At a Decade: Centers of Excellence in Culturally Competent Care
Melanie Tervalon, MD, MPH
Introduction
The rapidly increasing racial and ethnic diversity among Kaiser Permanente (KP) membership mirrors the demographic changes across the nation (Lynette DeSantis, personal communication, 2008 Nov).a This diversity calls for interventions that are culturally specific to improve patients’ health outcomes and to eliminate health disparities (see Kaiser Permanente Diversity Demographics).
This need is unequivocally demonstrated by scientific evidence that shows differential disease prevalence between population groups.1-5 The impact of disparities and the human story is repeatedly told:3-5 in the reports that prompted the creation, in 1999, of The Office of Research on Minority Health and, in 2000, the Culturally and Linguistically Appropriate Services Standards (CLAS);6 in the Institute of Medicine’s 2002 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care;3 and in the Annual 2007 National Healthcare Disparities Report (NHDR) by the Agency for Healthcare Research and Quality.4 Despite these significant efforts, disparities have not been reduced since the first NHDR in 2003.4
During the 1990s, frameworks emerged to reverse health-disparity trends—a complex process. In particular, the practice-based, community—informed approaches to health and health care—that placed culture in the nexus of essential elements for solving health disparities—created a rich body of experience and examples now known as the discipline of culturally competent care.8-12 By 1998, the KP National Diversity Council, on the basis of the ever-growing body of knowledge and practice, began integrating these principles through a deliberate, research-driven strategy. KP membership data, health-disparities data, and the organization’s mission and purpose required a breakthrough to address differential population health outcomes.13 The Centers of Excellence are an innovative and specific response to these imperatives.
History and Strategy
In 1999, the Centers of Excellence in Culturally Competent Care concept was created through sponsorship of the National Diversity Council.14 The Centers’ purpose was to demonstrate the practical dimensions of population-based health issues with respect to culture, race, and ethnicity, written into the original National Diversity Culturally Competent Care Provider Handbook series.15 The Institute for Culturally Competent Care (ICCC) emerged shortly thereafter as an oversight body for the anticipated proliferation of Centers across the Program.
Now almost a decade later, the ICCC, a unit of Kaiser Permanente’s National Diversity Department, guides the work of nine Centers of Excellence in Culturally Competent Care within KP (Table 1) in collaboration with the respective facility Medical Directors and Administrators. The Centers demonstrate that skilled staff who respectfully explore issues of culture, race, and ethnicity during the patient’s point-of-care contact, can make an important contribution to positive patient health outcomes and reduce racial and ethnic health disparities. The Centers’ population-based, data-driven, research projects move in the direction of unraveling and explaining the dynamic positive and negative processes by which culture, race, and ethnicity interact in health care delivery settings to impact patient health outcomes.
Given the urgent national need to reduce health disparities, Centers will rededicate their efforts to demonstrate the universal applicability of respectful patient-centered, culturally skilled, quality care, which is at the heart of cultural competence. This contemporary, research-driven strategy coincides with those of multiple national organizations, guiding the intellectual and practical deliverables required to combine the agendas of quality, service, community participation, social determinants of health, disparities, cultural competence and health outcomes research.4,9-11,16-19
The Center Story: Practice and Potential
Three principles guide the work of the Centers of Excellence in Culturally Competent Care Initiative (see Sidebar: Center Principles). Each Center addresses health and health care disparities from the culturally specific view of a given population group: African Americans, Armenians, Latinos, persons with disabilities, and women. Taken together, the health foci include: cardiovascular disease, stroke, hypertension, prostate cancer, sickle cell disease, mental health, asthma, diabetes, obesity, spinal cord and brain injury, patient and provider education, translation and interpretation services, and culturally competent, cross-cultural patient-clinician communication.
The stories of four Centers are told below as illustrations of how the strategy and the principles operate in the Centers’ work.
1. The Kaiser Foundation Rehabilitation Center
The Kaiser Foundation Rehabilitation Center (KFRC) at the KP Medical Center in Vallejo, CA has provided care for patients with disabilities since 1946. This 60-bed inpatient rehabilitation hospital and outpatient center is accredited by the Commission on Accreditation of Rehabilitation Facilities.
