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  • Institutional: differential access by race to goods, services and opportunities of society intended disadvantage material conditions, access to power Personally mediated: prejudice and discrimination Internalized: acceptance by members of the stigmatized racs of negative messages about our own abilities and intrinsic worth

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  • Brunilda Torres, LICSW Director, Office of Multicultural Health Massachusetts Department of Public Health Strategies for Protecting Patient Safety September 12, 2003 [email_address]
  • Office of Multicultural Health
    • To promote the optimal health and well being of immigrant, refugee and racial and ethnic minority communities statewide
    • To ensure that Massachusetts’ public health frameworks are inclusive of and responsive to the needs of these communities
  • Goals
    • Background from my perspective
    • Health Disparities
    • CLAS
    • Interpreter Services
  • History: improving health of population
    • 1789- 1st mortality tables: Rev Wigglesworth
    • 1900 Life expectancy: 47 years
    • 1900 main causes of death identified
    • 1950’s life expectancy 68
    • 1960’s and ‘70’s research: improved knowledge about predisposing conditions
    • These occurred throughout our national history that included slavery and Jim Crow– “separate but equal”
  • History
    • Civil Rights Act of 1964
    • “No person in the United States shall, on ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”
  • History
    • OMB directive 15 1977, revised in 1997 to include sub populations
    • Healthy People Initiative: improve health of country
      • 1979: Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention--national goals
      • improve data infrastructure
      • 1980: Promoting Health/Preventing Disease: Objectives for the Nation-- identified disparities
      • Healthy People 2000: reducing disparities among populations revised
  • History
    • Our understanding around vulnerability has changed
    • Federal supports: legislation and guidance
    • Frameworks develop to assist creation of local actions to addressing the needs of populations made vulnerable by race and limited English language capacity
  • Health Disparities
  • RACE
    • Not biologic construct reflecting innate differences
    • IS a social construct capturing the social classification of people in our race-conscious society
    • Race-associated differences in health outcomes may in fact be due to the impacts of racism
  • Source: Byrd, WM, Clayton, LA. An American Health Dilemma , Volume 1, A Medical History of African Americans and the Problem of Race: Beginnings to 1900 , New York, NY: Routledge. 2000. TIME SPAN CITIZENSHIP STATUS -YRS   PERCENT U.S. EXPERIENCE STATUS HEALTH & HEALTH SYSTEM EXPERIENCE   1619-1865   246   64.40%   Chattel slavery Disparate/inequitable treatment poor health status & outcomes. “ Slave health deficit ” & “ Slave health sub-system ” in effect   1865-1965   100   26.18%   Virtually no citizenship rights Absent or inferior treatment and facilities. De jure segregation/ discrimination in South, de facto throughout most of health system. “ Slave health deficit ” uncorrected   1965-2001   36   9.42%   Most citizenship rights So. med school desegregation 1948. Imhotep Hospital Integration Conf 1957-1964, hospital desegregation in federal courts 1964. Disparate health status, outcomes, and services with apartheid, discrimination, institutional racism and bias in effect.   1619-2001   382   100.00% The struggle continues   HEALTH DISPARITIES/ INEQUITIES   AFRICAN AMERICAN CITIZENSHIP STATUS & HEALTH EXPERIENCE FROM 1619 TO 2001
  • What are health disparities
    • Differences in health that exist among specific populations in the:
    • Incidence
    • Prevalence
    • Mortality
    • Burden of disease
  • HP 2000
    • Blacks: ~50% poor or near poor which is 2X rate white of poverty
      • Represents >2/3 of Black children
    • Life expectancy: almost 7 years less than the average life expectancy for Whites.
    • AIDS: leading cause of death for Blacks aged 25-44 and >60 percent of new AIDS cases occur among minorities; 40 are Blacks.
