Health Systems

A Model for the Nation’s Health Care Industry: Kaiser Permanente’s Institute for Culturally Competent Care
By Nilda Chong, MD, DrPh, MPH

_Introduction

_{Our nation's increasing diversity heightens the relation between medicine and culture to an unprecedented level: Provision of medical care to culturally diverse patients now relies more heavily on cross-cultural communication than at any other time. Medical care that addresses the cultural needs of diverse populations stands at the forefront of many discussions in the health care industry. As stated by a primary care physician in Minnesota, "While cultural diversity problems in medical care might seem 'soft' and beyond the pressing concerns of our highly regulated health care system, in fact, they end up being bottom-line issues as well. Patients of other cultures now compose a large segment of many practices, and the numbers are growing quickly as demographics shift."^1:p14}

_{The Health Plan membership of Kaiser Permanente (KP) reflects our nation's rapidly changing demographic profile. We serve one of the most culturally diverse communities in the world. KP Southern California Regional membership consists of 24% Latinos and 12% African Americans; KP Georgia's membership includes 37.8% African Americans; and KP Hawaii's membership is 33% Asian and 21% Hawaiian.² Our members speak more than 80 different languages, each representing a culture with unique beliefs, attitudes, and behavior. KP brings to life the complexity of our nation's diversity and multiculturalism. In a seminal article, epidemiologist Geoffrey Rose wrote, "It is an integral part of good doctoring to ask not only, 'What is the diagnosis, and what is the treatment?' but also, 'Why did this happen, and could it have been prevented?'"^3:p32 Finding answers to these questions can be complex because cultural differences may exist between clinicians and patients. In 2001, the Institute of Medicine's Committee on Quality of Health Care in America examined the US health care system and proposed "patient-centered health care" as one of the six dimensions necessary to meet patient needs in the 21st Century. The health care system must aim to provide "... care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions."^4:p6 A year earlier, in 2000, Oliver Goldsmith, MD, wrote, "... [c]ultural competency does create a compelling case for understanding the different ways patients act in a clinical setting and for communicating with patients to ensure the best possible clinical outcome."^5:p53}

_{Culturally competent health care organizations acknowledge and understand cultural diversity in the clinical setting, respect members' health beliefs and practices, and value cross-cultural communication. Eliciting the patient's perspective is important "... to assess the patient's point of view concerning the meaning of symptoms and the request for care ... [and] serves at least two important functions: showing respect for the patient's experience and individuality and gathering clinical information in an efficient way."^6:p82 Acknowledging and understanding a patient's cultural values can lead to effective communication, promote treatment adherence, and positively affect health outcomes.}

_{The KP West Los Angeles Medical Center--our first Center of Excellence in Culturally Competent Care--highlights the importance of understanding members' cultural values. With a patient population exceeding 45% African American, the center was started in 1999 with a focus on sickle cell anemia, congestive heart failure, and prostate cancer. (Prostate cancer appears in African American men at a younger age; and in this population, lower prostate-specific antigen values indicate disease, the cancer is more aggressive, and mortality rate from the disease is higher than among other groups.^7,8) A year later, the impact of the center's culturally competent care surpassed expectations: meperidine therapy was stopped for 93% of members in the Sickle Cell Anemia Program, dramatically enhancing their quality of life. Of the 49 patients who successfully completed the Congestive Heart Failure Program, none were hospitalized for congestive heart failure or used the emergency department for any other medical condition. Implementation of the Prostate Cancer Screening Program is underway.}

_{National Standards for Culturally and Linguistically Appropriate Services in Health Care}

_{Issued by the US Department of Health and Human Services' Office of Minority Health, the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS)⁹ is a blueprint for building culturally competent care health organizations. "Under the CLAS standards ..., health care organizations are encouraged to ensure that patients receive understandable and respectful care that is compatible with their cultural health beliefs, practices, and preferred language."^10:p2 Four of the 14 standards are mandated for recipients of federal funds; nine are recommended for adoption as mandates to federal, state, and national accrediting agencies; and one is suggested for voluntary adoption by health care organizations. Health care accrediting agencies are increasingly including CLAS standards within the scope of their compliance reviews.}

