CULTURAL CARING   BRINGING OCCUPATIONAL THERAPY INTO HIGH    DEFINITION FOR CLIENTS ACROSS CULTURESCristina Reyes Smith, O...
Objectives   Identify professional guidelines for clinical    practice when serving clients across diverse    cultures  ...
Occupational Therapy’s Roots in        Cultural Caring
Now and into the future:AOTA’s Centennial Vision "We envision that occupational therapy is a powerful, widely recognized, ...
   Settings…      Assisted living      Community       mental health      Corporations      Early intervention      ...
U.S. Population by Race/Ethnicity                    (Kaiser Family
World Population Distribution byRegionBased on United Nations Population Division, Briefing Packet, 1998 Revision  of Worl...
Professional Guidelines for Clinical    Practice Related to Serving  Clients Across Diverse Cultures
National Standards on Culturally andLinguistically Appropriate Services(CLAS)   Published by U.S. Department of Health & ...
CLAS Standards   Mandates for Federal fund recipients:     Standards   4, 5, 6, and 7*   Recommended adoption by accred...
List of CLAS Standards (1-4)Health care organizations should:Standard 1: Ensure patients/consumers receive  effective, und...
List of CLAS Standards (5-8)   *Standard 5: Provide verbal and written notices in preferred    language informing patient...
List of CLAS Standards (9-11)   Standard 9: Conduct initial and ongoing organizational self-    assessments of CLAS-relat...
List of CLAS Standards (12-14)   Standard 13: Ensure conflict and grievance resolution    processes are culturally and li...
OT Resources to Guide Practice   Occupational Therapy Code of Ethics    (AOTA, 2010)   OT Practice Framework (AOTA, 2008...
Occupational Therapy Code ofEthics   Public statement of principles for the profession   Promotes inclusion, diversity, ...
Occupational Therapy Code ofEthicsOccupational therapy personnel shall:Principle 1. Beneficence Demonstrate a concern for...
Occupational Therapy Code ofEthicsPrinciple 5. Procedural Justice   Comply with institutional rules, local, state, federa...
OT Practice Framework: Domain andProcess    2nd Edition published by AOTA in 2008    Explains promotion of health and pa...
OT Practice Framework (cont.)“All people need to be able or enabled to engage   in the occupations of their need and choic...
OT Practice Framework (cont.)Area of          Client         Performance         Performan   Context and ActivityOccupatio...
On Cultural Competency & Ethical Practi    Advisory Opinion released by AOTA     Ethics Commission    Highlighted ethica...
Five Competencies for the Future    Integrates concepts from Health Professions     Education: A Bridge To Quality (Insti...
Five Competencies for the FutureII.        Working in teams and integrating services            Providing continuity of c...
Current EvidenceNumerous studies have been conducted including: improving attitudes and reducing resistance towards  addr...
Kaul & Guiton, 2010   Reduced resistance and improved students’    attitudes towards medical cross-cultural    communicat...
Fung, Lagha, Henderson, &Gomez, 2010   Found that addressing interpreter position    significantly impacted patient satis...
Hudelson, Perron and Perneger, 2010   More likely to think providers should adapt to needs of    immigrant patients     ...
Bringing OT Into High Definition   For Clients Across Cultures
Strategies for OT Practice           Promote     Language          Language    Interpreting           Access     Proficien...
Promoting Language Access   Effective medical language interpretation     conductedby individual fluent in conversationa...
Promoting Language InterpretingProficiency   Recruit interpreters and translators from     Entitiesserving cultural grou...
Promoting Cultural Competence   Coordinate or collaborate with cultural    celebration events   Hold small/focus group d...
Promoting Community Partnerships   Provide services at community health fairs and cultural    festivals   Partner with m...
Potential Community PartnershipGroups   Poverty and             Student groups    homelessness            Civic groups...
Resources on Cultural Competence   “Unnatural Causes” PBS documentary series on socio-    economic and racial inequalitie...