  • HP 2000 report African American
  • Healthy People 2010
    • Increase the quality and years of healthy life
    • Eliminate health disparities
  • Racial/Ethnic Disparities in Health Care
    • Within Medicare:
      • Differential utilization based on race for:
        • Mammography (Gornick et al.)
        • Amputations (Gornick et al.)
        • Influenza vaccination (Gornick et al.)
        • Lung Ca surgery (Bach et al.)
        • Renal transplantation (Ayanian et al.)
        • Cardiac catheterization & angioplasty (Harris et al, Ayanian et al.)
        • Coronary artery bypass graft (Peterson et al.)
        • Treatment of chest pain (Johnson et al.)
        • Referral to cardiology specialist care (Schulman et al.)
        • Pain management (Todd et al.)
  • Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care ; IOM, 2002
    • Racial and ethnic disparities in health:
    • Exist within a broader context where discrimination is experienced
    • Persist when insurance status, age, income and severity of conditions are comparable
    • Are not explained by patient refusal to treatment
  • Unequal Treatment , continued
    • Result from bias, prejudice, stereotyping and clinical encounter uncertainty on the part of the provider
    • Result because of the complex and fragmented nature of health care delivery
    • RECOMMENDATIONS
    • public education campaign
    • target providers: awareness, knowledge and skills
    • address regulatory and policy development
    • develop health systems intervention: access
    • develop cross-cultural education
    • improve data collection and monitoring
    • increase research
  •  
  • “ I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character…” Martin Luther King Jr. “I Have a Dream” address delivered at the March on Washington for Jobs and Freedom, August 28, 1963
  • Racism
    • Institutional: regulations, barriers, etc.--necessary to identify to ensure access
    • Personally- mediated: bias; stereotyping, discrimination, prejudice--necessary to identify to develop provider training
    • Internalized: individual adopts/believes stereotype--necessary to debunk myths and develop appropriate patient materials
      • Camara Jones, MD, PhD at the CDC
  • Summary
    • There is a significant body of evidence that has identified disparities in health care
    • Recommendations of the IOM have implications for changes in institutions and practice within healthcare settings
    • To eliminate disparities, partnerships and more comprehensive policy approaches will be required
  • Massachusetts Disparities
  • Race and Hispanic Ethnicity 382,729 No race/more than one 428,729 287,549 Hispanic (all races) 240,613 143,392 Asian/PI 15,015 12,241 AI/AN 343,454 300,130 Black 5,367,286 5,405,374 White 6,349,097 6,101,425 Total 2000 1990
  • Percent of Persons Living Under Federal Poverty Level Race*/ Hispanic Ethnicity, MA:1999 Source: U.S. Bureau of the Census, 2000 SF3 Sample Data. * Race Alone
  • Educational Attainment (Less than High School) by Race*/Hispanic Ethnicity, MA:2000 Source: U.S. Bureau of the Census, 2000 SF3 Sample Data. * Race Alone
  • Persons with NO Health Care Coverage Adults aged 18+ years, MA: 2000 Source: Massachusetts Department of Public Health, BRFSS. Health care coverage: Responded “no” to the question “Do you have any kind of health care plan”. HP2010 0%
  • All cause Mortality Age-Adjusted Death Rates by Race/ Hispanic Ethnicity, MA: 2000 Age-adjusted to the 2000 US standard population. Source: Massachusetts Department of Public Health, Death certificates.
  • Age-Adjusted Rate of Hospital Discharges for Hypertension by Race/ Hispanic Ethnicity, MA: 1999 Age-adjusted to the 2000 US standard population. Source: Division of Health Care Finance and Policy’s Hospital Discharge Data.
