Disclosures

1. Medical Home in Pediatrics: The HOW TO Webinar Seriesbrought to you by the National Center for Medical Home Implementation How To Enhance Care Delivery for Diverse Patient PopulationsDiane Dooley, MD, FAAPContra Costa Regional Medical Center, California Dwight Yoder, MD, FAAPPediatric Partners of Mobile, AlabamaMarch 27, 2013

2. Disclosures We have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3. Webinar Objectives By the end of this webinar, the participant will be able to: Review the importance of effective provision of comprehensive care for patients and families who are vulnerable and/or medically underserved Explore specific strategies to deliver pediatric care in a culturally competent manner Highlight practical tools that can be used to assess patient and family needs in a culturally competent manner

4. Did You Know… • The portion of US children who are minorities has grown substantially: • By the year 2020, 44.5% of American children 0 to 19 years of age will belong to a racial or ethnic minority group • Hispanic children represent 1 out of 4 births • Almost 1 in 4 parents in the US are immigrants • 73.9% of Hispanic and 67% of non-Hispanic, black children did not meet all of the criteria used to measure quality of care, compared to 51.3% of white children • Children and youth with special health care needs who were Hispanic (32.2%) or non-Hispanic Black (36.8%) were far less likely to have families who reported that they had a medical home than White, non-Hispanic children (52.8%) • Minority children have high rates of unmet mental health needs: 88% of Latino children have unmet mental health needs while black children are more likely to be sent to the juvenile justice system for behavioral problems than placed in psychiatric care. References: America's Children in Brief: Key National Indicators of Well-Being, 2012: http://childstats.gov/americaschildren/glance.asp; March 2009 CPS, estimates by Pew Hispanic Center, www.pewhispanic.org; US Census Bureau. Middle Series, 2016–2020. Washington, DC.; National Center for Health Statistics [NCHS], 2007; Childrens Defense Fund: http://www.childrensdefense.org/policy-priorities/childrens-health/racial-ethnic-disparities/

5. Culturally Effective Care Toolkit Needs Assessment Results (September 2009) Do questions regarding the delivery of culturally effective care (such as language/interpretive services, traditional practices, cross-cultural communication) arise as you are caring for patients? n=278

6. Culturally Effective Care Culturally effective care is the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of cultural distinctions leading to optimal health outcomes. Cultureis used to signify the full spectrum of values, behaviors, customs, language, race, ethnicity, gender, sexual orientation, religious beliefs, socioeconomic status, and other distinct attributes of population groups. Ensuring Culturally Effective Pediatric Care: Implications for Education and Health Policy, Pediatrics 2004;114;1677

7. Communicating with Diverse Populations Diane Dooley, MD, FAAPContra Costa Health ServicesMartinez, California

8. Contra Costa Health Plan • Medicaid Managed Care Health Plan • Covers 110,000 low income children, mothers and adults • Majority of services provided at Contra Costa Regional Health Center Clinics 58% of parents report not speaking “English very well” 50% prefer Spanish

9. Pediatric Obesity – A Disparity Emerges Pediatric Nutrition Surveillance 2009Contra Costa – BMI-for-age > 95%ile

10. Causes of Health Disparities • Community level factors • Healthcare system-level factors • Care Process-Level variables • Clinical uncertainty • Clinical concerns regarding efficacy • Limited resources for language interpretation, translation • Time Pressure Differences in health care outcomes for diverse populations often result from issues of communication, culture and context -RWJ Equity Lens

11. Pediatric Obesity and Disparities Medical Literature • Language concordance between physicians and patients increases the quality of care, compliance with treatment and follow up and increases patient satisfaction. • Hispanic families are more likely to report that clinicians did not spend enough time discussing physical activity; quality of nutrition and physical activity advice rated poor or fair • California State law and Title VI of the Civil Rights Act require that health systems provide interpretation and translation services to limited English proficient patients

12. Measurement – Chart reviews • Identified evidence-based practice guidelines, MediCal Managed Care measurements and requirements • Develop chart tool • Serial chart audits with interval feedback and query with physician group 272 Charts reviewed June 2010 – March 2011

