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 11:30AM to 1PM @ TCH and live WEBCAST, RSVP carter.joyce@tchden.org
- Integrating Developmental Screening In a Pediatric Practice
- Medical Spanish Training For Your Office Staff

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Cross-cultural Communication

Eight Dimensions of American Culture

Written by Marcia Carteret
(Copyright © 2010. All Rights Reserved.)

Cultural aspects of everyday life are often difficult for people of dominant cultures to discern because their practices, traditions, values, and understandings are taken for granted as the norm. For them, there’s no apparent need to examine cultural difference, and thus, no inclination to do so. In the US, middle-class Americans are typically so unaware of their own culture they believe that American culture is a melting pot of other cultures. This misperception is further complicated by confusion over terms such as white, American, the dominant majority, mainstream, middle class, western, European American. For our purposes here, American means “middle-class European American” and refers specifically to the “cultural ways of the group that in recent decades has held a mainstream position in North America. These are people who are primarily of Western European descent, with a social position that is often characterized as middle class on the basis of having participated in high levels of formal schooling and associated occupations.” (Rogoff 2003)

Now that we’ve established what the term “American” points to in this article, let’s begin to look at some specific dimensions of American culture. A dimension of culture is a recognizable point of comparison used to explain how different cultures prefer to approach and solve
a universal problem. There are more cultural dimensions than we can possibly address here, so we will focus on a few that seem especially relevant to patient/provider interactions.

Time and Its Control
For Americans, time is a critical factor that is battled on a daily basis. We have an adversarial relationship to time. We talk about saving or wasting time, managing time and beating the clock. Americans invented day-timers and added the term multi-tasking to the English language. We invented fast food and made it even faster by adding the drive-thru. Now even our pharmacies offer drive-thru pick-up.

Many of the other cultures in the world have a more relaxed view of time. In a health care setting, busy practitioners may not realize that patients from different cultures often experience the rushed pace of an office visit as disturbingly impersonal. It is important to slow down enough to exchange a few words of personal conversation with patients. Ask how their family is doing. This gesture only takes a few moments. It puts patients more at ease so they can respond more openly to medical questions. If the doctor is clearly in a big hurry, patients will be even less likely to ask for clarification about treatment and medications. Establishing a conversational style also helps providers introduce conversation about cultural beliefs around illness which can be very important in diagnosing and achieving patient compliance. Physicians will succeed best with patients from different cultures when the care and the cure are experienced as inseparable.
Task vs. Relationship
Very closely related to time control is the American tendency to focus on getting things accomplished, so much so that building rapport with people gets overlooked. In more traditional cultures people focus on establishing rapport first and ensuring harmony in interactions with others. In health care settings, building trust between patient and doctor often depends on developing formal but warm interactions. In Spanish the word personalismo speaks to this balance of professionalism and friendliness. Taking a moment to ask about the family, a handshake that lingers just a bit longer than a business handshake - simple gestures such as these go a long way.

Comfort with Change
Americans are fundamentally optimistic and place faith in the future. As a young culture with few traditions tying us to ways of the past, our identity and inspiration are projected forward in time. Americans link change to progress, development, and growth. We like things that are “New and Improved!” Older traditional cultures consider change to be disruptive and unpredictable. In other words - negative. When a new medical procedure or miracle drug becomes available, Americans are likely to respond with optimism while patients from risk-adverse cultures will show pessimism. Doctors who demonstrate balance in this area will gain the most patient confidence. Clearly risk-avoidance varies from person to person within a culture, and plenty of Americans prefer what’s safe and predictable too. But as a generalization, we in the US do tend to take chances and embrace change.

