Articles

All the Ways CCHAP Can Help
Your Medicaid or CHP Patient, You and Your Practice

Healthcare for Middle Easterners

Colorado Medicaid Proposes A New Pilot Program To Reform Medicaid
It Will Be Released Any Day Now

Medical Home Tool Kit is Now Available

Provider Resource Helpline

Ongoing Services
- Announcing an Interactive Cross-Cultural Communications Website
  Designed Especially for Healthcare Professionals
- Language as a Communication Barrier in Medical Care for Hispanic Patients
  Plus A Spanish Course For Providers
- Postpartum Depression Screening For Mothers And Training For Your Practice
- 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
- Practice Manager's Meeting June 17 @ TCH 12pm
  RSVP carter.joyce@tchden.org
- Integrating Developmental Screening In a Pediatric Practice
- Medical Spanish Training For Your Office Staff

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All the Ways CCHAP Can Help
Your Medicaid or CHP Patient, You and Your Practice

This article describes the support services CCHAP provides your patients, providers and staff, and the services to which we link your practice. You can click on web links below to go directly to more information on our web site: CCHAP.org. This material has been available in a password protected area of our web site. Your practice has a user name and password in the hard copy manual you received from CCHAP. We have heard from practices that remembering the user name and password was a barrier to using the web information. So, we are in the process of creating an Internet tool that will allow you to keep an Icon on the desk top of all of your computers that will give you instant access to the most commonly needed information, without having to use the user name and password. We should have that desk top icon ready for you next month. In the meantime, you can simply click on the links, below.

Administrative Supports

Enhanced Provider Reimbursement –The Colorado Department of Health Care Policy and Financing (HCPF), which oversees state Medicaid, is working with CCHAP to implement the Medical Home initiative, which provides primary care practices with a supplemental fee, in addition to customary reimbursements, to reward completion of preventive care services for the Medicaid patients they serve. This higher reimbursement for preventive care visits (around 120-150% RBRVS) is available to all practices willing to fill out a medical Home Index questionnaire and willing to commit to providing a quality medical home for Medicaid children.

Enrollment and eligibility assistance– CCHAP and HCPF are partnering to assist CCHAP-affiliated practices with enrollment-related issues for Medicaid and CHP+ children. CCHAP also trains practices to work around problems with eligibility and enrollment. CCHAP now has the capability to assist families with document verification and will be a certified Presumptive Eligibility Site soon. For problems contact: Erlinda or Lorena at 720-744-5552

- CCHAP_Orientation Manual_CH03.pdf

Erlinda erlinda.deluna@coaccess.com or Lorena reyes.lorraine@tchden.org

Business Systems Assistance – CCHAP is able to provide assistance to your practice regarding the processing of Medicaid claims, coding, denials and issues around reimbursement. Other business systems might include web portal access, provider enrollment into Medicaid, etc. For contact information:

- CCHAP_Orientation Manual_CH04.pdf
See pages 4-2 and 4-3 for contacts

Practice administrators network - CCHAP has developed a Practice Manager’s Network that meets quarterly. This network allows practice managers to provide new information, lessons learned and support one another in the care of low-income children. Practice Managers are very involved in providing feedback to CCHAP in planning for further enhancements to the CCHAP support services. See the CCHAP newsletters and web site for dates, times and agenda. The next practice manager’s meeting is June 17, 2009 in the Castle Peak Conference Room at Children’s Hospital. We will send out dial-in information later this week.