  • Age-Adjusted Death Rates for HIV/AIDS by Race/ Hispanic Ethnicity, MA: 2000 HP2010 0.7 deaths/ 100,000 Age-adjusted to the 2000 US standard population. Source: Massachusetts Department of Public Health, Death certificates. ** Insufficient numbers **
  • Minority Perinatal Health Reports: Populations Asian Hispanic Black
  • Percentage of Preterm* Births by Race/ Hispanic Ethnicity, MA: 2000 Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation *Preterm = gestational age less than 37 weeks
  • Percentage of Preterm* Births among Black Infants by Ethnicity, MA: 1997-2000 Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation *Preterm = gestational age less than 37 weeks
  • Adequate Prenatal Care* by Race and Hispanic Ethnicity, MA: 2000 Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation *Adequate prenatal care is a measure of the timing and number of prenatal care visits. Based on Kessner Index.
  • Adequate Prenatal Care* among Asian Mothers by Ethnicity, MA: 1996-1997 Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation *Adequate prenatal care is a measure of the timing and number of prenatal care visits. Based on Kessner Index.
  • Non-English Language Preference by Race and Hispanic Ethnicity, MA: 2000 Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation
  • Spanish Language Preference among Hispanic Mothers by Ethnicity, MA: 1997-2000 Source: MA Department of Public Health, Bureau of Health Statistics, Research and Evaluation
  • Office Of Minority Health DHHS CLAS: Culturally and Linguistically Appropriate Services
  • OMH National Standards for Cultural and Linguistic Services
    • 14 standards: inform, guide, facilitate development of strategies
    • Three themes
    • -Culturally competent care
    • -Language access services (mandated)
    • -Organizational support for cultural competence
  • Standard 1 (CLAS definition--behavior and communication with patients)
    • Health Care Organizations Should Ensure That Patients/Consumers Receive From All Staff Members Effective, Understandable, and Respectful Care That Is Provided in a Manner Compatible With Their Cultural Health Beliefs and Practices and Preferred Language
    • Protocols that are known to all staff on treating patients who are from different backgrounds are clear
    • Respect for patient values and beliefs are paramount
    • Clinical and administrative information must be presented
    • Use patient’s language
  • Standard 2 (workforce diversity)
    • Health Care Organizations Should Implement Strategies To Recruit, Retain, and Promote at All Levels of the Organization a Diverse Staff and Leadership That Are Representative of the Demographic Characteristics of the Service Area
    • Diverse staff
    • Reflective of demographics
    • Value the journey
    • Assessment of needs of consumers
    • Proactive strategies
  • Standard 3 (staff training)
    • Health Care Organizations Should Ensure That Staff at All Levels and Across All Disciplines Receive Ongoing Education and Training in Culturally and Linguistically Appropriate Service Delivery
    • Communicates expectations
    • Communicate policies and procedures
    • Create environment for staff to be on the journey
    • Organization and sub-contracts and affiliates
    • CEU/CME
    • Content: working across differences, effective communication, conflict resolution, work with interpreters, clinical differences by race
  • Standard 4 (Interpreter Services mandate)
    • Health Care Organizations Must Offer and Provide Language Assistance Services, Including Bilingual Staff and Interpreter Services, at No Cost to Each Patient/Consumer With Limited English Proficiency at All Points of Contact, in a Timely Manner During All Hours of Operation
    • Ensure effective communication to LEP (OCR guidance)
    • LEP: a consumer who cannot speak, read or understand English that permits effective interaction with clinical and non-clinical staff
    • Preference is face to face with: bilingual clinical staff , then trained interpreter staff then contracted then telephonic
  • Standard 5 (notice of rights)
    • Health Care Organizations Must Provide to Patients/Consumers in Their Preferred Language Both Verbal Offers and Written Notices Informing Them of Their Right To Receive Language Assistance Services
    • The right to an interpreter at no cost
    • Posted signage
    • At all points of contact
    • Policies and procedures
    • Primary educational materials
    • Translation of pertinent patient materials
  • Standard 6 (Interpreter competencies)
    • Health Care Organizations Must Assure the Competence of Language Assistance Provided to Limited English Proficient Patients/Consumers by Interpreters and Bilingual Staff. Family and Friends Should Not Be Used To Provide Interpretation Services (Except on Request by the Patient/ Consumer)
    • Assess and assure training of interpreter staff
    • Interpreters must be competent in both languages-source and target
    • Interpreters must be trained in the art and ethics of interpreting
    • Family and friends ought not to be encouraged (forbidden in ERIL)
    • No use of children
  • Standard 7 (Translated materials)
