Ongoing Services
- Announcing an Interactive Cross-Cultural Communications Website Designed Especially for Healthcare Professionals
- The Colorado Pediatric Postpartum Depression Screening and Referral Toolkit
- Language as a Communication Barrier in Medical Care for Hispanic Patients Plus A Spanish Course For Providers
- Child Psychiatrist Available to Provide Conferences for You In your Office
- Child Psychiatry Telephone Consultation on Medicaid Children
- Practice Manager's Meeting January 13 @ TCH 11:30AM, RSVP carter.joyce@tchden.org
- Integrating Developmental Screening In a Pediatric Practice
- Medical Spanish Training For Your Office Staff

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Cultural Aspects of Pain and Pain Management

By Marcia Carteret
© 2009. All rights reserved

Even though the assessment and treatment of pain is a universally important health care issue, modern medicine still has no accurate way of measuring it. Patients are often asked to rate their pain on a scale from 1- 10: mild (1-4), moderate (5-6), and severe (7-10). Sometimes smiling and frowning faces are used as visual aids to help both doctor and patient convey what the numbers signify. Cultural differences in response to pain compound the inherent challenges of communication. Although nearly all people experience pain sensations similarly, studies show there are important differences in the way people express their pain and expect others to respond to their discomfort. There are also culturally-based attitudes about using pain medication. An understanding of the impact of culture on the pain experience is important in assuring effective and culturally-sensitive patient care.

Pain Response & Culture: It is well established that pain is a highly complex phenomenon that involves biological, psychological, and social variables.1  Patients’ culturally-based responses to pain are often divided into two categories: stoic and emotive. Stoic patients are less expressive of their pain and tend to "grin and bear it." They tend to withdraw socially. Emotive patients are more likely to verbalize their expressions of pain, prefer to have people around and expect others to react to their pain so as to validate their discomfort. We can make the broad generalization that expressive patients often come from Hispanic, Middle Eastern, and Mediterranean backgrounds, while stoic patients often come from Northern European and Asian backgrounds. If we use such broad generalizations to help understand human behavior, however, we must always keep in mind that while culture is a framework that directs human behavior, not everyone in every culture conforms to a set of expected behaviors or beliefs.  Rigid use of generalizations leads to cultural stereotyping which in turn can lead to serious inaccuracies. Any individual’s experience of pain will manifest itself in emotional and behavioral responses particular to his or her culture, personal history, and unique perceptions.

American Culture & Pain Response: For western health care professionals it is important to understand how our own culture affects the attitudes we may hold about pain. Only through this self-awareness can we establish a basis for comparison that allows us to see where our attitudes and beliefs are likely to collide with those of patients who come from very different cultures. We are apt to believe that our reaction to pain is "normal" and anything substantially different is "abnormal".  For example, a doctor or nurse raised in a family that encouraged stoicism may not know how to react to a patient who responds to pain with loud verbal complaints and may even discount such “overly expressive” reactions. There is a long tradition of stoicism in European American culture; generations of children, especially boys, would be admonished for crying like babies but applauded for keeping a stiff upper lip. In general, people made as little fuss as possible over injuries and illness.  Naturally, children socialized in this way will grow up to be “easy patients” who behave in ways consistent with the values of the western medical system. On the other hand, there are cultures where a child’s crying immediately elicits the greatest sympathy, concern, and aid. In such cultures, children’s’ health is fretted over constantly – even a sneeze can be seen as illness. This predisposes children to become more anxious about their health in general, and as adults, they may need greater reassurance from caregivers even in the face of minor symptoms. In general, when people are ill they revert to childhood behavior.  If complaining brought them attention as children, they will likely complain out of habit as adults – even if the desired results are not forthcoming from the caregivers around them.

