to Ensuring Cultural Competent Healthcare Services in Medicaid Managed Care and SCHIP Health Plans

Gregory A. Franklin, M.H.A.
Chief, Office of Multicultural Health
California Department of Health Services
Sacramento, California

Gregory A. Franklin, M.H.A., Chief of the Office of Multicultural Health, discussed how purchasing strategies and the application of policy have provided the foundation for the delivery of culturally and linguistically appropriate healthcare services in Medicaid and State Children’s Health Insurance Program (SCHIP) managed care organizations (MCOs) in California. Mr. Franklin began by reviewing the definition of cultural competency (see Introduction), and by discussing a framework for health. Personal health begins with the individual at the center of many other interactive variables (see figure). Policymakers have not only the ability, but also the responsibility to contribute to this process in a positive manner.

Chart: Determinants of Health (d-link)

The ethnic and racial composition of Californian residents is rapidly changing; therefore, cultural competency will play a large role in the process of determining health. While the white, African American, and Native American populations are decreasing, the number of Hispanic Americans and Asian or Pacific Islanders is growing simultaneously (see figure).

Graph: The Changing Ethnic and Racial Composition of California (d-link)

Source of statistics:
* 1990 statistics are from California Department of Finance 1990 Census Data.
** 2000 statistics are from U.S. 2000 Census Data.
*** 2040 statistics are from California Department of Finance Census Projection Data 1990.

Medi-Cal, California’s Medicaid Managed Care, includes a significant portion of this diverse population. As of April 2002, Medi-Cal enrollment was nearly 2.6 million, of which 45% of members are Latino/Hispanic, 18% African American, and 10% Asian/ Pacific Islanders. The Healthy Families Medi-Cal for Children program, SCHIP, includes an additional half-million members with a slightly different ethnic and racial make-up: Latino (66.7%), white (15.9%), Asian Pacific Islander (13.4%), and African American (2.9%). The larger portion of Latino and Hispanic children enrolled through S-CHIP reflects the recent growth of this group.

To ensure culturally competent, quality health services are delivered to these members, Medi-Cal has partnered with a range of organizations to enhance care. These groups include:

• Health Advocates

• Hospitals

• Managed Care Organizations

• Community Clinics

• Academia

• Legal Aide Society

• Immigrant Rights Organizations

• State Health Programs

• Provider Organizations

Mr. Franklin noted several important policy considerations that can support efforts to improve healthcare for California residents. First, the concept of “health” itself should be broadly defined in positive terms in order to stimulate proactive, preventive interventions.
Secondly, patients and providers need to recognize that the health is determined by sociocultural and economic issues as well as physical factors. And as previously noted, California’s changing demographics will have long term effects on policies that impact healthcare delivery.

With these considerations in mind, Medi-Cal has developed and disseminated numerous policy letters for providers and provider groups in the Medi-Cal network. The policy letters address issues such as linguistic services, translation of written informing material, Community Advisory Committees, and needs assessments. To meet the needs of a culturally and linguistically diverse population, Medi-Cal has identified “threshold languages” (languages common to a significant portion of the patient population) and requires that written material and oral translational services be available in these languages. Members have been informed of these services. Medi-Cal groups have been asked to establish a Community Advisory Committee for recruiting membership and identifying the group’s function. For translation of written informing materials, healthcare groups are required to create linguistically accessible documents and/or timeline for the creation of such materials.

Despite these efforts, some challenges still exist in delivering culturally competent care. There is no “one size fits all solution” for every provider or practice in the Medi-Cal system. Though enforcement and accountability are important, practical issues sometimes impede required activities. Other obstacles include competing priorities (i.e., the will of health advocates vs. State policy), access issues, and lack of dedicated funding.

Still, the future of quality healthcare depends on continued efforts to overcome these obstacles and bring culturally competent care to every Medi-Cal member throughout the State. Medi-Cal plans to incorporate policies throughout the State health department and make policies and processes available to other State agencies. As they continue to refine existing efforts in managed care, Medi-Cal would also like to develop fee-for-service models for enhancing culturally competent care. Finally, the organization plans to step up its efforts to monitor for compliance with these important policies.

