Ongoing Services

- Cavity-Free at Three Statewide Training
- How to refer children with developmental delays
- Provider Resource Helpline Helps Your Special Needs Children: Identify & Access All Resources and Care Coordination
- Medical Home Certification
- Post-partum Depression Screening
- Practice Manager's Meeting May 11, 11:30 to 1:00 PM @ TCH, RSVP carter.joyce@tchden.org
- Announcing an Interactive Cross-Cultural Communications Website Designed Especially for Healthcare Professionals
- Introducing the CCHAP Quick Reference Link
- Child Psychiatry Telephone Consultation on Medicaid Children
- Integrating Developmental Screening In a Pediatric Practice
- Medical Spanish Training For Your Office Staff
- Child Psychiatrist Available to Provide Conferences for You In your Office
- Language as a Communication Barrier in Medical Care for Hispanic Patients Plus A Spanish Course For Providers

^{Download Newsletter Thirty-Eight}

Cultural Aspects of Death and Dying

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

While the end of life experience is universal, the behaviors associated with expressing grief are very much culturally bound. Death and grief being normal life events, all cultures have developed ways to cope with death in a respectful manner, and interfering with these practices can disrupt people’s ability to cope during the grieving process. While health care providers cannot be expected to know the mourning ceremonies and traditions of each family’s culture, understanding some basics about how different cultures may prepare for and respond to death is important. Though difficult to ask, there are crucial questions that need to be part of conversations between doctors and nurses and families. For example:

• What are the cultural rituals for coping with dying, the deceased person’s body, the final arrangements for the body and honoring the death?
• What are the family’s beliefs about what happens after death?
• What does the family consider to be the roles of each family member in handling the death?
• Who should the doctor talk to about test results or diagnosis?
• Are certain types of death less acceptable (for example, suicide) or are certain types of death especially hard to handle for that culture (for example, the death of a child – this example may seem too obvious, but in countries with high infant mortality, there are indeed different attitudes about the loss of children.)3

This list of questions is so important because patients and families should be viewed as a source of knowledge about their special/cultural needs and norms – but health care professionals sometimes are at a loss about what to ask under such trying circumstances. There is perhaps no area where reliance on cultural reference books is less useful. The degree of acculturation is absolutely paramount in determining the beliefs and traditions a family will follow when coping with impending death, post-death arrangements and mourning. While we can find many similarities across cultures, such as wearing black as a sign of mourning, there are always exceptions. In China, for example, white is the color of death and mourning. Part of why the degree of acculturation is highly significant is that blending belief systems becomes more pronounced in highly acculturated persons. There are places in the world where accommodation is made for multiple faiths. For example, in Nigeria there is a triple heritage of Christianity, Islam, and ancestor worship2. Similar blending can be found in Caribbean nations and Mexico where Catholicism can be mixed with indigenous folk beliefs like Voodoo and Curanderismo. Another layer of expectation comes with living in the United States culture and relying on the Western medical culture. The mix of cultural/religious attitudes and behaviors surrounding death and dying can become very complex indeed. And when a death actually occurs, some individuals suddenly choose to break with tradition entirely, often creating chaos within families.
 
What follows in this article are some important points of consideration, but the list is introductory in nature at best. The on-line version found at www.dimensionsofculture.com provides active links for more in-depth exploration. There is a strong focus on religions because religion can be thought of as a cultural system of meaning that helps to solve problems of uncertainty, powerlessness, and scarcity that death creates. In placing death within a religious perspective, bereaved persons find meaning for an event that for many is inexplicable.1

Monotheistic Religions: Especially since the events of 911 changed many people’s views of Muslims, it is important to be aware that Christians and Muslims both believe death is a transition to a more glorious place and both believe in the sovereignty of a God (Allah) in matters of loss and take consolation in phrases such as “Allah giveth and Allah taketh away.” Both are also faiths springing from a single scripture, founder or sacred place. Readings from the Koran or Bible are important parts of the recognizing the departure of a loved one from this life. Similarly, in the Jewish faith, there is the expression mourners recite a few minutes before a funeral begins: “The Lord has given and the Lord has taken, blessed be the name of the Lord.” Both Muslims and Christians believe in the afterlife and view worldly life much in terms of preparing for eternal life. In the Jewish tradition, the focus is on the purpose of earthly life, which is to fulfill one’s duties to god and one’s fellow man. Succeeding at this brings reward, failing at it brings punishment.
 
