This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Organization & FinancingSAMHSA Managed Care Initiative Training SessionsJune 1997 Dates: June 10, 1997-SAMHSA Group, Parklawn Conference Center, Rockville, Maryland June 11, 1977-National Mental Health Liaison Group, American Psychiatric Association, Washington, D.C. Title: Enhancing Cultural Proficiency in the Managed Care Environment Speaker: Marcia Bayne-Smith, D.S.W., Assistant Professor of Urban Studies, Queens College, City University of New York Introduction Managed Care and Cultural Proficiency Dr. Bayne-Smith began the presentation on cultural proficiency with the concerns and strategies of managed care companies. She stated that the primary concerns are-(1) patient retention or the prevention of disenrollment and (2) increasing enrollments by finding new markets and ways to penetrate these markets. The strategies being considered to address these concerns include cultural or ethnic matching and case management services. Dr. Bayne-Smith warned that simply matching patients and providers by ethnic or cultural background will not automatically translate into compatibility. Within a culture, one must also consider issues of class, gender, and race. One should not assume that homogeneity exists within a culture. Case management is a more sensible strategy. While managed care companies are concerned about the cost, Dr. Bayne-Smith is optimistic that the companies will understand the value of a monetary investment. To retain the client population, case management services are necessary to take care of other aspects of the clients' lives. If people cannot keep health care appointments, they eventually disenroll, and the managed care company loses business. Case management services make sense politically and economically. Culture and Its Messages Dr. Bayne-Smith asked the audience two basic questions. The first question was-what is culture? The audience members responded with the following ideas: environment, language, norms, heritage, customs, a group, music, family, values, symbols, rituals, mores, religion, food, style of dress, folklore, dance, and identification. The next question was-how do you learn or acquire culture? Members of the audience replied that culture is learned from family, the church, literature, television, observation of people, and immersion within it. Dr. Bayne-Smith summarized the responses and stated that culture and its messages are unintentional, informal, and easily absorbed; culture permeates our entire social interactions; it becomes ingrained and shapes our world view. Culture is a mechanism that we use to assign meaning to our lives, to understand the world around us, and to situate ourselves in the world. It also becomes the framework by which we interpret and judge the behavior of others. Dr. Bayne-Smith noted that instead of using our culture as a reference point, many of us view our culture as "the truth"; therefore, other cultures must be wrong. She warned that we must recognize that there are many cultures and many truths. No single culture has a controlling share of the truth. The Goal Dr. Bayne-Smith stated that the goal in today's managed care environment is to enhance proficiency in cross-cultural service delivery. The questions that arise are-How do we become culturally proficient? How do we deliver competent alcohol, drug, and mental health prevention and treatment services to a culturally diverse population? How do we work with people and not judge them or interpret their behavior by our own standards? The goal shared by managed care companies, providers, and health care professionals is to improve accessibility and use of health care services, particularly by people who are traditionally underserved. Essential Tools for Enhancing Cultural Proficiency Dr. Bayne-Smith continued with a discussion of tools that can enhance cultural proficiency. She noted that it is impossible to learn about all cultures. However, one can make a situational assessment. Each professional, as part of an organization in a particular community, can assess how to better serve the members of that community. This involves a series of steps that includes self-assessment, organizational assessment, community assessment, and policy/legal assessment. Self-Assessment Self-assessment involves (1) identifying gaps in personal knowledge, (2) increasing personal awareness of attitudes and behavior toward cultures other than one's own, and (3) understanding that there are cultural differences in health beliefs, practices, perceptions of illness, and health-seeking behavior. Dr. Bayne-Smith noted that in many cultures the traditionally trained Western physician is the recourse of last resort. She offered her own Latin-American culture as an example. If a person is ill, the first attempt to feel well is self-medication with nonprescription treatment. The second attempt involves asking a family member or other trusted person for advice, perhaps someone who had a similar illness. The third step is a visit to the local healer-a curandera, babaloo, santero priest, obeah man, or voodoo priestess. The treatments range from teas and herbs to baths, compounds, and potions. Many people call this witchcraft or nonsense; however, it cannot be denied that local healers have helped many poor people feel healthy and well. We must be aware that people may try an alternative healer before going to a physician. Organizational Assessment Dr. Bayne-Smith stressed the importance of organizational assessment whether one is directly involved in delivering alcohol, drug, and mental health treatment and prevention services or serves as an administrator for these programs. Organizational assessment involves the following activities: (1) describe the organization's mission; (2) determine the written and unwritten values and beliefs that are shared by everyone in the organization; (3) examine the