Integrating Health Literacy, Cultural Competence, and Language Access Services Workshop Summary (2016) / Chapter Skim
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4 Addressing the Challenges
4 Addressing the Challenges
Pages 43-66
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From page 43... ...
, spoke about some of the legislative proposals and administrative advocacy that her organization has been involved with to advance integration. Marshall Chin, the Richard Parrillo Family Professor of Healthcare Ethics in the Department of Medicine at the University of Chicago, discussed his experiences directing the Robert Wood Johnson Foundation's Reducing Health Care Disparities through Payment and Delivery System Reform program office and some of the successful interventions incorporating concepts of health literacy, cultural competence, and language access.
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From page 44... ...
, the HEDIS, and its recognitions programs for patient-centered medical homes and specialty practices. Its accreditation programs for some 1,200 health plans and ACOs, including a multicultural health care distinction program focused specifically on issues of cultural competence, language access, and health care disparities, are probably the most relevant for this workshop.
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From page 45... ...
The multicultural health care distinction program standard also requires networks to support practitioners in providing effective language services. With regard to quality improvement, the health plan accreditation program requires improvement, but it does not focus on CLAS, nor is it prescriptive about where health plans focus their improvement efforts.
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46 FIGURE 4-1 Reporting of data on race, ethnicity, and language needs, 2014. SOURCES: NCQA, 2015, presented by French, October 19, 2015.
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She noted that California is considering making the multicultural health care distinction program a requirement for its TABLE 4-1 Results from Practices in the Patient-Centered Medical Home and Specialty Recognition Programs, 2014 Patient-Centered Patient-Centered Medical Home Specialty Practice Functional Requirement (N = 420)
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From page 48... ...
"As we heard earlier in the discussion, passion and advocacy are what is going to make purchasers and regulators bring these issues into their incentive and value-based purchasing programs," said French. STATE LEGISLATIVE APPROACHES TO INTEGRATION2 The 23-year-old CPEHN was founded during an era of health care reform by four partners -- the Asian & Pacific Islander American Health Forum, the Latino Coalition for a Healthy California, The California Black Health Network, and the California Rural Indian Health Board.
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From page 49... ...
addition, communities of color account for 60 percent of the state's residents who have purchased health insurance through Covered California, the state's health insurance exchange, with Spanish, Chinese, Korean, and Vietnamese as the top four non-English languages spoken by Covered California enrollees. The 2014 California Health Interview Survey found that individuals with language issues have limited access to both primary and specialty care (see Table 4-3)
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Commercial plan translation thresholds are based on enrollment numbers, while interpretation services are required in any language during business hours, which de Guia said has presented challenges at times. Legislation regulating commercial health plans also requires the plans to collect race, ethnicity and language data, which de Guia noted gets to the point that French made about incentivizing or mandating data collection.
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The broad coalition of organizations that CPEHN works with has been engaged in California policy making for several years now and has built a good, responsive relationship with DMHC. This coalition was involved in creating Covered California and helped include diversity provisions in Covered California's board and set its goal to have its enrollees reflect the racial and ethnic diversity of the state.
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From page 52... ...
CPEHN is also working to create alternative methods for surveying consumers with low English proficiency about their needs and experiences that go beyond CAHPS and similar surveys, particularly for individuals who do not speak the languages for which translated surveys are available. The organization is also focusing on developing a culturally appropriate workforce by incorporating promotoras and community health workers who can better address cultural competency in the health care system.
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From page 53... ...
He then noted that much of his presentation is based on the work of the 33 grantees and 12 systematic reviews of the health care disparities intervention literature funded by the Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change, as well as the experience gained from providing technical assistance to a variety of organizations. Based on the lessons learned from the Finding Answers program, Chin and his colleagues have developed a six-step roadmap for reducing racial and ethnic disparities in health care (Chin et al., 2012)
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On a sobering note, Chin said, stratified data and cultural competency training alone do not improve clinical performance measures (Sequist et al., 2010)
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Doing so means making equity an integral component of quality improvement efforts. The challenge, though, is that too often the people who work on quality are not the same people who work on equity.
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The policy level includes clinical performance standards linked to reimbursement or mandated by legislation. Such standards can be structural measures of culturally competent organizations such as interpreter use or clinical outcomes, or they can be equity index tools to rate organizations.
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Finally, at the community level, it is important to empower the community through the more effective use of community health workers and to help communities address the social determinants of health. An examination of 400 different interventions, Chin explained, shows there are not many magic bullets for success, though he and his colleagues identified six common themes among successful, evidence-based intervention strategies: • Multifactorial interventions attacking different levers; • Culturally tailored approaches are better than generic approaches; • Team-based care, particularly when the teams are led by nurses; • Involving families and community partners; • Patient navigators; and • Community health workers, along with interactive skills-based training.
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From page 58... ...
Other components of behavior change theory include environmental factors such as incentives and self-efficacy, which includes coaching, quality improvement collaboratives, and various approaches to give people the confidence they can change. Both internal motivations -- professionalism and an appeal to do the right thing -- and extrinsic motivations, including financial and other rewards, also play an important role in behavior change.
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We can do better." EFFECTIVE COMMUNICATION IN HEALTH CARE4 In the day's final formal presentation, Stacey Rosen described what North Shore–LIJ Health System is doing to realign and integrate its efforts in health literacy, cultural competence, and language access. North Shore– LIJ Health System, which in 2016 will be renamed Northwell Health, is the 14th largest health care system in the United States.
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From page 60... ...
When this office opened, it began with a multiyear strategic plan to establish goals and steps to embed a culture of diversity, inclusion, and health literacy across the complex North Shore–LIJ system, including among its medical students and in the community it serves. As a first step, the office performed the American Medical Association's community climate assessment toolkit survey at several of the system's hospitals to better understand their cultural competency and health literacy awareness and readiness.
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From page 61... ...
Rosen noted that a guiding principle of the Katz Institute is that all of its community initiatives, events, fact sheets, presentations, and other activities would all include the tenets of health literacy, cultural competence, and language access. Rosen then discussed a few examples of the programs run out of the Office of Diversity, Inclusion, and Health Literacy.
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The system's language access activities are now overseen by a systemwide committee, which coordinates activities conducted by the system's 20 hospitals and its larger ambulatory practices that reach into their surrounding communities in a spoke-and-hub model. Rosen noted that these activities have recently won several innovation awards and recognition from various organizations dedicated to diversity and inclusion.
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Bau asked him to say more about addressing the additional burdens that safety net providers and community health centers might have to integrating health literacy, cultural competence, and language access services. Chin replied that despite the ACA, the system still creates more challenges for safety net providers in terms of having the most challenging patients, in terms of morbidity and socioeconomic and cultural challenges, and with respect to limited resources.
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Upon opening the discussion to the workshop participants, an unidentified participant asked how health literacy is assessed and if a patient assessed for health literacy skills is a health-literate patient. French replied the NCQA standard for its patient-centered medical home program is for the practice to systematically assess the health literacy of its patients and not to be prescriptive about how the practice does that assessment.
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From page 65... ...
North Shore–LIJ's Office of Community and Public Health has developed its own set of patient education materials, in partnership with various organizations such as the American Heart Association and WomenHeart, that are acceptably well written and health literate. Chin noted that someone at his institution has developed a method of teaching patient-centered care using the EHR that includes forming a triangle with the patient so the physician and patient can look at the screen together, asking questions that use data on the screen, and not looking at the screen when talking about a sensitive issue or mental health issue, for example.
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