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Cultural Competency

University of Utah Health Plans

What is it?

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Cultural Competence refers to the ability to effectively interact with people from different cultures.

Four Components of Cultural Competence

Four Components

1. Awareness of one's own cultural views

2. Attitudes toward cultural differences

3. Knowledge of different cultural practices and worldviews

4. Cross Cultural Skills

Why is it Important?

Why is it important?

1. Unclear communication can cause the whole medical encounter to fall apart.

2. Racial and ethnic minorities are disproportionately burdened by chronic illness.

3. Lack of cultural competence may lead to patient dissatisfaction.

4. Stereotypes may ignore variation within groups.

Cultural Considerations

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Cultural Considerations

Things to Know

  • Language or literacy limitations
  • Differing culture among subgroups
  • Varying culture between regions
  • Importance of family/group in decision making
  • Norms about masculinity and femininity
  • Patient may resist expressing pain
  • Use of traditional healing methods
  • Different ideas about what is sacred or spiritual
  • Ask questions! Patient may not ask out of respect
  • Consider which topics may be sensitive or taboo

Interaction Do's and Don't

Don'ts

Do's

Do's and Don'ts

  • Provide clear instructions
  • Ask questions
  • Make direct eye-contact with patient
  • Use interpreters when necessary
  • Talk too quickly or loudly
  • Assume that a silent patient has no questions
  • Use non-designated staff to interpret

Interpreter Tips

  • Hold a brief introductory discussion
  • Speak in the first person
  • Speak in a normal voice, not too loudly
  • Avoid using medical jargon and technical terms
  • Avoid interrupting during interpretation
  • Maintain eye-contact with patient
  • Only use designated staff as translators

Questions

Quiz

A patient arrives for an appointment with her twelve year-old son. Although the patient does not speak English, her son does. Should the son be used to interpret for his mother during her appointment?

Your patient stays quiet throughout the visit and does not ask questions. Should you assume that they fully understand your directions?

Resources

Resources

For more information visit:

  • https://npin.cdc.gov/pages/cultural-competence

  • https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect

Utah's Medicaid Population

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Medicaid Annual Report (2013-2017)

  • The amount of people who have enrolled for Medicaid since 2013, has stayed at a constant 13%
  • Asian enrollment has decreased since 2013
  • Black enrollment has increased since 2013
  • Native American enrollment has increased since 2013
  • Pacific Islander enrollment has stayed the same since 2013
  • Pacific Islander's have the lowest rates of enrollment in Utah
  • White enrollment has stayed the same since 2013
  • Children have the most enrollment in Utah followed by those who are visually impaired
  • CHIP enrollment has decreased since 2013
  • Urban and rural enrollment for CHIP has stayed consistent
  • 10.1% of of people ages 65 and older have no health insurance
  • 9.7% of Utahans live in poverty
  • 402 people were uninsured in 2013, went to 265 in 2016, and has gone up to 282 in 2017.
  • According to the Kaiser foundation medicaid beneficiaries by race/ethnicity data-set in 2017 were:
  • 90% white
  • 1% black
  • 6% hispanic
  • 3% pacific islander
  • 1% American Indian/Alaska native

Mental Health and Utah Medicaid

  • Mental health benefits are provided to Medicaid members under Prepaid Mental Health Plans (PMHP)
  • They cover medical costs for:
  • ambulance
  • home health
  • over-the-counter drugs
  • hospital
  • specialists
  • prescriptions

  • They also cover specific mental health services related to:
  • case management services
  • evaluations
  • individual and group therapy
  • inpatient services
  • psycho-educational services
  • psychological testing
  • respite care

Refugees and Immigrants

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Who is a Refugee?

  • According to the UN definition, a refugee is someone who has been forced to flee his or her country because of persecution, war, or violence. A refugee has a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group.
  • It is important to keep in mind that a refugee is a term to describe a temporary position in life, it is not a term that should be used as an identifier.

Who are They?

Who is an Immigrant?

An immigrant is a person who chooses to resettle in another country. Reasons for moving may be for job opportunities, better living conditions, education opportunities can eventually become U.S. citizens.

Who is an Immigrant?

