CCHAP November Newsletter 2006

Contents:

- Newsletter Introduction -
- Individual Healthcare Plan -
- Cross-Cultural Healthcare -
- Why Everyone Needs to Learn More -
- Health Disparities In Children -
- Patient Transportation -
- Announcements -
- We Want Your Feedback -

Introducing The New CCHAP E-Newsletter

There are two groups of children in Colorado that experience poor health outcomes compared to the general population of children:

          Low income children (Medicaid and CHP+) – 33% of children in Colorado

          Racial and ethnic minorities - 30% of children in Colorado

These groups experience more difficulty accessing health care, they receive less preventive care, they have poorer immunization rates, higher rates of hospitalizations, higher complications rates, higher rates of certain chronic diseases and higher death rates. And, in Colorado, these two groups of children are growing rapidly:

          35% of all newborns in Colorado are born into a low income family

          2/3 of low income children are from ethnic or racial minority households

The Colorado Children’s Healthcare Access Program (CCHAP) pilot program, in which your practice participated, has proven that a good medical home in a private pediatric office like yours can dramatically improve the health outcomes for both of these groups of children. And, as you know, surveys of private practices show that there are special difficulties in providing optimum care for some low income and minority families. CCHAP and your practice have been instrumental in addressing the 10 barriers that made it difficult for private pediatric practices to provide care for these two groups of children. Providers and staff in these practices have asked for more information and advice about providing healthcare for the increasingly diverse families in their practices. This newsletter will serve as a forum for healthcare providers and staff to share ideas and information relevant to the healthcare they are providing for low income families and for minority families.

At the same time there is a new curriculum being implemented at the medical school on this very topic: the new Diversity Curriculum. The Section of Community Pediatrics in the Department of Pediatrics of the Medical School is now working with the new Diversity Curriculum faculty and the Division of Health Care Policy and Research at the Medical School to make the new Diversity Curriculum available in this newsletter, as well.

We surveyed the private practice providers involved in the CCHAP pilot program about how best to provide this information to you. The consensus was to develop an electronic learning community of providers and staff, through which we can share

• information from the literature,
• tips from other providers and staff (including our colleagues in public clinics)
• and information and resources from state, county and community organizations
• contributions from the Diversity Curriculum at the Medical School

We will make this available through:

• This monthly e-newsletter on a variety of topics related to the care of the two groups of under-served children. Topics selected by providers in CCHAP practices.
• Monthly telephone conferences that go into greater depth on selected topics than the e-newsletter can. We request that one person from each practice join us during these monthly noontime telephone conferences with experts in cross-cultural care.
• Quarterly face-to-face conferences on topics selected by providers, with CME credits
• Formal work shops (either on-line or face-to-face) on cross-cultural health care for which CME is available and for which providers can receive discounts on COPIC malpractice premiums.
• Web site with more detailed information on cross-cultural health care.
• Information library
• Links to other sites
• Discussion Boards on selected topics
• Links to on-line courses
• www.cchap.org

Feedback: Each e-newsletter will request feedback from you regarding how we can meet your needs and what topics you would like to see covered.

New Individual Healthcare Plan Form
For Special Needs Children

Parents feel it improves care!
Medicaid pays $103 for it!

An Individual Care Plan is a standardized summary of a child’s pertinent health record that the family can have available when:

• they see any of the child’s specialists
• they go to an emergency department or urgent care center
• they are traveling
• the child is admitted to a hospital
• paramedics are called to the school
• an insurance company requests a case summary to authorize claims payment or referral
• a school requests health information

The 4-page Universal Care Plan can be filled out in a visit with the parents, with or without the patient present, which normally takes less than 15 minutes, although some providers take 25 minutes. A copy of the Universal Care Plan can be downloaded from our website (click here)

The CPT code 99215 can be billed with the time in minutes documented. This code works for up to 45 minutes. Medicaid will reimburse $103 for this process. Commercial payers do not reimburse for the care plan at this time.