operating policies and procedures and the staff selection principles that shape the way both the organization and its employees behave; (4) ask yourself if you identify with the organization's culture. Community Assessment Dr. Bayne-Smith suggested the following questions to guide a community assessment: What are the target community's general values, beliefs, and practices toward health care and health care providers? What is the role of the family? What is the role of men in health care management in general and in health care of women in particular? What are the major religions practiced in the community, and what role do they play in health care utilization? What are the usual steps taken in the course of health seeking? As an example of community assessment, Dr. Bayne-Smith related the experiences of a New York City community. Several years ago, health care professionals serving a Latino community in the Bronx came together to found the Community Health Participation Program at Montefiore. These visionaries included: Victor Sidel, M.D., past president of the American Public Health Association and a distinguished professor at Montefiore Medical Center in the Bronx, the late Sally Cohen, a noted community organizer, and Roberto Belmar, M.D. who escaped Chile in 1973. This program was an outgrowth of their realization that, in the Bronx, more Latina women than Caucasian women died of cervical cancer. The Latina women were not contracting cancer at greater frequency, however, by the time they sought treatment, their cancers were quite advanced. Community assessment pointed to the cultural influences of various religious practices and methods of alternative healing. The founders made what are now considered revolutionary decisions. They acknowledged, first of all, that patients readily sought, and indeed preferred, the services of alternative healers, as opposed to biomedical western services. Secondly, the Community Health Participation Program was designed to encourage women in the community to practice preventive health care. Therefore, rather than ignore the alternative healers, the program succeeded by collaborating with the healers in the community in an effort to reach out to women and motivate them to seek preventive care in a more timely manner. Dr. Sidel chose to respect another culture. He understood there was a difference in seeking health care and did not label the alternative treatment as quackery. But he also did not lose sight of the advances in medicine. Dr. Sidel realized the need to strike an alliance with the santero priest in order to meet the needs of the community. Dr. Bayne-Smith stressed the importance of understanding the difference between organizational culture and community culture. She made the following comparisons:
Dr. Bayne-Smith also compared the definitions of "health" as perceived by the two cultures. In the organizational culture, health is defined as the absence of disease. In the Native-American culture, health means the balance and beauty of all things cultural, spiritual, and social. To successfully assess the community, one must understand that its culture is different from organizational culture. The challenge is to bring these two cultures together and at the same time not lose the tremendous benefits and advances of Western medicine. Policy/Legal Assessment Dr. Bayne-Smith listed four questions to consider in assessing the policy or legal issues of a specific cultural group. (1) What is the legal status of the targeted population or community? (2) On a state-by-state basis, depending on the region of responsibility, what do administrators know about the entitlements of certain cultural groups? (The next two questions focused on immigrant populations.) (3) Can clients seek health care services without putting their immigration status and that of their families in jeopardy? (4) Will the access to health care by immigrants and refugees be affected by welfare and immigration reform? Strategies for Improving Cultural Proficiency Personal Skills Enhancement Dr. Bayne-Smith noted that each one of us can increase our level of cultural proficiency. First, one can learn more about the community in terms of its health beliefs and practices, health-seeking behavior, and sociocultural traditions and experiences. Second, one can create opportunities-or join existing ones-to network and establish ongoing community dialogue on issues such as managed care policy and service delivery. Organizational Cultural Proficiency Dr. Bayne-Smith listed the following points to consider in developing organizational cultural proficiency: (1) identify the internal and external obstacles that limit the organization's ability to deliver services to culturally different populations; (2) identify gaps in knowledge and areas for future research, education, training, and planning; (3) create mechanisms for reaching out and involving culturally different patients/clients and organizations; (4) bring together traditional practitioners and folk healers in the planning, development, and implementation of culturally appropriate services; and (5) develop processes that will ensure that program development and implementation meet the needs of those who are culturally different. One important step toward enhancing cultural proficiency is provider education. Dr. Bayne-Smith suggested two sources for provider education. The first is through the Rosenthal Center for Complementary and Alternative Medicine at Columbia University. The Center has compiled a list of 48 alternative medical courses taught at 32 American medical schools. The courses range from the theoretical to the practical. The second source is "ethnomed," an electronic database that offers providers direct access to information on culture, language, health, illness, health beliefs and practices, and community resources for different refugee and immigrant groups in the Seattle