SUCCESSFUL PRACTICES IN MANAGED CARE

Arizona Health Care Cost Containment System (AHCCCS) Plans and the Provider Pocket Guide

Georgia Hall, Ph.D., M.P.H.
Executive Director
Institute for Health Professions Education
Phoenix, Arizona

Philip Nieri, MPA
Director of Compliance
Schaller-Anderson, Inc.
Phoenix, Arizona

Georgia G. Hall, PhD, MPH and Philip Nieri, MPA discussed how Arizona’s Medicaid program (AHCCCS) developed a cultural competency provider-education initiative in conjunction with its many contracted health plans throughout the State. AHCCCS subcontracts with health plans owned and/or managed by Catholic Healthcare West, CIGNA, United Health Care, Schaller Anderson, Inc. and various hospital based health care companies (e.g. IASIS Healthcare and Vanguard). These companies help manage services provided to 650,000 members in all Arizona counties. Members choose a plan and PCP to act as their “medical home”.

Because of the many separate entities involved in serving the AHCCCS patient population, the challenge was to create a plan that would improve provider awareness of cultural competency issues across the entire network. By believing that culturally appropriate care improves health outcomes and helps eliminate health disparities, AHCCCS and its subcontractors met that challenge head on. AHCCCS requires its health plans to participate in quality improvement efforts in both clinical and non-clinical areas that would be expected to have a beneficial effect on health outcomes and member satisfaction. One of these areas is cultural competency of services.

AHCCCS, with its subcontractors, established a framework for a cultural competency workgroup to coordinate compliance with cultural competency program requirements, including those imposed federally and by the State. The workgroup helped coordinate the development of annual cultural competency work plans and methods for reporting outcomes from the Cultural Competency Quality Improvement Project. The workgroup includes representatives from all AHCCCS health plans and program contractors from various sectors including compliance, quality management and operations. By engaging in discussions on compliance and by sharing “best-practices” ideas, the workgroup identified a strategy for action. The core idea was to reduce redundancy of culturally competent activities, particularly training and outreach to physicians, and develop new efforts to supplement existing training/outreach resources. A sub-committee was subsequently created by those health plans and programs contractors who volunteered to help.

The sub-committee focused on development of a cultural competency “pocket guide” to be distributed to every provider in an AHCCCS health plan. A consultant was hired to gather information about educational needs in providing culturally competent care and to ensure that information in the guide reflected AHCCCS requirements. The sub-committee also coordinated the printing/distribution of the guide for participating provider offices. Though it required significant coordination between the State and many individual health plans, the project presented a unique opportunity to jointly develop a useful resource for providers, proving that collaborative projects can work—in spite of competition and other perceived barriers.

A Culturally Conscious Approach to the Delivery of Healthcare Services

Josepha Campinha-Bacote, PhD, RN, CS, CNS, CTN, FAAN
President
Transcultural C.A.R.E. Associates
Cincinnati, Ohio

Josepha Campinha-Bacote, PhD, RN, CNS, BS, CTN, FAAN, President of Transcultural C.A.R.E. Associates, shared with the group the ASKED model of cultural competence, which she developed and published in 1998. According to Dr. Campinha-Bacote, cultural competency is the “process in which the healthcare provider continuously strives to achieve the ability and availability to effectively work within the cultural context of a client (an individual, family, or community).” Emphasizing the “process” aspect of her model, she states that cultural competence is a journey, not a destination; it is cyclic not linear.

The process of Cultural Competence involves interrelationships between five elements:

Cultural Awareness
Cultural Skill
Cultural Knowledge
Cultural Encounters
Cultural Desires

Hence, the ASKED model.

Cultural awareness requires “self-evaluation of one’s own prejudices and biases towards other cultures. [It is] the process of cultural humility.”[1] It is also a willingness to explore one’s own cultural and ethnic background. Basically, says Campinha-Bacote, cultural awareness means knowing yourself. On a broader level, this concept entails asking the question, “Is there racism in the delivery of healthcare services?” Dr. Campinha-Bacote cited several evidence-based studies that confirm that such racism does in fact exist.

Cultural knowledge includes obtaining a sound educational foundation concerning the various world views of different cultures. Within the field of healthcare, it also means obtaining knowledge of “biocultural ecology”—biological variations, disease and health conditions and variations in drug metabolism related to one’s background. Dr. Campinha-Bacote warns, though, that it is necessary to be wary of intra-ethnic and intra-cultural variations; even within cultural groups, many differences exist.