13. Measurement – Patient survey • Literature review and clinical queries regarding important aspects of care • Satisfaction, counseling, intended changes, respect, health education, language use, comprehension • Used some validated questions from CAHPS, developed own questions • Survey reviewed with promotoras, literacy level adjusted, translated 73 Surveys reviewed June 2010 – March 2011 Response rate 26%

14. Baseline Chart Review

15. Language Communication Survey results and chart reviews showed many gaps and uncertainties in communication • 81% of patients were very satisfied with their recent visit. Almost all patients planned to make lifestyle changes • 85% of Spanish-speaking patients reported that their provider either spoke their language or used an interpreter • 79% of Spanish-speaking families received care without documentation of interpreter use or provider certification

16. Provider focus groups Providers reported inadequate resources for patient education, group appointments, follow-up Questions were asked about the certification process Low literacy tools Latino staff members shared cultural issues regarding food and obesity Providers and patients agreed that care should be provided in the family’s preferred language Many providers commented that they did not feel comfortable with the use and availability of interpreter devices

17. Language Access Supports System policies regarding identification of race, ethnicity, language preference Identification of need Ongoing recruitment of bilingual staff, stipend for bilingual status, requirement for hiring in certain positions Bilingual staff Interpreter access Health Care Interpreter Network available, along with ad-hoc interpreters

18. Health Care Interpreter Network http://www.hcin.org/index.php/resources-video/ The Health Care Interpreter Network (HCIN) is a cooperative of California hospitals, and clinics sharing trained health care interpreters through an automated video/voice call center. Videoconferencing devices and all forms of telephones throughout each hospital and clinic connect within seconds to an interpreter on the HCIN system, either at their own hospital and clinic or at another participating hospital and clinics.

19. Language Access - Challenges • Resident physicians reported many barriers to using interpreters in the clinic setting, especially time constraints, convenience, normalization of underuse by peers and mentors • Objective Spanish-language testing in combination with education and enforceable policies may play an important role in decreasing non-proficient Spanish use and improving care for LEP patients Time constraints Provider certification Interpreter costs and qualifications

20. Language Access - Challenges • Patients using some form of interpreter had longer mean provider times (32.4 min vs. 28 min) • Provider self-perceived cultural competency was associated with discussion of sensitive topics, parental reports of quality of well child care more than language concordance Clinic flow and support Culturally appropriate resources and referrals

21. Improvements in Care

22. Conclusions • Language concordance is difficult to measure and document • Systems improve their performance when they move from “getting by” to a culture of equity • Access to interpreter services, and increased cultural competency improves care, but is difficult to accomplish Language and culture are critical components of care in pediatrics

23. Resources Kaiser Permanente Clinical Cultural and Linguistic Assessment: www.altalang.com/language-testing/ccla.html RWJ Roadmap to Reduce Disparities:www.solvingdisparities.org/tools/roadmap Health Care Interpreter Network:www.hcin.org References available on PubMedwww.ncbi.nlm.nih.gov/sites/myncbi/collections/public/1Zuqdiw6uFmOYYX721hwJ2KQ4/?sort=date&direction=ascending

24. Dwight Yoder, MD, FAAPPediatric Partners of Mobile, Alabama

25. What do we do when we have a patient in the office who does not speak English? • Verbal language as a subset of communication • Cultural awareness as a tool • Patterns of behavior that are evolving

26. Welcome to Mobile • An old city with rich, diverse culture • Early French and Spanish culture • Recent wave of Asian immigration

27. Vietnamese in Mobile • 2010 Census: 8,000 Asian inhabitants in Mobile County • Majority of Asians from Vietnamese Community • These numbers do not include mixed race families

28. Vietnamese in Mobile • Lower Middle Income Shop Owners • Variety of Skilled and Unskilled Laborers • Some Professionals in Business, Engineering, and Medicine

29. Vietnamese in Mobile • Community Broadly Organized Around Faith Based Groups: • Buddhist • Catholic • Evangelical Christian