    • Health Care Organizations Must Make Available Easily Understood Patient-Related Materials and Post Signage in the Languages of the Commonly Encountered Groups and/or Groups Represented in the Service Area
    • Effective language assistance program
    • Written materials that are routinely provided to English speakers
    • Identify language groups in area
    • Policies and procedures relative to translations
  • Standard 8 ( organizational frameworks )
    • Health Care Organizations Should Develop, Implement, and Promote a Written Strategic Plan That Outlines Clear Goals, Policies, Operational Plans, and Management Accountability/Oversight Mechanisms To Provide Culturally and Linguistically Appropriate Services
    • Identify how will target and reach out to diverse populations
    • Organizational values, systems, procedures identified and points of accountability/oversight for implementation and monitoring
  • Standard 9 ( Performance monitoring)
    • Health Care Organizations Should Conduct Initial and Ongoing Organizational Self-Assessments of CLAS-Related Activities and Are Encouraged To Integrate Cultural and Linguistic Competence-Related Measures Into Their Internal Audits, Performance Improvement Programs, Patient Satisfaction Assessments, and Outcomes-Based Evaluations
    • Obtain baseline
    • Inventory policies, practices and procedures
    • Identify capacities, strengths and weaknesses
    • Identify culturally and linguistic measures for QA
    • Link to outcomes and quality efforts: survey must be appropriate
  • Standard 10 (Data collection and analysis)
    • Health Care Organizations Should Ensure That Data on the Individual Patient's/Consumer's Race, Ethnicity, and Spoken and Written Language Are Collected in Health Records, Integrated Into the Organization's Management Information Systems, and Periodically Updated
    • Legal and appropriate to collect data
    • Allows for identifying who uses and not uses organization
    • Allows for monitoring assessment with usage: where does outreach need to occur
    • MIS ought to identify language of parent in case of minor
    • Needs to be an up-front process
  • Standard 11 (Community language needs assessment)
    • Health Care Organizations Should Maintain a Current Demographic, Cultural, and Epidemiological Profile of the Community as Well as a Needs Assessment to Accurately Plan for and Implement Services That Respond to the Cultural and Linguistic Characteristics of the Service Area
    • Community profile
    • Obtain a variety of baseline data
    • Variety of data sources and information
    • Quantitative and qualitative
    • Involve consumers/community
  • Standard 12 (C ommunity partnerships)
    • Health Care Organizations Should Develop Participatory, Collaborative Partnerships With Communities and Utilize a Variety of Formal and Informal Mechanisms to Facilitate Community and Patient/ Consumer Involvement in Designing and Implementing CLAS--Related Activities
    • Responsive service delivery is collaborative
    • Service delivery, policy and program development
    • Formal and informal mechanisms
    • Reciprocity and mutuality between community and institutions
  • Standard 13 ( Grievance policies and procedures)
    • Health Care Organizations Should Ensure That Conflict and Grievance Resolution Processes Are Culturally and Linguistically Sensitive and Capable of Identifying, Preventing, and Resolving Cross-Cultural Conflicts or Complaints by Patients/Consumers
    • Structure must allow for avenue to air complaints when patients not accommodate or feel misunderstood
    • Vulnerable populations
    • Information on right to file a grievance
    • Ombudsman or intermediary (Patient advocates)
  • Standard 14 (“report card”)
    • Health Care Organizations Are Encouraged to Regularly Make Available to the Public Information About Their Progress and Successful Innovations in Implementing the CLAS Standards and To Provide Public Notice in Their Communities About the Availability of This Information
    • Informing about progress
    • Develop own report card
  • Interpreter Services
  • Definitions
    • Interpretation: changing orally what someone says into another language for the listener
    • Translation: changing written material from one language into another while keeping the same meaning
  • Definition: non-English speaker
    • A person who cannot speak or understand
    • OR has difficulty speaking or understanding English
    • Because uses a spoken language other than English
  • Research Language Barriers and Access
    • Extensive bibliography: Jane Perkins, National Health Law Program: Ensuring Linguistic Access in Health Care Settings: An overview of Current Legal Rights and Responsibilities found at:
    • http://www.kff.org/content/2003/20030821/
  • Language Access
    • Latino pediatric access to care increased with parent ability to speak English
    • NES women cited inadequacy of translated materials as a factor in a decision to not obtain mammography (screen translated as fat)
    • Communication difficulty between patient and provider
    • A major reason cited by NES patients for their dissatisfaction with care
  • Why are interpreter services important?