The traditions around death and dying differ greatly across all three major monotheistic religious systems (as well as within different branches of each faith, i.e. Jehovah’s Witnesses and Mormonism in Christianity). They are highly nuanced and very hard for outsiders to understand thoroughly. Key rituals and practices that differ widely between religions include the preparation of the deceased person’s body, the permissibility of organ donation, and the choosing of cremation vs. burial.
 
Ancestor Worship: The premise of ancestor worship is based on understanding that the course of life is cyclical not linear. Those who are dead may not be seen physically, but are alive in a different world and/or can reincarnate in new births. Ancestor worship in various forms can be found in many parts of the world and is very strong in parts of Africa and Asia. Many Native Americans and Buddhists alike believe that the living co-exist with the dead. A central theme in all ancestor worship is that the lives of the dead may have supernatural powers over those in the living world – the ability to bless, curse, give or take life. In some cultures, worship of the dead is important, and includes making offerings of food, money, clothing, and blessings. In China there is the annual observance of “sweeping the graves” and as its name denotes, it is a time for people to tend the graves of the departed ones. In Mexico, there is The Day of the Dead (Dia de los Muertos), a holiday that focuses on gatherings of family and friends to pray for and remember those who have died. The Day of the Dead is also celebrated by many Latin Americans living in the U.S. and Canada. The intent of the celebration is to encourage visits by the souls of the departed so that those souls will hear the prayers and the comments of the living directed at them. It makes sense that in cultures where ancestor worship is common, the acceptance of organ donation and cremation may be low.

Buddhism and Hinduism: Hinduism does not have roots springing from a single scripture, founder or sacred place. It is more like an umbrella term describing a set of philosophies and ways of life. Buddhism has a single founder, but the Buddha is not prayed to in the same sense as a God or Allah. Buddhism is also a set of philosophies for living. There are marked differences between the two, or course, but in both death is not seen as the end of life; it is merely the end of the body we inhabit in this life. The spirit remains and will seek attachment to a new body and a new “life” – in Buddhism it is called a “kulpa,” which is a unit of time. Where a given person will be born again is a result of the past and the accumulation of positive and negative action, and the result of karma. Followers of both traditions keep in mind the impermanence of life. The transition of a soul to a new life is very important so both traditions observe specific rituals at the time of dying and the handling of the body. The corpse of a Buddhist should not be touched for 3-8 hours after breathing ceases as the spirit lingers on for some time. Hindus believe the body of the dead must be bathed, massaged in oils, dressed in new clothes, and then cremated before the next sunrise. It follows that cremation would be acceptable in a faith where the soul will be released to find another body to inhabit.

Truth-telling to Patients: In collectivist cultures, the good of the individual is often so enmeshed with the good of the family or in-group that family members may have a greater say in health care decisions than the patient does in some circumstances. In many countries, family members may become very upset if a physician reveals bad news directly to the patient. Families and patients may place great value on the right NOT to know! This is completely at odds with the standards set forth in the Patient Self Determination Act http://en.wikipedia.org/wiki/Patient_Self-Determination_Act which secures certain rights legally for all patients in the U.S. The health care system needs to be flexible enough to accommodate communication patterns that look different from those within the informed-consent tradition which insists doctors and nurses tell patients everything. So, a key question in cross-cultural health care situations would be: Who do you want me to talk to about test results or diagnosis?

Expressions of Grief: In some cultures, showing grief, including wailing, is expected of mourners because the more torment displayed and the more people crying, the more the person was loved. In other cultures, restraint is expected. Rules in Egypt and Bali, both Islamic countries, are opposite; in Bali women may be strongly discouraged from crying, while in Egypt women are considered abnormal if they don’t nearly incapacitate themselves with demonstrative weeping. In Japan, it is extremely important not to show one’s grief for a number of reasons. Death should be seen as a time of liberation and not sorrow, and one should bear up under misfortune with strength and acceptance. One never does anything to make someone else uncomfortable. In Latino cultures, it may be appropriate for women to wail, but men are not expected to show overt emotion due to “machismo.” In China, hiring professional wailers may be customary in funerals, which may sound odd, but this was also a common practice in Victorian England.

Conclusion: For health care professionals, providing culturally sensitive bereavement/end of life care is understandably an issue of discomfort. Language and cultural barriers obviously compound the challenges of being professionally appropriate and compassionate. Patients and families may be in need of compassion, advice, and guidance from doctors and nurses, but often the realities of a given situation include a press for time and both physical and emotional exhaustion among providers and families. It happens - sometimes we simply fail, in the moment, to express sufficient sensitivity and warmth when critical decisions must be made. The clinical facts are immediate and demand logical linear thinking which is natural for those trained in the Western medical tradition. For many cultures, such a direct approach may seem harsh, and decisions about something like organ donation might be experienced as inhumane immediately upon death. The questions suggested in this article can be used to ease some of the communication challenges and facilitate more openness between health care professionals and families around death and dying. Of course they should be tailored to the context of a given situation.

