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A few years ago, Claire Creech, CRC, CCM, CDMS, CLCP, was managing the brain injury cases of an older Korean man, a Japanese man, and three male Hispanic patients — all at the same time. Having a multicultural caseload made Creech acutely aware of the changing demographics of the patients served at the Shepherd Center in Atlanta, where she was case manager for the brain injury service.
"They were from three very diverse cultures, and there were a lot of differences in the responses from their families. It created a lot of conflict and miscommunication," says Creech, who now is senior case manager for the Center for Diagnostics and Evaluation at Shepherd Center.
As a case manager, you are likely to encounter an increasing number of patients from different cultures, all of whom have varying beliefs and family dynamics, yet they all need someone to understand them and where they are coming from in order to facilitate their recovery.
Our country’s demographics are undergoing radical changes. The U.S. Bureau of the Census estimates that by 2050 nearly half of U.S. residents will be from a different culture. "In case management, no one is immune any longer. We all need to understand how to deliver culturally competent care," says Kathleen Moreo, RN, Cm, BSN, BPSHSA, CCM, CDMS, CEAC, co-founder of Professional Resources in Management Education, an international health care education and case management company.
Both Washington, DC-based URAC, a leader in the accreditation of managed care and specialty organizations, and the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, have mandates that require providers to prove they deliver culturally competent care, Moreo points out. "Our health care industry has recognized the necessity for this," she notes.
Because of the world’s changing demographics, whether your case management clients have successful outcomes will depend on your ability to provide services in a culturally relevant and culturally responsive manner, asserts Josepha Campinha-Bacote, PhD, RN, CS, CNS, CTN, FAAN, president of Transcultural C.A.R.E. Associates in Cincinnati. "Changing demographics, along with long-standing disparities in the health status of people from diverse ethnic backgrounds, have challenged case managers to seriously consider cultural competence as a priority," Campinha-Bacote says.
As a case manager, you are liable to encounter problems with cultural issues from all sides, Creech points out. "The doctor, the family, and the therapists are all frustrated, and it’s up to you to intervene," she says. This means that case managers should develop an understanding of other cultures and know how to deal with cultural values and beliefs that conflict with Western medicine.
Sometimes, understanding cultural issues and being able to communicate with people of other cultures literally can be a matter of life and death, such as when it comes to patients’ use of alternative or folk remedies that might have serious negative interactions with prescribed drugs. "Case management is very enmeshed in medication side effects and compliance," Moreo says. "This is one of the issues we are faced with all the time."
It’s also important to understand that cultural sensitivity is necessary when dealing with all patients, regardless of their nationality or ethnic origin. "That blonde, blue-eyed person from Appalachia has family traditions and beliefs that are far more complex than those of my Cape Verdian culture," Campinha-Bacote says.
Because Moreo has been involved in health care and education on a national and international level, she has been sensitive to cultural competency for a long time. "It is important for us to recognize that when we talk about barriers to care, many times the problem is not with patients but with the providers. We have barriers because the provider and the patient have different languages, different beliefs, and different value systems. Sometimes we are the ones who cause the problem because we are unable to cross over that bridge," Moreo says.
To help you understand how difficult it may be for people from other cultures to articulate their beliefs, consider how reluctant a relative of yours might be to tell health care providers about his or her use of herbs, acupuncture, or other forms of alternative medicine. "We can understand from a cultural competency standpoint how much more uncomfortable people of other cultures and races must be," Moreo says.
Keep in mind that patients with no cultural barriers still may be labeled noncompliant for a number of reasons. "If you add culture into the mix, it compounds the problems that inevitably occur in a convoluted health system. Our entire health care system has an effect on how the patient recovers and complies with treatment," Moreo points out. "There are enough barriers without cultural issues."
Moreo, a past president of the Little Rock, AR-based Case Management Society of America, is co-chairing the review of the organization’s standards of practice. Cultural competency and sociocultural barriers to health care are among the areas slated for review.