Cultural Competence in Health Care and its Contribution to Eliminating

Racial/Ethnic Health DisparitiesHow far have we come and where do we need to

go?

Dennis P. Andrulis, Ph.D., MPHSenior Research Scientist, Texas Health Institute, Austin TX

Associate Professor, Health Management and Policy &Center for Emergency Preparedness

University of Texas School of Public Health

NIMHD/NIH Seminar Series ● Bethesda, MD ● August 25, 2011

Overview

Where does cultural competence stand

today?

Cultural Competence and the Affordable Care Act

Where are the knowledge gaps?

What are next steps?

Cultural Competence

“A set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations.

It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase

community participation, and close the gaps in health status among diverse population groups.”

–Cross et al., 1989.

Source: M, Beach. Patient-centeredness and cultural competence: their relationship and role in reducing health disparities. Commonwealth Fund 2006

Where does cultural competence stand today?

Cultural Competence: Status and Progress

Significantly greater consideration of its importance in access to and quality of health care among practitioners and health care organizations.

Support for Research and Program Innovation:

NIMHD/NIH has included cultural competence in its solicitations.

OMH, AHRQ and HRSA have made cultural competence a priority in training, education materials, research.

Foundations supporting cultural competence initiatives.

Cultural Competence: In Early States of Development

Research and reports exploring, defining and refining concepts and issues

132 articles between 1990 and 2000 303 between 2000 and 2005 

Increasing attention to important research questions to pursue.

Some movement toward pilot studies and case-controlled studies.

Source: Goode T. et al. The Evidence Base for Cultural and Linguistic Competency in Health Care, 2006.

Dark Blue : legislation requiring (WA, CA, NJ, NM, CT) or strongly recommending (MD) cultural competence training, which was signed into law. Purple : legislation which has been referred to committee and is currently under consideration.

Royal Blue : legislation which died in committee or was vetoed.

Cultural Competence:State Level Legislation2000-

2011

Source: Think Cultural Health, 2011

Progress in Promoting National Guidance and Standards

 National Quality Forum Seven domains: leadership, management/operations,

communication, care delivery/support, workforce diversity/training, community engagement, data—accountability/QI

Identifying preferred practices for each (e.g., community collaboration to implement clinical and outreach programs for diverse populations)

Healthcare disparities and cultural competency consensus standards

Selecting and evaluating disparity sensitive quality measures

Describe methodological issues with disparities measurement

Solicit and evaluate the value of new measures (completion 2012)

Progress in Promoting National Guidance and Standards – cont’d.

The Joint Commission Patient rights

Patients’ participation in care

Safety and quality of care

An integrated approach at multiple levels, involving ongoing monitoring & improvement is necessary to identify, develop and implement systems to promote health equity

New and revised standards:

Identifying and addressing patient communication

Providing language services, including addressing qualifications for language interpreters and translators

Collecting race, ethnicity and language data

Patient access to chosen support individual

Non-discrimination in patient care

Office of Minority Health CLAS Standards

Provide the framework for all health organizations to best serve the nation’s diverse communities

Set of mandates, guidelines and recommendations intended to inform practices related to cultural and linguistic competency in health care for patient care, language services and organizations

HHS Office of Minority HealthProgress in Promoting National Guidance and Standards – cont’d.

Affordable Care Act andCultural Competence

Diversity-Specific Provisions

Over three dozen provisions in ACA onrace, ethnicity, cultural competence,

language assistance and diversity.

Cultural Competence & Workforce Diversity

Cultural Competence Model cultural competence curricula. Cultural competence training for health professionals. Culturally appropriate patient decision aids. Culturally appropriate personal responsibility education for teen

pregnancy prevention. Culturally appropriate national oral health campaign.

Workforce Diversity Increase diversity among health professionals. Health professions training preference for cultural competence. Investment in HBCUs & minority-serving institutions. Collect & report workforce diversity data.

Data Collection & Disparities Research

Data Collection & Reporting Collect racial/ethnic sub group data in population

surveys. Collect/report disparities data in Medicaid & CHIP. Monitor disparities trends in federally funded

programs.

Health Disparities Research Examining disparities through comparative

effectiveness research (CER). Supporting research on topics of cultural competence

and health disparities.