Resources on Self-Assessment &Growth   ASHA Self-Assessment for Cultural Competence:    http://www.asha.org/practice/mult...
Supports and Barriers to Care for Clients and Communities Across         Diverse Cultures
Case Study1y.o. AA male patient “Alexander” Born premature at 23 weeks PMHx Grade IV IVH with post hemorrhagic  hydrocep...
Case Study (cont.)Supports                       Barriers   Stable family structure       Limited family income   Famil...
Patient “Alexander” Outcomes   Created journal to enhance provider communication     Included provider contact info and ...
Case Study55 y.o. female patient “Dina”: Recently diagnosed with diabetes Lives with husband and 2 middle-aged sons Low...
Case Study (cont.)Supports                      Barriers   Stable family structure      Limited family income   Family ...
Patient “Dina” Outcomes   Patient was able to access free medical clinic   Provided language interpreter services to fac...
Organizational CulturalCompetenceCase Study “DCC”
Organizational Case Study   Faith-based medical clinic “DCC” opened Jan.    2009   Free medical services for uninsured l...
Organizational Case Study (cont.)   Supports to Organizational Cultural    Competence     Incorporated, non-profit chari...
Organizational Case Study (cont.)   Barriers for Organizational Cultural    Competence     Limited patient access (hours...
Key Players &                         StakeholdersOrganizational                                                   Support...
Organizational Case Study (cont.)Objectives: Promote communication across language  barriers Provide culturally-sensitiv...
Organizational Strategies for“DCC”   Translator and Interpreter Training:     mission  and background of clinic     con...
Organizational Strategies for “DCC”                                       Patient-                                      Ce...
Organizational Strategies for “DCC”Meeting held for staff and volunteers: Discussed values, beliefs, and behaviors Discu...
Small Group Discussion (15min) Your culturalidentity and howit relates topractice Observedbarriers to carein variousprac...
Large Group Discussion andSynthesisInsightsandinnovations Continuedchallengesor questions Additionalresourcesfor furthe...
References
References   AOTA. (n.d.). The Road to the Centennial Vision. Retrieved from    http://www.aota.org/News/Centennial.aspx...
References (cont.)   Andrulis, D., Delbanco, T., Avakian, L., and Shaw-Taylor, Y. (n.d.).    Conducting a Cultural Compet...
References (cont.)   Hudelson, P., Perron, N. J., & Perneger, T. V. (2010). Measuring    physicians and medical students ...
References (cont.)   Management Sciences for Health. (2008). The culturally competent    organization. Providers Guide to...
References (cont.)   Wells, S. A. (2005). On Cultural Competency and Ethical Practice.    Retrieved from    http://www.ao...
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Cultural Caring: Bringing Occupational Therapy into High Definition for Clients Across Cultures (2011 AOTA Conference Presentation)

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Theses are the slides from a presentation by Cristina Reyes Smith, OTD, OTR/L and Susan Toth-Cohen, PhD, OTR/L from the 2011 AOTA Conference in Philadelphia, PA.

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Cultural Caring: Bringing Occupational Therapy into High Definition for Clients Across Cultures (2011 AOTA Conference Presentation)

  1. 1. CULTURAL CARING BRINGING OCCUPATIONAL THERAPY INTO HIGH DEFINITION FOR CLIENTS ACROSS CULTURESCristina Reyes Smith, OTD, OTR/L, Coastal Therapy Services, Inc., Charleston, SCSusan Toth-Cohen, PhD, OTR/L, Thomas Jefferson University, Philadelphia, PA
  2. 2. Objectives Identify professional guidelines for clinical practice when serving clients across diverse cultures Discuss supports and barriers to care uniquely experienced by clients across diverse cultures Discuss strategies and resources for enhancing clinical practice related to clients across cultures Discuss reflections on own culture/values and how they relate to practice
  3. 3. Occupational Therapy’s Roots in Cultural Caring
  4. 4. Now and into the future:AOTA’s Centennial Vision "We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting societys occupational needs.“ http://www.aota.org/News/Centennial.aspx
  5. 5.  Settings…  Assisted living  Community mental health  Corporations  Early intervention  Home health  Hospitals & clinics  Private practice  Schools  Skilled nursing facilities  Other community-based programs
  6. 6. U.S. Population by Race/Ethnicity (Kaiser Family
  7. 7. World Population Distribution byRegionBased on United Nations Population Division, Briefing Packet, 1998 Revision of World Population Prospects; and World Population Prospects, The 2006 Revision.
