CCHAP Home > Newsletter Articles > Newsletter Eighteen, May 2008

Articles
 
What Providers And Staff Need To Know About Culture
(Dimensions of Culture)
 
What is Continuous Quality Improvement?
What Can CCHAP Do To Help?
 
Presumptive Eligibility (PE)
(An Update)
 
Financial Help for Families Whose Commercial Health Insurance
Does Not Cover Medical Needs www.uhccf.org
 
Principles of the Patient Centered Medical Home
www.pcpcc.net
 

Ongoing Services
- Child Psychiatry Telephone Consultation on Medicaid Children
- Provider Resource Hotline for Children with Chronic Illness
- Integrating Developmental Screening In a Pediatric Practice
- Medical Spanish Training For Your Office Staff

^{Download Newsletter Eighteen}

  

   

What Providers And Staff Need To Know About Culture
(Dimensions of Culture)

  
This is the fifth in an on-going series of articles focusing on the importance of strong cross-cultural communications skills in healthcare settings. In last month’s issue, we focused on understanding what culture is and how crucial it is to the development of identity in human beings. The culture a person learns early in life becomes a set of hard-wired mental and emotional “operating instructions” for how to go about getting basic needs met. It is natural for people to feel resistance to cultural difference. Resistance is a phase we pass through in order become more cross-culturally aware and skillful. The process involves learning to see our own culture as one of many cultures that are equally valid within different contexts.  In order to do this effectively, we must develop deeper awareness of our own cultural ways as a baseline for comparison.  The statement, “green is different,” makes no sense unless we can say different from what.
   
American Culture
   
Cultural aspects of everyday life are often difficult for people of dominant cultures to discern because their practices, traditions, values, and understandings are taken for granted as the norm. For them, there’s no apparent need to examine cultural difference, and thus, no inclination to do so. In the US, middle-class Americans are typically so unaware of their own culture they believe that American culture is a melting pot of other cultures. This misperception is further complicated by confusion over terms - like white, American, the dominant majority, mainstream, middle class, western, European American. For our purposes here, American means “middle-class European American” and refers specifically to the “cultural ways of the group that in recent decades has held a mainstream position in North America. These are people who are primarily of Western European descent, with a social position that is often characterized as middle class on the basis of having participated in high levels of formal schooling and associated occupations.” (Rogoff 2003)
   
Now that we’ve established what the term American points to in this article, let’s begin to look at some specific dimensions of American culture. A dimension of culture is a recognizable point of comparison used to explain how different cultures prefer to approach and solve a universal problem. There are more cultural dimensions than we can possibly address here, so we will focus on a few that seem especially relevant to patient/provider interactions.
  
Time and Its Control
For Americans, time is a critical factor that is battled on a daily basis. We’re in an adversarial relationship to time. We talk about saving or wasting time, managing time and beating the clock. Americans invented day-timers and added the term multi-tasking to the English language. We invented fast food and made it even faster by adding the drive-thru.  Now even our pharmacies offer drive-thru pick-up.
  
Many of the other cultures in the world have a more relaxed view of time. In a healthcare setting, busy practitioners may not realize that patients from different cultures often experience the rushed pace of an office visit as disturbingly impersonal. It is important to slow down enough to exchange a few words of personal conversation with patients. Ask how their family is doing. This gesture only takes a few moments.  It puts patients more at ease so they can respond more openly to medical questions. If the doctor is in a big hurry, patients won’t ask for clarification about treatment and medications. Establishing a conversational style also helps providers introduce conversation about cultural beliefs around illness which can be very important in diagnosing and achieving patient compliance. Physicians will succeed best with patients from different cultures when the care and the cure are experienced as inseparable.
   
Comfort with Change
Americans are fundamentally optimistic and place faith in the future. As a young culture with few traditions tying us to ways of the past, our identity and inspiration are projected forward in time. Americans link change to progress, development, and growth. We like things that are “New and Improved!” Older traditional cultures consider change to be disruptive and unpredictable. In other words - negative. When a new medical procedure or miracle drug becomes available, Americans are likely to respond with optimism while patients from risk-adverse cultures will show pessimism.  Doctors who demonstrate balance in this area will gain the most patient confidence. Clearly risk-avoidance varies from person to person within a culture, and plenty of Americans prefer what’s safe and predictable too. But as a generalization, we in the US do tend to take chances and embrace change.
   