- contents -

Cross-cultural Health Care

By Angela Sauaia, MD, PhD and Steve Poole, MD

Two Key Points in cross-cultural healthcare:

1. You may be saying to yourself, “I don’t need this curriculum. I am not prejudiced. I treat everyone the same.” Of course you do….pediatric healthcare professionals are very special people in that way. But cross-cultural care is not about treating everyone the same…..it is about recognizing how each family is unique in how they think about and understand the illness, their customs and beliefs, hidden meanings, hidden concerns, other remedies or treatments, how they interpret your recommendations, etc. So, what can you do to understand how your patient’s family is unique? NEVER ASSUME that you know your patient’s and their family’s cultural background.
2. It is not what you know…..it is what you ask. Learning about other cultures may be helpful so we can become more aware that there are other ways to view the world. However, attempts to memorize norms or values of the “Latino”, “Asian”, or “African American” cultures and apply them to individual patients may not be effective and may instead contribute to stereotyping. And there are scores and scores of different Latino cultures…you can’t learn them all.  Instead, respectfully ask questions to understand how your patient’s/family’s unique culture will influence the child’s health outcomes.

Develop ONE approach that works for all families in all cultures. We suggest an approach that utilizes two components:

1. A mnemonic: LEARN
2. A list of issues and questions: The Cross-cultural Review of Systems

Respectfully ask questions to LEARN more about how their own unique cultural influences will affect your care, using the cross-cultural review of systems

• Listen carefully to their answers to questions from your cross-cultural review of systems.
• Explain how you view the symptoms, problem or illness.
• Acknowledge the differences between their beliefs, concerns, expectations, etc and your views.
• Recommend your treatment plan.
• Negotiate a compromise plan that respects their decision-making processes and their beliefs, concerns, expectations.

The Cross-Cultural "Review of Systems"

The following three categories of questions and issues will help in caring for all patients, but in particular those from a different social or cultural background than you.

Core Cross-Cultural Issues
          How (and by whom) are decisions made?  
          Who should be present for support? 
          Cultural Healing Traditions, Customs
                    Who have they seen (want to see)?  
                    What have they tried (want to try)? 
          Expectations from their health care provider and from modern medicine? 
          How to build trust with patient and family?
          Styles of communication and interpersonal etiquette: 
                    How does the patient relate? How should you relate?
                      Eye contact 
                      Physical contact 
                      Personal space 
                      Timing and pace in the encounter 
                      Direct or indirect questions

Meaning of the Illness 
          What caused illness? 
          Why did it start when it did? 
          What does illness do to you?  
          How severe is it? 
          What problems has the illness/problem caused? 
          What do you worry about the most?

Social Context 
          Social stress  
          Social support or isolated 
          Resources 
          English proficiency  
          Literacy 
          Understanding 
          Acceptance

Core Cross-Cultural Issues

Decision-making and support:

“Is there anyone else that you would like to be involved with this decision?” “Is there anyone else that you would like to be present?”

• Different families empower different family members with the decision to seek care and perhaps another for the role of making final decisions. For serious problems (as determined by their view of “serious”) they may need extended family, or members of their community or church members or spiritual leaders.
• Many families are used to having more family members present at the medical encounter than you may be used to. Try to adapt to it, but don’t hesitate to respectfully explain your concerns about how it might affect your patient’s willingness to be open or your patient’s mental or physical well being.

Cultural Healing Traditions, Customs: How do these factors influence the patient?

“What medicines, remedies, or treatments have you tried or would you normally do for this?” “What treatment have family or friends recommended to you? “What other healers, health advisors have you seen?” “What have they recommended?”

