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Culturally competent care understanding differences, improving outcomes

On average, racial and ethnic minorities are in poorer health, suffer worse health outcomes, and have higher disease and mortality rates than the rest of the population.1 In response to these health disparities, providers are starting to offer more services to meet the health needs of an increasingly diverse patient population. What is culturally competent care and how can it improve health outcomes?

A populAtion thAt’s becoming increAsingly diverse There are more than 90 ethnic groups represented in the population of the United States. This includes nearly 38 million people who are foreign born. Among the foreign born, 52 percent do not speak English well.2 Ethnic differences, cultural traditions, and language issues can all contribute to health care disparities. For example, Latina women with lung cancer are diagnosed in later stages and have lower survival rates than white women, and African-American men are less likely than white men to undergo heart bypass surgery.3

These health care gaps or disparities also exist in America’s increasingly diverse workforce. Large employers provide health benefits to two out of three Americans with health insurance, yet some employers are paying for care that’s inappropriate or inadequate for their employees. Without specialized care to combat disparities, employees predisposed to chronic health conditions have an increased likelihood of leaving the workforce—for a short while, an extended period, or even permanently—resulting in higher direct and indirect costs to employers.

understAnding heAlth dispArities Health disparities—differences in both health and health care—can result in health outcomes that are worse for one population relative to others.

• Health disparity—Greater incidence of health-related conditions within racial and ethnic groups, such as higher cancer rates in Latina women or higher mortality from heart disease for African Americans.4

• Health care disparity—Differences in the preventive, diagnostic, and treatment services offered to people with similar health conditions. For example, Latinos had worse access to care than non-Latino whites in 88 percent of prevention, treatment, and management measures for conditions such as cancer, heart disease, and diabetes.5

Health disparities in a culturally diverse workforce aren’t healthy for employees or business. Yet most employers don’t associate specific health-related conditions with racial or ethnic groups. For example, employers might not know that Asian Americans in their workforce may be at higher risk for stroke or that African-American employees may have higher rates of hypertension.

FOR DISCUSSION: Topics in health and productivity

contents

culturally competent care 1

A population that’s becoming

increasingly diverse 1

Understanding health disparities 1

Causes of disparities 2

Culturally competent care

is specialized care 2

Improving health and setting

standards—Kaiser Permanente

and culturally competent care 3

Improving care across

populations 3

A changing population requires

changes in health care delivery 7

Endnotes 8

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cAuses of dispArities A common belief is that health and health care disparities result from some racial and ethnic groups having unequal access to health care. However, evidence shows that when all population groups are equally insured, screening rates for health conditions or major diseases among minority populations are lower than those for whites.6 Other possible causes of health and health care disparities include:

• Cultural attitudes, values, and behaviors

• Socioeconomic status

• Occupational hazards

• Religious or spiritual beliefs

• Gender

• Age

• Sexual orientation

• Physical ability

• Environmental conditions

• Language barriers

When patients and caregivers come from different ethnic groups or occupations, or

possess different cultural attitudes, these differences may play out in the doctor’s office as misunderstandings resulting from miscommunication.

language barriers

Language barriers can contribute to high health care costs for the 50 million American residents who don’t speak English at home and the 22 million with limited English proficiency.9 One in three Latinos and more than one in five Asian Americans report extreme problems communicating with health care providers.10

This can pose a significant barrier for physicians and patients, especially when there are added time pressures or resource constraints, or when the patient’s health condition is particularly complex. Communication difficulties can also result in misdiagnosis and poor treatment compliance (for example, misunderstanding drug dosages).

culturAlly competent cAre is speciAlized cAre “Culturally competent care” is care that respects the health beliefs, values, and behaviors of culturally diverse popula- tions and individuals. It’s more than an understanding of health disparities.

A basic approach to providing culturally competent care and eliminating existing health disparities is for health care providers to develop their knowledge of different cultures and cultural groups. Building skills for working and inter- acting with patients can:

• Improve the overall health of different racial and ethnic populations

• Improve productivity of California businesses with a culturally diverse workforce

• Lower overall health costs

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cAncer heAlth dispArities for AsiAn AmericAns8

• Asian-American women—Cancer has been the number-one killer of Asian-American

women since 1980.

