Improving health care for immigrant and minority populations in the United States

Using practice, policy, and strategic alliances to drive change

Julia Puebla FortierResources for Cross Cultural Health Care

Resources for Cross Cultural Health Care

Policy development National CLAS Standards

Research Research agenda on cultural and linguistic

competenceEducation

Biennial conference seriesInformation dissemination

Newsletter and DiversityRx websiteProfessional networking and support

CLAS-talk listserv and ‘Your Voice’ project

Outline Financing and access to health services in

the U.S. Key forces and players Role of service delivery innovation Research on disparities and barriers to care Policy structures and models Non-profit and for-profit sector contributions Role of strategic alliances

Health care insurance in the U.S.

(Employment-based) private insurance Through networks of government and

private providers Government insurance

Medicare (elderly, disabled) Medicaid (low-income) Through participating providers

No insurance

Government/NGO clinics and hospitals Sliding scale fees ‘Charity’ care as part of mission

Private providers Self-pay Unreimbursed care (loss)

Refugees and health/social services

Government-funded resettlement program Local/regional health departments Voluntary Agencies Mutual Assistance Agencies

Community clinics/hospitals Private practitioners

Immigrants and health/social services May have employment-based health

insurance Sometimes have Medicaid Use of community clinics, hospitals Often self-pay Immigration status

Legal – government program eligibility Undocumented – neither public nor private

insurance

Key forces in improving access and quality of care for immigrants and minorities

Minority health and civil rights Cultural and linguistic competence Health disparities reduction Quality improvement The ever-elusive goal of cost-

effectiveness

Key players Minority and civil rights leaders State and local health departments Front-line providers in diverse communities Health services researchers State and national policy leaders

Federal government National health professional and quality

organizations Private foundations

Service innovation:Community oriented providers

Community health centers Public hospitals Public health departments Health education programs run by

community based organizations

Service innovations for diverse populations Medical interpretation and translation services

—on-site and telephone Cultural competence training Use of cultural mediators/community health

workers Patient/community involvement in governance

and planning Technical assistance to other health care

organizations on health/social/cultural/linguistic issues specific to ethnic minority populations

Power of service innovations

Community-oriented providers had legal mandates to be responsive to the needs of underserved populations  

They inspired and raised the performance bar for other providers

They drove the development of policy: gov’t requirements/programs need models and a track record of success

Policy framework

Minority health agenda (programmatic)

Refugee resettlement programs Civil rights laws State laws and regulations National CLAS Standards Minority health disparities reduction Quality improvement agenda

Offices of Minority Health Legislation to strengthen and expand the

scope of the federal Office of Minority Health and related programs (1990-) Additional funding More specificity about language and cultural

issues Increase number of minority health

professionals Support for state Offices of Minority Health

Development of National CLAS Standards

CLAS: Culturally and Linguistically Appropriate Services in Health Care

Research on model programs and policies Identification of common elements Draft standards—aimed at health care

organizations National public comment period Publication in the Federal Register

CLAS Standards: Categories of interventions Culturally Sensitive Interventions

Cultural competence education Race, ethnic and linguistic concordance Cultural mediators, community health

workers and culturally competent health promotion

Language Assistance Bilingual services, oral interpretation,

translated written materials

CLAS Standards: Categories of interventions

Organizational Supports for Cultural Competence Management and policy strategies Community engagement Information and data for planning and

evaluation Appropriate ethics and conflict

resolution processes

Unexpected impact

Highly symbolic impact Raised profile of the issue Spurred discussion, controversy,

refinements Offered an organizing framework Prompted action

NGOs and research, policy development, and advocacy Research and tool development to

enhance knowledge and good practice Consensus-building to advance key

issues State and federal policy analysis and

policy formulation Awareness-raising and advocacy to

improve practices and policy structures

Research on disparities and barriers to care Government and foundation funding for

research on minority/immigrant populations Barriers to care Comparative health status Effectiveness of targeted interventions

Institute of Medicine Report: “Unequal Treatment”

New government initiatives to address health disparities

Role of Strategic Alliances

Decision to reach beyond traditional ‘advocates’ to mainstream health stakeholders

Key role of money and convening power of foundations and government health agencies

Demonstrate the relationship between emerging national health agendas and this population

Synergy and support

Identify who has the power in health policy making

Bring them to the table Show how their agenda can’t

succeed unless these concerns are integrated

In time, they become your allies

State and Federal policy level States: coalitions of community clinics, ethnic

community organizations, civil rights advocates working with sympathetic health department officials and elected representatives

National: data from state and local programs, combined with national ethnic organizations, elected representatives and their staff. Federal health agencies not so sympathetic at first, except at Office of Civil Rights

Examples: language access

1995 briefing on language access –first time non-traditional stakeholders to the table

NHeLP language access coalition – informational at first, now working together for policy points in health care reform

Key issues and stakeholders Patient centered care: medical societies Quality of care: accreditation agencies,

hospital associations Patient safety/medical errors: risk

managers/legal departments Disparities reduction: NIH, AHRQ Effectiveness/cost containment: public

and private insurance agencies

Influence of quasi-regulatory agencies

Initiatives from key health care quality and accreditation organizations: The Joint Commission National Committee for Quality

Assurance The National Quality Forum

Role of for-profit sector

Service provider financial support for language and cultural

services Uncompensated care

Companies that provide interpretation and translation services

Consultants who do training and program support

Foundations

Major players The Robert Wood Johnson Foundation The Commonwealth Fund The WFF Kellogg Foundation The California Endowment Regional and community foundations

Final thoughts Policy statements are not enough

Funding for demonstrations, evaluations, research, technical assistance

Impact of success Awareness raising and advocacy to a

broad and influential audience Integration of the needs of diverse

populations into broader health priorities

For more information

Julia Puebla Fortier, Director Resources for Cross Cultural Health Care

rcchc@aol.com www.diversityRx.org