_{The Institute for Culturally Competent Care: A Model for the Nation}

_{Sponsored by the National Diversity Department, the Institute for Culturally Competent Care (ICCC) establishes KP as a model for the nation's health care industry. Cultural competency requires a system of care that ensures that members' cultural needs are considered and respected at every point of contact between the member and the organization. As the only health care organization with an institute dedicated to developing excellence and committed to supporting innovation in delivering culturally competent care, KP sets a new standard for the health care industry. The ICCC represents a response to three preeminent challenges: the rapidly changing demographic profile in the United States, the CLAS standards, and rising health care costs.}

_{The vision of the Institute is aligned with the KP Promise and with our commitment to provide personalized care to our members who are culturally diverse. Cultural diversity refers to cultural groups who share beliefs, practices, and values based on race, ethnicity, sex, religion, age, disability, sexual orientation, gender identity, and other characteristics.}

_{How Does the Institute for Culturally Competent Care Work?}

_{The ICCC is the catalyst for concentrating our expertise, for facilitating development of new knowledge, and for guiding our strat
egy to integrate cultural competence into our care delivery system. By increasing our understanding of cultural competence, the institute facilitates operation of the concept through the Centers of Excellence in Culturally Competent Care.}

_{Each Center of Excellence in Culturally Competent Care is a regional center that successfully integrates cultural competence into its local health care delivery system. The center focuses on two or three health issues that significantly affect a population that is highly represented in the local membership. The center then develops culturally relevant care management programs to positively affect health outcomes by maintaining and improving the health status of the given population. The centers have a commitment to share the effective practices and knowledge that they generate with KP Regions serving demographically similar member populations.}

_{The ICCC selects and supports the Centers of Excellence in Culturally Competent Care in identifying the most effective approaches to delivering culturally competent care. The Institute serves as multidisciplinary resource, coach, and consultant as centers build culturally sensitive care systems in facilities across the nation. The institute assists the centers by:}

• _{Providing expertise and technical assistance to KP teams interested in incorporating cultural competency into their programs;}
• _{Acting as a repository of information, including extensive literature and the most current knowledge base on culturally competent care;}
• _{Facilitating the sharing of experience and expertise across centers;}
• _{Disseminating to all KP regions the new knowledge generated by the centers;}
• _{Supporting research that can validate innovative initiatives to promote health and treat diseases among members of diverse cultures;}
• _{Assessing community linkages and assisting centers in choosing the most effective approaches for culturally diverse communities;}
• _{Providing and assisting with identification of financial support.}

_{With the Institute's support, three new Centers of Excellence for Culturally Competent Care were launched at the end of 2001. The focus of the centers reflects the increasing diversity of our membership: Latinos (Colorado), Linguistic Services (San Francisco), and Members with Disabilities (Vallejo, California). Future Centers of Excellence focusing on Eastern European populations and women's health, among other groups and topics, are in the planning stages.}

_{Advantages of Providing Culturally Competent Care}

_{Providing culturally competent care can be a strategy to decrease rates of hospitalization. African Americans as well as Latinos are the most likely groups to be hospitalized for preventable causes.¹¹ Designing culturally appropriate instruments may also lead to collecting quality data on patient satisfaction. In addition, clinician satisfaction is likely to increase when effective communication is established with patients.}

_{Mental Health
When migrants arrive from patriarchal societies, the gender roles they bring with them may be attached to values of their
culture. For example, Mexican women who involuntarily migrated to the United States because of imposed male authority have more depression than their counterparts who migrated voluntarily.¹²}

_{Diabetes
A diabetes intervention project was undertaken to provide a culturally sensitive, community-based alternative to the mainstream health care system in management of diabetes in a multiethnic community in Waianae, Hawaii. The intervention facilitated early detection of problems and increased the opportunity to coordinate care. In addition, timely physician visits promoted effective medical intervention. In turn, intervention during early stages of acute illness avoided both hospitalization and more costly care.¹³}