• Vietnamese-American men—Have the highest rate of liver cancer of all ethnic groups.

• Korean-American men—Experience five times the rate of stomach cancer of white men

and the highest rate of incidence and mortality rates among all other Asians.

• Southeast Asian Americans—Lung cancer rates are 18 percent higher for

Southeast Asians (which includes people from Cambodia, Laos, Thailand, and Vietnam)

than for whites.

• Filipino Americans—Have the second-lowest five-year survival rates for colon and

rectal cancers of all U.S. ethnic groups. (Native Americans have the lowest rate.)

Latino and African- American adults are more susceptible to chronic conditions such as high blood pressure, heart disease, diabetes, asthma, anxiety, depression, and obesity than white adults.7

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communication and nonverbal cues

Using translated materials and interpret- ers are ways to help improve communi- cation between caregivers and patients, but cross-cultural training can help health care professionals consider much more. Patients from different parts of the world may exhibit body language and nonver- bal cues that mean different things. The following are examples of nonverbal cues observed in clinical settings:

• Smiles—Depending on the culture, a smile could signal agreement, bold- ness, respect, embarrassment, or sexual invitation.

• Touch—Many Asian Americans and Pacific Islanders are uncomfortable with casual touching or hugging.

• Personal space—Some Latinos may be used to less personal space and may feel uncomfortable with distance.

• Eye contact—Women may be less comfortable with eye contact than men.

• Tone of voice—Patients with limited English proficiency may rely more on tone and nonverbal communication.

• Family—Among African Americans and Latinos, family members can play an important role in treatment adherence and health care decisions.

• Folk medicine practices—Folk healers can be important to many cultures, including Native Americans, recent immigrants, and some Latino populations.

Not every member of a group necessarily exhibits these behaviors. Individuals within any group may express a wide range of behaviors. Nevertheless, it’s worthwhile for caregivers to consider these cues.

improving heAlth And setting stAndArds—Kaiser Permanente and culturally competent care Chances are, some of your or your clients’ workforce is among the 1.25 million Latino, 1 million African-American, and 750,000 Asian-American and Pacific Islander members we care for. And you’ll be glad to know that Kaiser Permanente is the only health care organization that has a business entity dedicated to culturally competent care.

improving cAre Across populAtions One of the ways we work toward pro- viding uniform quality of care to our diverse member population is through our Institute for Culturally Competent Care (ICCC). The ICCC guides strategy to integrate cultural competence into our care delivery system by advising cross-cultural training content, de- veloping publications, and more. There are also large-scale initiatives aimed at eliminating health disparities. For example, the ICCC designates Centers of Excellence in culturally competent care as model programs on cross-cultural care delivery.

improving access to care for members with limited English proficiency

National Linguistic & Cultural Pro- grams (NLCP) develops diversity initiatives within Kaiser Permanente to help members with limited English proficiency access care. The NLCP team understands the subtleties between dif- ferent cultures and uses that knowledge to provide linguistic and culturally appropriate tools, training, and leadership

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pAtient scenArios: how culturAl differences And miscommunicAtion cAn Affect heAlth

Scenario #1—A Russian patient breaks his wrist. He goes to the hospital, receives a cast, and goes home. Because he speaks limited English, he can’t tell his physician his

cast is cutting off his circulation. The patient removes the cast himself, causing the bones

to heal incorrectly, requiring further medical treatment and expense.

Scenario #2—A doctor is on the phone with a Chinese patient who complains of head and neck pain. The doctor suspects meningitis and asks the patient to come in for testing.

However, the patient wants to try using traditional herbal medicine first. How should the

doctor persuade the patient to seek immediate medical attention?

The National Linguistic & Cultural Programs team at Kaiser Permanente has created Vietnamese, Korean, Russian, and Armenian versions of our health glossary, in addition to Spanish and Chinese editions.