Resources
1. Gire, J. T. (2002). How Death Imitates Life: Cultural Influences on Conceptions of Death and Dying
The University of Washington.  Retrieved April 16, 2010 from http://www.ac.wwu.edu/~culture/gire.htm.

2. Eyetsemitan, F. (2002) Cultural Interpretations of Dying and Death in a Non-Western Society: The Case of Nigeria.
The University of Washington. Retrieved April 17, 2010 from www.ac.wwu.edu/~culture/Eyetsemitan.htm.

3. Culture and Response to Grief and Mourning (2009, Sept. 3)
Retrieved Apr. 12, 2009 from The National Cancer Institute Site at http://www.cancer.gov/cancertopics/pdq/supportivecare/
bereavement/Patient/page10
 
Lobar, Sandra L., Youngblut, JoAnne M., Brooten, Dorothy (2006). Cross-Cultural Beliefs, Ceremonies, and Rituals Surrounding Death of a Loved One. Pediatr Nurs 32(1), 44-50.

- Top of Article - Top of Page - CCHAP Home -

Practice Manager’s Corner - May

Kevin Heckman

CORRECTION!

The information regarding Third Party Insurance related to Medicaid that appeared in CCHAP Newsletter 37, Article 4 contained inaccurate information in regards to the correct contact for these issues.

To expedite Medicaid provider's requests to end commercial health insurance for Medicaid clients and to get assistance with billing issues, please call Medicaid Provider Services (ACS) at 303-534-0146 or 1-800-237-0757. Medicaid Provider Services has the capability to end commercial health insurance for Medicaid clients and also instruct providers how to properly submit claims when Medicaid has denied claims due to inaccurate insurance information in our billing system.  If a provider is not satisfied with the service of ACS, they may then contact Pete Garcia and he will make sure the issue gets resolved.

We apologize for the incorrect information that was previously communicated.

 
MEDICAID and CHP+ Eligibility Expansion Effective May 1, 2010
Almost 70,000 more Coloradans will be eligible for Medicaid and CHP+ as of May 1, 2010. This is the first expansion as a result of the Colorado Health Care Affordability Act provider fee.

An estimated 44,000 parents who have a child on Medicaid and 24,000 children and pregnant women will be eligible for health care coverage as a result of the hospital provider fee, at no cost to the taxpayer.

CHP+ eligibility is increasing from 205% of the FPL, or $45,000 per year for a family of four, to 250% FPL, or about $55,000 per year for a family of four. Eligibility for parents with a child on Medicaid can now make up to 100 percent of the federal poverty level - $22,056 per year for a family of four. This is up from 60%, or $13,234.

More information is available at:
www.colorado.gov/hcpf > Partners & Researchers > At a Glance > April 2010

HEADS UP!
MEDICAID FEE SCHEDULE Updated April 15, 2010
www.colorado.gov/hcpf  > Providers > Provider Services (scroll down on page)
One change of note: Outpatient Consultation as well as Hospital Consultation codes are no longer a covered benefit (99241 – 99245 and 99251 - 99255). Please use an applicable alternate E/M code.

Early Periodic Screening, Diagnosis & Testing (EPSDT)
EPSDT and Medicaid Lead Testing Requirement for Children
All children enrolled in EPSDT/Medicaid must be tested for lead poisoning at 12 and 24 months of age.
If these children are not tested at these intervals, testing for lead levels in EPSDT/Medicaid children must be conducted between 36 and 72 months of age. Section 1905(r)(5) of the Social Security Act requires that any medically necessary service be provided to EPSDT clients. The Colorado Medical Assistance Program would like to remind providers of the Centers for Medicare and Medicaid Services (CMS) blood lead testing requirement and that it is a medically necessary service because all EPSDT/Medicaid children are considered to be at risk for lead poisoning.
A finger-stick blood lead test which generates a result greater than 10 micrograms/deciliter must be confirmed using a venous blood sample. Providers may defer blood level testing at the above intervals only if previous lead testing is documented in the child’s health record.
While recent guidelines from the Centers for Disease Control suggest alternative methods of risk assessment for lead exposure, CMS blood lead testing requirements remain in effect.
For more information, please visit http://www.cdphe.state.co.us/ap/down/leadservices.pdf
or contact George deCurnou at 303-866-6010 or George.deCurnou@state.co.us

Medicaid Provider Bulletins
Reminder:  Don’t forget to review the monthly bulletins which are available on the HCPF website at:
www.colorado.gov/hcpf > Providers > Provider Services > Provider bulletins

- Top of Article - Top of Page - CCHAP Home -

CCHAP Quality Improvement Resources Now Available!

