Providers who deliver patient-centered, culturally competent care better serve BIPOC patients by minimizing bias, thereby improving the patient experience to achieve improved health outcomes.
What is culturally competent care?
Culturally competent care calls on providers to go beyond standard protocols when treating patients to also consider the cultural customs, value systems, traditions and beliefs that compose patient lifestyles, affecting their overall health and well-being. Applying this to healthcare practice can have a significant impact on closing the long-standing disparities within our healthcare system.
In a recent interview, I discussed what cultural competency in healthcare looks like, some of the challenges facing BIPOC patients, and efforts to bridge the gaps in care.
Listen to the audio version of my interview here:
Role of cultural competency in health equity and closing disparities
What does cultural competency mean in the health care setting? Can you offer any specific, real-life examples/scenarios/anecdotes that illustrate its impact on patient care, experience, and outcomes?
I define cultural competency in healthcare as a process of educating all types of healthcare providers on the varying populations in which they serve. We do that to bridge the gap in those cultural and belief systems that exist between patient and provider. As people, we are products of our environments. How we were brought up, the ZIP code in which we were brought up, location, the social network around us as we were being raised. All that data feeds into how we become adults and who we are as adults. That feeds into our belief systems, our values, our morals. And gaps can exist between patient and provider based off those differences.
I'll share a personal experience that I think will kind of shed some light on differences.
I'm Native American, Lumbee Indian from Pembroke, North Carolina, which is a very small rural farming community in Robeson County which is I think it is the largest county in the state. It's the poorest county in the state, and it's one of the poorest counties in the nation. My grandmother who was Lumbee Native American suffered from heart problems. And she refused to go to a doctor unless she knew this doctor specifically, and by that, I mean knew this doctor's parents.
We had another physician who was there, but he didn't identify as Indian or a person of color, and she would never go see this physician. And I asked her "Well, why did you start seeing your physician, but you never wanted to go see, you know, doctor so and so?"
"It's because I knew this one's mom and dad. I knew he was raised in the community; I knew that he was brought up in the church that I attended ever since I was a little girl. So, I know I can trust him, and I can trust my life with him, because when I go see a doctor, I'm kind of putting my life in their hands."
So that trust is very important between patient and provider. As time has progressed, I think the relationship between patient and provider has shifted. Decades ago, the provider played a role that was more authoritative. They gave direction, the patient listened, the patient followed suit. That is completely shifted now because people are a whole lot more informed, and we just have more connectivity to data. We have Web MD now, we have Mayo Clinic. So, when patients are more informed, the provider now is going to act as a facilitator in the conversation.
But the trust is still vital between that relationship. Even though it has shifted, trust still has to be there, because patients still want to be able to trust their provider. And if the patient can't trust them, they might feel attacked, they might feel disadvantaged, and they may forgo seeking care. And if they forgo seeking care, they're more prone to adverse health outcomes, they're more prone to more acute episodes, which we want to prevent.
As I had said a little bit earlier, cultural competency, patient centered-ness, and this value approach that we have in healthcare now, ensures that we are moving beyond this more acute level to where we're helping address more upstream impacts of patients.
Gaining perspective to implement culturally competent care
What barriers do patients of color face, both on an individual and policy level when it comes to accessing care? How might these barriers different in urban vs. rural areas?
I think it's important when a provider is coming into a community that they seek information about the historical context of a community, the historical context of the people. Going back to my example in Robeson County, which is majority Native Americans, it's important that these providers are educated on the historical context of the people in which they serve. They have to be aware that some historical injustices that's been placed on people of color put them at certain disadvantages. And that it's going to be more difficult for them to get over, versus when they haven't had to go through these historical injustices.
These historical injustices, such as enslaving African Americans or forcing relocations of Native Americans from their original lands, should be acknowledged, and understood. I think people should be open to the fact that families went through these events and things have passed on from generation to generation. They must understand that there's more hurdles to jump through for people of color to get where they want to be with their healthcare. And now that people are more informed, physicians should be open minded to putting the patient at the center of their care and engaging them in their care. What is the patient's goals? What are your goals of care? What are your goals for treatment? And then align the treatment regimen with the patient's goals.
