Cultural Competence in Health Care and its Contribution to Eliminating Racial/Ethnic Health Disparities How far have we come and where do we need to go? Dennis P. Andrulis, Ph.D., MPH Senior 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 Legislation 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 Health Progress in Promoting National Guidance and Standards – cont’d.

Affordable Care Act and Cultural Competence

Diversity-Specific Provisions Over three dozen provisions in ACA on race, 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% FPL Small business (<25 employees) tax credits State-based health insurance exchanges Support for Community Health Centers Support for nurse-managed health centers, teaching centers & school-based clinics Community health teams Primary care extension programs Pilots on regional emergency & trauma care

Public Health & Community Programs Childhood obesity demonstration projects National diabetes prevention program Education campaign for breast cancer Community transformation grants Non-profit hospital community needs assessment requirement

Quality Improvement & Cost Containment National Strategy for Quality Improvement Developing & evaluating quality measures Linking Medicare payments to quality outcomes Pediatric 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 School-based Health Clinics  $50 million for each FY for capital grants for facility construction, expansion and equipment. Primary Care Extension Program  $120 million in 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 System The 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