CCHAP now has a variety of QI educational tools and resources available for practices wishing to implement QI projects and/or beef up their quality improvement IQ. We hope that these tools will increase your QI confidence, and provide a roadmap for how to get QI started in your practice!

• QI Chapter
  • We’ve recently added a Quality Improvement Chapter to our CCHAP Orientation Manual. Please use this chapter as a quick reference guide.
    Click here to be taken to the online Orientation Manual (CCHAP affiliated login required).
• QI Video Training Session
  • This video is from our March 11, 2010 Practice Manager’s meeting. This training quickly highlights the Do’s and Don’t of QI.
    Click here to view the video and/or download meeting handouts.
• Quality Improvement Coach
  • Remember, QI coaching is available – for FREE – to CCHAP affiliated practices wishing to improve their Medical Home. Call or email today!

  
Angie Goodger, MPH, MHA
Quality Improvement Coach
720-346-4903 Cell
720-777-7338 Fax
angela@cchap.org


Great things are not done by impulse,
but by a series of small things brought together.
~Vincent Van Gogh

- Top of Article - Top of Page - CCHAP Home -

New Look for Medical Identification Cards
June 1, 2010

Beginning June 1, 2010 the Department will begin issuing Medical Identification Cards with a new look. The new cards will be bilingual – English and Spanish – and more informative. A sample of the new card is below.

These new cards do not replace cards issued before June 1, 2010, therefore, please accept both versions.   Please contact Roberta Lopez at 303-866-6114 or Roberta.Lopez@state.co.us if you have any questions.



Card Front – Sample

- Top of Article - Top of Page - CCHAP Home -

 
Colorado Department of Health Care Policy and Financing
Efficiencies and Cost-Containment Initiatives
March 2010

The mission of the Department of Health Care Policy and Financing is to improve access to cost-effective, quality health care services for Coloradans. Since 2007, Governor Ritter, the Department and the General Assembly have implemented an approach to health care reform that is strategic, incremental and system-wide so that every Coloradan can access high-quality, affordable health care. The results of this approach are the implementation of many strategies that improved access to health care; created efficiencies; defined consumer value for the dollar; and promoted transparency to the taxpayer.

