Cultural Competence in Health Care and its
Contribution to Eliminating Racial/Ethnic
Health Disparities
How far have we come and where do we need to go?
Dennis P. Andrulis, Ph.D., MPH
Senior Research Scientist, Texas Health Institute, Austin TX
Associate Professor, Health Management and Policy &
Center for Emergency Preparedness
University of Texas School of Public Health
NIMHD/NIH Seminar Series ● Bethesda, MD ● August 25, 2011
Overview
 Where does cultural competence stand today?

Cultural Competence and the Affordable Care Act
 Where are the knowledge gaps?
 What are next steps?
Cultural Competence
“A set of attitudes, skills, behaviors, and policies
that enable organizations and staff to work
effectively in cross-cultural situations.
It reflects the ability to acquire and use knowledge of the
health-related beliefs, attitudes, practices, and
communication patterns of clients and their families to
improve services, strengthen programs, increase
community participation, and close the gaps in health
status among diverse population groups.”
–Cross et al., 1989.
Source: M, Beach. Patient-centeredness and cultural competence: their relationship and role in
reducing health disparities. Commonwealth Fund 2006
Where does cultural
competence stand today?
Cultural Competence:
Status and Progress
 Significantly greater consideration of its importance
in access to and quality of health care among
practitioners and health care organizations.

Support for Research and Program Innovation:

NIMHD/NIH has included cultural competence in its solicitations.

OMH, AHRQ and HRSA have made cultural competence a priority
in training, education materials, research.

Foundations supporting cultural competence initiatives.
Cultural Competence:
In Early States of Development
 Research and reports exploring, defining and refining
concepts and issues
 132
articles between 1990 and 2000
 303 between 2000 and 2005
 Increasing attention to important research questions
to pursue.
 Some movement toward pilot studies and case-
controlled studies.
Source: Goode T. et al. The Evidence Base for Cultural and Linguistic
Competency in Health Care, 2006.
Cultural Competence:
State Level Legislation2000-2011
Dark Blue : legislation requiring (WA, CA, NJ, NM, CT) or strongly recommending (MD) cultural
competence training, which was signed into law.
Purple : legislation which has been referred to committee and is currently under consideration.
Royal Blue : legislation which died in committee or was vetoed.
Source: Think Cultural Health, 2011
Progress in Promoting
National Guidance and Standards
 National Quality Forum

Seven domains: leadership, management/operations,
communication, care delivery/support, workforce
diversity/training, community engagement, data—
accountability/QI

Identifying preferred practices for each (e.g., community
collaboration to implement clinical and outreach programs for
diverse populations)

Healthcare disparities and cultural competency consensus
standards

Selecting and evaluating disparity sensitive quality measures

Describe methodological issues with disparities measurement

Solicit and evaluate the value of new measures (completion 2012)
Progress in Promoting
National Guidance and Standards – cont’d.
 The Joint Commission

Patient rights

Patients’ participation in care

Safety and quality of care

An integrated approach at multiple levels, involving
ongoing monitoring & improvement is necessary to
identify, develop and implement systems to promote
health equity

New and revised standards:

Identifying and addressing patient communication

Providing language services, including addressing qualifications for
language interpreters and translators

Collecting race, ethnicity and language data

Patient access to chosen support individual

Non-discrimination in patient care
Progress in Promoting
HHS Guidance
Office ofand
Minority
Health
National
Standards
– cont’d.
 Office of Minority Health
CLAS Standards

Provide the framework for all health
organizations to best serve the nation’s
diverse communities

Set of mandates, guidelines and
recommendations intended to inform
practices related to cultural and linguistic
competency in health care for patient
care, language services and organizations
Affordable Care Act and
Cultural Competence
Diversity-Specific Provisions
Over three dozen provisions in ACA on
race, ethnicity, cultural competence,
language assistance and diversity.
Cultural Competence & Workforce Diversity
 Cultural Competence





Model cultural competence curricula.
Cultural competence training for health professionals.
Culturally appropriate patient decision aids.
Culturally appropriate personal responsibility education for teen
pregnancy prevention.
Culturally appropriate national oral health campaign.
 Workforce Diversity




Increase diversity among health professionals.
Health professions training preference for cultural competence.
Investment in HBCUs & minority-serving institutions.
Collect & report workforce diversity data.
Data Collection & Disparities Research
 Data Collection & Reporting



Collect racial/ethnic sub group data in population surveys.
Collect/report disparities data in Medicaid & CHIP.
Monitor disparities trends in federally funded programs.
 Health Disparities Research