Asian Culture & Stoicism: Patients from Asian cultures may often exemplify stoicism in the face of pain, which relates directly to strong cultural values about self-conduct. Behaving in a dignified manner is considered very important, and a person who is assertive or complains openly is considered to have poor social skills. This behavior might be tolerated in very small children, but not in adolescents and adults. In traditional Asian cultures, preserving harmony in interactions with others is very important, so an individual should never draw attention to himself, especially in negative ways. Though an individual may feel sadness or pain, it is not customary to make this obvious. On a related note, some Asian patients will be socialized to observe status differences between people and will avoid making demands of health care professionals for this reason. Asian societies have traditionally emphasized status differences between people based on variables such as age, sex, education, and occupation. A doctor or nurse will most surely be seen as a person of high status, not to be questioned or bothered with complaints about discomfort.

Putting Pain Into Words: The limitations of language to convey experience – even between people who speak the same language – are extremely obvious when we can’t explain something as important as the intensity of pain we feel or the unrelenting worry and frustration pain sometimes causes. To further complicate communications, not all cultures describe pain in the same way. Words such as “sharp,” “throbbing,” “stabbing,” or “aching” make sense to most people in the U.S., but in many tribal cultures stories or symbols are essential in relating one’s worldview, so very different words are used to describe pain.  Clinicians might be baffled by patients explaining their pain in terms of natural symbols like lightning, trees with deep spreading roots, spider webs, or the tones of drums and flutes.2 In cultures where evil spirits are believed to cause illness and pain, patients may talk about their suffering as punishment. Indeed, some patients will need help in understanding how to talk about pain in ways western doctors and nurses can interpret. Through careful listening and probing health care professionals will uncover what is really happening with each patient’s pain. Keep in mind that referencing pain measurement tools that rely on numbers or any kind of linear format, such as a row of faces, won’t work equally well across cultures. People in some cultures attach great superstition to particular numbers, and smiling does not suggest feeling good in all cultures. In fact, in some Asian cultures, people tend to smile when they are embarrassed or angry.

Religious and Spiritual Aspects of Pain: In many cultures around the world where belief in fate and karma are strong, people often believe illness and injury are caused by a higher power. In many cases, the acceptance of pain is important in demonstrating a person’s religious faith. In one case, a Nigerian refugee to the U. S. suffered a severe knee injury and underwent arthro-miscroscopic surgery. His American nurse waited for him to request pain medication, but he never did. Being Muslim, he offered his pain to Allah in thanks for the good fortune of being allowed the special surgery.3 In a similar case, a Filipino patient hospitalized for shoulder surgery admitted to his nurse that he was in severe pain. However, he wasn’t taking his pain medication because he believed it was God’s will that he had such pain, and God would give him the strength to bear it.4 A similar stoicism in the face of pain may be common among Buddhists who believe acceptance of suffering leads to spiritual growth. Among some Native Americans, the blessing of medications by a tribal medicine man puts a patient more at peace with the creator which in turn makes the medicine “stronger”.

Cultural Perceptions of Pain Treatments:
A tendency to discount immediately the sort of cultural practices and beliefs mentioned above can be countered by invoking the placebo effect, which is well-documented. There is also its opposite – the “nocebo effect” where a person who disbelieves in a treatment experiences a worsening of symptoms due to pessimism about getting well. What motivates people’s reactions to placebos is interesting in how it parallels different cultural perceptions and expectations around medicines in general. Are shots more effective than pills? Does a bigger pill work better than a smaller one? Is bitter medicine stronger and more effective than medicine that tastes good? Answers to questions like these are indeed often dependent upon cultural background. In some cultures, people believe that the more intrusive a procedure is, the better it is for them. So, an intravenous pain medication would be preferred to narcotic analgesic tablets even if the tablets were highly effective. In some countries, injections are very common; so a Cambodian patient, for example, might believe that without an injection, treatment is inadequate. A Filipino or East Indian patient might reject pain medications altogether out of fear of harmful effects, including addiction.  Clearly, it is important to explain the rationale behind use of pain medication to all patients, and to ask patients from different cultural backgrounds which type of medication is preferred in their culture.  Also, how do they feel about taking pain medications personally? Since cultural and/or religious reasons may inhibit someone from asking for pain medication, it is often necessary for doctors and nurses to anticipate a patient’s pain needs and to initiate important discussions.