• Preferred Drug List established by Executive Order to better manage the pharmaceutical benefits for Medicaid clients, using objective, scientific evidence to determine the efficacy of medications and to create a rational formulary for Medicaid clients. The use of the list and the aggressive negotiation of rebates from pharmaceutical companies are saving the state over $9 million per year.
• Long-Term Care Partnership launched to ensure older Coloradans have access to long-term care services when they need them, and provides an alternative to using Medicaid as their only resource for long-term care. The program has helped more than 6,000 middle-income Colorado families purchase affordable, quality long-term care insurance. 
• Medical Homes for Children established standards for providers to ensure children have access to preventative care, coordination of services, and 24/7 phone consultation. The state is saving money and improving care for children by avoiding unnecessary use of emergency departments for services that should be provided in primary care settings. Currently, 236,000 children are served in medical homes. 
• Colorado Regional Integrated Care Collaborative is a program designed to better serve high-need/high-cost Medicaid clients. Health plans provide robust care-coordination and manage the utilization of services. Savings are found through avoiding unnecessary hospitalizations and better coordinated care that reduces duplication of services. 
• PACE programs that coordinate services between Medicare and Medicaid were expanded to eight sites, allowing 2,000 elders to live at home and in their communities instead of in nursing facilities. An expansion is planned for 2010. 
• Emergency Room Diversion projects were funded in two communities with a federal grant. The projects are designed to educate Medicaid clients regarding inappropriate use of emergency rooms when primary care providers are available to serve them. Thousands of individuals in these two communities have since scheduled visits with primary care clinics. 
• The Benefits Collaborative is a Department-led initiative for defining the amount, scope and duration of each Medicaid benefit. This effort will save the state money by ensuring that all benefits offered are medically necessary and consistent with current evidence and medical standards. 
• Colorado Health Care Affordability Act (HB09-1293) expands coverage to more than 100,000 Coloradans without General Fund by using the hospital fees to draw down federal Medicaid matching funds. The combined $1.2 billion will support Medicaid and CHP+ expansions and will be used to improve hospital reimbursement. Covering more of the uninsured reduces the amount of uncompensated care in the health care system, and reduces the amount of cost-shifting of that care that is passed on to individuals with insurance. 
• Program Integrity activities identify potentially excessive or improper utilization, or improper billing to Medicaid by providers. These efforts recover approximately $8 million per year. 
• Benefits Coordination is designed to recover costs for medical care paid for by Medicaid from other insurance plans, trusts, estate recoveries, and recovering any payments to clients who were discovered to be ineligible for Medicaid. The Department recovered $45 million of Medicaid payments from estate recovery efforts. 
• Health Information Technology is a key tool in improving health outcomes and reducing unnecessary expenditures in the health care system. The Department is partnering with CORHIO, the statewide entity establishing guidelines and developing health information exchanges, to develop the tools for providers to exchange data and information about Medicaid clients. This will save the state money by allowing providers to talk with one another through secure internet or email capabilities, sharing information about client tests and treatments that will avoid duplication of services, repeated tests, and the use of inaccurate information that leads to medical errors. 
• Smoking Cessation is an important tool for improving health outcomes and reducing Medicaid costs associated with tobacco-related illnesses. Medicaid coverage was expanded to provide clients access to additional medications to help them quit smoking successfully. 
• Medical Errors, or serious reportable events, will no longer be covered by Medicaid as a result of Executive Order D 006 09. This policy results in improved patient safety, decreased Medicaid costs and saves taxpayers money. 
• Avoidable Hospital Readmissions that occur within 24 hours of discharge for a related condition will no longer be reimbursed by Medicaid. This policy will encourage better patient support during and after a hospital discharge and save taxpayers money. 
• Quality Incentive Payment Programs were adopted to provide financial incentives to nursing homes to provide higher quality services, and will be implemented with hospitals as well. A certain portion of the payment will be directly related to the achievement of quality and outcome goals. 
• Prior Authorization is an important tool in managing the utilization of high cost benefits. Medicaid now requests all outpatient clinics obtain prior authorization for non-emergent CT, non-emergent MRI and all PET scans. Justifying these non-emergent services ensures necessity and saves taxpayers money. 
• The Nurse Advice Line is being aggressively marketed to Medicaid clients as a way to reduce unnecessary use of emergency rooms. The toll-free number is now on Medicaid identification cards, in enrollment packets, and in client correspondence. The Department sent letters to clients who visited ERs more than six times, giving them the toll-free number and scheduling many of them for visits with primary care providers. The number of calls to the line increased by 300% in 2009. 
• The Accountable Care Collaborative will save the state approximately $14 million per year by holding regional organizations accountable for delivering high -quality, patient-centered, coordinated care to Medicaid clients using community-based care coordinators. 
• CHP+ at Work will be expanded, allowing the Department to provide coverage to more children through their parents’ insurance. This keeps families in the same plan, and allows the Department to pay premiums for children instead of enrolling them in a public plan. 
• Three-Share Community Projects are health coverage programs that bring together employers and workers without coverage, with community providers offering direct services to those workers. Everyone shares in the cost – the employer, the employee and the community so individuals get good, basic primary care services. The Department will support the expansion of the project in Pueblo and expand to the San Luis Valley. This expansion will be accomplished with $761,000 from a five-year federal grant. 
• The Center for Improving Value in Health Care will establish an all-payer claims data based, giving providers and consumers’ information about the costs and quality of health care provided throughout Colorado. Consumers will have transparency into the costs of services, and be able to plan for out-of-pocket expenses associated with their health care. 
• Public Health and Population Health Initiatives can save the state and other payers’ money by focusing on keeping the overall population healthy. The Department will be partnering with Baby and Me - Tobacco Free – a program that combines smoking cessation support specific to pregnant women with the incentive of free diapers to help motivate the women to stay smoke-free during the first months of the baby’s life. The Department will be promoting 5 Alive! – a collaborative, community-wide initiative to provide a supervised wellness program to Colorado 5th graders who have limited access to healthy lifestyle choices for fitness and nutrition. The Colorado Behavioral Healthcare Council will assist the Department to survey behavioral health providers on their current health promotion activities and interventions; identify improvement areas; and implement and evaluate needed health promotion and wellness interventions. 
• Veterans in the Veterans Affairs Health Care System connects eligible Colorado veterans with benefits for which they are eligible but of which they have not yet taken advantage. By working with Veterans Affairs to establish regular care for Colorado’s veterans, the high costs of emergency care can be avoided while maximizing the federal dollars contributed to the VA program. 
• Health Insurance Buy-In Program will enroll an additional 100 new clients for FY 2009-10. The program generates savings by paying the premiums, deductibles, and co-insurance for clients who would otherwise be utilizing higher cost services. The clients can continue seeing their physicians of choice thus maintaining continuity of care. 
• Fluoride Varnish Treatments allow the Department to avoid costly dental and medical procedures by providing children up to age 6 with effective, preventive dental care though fluoride varnishing. 
• Manual Pricing of DME, Injectibles, and Medical Services removal allowed the Department to automatically set reimbursements a percentage of Medicare while ensuring that for goods and services where no Medicare rate information exists, rates were set using the Department’s average paid, other states' Medicaid average paid, or the commercial average paid rate. By developing an automated reimbursement rate setting methodology, the Department ensures that it is always generating value for medical goods and services by reimbursing at appropriate prices. 
• Evidence-Guided Utilization Review will divert clients away from inappropriate medical care by providing reviews of services received and reimbursing only those services that are medically necessary. The Department’s designated Quality Improvement Organization (QIO) will expand the scope of services currently reviewed, providing additional savings while also identifying situations and allowing for intervention where utilization patterns are not in the best interest of our clients. 
• Coordinated Payment and Payment Reform will streamline payment processes, enhance recovery efforts and provide for proactive integration of care while expanding the application of performance-based payment structures which incentivize desired outcomes. Physician Payment Reform and Waiver Rate Reform will create payment plans based upon health outcomes, allowing the Department to purchase better health rather than to simply purchase medical services.