    • Census 2000: Massachusetts
    • Fastest growing communities
          • Latino by 49% (US 58%)
          • Asian-Americans by 66%
    • Languages spoken: >140 (US >300)
    • Language other than English: 18.2 % (US 17%)
    • Language proficiency :7% speak English less than very well (US 8%)
  • Why are interpreter services important?
    • Workforce Issues
      • DMA identified language differences between providers and patients as primary barrier to delivering competent and effective services
      • Health care workers tend to be stable
      • Current workforce lacks language capacity
      • Poor graduation rates
      • Graduates not entering health fields
  • Laws/regulations
    • Title VI Civil Rights Law 1964 (ensure language access)
    • Voting Rights Act 1965 (bans English only elections)
    • Food Stamp Act 1977 (written and oral assistance)
    • Older Americans Act (outreach)
    • Substance Abuse and Mental Health Administration Reorganization Act (services)
    • Executive Order 13166: Improving Access to Services for Persons with Limited English Proficiency
  • Laws/regulations
    • Equal Educational Opportunities Act (accommodate language differences impede learning)
    • Disadvantaged Minority Health Improvement Act (OMH to enter into contracts which increase LEP access)
    • HCFA (CMS) regulations require evaluations to be in the language of the patient
    • CA: requires adequate communication methods
    • NJ: communication must be patient language for substance abuse
    • MA : ERIL: interpreters in ED settings
  • DOJ/DHHS Guidance:Language access must be provided: www.lep.gov
    • Four factor analysis
    • Number or proportion of LEP persons served or encountered (lang assessment)
    • Frequency of contact with the program by LEP
    • Nature and importance of program to LEP
    • Resources available and cost considerations
  • Guidance: One size does not fit all
    • Interpreter services is an evolving profession
      • Standards are evolving and limited # of interpreters
    • Hospitals have differing needs, resources, patient populations and community resources
      • Urban/rural
      • Multiple languages differ by region
      • Community composition
    • Many hospitals initiated interpreter services in response to federal guidance and requirements
  • Massachusetts Hospital Based Interpreter Services
  • Massachusetts
    • ERIL: Emergency Room Interpreters Law, 2000
    • Massachusetts: Determination of Need requirements
      • 52 hospitals
      • Developed IS as a condition of the DoN
    • MMIA’s Standards of Practice nationally recognized
      • Collaborating with other national groups
      • California Health Interpreters Association
      • Washington state
  • ERIL requires provision of competent interpreter services
    • In acute care hospitals
    • For all emergency room services
    • To non-English speaking persons seeking ED care or treatment
    • As a condition for licensing
  • Definitions Competent interpreter services are performed by a person who is: - Fluent in English - Fluent in the patient’s language - Trained and proficient in the skill and ethics of interpreting - Knows the specialized terms and concepts used in medical care
  • Linguistic Competence: Ensuring trained interpreter improves clinical quality
    • Bear down : push down, carry a weight, bend down, sit down, beard, chin
    • Bladder: liver, vagina
    • Seizures: kidnapping, cramps, stitches, lose consciousness
    • Lack vocabulary: Hmong
  • The Hmong language has no word for cancer, or even the concept of the disease. “We’re going to put a fire in you” is the how an inexperienced interpreter radiation treatment to the patient, who refused treatment. Anne, Morse. Language Access: Helping Non-English Speakers Navigate Health and Human Services , National Conference of State Legislatures, 2003
  • Delivery System Design
    • Coordination and Administration
    • Scheduling and tracking
    • Models of Oral assistance
      • staff
      • contract
      • employee language banks
      • community language banks
      • telephonic and remote simultaneous
    • Guidelines for translation: common written patient materials
  • Translation: Use trained translator
    • English to be translated
    • Rheumatoid arthritis can be acute or chronic. Acute rheumatoid arthritis is more common during adolescence. The cause is believed to be due to an over-sensitive reaction of the joints to the Beta Hemoylic Streptococcous. The most common sites of infection are the throat and tonsil.