area. Community Empowerment Dr. Bayne-Smith urged that professionals in the managed care environment become advocates for those who are culturally different. They can work with communities in the following ways: (1) establish forums for ongoing dialogue on issues affecting group health, such as managed care policy, program planning, and service delivery; (2) help develop community health care agendas; (3) prepare and convey messages about alcohol, drugs, and mental health; (4) identify and share more effective models for managed care service delivery to the targeted community or culturally different group; and (5) develop strategies for culturally different groups to gain or increase access and use of culturally compatible prevention-education and treatment services. Policy Advocacy Dr. Bayne-Smith stressed the need for policy advocacy in tandem with community advocacy. For those in the policy arena, there is an urgent need to collect data, conduct research, and address fiscal appropriations decisions. She added that since public dollars are appropriated and distributed based on policy, it is important to teach communities how to advocate. The following activities were highlighted: (1) affect legislative and governmental change; (2) provide culturally sensitive and effective alcohol, drug, and mental health treatment services; (3) challenge incorrect evaluation methodologies; and (4) challenge managed care assumptions about cultural influences on medical necessity. Implications of Cultural Proficiency The implications of cultural proficiency in a managed care environment are clear. First, the managed care organizations will have access to populations considered hard to reach. Second, there will be a greater wealth of knowledge, including a more comprehensive personal, professional, and organizational understanding of the target population. Third, working relationships and partnerships can be established within the community. In sum, the success of managed care organizations will depend on a level of cultural proficiency that includes everything from policies and programs to staffing patterns. Cultural Proficiency Roundtables Dr. Bayne-Smith explained that cultural roundtables are a mechanism that brings participants together to help them adapt strategies and plan for the subsequent implications in their own work, institutions, and communities. To demonstrate the dynamics of cultural roundtables, Dr. Bayne-Smith divided the audience into groups. She assigned each group a specific question to discuss for 15 to 20 minutes. She requested that each group select a member to record and explain its findings. The following questions and responses were presented:
SAMHSA-Group 1 Define the target population using basic demographic data, find out employment rates, identify which institutions are most used, and which government agencies programs are most used. Define the gaps between what our perceptions of alcohol, drug, and mental health services are and what the population's perception is. Once we define the gap, we can direct our assessment toward filling that gap. Next, involve the community, through either grassroots outreach service or asking other community people to pick up the evaluation and assessment in order to eliminate the sense of intrusion. Identify what resources are clearly available, and allow the community to express its needs. National Mental Health Liaison-Group 1 Group 1 made the following points:
SAMHSA-Group 2 We defined ourselves as SAMHSA which services the States; for example, California has different needs from Connecticut. The answer comes down to the individual and respect for individuals regardless of culture. We need to educate individuals and immerse ourselves in the populations that we serve to learn more about the needs of the community. Respect for the individual starts on an individual level and spreads into the greater organization serving the target population. National Mental Health Liaison-Group 1 (The answer given for the first question was intended to answer the second question as well.)
SAMHSA-Group 3 The group came up with five suggestions for changing government policies to eliminate obstacles. 1. CMS (the the Centers for Medicare and Medicaid Services) is the group that administers Medicare and Medicaid. If CMS would reimburse nontraditional services, such as acupuncture or other treatments that different ethnic groups might choose to use, they would be drawn into the service delivery system. 2. Grants should be reviewed to see if the target group included ethnically different people, and policies should be set out in grant application rules that would require those applying for a grant to reach culturally different people. 3. Persons of different sexual orientation, such as nonmarried partners or same sex partners, should be included in health care insurance coverage. 4. Under Medicaid waivers-when an application is made, suggest that when States obtain a Medicaid waiver in managed care, they require culturally appropriate services; or change Medicaid so that the State does not need to apply formally in order to require that culturally appropriate services be included. 5. Do not restrict the provider network; allow any minority provider to be reimbursed and included in the network. National Mental Health Liaison-Group 2 Acknowledge that what we are doing now is important-understanding the value of diversity, the value of difference. The notion of a "color-blind" society is a barrier in and of itself. Specific government regulations can create barriers. For example, ethnicity and gender cannot be used as a selecting criterion for the federal civil service. If a predominantly female population is being served, maybe gender is important. Some practices need to change such as a doctor telling a patient to take a medication after each meal, but the patient is never asked how many meals he/she eats.