- Top of Article - Top of Page - CCHAP Home -

 
Healthy Homes / Healthy Kids

A Project to Improve Housing For Children With Asthma

We are pleased to announce a cooperative project between National Jewish Health and Northeast Denver Housing Center sponsored by HUD that will help identify and fix or remediate asthma triggers in the homes of children living in Northeast Denver.  In addition to helping families this project examines the efficacy of a low-cost, sustainable home assessment and intervention system for indoor asthma triggers.  Past research has shown that environmental factors within homes can significantly impact the asthma symptoms of the people who live within those homes.  The purpose of this study is to evaluate home environmental factors and to determine if knowledge of potential hazards, combined with educational intervention and possible remediation will reduce the impact of the home environment upon children with asthma.

We are looking for:

• Families who speak English or Spanish and have a child under the age of 12 with asthma or recurrent wheezing;
• Families who live in one of the following neighborhoods:
  Globeville, Elyria Swansea, Five Points, North Capital Hill, Cole, Whittier, Skyland, Northeast Park Hill, City Park West, City Park North and Clayton

For participating, families receive:

• A detailed report about any problems we find and what you can do to improve these.
• A free vacuum cleaner and other household cleaning and safety supplies.
• The possibility of free professional assistance in repairing problems.                    

Each family enrolled in the project will receive 2 home visits, approximately 9 to 12 months apart.  During the initial home visit the project staff will ask the participant some questions about their home environment and their child’s asthma.  They will also conduct a visual survey of the participants home and will collect dust and air samples.  This visit will last about 3 hours and the participant will be given approximately $150.00 worth of cleaning supplies, including a vacuum cleaner.

Shortly after the first visit we will mail the parent the results of what we found including recommendations for how conditions in the home might be changed in order to improve your child’s asthma.  If the parent agrees, the results of these tests will also be sent to you and the child’s health care provider.  Project Staff will also speak with the parent over the phone in order to go over the results and the recommendations made.   Depending on the problems identified, families may be offered up to $5000 in professional remediation provided through the Northeast Denver Housing Center.

We hope that you will consider sharing information about this project with eligible families within your practice.

For more information please call Mike Vandyke, PhD at 303-398-1034 or Andres Diaz at 303-398-1447.

CLICK HERE to download flyer in English and Spanish

- Top of Article - Top of Page - CCHAP Home -

 
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.

Announcements:

Thank you to Pediatric Partners of Glenwood Springs, particularly Brian McGill, for coordinating a Cavity Free Training on February 16th.  15 people attended.  That is a great turnout.  

More training is scheduled for March. March 18th in Durango hosted by Pediatric Partners of the Southwest and on March 26th hosted by Miramont Family Medicine in Ft. Collins.