Conclusion: Part of understanding our own culturally-based attitudes about pain includes gaining awareness of the things we take for granted. We have come to expect pain management as part of proper treatment in the U.S., but in many countries pain medications aren’t readily available or affordable. Or, their use may be stigmatized - as being self-indulgent, addictive, etc. An appreciation of the influence of culture on affective responses to pain and expectations for pain treatment is critical to culturally responsive management of people in pain.  The role of the health care provider is to help patients advocate for what feels appropriate for them within their cultural context. 

For more information on this and related topics visit www.dimensionsofculture.com.

References
1. Michelle A. Fortier, M.,Cynthia T. Anderson, C. and Kain, Z. Ethnicity Matters in the Assessment and Treatment of Children's Pain PEDIATRICS Vol. 124 No. 1 July 2009, p. 378
2. Burhansstipanov L. Lessons Learned from Native American Cancer Prevention, Control and Supportive Care Projects. Asian American and Pacific Islander Journal of Health. Summer- Autumn 1998: vol. 6. No. 2. pp. 91-99.3,4 Geri-Ann 3,4. Galanti, Caring for Patients from Different Cultures (Philadelphia: University of Philadelphia Press, 1997 p. 35

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All CCHAP-affiliated Practices Now Can Receive
TELEPHONE CONSULTATION ON MENTAL HEALTH ISSUES
FOR CHILDREN ON MEDICAID

Rick March is a child psychiatrist who has received grant monies to provide phone consultation regarding children and adolescents with mental health problems throughout Colorado.  He has over twenty years experience in child psychiatry and is available weekdays during regular business hours.  If you do not reach him directly, he would be able to speak with you, at the outside, by the next business day.  Dr. March is at the Mental Health Center of Denver which provides services for children who live in Denver County.  However, he may be able to arrange to see other patients outside this catchment area, possibly in your practice in very difficult cases.  He is also available to provide educational presentation for your providers on a wide variety of mental health topics.

His direct line is 303-504-1500

So, telephone consultation from a child psychiatrist for Medicaid children cared for in a CCHAP-affiliated practice is now available in all counties in Colorado.  

For Boulder and Jefferson Counties – Don Bechtold, MD – 303-432-5172
For Adams, Arapahoe and Douglas Counties – Joe Pastor, MD – 303-853-3888
For all other counties (including Denver) – Rick March, MD – 303-504-1500

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INTRODUCING THE CCHAP QUICK REFERENCE LINK!

Do you need to know the one telephone number to call for a Medicaid mental health referral?  Want to reach the CCHAP social worker?  Need help in finding resources for a special needs child?  Having trouble remembering all of the 14 support services CCHAP provides for your practice?   We have a quick reference link for your desk top!  For these things and many more…

Recently, our advisory group of physicians and practice administrators suggested an idea for a quick and easy way to access CCHAP affiliated resources for frequently used contacts and services.  We liked the idea and have developed a web link that will quickly access a single page that contains contact information as well as additional links to documents and web pages.  The goal is to have a computer desktop shortcut that, with just a click or two, will provide CCHAP affiliated providers and staff with the information you need, when you need it.  

Because this new tool is for you, we want it to be pertinent and efficient.  So please, if you have ideas as to how to improve on this, contact Kevin Heckman heckman.kevin@tchden.org or 720.777.6309, our Program Administrator, with your feedback and suggestions.  Thanks!

INSTRUCTIONS:

1. Click on this link http://www.cchap.org/qr/ to open the Quick Reference Link web page (Note: you can also type this address into a web browser manually).
2. In your browser window menu (upper left corner) click File>Send>Shortcut to Desktop. 
3. The Quick Reference Link is available from any computer with internet access.