Cultural Competence in Health Insurance Reforms

Cultural & Linguistic Requirements of Exchanges and Participating Health Plans: Non-discrimination in health insurance exchanges. Culturally & linguistically appropriate summary of

benefits. Culturally & linguistically appropriate claims appeal

process. Incentive payments for cultural competence & reducing

disparities.

General Provisions

Over three dozen general provisions with potentially major implications for

racially/ethnically diverse populations

Health Insurance Reforms & Access to Care

Expansion of Medicaid eligibility to 133% FPLSmall business (<25 employees) tax creditsState-based health insurance exchangesSupport for Community Health CentersSupport for nurse-managed health centers,

teaching centers & school-based clinicsCommunity health teamsPrimary care extension programsPilots on regional emergency & trauma care

Public Health & Community Programs

Childhood obesity demonstration projectsNational diabetes prevention programEducation campaign for breast cancerCommunity transformation grantsNon-profit hospital community needs

assessment requirement

Quality Improvement & Cost Containment

National Strategy for Quality ImprovementDeveloping & evaluating quality measuresLinking Medicare payments to quality

outcomesPediatric Accountable Care Organizations Reduction in Medicare & Medicaid

Disproportionate Share Hospital (DSH) Payments

Highlights

Great breadth of opportunities in ACA to reduce disparities and improve health equity.

Federal agencies, generally assigned leading responsibility for advancing and implementing these provisions.

Many provisions related to equity, cultural competence and language assistance have received appropriations and offer opportunities for community based organizations, county agencies and states to pursue funding.

However, important provisions, with a strong evidence base for need have not received appropriations as yet and may require state, county and community organizations to take innovative approaches to achieve their objectives.

Primary Care Opportunities

Community Health Centers HRSA providing $10 million for new & expanded services for up to 125 FQHCs,

a maximum of $80,000 for 1 year per award in 2011.

School-based Health Clinics $50 million for each FY 2010-2013 for capital grants for facility construction,

expansion and equipment.

Primary Care Extension Program $120 million in 20011 to establish program to support and assist primary care

providers to improve community health.

Health Professions Training Opportunities HRSA grant programs for training in dentistry, primary care, & personal and

home care aides, with preference given for experience in cultural & linguistic competence.

Prevention Opportunities

Community Transformation Grants Over $100 million for 75 grants to help communities implement

projects proven to reduce chronic diseases as well as health disparities.

Investment in Prevention $750 million to reduce tobacco use, obesity and heart disease, and

build healthier communities ($298 mil for community prevention, $182 mil for clinical prevention, $137 mil for public health, $133 mil for research).

Personal Responsibility Education $75 million for states in 2011 to educate youth in

culturally/linguistically appropriate ways to prevent teen pregnancy and sexually transmitted infections.

Opportunities in Health Insurance Programs

Community Based Care Transition Program Funding in 2011 for eligible hospitals and community-based organizations that

provide evidence-based transition services to Medicare beneficiaries with multiple chronic conditions to prevent hospital readmission.

CHIP Childhood Obesity Demonstration $25 million in 2011 for a demonstration program to develop a model for reducing

childhood obesity.

Medicaid Prevention and Wellness Initiatives State grants in 2011 to provide incentives for Medicaid beneficiaries to

participate in evidence-based programs to prevent/manage chronic disease.

State Health Insurance Exchanges State planning and establishment grants for health insurance exchanges, which

can also be used to set up a navigator program and provide appeals process and benefit summaries in culturally/linguistically appropriate ways.

Cultural Competence Opportunities (with no appropriations)

Model Curricula for Cultural Competency Opportunity to test impact of a range of cultural

competency training programs on health outcomes and to identify efficacy & effectiveness.

Facilitating Shared Decision Making Patient decision aids are required to present up-to-date

clinical evidence about risks and benefits of treatment options to meet cultural & health literacy requirements of populations.

Community Access & Prevention Opportunities (with no appropriations)

Community Health Teams (CHTs) As states adopt medical home models, more low income &

diverse individuals with chronic illness will be able to turn to a CHT to help them link with a full range of health and social services they may need.

Community Health Workers (CHWs) Use of CHWs in health intervention programs associated

with improved access, prenatal care, pregnancy and birth outcomes, health status, screening behaviors & reduced health care costs.

Oral Health Prevention Activities Blacks, Hispanics, & AI/AN have poorest oral health

access and outcomes & could significantly benefit from these programs.

Where are our knowledge gaps?