Personal Control Over Destiny
Americans tend to believe that every individual has primary control over his or her destiny. There isn’t typically a strong belief in the power of fate or karma. In many cultures there is a belief that things, including illnesses, happen because a higher power has intervened. People may show a tendency to resign themselves to bad things in a way that Americans never would. “It s God’s will.” This doesn’t mean patients/families won’t put faith in an American doctor’s medicine, but there may be surprising belief systems operating around what has caused illness or how much control they can exert on the outcome. A Hispanic mother may believe that her child has Mal d’ojo, or has been cursed with the “evil eye.” Members of the traditional Hmong culture believe a baby’s soul can be detained by a malevolent spirit called a dab causing a number of serious illnesses including epilepsy.

Self-Sufficiency
Closely related to the American emphasis on individual control over destiny is the value of being self-sufficient. To succeed without depending on others shows supreme self-determination, self-reliance, and self-confidence. The concept of being self-sufficient, however, doesn’t translate into all languages and the trait is not valued in many other cultures. People from Hispanic and Asian cultures, who have strong attachment to families and communities, emphasize a skillful use of the bonds between families and friends when making decisions and getting things done. Interdependency is a more helpful cultural adaptation in many cultures around the world. The US health care system presents all of us with a unique set of challenges, but those who are from different cultures will really struggle to demonstrate the kind of self-sufficiency we respect in America. The very nature of working together to find solutions means everyone – provider, staffs, patients, and their extended families - relinquishes self-sufficiency to some degree.
Status
In American culture we value the idea of equality. The quotation "All men are created equal..." is arguably the best-known phrase in any of America's political documents. (Thomas Jefferson first used the phrase in the Declaration of Independence as a rebuttal to the going political theory of the day: the Divine Right of Kings.) Perhaps in reality some of us are clearly more equal than others, yet egalitarianism is a defining aspect of American culture and one in which we differ from other cultures that actually embrace a set social hierarchy. Americans' insistence on collapsing social hierarchy leads to our preference for informality in social interactions, demonstrated in a well-known tendency to use first names when we address others, even with strangers. This degree of informality can make people from some other cultures uncomfortable, especially when there is a perceived status difference between people, as in patient/family/doctor interactions. It is best to rely on formal terms of address, using Mr. and Mrs., instead of first names. This will likely make people in many cultures more comfortable.

Language
Language use as a cultural dimension deserves a whole separate article, but the basics can be touched on here. Americans are low context communicators, so the words we speak are expected to deliver everything that’s important during verbal interaction. We pay far less attention to factors such as body language and the context of what is being said. In high context cultures, gesture, body language, eye contact, pitch, intonation, word stress, and the use of silence are as important as the actual words being spoken in conversation. High context cultures tend to communicate in a less direct fashion. Americans, being low context, are comfortable with very direct speech and sometimes seem abrupt to people from high context cultures. We miss the nuances of conversation. Americans appreciate communication that gets straight to the point and tend to interrupt when conversation isn’t moving along. People from many other cultures do not feel they have had a chance to adequately explain their concerns until they have told “the whole story.” This is important to keep in mind when communicating with people from different cultures, especially those who are relatively new to the US. Interactions with Americans who are highly verbal and direct can be challenging for someone who is accustomed to telling a story as a way of answering a question. Americans aren’t the only direct/high context communicators in the world, but we certainly rank among them.

Individualism
Cross-cultural research shows US Americans score higher on this cultural value than any other culture in the world. All the values we’ve addressed up to this point are closely related to this one aspect of American culture. Individualism is the belief that each individual’s interests should take precedence over those of the social group. Collectivist cultures, by comparison, assign value based on the role a person plays within a group. If people were stars in the sky, being one of the seven brightest stars forming the Big Dipper would be more important to someone from a collectivist culture than being the single brightest star. In American culture, where the individual is paramount, everyone wants to be the North Star.