Kevin C. Heckman
Program Administrator
CCHAP
720.777.6309

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Quality Improvement Made Easier

If the phrase “Quality Improvement” (QI) causes you a bit of distress, you are not alone.  The reality is that effective QI doesn’t have to be implemented on a grand scale, nor does it have to be difficult. Plus, CCHAP is here to help!

No doubt, your practice has already implemented QI projects. Perhaps you didn’t even think of them as “Quality Improvement” because the new or “tweaked” process seems logical, necessary, and efficient.

When we talk about QI, the discussion is really about enhancing the value or excellence of something (for example, a process or a procedure) through a systematic approach.

Making QI easy:

• Medicaid asks that your practice do a quick practice self-assessment,   The Medical Home Index (MHI).  As you do the MHI you will naturally think of things you would like change or adjust.   QI simply involves working together as a team to discover logical and efficient ways to improve effectiveness, efficiency, ROI, communication, performance, etc. in your topic area.
• Be SMART about it! Make sure that your goals are SMART Goals. A SMART Goal is Specific, Measurable, Achievable, Realistic and Timely.
• Plan-Do-Study-Act (PDSA) is a widely accepted model for the implementation of a QI project.  It is a relatively simple and effective way to evaluate and improve current or future processes by planning what you want to do, implementing the plan, studying the results, and then acting on your findings in order to produce better outcomes.

Your QI Coach is here to help take the hassle out of QI by offering FREE technical assistance. Practices will be assisted in developing continuous quality improvement programming and making any changes they feel they want to make to improve efficiency or to improve their “medical home-ness.”

Want to get started?  Contact Angie Goodger at angela@cchap.org

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Practice Manager’s Corner - December
Kevin Heckman

SYNAGIS UPDATE AND GOOD NEWS!

Effective December 1, 2009, the Medicaid reimbursement for Synagis has been increased to $954.56!

Medicaid protocols for Synagis have been updated as of November 1st.  The new policy is based on the American Academy of Pediatrics (AAP) 2009 and the Colorado Chapter of the AAP recommendations for Respiratory Syncytial Virus (RSV) prophylactic therapy. Synagis® is used to prevent serious lower respiratory tract disease caused by RSV in pediatric patients at high risk for RSV disease. Synagis® is administered by intramuscular injections, at 15 mg per kg of body weight, once a month during expected periods of RSV frequency in the community. Please refer to the November 2009 Medicaid Provider Bulletin for complete details.  The bulletin is available on line at:
http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1246972411343

Add-A-Baby Requests
(Reprinted from Medicaid Provider Bulletin November 2009)

On October 1, 2009, the Department began accepting all Add-A-Baby requests for processing. Although the eligibility sites will continue to be able to add babies to Medicaid upon request, the Department is giving providers an alternative means to making babies eligible within five business days of the form request being received.

Providers can submit the Add-A-Baby form to the Department in three different ways:

1. An email submission can be sent by completing the Add-A-Baby Form (Fill-in) located under “Other Forms” in the Provider Services Forms section and emailing it as an attachment to add-a-baby@hcpf.state.co.us. The email must be encrypted for security purposes, please follow the instructions below:
   How to encrypt the Add-A-Baby form:
             a. In Microsoft Word, select the Tools option from the menu bar
             b. Select Options… from the drop down menu
             c. Click on the Security tab and enter “hcpf” in the Password to open: field located in the File encryption options for this
                document section
             d. Click OK
2. Submit the completed form by fax to the Department at 303-866-4517, Attention: Shawna Moreno or mail the completed form to Health Care Policy and Financing, 1570 Grant Street, Denver CO, 80203, Attn: Shawna Moreno. The standardized Add-A-Baby Form (Print and Fax/Mail) is available under “Other Forms” in the Provider Services Forms section. 
3. An online form is available through the Clients & Applicants section of the Department’s Web site. Click on Report the birth of a Medicaid or CHP+ baby online under the “I am a Medicaid/CHP+ client, how can I report the birth of my newborn?” question.