Personal Control Over Destiny
Americans tend to believe that every individual has primary control over his or her destiny. There isn’t typically a strong belief in the power of fate or karma. In many cultures there is a belief that things, including illnesses, happen for a reason and may be beyond our control. People may show a tendency to resign themselves to bad things in a way that Americans never would. “It s God’s will.”   This doesn’t mean patients/families won’t put faith in an American doctor’s medicine, but there may be surprising belief systems operating around what has caused illness or how much control they can exert on the outcome. A Hispanic mother may believe that her child has Mal d’ojo, or has been cursed with the “evil eye.” Members of the traditional Hmong culture believe a baby’s soul can be detained by a malevolent spirit called a dab causing a number of serious illnesses including epilepsy.
   
Self-Sufficiency
Closely related to the American emphasis on individual control over destiny is the value of being self-sufficient. To succeed without depending on others shows supreme self-determination, self-reliance, and self-confidence. The concept of being self-sufficient, however, doesn’t translate into all languages and the trait is not valued in many other cultures. People from Hispanic and Asian cultures, who have strong attachment to families and communities, emphasize a skillful use of the bonds between families and friends when making decisions and getting things done. Interdependency is a more helpful cultural adaptation in many cultures around the world. The US healthcare system presents all of us with a unique set of challenges, but those who are from different cultures will really struggle to demonstrate the kind of self-sufficiency we respect in America.  The very nature of working together to find solutions means everyone – provider, staffs, patients, and their extended families - relinquishes self-sufficiency to some degree. 
   
Language
Language use as a cultural dimension deserves a whole separate article, but the basics can be touched on here.
   
             Americans are low context communicators, so the words we speak are expected to deliver everything that’s important during verbal interaction. We pay far less attention to factors such as body language and the context of what is being said. In high context cultures, gesture, body language, eye contact, pitch, intonation, word stress, and the use of silence are as important as the actual words being spoken in conversation. High context cultures tend to communicate in a less direct fashion. Americans, being low context, are comfortable with very direct speech and sometimes seem abrupt to people from high context cultures. We miss the nuances of conversation. Americans appreciate communication that gets straight to the point and tend to interrupt when conversation isn’t moving along.  People from many other cultures do not feel they have had a chance to adequately explain their concerns until they have told “the whole story.”  This is important to keep in mind when communicating with people from different cultures, especially those who are relatively new to the US. Interactions with Americans who are highly verbal and direct can be challenging for someone who is accustomed to telling a story as a way of answering a question. Americans aren’t the only direct/high context communicators in the world, but we certainly rank among them.
   
Individualism
Cross-cultural research shows US Americans score higher on this cultural value than any other culture in the world. All the values we’ve addressed up to this point are closely related to this one aspect of American culture. Individualism is the belief that each individual’s interests should take precedence over those of the social group. Collectivist cultures, by comparison, assign value based on the role a person plays within a group. If people were stars in the sky, being one of the seven brightest stars forming the Big Dipper would be more important to someone from a collectivist culture than being the single brightest star. In American culture, where the individual is paramount, everyone wants to be the North Star. 
   
Individualism versus collectivism is an important dimension of culture because it affects the way people live together – for example in nuclear families or extended families – and it has many implications for values and behavior. Childrearing as a whole is handled differently in collectivist cultures. The child in a collectivist culture is seldom alone, either during the day or night. Children are reared by an extended kin group that may or may not include family like ties with persons who are not biological relatives.  Important health decisions are not made solely by an individual – parent or otherwise. In many collectivist cultures, the term “family” doctor points to a medical relationship that is indeed more like family. Several generations visit the same physician, establish rapport and hold certain expectations for interaction with their doctor. Compare this to searching for doctors on the internet in the United States, or having to choose from an approved list of physicians in a managed care network. Feeling like an isolated stranger visiting a doctor’s office can cause great anxiety for a recent immigrant. There’s much uncertainty about how the medical system works, about insurance, about how an American doctor will relate to cultural and language barriers. All of these worries are an added burden to the actual illness that requires medical attention in the first place. So, a mother from a collectivist culture will likely bring a grandmother, aunt, or family friend for support when she visits a pediatrician. Big decisions about procedures, such as surgery, may take hours as wives ask husbands, husbands consult elder brothers, elder brothers consult the father or perhaps even a community healer. This can create confusion and frustration for western doctors, but collectivism is a deeply rooted value. The classic American individualist who stays aware of how collectivist cultures operate will be much more skillful in cross-cultural interactions.  Being group-oriented isn’t better or worse than being more individualistic. Both ways of approaching life have advantages. As with all the dimensions of cultures, awareness of difference without judgment is the path leading to happier healthier patients and successful providers.
   