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for caregivers. Some NLCP accomplish- ments include:

• Health care interpreter training program—Trains high-quality interpreters within the Kaiser Permanente medical community.

• Communication materials— Provides consultation of language- specific materials for members, such as provider handbooks and training manuals.

• Awards and grants—Recognized by the California Department of Human Services, the California State Assembly, the Chinese for Affirmative Action group, NurseWeek, and others.

recognized for excellence in diversity

Many organizations have honored Kaiser Permanente for its diversity practices:

• America’s Health Insurance Plans (AHIP) Innovation and Excellence Community Leadership Award, 2007 and 2005

• DiversityInc Top 50 Companies for Diversity, 2006 and 2007

• DiversityInc Top 10 Companies for African Americans, 2005

• National Committee for Quality Assurance (NCQA) Recognizing Innovation in Multicultural Health Care Award, 2007 and 2006

• Asian Enterprise magazine Top Companies for Asian Pacific Americans Award, 2007

• Prof iles in Diversity Journal International Innovations in Diversity Awards, 2007

Filling the gap at all medical centers— the qualified bilingual staff model

Another way we’re helping physicians deliver culturally competent care is by identifying existing qualified Kaiser Permanente bilingual staff and working with them to enhance their linguistic skills and cultural knowledge. Staff members can then improve their interaction with patients with limited English proficiency, ensuring that culturally and linguistically competent services are available at each point of contact.

Award-winning interpreter services

Two of our programs earned the Recognizing Innovation in Multicultural Health Care Award from the NCQA, a private, nonprofit organization dedicated to improving health care quality.

• Qualified Bilingual Staff Model— This program identifies existing qualified Kaiser Permanente bilingual staff and works to enhance their linguistic and cultural skills.

• Health Care Interpreter Certificate Program (HCICP)—This program develops training and internship programs, along with national cer- tification standards. So far, more than 1,000 graduates have provided interpreter services in more than 10 different languages.

Centers of Excellence—focusing on specific health issues

Culturally competent care research provides us with valuable insight into ways to approach the care of our member populations. The Centers of Excellence in culturally competent care build on the principles derived from this research. Promising practices are disseminated throughout Kaiser Permanente, contributing new knowl- edge about the role of culture in health care. Here are some of our Centers of Excellence:

california

• African-American Health • Armenian Health • Members with Disabilities • Women’s Health

colorado

• African-American Health • Latino Health

Mid-Atlantic States

• Latino Health

Ohio

• Latino Health

Clinical modules—improving access to care for different member populations

Kaiser Permanente has established clinical modules within medical centers

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DiVErSity At wOrK

• People of color comprise half of

Kaiser Permanente’s national board

of directors.

• Of our 156,000 employees,

77 percent are women and

57 percent are minorities.

• Our multicultural staff associations

include racial, ethnic, gender,

disability, and sexual-orientation

groups.

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throughout California that target a specific language group or disease population, and address concerns about access to care and care delivery for specific patient populations. Because the staff speak the same language and understand the culture of their patients, they can communicate more effectively. Here are a few of our clinical modules in California:

• Chinese Primary Care Module— Montebello and San Francisco

• Latino Family Practice Module— Garden Grove

• Spanish Primary Care Module— San Francisco

• Vietnamese Family Practice Module—Garden Grove

• Latino Primary Care Module— East Los Angeles and Sacramento

Ongoing training and workshops for staff

Our efforts to embrace cross-cultural relations, communication, and care go beyond language training and support. Our staff members are reg- ularly improving their skills and knowl- edge through:

• Intercultural training for residents, primary care physicians, nurses, allied health professionals, and other specialists.

• Discussion of the needs of our diverse membership and workforce by the National Diversity Council and the Regional Cultural Diversity Taskforce.

• Annual National Diversity Conference, featuring a range of topics including language services,

workforce diversity, and cross- cultural service delivery.

• Health care interpreter and bilingual staff training program.