_{Postoperative Use of Analgesic Agents
Ng, et al reported "significant differences ... in analgesics administered to black, Hispanic, and white patients."^14:abstract These researchers concluded that the cultural elaboration of pain involves experiences and expressions that are highly diverse because they are based on cultural perception, interpretation, meaning, and the level of distress communicated to staff.¹⁴}

_{Rising Health Care Costs}

_{Containing the rising cost of health care also is critical. Annually, Americans invest 13.6% of the US gross domestic product (GDP) in the health care sector; and this expenditure will reach an estimated 16% of GDP--or more than $2 trillion--by 2007.¹⁵ Most health care expenditures involve care for patients with chronic disease, which affects almost 50% of the US population.^16,17 According to the Institute of Medicine, "Health care for chronic conditions is very different from care for acute episodic illnesses. Care for the chronically ill needs to be a collaborative, multidisciplinary process."^4:p9}

_{Crosscultural Communication}

_{"Effective methods of communication, both among caregivers and between caregivers and patients, are critical to providing high-quality care."^4:p9 Thus, knowing what to say is as important as understanding how to say it. For example, a diabetic Latina who is advised to eat foods to which she is accustomed, instead of newly introduced foods, and is encouraged to enlist family support may be more likely to manage her disease effectively, to stay healthier, and to decrease her chance of requiring hospitalization. A monolingual Chinese patient with heart disease who, aided by an interpreter, more clearly understands the impact of exercise on his health, may be more inclined to adhere to an exercise regimen than he would if he lacked the assistance of an interpreter. A lesbian woman may be more likely to return regularly for a Papanicolaou smear if she is asked about her sexual relationships using gender-nonspecific language; and these regular checkups may reduce the likelihood of late-stage cervical cancer. A member with a disability will feel more comfortable hearing that he or she "uses a wheelchair" instead of being classified as "wheelchair-bound." An elderly African American man with congestive heart failure may adhere to his prescribed medication and be less likely to visit the emergency department if he believes that his religious beliefs are integrated into his treatment plan. In sum, providing culturally competent care is about communicating effectively and about respecting diverse health beliefs and practices.}

_{Future of the Institute for Culturally Competent Care}

_{The ICCC actively seeks partnerships to develop training tools. The Culturally Competent Care (CCC) Pocket Card¹⁸ is a perfect example of a collaborative effort undertaken jointly by the ICCC and the Care Management Institute (CMI) in 2001. The CCC Pocket Card reaffirms the KP Promise through the ICCC and CMI. The ICCC and CMI work together to embed evidence-based best practices and current knowledge in culturally competent care into care management programs and tools as well as to personalize and enhance clinical encounters between our clinicians and our diverse membership. This year, the ICCC and CMI received one of two American Association of Health Plans grants in Innovation in Quality Improvement to develop "Cultural Pearls of Wisdom for Chronic Disease Prevention and Management." The "Cultural Pearls of Wisdom" is a point-of-care tool that will describe key points to assist clinicians in communicating with patients or their representatives from diverse cultures and in negotiating treatment for their patients.}

_{The first module of the ICCC's training curriculum, "Introduction to Diversity and Culturally Competent Care," has been introduced as a pilot program and will be used to train regional teams. Three other modules are in the planning stages: Module 2, Cultural Awareness; Module 3, Cultural Knowledge; and Module 4, Cultural Skills. Completion of the four modules will lead to KP's own certification process in culturally competent care for regional trainers. In addition, the Culturally Competent Care Toolkit will be disseminated throughout the
KP Regions in 2002.}

_{The ICCC's long-term goal is to develop culturally competent clinical expertise for each major population group represented in the Program's membership. This expertise will positively impact the health of our diverse membership and further define Permanente Medicine as the standard-bearer in the industry. As the work of the ICCC and individual Centers for Culturally Competent Care is validated and as knowledge is transferred across the KP Program, we will further distinguish ourselves as the leader in a highly competitive health care market.}