Family Supports and Clinical Services

Social Services Support – CCHAP provides a Social Worker and Resource Coordinator for its practices. The Social Worker and Resource Coordinator assist families with Medicaid, CHP+ and who are uninsured cope with the many socio-economic and psychosocial issues that influence families’ abilities to access and appropriately utilize health care services. Types of referrals they process are: financial assistance, housing, food/nutrition, day care, substance abuse, family violence, parenting skills, smoking cessation, legal problems, transportation, etc. CCHAP will assist your practice in connecting with community-based organizations in your county to assure long term success for these referrals. Contact Erlinda or Lorena:

720-744-5552
- CCHAP_OrientationManual_CH03.pdf
Erlinda erlinda.deluna@coaccess.com or Lorena reyes.lorraine@tchden.org

Mental Health Services - CCHAP continues to develop new service delivery models to improve a child’s access to mental health services. CCHAP has formalized its current arrangement with behavioral health organizations and mental health centers around the state to: 1) improve access for children, 2) improve communication regarding patients between mental health providers and the practices, and 3) relax the diagnosis-driven eligibility criteria for Medicaid children so that all CCHAP provider referrals for child behavioral health assessments will be accepted and all referred children will be quickly evaluated and treated. To find the right phone number to call to refer a child, you need to know if the child is Medicaid or CHP+ and what county their Medicaid or CHP+ card was issued in. Then go to our chapter at:

- CCHAP_OriantationManual_CH06.pdf
see pages 6-2, 6-3 and 6-4 for specific county contact numbers

CCHAP has negotiated for a Child Psychiatrist to be available for telephone consultation on Medicaid patients in a metro Denver counties:

- CCHAP_OriantationManual_CH06.pdf
            see page 6-6

Provider Resource Hotline For Children with Special Health Care Needs - CCHAP has worked closely with Family Voices to create a hotline for primary care practices that helps providers determine the most appropriate resources for their specific children with chronic illness or special needs and helps link families with all of those resources. To ask for help in finding resources for your patient: 1-877-731-6017

http://www.familyvoicesco.org/hotline/index.htm
providerhelpline@familyvoicesco.org
303-733-3344 (fax)

Case Management/Care Coordination - CCHAP continues a multi-pronged approach to case management that includes practice-based strategies, staff training, and collaboration with community organizations and state agencies. CCHAP utilizes the CCHAP resource coordinator and HCPF care coordinators to evaluate, educate and assist families that overutilize emergency departments or frequently miss office appointments (no-shows).

For Medicaid patients call 303-866-6167 or 303-866-6006 or go on the EPSDT Toolkit website at http://chcpf.state.co.us/HCPF/EPSDT/EPSDT_Final_page2.asp

or call Erlinda or Lorena - 720-744-5552

For CHP+ patients call Erlinda or Lorena at 720-744-5552

Asthma Case Management - The Pediatric Pulmonary Division at The Children’s Hospital offers an asthma case management program for children whose asthma is poorly controlled, as well as education and support for families, and follow up care with the appropriately health care provider. They require an initial appointment to begin the education process. At the initial visit, the asthma specialists will develop an asthma care plan and coordinate care with your practice providers. The nurse case manager provides asthma education and follow-up by phone to assist with decisions at home regarding care. To refer a child/family for an appointment, call 720-777-6181. After that initial visit, the asthma case management nurse will follow the patient and keep in touch with your office..

Transportation - CCHAP helps practices obtain transportation for those Medicaid, CHP+ and uninsured families who need assistance. CCHAP links practices and patients with their local EPSDT care coordinator to provide non-urgent transportation. Additionally, CCHAP provides cab vouchers to assist CHP+ or uninsured patients for whom transportation is not a covered benefit, or to Medicaid patients in emergency situations. To learn more about what is available in your specific area: CCHAP_OrientationManual_CH08.pdf

Cross-Cultural Communication Training – Primary care practices are finding that the families they serve are becoming increasingly diverse. Staff and providers have asked for assistance with learning how to adapt to the growing number of families from various ethnic, cultural and racial groups. CCHAP has a well-trained, highly experienced Director of Cross-Cultural Health Care who can bring cross-cultural communication training to CCHAP practices. To schedule a training for your practice or to ask for consultation:

720-777-3124 Marcia Marcia@dimensionsofculture.com

http://www.dimensionsofculture.com/home

Dimensions Of Culture Website - Interactive Cross-Cultural Communications Website,
Designed Especially for Healthcare Professionals: www.dimensionsofculture.com

• A Website to Support On-going Training for Healthcare Professionals in Colorado
• An Interactive Website for Building a Learning Community

Developmental Screening - CCHAP recommends developmental screening using a well-standardized screening tool on all low-income children. Medicaid pays $38 for developmental screening with a standardized screening tool at well child visits through 5 years old. CCHAP helps practices link with free services for selecting and obtaining screening tools, obtaining staff training and received a high level of reimbursement for developmental screening. CCHAP recommends practices work closely with the Colorado ABCD program.