Examining disparities through comparative effectiveness
research (CER).
Supporting research on topics of cultural competence and
health disparities.
Cultural Competence in Health Insurance Reforms
 Cultural & Linguistic Requirements of Exchanges
and Participating Health Plans:




Non-discrimination in health insurance exchanges.
Culturally & linguistically appropriate summary of benefits.
Culturally & linguistically appropriate claims appeal process.
Incentive payments for cultural competence & reducing
disparities.
General Provisions
Over three dozen general provisions with
potentially major implications for
racially/ethnically diverse populations
Health Insurance Reforms & Access to Care
 Expansion of Medicaid eligibility to 133% FPL
 Small business (<25 employees) tax credits
 State-based health insurance exchanges
 Support for Community Health Centers
 Support for nurse-managed health centers, teaching
centers & school-based clinics
 Community health teams
 Primary care extension programs
 Pilots on regional emergency & trauma care
Public Health & Community Programs
 Childhood obesity demonstration projects
 National diabetes prevention program
 Education campaign for breast cancer
 Community transformation grants
 Non-profit hospital community needs assessment
requirement
Quality Improvement & Cost Containment
 National Strategy for Quality Improvement
 Developing & evaluating quality measures
 Linking Medicare payments to quality outcomes
 Pediatric Accountable Care Organizations
 Reduction in Medicare & Medicaid
Disproportionate Share Hospital (DSH) Payments
Highlights
 Great breadth of opportunities in ACA to reduce disparities
and improve health equity.
 Federal agencies, generally assigned leading responsibility for
advancing and implementing these provisions.
 Many provisions related to equity, cultural competence and
language assistance have received appropriations and offer
opportunities for community based organizations, county
agencies and states to pursue funding.
 However, important provisions, with a strong evidence base
for need have not received appropriations as yet and may
require state, county and community organizations to take
innovative approaches to achieve their objectives.
Primary Care Opportunities
 Community Health Centers

HRSA providing $10 million for new & expanded services for up to 125
FQHCs, a maximum of $80,000 for 1 year per award in 2011.
 School-based Health Clinics

$50 million for each FY 2010-2013 for capital grants for facility construction,
expansion and equipment.
 Primary Care Extension Program

$120 million in 20011 to establish program to support and assist primary
care providers to improve community health.
 Health Professions Training Opportunities

HRSA grant programs for training in dentistry, primary care, & personal
and home care aides, with preference given for experience in cultural &
linguistic competence.
Prevention Opportunities
 Community Transformation Grants

Over $100 million for 75 grants to help communities implement projects
proven to reduce chronic diseases as well as health disparities.
 Investment in Prevention

$750 million to reduce tobacco use, obesity and heart disease, and build
healthier communities ($298 mil for community prevention, $182 mil for
clinical prevention, $137 mil for public health, $133 mil for research).
 Personal Responsibility Education

$75 million for states in 2011 to educate youth in culturally/linguistically
appropriate ways to prevent teen pregnancy and sexually transmitted
infections.
Opportunities in Health Insurance Programs
 Community Based Care Transition Program

Funding in 2011 for eligible hospitals and community-based organizations that
provide evidence-based transition services to Medicare beneficiaries with
multiple chronic conditions to prevent hospital readmission.
 CHIP Childhood Obesity Demonstration

$25 million in 2011 for a demonstration program to develop a model for
reducing childhood obesity.
 Medicaid Prevention and Wellness Initiatives

State grants in 2011 to provide incentives for Medicaid beneficiaries to
participate in evidence-based programs to prevent/manage chronic disease.
 State Health Insurance Exchanges

State planning and establishment grants for health insurance exchanges,
which can also be used to set up a navigator program and provide appeals
process and benefit summaries in culturally/linguistically appropriate ways.
Cultural Competence Opportunities
(with no appropriations)
 Model Curricula for Cultural Competency

Opportunity to test impact of a range of cultural competency training
programs on health outcomes and to identify efficacy &
effectiveness.
 Facilitating Shared Decision Making

Patient decision aids are required to present up-to-date clinical
evidence about risks and benefits of treatment options to meet
cultural & health literacy requirements of populations.
Community Access & Prevention Opportunities
(with no appropriations)
 Community Health Teams (CHTs)

As states adopt medical home models, more low income & diverse
individuals with chronic illness will be able to turn to a CHT to help
them link with a full range of health and social services they may
need.
 Community Health Workers (CHWs)

Use of CHWs in health intervention programs associated with
improved access, prenatal care, pregnancy and birth outcomes,
health status, screening behaviors & reduced health care costs.
 Oral Health Prevention Activities