Three main levels of gaps:

1. Individual

2.Organization

3.Community

1. Individual Level

Research and knowledge regarding incidence and prevalence of disparities-related conditions has matured as has documentation and tracking of rates and outcomes.

But knowledge gaps remain as to why disparities in outcomes have remained resistant to significant, consistent positive change in closing gaps.

Cultural competence initiatives and research seen as potentially significant strategies for reducing disparities

Individual Level: Evidence to Date

Few studies on intermediate effects of short term interventions (e.g., increased screening rates for cancer and improving HbA1c levels)

Some notable progress in: Documenting role of language and need for linguistic competence—

medical error, Title V civil rights violation costs, adverse events; Testing specific interventions—interpreters, materials etc

Little focus on outcomes such as reduction of disease incidence in a population

Little focus on effects on rates of disease morbidity or mortality

2. Organization Level

What role does the health care organization play in diminishing or perpetuating disparities gaps?

How do organization actions/inaction, responding to system incentives (e.g., reimbursement) affect disparities?

This is relevant in the era of health care reform, as resistance to change to address diverse patient needs intersects with new incentives to improve patient access and quality. What are characteristics of low performing health programs compared

with high performance health systems?

What are the implications and impact of pay for performance in the context of disparities gaps?

Organization Level: Evidence to Date

A few studies examined organizational policies--e.g.,

Diverse workforce recruitment, training, written materials, practitioner evaluation—demonstrated more appropriate use of asthma medications for children and greater parental satisfaction (Lieu et al, 2004)

Racial-ethnic concordance correlated with higher rates of physical exams in a drug abuse treatment program (Campbell & Alexander, 2002)

3. Community Level

There remains little knowledge about the influence of place and geographic differences in contributing to disparities. Beyond the more obvious and ‘usual suspects’—e.g.,

poverty, lack of education—what community factors perpetuate disparities?

What weight should be given to these characteristics in understanding disparities?

What are the social determinants of health that obstruct or facilitate access, quality and outcomes?

Fig. 1 The Current Health Care SystemThe medical care system functions as a funnel because individual illness is an outcome of, and final common

pathway for, society’s ills.

–J. Horowitz. The New England Journal of Medicine. Vol. 329, Number 2: 1993, pg 131

Community Level: Evidence to Date

 New and growing areas of focus:

Social determinants

Integration of community perspective and knowledge into programs (health workers, navigators, outreach)

Intersection of the health care, community and social environment

Measurement—Health Impact Assessments

Summary: Cultural Competence Knowledge Gaps

Still very short on documenting clinically what, specifically, constitutes a cultural competence intervention, what works, when and how.

Little guidance to organizations for integrating cultural competence into actions to improve health care processes and outcomes.

Relationship and importance of community engagement in providing culturally competent care increasingly acknowledged, but indeterminate.

What are Next Steps?

1. Cultural Competence-Related Research and Initiatives

Identify effective strategies for tailoring disease and wellness management to diverse individuals. NIH-based or other funded research into the efficacy of related

interventions generally and for specific conditions and groups of conditions (e.g., chronic disease).

Developing an evidence base for chronic disease management of diverse patients; need large sample longitudinal studies

Supporting research and assessment linking health care organization actions/policies with reducing disparities

Creating and testing specific interventions that train, educate and support participation of health care settings and practitioners in broader inter-sectoral strategies to promote health and prevent chronic illness

2. Cultural Competence Guidance

With the enactment of health care reform, need guidance to the field on cultural competence. Define what constitutes the field of cultural competence. Identify what the field needs to do to create an evidence-

base. Develop applicable and relevant measures of effect. Ground the link of cultural competence to quality, cost and

effectiveness. Determine the efficacy and role of cultural competence and

related interventions in achieving prevention objectives.

3. Training and Education

Separate the wheat from the chaff in training and education--Identify what constitutes effective diversity training and education.

Linking diversity training to progress in achieving desired processes and outcomes of care.

4. Policy and Programs

Creating and formalizing a federal and national strategy to promote inter-sectoral programs, initiatives and policies at the federal level. Promote interagency/community collaboration at the state/local

level to advance prevention and health care goals.

Develop research and demonstrations financially supporting health care practitioners and their settings in developing effective collaborative initiatives with housing, transportation, community representatives and others to improve health.

Demonstrations and evaluations of programs implementing CLAS, NQF and other recommendations.

5. Translation of Research to Practice and Policy