• Staff associations for African Americans, Armenians, Asian Americans, Pacific Islanders, persons with disabilities, and lesbian, gay, bisexual, and transgender individuals.

expanding multicultural resources for members

We’ve developed resources that are proving popular with both members and employers. Online resources include preventive tools that empower members to conveniently research different health- related topics, read up on medicines, and locate appropriate services. Services vary by region.

• In many regions, Chinese, Spanish, Tagalog, and Vietnamese speakers can use our Member Service Call Center. The AT&T Language Line is used for 140 different languages.

• Member guidebooks and newsletters are translated into 11 languages.

• Physicians and other caregivers at each of our medical facilities can download brochures translated into different languages that cover more than 40 different health-related topics, such as diabetes care, mental health, and medications.

A wealth of resources for Spanish-speaking members

Here are a few of the ways we’re im- proving access to care for our Spanish- speaking members at different medical centers. Every service, class, and resource listed below is available in Spanish.

examples of services available to members everywhere

• La guía en español—This is a part of Kaiser Permanente’s Web site for Spanish-speaking members. It has information about online services in Spanish, as well those in English, including:

o Spanish-language health encyclopedia with 225 topics

o Drug encyclopedia with more than 6,000 entries

o Featured health topics in Spanish

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tOP 10 lAnguAgES uSED by OVEr-thE-PhOnE intErPrEtErS

In 2006, interpreters assisted members at our facilities across the nation in these

languages:

• Arabic • Korean • Russian • Tagalog

• Cantonese • Mandarin • Spanish • Vietnamese

• Japanese • Punjabi

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o Printable Healthy Living brochures

o Los programas para una vida sana— Interactive healthy lifestyle pro- grams by HealthMedia® for weight management, smoking cessation, nutrition, stress reduction, and health assessment*

• For bilingual Internet users able to navigate English-language Web sites, La guía en español explains the secure features available in English, including:

o Personal health information such as lab results, allergies, and immunization records

o Appointments and prescription refills

o Medical staff directory, searchable by spoken language

o Facility directory

• La Salud en Casa: Guía Práctica de Healthwise y Kaiser Permanente (Kaiser Permanente Healthwise® Handbook)—A publication to help recognize and cope with more than 200 common health problems. It has information on prevention, when and how to treat yourself, and when to call Kaiser Permanente. It’s available to members at no charge.

examples of multilingual features and services available to members

• The Incredible Adventures of the Amazing Food Detective— A Web-based game developed by Kaiser Permanente health care

professionals, available in English and Spanish to help combat childhood obesity. The video game, which en- courages kids to play outside, pro- vides an interactive way to educate children about healthy food choices and physical activity.

• Partners in Health†—Our member newsletter is available in Spanish, Farsi, Russian, Hmong, Vietnamese, Armenian, Korean, Tagalog, and Chinese, as well as English.

• Patient communication aid— Hospitalized members have access to a packet of photos with English descriptions matched with Chinese translations to assist in communications with caregivers.

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SPOtlight On thE KAiSEr PErMAnEntE SOuth SAn FrAnCiSCO MEDiCAl CEntEr

At our South San Francisco facility, physicians can use a speakerphone in the exam room to contact Language Line services to access

interpreters. There are also many health care staff with Qualified Bilingual Status for Levels 1 and 2.

level 1 employees interpret nonmedical information for patients who speak limited English. They receive eight hours of training, which includes the code of ethics, role of the interpreter, and interpreting standards of practice.

level 2 employees converse and conduct basic medical interpreting in their work area. They receive 24 hours of training, which also includes basic medical terminology. Languages spoken include:

• Burmese

• Cantonese

• Chiu Chow

• Hindi

• Japanese

• Korean

• Laotian

• Mandarin

• Punjabi

• Shanghainese

• Spanish

• Tagalog

• Taiwanese

• Tamil

• Thai

• Urdu

• Vietnamese

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* These services are extra services provided by entities other than Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., and are neither offered nor guaranteed under any of our contracts. These entities may change or discontinue offering these services at any time. Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., disclaims any liability for the services provided by these entities.

† Partners in Health is not available in the Mid-Atlantic States region. In the Ohio region, it is published three times a year and only in English.