30. Vietnamese in Mobile • Vietnamese families that need language assistance are in “Survival Mode” • Non-Urgent medical questions not addressed in this context due to frustration and time constraints • Mental Health takes a back seat

31. My Introduction to the Vietnamese Community • National Service Corps in Bayou la Batre 2000-2003 • Large Vietnamese population includes many new arrivals • Minimal staff assistance • Vietnamese study with assistance from community members and University of South Alabama • Patients from this community later followed me to my private practice in Mobile

32. Failure to Communicate • Dual problem of verbal and cultural understanding • Cultural differences mean that language alone would not bridge the communication gap • But words are a good starting place

33. Stocking a Tool Kit • Developing a flexible skill set for dealing with communication issues • Many communication problems require use of multiple tools • Three main categories: • Engineering • Market • Behavioral

34. The Engineering Solution • Technical: assumes relatively straightforward solution • Use of Informatics • Could be implemented as a requirement • Not a complete solution, but better than our current paradigm

35. The Market Solution • “Technical non-Technical” approach • No restrictions or requirements placed on provider behavior; the market will find a solution • Assumes the existence of an economically viable solution under current payment system • The “Race to the Bottom” • This is the current state of affairs in my community

36. The Behavioral Solution • Can we change physician behavior? • Can we select for a different set of behaviors at the physician training level? • Will we need system structure changes (engineering)? • Will the changes need to be incentivized (marketing)?

37. Current Assets • Family members as interpreters: concerns regarding objectivity, privacy, technical language, especially when children are used • Community members as interpreters: privacy, competency, reimbursement concerns • Technological solutions: improving rapidly • Professional interpreters: vast improvements in competency, privacy, objectivity, but costly and still time consuming

38. Can We Create New Assets? • Language Learning as a viable alternative for most physician encounters with non-English speaking patients

39. Motives for Language Learning in the Patient Care Setting • Better quality overall communication • Improved relationship with patients and their families • Learning about different cultures • Overcoming privacy problems

40. Language Learning Strategies • Setting appropriate goals • Using a variety of methods: written materials, recorded materials, online tutoring, local teaching when available • Monitoring progress: fast enough to make progress, slow enough to provide reinforcement • Employing professional teachers

41. Limits of Language Learning • Time constraints: a long term investment, like medical training • Ability versus Desire: Language Learning is “want to” • Engineering solution: may not solve all of your communication problems • In the end, some patients will still choose a • physician who they can’t talk to!

42. Pitfalls of Language Learning Solution • Loss of Objectivity: you may become more involved in your patients’ lives than you intended • Patient encounter as language lab • Patient encounter as anthropology workshop

43. Benefits of Language Learning • Increased patient confidence • Improved community credibility • Improved provider satisfaction

44. Language Learning as part of the Medical Home Concept • Becoming a community asset • Providing comprehensive, culturally appropriate services • Enhanced reimbursement: already starting to see this in global fee increases

45. Case Presentation: Peter (2003) • New 12 year old Vietnamese patient with asthma • Surprising new role for the physician/interpreter: father and son cannot communicate • Looking for context in religious affiliation

46. Case Presentation: Theresa (2007) • New 5 month old Vietnamese infant with fever • Absolute respect for authority • Falling through the cracks: patient referred non-Vietnamese speaking physician for insurance reasons

47. Case Presentation: Diem (2011) • 4 day old Vietnamese infant • Referred by friends due to mother’s limited English skills • Highlights my evolving role in the community • Everything for the family

48. Conclusion • Patient/physician communication is very complex • Direct communication between patient and health care providers is best, however patients will choose to access the health care system based on many criteria • Consider making language learning an integral part of physician training

49. Additional Resources • National Center for Cultural Competency • http://nccc.georgetown.edu/ • National Center for Medical Home Implementation • Cultural Effectiveness Spotlight Issue • Health Resources and Services Administration Resources • http://www.hrsa.gov/CulturalCompetence/index.html • American Academy of Pediatrics – Health Equity Resources • http://www2.aap.org/commpeds/resources/health_equity.html • American Psychological Association – Health Disparities • http://www.apa.org/topics/health-disparities/index.aspx

50. Questions?