The Center of Excellence for persons with disabilities at KFRC (demonstrating Principle 1) was founded in 2001 and is well known nationally and internationally for providing expert, interdisciplinary rehabilitative care to survivors of stroke, spinal cord injury, brain injury, and other disabling conditions.
In collaboration with the University of Washington, in Seattle, WA and with funding from the Centers for Disease Control, the Center examines how demographic and socioeconomic patient characteristics influence rehabilitation care following stroke to determine if disparities exist in the population under study. This Center works to unravel the details that contribute to the disparity in treatment protocols and care outcomes, based on place of treatment, and to understand the characteristics of patients more likely to be referred to nursing homes. KFRC’s efforts to identify disparities and barriers to care for people with disabilities will assist the Kaiser Foundation Health Plan in directing programs and resources to improve care to members with disabilities.
2. Latino Center of Excellence, Denver, Colorado
Launched in 2001, the Latino Center of Excellence (LaCE) Denver, CO, (demonstrating Principle 2) focuses on achieving improved outcomes for Latinos by attaining higher efficiencies in care delivery, by developing greater capacity to treat increased demand, and by developing replicable delivery models in diabetes care. In 2006, LaCE implemented KP’s aspirin, lisinopril and lovastatin (ALL) protocol—a cardiovascular risk reduction strategy that focuses on maximizing prevention for those most at risk—to address disparities in cardiovascular disease among Latino patients with diabetes. The specific challenge was to adapt a KP population management strategy to the needs of Latino patients. The initiative used the tripartite medication regimen for Latino patients, over age 55 years with CAD and/or diabetes, and developed a culturally appropriate outreach intervention that included:
• an interdisciplinary, Spanish-speaking, primary care team of bilingual physicians, charge nurses, and medical assistants
• simplified Spanish instructions (“just take these three pills each day”) to increase adherence amidst varying health literacy levels
• communicating instructions in Spanish
• bundling fixed doses of the three medications so that one visit could accomplish what often took many visits using only generic or inexpensive medications
• active follow-up with trained members of the health care team; and
• minimizing redundant and unnecessary laboratory tests.
The indicator of ALL medication pick up (medication “adherence”) was one benchmark of improvement, along with the percentage of those patients having an eye exam and HbA1c tested in the previous 12 months, and reaching the target goal of LDL levels less than 130mg/dL.
“The ALL Initiative” (aka “PHASE” in the KP Northern California Region) is in operation in all KP regions, and is also being supported among KP’s “safety net” partners—organizations outside the KP system that serve a disproportionate number of underserved and minority populations.
3. The Women’s Center of Excellence
Started in 2002, this Center (demonstrating Principle 3), which is located in Northern California, houses the Diversity, Data and Demographics Program (DDDP). This innovative, replicable, and culturally sensitive patient and physician satisfaction evaluation method was adopted and implemented at the Center in 2005. The DDDP provides physicians with culturally specific data regarding their patient profiles in an effort to improve the patient care experience and quality outcomes. The increase in physicians’ understanding of their patients’ needs results in increased patient-physician communication, strengthens the patient-physician relationship, patient satisfaction in quality of service, and physician satisfaction in their work.10,12 This evaluation method identifies culturally complex issues at the individual, departmental, and facility level resulting in unique solutions that are easy to implement, with demonstrated improvement in three months through educational interventions and physician coaching. As importantly, physician satisfaction scores improved along with physician retention, especially among women and bilingual physicians. Over 150 physicians participated in this process. Notably, the DDDP originated from an individual Ob/Gyn physician’s reflection on his own patient satisfaction data, which showed increased patient satisfaction with older female patients than with younger women, ages 18-35 years.
The Women’s Center of Excellence DDDP approach to culturally contextualizing the patient and physician’s approach has a potentially large positive impact on the business success of the organization by specifically responding to the needs of an increasingly diverse population at the point of the clinical encounter.