• Families may travel to their country of origin and receive over-the-counter medications that require a prescription here.
• They may use herbal remedies or alternative remedies before coming to see you. They may not know the name of what they have been given, so ask if you can see the medication or the home treatment if your patient cannot identify the substance.
• It is important to be non-judgmental about these remedies, but also to inquire in detail about them. Keep in mind that often the advice from traditional healers and herbal remedies may be quite useful and many times not different than your own advice. As a specific example, many Latino families will use "Te de manzanilla" (chamomile tea) for infants with "colico" (colic). This is a relatively benign intervention, which at least in 1 small controlled trial, showed some significant efficacy. Clearly though, the important point is to avoid free water intoxication of very young infants from giving too much tea. So rather than discrediting the tea's use, you can try to work with the families, and just make sure they are not giving more than 1-2 ounces a day of the tea to the infant. (This is a tip from Simon Hambidge, MD at Denver Health).
• Make sure that nothing harmful is being used ( for example, lead-based liquids for gastric upset). For example, greta and azarcon (also known as alarcon, coral, luiga, maria luisa, or rueda) are Latino traditional remedies taken for an upset stomach (“empacho”), constipation, diarrhea, vomiting, and used on teething babies. Greta and Azarcon are both fine orange powders that have a lead content as high as 90%. Ghasard, an Indian folk remedy, has also been found to contain lead. It is a brown powder used as a tonic. Ba-baw-san is a Chinese herbal remedy that contains lead. It is used to treat colic pain or to pacify young children. Other folk remedies that may contain lead are listed at: Centers For Disease Control And Prevention.
• “Is there anything else that you feel we need to do (or to address)?”
  There may be aspects of the medical encounter that may be of importance to the patient/family, either because they are part of the encounter in their country of origin or because traditional healers use them.
• Consider the impact religion will have in your patient’s health care recovery.  Regardless of your own beliefs, let them express to you the importance of their religion and assist them in dealing with the fear the patient might be feeling.  You may want to engage the help of a clergy member they have identified them as an important influence.
• A mental health referral or diagnosis may not be seen as an illness. It may be seen as a weakness and an embarrassment to family. Or seen as the result of misbehavior or a lack of will on the part of the sufferer. This is one instance when our medical culture can be powerful. Treat these issues with respect. Ask what they think about the referral or diagnosis and respectfully provide your feeling about their concern.

Expectations for their health care provider and for modern medicine:

“What kind of treatment were you hoping (or expecting) to receive today?”

The provider’s role and the parent’s expectations are influenced by their past experiences with health care in their country of origin and their past experiences with health care in US. Often, non-compliance is the result of the parent receiving advice or treatment that is very different form what they expected.   When this difference is recognized and discussed by the provider, compliance is usually improved.

Trust

“Have you been happy with your care in the past?” “What has been your experience with doctors in the past?

Does the patient trust the healthcare system? Many families have experienced forms of prejudice or less than respectful treatment. This may influence their response to your care. You can explore whether the family has experienced prejudice in US (or elsewhere) or has had bad experiences with health care providers before by asking respectfully. Build trust and reassure the family of your intentions.

Styles of Communication and interpersonal etiquette: How does the patient relate?

  Eye contact

  Physical contact

• All cultures have rules dealing with who, how, why, when, and under what circumstances people may engage in physical contact. Some cultures discourage physical contact between certain people, for example between a male provider and the patient’s mother. Take your cues from the parent’s behavior and if you make a mistake, simply apologize, explain what the touch means in your culture and move on.

  Personal space

• All human beings are territorial to some degree and, although personal space is always context-sensitive and variable, group norms exist for all cultures. The “size” of our specific personal “space” is unconsciously acquired in early childhood. Interpersonal space in sitting, standing, and speaking have cultural meanings and may trigger intense emotional responses when violated. Knowing the general rule-of-thumb about traditional boundaries for a culture is important if you are not to be perceived as "a cold person" by standing too far away, or "threatening" or “romantic,” by standing too close. Many cultures prefer being closer to each other than Americans. When providers place themselves two feet or more away, this may be perceived as not only physically distant but also uninterested and detached. Take clues from the family in front of you. You may want to try sitting closer and leaning forward.