  • Translation continued
    • English to Chinese to English
    • Wet Wind Style Joint inflammation has fast and slow type. The fast type sees more at small year type. The reason for its up believes to be the joint’s over-sensitive reaction to the blood-dissolving chain-ball bacteria. And the affecting path is most frequently the swallow tube and the flact-peach gland.
    • Source: Harvard Pilgrim HealthCare, Shani Dowd, June 2002
  • Key Issues
    • Policies and procedures
    • Identification of a coordinator
    • Notices and signage
    • Access
    • Training, education and qualifications
    • Patient records
    • Translated materials
  • Structural elements
    • Written policies and procedures
    • Available to staff
    • Identify timeliness of access
    • Identify circumstances for use of telephonic services
    • Monitor and assure quality
  • Structural elements continued
    • Annual needs assessment
    • Coordinator identified to:
    • -Conduct the annual needs assessment
    • -Develop written policies and procedures specific to the ED
    • -Assess interpreter skill
    • -Develop institutional training
    • -Ensure timely early identification of patient’s needing an interpreter
  • Structural elements continued
    • Coordinator (Con’t)
    • -Develop ongoing, documented quality assurance program as part of hospital QA
    • -Develop and publicize grievance procedures for problems with access
  • Structural Elements
    • Monitoring and Evaluation
    • Users: patients, staff and providers and interpreters
    • User satisfaction surveys including the non-English speaker
    • Process indicators: Is the system working in a way that everyone understands
    • Quality indicators: Are IS meeting user needs?
    • Outcome indicators: Are IS making a difference?
  • Risk Reduction
    • Documentation in the medical record
      • Patient language preference
      • Interpreter’s name
      • Declination of service: reason and interpreter
    • Provide timely and uniform communication
    • Ensure systematic data collection
      • access to IS to correct language and race fields
      • utilize this data for assessment
  • Summary Hospital Based IS
    • Hospital based interpreter services programs are most effective when
    • Structured rather than ad hoc
    • Comprehensive policies and procedures are developed
    • A community needs assessment and an internal resource assessment
    • Initial and ongoing training is offered
    • Competency protocols are established
  • Closing comments
    • Perception: societal and experiential
    • Theories and research often fail to include racial, ethnic and linguistic minority subjects and have limited applicability
    • Lack of inclusion in research has rendered them invisible and assumed knowledge has driven the process of healthcare delivery
    • Vulnerable populations not monolithic
    • Immigrant--multiple ethnicities, different immigrant experience
    • Minority groups--multiple ethnicities
  • Summary
    • Experiencing the health system may be negative
      • disrespect
      • lack of language access
      • experience of health disparities
    • Acknowledging our limited understanding is critical
    • Asking about their experience is critical
    • Involving community consumers critical to the development of effective patient safety strategies