  8. 8. Professional Guidelines for Clinical Practice Related to Serving Clients Across Diverse Cultures
  9. 9. National Standards on Culturally andLinguistically Appropriate Services(CLAS) Published by U.S. Department of Health & Human Services Office of Minority Health (OMH), 2007 Directed at health care organizations and providers For integration in partnership with communities Topics include:  Culturally Competent Care (Standards 1-3)  Language Access Services (Standards 4-7)  Organizational Supports for Cultural Competence (Standards 8-14) (OMH, 2007)
  10. 10. CLAS Standards Mandates for Federal fund recipients:  Standards 4, 5, 6, and 7* Recommended adoption by accrediting agencies:  Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13 Voluntary adoption by health care organizations:  Standard 14 (OMH, 2007)
  11. 11. List of CLAS Standards (1-4)Health care organizations should:Standard 1: Ensure patients/consumers receive effective, understandable, and respectful care compatible with cultural health beliefs, practices, and language.Standard 2: Implement strategies to recruit, retain, and promote diverse staff and leadership representative of the service area.Standard 3: Ensure staff at all levels/disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.*Standard 4: Offer and provide free language assistance services for each patient/consumer at all times. (OMH, 2007)
  12. 12. List of CLAS Standards (5-8) *Standard 5: Provide verbal and written notices in preferred language informing patients of right to language assistance services. *Standard 6: Assure competence of language assistance provided by interpreters and bilingual staff. (Family and friends not used unless requested by the patient/consumer). *Standard 7: Provide easily understood patient-related materials and signs in commonly encountered languages in the service area. Standard 8: Develop, implement, and promote written strategic plan to provide culturally and linguistically appropriate services. (OMH, 2007)
  13. 13. List of CLAS Standards (9-11) Standard 9: Conduct initial and ongoing organizational self- assessments of CLAS-related activities and integrate related measures into audits and performance improvement programs. Standard 10: Ensure data on the individual race, ethnicity, and language (spoken and written) are collected, integrated, and periodically updated. Standard 11: Maintain current demographic, cultural, and epidemiological community profile and needs assessment for planning/implementing services. Standard 12: Develop participatory, collaborative partnerships with communities and facilitate involvement in designing/implementing CLAS-related activities. (OMH, 2007)
  14. 14. List of CLAS Standards (12-14) Standard 13: Ensure conflict and grievance resolution processes are culturally and linguistically sensitive and effective for cross-cultural conflicts or complaints. Standard 14: Regularly provide public information about progress/successful innovations in implementing CLAS standards and about availability of the information. (OMH, 2007)
  15. 15. OT Resources to Guide Practice Occupational Therapy Code of Ethics (AOTA, 2010) OT Practice Framework (AOTA, 2008) On Cultural Competency and Ethical Practice (Wells, 2005) Five Competencies for the Future (Moyers, 2003)
