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| CCHAP Home > Newsletter Articles > Newsletter Twenty-One, September 2008 | |||
CCHAP Newsletter Twenty-One |
Articles
Using the Clearest English Possible:
8 Tips for Communicating with Limited English Proficiency Patients and Families
Child Psychiatrist Available to Provide Teaching for You in Your Office
How To Refer A Child (0-5 Years Old) Who Has Developmental Delays,
Social / Emotional Problems or Complicated Medical Problems
Practice Manager’s Corner
The Cross-cultural Curriculum for the Department of Pediatrics
The syllabus is now available for you and your practice
Grand Rounds at Children’s Hospital – September 12, 2008 at 12:30PM
Department of Pediatrics Cross-cultural Health Care CurriculumOngoing 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 Twenty-One 
Using the Clearest English Possible:
8 Tips for Communicating with Limited English Proficiency Patients and Families
By Marcia Carteret
Many of the CCHAP practices I have visited for the purpose of cross-cultural training are lucky to have staff and providers on their team who speak Spanish and other foreign languages. However, some practices are seeing patients from such diverse cultural backgrounds that it is impossible to have staff and providers capable of understanding all the languages of these patients. During cross-cultural trainings, we talk about the fact that patients from different cultures often nod their heads during conversations with healthcare providers, but this does not necessarily mean that they understand what is being said to them. Culturally, a head nod may be a gesture of respect, a way of saying, “Yes I am listening and being attentive. I recognize and appreciate your professional expertise.” The key question that comes out of this particular conversation in trainings is, “What can be done to make sure patients understand what is being said to them?”
The answer is twofold. First, it is absolutely critical in any healthcare situation that open communication take place, so don’t back off from asking questions in a culturally sensitive way. Americans often experience paralyzing anxiety around political correctness, which definitely shuts down vital communication. You have to push yourself to reach beyond your comfort zone in many situations. Secondly, try your hardest to use the clearest English possible when speaking to non-fluent English speakers. Naturally, you don’t want to offend anyone by oversimplifying, but always be prepared to err on the side of simplicity to maximize understanding. The tips that follow can be adapted to a broad range of nonnative speakers.
TIP #1: Keep in mind, English is a difficult language. We take for granted in the US that much effort is made by people around the world trying to learn our language. If English is your first language, you may not realize you were lucky to learn English without much conscious effort and it is hard to appreciate the struggle of those who have to put great effort into speaking and understanding it. Consider this illustration of how difficult English is: If the word through is pronounced “throo” then why is enough pronounced “ee-nuff?” Why isn’t the word cough pronounced “coo?” Why is threw sometimes spelled through, and why do these two words that sound exactly the same mean two completely different things?
It’s also very difficult to learn which syllable gets the accent in English words: beginning (DEN-ver), middle (col-o-RAD-o), or end (cor-TEZ). In many other languages the accents are equal or they are indicated in the spelling of the word like Còmo està. Also consider the strange spelling of English words like science and since not to mention the illogical trio their, there, and they’re.
TIP #2: Keep it Simple. In work settings, we slip into our professional roles, often changing our way of speaking automatically so that we choose words like utilize instead of use. With limited English proficiency patients and families, the 5¢ word is always better than the 75¢ word. Basics such as good, give, take, more, less will be better choices than positive, administer, increase, decrease. Keep word choice simple and keep sentences simple as well. Avoid run-on sentences. Americans tend to be uncomfortable with silence, so we ramble on if there’s a break in conversation. As we ramble, we tend towards more complex ideas rather than simpler ones. Allow some silence between simple phrases.
TIP #3: Give and Seek Feedback. Even if you are using simpler words and shorter sentences, you can’t be certain there has been communication until the receiver acknowledges it with feedback. Remember, head nodding does not count as feedback with people from many different cultures. Even with Americans, and definitely with children, head nodding is often a sign of partial comprehension. So you must ask clarifying questions.
There are two kinds of questions.
- Close ended questions: These usually begin with do, did, does, is, are, will, or can. These can be answered with a simple yes or no – or a head nod. Avoid the use of close-ended questions with LEP patients because in many cultures people will frequently simply say yes even if they don’t understand you. If a person doesn’t want to contradict the doctor or other healthcare professional, nodding or saying yes is a way of keeping harmony in the interaction. A patient or parent may nod and then leave the doctor’s office with little understanding of what to do next. Or, the person may have no intention whatsoever of complying with the recommendations for treatment that were given for cultural reasons that were never discussed.