Summary
This article has introduced six dimensions of American culture. Learning about our own cultural patterns provides us with a baseline for comparing cultures that are different. As we develop self-awareness around cultural experience, we are able to observe without leaping to judgment. We realize there’s a difference between what we actually observe and how we label our observations based on our own cultural programming. In the process of becoming more aware of interactions with culturally diverse patients, providers hone communications skills that benefit all patients. Increased patient satisfaction and health outcomes lead to happier providers and more successful practices. Certainly within the medical culture, that’s seen as a win-win situation of great value.

Do you want to think more about your culture?
View some questions that will help you think more about your own culture.
click here

  

- contents - newsletter archive - home -

  

What is Continuous Quality Improvement
Why Your Practice Will Begin to Use CQI

  
What is continuous quality improvement (CQI)?
           The continuous quality improvement (CQI) movement in health care comes from the business world originally.  It was developed as a way to manage processes in a way that identifies and fixes the  barriers that stand in the way of  performing at the highest level of quality.  This perspective breaks away from the culture of blame.  The focus is on working as a team towards improving  processes (the way the practice does things).

CQI helps practices:
           identify processes to focus on, 
           organize thinking related to that process, 
           clarify what is known, 
           develop a plan to improve the process, 
           measure how effective the plan is 
           and make little changes to make it even better. 
The improvement process includes planning, doing, checking, and reevaluating.

How is CQI different from Quality Improvement (QI) or Quality Management (QM)?
Traditional QI or QM is data collection and reporting of quality measures, often used by health plans to make decisions about reimbursement.  CQI takes the next steps of using the data to improve practice processes to improve the quality of care for the long term. 

Why is CQI important for your practice?
All of the health plans (including Medicaid and CHP+) are in the process of developing “standards” for primary care practices.  These standards will determine the level of reimbursement the practice receives.   So, practices will need to identify outcomes and processes needing improvement and have a way to improve the processes that will improve their performance on those standards.  The aim goes beyond just improving “scores.”  The aim is to actually improve the quality of care the children receive.  To do that the practices will need to improve their practice processes.

CCHAP is committed to helping your practice
improve processes and outcomes of your choosing.

Aims of CCHAP’s CQI process
           The main aim of CCHAP’s CQI process is to help you develop a culture of quality in your practice.  As the name states, this is a continuous ongoing process.  There is no direct endpoint.  All of the right people in the practice need to be involved in the process.  Not only will this bring multiple perspectives into the brainstorming, but it will take into account perspectives of all who are affected by a change in workflow or thought processes in your practice.  We can help you assess your starting point, develop your plan, change processes, measure how you are doing and adapt your processes.   

CQI focus of next Practice Manager’s Meeting
           At the next Practice Manager’s Meeting we will be discussing CCHAP’s CQI mission and goals.  We will discuss what areas of focus you are interested in starting with.  We will have a discussion as to what we can do to aid you in your CQI efforts.  Please think about what your practice would like to focus on.  Also think about someone in your practice who may be appropriate to act as your “quality champion”.  This person does not need to be a clinician or practice manager.  It could be an MA, receptionist, lab tech – whoever you think could provide appropriate interest, enthusiasm, and leadership to be the go-to person to kick off these efforts.  We look forward to hearing your ideas.
 

