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Fact: Most of the major accrediting agencies, including the Joint Commission on Accreditation of Healthcare Organizations, the National Commission on Quality Assurance, URAC, and even Medicare and Medicaid, now require hospitals to incorporate into their practice a certain degree of cultural or linguistic competency.
The national standards are generally established, and requirements fall into four categories: linguistic services, translated signs and materials, obligations to provide specific languages, and some kind of office of diversity. There are more requirements to come. In spring 2001, a surgeon general’s report is expected to address mental health, race, ethnicity, and culture. Though it is not yet finalized, this report will provide direction and possibly requirements or guidelines for the future.
More important than the fact that requirements exist, however, is that hospitals, patients, and payers all benefit from a culturally appropriate care model. For one thing, there can be a great reduction in the cost of services. "Clinically appropriate services are always the most cost-effective," stresses Beth Remus, RN, BGS, MS, MSS, president of Remus and Associates in Chicago, who is an independent consultant and leader in the field of cultural competency in health care.
In her presentation at the recent Hospital Case Management Summit in San Diego, Remus said that in the area of medication alone, studies in ethnopsychopharmacology have found that different responses to medications are linked with different cultures. To use the correct ones means reduced costs to the patient and the facility, and better care. For example, in mental health, the therapeutic range of lithium differs among ethnic groups: Asians have a lower therapeutic range (0.4 - 0.8 mEq/L) than Americans (0.6 - 1.2 mEq/L). Also, side effects vary across ethnic groups.
"Basically, the idea that a drug will act identically in two different people is being re-thought." Remus says. It’s a fairly new concept, she adds. "I have looked around and not found anyone studying from this direction but . . . there is more and more literature relating to misdiagnosis and therefore mismedication and treatment, which is very costly."
In hospitals, the move toward complete cultural competency is just beginning. "Diversity training" has been a buzzword for several years, in business, health care, and virtually every other industry. But it’s only a stepping stone, Remus says.
Francie Handler, RN, BSN, CMC, team supervisor in case management at St. Vincent’s Hospital in Santa Fe, NM, says that in her facility, "We’re are doing diversity training on a departmental level at this point; hopefully soon it will be hospitalwide," she says. Even though the area’s population includes both Hispanic and Native American cultural groups, and competency is essential in the hospital staff, she says, "We probably need more formal training. No matter how much you know, you still need to hear it again and again."
So, how do hospitals go about becoming competent? Case management can be a conduit, Remus says. "Case management is an excellent place to begin the process. The case managers and their support staff are the link; they play a multifunctional role in bridging the gap between mainstream organizations (i.e., the hospital) and the ethnic minority communities and their provider networks." For example, if Hospital A is not particularly culturally competent, but its case management department is, it can immediately shift gears and make sure that the patient’s cultural needs are met, she adds.
Handler agrees. "I think case management is in a critical spot because we’re often the first people who go in and . . . do our assessments. We’re often the first people who, for example, bring in an interpreter, and [language is] so critical to developing a trusting relationship and getting the information you need." Several of St. Vincent’s discharge planners are Hispanic and fluent in Spanish, so there are also important links to the community resources within the case management department, she adds.
As an individual case manager, or as a department, there are several steps you can take to get on the road toward cultural competency. Remus suggests the following:
• Seek out training within the population. "There’s a lot out there," she says, and especially in the urban areas, it’s easy to find courses and instructors. You’ll want someone, preferably, who is of the culture you’re studying.
Handler says that her facility often requests guidance on cultural issues from Santa Fe’s Public Health Services Hospital, which treats the area’s Native American population and has recently asked some people from Public Health Services to present an educational program to the St. Vincent’s case management staff on subjects they feel are important to the Native American population.
• Read about the culture you’re serving. "If you read a couple of references, and a couple of articles, I’m not saying you’ll know it all," says Remus, but you’ll start to hear the same information over and over, and start to understand about the people in a particular group — their customs and norms and typical behaviors.
• Start a "cultural catalog" about the population group. "Include in it things like nonverbal communication issues you observe: spatial things, touching things," Remus says. It also helps to list specific dietary restrictions, healing rituals and folk medicines, medical risks and socioeconomic factors, and community resource information, such as "Which doctors in the community speak this language? Which social workers do?" It becomes a resource book that even can be used during the orientation and training of your case management department’s new hires, she suggests.
• Learn some of the everyday phrases and their uses in the language of that population. You can’t be culturally competent if you don’t know the basics of their language, and it really says something about your interest in and your openness toward the population. Evidence that America’s diversity is growing has been available since the most recent U.S. Census data were compiled. Take a look at the patients around you, and you might see a small sampling of what the census found. At least 210 different nations are represented within the borders of the United States; experts predict that by the middle of the 21st century, the average U.S. citizen will trace his or her ancestry to Asia, Africa, the Pacific islands, or a Hispanic country — not to Europe; and since 1980, the number of people who speak a language other than English at home has increased by 43% to 28.3 million.
We really can’t call it a melting pot, according to Remus. "I would suggest that we’re a mixed salad. Ethnic groups are no longer that interested in melting into the country; they are interested in maintaining their ethnic backgrounds, their dynamics, and their uniqueness." For health care facilities, this poses a challenge not only to provide the appropriate required services, but to develop different attitudes and mindsets. However, Remus says, "Eliminating the disparities is going to be very difficult in this country."
Hospital facilities that serve very diverse populations might have a harder time implementing new practices for every ethnic group that they serve. But Remus says it’s possible to take baby steps. "I start from where the priority is and weave one in at a time," she says. "Once you learn the skills set for changing an organization, you can do it again and again." Besides that, on a practical level, the larger, philosophical movement toward becoming culturally competent is still in its infancy. There are no real best practices going on out there right now, Remus explains. "This is a real grace period. If organizations go forward and start making [any] movement towards the goal of being culturally competent, they’re ahead of everybody."
Beyond all the rules and the cost benefits, Remus says, "The thing that touches my heart is that being culturally competent is ethically and socially the right thing to do." Getting to the real implementation of cultural competence might seem an endless journey, but case management departments and hospitals overall can treat it as a performance improvement project, Remus notes. "Find out who you’ve got, then complete a mini-assessment of your department, relative to that population," she says. Most importantly, assess and evaluate your progress as you become more culturally competent.
Remember, actions speak louder than words. "A case manager can be the one — the source of information for others in the hospital — just by doing what’s right," Remus says. "I can see case managers being highlighted in hospital newsletters, not because they’re touting [cultural competency] but just by doing it."
[For more information, contact:
Beth Remus, RN, BGS, MS, MSS, President, Remus and Associates Inc. 523 S. Plymouth Court #903, Chicago, IL 60605. Telephone: (312) 986-1302.
Francie Handler, RN, BSN, CMC, Team Supervisor, Case Management Services, St. Vincent Hospital, 455 St. Michael’s Drive, Santa Fe, NM 87505. Telephone: (505) 820-5823.]