CCHAP Home > Newsletter Articles > Newsletter Twenty-Two, October 2008

CCHAP Newsletter Twenty-Two October 2008

Articles

Cultural Values of Latino Patients and Families

Early Findings: Immunization Reminder-Recall Study
for Medicaid Children in CCHAP-affiliated Practices
 
Practice Manager’s Corner
 
Definition of a Medical Home

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Making the Case For The Cross-cultural Curriculum
For the Department of Pediatrics And Private Practices
 
View The September 12th Children’s Hospital Grand Rounds On-Line
www.thechildrenshospital.org/onlinegrandrounds

Ongoing Services
- Child Psychiatrist Available to Provide Conferences for You In your Office
- The Cross-cultural Curriculum for the Department of Pediatrics
  The syllabus is now available for you and your practice
- 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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Cultural Values of Latino Patients and Families

 
By Marcia Carteret © Copyright 2008

Failure to understand and respond appropriately to the normative cultural values of patients can have a variety of adverse clinical consequences: reduced participation in  preventive screenings, delayed immunizations, inaccurate histories, use of harmful remedies, non-compliance, and decreased satisfaction with care to name a few. A primary challenge in working with patients from different cultural backgrounds is being able to use cultural generalizations appropriately without losing sight of the individual patient/family. To succeed in this challenge, clinicians must keep in mind that variations occur between cultural subgroups just as individuals subscribe to group norms to varying degrees. Factors such as socio-economics, education, degree of acculturation and English proficiency have an enormous impact on a person’s health beliefs and behaviors. In this newsletter article we will take a look at Latino culture specifically, keeping in mind that a wealthy Cuban American who has been in the United States for many years will likely have cultural values that are markedly different from a recent immigrant to the US from Mexico.
Definitions: Latino vs. Hispanic
The term Latino denotes all persons living in the United States whose origins can be traced to the Spanish-speaking regions of Latin American, including the Caribbean, Mexico, Central American, and South America. ( Flores 2000) The term Hispanic was created by the U.S. federal government in the early 1970s in an attempt to provide a common denominator to a large and highly diverse population with connection to the Spanish Language. It is often considered a somewhat narrow indicator by those who prefer the term Latino.
A Collectivist Culture With Strong Family Values
Latinos tend to be highly group-oriented. A strong emphasis is placed on family as the major source of one’s identity and protection against the hardships of life. This sense of family belonging is intense and limited to family and close friends. People who are not family or close friends are often slow to be given trust. The family model is an extended one; grandparents, aunts, cousins, and even people who are not biologically related may be considered part of the immediate family. The term Latinos use to describe their supreme collective loyalty to extended family is familismo. Financial support of the family by the individual and vice versa is important and expected. The decisions and behavior of each individual in the extended family are based largely on pleasing the family; decisions are not to be made by the individual without consulting the family. Failure of the clinician to recognize familismo can potentially lead to conflicts, non-compliance, dissatisfaction with care and poor continuity of care.  Familismo can delay important medical decisions because extended family consultation can be time consuming. To gain the trust and confidence of the Latino patient/parent, it is important to solicit opinions from other family members who may be present and give ample time for the extended family to discuss important medical decisions.  
A Hierarchical Culture That Values Respecto
The term power distance is used in the field of intercultural communications to compare the extent to which less powerful members of a society accept that power is distributed unequally.  When power distance in a society is high, people tend to believe that everyone has their rightful place and they understand that not everyone is treated equally.  When power distance is low, people believe that everyone should have equal rights and the opportunity to change their position in society. In Latin American cultures, people tend to expect status differences between members of a society which is very different from U.S. American culture. Latinos place a high value on demonstrating respecto in interactions with others, which literally translates into respect. Respecto means that each person is expected to defer to those who are in a position of authority because of age, gender, social position, title, economic status, etc. Healthcare providers, and doctors especially, are viewed as authority figures. Thus, Latino patients/parents will tend to demonstrate respecto in healthcare encounters. They may be hesitant to ask questions or raise concerns about a doctor’s recommendations, being fearful that doing so might be perceived as disrespectful. They may nod to demonstrate careful listening and respect when a doctor is talking, rather than agreement about treatment.
         Respecto is also expected on a reciprocal basis by Latinos when dealing with healthcare professionals. This is especially the case when a young doctor is treating an older Latino patient. It is important to approach Latino patients/parents in a somewhat formal manner, using appropriate titles of respect (Senor [Mr.] and Senora [Mrs.] and appropriate greetings [good morning or good afternoon]. This is especially true with older Latinos. U.S. Americans are recognized the world over as being highly informal. We jump to a first name basis with strangers almost immediately, signaling a collapse of status differences by doing so. Good intentions aside, people from many traditional cultures will not appreciate this informality. It will make them uncomfortable and may even be seen as rude behavior in certain situations.
Hierarchy in Latino Families
Latino families are often stratified based on age and sex. Generational hierarchy is expected - grandparent, child, grandchild. The oldest male (direct relative) holds the greatest power in most families and may make health decisions for others in the family. Latino men traditionally follow the ideal of machismo. They are expected to be providers who maintain the integrity of the family unit and uphold the honor of family members. Many Latino females, at least publically, are expected to manifest respect and even submission to their husbands, though this compliance varies by individual and is affected by acculturation in the U.S. Women follow the ideal of marianismo which refers to the high value Latino women place on being dedicated, loving and supportive wives and mothers. They are responsible for teaching Latino children culture and religion and for being ready to help those in need both in the family and community. It bears repeating that upward mobility, education and other societal factors are changing the above, but in isolated communities and among new immigrants, little has changed.
Latinos and Uncertainty Avoidance/Fatalismo