  16. 16. Occupational Therapy Code ofEthics Public statement of principles for the profession Promotes inclusion, diversity, independence, and safety Relates to all recipients in various stages of life, health, and illness Aims to empower all OT beneficiaries Extends to recipients as well as colleagues, students, educators, businesses, and the community (AOTA, 2010)
  17. 17. Occupational Therapy Code ofEthicsOccupational therapy personnel shall:Principle 1. Beneficence Demonstrate a concern for the well-being and safety of the recipients of their services.Principle 2. Nonmaleficence Intentionally refrain from actions that cause harm.Principle 3. Autonomy and Confidentiality Respect the right of the individual to self-determination.Principle 4. Social Justice Provide services in a fair and equitable manner. (AOTA, 2010)
  18. 18. Occupational Therapy Code ofEthicsPrinciple 5. Procedural Justice Comply with institutional rules, local, state, federal, and international laws and AOTA documents applicable to the profession of occupational therapy.Principle 6. Veracity Provide comprehensive, accurate, and objective information when representing the profession.Principle 7. Fidelity Treat colleagues and other professionals with respect, fairness, discretion, and integrity. (AOTA, 2010)
  19. 19. OT Practice Framework: Domain andProcess  2nd Edition published by AOTA in 2008  Explains promotion of health and participation through engagement in occupation  Relates to people, organizations, and populations  Core beliefs of profession include:  positive relationship between occupation and health  people are occupational beings (AOTA, 2008)
  20. 20. OT Practice Framework (cont.)“All people need to be able or enabled to engage in the occupations of their need and choice, to grow through what they do, and to experience independence or interdependence, equality, participation, security , health, and well-being” (Wilcock & Townsend, 2008, p. 198).
  21. 21. OT Practice Framework (cont.)Area of Client Performance Performan Context and ActivityOccupation Factors Skills ce Environmen Demands Patterns tActivities of Values, Sensory Habits Cultural Objects UsedDaily Living Beliefs, Perceptual Routines Personal and Their(ADL) and Skills Roles Physical PropertiesInstrumental Spirituality Motor and Rituals Social SpaceActivities of Body Praxis Skills Temporal DemandsDaily Functions Emotional Virtual SocialLiving (IADL) Body Regulation Skills DemandsRest and Structures Cognitive Skills SequencingSleep Communication and TimingEducation and Social Skills RequiredWork ActionsPlay RequiredLeisure BodySocial FunctionsParticipation Required Body StructuresFigure 4. Aspects of Occupational Therapy’s Domain
  22. 22. On Cultural Competency & Ethical Practi  Advisory Opinion released by AOTA Ethics Commission  Highlighted ethical care requires acknowledging the relationship between  trust,  culturalcompetence, and  the therapeutic relationship. (Wells, 2005)
  23. 23. Five Competencies for the Future Integrates concepts from Health Professions Education: A Bridge To Quality (Institute of Medicine, 2003) For professional development and entry-level educationI. Client-centered care:  Understand client differences, values, preferences, and expressed needs.  Effective communication skills (listen carefully, clearly inform client, etc.).  Collaborative clinical decision-making between client and clinician.  Knowledge of how community health is influenced by health of each citizen.  Community engagement in occupations influences individual health.