- Open-ended questions: These usually begin with the 5 Ws – who, what, when, where, why (and how or how many). It’s not possible to answer these questions with a nod, shrug, or simple yes/no. For example, you might ask a patient/parent, “What do you think has caused this illness?” Or, “How long have you been seeing these symptoms?” “What are you most worried about?”
TIP#4: Not Understanding vs. Misunderstanding. Keep in mind that when people don’t understand you, you are more likely to get some indication of miscommunication than when they MISunderstand you. When there’s a lack of understanding, there’s often a break in the conversation. A person may ask you to repeat what you have said or you may read confusion in facial expressions. But when people misunderstand, they may be less likely to indicate this, especially if they come from an indirect and face saving culture. For example, the English words want and won’t sound very much alike to a nonnative speaker. You may say to a person, “I want to help you,” but she may hear “I won’t help you.” She may be perplexed that this is your response, but she may be very inclined to accept the word of a healthcare professional who is in a position of authority. She may perceive you as being uncaring, but certainly won’t say so. Many misunderstandings go unnoticed by both parties. Asking clarifying questions is crucial.
TIP#5: Speak Slowly and Clearly – NOT Loudly. Often when people don’t understand our language we treat them as if they are deaf or “slow” without realizing it. Articulate your words in shorter phrases rather than just speaking more loudly.
TIP #6: Repeat if Necessary. Much of what we gain from a conversation is the context or general content of the discussion. Our brains constantly fill in the missing information. If we don’t actually hear every word, we compensate. For example, if I say, “I left you a message on your______” you will almost automatically fill in the blank with cell phone, phone, or voicemail. Nonnative speakers will struggle to do this. So repeat key phrases and summarize key points. Also, make it clear at the outset that you are happy to repeat anything you say in conversation.
Tip #7: Avoid Acronyms, Idioms, Abbreviations. The medical culture has a language of its own that includes many acronyms such as ED, HMO, NPO, etc. Always take the time to say things the long way and avoid terms that will create confusion for nonnative speakers. It’s best when setting appointments to say “eight o’clock in the morning” instead of “8 a.m.” Common expressions and idioms can also block communication. If you say, “I’ll run that past the doctor,” an LEP patient may literally picture you running to the doctor which sounds urgent when you intended a casual tone. Imagine how confusing an expression such as “we can kill two birds with one stone” might sound in the context of a doctor’s appointment. I’ve often been surprised at the language people use in cross-cultural settings with nonnative speakers. Especially when we are rushed, tired or stressed our self-awareness slips.
TIP #8: Write It Down, Demonstrate While Speaking. Providing simple notes about the key points of an office visit and expectations for patient follow up can be very useful to LEP patients and families. Written material with more detailed information about medications and treatments can also be very helpful in conjunction with thorough explanation in the doctor’s office. A really thorough explanation will include checking for understanding via open ended questions, gesturing while speaking, demonstrating the application of topical medications, etc. Even English learners who have had the benefit of formal education were probably exposed largely to workbooks and taped dialogues. They have little practice with actual conversation and can’t understand native speakers. For those persons who have had no formal schooling, written material may be beyond their capacity entirely, but perhaps someone at home can help translate what is written. That way they have a reference point for what was said in conversation with the healthcare provider. Written material can be taken away and read at a leisurely pace without pressure is often greatly appreciated.
Communicating with limited English proficiency patients is one of the greatest challenges for healthcare professionals. Having a fluent speaker on hand who is either a trained interpreter, a staff member, or adult family member is ideal, but not always possible. Hopefully, the eight practical tips covered here will prove helpful, along with adopting a determined mindset about overcoming the fear of making mistakes in conversation with culturally different patients. Being willing and able to ask questions in a culturally sensitive way is vital. For providers, it is also important to be familiar with the LEARN mnemonic: listen, explain, acknowledge, recommend and negotiate. Review the LEARN mnemonic in the new Cross-cultural Healthcare Curriculum. Download the Curriculum and view page 50. click here
For more on helping families with limited English proficiency visit the new Cross-cultural Healthcare Curriculum. Download the Curriculum and view page 37. click here
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Child Psychiatrist Available to Provide Conferences for You In your Office
Rick March, MD is a child psychiatrist at the Mental Health Center of Denver. He is available to provide teaching on a variety of child Psychiatry topics (below) in your office. He is also willing to discuss cases with you, as well. Please contact him to take advantage of this wonderful opportunity.