Please note that the Department will only accept the official form for Add-A-Baby requests. We ask that providers do not alter the form in any way, since all of the information on the form is needed to process the requests.
Please contact Shawna Moreno at shawna.moreno@state.co.us or 303-866-4456 if you have any questions.

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Cavity-Free at Three

Cavity Free at Three is a statewide effort aimed at improving oral health in children and pregnant women.  We are working with CCHAP to offer our program model to interested participants.  Recent Medicaid guidelines allow primary caregivers to provide oral health counseling along with fluoride varnish application and receive reimbursement for these services.  In order to participate, the medical provider as well as staff members involved in this provision of care should complete online training through the Smiles for Life Curriculum.  

Simply visit  http://www.smilesforlife2.org, and complete Module 2:Child Oral Health and Module 6: Fluoride Varnish.   After the online process is completed, we plan a coordinated effort for site visit based training opportunities offering hands on demonstrations as well as follow up and support of our program.

We are in the process of coordinating training opportunities throughout the state of Colorado beginning early 2010.  This will allow for representatives from your group to attend trainings in your area.  If you are interested in hosting a training, or learning more about Cavity Free at Three opportunities, please contact Anita Rich at rich.anita@tchden.org.  If you have questions specific to our program, please contact karen.savoie@ucdenver.edu or visit  http://cavityfreeatthree.org. Thank you.

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Medical Home Certification

Around 50 of the 150 pediatric and family practices that CCHAP currently works with are in the process of obtaining “medical home certification.”    The Colorado Department of Health Care Policy and Financing (HCPF), which administers Medicaid in Colorado, is directed by  Senate Bills 07-130 and 07-211 to document that children on Medicaid receive care in a quality medical home.  So, HCPF is asking practices that are receiving the enhanced reimbursement (as a CCHAP – affiliated practice) to obtain Medical Home Certification to document the quality of the medical home they provide to children on Medicaid.  Practices that have affiliated with CCHAP in the past 8 months have already begun the certification process.  The remaining CCHAP-affiliated practices will be asked to begin the certification process very soon.  

Medical home certification is a three step process.  The CCHAP orientation is step one.  The following two steps also need to be for practices that were oriented in the past and are already receiving the enhanced reimbursement.  Each CCHAP-affiliated practice will be asked to:

• Conduct a self-assessment survey of practice staff and providers called the Medical Home Index.  This brief survey seeks to determine your perception of how well you are doing in providing a medical home.  The survey also will be given to some parents in your practice.
• After reviewing your survey results, you will be asked to select some aspect of “medical home-ness” to improve using a quality improvement process.  CCHAP staff is available to coach you through the quality improvement process if you wish and we have QI projects already prepared for you to implement easily in your practice if you wish.  You may already have QI projects going, which will likely meet this objective.

Medical Home
The American Academy of Pediatrics and the American Academy of Family Practice have promoted the concept of a medical home for many years now.  A recent combined statement by the two academies reaffirmed their support of the concept.  The Academies believe that all children should have a medical home where care is accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective.  For a reminder of the American Academy of Pediatrics and the American Academy of Family Medicine description of a medical home for children, click here. 
And if you want someone to come to your office to present a more description of what a medical home is and does, please contact: Anita Rich (Rich.Anita@tchden.org) or Angie Goodger (angela@cchap.org) for more information.

Medical Home Index
Starting in April 2009, recently oriented CCHAP practices began the process of Medical Home Certification.  The Medical Home Index is completed at a group meeting of your practice with as many of the practice staff and providers as possible. During this meeting the group will complete a Medical Home Index self-assessment, discuss how each indicator rated relates to a quality Medical Home.  The facilitator will conduct informal interviews of families coming to your practice that day asking them to assess the practice’s medical “homeness.”  For a look at the medical home index, click here.