  Timing and pace in the encounter

• All cultures have well-established patterns that they see as important to maintain regarding the pace and flow of verbal exchanges, "turn-taking," and "pauses," "silences," and “interruptions” during conversation. This can be very subtle, but when people are "out of sync," miscommunication can occur. All this hinges on "timing.” When they are excited, many individuals are quick to interrupt another speaker, some prefer the relatively direct communication style, others favor the indirect style.
• Many cultures prefer a slow, polite and friendly beginning to the encounter rather than jumping quickly to the problem. Take time to develop relationships and to build trust. Most cultures like the provider to show interest in them as people.
  “Tell me a little about yourself.” “I would like to hear about your family.” “Where is your family from? How did they decide to come to Denver?”
• When your patient’s parent nods his or her head, it does not necessarily signify agreement, but that he or she is listening to you. Silence may be a sign of not understanding or disagreement.

  Direct or indirect questions

• In some cultures, a direct style of communication will be considered brash and insensitive (Latinos and Asians, for example). For others a less assertive or less direct style may seem restrained and even somewhat impersonal (Australians, Germans and Russians). Notice the style of the parent and adapt to it. Be willing to explain your communication style. This takes only few seconds, as you say, for example, “I tend to be very direct, go directly to the issue. I hope that will be OK for you.”
• Many cultures prefer that providers indirectly ask personal/private questions about alcohol use, mental problems, violence, stressors, or sexual practices.
  

Meaning of the Illness

“What do you feel caused this illness/problem?” “What have other family members or friends told you?” “What concerns (worries) you the most?” "Why do you think it started when it did?" “How does it affect you?”

• Some cultures have a way of thinking about illness that is different from the way those of us in the medical culture think. These beliefs highly influence the way the patient or parent describes symptoms, how well they understand what we say and how well they adhere to treatment. It may be particularly helpful to assess the patient's conceptualization of illness, or “explanatory model”, when the physician does not feel s/he understands the patient's behavior, especially when there is non-adherence to a treatment, or when there is some sort of conflict.
• Some cultures have beliefs that may seem to us to be superstitious. They might believe that the illness is punishment from God for bad behavior. Or they might believe their illness was caused by a spell cast or by someone who is jealous or evil. Feel free to reassure the patient/parent that these were not part of the cause of the problem.
• Some cultures have a fatalistic view of illness. They may feel that God’s will has a far greater impact on the outcome of the illness than medication. They may believe that God determines the outcome of illness and they may not actively participate in health care recovery. The family may believe in fate or destiny rather than in medicine. Yet, keep in mind that they sought your advice, so they do recognize its value. If beneficial to the patient, clarify these issues, or try to interpret the medical facts within the context of their beliefs. Remind the patient/parent that they can affect the outcome, by actively participating in the treatment.
• Families may have fears about the cause or the inevitable outcome that they are shy about expressing.

Of course, we should always show respect for patient’s concerns and empathize, but respectfully describe our view of the illness, the treatment and the importance of their participation in the treatment process.

Social Context

The “social context” is of equal importance as an area of exploration, given how intertwined social factors are with cultural factors. Certain key areas to consider are:

Social stress – “How has your life been recently?” Have there been problems?” “Has your family had to cope with much change?”

Social support or isolated – “Do you have people in your life who can help you?” “Are there people you can turn when things are bad or difficult?”

• Although many cultures highly value family and community support, some families are isolated, especially recent immigrants.
• In a busy office visit, providers often worry that they haven’t been able to help much; but, simply helping a family identify the people or community resources they can call on for support or advice can be of tremendous value.

Resources – “Can you afford the medicine(s)?” “Do you have transportation?” “Are there any problems in your family that will make it difficult to follow the treatment plan?"

English proficiency - “Are you able to understand what I have said? “Would you like someone to interpret for you?”

Literacy – “Will you be able to understand this written information?”