- Top of Article - Top of Page - CCHAP Home -

 
How to Refer Infants and Toddlers for Early Intervention Services

Bill Campbell

This is a quick reminder that for children suspected of having developmental delays, the referral resources depend on the age of the child.   Refer  infants and toddlers to Early Intervention Colorado if they are suspected to have significant developmental delays, or if they have any health conditions associated with a high probability of developmental delay.  Refer preschoolers and children not already enrolled in public school to Child Find for similar concerns.  For families whose children are already enrolled in public school, the parents have the right under special education law to request a comprehensive educational evaluation, but it’s best if they start by request a formal meeting with school staff, including the teacher, a special educator, and a school administrator.  At the end of this article you’ll find a link to a referral flow chart that outlines the decision-making process for referring children of different ages for developmental and educational assessments, but the following paragraphs will focus on how to refer infants and toddlers for early intervention services.

Developmental delay is common among infants and toddlers (at least 10 percent of infants and toddlers have delays in one or more areas of development).  Early intervention services have been shown to be effective in helping children with developmental delays, particularly children with autism spectrum disorders and other communication handicaps.  All 50 states have developed early intervention programs in accordance with Part C of the Individuals with Disabilities Education Act.  All 50 states also have special education procedures and services for preschoolers and school-age children.  

Colorado’s early intervention program is called Early Intervention Colorado (formerly Early Childhood Connections), or “EI Colorado” for short.  It’s designed to promote the best possible outcomes for infants and toddlers (birth up to 36 months of age) who have significant developmental delays (or health conditions associated with a high probability of developmental delay).  In order to take advantage of early intervention services during this critical developmental period, families need to know how to access them.  The following paragraphs explain this, and additional information can be found in the “Make a Referral” section at www.eicolorado.org.

While anyone – including the parents -- can refer a family to EI Colorado, primary care providers (PCPs) are the main source of referrals.   And using a standardized screening test is the most reliable way to identify children with delays.   A recent quality improvement initiative in the Denver metro area suggests that infants and toddlers are more likely to proceed through the evaluation phase if the PCP sends a referral form to the local EI Colorado program, in addition to having the family call the referral contact person there.
The PCP should inform the family that further evaluation is recommended to see if the child and family may benefit from early intervention services.  You can give the family an early intervention flier or panel card that briefly explains this, and also tells the family how to contact their local EI Colorado program.  These informational cards can be obtained for free from your local EI Colorado program office (e.g., from Denver Options for those residing in Denver), or you can order panel cards for free on the EI Colorado website (www.eicolorado.org) by clicking the “order public awareness materials” link on the home page or in the “Make a Referral” section.  You’ll find a lot of other information in the “Make a Referral” section, such as explanations of the early intervention assessment process and even links to professional medical society recommendations for the medical evaluation of children with developmental delay.

The process for having the infant or toddler evaluated begins with making a referral to EI Colorado.  The referral form should be completed by the PCP office during the visit, and the parent or legal guardian should be asked to sign the consent to release medical information at the bottom of the referral form.  You can obtain referral forms in English and Spanish for free from the EI Colorado website.  Or you can access the referral forms specific to your local EI Colorado program in the “Make a Referral” section of the website by clicking on the “Make a Referral” link and then scrolling down to the link that says: “To refer to Colorado's early intervention system click here to locate the appropriate Community Centered Board! (includes referral form)”.  You’ll then be taken to a page where you can enter or search for the specific local EI Colorado program, which will then take you to a page with that program’s contact information and links to referral forms with preprinted local program name and fax number.  I’ve found it easiest to keep preprinted referral forms handy rather than printing a form for every referral.

If the child was referred because of concerns on standardized developmental screening, please document the tool you used and fax the screening instrument along with the referral form; this will help the evaluation team understand the screening results and develop an assessment plan without repeating the screening.  I should mention at this point while the evaluations are conducted by Child Find teams from the local school districts or BOCES, the local EI Colorado programs arrange these and provide coordination throughout the process, so please refer infants and toddlers to the local EI Colorado programs directly (a service coordinator will be assigned and contact the local Child Find team within a couple of days).

Provide the family with a copy of the referral/consent form and the contact information for the local EI Colorado program, and arrange a follow-up visit for about 2 months later.  Explain to the family that a service coordinator will be assigned within a couple of days of the referral to help the family through the next steps; the developmental assessment should be completed within 45 calendar days, as well as the Individualized Family Service Plan (IFSP) if the child is found to be eligible for services (both are at no cost to the family).  Ask the family to bring copies of the IFSP and any evaluation reports.  Even though the Early Intervention and Child Find teams do not provide medical diagnoses, their findings can be important to you in helping the family understand the significance of the developmental delays and in guiding further appropriate medical evaluations.

