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Addressing culture in health care delivery: policy, practice and research


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An overview of practice, policy and research on cultural competence in health care delivery. Delivered to the National Science Foundation workshop on intercultural systems design, May 2009.

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Addressing culture in health care delivery: policy, practice and research

  1. 1. Addre s s ing c ulture in he alth c are de live ry The inte rplay o f prac tic e , po lic y de ve lo pme nt and re s e arc h Julia Puebla Fortier Resources for Cross Cultural Health Care
  2. 2. Outline  Howculture affects health  Early practice-based approaches  Developing the policy fram ork ew  W difference does it m hat ake? Research and evidence  Other key initiatives  Moving forw in any case ard
  3. 3. Howculture affects health  Case exam ple: New arrived Som ly ali refugee in sm M estern tow w all idw n ith an infant w diarrhea. ith
  4. 4. Culture, as it relates to health “ thoughts, com unications, actions, custom beliefs, values, The m s, and institutions of racial, ethnic, religious, or social groups. Culture defines howhealth care inform ation is received, how rights and protections are exercised, w is considered to be a hat health problem howsym , ptom and concerns about the problem s are expressed, w should provide treatm for the problem ho ent , and w type of treatm should be given. In sum because hat ent , health care is a cultural construct, arising from beliefs about the nature of disease and the hum body, cultural issues are an actually central in the delivery of health services treatm and ent preventive interventions. (From the National CLAS S tandards )
  5. 5. Cultural and linguistic com petence … “ set of congruent behaviors, attitudes, and policies that com a e together in a system agency, or am , ong professionals that enables effective w in cross-cultural situations. ‘ ork Culture’ refers to integrated patterns of hum behavior that include the an language, thoughts, com unications, actions, custom beliefs, m s, values, and institutions of racial, ethnic, religious, or social groups. ‘ petence’ plies having the capacity to function Com im effectively as an individual and an organization w ithin the context of the cultural beliefs, behaviors, and needs presented by consum and their com unities” ers m (From the National CLAS S tandards , bas e d on Cros s , Baz ron, De nnis , & Is aacs , 1989).
  6. 6. Practice-based approaches  Organizational settings  com unity clinics, public health m departments, public hospitals  Interventions  Ethnic-specific practices/hours  Bilingual/bicultural staff  Interpretation services  Com unity health w m orkers/cultural liaisons  Translated w ritten docum ents
  7. 7. “System of care and the ” diverse patient Refugee patient >> health departm screening >> ent com unity clinic >> m hospital >> laboratory >> pharm acy
  8. 8. Developing the policy fram ork: w drives action ew hat  Title VI of the Civil Rights Act  State activity  Federal CLAS Standards  Institute of M edicine report on health disparities  Public and private quality im provem ent initiatives: processes and outcom es
  9. 9. Changing incentives  Access to care (civil rights/advocacy)  Legal and quasi-legal (requirem ents/liability avoidance)  Business case (cost effectiveness, ROI)  Quality improvem (process) ent  Does it m ake a difference (outcom es)
  10. 10. W an evidence base for hy cultural competence?  Patients often have access and health status deficiencies that need to be addressed  It’ not business as usual for providers s and organizations  It requires additional tim effort, and e, resources  Policym akers and payors w results ant
  11. 11. S e tting the Ag e nda for Re s e arch on Cultural Compe te nce in He alth Care  Agency for Healthcare Research and Quality, Office of Minority Health, Resources for Cross Cultural Health Care  Literature reviewand analysis  Research advisory com ittee m  Research agendas by type of intervention
  12. 12. Research questions  Did the intervention:  Do w it w supposed to do? hat as  Affect processes of care?  Im prove access to service/appropriate utilization?  Affect patient satisfaction, health behaviors?  Affect patient health outcom es?  Im prove efficiency, cost-effectiveness?
  13. 13. Categories of interventions  Culturally Sensitive Interventions  Cultural competence education  Race, ethnic and linguistic concordance  Com unity health w m orkers and culturally com petent health prom otion  Language Assistance  Bilingual services, oral interpretation, translated written m aterials
  14. 14. Categories of interventions  Organizational Supports for Cultural Com petence  M anagem and policy strategies ent  Com unity engagem m ent  Information and data for planning and evaluation  Appropriate ethics and conflict resolution processes