 

_{Acknowledgments
The following people reviewed the manuscript: Ronald Knox, BS; Gayle Tang, MSN, RN; Sue Tico, BA; Andrea Ford Roberts, Esq; Carlos Vargas, BA, from the KP National Diversity Department; and Kathleen Barco, BA, APR, from the National Public Affairs Department. Saleena Gupte, MPH, doctoral student, School of Public Health, University of California, Berkeley assisted with the project.}

_References

1. _{Setness PA. Culturally competent health care: meeting the challenges can improve outcomes and enrich patient care. Postgrad Med 1998 Feb;103(2):13-6.}
2. _{Kaiser Permanente. National Market Research. Satisfaction Tracking And Reporting Program (STAR). Demographic report on KP members: 1990 to present. [Oakland (CA): Kaiser Permanente; 2000].}
3. _{Rose G. Sick individuals and sick populations. Inter J Epidemiol 1985 Mar;14(1):32-8.}
4. _{Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001. Available on the World Wide Web (accessed June 4, 2002): www.nap.edu/catalog/10027.html.}
5. _{Goldsmith O. Culturally competent health care. Perm J 2000 Winter;4(1):53-5.}
6. _{Frankel RM, Stein T. Getting the most out of the clinical encounter: the Four Habits Model. Perm J 1999 Fall;3(3):79-88.}
7. _{Lubeck DP, Kim H, Grossfeld G, et al. Health related quality of life differences between black and white men with prostate cancer: data from the cancer of the prostate strategic urologic research endeavor. J Urol 2001 Dec;166(6):2281-5.}
8. _{Thompson I, Tangen C, Tolcher A, Crawford E, Eisenberger M, Moinpour C. Association of African-American ethnic background with survival in men with metastatic prostate cancer. J Natl Cancer Inst 2001 Feb 7;93(3):219-25.}
9. _{United States. Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care: final report. Washington (DC): Office of Minority Health, Department of Health and Human Services; 2001.}
10. _{Ross H. Office of Minority Health publishes final standards for cultural and linguistic competence. Closing the Gap 2001 Feb-Mar;1-2:10.}
11. _{Gaskin DJ, Hoffman C. Racial and ethnic differences in preventable hospitalizations across ten states. Med Care Res Rev 2000;57 Suppl 1:85-107.}
12. _{Salgado de Snyder VN. Mexican women, mental health and migration: those who go and those who stay behind. In: Malgady RG, Rodriguez O, editors. Theoretical and conceptual issues in Hispanic mental health. Malabar (FL): Krieger; 1994. p 114-39.}
13. _{Humphry J, Jameson LM, Beckham S. Overcoming social and cultural barriers to care for patients with diabetes. West J Med 1997 Sep;167(3):138-44.}
14. _{Ng B, Dimsdale JE, Shragg GP, Deutsch R. Ethnic differences in analgesic consumption for postoperative pain. Psychosom Med 1996 Mar-Apr;58(2):125-9.}
15. _{Smith S, Freeland M., Heffler S, McKusick D. The next ten years of health spending: what does the future hold? The Health Expenditures Projection Team. Health Aff (Millwood) 1998 Sep-Oct;17(5):128-40.}
16. _{Hoffman C, Rice DP, Sung HY. Persons with chronic conditions. Their prevalence and costs. JAMA 1996 Nov 13;276(18):1473-9.}
17. _{University of California, San Francisco, Institute for Health and Aging. Chronic care in America: a 21st century challenge. Princeton (NJ): The Robert Wood Johnson Foundation; 1996.}
18. _{Kaiser Permanente Medical Care Program, Institute for Culturally Competent Care. Culturally competent care [pocket card]. [Oakland (CA)]: Institute for Culturally Competent Care, Kaiser Permanente Medical
    Care Program; 2001.}