SAMHSA-Group 4 First, assess the community and observe how community members go about their day-their schooling, business, their children, the religious practices. Permeate that culture and learn about it. Be prepared for skeptics-people won't necessarily believe your good will or good faith. Be prepared to go back again and again until they do believe you. Figure out the means of communication, such as television, radio, or community newspaper. Find the gatekeepers of the community-who does everyone go to with questions or concerns? First establish a trust level with the gatekeepers. Then try to establish a sense of community through the gatekeepers. Involve community members in town meetings, and ask what their health care concerns are. Restructure health care with the community, by the community, and for the community. National Mental Health Liaison-Group 2 Take time to get involved; show up especially around holidays when people display their culture, and customs are more evident. Do not be afraid to make mistakes; do not be afraid to learn. Be proactive: provide training on a much larger scale. Learn to value diversity instead of just pointing out differences. Conclusion Dr. Bayne-Smith emphasized the need to learn about different cultures and to respect people who are different. As an example, she related the story of a young graduate from Cuba's Family Physician Program. The young doctor spent a year in the mountain area and in his rounds visited an old man who was very respected in his community. The doctor performed a basic exam and found the man's blood pressure to be very high. He asked the man what people in the mountain community did to treat high blood pressure. The old man replied that they drink quanabana juice. The doctor said that is good. He told the man that his blood pressure was high, and that he wanted him to drink the quanabana juice. The doctor added that once a day, when the man drank the juice, he should also take a pill supplied by the doctor. There was no argument as the doctor respected the man's culture, and in return the man respected the doctor's advice. Dr. Bayne-Smith concluded with a story about geese. She acknowledged that workshop participants are aware that geese fly south in the winter, and that they fly in a "V" formation. She then explained that research on flight patterns indicates that by flying behind each other, the bird in front with each flap of its wings generates about 27 percent greater air current-on which the bird in the back moves forward. When geese fly in formation, they are able to travel 71 percent further than if they tried to travel alone. The research also found that if a bird goes down, perhaps due to a gunshot wound, two other birds accompany it. They stay with the injured bird until either it is well enough to fly or it dies. When ready to resume flight, the birds wait for the next formation; they do not travel alone. The moral of the geese story is that when one collaborates and coordinates one's efforts with others who are traveling in the same direction, the group is more likely to reach its goal faster and is more likely to be successful than one person acting alone. Working together is the essence of cultural proficiency. Question and Answer Session I
1. A. Our reactions to people who are disabled, gay, or lesbian are so much a part of what society reacts to and society's behavior toward those people. There are families in which members are not allowed to make fun of disabled people; in other families it is okay. Q. Family is where you learn culture. Sexual preference is one area where families are ostracizing. A. Absolutely, but in many ways the family may have contributed to the formation of sexual preference. As clinicians, we all know about reaction formation and what goes into choices and decisionmaking. These are always influenced by family, often in ways we do not recognize. Question and Answer Session II
1. A. I have been trying to study culture, but I am not going to stand here and say that it is easier. Or that approaching it from the other side would not make more sense. In the book I edited, I looked at race, gender, and health. Within race, I looked at class because a disproportionate number of people of color are poor. So there was a connection between race and socioeconomic status that is also influenced by culture. It is a chicken-and-the-egg situation.
2. A. Culture is stronger. However, the question is worthy of research. Q. I would hypothesize that upper-class Hispanics are into machismo less. A. I would say that it depends on the number of years living in America and the level of acculturation. Q. Are health practices more a function of class or culture or level of education? A. The level of education is the great divider. The more educated, the greater the likelihood to use Western medicine or Western medicine in conjunction with alternative treatment. Provider education is important to help those less educated.
3. A. Culture is stronger for people who have recently arrived in America. Many countries outside of the United States do not use doctors as Americans do. In addition, immigrants do not understand the degree of specialization or the government structure. In many populations that we deal with, culture is a serious consideration. People come from cultures where beliefs are totally different.
4. A. To say that access to health care is determined by our jobs is a fallacy in a way because we also have access through public insurance-Medicare and Medicaid. Now with welfare reform, that is changing. Many people who previously qualified for Medicaid will not qualify. We also know that there are about 50 million Americans who go to work every day and do not have health insurance. These are the working poor. The system does not meet their needs, and managed care does not meet their needs. To enroll in managed care, you have to have some sort of insurance, either public or private. What do we as a nation want to do about that? In part, we must advocate politically, or nothing will happen. It is unconscionable to move people off welfare and not provide them with health insurance, day care, skills training, and education so they can enter the job market at a level where they can sustain themselves. |
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