He can be reached at Rick.March@MHCD.org
Here are some of the topics he can cover for you.
- Diagnosing Depression in Children and Adolescents
- SSRI’s and Black Box warnings
- Suicide and self-abuse
- Diagnosing Bipolar Disorder in Children and Adolescents (including differential diagnosis)
- Atypical Antipsychotics
- Mood Stabilizers and Antidepressants
- Pediatric Psychopharmacology and the FDA
- Kid with ADHD who don't get better on stimulant medication
- Psychosis in Children and Adolescents
And, remember there is a child psychiatrist on call available by phone for your Medicaid children…..
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 to 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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How To Refer A Child (0-5 Years Old) Who Has Developmental Delays,
Social / Emotional Problems or Complicated Medical Problems.
For more information on this, please contact:
Bill Campbell, MD, FAAP
Assistant Professor of Pediatrics
University of Colorado Denver School of Medicine
Campbell.William@tchden.org
Referring a child 0-3 years old
The following is an algorithm that explains the processes that make up the Early Childhood Connections program, from the initial referral to determining eligibility. It is a good place to start for children for whom you have concerns about developmental or social/emotional problems or for special needs child. The flow chart also discusses the planning process for early intervention supports and services for eligible infants and toddlers, including transition planning when a child approaches three years of age. Visit the website http://dev.civicore.com/cffc2/ to follow the links for more information.
Referral Process for Children 3-5
The following is a algorithm that explains the process for referring a child age 3 - 5 with medical, behavioral, developmental and/or other concerns. Many steps in the referral process have additional resource links to support that step in the process. Visit the website http://dev.civicore.com/cffc2/ to follow the links for more information or for a printable version.
These guidelines were developed in partnership with:
Colorado Behavioral Healthcare Council
Colorado Children's Healthcare Access Program
Colorado Department of Education Early Childhood Initiatives
Colorado Department of Health Care Policy & Financing
Colorado Department of Human Services, Division of Mental Health
Division for Developmental Disabilities
Colorado Department of Public Health and Environment Health Care Program for Children with Special Needs
JFK Partners, University of Colorado School of Medicine
Project BLOOM
Smart Start Colorado
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Practice Manager’s Corner
September 2008
Christina Ells
Resource Guides
As discussed in the Practice Manager’s meeting, Resource Guides are now available to assist you with Medicaid and CHP+ families. This guide was created to give you more in-depth resources for solving issues such as Medicaid and CHP+ Add-A-baby, transportation and general socio-economic referrals. Please let me know if you prefer to have a guide sent to you in hard copy, otherwise it will be posted on the website along with the Orientation Manual. Enter your user name and password…a link to the new Resources Guide will be on that page.
Immunizations
To clarify some residual confusion regarding billing Medicaid for pediatric immunizations, I am attaching a link to a wonderful AAP article that outlines specifics regarding immunization administration. Please read the article here: http://www.cispimmunize.org/pro/pdf/Attachment%20D_Overview.pdf
Keep in mind that immunization billing for Medicaid is now billed exactly as you would bill any commercial insurance. You are reimbursed for the administration codes used, and the vaccine CPT codes are needed only to identify which immunizations were given at the visit. Since you receive VFC for your Medicaid patients, you will be reimbursed $0.00 for your vaccine line item(s). If there is still confusion, please contact me for clarification.
Training
ASC (Medicaid’s fiscal agent) is conducting statewide beginning and specialty billing workshops from 9/9/08 – 9/23/08 and 10/7/08 – 10/23/08. If you haven’t already attended a training, I recommend you or a billing staff person attend. There are many nuances about billing Medicaid that can be overwhelming and confusing.
Rx Pads
Effective October 1, 2008, Tamper-Resistant Rx pads will require: 1. One or more industry-recognized feature designed to prevent unauthorized copying of a completed or blank prescription form; 2. One or more industry-recognized feature designed to prevent erasure or modification of information written on the prescription by the provider; and 3. One or more industry-recognized feature designed to prevent the use of counterfeit prescription forms. Please check to make sure your Rx pads contain these three features.