Quality Improvement Projects
Within a few weeks after the practice takes the MHI, you will be contacted by a Quality Improvement Coach with CCHAP. At that time, you will receive your Medical Home Index results, as well as guidance as to how to interpret the results. HCPF asks that you select an element of being a medical home that your practice wishes to work on.   The Quality Improvement Coach from CCHAP – at no cost to your practice – is available to help you decide what your practice would like to work on, develop strategies for making the changes you want to make, and measure the effectiveness of the resultant changes.   

The higher reimbursement practices receive for preventive care is the reward for your practice’s commitment to providing a quality Medical Home for children on Medicaid.


AAP and AAFP Board Certification for pediatricians and family physicians
Both the AAP and the AAFP require that all physicians, when they recertify, develop a quality improvement project in their practice as part of their recertification.  So, CCHAP is helping you obtain both professional board certification and Colorado Medicaid medical home certification.

For more information
Shortly, we will be expanding the Medical Home Certification process to all CCHAP practices.  More information will follow. You may also contact Anita Rich (Rich.Anita@tchden.org) or Angie Goodger (angela@cchap.org) for more information.

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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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The Colorado Pediatric Postpartum Depression Screening and Referral Toolkit

Developed by Brian Stafford, MD, MPH
Medical Director, Perinatal Mental Health Program, The Children’s Hospital

Click here to download the complete toolkit to enable a primary care practice
to recognize and refer women with post-partum depression.    

Why should every pediatric and family practice implement this toolkit?

•  Postpartum depression is a serious medical and psychiatric illness and a significant health concern.
• Approximately 12% of all new mothers develop symptoms consistent with a major depression in the post-partum period
• If left untreated, half of these mothers, about half will continue to have symptoms that last greater than1 year.
• These symptoms include sadness, lack of energy and pleasure, irritability, guilt, anxiety, as well as thoughts of wanting to harm the infant.
• Several lines of research have shown that post-partum depression has significant risk for the child’s cognitive, social, and emotional development and may impact school readiness.
• In addition, the depressive symptoms lead to difficulties in the mother-infant and parental relationship.
• The depressive symptoms are also associated with excessive urgent care and emergency room visits as well as missed scheduled routine pediatric visits.
• Providing pediatric anticipatory guidance to a depressed caregiver does not change any parental behaviors in regard to safety, sleep, nutrition, reading, and interaction.
• Pediatric care providers of infants are in a strategic position to screen and refer depressed mothers for behavioral health evaluation and support.
• Pediatric provider inquiries about maternal health have been viewed as appropriate by mothers.
• Pediatricians, historically, like other primary care providers, have low rates of detecting maternal depression and few pediatricians have a systematic approach to screening for maternal depression.

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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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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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Child Psychiatry Telephone Consultation on Medicaid Children

Rick March is a child psychiatrist who has received grant monies to provide phone consultation regarding children and adolescents with mental health problems throughout Colorado.  He has over twenty years experience in child psychiatry and is available weekdays during regular business hours.  If you do not reach him directly, he would be able to speak with you, at the outside, by the next business day.  Dr. March is at the Mental Health Center of Denver which provides services for children who live in Denver County.  However, he may be able to arrange to see other patients outside this catchment area, possibly in your practice in very difficult cases.  He is also available to provide educational presentation for your providers on a wide variety of mental health topics.

His direct line is 303-504-1500

So, telephone consultation from a child psychiatrist for Medicaid children cared for in a CCHAP-affiliated practice is now available in all counties in Colorado.  

For Boulder and Jefferson Counties – Don Bechtold, MD – 303-432-5172
For Adams, Arapahoe and Douglas Counties – Joe Pastor, MD – 303-853-3888
For all other counties (including Denver) – Rick March, MD – 303-504-1500

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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 33, December 2009