Importance

Importance of these populations

  • Health care is an important indicator of successful integration for both populations, and will provide them with a sense of safety and stability in a new country.
  • Refugees and immigrants typically come with lots of health problems, more than the ordinary illness. Depending on how they arrived at the U.S., they most likely were not able to treat their illnesses and thus arrive in worse conditions than when they started their journey.
  • Once in the U.S. their various health issues may be left untreated due to their fears and uncertainties about the American healthcare system. Not only is health care and health insurance confusing, but it can take a while to understand it.

Do's and Dont's

Dos and Donts

  • Refugees and Immigrants may not want to let on that they are confused about a term or about a recommendation they get from their health care provider. Most of them have come from countries in which a health care provider is hard to come by and often expensive. They may not be used to being in a health care system in which they are expected to not only see physicians every so often, but also to take part in follow-up visitations as well as follow through with prescriptions.

Do's and Dont's

What you should do:

1. Use variety of instruction methods

2. Encourage questions and use Ask Me 3: What is my problem? What can I do to fix it? Why is it important for me to do it?

3. Use Teach Back: They tell you what you tell them

4/5. Office staff should confirm preferences during scheduling

6. Ask about home remedies and healers

7. Inform patients of the need for follow-up

8. Explain why patients may need to be seen by another doctor

9. Make HIPAA forms easy to understand, maybe in preferred languages

10. Approach these topics slowly and considerately.

What they don't tell you:

1. I tell you I forgot my glasses because I am ashamed to admit I don’t read very well.

2. I don’t know what to ask and I am hesitant to ask you

3. When I leave your office I don’t know what I should do next

4. I am not able to make important decisions by myself

5. I am more comfortable with a female doctor

6. I use botanicals and home remedies but don't think to tell you

7. My expectations do not align with U.S. managed care

8. I'm bewildered by requirements to visit multiple doctors

9. I fear my health information will be released to my community

10. Controversial topics like sex, pregnancy, pain management, mental illness, drug addiction, medicine, weight, domestic violence may be hard to discuss for some

Things to know

Why Refugees/Immigrants won't visit health centers

  • financial barriers
  • no health care voucher
  • on the waiting list for health insurance
  • no good physician known
  • fear or doctors/distrust of health care providers
  • transportation issues
  • lack of time
  • not a top priority

Cultural Value Differences

Resources

Catholic Community Services: A refugee resettlement organization that aims to help refugees and immigrants adjust to life in Utah. Case managers help refugees and immigrants for 2 years; more than any other resettlement agency in the U.S. who only help for 6 months-1 year.

https://www.ccsutah.org/

International Rescue Committee: Another refugee resettlement organization that aims to help integrate refugees and immigrants into Utah. They deal with 5 major factors: health, education, economic well-being, empowerment, and safety. One of about 40 cities in the U.S. who provide these services.

https://www.rescue.org/

Asian Association of Utah: A refugee resettlement agency that helps refugees and immigrants with issues relating to education, health care, economic achievement, and legal issues among other things:

http://www.ric-aau.org/

UNHCR: A branch of the United Nations that brings refugees into the United States through a lengthy process that involves numerous interviews and background checks. Members advocate for refugee and immigrant rights.

https://www.unhcr.org/afr/

Quiz

Questions

What is the difference between a refugee and an immigrant?

If you notice a client continually nodding and agreeing along with the information they are asking you, what should you do to ensure they actually understand you?

Knowing what you know about the American health care system, how would you feel if you immigrated to a new country that practices different methods of health care?

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Elderly and Disabled

Medicaid Definition

  • Medicare is available to most individuals 65 years of age and older.
  • Medicare has also been extended to persons under age 65 who are:
  • receiving disability benefits from Social Security or,
  • the Railroad Retirement Board and,
  • those having End Stage Renal Disease (ESRD).

Who are they?

Acknowledge we all need help throughout our lives.

At a time when older patients have the greatest need to communicate with their physicians, life and physiologic changes make it the most difficult.

Dos and Donts

Poor communication with this vulnerable population can undermine your efforts to provide good patient care.

Provide clear visit summary

Example

Tips for Physicians

  • Allow extra time for older patients.
  • Minimize visual and auditory distractions.
  • Sit face to face with the patient.
  • Don’t underestimate the power of eye contact.
  • Listen without interrupting the patient.
  • Speak slowly, clearly and loudly.

Tips for Physicians

  • Use short, simple words and sentences.
  • Stick to one topic at a time.
  • Simplify and write down your instructions.
  • Use charts, models and pictures to illustrate your message.
  • Frequently summarize the most important points.
  • Give the patient a chance to ask questions.