- CCHAP_OrientationManual_CH11.pdf

Immunizations - CCHAP-affiliated practices receive assistance with building the Colorado Immunization Registry into their practice in order to improve their documentation of immunization status, to communicate between practices, and to implement client and provider reminders to improve immunization rates. CCHAP and CIIS assist the practice in doing reminder recall to get all children in for needed immunizations and preventive care. To contact CIIS to get your practice on the registry, call 1-888-611-9918

http://coloradoimmunizations.info/ciis/index.htm

Becoming an Effective Medical Home - CCHAP promotes the medical home concept as described by the American Academy of Pediatrics for all children. CCHAP works with HCPF (Medicaid and CHP+) to assist practices in assessing how well the practice is providing the components of a medical home, using the Medical Home Index, a practice self-assessment survey. HCPF and CCHAP also provide coaching for practices in making the changes that they practice wants to make. CCHAP provides a variety of materials, services and technical assistance to assist practices with all components of a medical home.

Continuous Quality Improvement (CQI) / Best Practices – CCHAP works closely with HCPF, Family voices and the Colorado Clinical Guidelines Collaborative (CCGC) to provide practices with technical assistance to enable practices to develop continuous quality programming. Practices will be assisted in making any changes they feel they want to make to improve efficiency or to improve their “medical home-ness.” To learn more about QI coaching, please contact: Anita Rich at 720-777-5495.

Spanish Interpretation Training for Pediatric Practices - CCHAP offers a convenient, time-efficient, cost-efficient medical Spanish interpretation training program for pediatric office staff and providers. It is provided as a telephone conference, during practice office hours at lunch time. Training in medical Spanish interpretation includes:

Medical (pediatric) terminology
The subtle differences in the two languages in word selection and grammar
Culturally appropriate communication skills
Professionalism and etiquette of interpretation
Confidentiality and HIPPA issues

This program is for people in the practice who already speak Spanish and English. The sessions will be conducted via telephone, using handout materials and the Internet, and will also include role-playing. The faculty is Maria Soto, a certified Spanish Interpreter and trainer, with International Language Services. An assessment of each individual’s skill level will be done during a5-10 minute phone call prior to first telephone conference/class. A certificate of completion will begiven after completion of all 6 sessions.
When: Wednesdays from 12:15 to 1PM -The next session will begin as soon enough people are interested in attending. How long: 45 minute sessions for 6 weeks

Price: $20 per session. Please send check for $90, payable to International Language Services, 12572 West Brandt Place, Littleton CO 80127.

Registration – Register simply by emailing the information below to ilssoto@aol.com

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Healthcare for Middle Easterners

By Marcia Carteret

Culturally driven attitudes and behaviors often create communication challenges between Middle Eastern patients and Western health care professionals. Middle Easterners approach life differently in significant ways from Westerners i.e., in terms of time control, power distance, male/female roles, personal space, and privacy. Similarly, problems in providing health care also develop around family involvement with patient care and ways of handling “bad news.” This article provides some general guidelines in understanding the cultural characteristics of Middle Easterners, but as always, it is crucial to see the individual in any healthcare encounter. The degree of exposure to Western and/or American culture greatly affects an individual’s attitudes and behaviors. Religious affiliations are also extremely influential. While it is useful to apply generalizations when learning about patterns of communication, it is also important to avoid applying hard and fast rules in any cross-cultural interaction.

