CCHAP Home > Newsletter Articles > Newsletter Nineteen, June 2008

Articles
 
Basics of Cross-Cultural Communication
 
New Medicaid Rates – Dramatic Increases
Starting in July
 
Jewish Family Services
Mental Health Services and Help with School-Related Issues
For Families of All Cultures
 
Practice Manager’s Corner
 
For Those Practices Participating in the
Immunization Reminder Project
 

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

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Basics of Cross-Cultural Communication

Marcia Carteret

Often, people attending cross-cultural communication trainings expect to learn a lot about cultural do’s and don’ts that can be applied reliably in interactions with patients. They are disappointed when I say that such lists are impractical if not downright problematic. There are three reasons I point to when explaining why lists of dos and don’ts won’t work. First, even if it were possible to assemble a comprehensive list of facts for each culture, the challenge of memorizing such information and keeping it straight would be enormous – and people don’t use lists, anyway. Second, people are varied in every culture and no simple list would be capable of capturing the variations within each culture. Third, and perhaps most important, interactions between people happen within a given context and it is the context that should dictate behavior more than memorized lists of ritual greetings, cultural rules of etiquette and so on.

In Thailand, it is considered rude to touch someone’s head - even a child’s. Also, inferiors generally keep their heads at a lower level than those they consider their superiors. Knowing these two things, would you need to adjust your behavior with a Thai family during an office visit in Denver? How would you determine your rank versus theirs? Do these same two rules of behavior apply across Asian cultures?

Clearly, lists of cultural dos and don’ts may actually create more confusion than clarity. In place of culture-specific lists, it proves more useful to build awareness around a set of solid generalizations that apply when conversing with a variety of non-American cultures. First, in order to establish a strong baseline of comparison, it is important to learn about key dimensions of American culture that have practical application in healthcare settings. For a review of these, refer to last month’s article. (www.cchap.org/nl18) Once you are grounded in an understanding of your own cultural norms, keep in mind the following basics for conversing cross-culturally.

Formality in Interactions: Americans tend to be very informal because we value equality among people and will often downplay overt expressions of status. This is related to our strong sense of individualism. We tend to be on a first name basis with a lot of people regardless of social position or rank within organizations. However, many of our patients will come from cultures where there is an element of formality in interactions between people early in relationship. For example, verbal and nonverbal communications with Hispanics are characterized by respecto while Asians focus on the importance of maintaining face/harmony in interactions. This is especially true with older persons and those who come most recently from very traditional societies. Over-familiarity, signaled right off by a casual use of first names, would not be appreciated in these cultures. Mr., Ms., and Mrs. should be used as a rule.

Eye Contact: Americans typically look directly into each other’s eyes when talking, conveying informality, spontaneity, and equality in their exchange of glances. When eyes shift and avoid meeting those of the other person, Americans may sense disinterest or perhaps even deception. However, a lack of consistent and strong eye contact may be a sign of respect or humility in other cultures. In some Asian cultures, eyes may be downcast or sweeping, and this often disturbs Americans. “He wouldn’t look me in the eye!” In Hispanic culture, direct eye contact is used far less and direct disagreement with a provider is uncommon.

Head Nodding: Nodding of the head may be a sign of acknowledgement rather than agreement in some cultures. The nod may be saying, “Yes, I am listening to you intently” rather than “yes I understand what you are saying and I agree.” The usual response to a decision with which the patient or family disagrees is silence and noncompliance. So, nodding and silence may mean “I am listening…but I am not in agreement.” The only way to know is to ask in a respectful manner what they are going to do (or are willing to do).

Taking Turns in Conversation & Silence: The way conversation gets passed between people varies greatly between cultures, and it is the length of sustained eye contact that cues conversational turn taking. Americans tend to make medium-length eye contact before looking away, and they use a longer direct gaze to cue changing speakers. In other cultures, where a direct gaze may be confrontational, lack of eye contact may make it awkward for Americans to pass conversation back and forth. Being generally uncomfortable with any period of silence in conversation, Americans will tend to rush through pauses and quickly complete sentences that dangle. As a result, people from less direct cultures may struggle to participate equally in conversation with Americans, an obvious hindrance in successful patient-provider exchanges. The solution is to practice allowing silence, which necessitates slowing down conversation and more careful listening as well. Being a task-oriented culture, Americans tend to want conversation to get to the point, where other cultures will use it to build relationship. The use of silence suggests really hearing, considering, and valuing what is being said by the other person and is critical in cross-cultural interactions to establish trust.