Blacks, Hispanics, & AI/AN have poorest oral health access and
outcomes & could significantly benefit from these programs.
Where are our knowledge gaps?
Three main levels of gaps:
1. Individual
2. Organization
3. Community
1. Individual Level
 Research and knowledge regarding incidence and
prevalence of disparities-related conditions has matured
as has documentation and tracking of rates and
outcomes.
 But knowledge gaps remain as to why disparities in
outcomes have remained resistant to significant,
consistent positive change in closing gaps.
 Cultural competence initiatives and research seen as
potentially significant strategies for reducing disparities
Individual Level: Evidence to Date
 Few studies on intermediate effects of short term
interventions (e.g., increased screening rates for cancer and
improving HbA1c levels)
 Some notable progress in:
 Documenting role of language and need for linguistic competence—
medical error, Title V civil rights violation costs, adverse events;
 Testing specific interventions—interpreters, materials etc
 Little focus on outcomes such as reduction of disease
incidence in a population
 Little focus on effects on rates of disease morbidity or
mortality
2. Organization Level
 What role does the health care organization play in
diminishing or perpetuating disparities gaps?
 How do organization actions/inaction, responding to system
incentives (e.g., reimbursement) affect disparities?
 This is relevant in the era of health care reform, as resistance
to change to address diverse patient needs intersects with new
incentives to improve patient access and quality.

What are characteristics of low performing health programs compared
with high performance health systems?

What are the implications and impact of pay for performance in the
context of disparities gaps?
Organization Level: Evidence to Date
 A few studies examined organizational policies--e.g.,

Diverse workforce recruitment, training, written materials,
practitioner evaluation—demonstrated more appropriate use
of asthma medications for children and greater parental
satisfaction (Lieu et al, 2004)

Racial-ethnic concordance correlated with higher rates of
physical exams in a drug abuse treatment program (Campbell
& Alexander, 2002)
3. Community Level
 There remains little knowledge about the influence
of place and geographic differences in contributing
to disparities.

Beyond the more obvious and ‘usual suspects’—e.g., poverty,
lack of education—what community factors perpetuate
disparities?

What weight should be given to these characteristics in
understanding disparities?

What are the social determinants of health that obstruct or
facilitate access, quality and outcomes?
Fig. 1 The Current Health Care System
The medical care system functions as a funnel because individual illness is an
outcome of, and final common pathway for, society’s ills.
–J. Horowitz. The New England Journal of Medicine. Vol. 329, Number 2: 1993, pg 131
Community Level: Evidence to Date
 New and growing areas of focus:

Social determinants

Integration of community perspective and knowledge into
programs (health workers, navigators, outreach)

Intersection of the health care, community and social
environment

Measurement—Health Impact Assessments
Summary:
Cultural Competence Knowledge Gaps
 Still very short on documenting clinically what,
specifically, constitutes a cultural competence
intervention, what works, when and how.
 Little guidance to organizations for integrating
cultural competence into actions to improve
health care processes and outcomes.
 Relationship and importance of community
engagement in providing culturally competent care
increasingly acknowledged, but indeterminate.
What are Next Steps?
1. Cultural Competence-Related
Research and Initiatives
 Identify effective strategies for tailoring disease and
wellness management to diverse individuals.

NIH-based or other funded research into the efficacy of related
interventions generally and for specific conditions and groups of
conditions (e.g., chronic disease).

Developing an evidence base for chronic disease management of
diverse patients; need large sample longitudinal studies
 Supporting research and assessment linking health care
organization actions/policies with reducing disparities
 Creating and testing specific interventions that train,
educate and support participation of health care settings
and practitioners in broader inter-sectoral strategies to
promote health and prevent chronic illness
2. Cultural Competence Guidance
 With the enactment of health care reform, need
guidance to the field on cultural competence.





Define what constitutes the field of cultural competence.
Identify what the field needs to do to create an evidence-base.
Develop applicable and relevant measures of effect.
Ground the link of cultural competence to quality, cost and
effectiveness.
Determine the efficacy and role of cultural competence and related
interventions in achieving prevention objectives.
3. Training and Education

Separate the wheat from the chaff in training and
education--Identify what constitutes effective diversity
training and education.

Linking diversity training to progress in achieving desired
processes and outcomes of care.
4. Policy and Programs
 Creating and formalizing a federal and national strategy
to promote inter-sectoral programs, initiatives and
policies at the federal level.

Promote interagency/community collaboration at the state/local
level to advance prevention and health care goals.

Develop research and demonstrations financially supporting health
care practitioners and their settings in developing effective
collaborative initiatives with housing, transportation, community
representatives and others to improve health.
 Demonstrations and evaluations of programs
implementing CLAS, NQF and other recommendations.
5. Translation of Research to Practice and Policy