- contents - newsletter archive - home -

   

Presumptive Eligibility (PE)

  
Practice Manager’s Corner
By: Christina Ells

As of January 21, 2008, Colorado Medicaid began to offer Presumptive Eligibility to pregnant women and children/adults under the age of 18. There are many sites throughout the state that offer PE enrollment. Please click on the link below for a list of participating sites. You can refer patients and families to these sites for assistance with PE applications.

http://www.chcpf.state.co.us/HCPF/pdf_bin3/UpdatedPESiteList-2008-dist.pdf

Presumptive Eligibility is determined by the following criteria:

•  Financially qualified children ages 0-18 and parents with dependent children
• Parents whose income is at or below 60% of the Federal Poverty Level
• Children age 6-18 whose family income is at or below 100% of the Federal Poverty Level
• Children under the age of 6 and pregnant women whose family income is at or below 133% of the Federal Poverty Level

Documentation Needed:

• U.S. citizens need to provide U.S. citizenship and identity information
• Non-citizens need to provide USCIS (INS) documentation for full benefits
• Non-citizens seeking Emergency Medical Services only do not need to provide documentation

Medicaid PE for children includes coverage of all Medicaid covered services while PE for pregnant women only covers outpatient services. Client eligibility may take up to 72 hours to process. 

Any Medicaid covered services provided within the first 60 days of PE determination are automatically covered (assuming correct billing and coding procedures are followed), so your practice assumes no liability to see children covered by PE. This is greatly beneficial to your practice because it guarantees you will receive reimbursement for the children you see.

- contents - newsletter archive - home -

  
 

Financial Help for Families Whose Commercial Health Insurance
Does Not Cover Medical  Needs

www.uhccf.org

 
 

- contents - newsletter archive - home -

Principles of the Patient Centered Medical Home

www.pcpcc.net

 
 

- contents - newsletter archive - home -

  

Child Psychiatry Telephone Consultation on Medicaid Children

The Behavioral Health Organizations and the Mental Health Centers in the greater metro area have very generously made available telephone consultation by child psychiatrists to help providers in CCHAP – affiliated practices make manage their  Medicaid children with complicated mental health issues or complicated medication regimens.   These child psychiatrists are also willing to come visit your practice to get to know you and even to discuss cases.   We are very grateful for this very generous support for your Medicaid children.

Denver County – Rick March, MD – 303-504-1520
Jefferson County – Don Bechtold, MD – 303-432-5172
Adams, Arapaho and Douglas Counties - Joe Pastor, MD – 303-853-3888
   

- contents - newsletter archive - home -

  

PROVIDER RESOURCE HOTLINE

(Clarification of previous information)

To Help You Find All Appropriate Services and Resources
           for Your Chronically Ill or Special Needs Patients

Including Case Management or Care Coordination for the Child

And Education Resources and Support Services for Their Parents

                       Call  1-877-731-6017

                       Fax: 303-691-0846

                       Email: providerhotline@familyvoicesco.org

• Case management
• Care coordination
• Specialized services, resources, medical equipment, therapies
• Parent/patient education about chronic illness / special needs
• Parent/patient support services
• Help in finding funding for uncovered services

• You are seeing a new patient (new to Colorado) who is an infant with 22q Deletion Syndrome,  congenital heart disease, cleft palate and an oxygen requirement of undetermined etiology.  Parents want to link up with all of the support services and a parent group like they had where they used to live.
• A child with multiple developmental delays also has behavioral problems.  The parents are not sure they are getting all the help their child is entitled to and they want a parent  support group and they are asking for counseling.
• A parent with a disabled child wants your help in applying for some sort of waiver that you aren’t familiar with.

Monday thru Friday from 8AM to 4PM
Voicemail available 24/7

Provides follow-up with the provider office and with the family

CLARIFICATION 
Contact Erlinda or Lorena with CCHAP at PHONE 720-744-5522; FAX 303-751-9048
  –   When you are only wondering about socio-economic issues like food stamps, housing, Medicaid 
        eligibility, legal aid, abuse, etc.
 
If the hotline can answer your questions immediately, you can pass the information to the family while they are in the office or we can contact the family and give the information to them.

If the information is not immediately available, we will research the question or case and provide the information to you and the family later in what ever manner you and the family wish (via phone, fax, or email).

If you feel the family needs more assistance or follow- up, just let us know and share the family’s contact information with us or provide the family with our number for them to contact us directly.