Tips for Staff

  • Schedule older patients earlier in the day.
  • Greet them as they arrive at the practice.
  • Seat them in a quiet, comfortable area.
  • Make signs, forms and brochures easy to read.
  • Be prepared to escort elderly patients from room to room.
  • Check on them if they have been waiting in the exam room.
  • Use touch to keep the patient relaxed and focused.
  • Say goodbye, to end the visit on a positive note.

Tips for Staff

Heterogeneous Life Experiences

Things to know

  • A wide range of life experiences often influence their perception of medical care and illness.
  • May affect willingness to adhere to medical regimens and communicate effectively with healthcare providers.
  • Communication can be hindered by normal processes and may change over time.
  • Changes may involve sensory loss, decline in memory, and slower processing of information.
  • May feel like they are losing power and influence over their own lives and separation from family and friends.

Questions

What are some ways you can adjust your typical care habit when meeting new patients that are disabled or aging?

Quiz

What might impact an elderly or disabled patient's perception of care?

How should the discharge summary be adjusted to fit the needs of an elderly patient?

Salt Lake County Aging & Adult Services: https://slco.org/aging-adult-services/ombudsman-program/

Aging and Disability Resource Center (ADRC): https://www.utadrc.org/

Resources

Division of Services for People with Disabilities (DSPD): https://dspd.utah.gov/

Utah State Office of Rehabilitation Administration’s Division of Services for the Deaf and Hard of Hearing: http://www.deafservices.utah.gov/

Utah Aging Alliance:

https://utahagingalliance.org/

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LGBT Community

LGBT stands for Lesbian, Gay, Bisexual and Transgender

This is a community that has traditionally faced disparties in health which include:

Consequences of LGBT Stigma

Access to Healthcare

-Lower rates of insurance coverage

-Lack of provider knowledge about LGBT health

-Previous discrimination in healthcare

-Lack of identifying information on intake forms

-Studies show that victims of hate crimes are more likely to suffer poor health

- The increase in mental health problems in states without LGBT protection

-The shorter lifespans of LGBT people who live in states without LGBT protection

-LGBT rights vary throughout the country

Things to Know

Specific Health Concerns for the LGBT Communiy:

-Obesity/High BMI: Much higher in lesbian and bisexual women

-Mental health concerns including depression and anxiety

-MSM (men who have sex with men) health concerns

-Transgender health concerns

-Body image and eatings disorders in homosexual men

-Tobacco increased in all subpopulations

-Alcohol/drugs: Increased use

-STDs: Increased rate in MSM (men who have sex with men) and lack of knowledge

-HPV: Including cervical paps AND anal paps

-HIV: Highest incidence in trans women of color

Do's and Don'ts

Do

Don't

-Create a safe non-judgemental environment for LGBT persons

  • Post a non discriminatory policy that includes sexual orientation and gender identity
  • Include LGBT images, data, and language on all handouts and brochures
  • Language Matters: ask for preferred pronouns and then respect them
  • Add a transgender option on intake forms

-Remain unbiased and focus on serving your patient

  • The largest obstacle that affects care for the LGBT commuinty and health providers stems from a lack of trust. Regardlless of your personal views, focus on giving them the best healthcare possible

-Do not ask for sexual history if not relevant

  • If relevant, ask open ended questions that do not assume heterosexuality i.e. "Are you in a relationship" vs. "Are you married?"
  • Keep reactions nuetral when asking about sexual history

-Do not ask for private information in front of family members

  • LGBT members may not be completely honest in the presence of family members. Ask for privacy when discussing sexual history and other sensitve issues

Questions

You have a patient whose sex is listed as "male", but it appears that they are expressing as female. What do you do?

Your patient is accompanied by an older adult who could possibly be a parent. According to you results, you need to ask some questions about sexual history. What should you do first?

Resources

The Trevor Project

Utah Aids Foundation

Helps prevent against HIV infection and empowers people living with HIV/Aids to live healthier and happier lives

S 1100 E, Salt Lake City, UT

(801)-487-2323

The Trevor Project is the leading national organization providing crisis intervention and suicide prevention services to lesbian, gay, bisexual and transgender young people under 25

1-866-488-7386

www.thetrevorproject.org

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