Practice Survey
If you haven’t already, please fill out the Practice Survey that was e-mailed to you. Feedback from practices is instrumental and helps us determine what programs need improvement and where gaps in services exist. We appreciate your time and energy in assisting us with this survey. On October 1, 2008, we will draw completed surveys from a hat and reward the winning practice with a $100.00 gift certificate to a restaurant of your choice. So get cracking! The more surveys your practice staff fill out, the better your chances of winning!
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The Cross-cultural Curriculum for the Department of Pediatrics
The syllabus is now available for you and your practice
There is a syllabus available on the CCHAP web site that covers a variety of topics related to cross cultural health care. Click Here to view the entire curriculum or visit www.cchap.org/cchc-syllabus/. The following topics are covered:
Demographics of Colorado’s Children
Health Disparities among Colorado’s Children
Health Disparities
Poverty
Genetics
Environmental exposures
Life style behaviors
Provider’s ability to understand/accommodate the patient’s / parent’s culture
Provider’s ability to communicate well with families
Patient’s / parents limited English proficiency
Patient’s / parent’s limited health literacy
Disimination
What can Providers do to improve outcomes?
Race, Ethnicity and Culture (Definitions)
Cross-cultural Communication
Generalization versus stereotyping
What providers need to know about culture? (Dimensions of culture)
Basics of cross-cultural communication
How to communicate with and help families with Limited English Proficiency
How to communicate with and help families with Limited Health Literacy
The Cross-cultural Health Care toolkit
Keys to success in cross-cultural communication
LEARN mnemonic
Cross-cultural health care Review of Systems
Case Studies
Examining our Own Personal Biases
8 Steps You Can Take to Enhance Your Skills in Cross-cultural Health Care
The Institute of Medicine’s Guidelines
The CLAS Standards (Guidelines for organizational change)
References
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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
The PROVIDER RESOURCE HOTLINE assists providers to identify all appropriate services and resources for children with chronic illness or special needs and for their parents:-
Case management
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Care coordination
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Specialized services, resources, medical equipment, therapies
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Parent/patient education about chronic illness / special needs
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Parent/patient support services
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Help in finding funding for uncovered services
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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.
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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.
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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
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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.
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The ABCD project is partnering with CCHAP to provide training and support to pediatric practices to implement developmental screening.
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Medicaid will reimburse $34.00 to providers if you use a standardized, validated developmental screening test at an EPSDT visit.
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The Colorado Chapter of the AAP supports the ABCD project.
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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.
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The most time-efficient tool is one in which the parent completes a questionnaire.
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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.
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What providers are saying about implementing either the ASQ or the PEDS parent questionnaire developmental screening tools:
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It takes 1-2 minutes for an MA, LPN or RN to score.
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It takes less than a minute of the provider’s time if the MA, LPN or RN scores the questionnaire.
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In many instances, it reduces the length of the visit.
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It helps providers concentrate on the concerns/priorities of the parents.
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It reduces the number of concerns that come up as you are walking out the door at a well care visit.
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It improves patient satisfaction.
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It promotes positive parenting practices.
- It increases provider confidence in decision-making for when to refer a child for further developmental evaluation.
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- 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:
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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.
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Scoring is simple—Only three responses:
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Sometimes, occasional or emerging response from
child = 5 points -
Yes, child performs specified behavior = 10 points
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Not Yet = 0 points
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If the child’s total score falls in a shaded area of the bar
graph for any developmental area, further diagnostic
assessment is recommended.
PEDS is another tool commonly used by practices involved in
a pediatric surveillance program. Provider feedback has
been positive. “The PEDS is nice because physicians value
knowing the issues parents want to address before going
into the room.”
Frances Glascoe, PhD, Associate Professor, Division of
Child Development, Vanderbilt University School of
Medicine:
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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.
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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
Medical (pediatric) terminology
Subtle differences in the two languages in word selection and grammar
Culturally appropriate communication skills
Professionalism and etiquette of interpretation
Confidentiality and HIPPA issues
Name of student:
Job title:
Pediatric practice name:
Work phone number:
Home phone number:
Is your first language English or Spanish?
If Spanish is your second language, how long have you been speaking it?
What time is your usual lunch hour?
What is your goal in enrolling in this class?
Price: $20 per session.
After your registration and start date is confirmed, please send a check for $120,
payable to International Language Services
12572 West Brandt Place, Littleton CO 80127.
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CCHAP Home > Newsletter Articles > Newsletter Twenty-One, September 2008