• Nutrition Guidelines on the Mexican Diet—Bilingual Spanish and English dietary guide encourages healthy eating habits by featuring culturally competent cooking tips, recipes, and menus specific to the Mexican diet.

A chAnging populAtion requires chAnges in heAlth cAre delivery For more than 60 years, we’ve laid the groundwork for diversity and culturally competent care. Our integrated structure enables us to have a unified approach to change by unifying our efforts across administration, hospital, insurance— all parts working together. Participants are working on many fronts to identify and create solutions that contribute to the elimination of health disparities. And we’ll continue our work by pro- ducing even more member materials in

languages other than English, training our caregivers in cross-cultural care, adding more non-English-language content on kp.org, and pursuing initi- atives to improve patient and workforce health outcomes.

Culturally competent care will help us to improve access to high-quality care across populations, creating a ripple effect that will boost health and lower overall health care costs for everyone. Our longtime emphasis on prevention is the perfect foundation to this end.

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SPOtlight On OhiO AnD Our AFriCAn-AMEriCAn MEMbErS

African-American men are 30 percent more likely to die from heart disease than white

men.11 That’s why our Center of Excellence in Culturally Competent Care in African-

American Health in Ohio focuses on identifying ways to reduce the risk of a cardiac

event (heart attack, admission for ischemic heart disease, or cardiac death) in the

African-American population. The Center is currently conducting three initiatives:

• working with ministers of African-American churches

Ministers in largely African-American churches are asked to notify their congre-

gations of planned cardiac screenings at local churches in Cleveland and Bedford

Heights. Screenings are free and available to all community members whether they’re

Kaiser Permanente members or not. Participants receive a summary of their cardiac

risk, along with dietary and follow-up recommendations.

• Outreach mailings

Outreach mailings contact members over 44 years old who have incomplete

information in their health records. The members receive invitations to evening

screenings to determine their cardiac risk. The screenings evaluate blood pressure,

cholesterol levels, and smoking status, as well as assess diabetes risk.

• Physician contact of high-risk members

Primary care physicians contact members with more than two risk factors for heart

disease so they can take steps to lower their risk factors.

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Kaiser Permanente Chairman and CEO George Halvorson is one of seven executives who received the 2007 CEO Diversity Leadership Award from the Diversity Best Practices organization.

endnotes 1 National Vital Statistics Report, Volume 50, No. 15, September 16, 2002. 2 Selected Characteristics of the Native and Foreign Born Population, U.S. Census Bureau, American Fact Finder, 2006 American Community Survey. 3 “Why Companies Are Making Health Disparities Their Business: The Business Case and Practical Strategies,” National Business Group on Health, p. 7, December 2003. 4 “Health for All: California’s Strategic Approach to Eliminating Racial and Ethnic Health Disparities,” The California Campaign to Eliminate Racial and Ethnic Disparities in Health, November 2003. 5 2005 National Healthcare Disparities Report, Agency for Healthcare Research and Quality, December 2005. 6 Ruffin, John, PhD, Fiscal Year 2006 Budget Request, National Institutes of Health, Department of Health and Human Services, March 2005. 7 Health Care Quality Survey, The Commonwealth Fund, 2001. 8 The Unequal Burden of Cancer Among Asian Americans, Asian American Network for Cancer Awareness, Research and Training, www.aancart.org/Unequal%20Burden.htm (accessed June 21, 2007). 9 Flores, Glen, MD, “The Impact of Medical Interpreter Services on the Quality of Health Care: A Systematic Review,” New England Journal of Medicine, July 20, 2006. 10 Flores, G., MD, The Office of Minority Health Consensus-Building Meeting, United States Department of Health and Human Services, March 2003. 11 Af rican American Prof iles, United States Department of Health and Human Services, Office of Minority Health, Data/Statistics, www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=51 (accessed November 2007).

Information in this publication was accurate at the time of production. However, details may have changed since publication. For the most current information on our plans and services, check with your sales executive or account manager.

kp.org Business Marketing Communications 0503-0262-01-r99 February 2009

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