When contacting us, please provide us with the following information:
Your provider office and PCP name
Name of Child
Date of Birth
Medical Condition / Primary Disability
Type of insurance
Resource or service requested
Who should we contact with information?
Family Contact Information
How is it best to provide information back to you: phone, fax, email or voicemail

DOWNLOAD A REFERRAL FORM CLICK HERE

DOWNLOAD AN 8.5 x 11 FLIER TO KEEP ON HAND AS A REMINDER  CLICK HERE

Next time you see a special needs child, call us to see how we can help

Questions about the hotline?  Call 1-877-731-6017

The Provider Hotline Is Sponsored By
Family Voices and CCHAP

 

   

- contents - newsletter archive - home -

  

Integrating Developmental Screening
Into a Pediatric Practice

• The Colorado Assuring Better Child Health & Development (ABCD) project has received a three year grant to provide training and technical assistance to providers to implement a “validated” developmental screening tool at well child visits for infants/toddlers birth to five.
• The ABCD project is partnering with CCHAP to provide training and support to pediatric practices to implement developmental screening.
• Medicaid will reimburse $34.00 to providers if you use a standardized, validated developmental screening test at an EPSDT visit.
• The Colorado Chapter of the AAP supports the ABCD project.
• Early detection and intervention improves outcomes.  Many delays in children’s development are missed in the first 4-5 years of life without a standardized, validated screening test. 
• The most time-efficient tool is one in which the parent completes a questionnaire.
• To comply with 2010 recertification guidelines by the American Board of Pediatrics, documentation will be required to show levels of involvement in practice improvement initiatives. By implementing the use of a “validated” developmental screening with a sensitivity and specificity rating of 70% or greater like the ASQ or PEDS, practices are taking steps to integrate quality improvement into their practices.
• What are providers saying about implementing either the ASQ or the PEDS parent questionnaire developmental screening tools:
• It takes 1-2 minutes for an MA, LPN or RN to score.
• It takes less than a minute of the provider’s time if the MA, LPN or RN scores the questionnaire.
• In many instances, it reduces the length of the visit.
• It helps providers concentrate on the concerns/priorities of the parents.
• It reduces the number of concerns that come up as you are walking out the door at a well care visit.
• It improves patient satisfaction.
• It promotes positive parenting practices.
• It increases provider confidence in decision-making for when to refer a child for further developmental evaluation.
• Eileen Auer Bennett, the Colorado State ABCD Coordinator and her team are available to assist providers in getting started. Training and technical assistance will be provided to practices to implement a standardized tool such as the ASQ or PEDS. Support will also be given to office staff on how to incorporate a standardized developmental screening tool into the current office work flow.

For more information, please contact:
            Eileen Auer Bennett
            720-333-1351
            ileanben@yahoo.com

The Ages & Stages Questionnaire (ASQ) is a well respected screening tool.  It has the best sensitivity and specificity.  It is standardized across various common minorities.   Health care providers have identified the following advantages:

• Parent completed—Parents are partners in their child’s
  assessment and intervention activities.
• Serves as a talking guide with parents identifying a
  child’s strengths as well as things the child is not
  doing yet.
• Practical—Scoring takes 1-2 minutes and can be done
  by paraprofessionals.
• Cost-efficient—May be photocopied repeatedly.
• Scoring is simple—Only three responses:
1. Sometimes, occasional or emerging response from
   child = 5 points
2. Yes, child performs specified behavior = 10 points
3. Not Yet = 0 points
• If the child’s total score falls in a shaded area of the bar
  graph for any developmental area, further diagnostic
  assessment is recommended.

• Developed out of four cross-validation studies on a
  nationally representative sample of families.
• Uses parent concerns or judgments about the child’s
  development and behavioral status.
• Easy to score—two minutes to elicit and interpret.
• Enables health care providers to determine the need to
  refer and where.

Visit www.pedstest.com to view and order the PEDS tool online.
 

- contents - newsletter archive - home -

  

Spanish Interpretation Training for Pediatric Practices

- contents - newsletter archive - home -

   CCHAP Home > Newsletter Articles > Newsletter Eighteen, May 2008