  24. 24. Five Competencies for the FutureII. Working in teams and integrating services  Providing continuity of care (reliable processes to manage health needs continuously and without disruption).III. Evidence-based practice  Using best available research evidence with clinical expertise and client values to select strategies for optimum care.IV. Quality improvement competencies  Knowledge of standardization and simplification.  Improvement strategies for changes in systems and processes.V. Informatics  Technological management to enhance patient care and reduce error. (Moyers, 2003)
  25. 25. Current EvidenceNumerous studies have been conducted including: improving attitudes and reducing resistance towards addressing cross-cultural communication (Kaul & Guiton, 2010), improving patient satisfaction for patients with limited English proficiency (Fung, Lagha, Henderson, & Gomez, 2010), and measuring attitudes toward caring for immigrant patients (Hudelson, Perron and Perneger, 2010)
  26. 26. Kaul & Guiton, 2010 Reduced resistance and improved students’ attitudes towards medical cross-cultural communication by  Utilizing upper-level students with clinicians as instructors  Providing opportunities to relate to culture personally and medically  Providing opportunities to practice skills to address culture
  27. 27. Fung, Lagha, Henderson, &Gomez, 2010 Found that addressing interpreter position significantly impacted patient satisfaction  Instructed interpreter to sit behind patient to support clinician-patient eye contact
  28. 28. Hudelson, Perron and Perneger, 2010 More likely to think providers should adapt to needs of immigrant patients  Medical students, hospital doctors, women, those trained in cultural competence, and those interested in immigrant care Had greater interest in caring for immigrant patients  Medical students, doctors with more immigrant patients, and those trained in cultural competence Gave greater importance to psychosocial contexts for immigrant patients  Medical students, women, those younger, those trained in cultural competence, and those interested in immigrant care
  29. 29. Bringing OT Into High Definition For Clients Across Cultures
  30. 30. Strategies for OT Practice Promote Language Language Interpreting Access Proficiency Cultural Community Competence Partnerships
  31. 31. Promoting Language Access Effective medical language interpretation  conductedby individual fluent in conversational and medical vocabulary in both languages Effective medical document translation  Verified for meaning, grammatical, and contextual accuracy Effective signs and patient information  Verified for meaning, grammatical, and contextual accuracy
  32. 32. Promoting Language InterpretingProficiency Recruit interpreters and translators from  Entitiesserving cultural groups in the community  Diverse university, religious, and social groups  Language-oriented organizations and businesses  Medical interpreting education/certification programs Collaborate with academic or community entities for Medical Interpreting workshops Utilize non-medical interpreters for non- medical patient encounters
  33. 33. Promoting Cultural Competence Coordinate or collaborate with cultural celebration events Hold small/focus group discussions for reviewing articles, topics, or resources Explore personal cultural identities and their influences on health and occupation Invite individuals from diverse cultures to share their stories and occupations Distribute resources on cultural competence
  34. 34. Promoting Community Partnerships Provide services at community health fairs and cultural festivals Partner with media and publications to promote health and wellness events, resources, or information Collaborate with public or advocacy groups to address social conditions which impact health and well-being Collaborate with educational institutions incorporating student learning into practice
  35. 35. Potential Community PartnershipGroups Poverty and  Student groups homelessness  Civic groups Racism and social inequality  Media and broadcasting Crime prevention Domestic and child  Small Businesses abuse prevention  Corporations Professional  ESL and language associations organizations Cultural groups Religious groups
  36. 36. Resources on Cultural Competence “Unnatural Causes” PBS documentary series on socio- economic and racial inequalities in health (Adelman, Smith, & Herbes-Sommers, 2008): www.unnaturalcauses.org “Providers Guide to Quality and Culture” (Management Sciences for Health, 2008): http://erc.msh.org/mainpage.cfm?file=1.0.htm&module= provider&language=English National Center for Cultural Competence: http://www11.georgetown.edu/research/gucchd/nccc/ AARC Cultural Diversity Resources: http://www.aarc.org/resources/cultural_diversity/assessi ng_competency.cfm