(Before reading further in this article about the core values, beliefs, and cultural behaviors of people from the Middle East, it may prove helpful to learn more about what the term Middle Easterners encompasses. http://en.wikipedia.org/wiki/Middle_East)

The Importance of Family In Middle Eastern Cultures
Humans develop their sense of identity and self-esteem within a particular cultural context or group, and assuring in-group survival is arguably the strongest of human drives. Though the need to be affiliated with other persons is a universal human need, the intensity of the need varies among individuals and cultural groups. The need for affiliation is very strong among Middle Easterners. They thrive on a large network of relationships. During illness or crisis, Middle Easterners rely heavily on other persons in their “in-group” instead of trying to cope more individually as many Americans would typically do. A person seeking medical care may be accompanied by one or more persons in Middle Eastern culture who expect to be present during the examination or interview, who listen carefully and often answer for the patient. Usually it is an elderly person who will feel offended if not invited into the physician's office, or intimates of the patient who consider themselves duty bound to be there, lest their failure to be there is considered a lack of attention. The intense connection to family and close friends that is seen in many Middle Easterners is often accompanied by mistrust and doubt about the intentions of those outside their intimate circle. Thus, family members typically see it as their job to make sure that the patient gets the best care possible from medical professionals. Repetition of demands is often made to show emphasis, as is a loud tone of voice. Family and friends are expected never to leave a patient alone and to constantly shower care and attention. A great deal of patience is sometimes needed in dealing with these "demanding" family members.

A Few General Guidelines for Dealing with Middle Eastern Families:
(These to not apply to every individual)

• It is usually appropriate to speak first to the family spokesman. The one with the most authority in any situation is usually the oldest and most educated person.   

• Sexual segregation is usually extremely important. Assign same-sex caregivers whenever possible, and maintain a woman's modesty at all time  

• Accept the fact that women may defer to husbands for decision-making regarding their own and their children's' health. This is not necessarily a sign of spouse abuse.  

• Accept that the husband may answer questions addressed to his wife. 

• Direct eye contact with members of the opposite sex may be interpreted as a sign of sexual interest particularly from female to male.  

• Personal problems are usually taken care of within the family; they will probably not be receptive to counseling.  

• Loud and expressive emotions are accepted, especially during childbirth, after someone has died, or when coping with pain. 

• Negative information should be presented with great care. A common communication practice in the Middle East is to reveal the news of a tragedy or a poor prognosis in stages. Bad news is often not given to the patient directly.

High Context Communicators
Given the intensity and frequency of their relationships, Middle Easterners tend to be highly contextual communicators. This means that persons seek understanding of events by examining the context in which they occur. A Middle Easterner needs to know more about another person than an American does for a relationship to develop. American culture is low in context; the emphasis is on the verbal message and less so on the context in which the message is given.

Time Control
Punctuality is less important in the Middle East than in the United States. A patient might be late for an appointment, or not come at all, because another matter immediately at hand was seen as more important than the previously scheduled appointment. The matter taking precedence often involves meeting the needs of someone a person feels obligated to in a reciprocal relationship – i.e. a family member or close friend. Americans, being task-oriented, plan their days around getting things accomplished and are annoyed by a nonchalant approach to time. Americans who are left waiting for more than a few minutes may feel they are being disrespected; the late arriver should offer a good explanation for not showing up on time. Middle Easterners on the other hand may be offended by the Americans attention to getting things done rather than taking the time to establish a relationship.

Personal Space When Conversing
People from different cultures use space during conversation in very different ways. The appropriate conversational distance between Middle Easterners is twice as close as Americans are used to. Middle Easterners also touch more frequently. This difference in personal conversing space can make Westerns feel very uncomfortable. The collapsing of personal space may feel invasive or even somewhat aggressive.
 
Personal Privacy
People from the Middle East may tend to resist disclosing detailed personal information to strangers, including healthcare professionals. Data for health histories may not be willingly given and request for information may be viewed with some suspicion until it is clear why the questions are being asked. Once trust with a caregiver is established, personal information is given more freely.