4. The Latino Center of Excellence Mid-Atlantic States
Since July 2007, the Latino Center of Excellence (LCE) in the Mid-Atlantic States (MAS) has provided culturally competent and linguistically appropriate services and resources to Latino patients. The LCE goals are to optimize Latino members’ health outcomes, to improve their compliance with medical recommendations, and to increase satisfaction with services. This is accomplished by:
• training staff through the KP Qualified Bilingual Staff program
• maximizing the use of the comprehensive HealthConnect asthma template by clinicians
• offering Spanish-language asthma education guides and classes
• creating patient asthma action plans at the time of the clinical encounter in the preferred language of the patient; and
• meeting language-appropriate signage and telephone language-line requirements at all service locations.
LCE offers its services in four MAS Medical Centers: Gaithersburg, Germantown, Loudoun County and Prince George’s County.
This Center’s research focus combines the elements of recording baseline information with regard to Latino patients and asthma, introducing interventions and measuring what change there is, if any, in patient outcomes. Some areas included in this multilevel investigation are: physician knowledge about current asthma protocols, treatment, and practice; cultural considerations when working with Latino families; language differentials between patients and providers; the influence of IT systems on care outcomes; and interventions such as bilingual- and Spanish-only asthma educational guides and classes. This Center will provide rich practical data applicable to Latino patients with asthma, and undoubtedly, will reveal lessons for all KP patients.
Research and Evaluation
Inherent in the structure of the Centers of Excellence is an evaluation component based on each Center’s formal agreement to provide culturally specific, evidence-based practice, consistent with the strategy and principles. Each Center signs a Memorandum of Understanding in which the proposed cultural intervention is evaluated as a research project, complete with data collection, analysis and reporting methods that will advance the field of knowledge and practice in eliminating health care disparities. In this regard, the evaluation methods include ways to uncover, and give language to the processes that create successful outcomes, and also what limits success. The biyearly site-visits to the Centers by the Director of the ICCC serves as a quality control mechanism, engaging Center leads, researchers, clinicians and staff in an active, relationship-based, close review of benchmarks and deliverables. An overall evaluation for the Centers is in development, and a schema will be completed by 2009.
Sustain and Transfer
The nine Centers of Excellence in Culturally Competent Care show great promise (Table 1). Locally, Centers engage in a unique community health partnership giving clinicians the opportunity to enhance their skills. Regionally, Centers recount promising, population-based health models and lend strength to the business case for recruiting and retaining a diverse membership—through services that indeed support positive health outcomes and health status. Across the regions, Centers are well positioned to disseminate and replicate successful programs, to demonstrate cost effectiveness and equity in the standard of care, and to contribute culture-specific methods for reducing health disparities. The KP Health Disparities’ Vision/Strategy Statement, in the tradition of Sidney Garfield, MD’s visionary care, states:
“Kaiser Permanente will be a leader in eliminating disparities in health and health care. We will do this by providing equitable care to our members, targeting resources to areas of need in the communities we serve, and identifying and implementing strategies and policies that support equity in health nationwide, including universal health coverage.”20
This strategic commitment from the national level and from the highest officer in the organization reinforces the importance placed on the Centers of Excellence as models within the organization where this commitment is advanced and actualized. In addition, KP intends to open at least two new Centers next year, with start-up funding from the National Diversity Council. Plans for the Center of Excellence in Childhood Obesity, Pacific Northwest and for a Center focused on the Asian-American population are under discussion. Sustaining the Centers requires capable leadership, adequate personnel, and the ability to integrate the culturally competent care concept across KP operations. Plans for publishing the results from the Centers of Excellence research and activities in peer-reviewed journals are underway. Given KP’s prominence in the health care industry, we expect that the lessons, which include the successes and limitations of the Centers’ research and initiatives, will inform the work of many constituents in health care and health care delivery.
a Consultant, National Market Research, Kaiser Permanente, Pasadena, CA
Disclosure Statement
The author(s) have no conflicts of interest to disclose.
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