  37. 37. Resources on Self-Assessment &Growth ASHA Self-Assessment for Cultural Competence: http://www.asha.org/practice/multicultural/self.htm Cultural Competence Health Practitioner Assessment (CCHPA): http://www11.georgetown.edu/research/gucchd/nccc/features/ CCHPA.html “A Guide to…Planning and Implementing Cultural Competence Organizational Self-Assessment” (Goode, Jones, & Mason, 2002): http://www11.georgetown.edu/research/gucchd/nccc/docume nts/ncccorgselfassess.pdf “Conducting A Cultural Competence Self-assessment” (Andrulis, Delbanco, Avakian, and Shaw-Taylor, n.d.): http://www.consumerstar.org/pubs/Culturalcompselfassess.pd
  38. 38. Supports and Barriers to Care for Clients and Communities Across Diverse Cultures
  39. 39. Case Study1y.o. AA male patient “Alexander” Born premature at 23 weeks PMHx Grade IV IVH with post hemorrhagic hydrocephalus, sensorineural hearing loss, CVI, and dysphagia Lives with great- grandmother, grandmother, mother, and young cousins Family resides in inner city community
  40. 40. Case Study (cont.)Supports Barriers Stable family structure  Limited family income Family language/literacy  Limited family education Family familiarity with  Some distrust of healthcare system healthcare system  Medical complications Family organizational  Limited transportation skills  High provider turnover Access to early  Limited provider intervention services communication
  41. 41. Patient “Alexander” Outcomes Created journal to enhance provider communication  Included provider contact info and pt. medication list Informally inquired about the “lived experience” of the patient and family Collaborated with family on goals and objectives Integrated home programs into family routines Educated family on interventions, potential outcomes, and medical resources Directed family to community-based resources for additional funding and supplies
  42. 42. Case Study55 y.o. female patient “Dina”: Recently diagnosed with diabetes Lives with husband and 2 middle-aged sons Low income, high crime community Pt. speaks only Spanish
  43. 43. Case Study (cont.)Supports Barriers Stable family structure  Limited family income Family organizational  Limited family skills education Access to charitable  Limited language healthcare services fluency Some transportation  Limited literacy  Limited familiarity with healthcare system  Limited trust of healthcare system
  44. 44. Patient “Dina” Outcomes Patient was able to access free medical clinic Provided language interpreter services to facilitate clinical encounter Provided medical information in native language Educated on medications, potential outcomes, and medical resources Educated on necessary lifestyle changes (i.e. diet and exercise, etc.) Educated on relevant features of the healthcare system
  45. 45. Organizational CulturalCompetenceCase Study “DCC”
  46. 46. Organizational Case Study Faith-based medical clinic “DCC” opened Jan. 2009 Free medical services for uninsured local residents Low-income, low-education, & high-crime area Racially diverse community (White, AA, & Hispanic) Staffed by medical and non-medical volunteers (mostly from neighboring communities)
  47. 47. Organizational Case Study (cont.) Supports to Organizational Cultural Competence  Incorporated, non-profit charitable organization  Enthusiastic coordinators and volunteers  Large volunteer base (over 300 initially)  Free-standing facility acquired in October 2008  Informed by Community Health Needs Assessment  Established sub-committees for various needs  Relationship established with community and host church  Website established for communication
  48. 48. Organizational Case Study (cont.) Barriers for Organizational Cultural Competence  Limited patient access (hours and transportation)  Limited staff training and experience in the setting  Limited knowledge of potential cultural challenges  Limited resources to facilitate cultural competence  Limited staff to assist non-English speaking patients  Limited trust from community groups  Limited referral systems for culturally-relevant
  49. 49. Key Players & StakeholdersOrganizational Supports & Environment Barriers & Culture Cultural Competence Plan Organization National CLAS Mission Statement Standards Development of Cultural Competence Plan
  50. 50. Organizational Case Study (cont.)Objectives: Promote communication across language barriers Provide culturally-sensitive clinical care Establish sense of trust and safety for patients Access community resources to address issues