Individualism versus collectivism is an important dimension of culture because it affects the way people live together – for example in nuclear families or extended families – and it has many implications for values and behavior. Child rearing as a whole is handled differently in collectivist cultures. The child in a collectivist culture is seldom alone, either during the day or night. Children are reared by an extended kin group that may or may not include family like ties with persons who are not biological relatives. Important health decisions are not made solely by an individual – parent or otherwise. In many collectivist cultures, the term “family” doctor points to a medical relationship that is indeed more like family. Several generations visit the same physician, establish rapport and hold certain expectations for interaction with their doctor. Compare this to searching for doctors on the Internet in the United States, or having to choose from an approved list of physicians in a managed care network. Feeling like an isolated stranger visiting a doctor’s office can cause great anxiety for a recent immigrant. There’s much uncertainty about how the medical system works, about insurance, about how an American doctor will relate to cultural and language barriers. All of these worries are an added burden to the actual illness that requires medical attention in the first place. So, a mother from a collectivist culture will likely bring a grandmother, aunt, or family friend for support when she visits a pediatrician. Big decisions about procedures, such as surgery, may take hours as wives ask husbands, husbands consult elder brothers, elder brothers consult the father or perhaps even a community healer. This can create confusion and frustration for western doctors, but collectivism is a deeply rooted value. The classic American individualist who stays aware of how collectivist cultures operate will be much more skillful in cross-cultural interactions. Being group-oriented isn’t better or worse than being more individualistic. Both ways of approaching life have advantages. As with all the dimensions of cultures, awareness of difference without judgment is the path leading to happier healthier patients and successful providers.

Summary
This article has introduced eight key dimensions of American culture. Learning about our own cultural patterns provides us with a baseline for comparing cultures that are different. As we develop self-awareness around cultural experience, we are able to observe without leaping to judgment. We realize there’s a difference between what we actually observe and how we label our observations based on our own cultural programming. In the process of becoming more aware of interactions with culturally diverse patients, providers hone communications skills that benefit all patients. Increased patient satisfaction and health outcomes lead to happier providers and more successful practices. Certainly within the medical culture, that’s seen as a win-win situation of great value.


References
The Cultural Nature of Human Development (by Barbara Rogoff 2003)

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Quality Improvement
UPDATE

CCHAP 2009 Quick Stats …

In 2009, 48 practices completed the Medical Home Index (MHI) (31 pediatric practices, 17 family practices). Currently, 18 of those practices are either planning or have implemented 21 different Quality Improvement projects:

• 52% of QI projects involve age appropriate preventative care and screening
• 33%  of QI projects involve improving practice family centered-ness 

In 2009, CCHAP worked with 11 practices that began QI projects to assess their effectiveness in administering the Ages and Stages Questionnaire (ASQ) as their developmental screening. The number of developmental screens completed by these 11 practices during the first three quarters of 2009 has steadily increased, which of course means their reimbursement for developmental screening has also increased. 

CCHAP is Available to Help Your Practice
To Make Whatever Changes You Wish

Did you know that all board certified pediatricians and family physicians, which they go through recertification, will be required to do a QI project?  Let us help. Angie Goodger is available to help your practice select something you want to improve and to coach your practice through the process of setting up a QI project to make the improvement you select. You can reach her at Angie@cchap.org.

Quality Improvement Tips
Measurement

A vital piece of Quality Improvement is measurement of progress. In order to measure progress, you need to first clearly define what you want to change and what outcome you want to have happen.  The next step is to measure where you are now: what is your baseline level.   Then, you create your plan and implement it.  At the end you measure where you are again, to  determine whether or not your specific change has actually led to an improvement.

So, key first steps of QI are to decide what you want to have happen, how you will measure it and then measure where you are at the beginning.   When defining your measurements, keep the following in mind:

• Keep it simple: gather just enough data to learn what you want to learn.
• Don’t rely only on hunches.
• Look at data that you are currently using to see if that will meet your needs. 
• How can data be collected most easily, concurrently?
• What data is easily available from other sources?

It’s important to ensure validity of monitoring data. During your planning, be sure to consider:

• Who will collect the data?
• How will the data be collected and how often? 
• Are data consistent with reality?

At its core, Quality Improvement is a factual, data driven approach to see if changes in care practices, or process, make a difference in outcomes.