Power Distance
Middle Easterners desire to please or to appear good, and less dominant persons must at all costs placate stronger ones. This is important to consider in the face of power distance in healthcare situations, especially between male doctors and their patients. Because the authority of a physician is never questioned, a Middle Easterner is not likely to ask questions or give information that would contradict or show disrespect. Also, depending on the degree of acculturation in the U.S., religious views, etc., a Middle Easterner may feel uncomfortable interacting with a female doctor as a person of real authority. The emphasis in this last statement is on the possibility, not on any likelihood.

Health and Illness Behavior
Middle Easterners generally have respect for Western medicine. However, in working with any immigrant population, health care professionals should be aware of common folk beliefs and practices.

• Much like Latino people, Middle Easterners may believe in illness causation such as the Evil Eye. In this belief, anything that provokes jealousy in another gives the envious person the power to cause illness or misfortune for the lucky person or family. Often the object of envy is a beautiful baby or child.

• Much like Latino and Asian people, Middle Easterners believe in the importance of balancing "hot" and "cold" foods – qualities that do not necessarily have to do with actual food temperature. They avoid eating incompatible foods at the same meal.

• Health professionals have frequently observed among Middle Easterners a fatalistic acceptance of disease or death - it's all in Allah's hands.

Also keep in mind the following:

• Preventive care is not practiced in the Middle East and medication is heavily used. Middle Eastern patients may expect to receive a prescription.

• Middle Easterners often fear hospital admission because hospitals are considered places of misfortune where people go to die.

• Moslems are concerned that a family cannot be sure that the body of one of its members will be treated correctly according to religious customs, should a patient die in hospital.

• Family members do not plan for death and never give up hope until a patient has actually died; grief is not permitted to be shown in the presence of a dying person. Once death has occurred, mourning is loud and obvious and expected to be so. A person who is not overcome with emotion is not admired.

• It takes more time to consult with a Middle Eastern family, and that scheduling should be arranged accordingly when possible.

Conclusion

Western medical professionals may indeed find working with Middle Eastern patients can be challenging. However, once trust has been established, Middle Easterners are typically cooperative and willing to comply with their doctor’s recommendations for treatment. Working with Middle Easterners gives U. S. healthcare professionals the enriching opportunity to compare their own cultural values, beliefs, and behaviors with those of people from more traditional cultures. Every patient/family encounter is an opportunity to practice effective cross-cultural communication skills that help increase positive health outcomes.


REFERENCES
Galanti, G.: Caring for Patients Different Cultures. Fourth Edition. ISBN-10: 0812220315

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Colorado Medicaid Proposes A New Pilot Program To Reform Medicaid

 
Colorado Medicaid will be releasing in the next week or two a description of what they want Medicaid to be like in the future. CCHAP will assist you in giving your opinion to Colorado’s Medicaid on their reform proposal. When the proposal is released, there will be just a few weeks to send in your response. This may be your only chance to give your opinion.

We have reviewed an advance copy of the proposal. The draft we reviewed was 77 pages and their request for input included 231 questions. CCHAP will provide you with a much shorter summary. A group of practice managers and providers from CCHAP-affiliated practices have met, reviewed the advanced copy of the plan and have created a set of recommendations. These recommendations have also been reviewed by representatives from the Colorado Chapter of the American Academy of Pediatrics Executive Committee and Legislative Committee. The combined recommendations will be provided to you. You can use any or all of this information in your response to Colorado Medicaid. We will make it as easy as possible to send in your response.
 
If you want to be on the emailing list to receive updated information and invitations to the public forums, please email baltazar.rocha@state.co.us.
 