Use of Body Language: Americans tend to be moderately expressive when it comes to body language, gesturing freely compared to most Asians, but seeming constrained when compared to some Latin or Arab cultures. An American might misread an exaggerated use of hands or arms in conversation as an indication of excitability or distress in a person when, if fact, it means nothing of the sort. Keeping this in mind, providers should stay aware of how their own gesturing could be interpreted. Moving hurriedly and gesturing broadly might create discomfort for an Asian patient/parent but go relatively unnoticed by someone from the Middle East.

Use of Humor, Smiling and Laughter: A wise interpreter will avoid translating humor for the good reason that jokes and sarcasm don’t translate well across cultures. In some cultures, humor can even be seen as aggression or dominance. Americans, because we are individualistic and confident, tend to do a lot of put-down humor. We love to poke fun at ourselves and others. This can be confusing for people from other cultures where close attention is paid to preserving the dignity of all people in a given interaction – in Asian cultures this is called saving face. A well-intentioned provider, whose position automatically conveys status, would confuse some families by poking fun at himself. It could easily disrupt the sense of trust vested in him or her, especially for patients from formal cultures.

Finally, in American culture, there’s a big difference between a wry smile and happy smile, just as in many Asian cultures a ‘masking smile,’ with corners of the mouth turned down, is a polite way of letting you know what you are doing is not appropriate. Similarly, in many Asian cultures, especially in Japan, laughter can be a sign of embarrassment rather than a response to humor as it typically is in the US. Healthcare workers interacting with patients from Asian cultures need to remember the difference between high and low context cultures. Reading facial expressions, body language, etc. is second nature to people from Asian cultures, but goes unnoticed by many Americans unless they make a concerted effort to pay closer attention in cross-cultural situations.

Summary: Since lists of dos and don’ts for a culture can prove impractical for many reasons, it is best to work on developing a cross-cultural mindset instead. This means building awareness around what we call culture-general frameworks that call attention to areas of difference that are most important to consider when first encountering someone from another culture. By observing families in light of these generalizations, and by being willing to adjust to what you are hearing and observing, you will develop your own practical style. The most effective and practical approach will be to carefully apply these generalizations but leave room for individual differences and variations.

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New Medicaid Rates – Dramatic Increases
Starting in July

The Colorado Department of Health Care Policy and Financing (the Department) administers the State’s public health insurance programs such as Medicaid and CHP+. Under the leadership of Joan Henneberry, the Executive Director, and staff in the Department, the legislature approved provider rate increases effective July 1, 2008. This is reflective of commitment by Governor Ritter, the Department, and the legislature to the importance of preventive care and increasing provider capacity. Effective July 1, 2008, reimbursement rates for many services will be increased up to 90% of Medicare. Those practices participating in the CCHAP medical home project will also receive enhanced reimbursement for EPSDT well-child visits in addition to the July increases. The Colorado Chapter of the American Academy of Pediatrics, Ruth Aponte (their lobbyist) and the many pediatricians that have been attending meetings with the Department over the past several years should also be acknowledged for their efforts.

The attached table shows the common visit codes, plus developmental screening, hearing and vision testing and the reimbursement for an individual care plan (which is the established patient, high complexity visit code). Please note that Medicaid pays very well for standardized developmental screening.