  51. 51. Organizational Strategies for“DCC” Translator and Interpreter Training:  mission and background of clinic  concept of “cultural caring”  need for enabling language access  roles/qualifications for interpreters & translators  interpreter etiquette  ethical/legal considerations  resources for further study
  52. 52. Organizational Strategies for “DCC” Patient- Centered Respectful of Knowledgeable Others Seeking Humbly Understanding Educating Ambassador SkillfulCommunicator of Cultural Leading Caring Interpreters & translators as “Ambassadors of Cultural Caring”
  53. 53. Organizational Strategies for “DCC”Meeting held for staff and volunteers: Discussed values, beliefs, and behaviors Discussed importance of patient access to skilled language interpreting services Discussed importance of sensitivity to cultural issues for “cultural caring” Discussed individual and organizational strategies for working across cultures
  54. 54. Small Group Discussion (15min) Your culturalidentity and howit relates topractice Observedbarriers to carein variouspractice settingsrelated tocultural factors Strategies for•developingculturallycompetentclinicians andorganizations inyour practicearea
  55. 55. Large Group Discussion andSynthesisInsightsandinnovations Continuedchallengesor questions Additionalresourcesfor furtherstudy
  56. 56. References
  57. 57. References AOTA. (n.d.). The Road to the Centennial Vision. Retrieved from http://www.aota.org/News/Centennial.aspx AOTA. (2010). Occupational therapy code of ethics. American Journal of Occupational Therapy, 64, in press. Retrieved from http://www.aota.org/Practitioners/Ethics/Docs/Standards/38527.asp x AOTA. (2008). Occupational therapy practice framework: Domain and process 2nd edition. American Journal of Occupational Therapy, 62(6), 625-683. Adelman, L. (Executive producer), Smith, L. M. (Co-executive Producer) & Herbes-Sommers, C. (Senior Producer). (2008). Unnatural Causes: Is Inequality Making Us Sick? [Television Broadcast]. San Francisco: California Newsreel in association with Vital Pictures, Inc.
  58. 58. References (cont.) Andrulis, D., Delbanco, T., Avakian, L., and Shaw-Taylor, Y. (n.d.). Conducting a Cultural Competence Self-Assessment. Retrieved from http://www.consumerstar.org/pubs/Culturalcompselfassess.pdf Fung, C. C., Lagha, R. R., Henderson, P., & Gomez, A. G. (2010). Working with interpreters: how student behavior affects quality of patient interaction when using interpreters. Medical Education Online, 15. doi: 10.3402/meo.v15i0.5151 Goode, T. D., Jones, W., & Mason, J. (2002). A Guide to…Planning and Implementing Cultural Competence Organizational Self- Assessment. Retrieved from http://www11.georgetown.edu/research/gucchd/nccc/documents/nc ccorgselfassess.pdf
  59. 59. References (cont.) Hudelson, P., Perron, N. J., & Perneger, T. V. (2010). Measuring physicians and medical students attitudes toward caring for immigrant patients. Evaluation & the Health Professions. Retrieved from http://ehp.sagepub.com.proxy1.lib.tju.edu:2048/cgi/rapidpdf/016327 8710370157v1 Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academy Press. Kaiser Family Foundation. (2010). Distribution of U.S. Population by Race/Ethnicity, 2010 and 2050. Retrieved from http://facts.kff.org/chart.aspx?ch=364 Kaul, P., & Guiton, G. (2010). Responding to the challenges of teaching cultural competency. Medical Education, 44(5):506.
  60. 60. References (cont.) Management Sciences for Health. (2008). The culturally competent organization. Providers Guide to Quality and Culture. Retrieved from http://erc.msh.org/mainpage.cfm?file=9.1.htm&module=provider&la nguage=English Moyers, P. (2003). Five competencies for the future. OT Practice, 8(20), 8. Population Reference Bureau. (2011). World Population Distribution by Region, 1800–2050. Retrieved from http://www.prb.org/Educators/TeachersGuides/HumanPopulation/Po pulationGrowth/QuestionAnswer.aspx Wallace, E. A., & Duffy, F. D. (2010). Cultural competency training and performance measures to reduce racial disparities in health care quality. Annals of Internal Medicine, 152, 685.
  61. 61. References (cont.) Wells, S. A. (2005). On Cultural Competency and Ethical Practice. Retrieved from http://www.aota.org/Practitioners/Ethics/Advisory/36525.aspx U.S. Department of Health & Human Services Office of Minority Health. (2007). National Standards on Culturally and Linguistically Appropriate Services (CLAS). Retrieved from http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15

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