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Building Your Medical Home Toolkit

Online Launch June 1, 2009
www.pediatricmedhome.org

Brought to you by the AAP/MCHB/National Center for Medical Home Implementation, the Building Your Medical Home Toolkit supports the primary care pediatrician's development and improvement of a pediatric Medical Home. It also prepares a pediatric office to apply for and potentially meet the National Committee for Quality Assurance (NCQA) Physician Practice Connections Patient Centered Medical Home (PPC-PCMH) Recognition program requirements. The Toolkit can help a practice assess and improve its medical home capacity with resources and downloadable tools organized into six building blocks that provide guidance for implementation:

• Care Partnership Support addresses family access and communication
• Clinical Care Organization addresses standards for practice organization and use of clinical information
• Care Delivery Management addresses the promotion of clinical care that is consistent with scientific evidence, as well as patient and family preference
• Resources and Linkages addresses successfully linking patient and families with community resources to help meet their needs
• Practice Performance Measurement addresses the organization and promotion of safe and high quality care
• Payment and Finance addresses the need to match quality care and NCQA recognition with payment and value

The National Center for Medical Home Implementation is a cooperative agreement between the Maternal and Child Health Bureau/HRSA and the American Academy of Pediatrics. The National Center works to ensure that all children and youth, including those with special health care needs, have the services and support necessary for full community inclusion through medical homes.

Building Your Medical Home Toolkit content was developed by Jeanne McAllister, Director of the Center for Medical Home Improvement, Crotched Mountain Foundation in New Hampshire, with guidance from AAP leadership and the National Center's Project Advisory Committee members. For more information about the National Center, please visit www.medicalhomeinfo.org or contact Angela Tobin, Manager of Technical Assistance, at atobin@aap.org.

Thank you.
Angela Tobin, AM, LSW
Manager, Technical Assistance
Division of Children with Special Needs
The National Center for Medical Home Implementation
American Academy of Pediatrics
phone: 800/433-9016, ext. 7621 direct: 847/434-7621 fax: 847/228-5034
e-mail: atobin@aap.org

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Provider Resource Helpline

 
To Assist You In Connecting Your Patient with a Chronic Health Condition or Special Needs
And Their Families
With Appropriate Services and Resources
 
Call 1-877-731- 6017
 
Fax: 303-733-3344
 
Email: providerhelpline@familyvoicesco.org

The PROVIDER RESOURCE HELPLINE assists providers in identifying appropriate services and resources for children with chronic illness or special needs and for their parents:

• Specialized services, resources, programs, medical equipment, therapies
• Parent/patient education about chronic illness / special needs
• Parent/patient support services
• Case management
• Care coordination
• 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.
• One of your patients has heart disease and is failing to thrive. Surgery can’t be done until the child is larger. You need someone to weight the child each week, provide feeding guidance and support the parents.

Hours of operation:
 
          Monday thru Friday from 8 AM to 4 PM
          Voicemail available 24/7
 
We can provide the information to you or your staff for you to give the patient....
Or we can work directly with the patient and family.....your choice.
The helpline will provide follow-up to your office on how the patient and family are doing

If the information on appropriate resources is not immediately available, we will research your question or case and provide the information to you and the family as soon as possible in whatever manner you and the family wish (via phone, fax, or email).

When contacting us, please provide us with the following information:

1. Your provider office and PCP name
2. Name of Child
3. Date of Birth
4. Medical Condition / Primary Disability
5. Type of insurance
6. Resource or service requested
7. Who should we contact with information?
8. Family Contact Information
9. How is it best to provide information back to you: phone, fax, email or voicemail

TO DOWNLOAD A REFERRAL FORM CLICK HERE
 
Next time you see a child with any chronic health problem or a special needs child, call us to see how we can help.
 
Questions about the helpline? Call 1-877-731-6017

The Provider Resource Helpline Is Sponsored By

Family Voices and CCHAP

CLARIFICATION:

Contact Erlinda or Lorena with CCHAP at 720-744-5552 (phone) or 303 -751-9048 (fax) when you are only concerned about socio- economic issues like food stamps, housing, Medicaid eligibility, legal aid, abuse, etc. Contact the hotline for clinical referral needs.

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Announcing an Interactive Cross-Cultural Communications Website
Designed Especially for Healthcare Professionals

dimesionsofculture.com

 
Register now! Click the link above and get full access
with your own secure login and password!