“A basic fact of life is that time goes only one way. We are caught in a present that is just an infinitesimal borderline between past and future. We have to live with a future that moves away as fast as we try to approach it, but onto which we project out present hopes and fears. In other words, we are living with an uncertainty of which we are conscious.” (Hofstede 2001)

Because human beings display a variety of cultural attitudes about controlling external forces, our attitudes about time, destiny and fate can be dramatically different.  In US American culture, we struggle to accept things as they are which creates high levels of stress and anxiety in our lives.  Our inner urge to be busy is directly correlated to a need to control life’s uncertainty and feelings of powerlessness toward external forces.  We focus on the individual as the locus of control in decision making and put little faith in fate or karma. We also exhibit an adversarial relationship to time, constantly needing to control the time shortage we face. We believe that multi-tasking is an important skill to develop and we rely heavily on technologies to help us do things like check our email while eating breakfast.
Latinos, by comparison, often have a strong belief that uncertainty is inherent in life and each day is taken as it comes. The term fatalismo is often used by Latinos to express their belief that the individual can do little to alter fate. This mindset manifests in health beliefs and behaviors in significant ways.  Latino patients are more likely than whites to believe that having a chronic disease like cancer is a death sentence. They may prefer not to know if they have cancer, and may believe that cancer is God’s punishment. As a result of fatalismo, Latino patients may be less likely to seek preventive screenings and may delay visiting a western doctor until symptoms become severe. They may avoid effective therapies for cancer and other chronic diseases, especially radical new treatments and invasive procedures. (Flores 2000)
         It makes sense that a culture tolerant of uncertainty tends to have a relaxed attitude towards time. Many Latinos definitely treat time as flexible and do not value punctuality the way their healthcare providers may expect them to. In fact, within the Latino community, not being on time is a socially accepted behavior. This explains a tendency for Latino patients/parents to show up late for healthcare appointments fully expecting to be able to see their provider. Similarly, Latinos are more accepting of certain levels of chaos and don’t expect orderly processes. The western medical model, with its focus on data gathering and tracking, and its insistence on adhering to specific appointment procedures, may seem unduly regimented to less acculturated Latinos, especially those who are new immigrants.  
Task vs. Relationship/Simpatia and Personalismo
If U.S. Americans are time and task oriented, Latinos tend to be more focused on relationship. The word simpatia means “kindness” and refers to an emphasis on politeness and pleasantness even in the face of stress. Latinos expect that healthcare providers demonstrate simpatia and personalismo which translates into “formal friendliness.” Latinos may read the neutral or businesslike affect of western doctors as negative. If the physician seems hurried, detached and aloof, the Latino patient/parent may experience resentment and be dissatisfied with care. This of course reduces the likelihood of compliance with the doctor’s recommendations for treatment and follow-up. A physician should be attentive, take their time, show respect, and if possible communicate in Spanish. Physical gestures such as handshakes or even placing a hand on the shoulder help to communicate warmth. Latinos also expect their healthcare provider to exhibit confidence.