• Up to 40% of immigrants are not able to read the handouts they are given by healthcare providers (even in their language).
• And 50% of Medicaid parents are not able to read the handouts they are given.

Understanding and Acceptance
“Have I explained this well enough? Do you feel you understand this well enough?” “I would like to be sure I have explained the plan well enough. Can you please tell me what you have understood and what you will be doing ?”

• Most parents do not readily admit when they do not understand, because of embarrassment.
• "Please help me understand what you think about what I have recommended…even if you don’t agree.” Out of a sense of respect, parents from many cultures will avoid disagreeing with, or expressing doubts to their health care provider about, the treatment they are receiving. They may avoid expressing negative feelings directly and this may affect patient care by patient's withholding information, not following treatment recommendations, or terminating medical care.
• “This is complicated. Would you like me to explain it again? Do you have questions or concerns about what I have said?”
  Parents from any culture may be reluctant to ask questions or admit they are confused about instructions or treatment.

Collaborate on a plan (the EARN portion of the mnemonic)

 This step includes the EARN portions of the LEARN mnemonic.

Explain – Present your perception of the illness and its causes. Explain how you see the cause and meaning.

Acknowledge - Explain how your view differs from their view. In some cultures, as we have discussed in other newsletters, the patient or parent may be expected to be passive when ill. Educate the child and parent about the importance of taking an active role in his or her recovery.

Recommendations - Give your treatment recommendations. Acknowledge how they are different than the family had expected or wanted, or what they had done previously.

Negotiate (Collaborate) -

“ My treatment plan may be different than what you were expecting (different than what you have been doing….different than what you are used to). How are you feeling about that? Do you have any concerns with what I have suggested? Do you feel you will be able to do what I have recommended?”

In cross-cultural care, the degree of treatment adherence is directly proportional to how well the provider understands the patient’s cultural influences, the meaning of the illness and the social context, and how well the provider collaborates with the patient/parent in a way that responds to these influences. Incorporating those things from the family’s culture that they would like to do, or have tried, and that aren’t harmful (or perhaps are helpful), dramatically increases the treatment adherence. Sometimes what is acceptable is better than what is optimal, if the risk of trying to secure the optimal means losing the patient's trust or buy-in. Oftentimes, this requires exploring the cross-cultural review of system and then compromising and formulating a mutually acceptable plan.

Indicate that you are willing to collaborate with them. Decide what’s critical and be willing to consider compromise on anything else.

Explore other barriers like expense, transportation, or people in their environment who will not support your recommendations.

    
Always ask at the very end…. “Do you have any other questions or concerns?” “Is there anything that will make this difficult for you to do?” And be sure to wait sufficiently long after asking these questions for the patient, parent or family members to get up the nerve to ask that last question or bring up that last concern. The last question or concern is often the very most important one in the whole process, so be sure to give it the time and attention it deserves.

“As powerful as the culture of your patient and her family is, the culture of biomedicine is equally powerful.” (Arthur Kleiman). The patient sought your help because (s)he recognizes its value. People are likely to follow your advice if they understand why they need to. If you can make your advice fit within their cultural context (and often they are not mutually exclusive), chances are they will follow it, if they understand it.
 

Why Everyone In Your Practice Needs To Learn More About

Cross-cultural Health Care

The Business Case

The Demographics

• Racial and ethnic minorities make up 1/3 of the Colorado population and are the most rapidly growing group.
• Over one-third of the children in the seven Metro Denver counties (and in Colorado) are Hispanic, African-American, Native-American or Asian-American.
• 99.4% of Colorado’s pediatricians are white, non-Hispanic.
• 40% of all Colorado newborns are born into poverty, the majority of whom are born into cultures other than their provider’s.

Your Practice Will Save Money

• Lower malpractice premiums for providers who take a course on cross cultural care.