A Website to Support On-going Training for Healthcare Professionals in Colorado

Because culture can have important clinical consequences, this website is devoted to supporting the self- development of healthcare professionals in basic cross-cultural communication competencies that impact health outcomes for patients. In place of the typical "diversity training" approach, practical communication strategies are emphasized that can be put to use immediately in private practices, clinics, and hospital settings.

An Interactive Website for Building a Learning Community
 
The content of this cross-cultural communications website focuses on reinforcing key concepts presented in cross-cultural communication trainings by Marcia Carteret. Additionally, this site presents the opportunity for physicians and staffs in multiple healthcare settings to interact with one another through threaded discussions. Because nothing can replace real life experience in the learning process, a virtual learning community will make it possible to share true stories and post useful questions while culture and medical experts facilitate discussions.
 
Website Features
 
Listed here are the pages that currently make up dimensionsofculture.com. Please note that some pages require a login and password because only select groups of healthcare professionals, including all CCHAP pediatric practices, will have full access to the “community” pages.

Public Pages

• Home Page
• Greetings from the Site Editor
• Culture Calendar- Monthly religious and cultural holidays
• Culture Quest – Information about cultural happenings in our community, as well as statewide and nationally.

Healthcare Community Pages (Login/Password Protected)

• Newsletters – Monthly articles addressing key cross-cultural communication topics written by Marcia Carteret and other guest contributors.
• Interactive Forums– an interactive on-line community dialogue between healthcare professionals about communicating with patients from different cultural backgrounds. 
• Provider Profiles– An ongoing series of profiles introducing some of the dynamic and culturally diverse doctors working in the CCHAP network of pediatric practices
• Culture Ambassadors – A panel of representatives from cultures around the globe, with a strong focus on the cultures most heavily represented across out state.

This website is designed to meet the needs of the healthcare community served by Colorado Children’s Healthcare Access Program. If you are a participating CCHAP provider or staff member and have suggestions for the website, please contact Marcia Carteret at mcarteret@gmail.comor 720-777- 3124. Your comments and suggestions will help make dimensionsofculture.com an effective tool for learning and community building.

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Abe Grinberg MD, FAAP MPH
   

Language as a Communication Barrier in Medical Care for Hispanic Patients
 

           Communication with patients and their families is essential in providing quality medical care. Cultural and language barriers create a void in the delivery of safe health care, customer satisfaction and quality of care. The public debate on how to bridge cultural and language barriers has a long history. The use of formal interpreters and translators is associated with the ability to eliminate these barriers; however, the ability to communicate directly with health professionals in a common language is associated with an increase level of trust in medical settings.

           There are 7 important points to have in mind when addressing cultural and language barriers with the Hispanic patients and their families:

1. The number of people speaking a language other than English at home and the number of Americans Limited in English Proficiency (LEP) in the United States is significant. It is expected that the total number of people in these two groups will continue to increase at a faster rate than the one of the general population in the USA. About two thirds of them are Spanish speaking individuals (₁) (₂).
2. Multiple studies document that quality of care can be seriously compromised when Spanish LEP patients need but do not get translation and interpretation services (₃) (₄).
3. Studies also document that the quality level of interpretation offered by bilingual providers and professional hospital interpreters is high. However, the quality of interpretations offered by hospital employees who are not professional interpreters, family members, relatives, friends, and ad-hoc translators are many times incorrect and of poor quality (₅).
4. Interpretation errors are common. About 60% of the errors have potential clinical consequences. Even professional interpreters commit significant errors about 50% of the time (₅).
5. Patients, who interact with a bilingual provider, frequently rate them as more friendly, respectful, and concerned when compared to those who interact with a translator or interpreter. Patients and families who are taken care by a provider who speaks their own language frequently have a more accurate recall of critical information about the encounter than those who interact with a provider who uses a translator or an interpreter(₆)(₇).
6. There are data that suggest that the length of hospital visits, the incidence of any testing, the cost per visit and the number of hospital admissions are decreased in those patients who interact with a provider who speaks their own language when compared to those providers who use a translator or interpreter during the course of the medical encounter (₈). 
7. There is evidence that courses in Medical Spanish can help health care professional achieve fluency in Spanish at the functional level and promote cultural awareness that strengthen communication skills. The promotion of such courses is associated with decreased interpreter use and increased patient and family satisfaction (₉).