Conclusion
Healthcare providers need to be familiar with the normative cultural values affecting interactions with their patients from different cultures. While it is impossible to know everything about every culture, clinicians can learn about important cultural values by using published references, consulting colleagues from other ethnic groups, and speaking to interpreters and community members. It is also important to learn to ask patients questions in a culturally sensitive way, understanding that fear of making mistakes in communicating with them blocks the exchange of vital information.  
The information provided here about Latino culture is meant to assist clinicians by providing a general framework. No hard and fast rules about interacting with Latino patients and families are being offered because they would lead to stereotyping. A cross-cultural mindset requires understanding one’s own health beliefs and behaviors first and then applying that baseline of understanding as a means of making effective comparisons across cultures. Clinicians should keep in mind that individuals subscribe to group norms to varying degrees. Factors such as socio-economics, education, degree of acculturation and English proficiency have an enormous impact on an individual’s health beliefs and behaviors. All these factors challenge one’s ability to understand and treat patients in cross-cultural settings, but meeting those challenges can be vital in reducing health disparities for Latino Americans in the U.S.
Sources Referenced for this Article
1. Hofstede, GH. Cultures Consequences. Second Edition 2001
2. Flores G. Vega LR. Barriers to Health Access for Latino Children: a review. Family Med 1998:30:196205
3. www3.Baylor.edu/Charles_Kemp/Hispanic_health.htm



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Early Findings: Immunization Reminder-Recall Study for
Medicaid Children in  CCHAP – Affiliated Practices

By Tiffany Martin Brown, PhD

           CCHAP carried out an immunization reminder-recall for some of your practices between June and August.  This article outlines some of the findings related to carrying out a reminder-recall on kids on Medicaid seen in your practices which may be helpful for you to keep in mind when using CIIS or carrying out your own reminder-recall.  Though we focused on your kids on Medicaid, many of these tips are applicable to all your kids.
           We started out wanting to follow 11,767 kids who were 0-18 years, needed at least one immunization using the guideline 4:3:1:3:3 (4 DTaP, 3 IPV, 1 MMR, 3 Hib, 3 HepB) and for whom the practice had submitted a claim to Medicaid between June 2006 through June 2007.  Using CIIS, we determined that 9,868 of them needed at least one of the recommended immunizations.  In order to carry out the immunization reminder recall, we attempted to link siblings, so families only received one call for all their children.  Even though our calls were made using the family as the unit, the results presented here represent information on individual patients.

• Only 64% of kids had information which would allow us to reach them.  (15% had a wrong number, fax number, etc., 33% were disconnected numbers)
• Of those that were able to be contacted, we made 6,333 call attempts on 1,807 families.
• We were able to contact 737 kids’ parents/guardians (11% were contacted directly, 67% were left a voice message when we could identify that it was the correct person attempting be reached)
• Parents/guardians overwhelmingly report their preference to be called by home phone (65%) or cell phone (28%) and not through post cards (2%) or work phone (1%).
• Disconnected numbers may be reconnected.  Forty disconnected numbers became reconnected contactable numbers during the intervention time frame.
   