Explanation of the columns in the table:

1. CPT code
2. Type of visit or service
3. The Medicaid reimbursement rate for the last year (2007-2008) for that code
4. Colorado Medicare rate for comparison. As you know, the Medicare rate is considered to be 100% of RBRVS
5. This column compares last year’s Medicaid rates with the current Medicare rates. It is last year’s Medicaid rates as a percentage of Medicare rates.
6. This column (yellow) represents the new Colorado Medicaid rates that will begin July, 2008.
7. This column represents the new Medicaid reimbursement rates as a percentage of Medicare rates. Note that the common office codes are at 90% of Medicare, which is a dramatic increase.
8. This column (green) represents the additional reimbursement for preventive care visits that the Department has been giving to CCHAP-affiliated practices. This will continue to be added to the new rates.
9. This column represents the total reimbursement for the preventive visit codes for practices affiliated with CCHAP. This includes the addition of a 96110 on top of the preventive code for developmental screening for children up to age 4.
10. This column represents the total reimbursement after July 1, 2008 for practices affiliated with CCHAP. This includes the addition of a 96110 on top of the preventive code for developmental screening.

The yellow column shows the new rate increases. The green column shows what the HCPF-CCHAP preventive care program adds to the new rates.

Click here to download the table (.xls)
Click here to download the table (.pdf)

CCHAP is working with The Daniels School of Business to complete a very detailed analysis of the cost of providing care for Medicaid children in private pediatric practices (right down to the tongue depressors and the light bills). For those practices that have participated, we have been able to help the practice determine what the effect on their bottom line is by adding incremental Medicaid patients to their practice. If you would like more information on this, contact Steve Poole at poole.steven@tchden.org.

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Jewish Family Services
Wonderful Services and Your Patient Needed Not Be Jewish

Stacey Weisberg
 
A patient you are treating and his family could benefit from counseling. They are depending on you to refer them to a provider where they will be treated by skilled professionals with outstanding cultural competency. They need payment options or the counseling they need may not take place. Where do you turn to help them?

Jewish Family Service Counseling Center is just such a place regardless of the family’s race, religion, or country of origin. We provide quality, compassionate mental health treatment to children, adolescents and their parents. Our services include comprehensive individual, couple or family therapy and case management. JFS treats those dealing with grief, divorce, depression, trauma and anxiety. We have specialty programs for those families who are from other countries or speak languages other than English. We have a specialty in Russian Mental Health.

JFS also provides mental health, case management and information & referral to students in many public schools in our Kid Success program. We also help promote cultural adjustment for refugee and immigrant students and families in our International Kid Success program.

JFS might be a resource for a child or family you know, please call us at (303) 597-7777. If we are not the best place for your referral, we will guide you to the resources you need. JFS accepts fee for service, private insurance and Medicaid. For more information, please visit our website at www.jewishfamilyservice.org

See the following Brochures (.pdf):
             Counseling
             Helping Children Be successful in School
             Counseling and support for children who have recently immigrated to the US
             Mental Health Services for Russian immigrant children 

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Practice Manager’s Corner

Christina Ells
 
Immunizations:

As many of you know, the procedure for billing immunizations has changed for all Medicaid vaccines. Please be sure to read the May Medicaid Bulletin carefully to ensure that you are billing codes correctly. Any claims that were not paid need to be resubmitted as an adjustment.

Website:

We are in the process of updating our resource list online, and have added some really great local resources for families. Please be sure to visit the website after June 10th and download or print a new copy of resources.

Practice Manager’s Meetings:

We have decided to change the format for practice Manager’s Meetings in order to meet the ever increasing demands for you at your practices. Therefore, meetings will be held quarterly instead of every other month. Of the four annual meetings, two will be held onsite at Children’s Hospital and two will be held via web cast or conference call. We know you are extremely busy, and want to make PM meetings effective and efficient.

This means that most changes to billing and CCHAP programming will be communicated via e-mail. If you prefer another method of communication, please contact Miranda Meadow at 720-777-5495 and let her know your preference. Thank you!
  

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For those practices participating in the
immunization reminder project

Please let your staff know that our reminder recall team is starting calls. Lists are going out to you so you know what kids need to be immunized. We will be bringing kits to your practices to help aid you in this process. The kits will include sheets telling individual patient immunizations needed and will indicate known siblings also needing immunizations. Also included are English and Spanish versions of appointment reminder postcards for families who have made an appointment for immunizations two weeks or more out. There will be an index box to organize appointment reminder postcards needing to be sent.
   

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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 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
   

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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 whatever 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

 

   

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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 providers are 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.
 

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Spanish Interpretation Training for Pediatric Practices

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