          Bear in mind that Hispanics embrace people when they make an effort to speak their own language. They tend to be tolerant and have a tendency to develop relationships that are based on friendship and respect. You will make them fill comfortable and help them feel that you are concerned about their medical care.
 
          “Dele a un hombre un pescado y él comerá por un día. Enséñele cómo pescar y comerá por el resto de su vida” (Lao Tzu. Filósofo Chino).

1. 1. Flores Glenn. 2005. The Impact of Medical Interpreter Services and the Quality of Health Care: A Systematic Review. Medical Care Research and Review 62: 255- 299
2. Colorado Alliance for Immigration Reform. U.S Immigration Data, Projections and Graphs. Retrieved: October 2, 2008. http://www.cairco.org/data/data_us.html
3. Flores, Glen., Abreu, Milagros., Schwartz, Ilan., and Schwartz, MD, and Hill, Maria. (2000). The importance of language and culture in pediatric care: Case studies from the Latino community. The Journal of Pediatrics. 137 (6): 842-848
4. Flores G. Language Barriers to Health Care in the United States. NEJM 2006; 355:229-23
5. Flores G., M.B. Laws., S.J. Mayo., B. Zuckerman., M. Abreu., L. Medina and E. J. Hardt. 2003. Errors in clinical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 111: 6- 14
6. Baker, David W., Hayes, Risa., and Puebla Julia. 1998. Interpreter Use and Satisfaction with Interpersonal Aspects of Care for Spanish-Speaking Patients. Medical Care. 36(10):1461-1470 
7. Seijo, R., H. Gomez and J Frienderber. 1995. Language as a communication barrier in medical care for Hispanic patients. In. Hispanic Psychology_Critical issues in theory and research, edited by A.M. Padilla, 169-181. Thousand Oaks,Ca: Sage.
8. Hampers, L. C and., McNulthy, J.E. 2002. Professional Interpreters and Bilingual Physicians in a Pediatric Emergency Department. Arch Pediatr Adolesc Med. 156:1108-1113.
9. Suzan S. Mazo., Louis C. Hampers., Vidya T. Chande. Steven E. Krug. (2002).Teaching Spanish to Pediatric Emergency Physicians: Effects on Patient Satisfaction. Arch Pediatr Adolesc Med 156: 693-695

Course in Medical Spanish customized for pediatric care providers. Once a week for 12 weeks (2 hour class), includes also 6 month internet access to “Spanish for health care course”. Flexible schedule to accommodate participants’ preferences; Classes take place at the providers’ office for groups of 8-12 students.
$ 389 dollars per student. Includes 6 month internet access to the on line training course.
          Contact: Abe Grinberg MD (720) 748-7669.
          abe@bilingualmed.com my web-site www.bilingualmed.com

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Postpartum Depression Screening For Mothers
And Training For Your Practice

Postpartum Depression is a significant public health issue affecting 1 out of 8 new mothers. In Colorado, it is underidentified and undertreated. The Rose Community Foundation has funded Dr. Brian Stafford and The Kempe Center¹s Postpartum Depression Intervention Program to provide Free Medical Education and On-Site assistance to practices in the Denver Metropolitan area in order to assist their identification, education, treatment, and referral for women with this condition. Practices will receive a free talk as well as a free tool kit and fliers and brochures to assist them. This provider education is paired with a public awareness campaign on this issue titled, 'Oh baby, this isn¹t what I expected.' Interested practices or practitioners should contact the Kempe Center at 303-864- 5845 or Dr. Brian Stafford at tafford.brian@tchden.org to schedule the on-site pre-clinic or lunchtime training.

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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
• Kids 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 psychiatriststo 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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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.comto 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 2009 Colorado Children's Healthcare Access Program and other entities as noted.

 CCHAP Home > Newsletter Articles > Newsletter Twenty-Nine, June 2009