      COPIC offers two ERS discount points on your malpractice premiums if you:

• complete a 3-hour on-line course
• attend a 4-hour workshop on cross cultural care
  
  For more information, see announcements. 
• Recent research shows that using the methods described in this and subsequent newsletters will reduce the time taken per patient over the long run.

Improve parent and patient satisfaction

The methods described in this and subsequent e-newsletters can be used with all families in your practice from any socio-economic level or culture to improve patient and patient satisfaction.

Improve Your HEDIS Outcomes

• Better compliance with treatment
• Higher immunization rates
• Lower ED utilization rates
  

Reduce Practice Liability

• Fewer medical errors
• Better compliance
• Higher parent/patient satisfaction rates

Federal Guidelines

Guidelines are now just recommendations, but it is anticipated that they eventually become regulations for practices. See guidelines on our web site. (click here)

Transportation For Your Medicaid Children

DID YOU KNOW THAT MEDICAID PAYS FOR TRANSPORTATION?

Logisticare

Logisticare is contracted by HCPF to provide non-emergency transportation for patients who need it to medical appointments covered by Medicaid. Rides can be requested by calling Logisticare’s reservation line at 800-284-5150. The dispatcher will ask if the parent has any alternate means of transportation (such as a neighbor or relative) or if they can take the bus or if they just need gasoline. If there is no other means of transportation available, Logisticare will order taxi service to and from the appointment. (This service is not available for CHP+ patients.)

Unfortunately, however, Logisticare strictly enforces their rule that transportation must be requested with at least 72-hours advance notice. Obviously that is not helpful when a child is sick and needs a same-day or next-day visit. In that situation, CCHAP provides cab vouchers for your patients who need transportation.

Metro Taxi Vouchers

CCHAP practices may use the cab vouchers we provide if Logisticare will not provide transportation because of the 72-hour notice rule or if a CHP+ or temporarily uninsured or ineligible patient needs transportation to an appointment. CCHAP’s goal is to make sure the patient’s health and your practice are not impacted by the family’s lack of transportation.

If a practice staff member calls Logisticare for a patient, they can use the account number over the phone instead of using an actual voucher slip. This number should be protected (like a credit card number) to avoid misuse; it should not be given to a patient or parent. Please fill out the CCHAP Cab Voucher Log (in the orientation manual), and fax it to 303-764-8078 for billing purposes whenever the Metro Taxi service is used.

If an appointment is scheduled at least 72 hours ahead of time, the parents of Medicaid-insured patients should be reminded to take responsibility for calling Logisticare to request a ride if they need one. A referral to Erlinda Diaz can be made if the family needs additional assistance concerning their lack of transportation or appointment adherence.

If your practice needs additional vouchers, the account number or further information, please call Joanie at 303-861-6309 or email muzzulin.joan@tchden.org

A Free Workshop for all members of your practice:

Cross Cultural Health Care for Children

November 16, 2006
8am to Noon
Nighthorse Campbell Native Health Center on the Fitzsimons Campus
Continental breakfast will be served
Providers will receive
2 ERS discount points on COPIC insurance
and 7 category 1 CME credits
RSVP to Joanie Muzzulin by October 31st
muzzulin.joan@tchden.org
303-861-6309

Monthly Learning Community Telephone Conference

December 7, 2006
12:30 to 1:30PM
Topic: Language Barriers and Office Translation
Please identify at least one person from your practice to participate
Please contact: Joanie Muzzulin
muzzulin.joan@tchden.org
303-861-6309

Feedback

What topics would you like to hear more on?

What problems do you face that you would like to hear what others do to handle?

Are there tips you would like to share with others?

Send your suggestions, topic, thoughts, tips to:

Steven Poole MD

Poole.Steven@tchden.org

Contents:

- Newsletter Introduction -
- Individual Healthcare Plan -
- Cross-Cultural Healthcare -
- Why Everyone Needs to Learn More -
- Health Disparities In Children -
- Patient Transportation -
- Announcements -
- We Want Your Feedback -