  
• We made 319 Spanish speaking calls.  We found that of 34% those needing a Spanish-speaking caller were not documented as Spanish under language in CIIS.  
  

We will recommend strategies to work with the challenges posed by these findings and will report further findings in the next Immunizations Corner.  Stay tuned…

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Practice Manager’s Corner
October 2008

By Christina Ells

Synagis

As you may have noticed, the reimbursement for Synagis according to the Medicaid fee schedule is $0. CCHAP has verified that this is incorrect, and that the state currently anticipates reimbursing $771.40 for Synagis. I have heard feedback from practices that Synagis will cost over $800 this year, leaving you with a loss of income per vial. Apparently, Medicaid is looking in to increasing reimbursement for Synagis, but as of now they will reimburse $771.40 per vial.

If your practice anticipates administering Synagis this season, it will be a difficult business decision to make whether to follow-thorough with the treatment or not in office.

CCHAP becomes Document Verification Site!

CCHAP is now able to verify documents for Medicaid applications to make the process run smoother and quicker for you and you families. Simply call Erlinda or Lorena to schedule an appointment! We are also pursuing Presumptive Eligibility Site Certification and should receive that in early November. That means we will be able to assist families in applying for and receiving presumptive eligibility for their children.

Save the Date

The next Practice Manager’s Meeting will be held on Tuesday, November 18th from 12 – 1:00 pm. More details to follow.

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A Medical Home

 

There is a lot of talk these days about every child needing a medical home.  We will discuss this issue in the next several newsletters.  This month, we provide the American Academy of Pediatrics definition.  The American Academy of Family Physicians has a very similar definition.  Next month, we will review the Colorado laws regarding medical homes.  The following month we will describe the process by which practices can evaluate the degree to which they are providing a medical home and methods for determining if you want to make changes and if so, what changes you might want to make.

The American Academy of Pediatrics believes that all children should have a medical home where care is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective.

Accessible
• Care is provided in the child’s community
• All insurance, including Medicaid, is accepted and changes are accommodated

Family-Centered
• Recognition that the family is the principal caregiver and the center of strength and support for children
• Unbiased and complete information is shared on an ongoing basis

Continuous
• Same primary pediatric health care professionals are available from infancy through adolescence
• Assistance with transitions (to school, home, adult services) is provided

Comprehensive
• Health care is available 24 hours a day, 7 days a week
• Preventive, primary, and tertiary care needs are addressed

Coordinated
• Families are linked to support, educational, and community-based services
• Information is centralized

Compassionate
• Concern for well-being of child and family is expressed and demonstrated

Culturally Effective
• Family’s cultural background is recognized, valued, and respected

A medical home is not a building, house, or hospital, but rather an approach to providing health care services in a high-quality and cost-effective manner. Children and their families who have a medical home receive the care that they need from a pediatric health care professional whom they trust. The pediatric health care professionals and parents act as partners in a medical home to identify and access all the medical and non-medical services needed to help children and their families achieve their maximum potential.
 

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Making the Case For The Cross-cultural Curriculum
For the Department of Pediatrics And Private Practices

View The September 12th Children’s Hospital Grand Rounds On-Line
Requires Adobe Flash Player.
www.thechildrenshospital.org/onlinegrandrounds

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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…..
 

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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
• 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

Examples:

• 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

An assessment of each individual’s skill level will be done during a 5-10 minute phone call prior to first telephone conference/class.  Maria will contact you to schedule this initial individual telephone call upon receipt of your registration email.  A certificate of completion will be given after completion of all 6 sessions. The faculty is Maria Soto, a certified Spanish interpreter and trainer with International Language Services.


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Copyright 2008 Colorado Children's Healthcare Access Program and other entities as noted.

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