  15. 15. Research Agenda: Racial/linguistic concordance  Lit reviewsuggests positive effects  Research questions:  Im pact on clinical encounter  Delivery and health outcom es  Effect on organizations  M ethodological and policy considerations  Subject recruitm ent  Value of qualitative research
  16. 16. Research agenda: Language assistance services  Lit review im : pact of language barriers on outcom and im es, pact of language services interventions  Research questions:  Effect of provider/interpreter language proficiency on patient com prehension, adherence  W affects provider use of available hat interpreter services?
  17. 17. Language Assistance Services: Additional research questions  Do translated pre-op instructions lead to decreased rescheduling of procedures?  Do verbatim translated consent form s lead to different patient choices for high-risk procedures than sum arized m consent form s?
  18. 18. Overall methodological challenges  Definitions: broad and specific  Standardization: interventions, outcome m easures  Study design  Controls, random ization  Sam sizes ple  Isolation of the intervention effect  Generalizability
  19. 19. Methodological challenges  Data challenges  Lack of race, ethnicity and language data, and standardization of collection  Participation issues: patient and provider  Linkages betw een researchers and practitioners  Research funding  Publication barriers
  20. 20. The Ev ide nce Bas e for Cultural and Ling uis tic Compe te ncy in He alth Care  Com onw m ealth Fund, National Center for Cultural Com petence  Literature reviewand analysis  Focus on health outcom and w es ell- being, and on costs and benefits  25 of 561 studies m reviewcriteria et
  21. 21. Outcom and w being: es ell findings  9 cancer-related studies: 3 show ed behavioral changes  8 diabetes-related studies: 3 show ed improved HbA1c levels  2 organizational level studies: 1 show ed < appropriate use of m eds and patient satisfaction
  22. 22. Outcom and w es ell-being: limitations  Lack of definitions/measurem ents of CC  Isolation of the CC aspects of an intervention  Study design problem sam sizes, s: ple control groups.
  23. 23. Other initiatives  Hospital Research and Education Trust: Race, ethnicity and language data study and toolkit  Robert W ood Johnson Foundation: “Speaking Together” quality improvem initiative ent  AM Ethical Force Program initiative A : on patient-provider com unication m
  24. 24. Race, ethnicity and language study and toolkit  National advisory com ittee to develop m a fram ork for data collection ew  Online toolkit for health care organizations  Studies to integrate patient data with clinical perform ance m easures, and to link data w quality of care m ith easures
  25. 25. “ Speaking Together”  Perform ance m easures and quality im provem for hospital based ent interpreter services programs:  Screening for preferred language  Patients receiving qualified language services  Patient w tim for interpreters ait e  Tim spent interpreting e  Interpreter w tim for encounter start ait e
  26. 26. AM Ethical Force: A Patient centered com unication m  Consensus panel, fram ork, toolkit ew and pilot testing  6 areas of organizational performance:  Understand organizational com itm m ent  Collect information  Engage com unities m  Develop w orkforce  Engage individuals  Evaluation perform ance
  27. 27. Moving forw in any case ard  Initiatives from key health care quality and accreditation organizations:  The Joint Com ission m  National Com ittee for Quality Assurance m  The National Quality Forum
  28. 28. The Joint Com ission m  Early interest  Crossw of CLAS standards and JC alk standards  Hos pital, Lang uag e and Culture study  Plan for standards and im plem entation guide
  29. 29. National Com ittee m for Quality Assurance  Voluntary standards and accrediting body for m anaged care plans  Test w aters w CLAS aw ith ards program –highlight best practices  Proposal for a newCLAS standard this year  Focus on data collection, staff diversity/ cultural com petence, language services
  30. 30. National Quality Forum  Com prehensive fram ork and preferred ew practices for measuring and reporting cultural com petency  45 preferred practices in 6 domains:  Leadership  Integration into managem system ent s  Patient-provider com unication m  Care delivery structures  W orkforce diversity and training  Com unity engagem m ent
  31. 31. NQF standard evaluation criteria  Generalizability  Benefit  Readiness  Effectiveness  Research studies, experiential data— including broad expert agreem ent, widespread opinion, or professional consensus show the practice is ing “obviously beneficial” self-evident, or or organization/program data linking the practice to improved outcom es.
  32. 32. Role of foundations and governm ent  The California Endow ent, The m Com onw m ealth Fund, The Robert W ood Johnson Foundation  State requirem ents: CA and interpreter services, NJ and cultural competence training  Federal program interpreter services s:
  33. 33. For m inform ore ation: Julia Puebla Fortier Resources for Cross Cultural Health Care rcchc@ w w w