Speaking of medical evaluations, you may have already initiated some when you first became concerned about possible developmental delays.  For example, children with language delay should be referred for formal audiology evaluations.  You don’t need to wait for audiology or other medical evaluations or treatments to be completed before referring to EI Colorado for early intervention evaluations and services.  The link to the referral flow chart at the end of this article illustrates the parallel processes for medical and developmental evaluations.  Professional medical society recommendations during recent years have offered specific recommendations regarding the medical evaluation and follow-up by primary care physicians/clinicians for children with developmental delay, cerebral palsy, and autism spectrum disorders.

And speaking of developmental evaluations, you can usually wait for the results of the early intervention or special education evaluations before referring for diagnostic medical developmental evaluations, such as those done in the Child Development Unit at The Children’s Hospital.  But if an autism spectrum disorder is suspected, then you should refer simultaneously to EI Colorado (for early intervention services) and to a medical center or clinic with special expertise in autism spectrum disorders (for the diagnostic medical evaluation).  The referral flow chart below gives other examples of where to refer children for medical or behavioral evaluations and treatment.

Click here to view the referral flow chart

I hope this information is helpful to you in getting early intervention services for infants and toddlers as soon as possible, and in getting preschoolers and school age children the help they need.

Please feel free to call me with any questions at 720-777-6632, or email me at Campbell.william@tchden.org.

Also see these two web sites for more detailed algorithms

The link for the 0-3 year-old flow diagram: click here
The link for the 3-5 year-old flow diagram: click here

These are the referral forms that are used state wide for Early Intervention.

• English - click here
  
• Spanish - click here

- Top of Article - Top of Page - CCHAP Home -

The Provider Resource Helpline Helps Your Special Needs Children:
Identify and Access All Resources
Assists with Care Coordination

          The American Academy of Pediatrics has promoted the concept of providing a medical home for children with special health care needs for over a decade.  At a recent focus group of family physicians and pediatricians discussing medical home, primary care providers said that finding the available resources and coordinating care for children with multiple problems was the most challenging of the roles of a medical home.  
          The Provider Resource Helpline is a service created to address this need through a collaboration among CCHAP, Family Voices, and the Colorado Department of Health Care Policy and Financing (HCPF), which administers Medicaid and CHP+.  Family Voices of  Colorado is a chapter of the national, grassroots organization composed of families and friends who care for and about our children with special health care needs.

Provider Resource Helpline
Helping care for our children with special health care needs

Information for families
Valuable community resources
Care coordination

1.877.731.6017

The Colorado Provider Resource Helpline is here:

• To give providers information and access to valuable community resources for children with special health care needs.
• To provide case management and care coordination services to families.
• To identify shortages in services/barriers through the data collected.
• To provide family-centered programs, training and education.

When Calling, Please Have the Following Information:

• The PCP name and office phone and fax information.
• Name and date of birth of patient.
• Medical condition / disability of patient.
• Resource question or service need of patient/family.
• Family Contact information, if the provider wishes us to follow up directly with the family.

If the helpline can answer your question immediately, you can provide the information to the family while they are still in the office.  If we are unable to answer immediately, we will contact you with an answer as soon as possible following the patient’s visit (via phone, fax, or email). 

Download Flyer

- Top of Article - Top of Page - CCHAP Home -

 
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 are the two steps needed for medical home certification 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.

Quality Improvement Coach
Your CCHAP Quality Improvement Coach is Angie Goodger. Angie holds masters degrees in Public Health and Healthcare Administration.  Angie comes to us from Minnesota where she previously worked as a home healthcare manager. Angie is very excited about working with your practice using Quality Improvement methods to work on those issues you want to address.

- Top of Article - Top of Page - CCHAP Home -

 
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.

- Top of Article - Top of Page - CCHAP Home -

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.

- Top of Article - Top of Page - CCHAP Home -

 
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

- Top of Article - Top of Page - CCHAP Home -

 
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

- Top of Article - Top of Page - CCHAP Home -

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.

- Top of Article - Top of Page - CCHAP Home -

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.

- Top of Article - Top of Page - CCHAP Home -

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…

- Top of Article - Top of Page - CCHAP Home -

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

- Top of Article - Top of Page - CCHAP Home -

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

 CCHAP Home > Newsletter Articles > Newsletter 38, May 2010