Cultural skill is the ability to collect culturally relevant data regarding a client’s health history and current medical problem. This is done using a cultural assessment tool. Conducting a culturally-based physical examination is also part of cultural skill in healthcare. These assessments should be conducted in a culturally-sensitive manner. Dr. Campinha-Bacote reminded the audience that everyone should be given a cultural assessment. Only conducting an assessment with patients who “look like” they might need one is a culturally bias practice itself. A cultural assessment tool is available in Dr. Campinha-Bacote’s book, The Process of Cultural Competence in the Delivery of Healthcare Services.[2] The ultimate goal of a cultural assessment is to determine appropriate culturally responsive interventions, which ask providers to recognize the differences in individuals, but build upon similarities to others.

Another element of the process is the cultural encounter. Cultural encounters are the process by which healthcare providers directly engage in face-to-face, cross-cultural interactions. The goals of these interactions are to generate a wide variety of verbal responses (i.e., encourage patients to communicate openly) and to send and receive both verbal and non-verbal messages accurately and appropriately in each culturally different context.[3]

Perhaps the most vital component of the ASKED model is cultural desire. This, unlike the other four elements, is not necessarily a learned behavior; rather, it is based upon provider’s internal motivation to engage in the cultural competency process—because they want to, not because they have to. Characteristics of a provider who has cultural desire include compassion, authenticity, humility, openness, availability, and flexibility. Dr. Campinha-Bacote emphasizes that skill, knowledge, and awareness matter very little without desire: “People (i.e., patients) don’t care how much you know until they first know how much you care.”

One application of the ASKED model of cultural competence is the BE SAFE model, a culturally competent model for caring for African Americans with HIV/AIDS. Following Dr. Campinha-Bacote’s presentation, her colleague John McNeil, MD, Principal Investigator for National Minority AETC in Washington, D.C., describe the BE SAFE model.

Footnotes:

[1] Tervalon, 1998.
[2] Campinha-Bacote, J. “Cultural Skill” in The Process of Cultural Competence in the Delivery of Healthcare Services. 1998, 3rd edition. OH: Transcultural C.A.R.E. Associates.
[3] Adapted from Sue, 1982.

Model of Cultural Competency for Working with African American Patients Infected With HIV

John McNeil, MD
Principal Investigator
National Minority AETC
Washington, D.C.

John McNeil, MD, Principal Investigator for the National Minority Aids Education Training Center (AETC) in Washington, D.C., discussed cultural competency in a very specific context: caring for African Americans with HIV or AIDS. Dr. McNeil noted that people of African decent who reside in the United States are a hybrid population. Most African Americans have genetic make-ups that cross African ethnic groups and other racial groups, primarily European and American Caucasian, as well as Native American. Caribbean population mixtures include East Indians, Chinese, and Indigenous West Indians. Nearly one million individuals have emigrated from nations in Africa and the Caribbean since 1994, with Florida, New York and New Jersey being the most highly populated areas. Within the African American community, many cultural differences exist, and recognizing these differences is vital to providing culturally competent healthcare.

Moreover, providing culturally appropriate care for African American patients with HIV requires a unique sensitivity to issues that transcends race or ethnic background. There are shared behaviors and issues that create a culture associated with the disease itself. Patients with HIV/AIDS experience emotional distress, sexual orientation issues, economic hardship, and societal discrimination. They may also participate in high-risk behavior and substance abuse as part of their daily lives. Understanding and addressing these issues is vital to providing culturally competent care.

The National Minority AIDS Education and Training Center developed a model of cultural competency for African American patients with HIV/AIDS. A multidisciplinary panel comprised of physicians, nurses, dentists, physicians’ assistants, and HIV educators was organized; the panel included a heterogeneous mix of individuals born in America, the Caribbean, Africa, and Cape Verdean. The primary aims of the panel were to 1) encourage a deeper understanding of cultural competency as it relates to the HIV infected patient, 2) assist clinicians working with HIV-infected patients to develop their understanding of intra-ethnic variations, and 3) develop an understanding of the role HIV plays in values, beliefs, and customs of a patient. These aims were achieved through the development of the model and dissemination of information to care providers.

The result of the panel’s efforts was the BE SAFE model for culturally competent care for African American patients with HIV/AIDS. The model is based upon the principles of Josepha Campinha-Bacote’s model of cultural competency. BE SAFE is an acronym for six major factors that influence the quality of care these patients receive: Barriers, Ethics, Sensitivity of providers, Assessment, Facts, and Encounters. Providers are encouraged to consider all elements of the model in their daily practice. The BE SAFE model is detailed in the figure below; each list identifies major issues to consider during each step of the BE SAFE process of culturally competent care.