And remember, Angie Goodger is available to help you through the process.
Angie@cchap.org

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PRACTICE MANAGER MEETING
Live Web Cast!!
Wednesday, January 13th
11:30 – 1:00 PM
Medicaid Billing Presentation

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Practice Manager’s Corner - January
Kevin Heckman

MEDICAID PATIENT LIST REQUEST (REMINDER)

We have heard back from about 30% of CCHAP practices that have sent us their Medicaid patient ID lists.  If you have not yet sent us your list, please take a few minutes to get us your report no later than January 15th.  Generating this list is not difficult for most practices and we can help you.  Please see the Options below for guidelines.

Health Care Policy and Financing (HCPF) relies a great deal on CCHAP to assist them with determining how many Medicaid children are being served by Medical Home practices like yours and then how many more Medical Homes are needed to serve the needs of children throughout the state. With the climate of economic instability within the state budget, services and reimbursements are at risk.  The more information that we can provide to HCPF regarding the number of children being cared for by private practices, the better prepared they will be to support the current level of Medicaid reimbursement for providers to Medicaid children and avoid any further cuts in reimbursement.

Last April we contacted our current CCHAP affiliated practices to get a count of how many patients you thought made a Medical Home with your practice.  This data was extremely helpful and we are asking for your help again now.

The data we need from you is a report that lists all unique Medicaid patients (just their Medical ID number – no names and no duplicates) who have been seen by a provider in your practice sometime within the past 2 years.  We anticipate that we will need to collect this data from each of you approximately every 6 months, so if you can design a report that produces this data and then send it to us in an Excel spreadsheet, we would be most grateful. Please try to get me this data by year end.

1. If you enter all Medicaid claims on the Medicaid Provider Portal, you can generate this list easily as follows:
   
   • Log in to the provider portal > Go to the data maintenance tab > then the client maintenance sub-tab > Options are available to sort (by DOB to eliminate older patients), print and download to Excel.
2. If you use an EDI and clearinghouse system to submit claims, here are some basic guidelines to generate a report.  Since all systems have unique reporting capabilities, please call Kevin if you need help.  We want to make this as easy as possible for you:
   
   • Constrain on Medicaid only
   • Constrain on DOS within past 2 years
   • Constrain on DOB < 21 years of age
   • Report Medicaid ID number of patient (this is the only column of data that we need on this report)
   • Report only one instance of the ID to avoid duplicates
   • Download report to Microsoft Excel, if possible

Please email the Excel file to heckman.kevin@tchden.org and please call me for help on this request.  I can be reached at 720.777.6309. I want to make this as easy for you as possible!
 

YOUR VOICE WAS HEARD
Update On Medicaid Reform in Colorado

Below is an update of the Accountable Care Collaborative activities.

As you recall, Colorado Medicaid proposed to conduct a pilot program in late 2010 for one year in which new regional care coordination organizations would be formed to do many things that a managed care organization would do to help Medicaid recipients and providers.   And if the pilot is successful, then this approach would be expanded statewide to all Medicaid recipients and providers probably in 2012.   You may recall that one concern that private practices had was that the payment to providers was going to be basic Medicaid reimbursement plus a possible distribution of some portion of  shared savings at the end of the year. Many CCHAP practices expressed concern that this  approach would not adequately cover their costs.   CCHAP-affiliated practices were worried that they would not continue to receive the current higher reimbursement for meeting the medical home standards and providing preventive care that they currently receive.  Colorado Medicaid heard your voice and recently issued that following public statement.  
 
“Colorado Medical Homes for Children practices, including the Colorado Children's Healthcare Access Program (CCHAP), serve as medical homes for a large number of children who are enrolled in Medicaid.  The Department expects that these practices will continue to deliver comprehensive health care services to children in a similar way when the ACC is implemented.  The existing Pay for Performance payment structure for these participating providers will not change under the ACC.”

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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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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 2010 Colorado Children's Healthcare Access Program and other entities as noted.

 CCHAP Home > Newsletter Articles > Newsletter 34, January 2010