I'll give you another example. My dad has diabetes, and he went to see one physician. His A1C was very high, and this physician was completely adamant about him starting insulin and completely changing the way he ate. That cannot be done cold turkey. That takes a behavior change. I stepped in and said "Let's get him linked up with a diabetes educator that understands how he was raised. He was raised on a farm; they ate three large meals a day. They had dessert every single time after a meal. It was just customary. Sundays were the times he would spend as a family going around and eating little sweets and having coffee with people who came and visited. This was part of the culture; this was what he was used to. You can't just lay that down, quit it and completely change.
What needs to be done like in the case of diabetes, is physicians link patients to a diabetes educator who can help get them situated on what behavior needs to take place so that they can get to a goal where they reduce their A1C and they're comfortable with their insulin and they're comfortable with their blood glucose levels.
Improve outcomes with patient-centric behaviors
What research/evidence is there that cultural competency improves outcomes?
There are successful examples of efforts to address cultural competency, such as providing interpreter services to overcome a language barrier or providing health educational services to patients to overcome barriers of health literacy, which is also very important for cultural competence. Motivational interviewing, patient navigators, and care managers can ensure continuity of care and linking patients to resources after acute episodes of care are also very important efforts that have been shown to close disparities and gaps in care.
Another specific example of improved outcomes is the development and implementation of AHRQ's Re-Engineered Discharge (RED) Toolkit. It's a 12-component resource which ensures discharge readiness from acute savings to prevent subsequent outcomes like readmissions. The person who is getting ready to discharge the patient must assess that this patient's actually ready for discharge. Such as, is there a follow up appointment needed, and is that scheduled? What other resources are needed when you leave this setting? What other resources do you need? Are you able to get your medications? Are you able to afford transportation from wherever you're going back to this health appointment?
Studies show that when a patient is discharged from a hospital setting and there's a follow up appointment scheduled and that patient actually arrives at that follow up appointment, the risk of a subsequent acute care readmission drops by 40 percent. It's important that their follow-up care is there, and they actually follow through with that care. Building that into the discharge readiness is important. This is a very good example of how health systems in general can prepare to prevent subsequent outcomes like readmissions.
The RED Toolkit will have future adaptations created for many different people of color, people of different ethnicities, sexual orientation, etc. AHRQ has some very good toolkits that can be adapted to different, diverse populations.
Establishing discharge readiness
What are the challenges to achieving cultural competency across specialties such as psychiatry and OB/GYN? What impact does the shortage of mental health providers who identify as people of color have on patient experience, outcomes, and access?
Coming from a healthcare system that used discharge readiness, there was a process around it. Processes vary from system to system. I do think there should be a more standardized approach to it and culturally competent care should be built into that discharge readiness toolkit to ensure that every person we talk to, we are asking them questions that align to that particular person's background and health literacy. This makes sure that we are hitting the marks on that particular patient.
Understand patient goals
What are some other actions that can be taken to address cultural competency?
We want to make sure that patients understand what is needed of them after they're leaving the hospital, we want to make sure they understand their treatment regimen, their treatment care, their treatment plan, and process. We should assess what their goals are and align that treatment plan with their goals. Providers can invite them to take part in their care, not just give directions, so they're completely engaged. We also need to define what the resources are and what they need, because when they leave our facilities, they're going back to a home or some other setting in the community that we no longer are in control of, and we need to understand what the gaps are there.
We need to be able to link them with resources to close those gaps. I think that's where care managers or patient navigators can come in. We can assign a patient to those care managers to help close those gaps and assign navigators to help the patient better navigate healthcare systems.
Stigmas around care
How can providers create a culturally competent approach to care without relying on stereotypical thinking? What role does a patient-centered approach rooted in cultural humility have in achieving this? What role does patient choice play (for example, patients deciding on therapy vs. digital care)?
Stigma is definitely more profound in rural areas I think, given that rural areas are small, and everyone knows everyone. I'm from a town where we know everyone—the people down the road, the people across the road, the people across the river. And we go to church and school with everyone. In rural places, the service area is smaller and if everyone knows everyone and you're seeking care for mental health, you're going to be afraid that so-and-so will know about it and pass it on. After a while the whole town or the whole community is going to know. So that stigma is a challenge to achieving cultural competency in mental health settings.
The shortage of mental health providers who identify as people of color can have a major impact on the care that's being offered. Since there is a stigma around mental health, the idea of trust is very important. I think with mental health we must talk about community engagement. One example, especially in rural areas, is that lots of people are usually religious, they're more faith-based, which means a lot of people put faith and trust in pastors. A lot of pastors in rural areas will sit down and have a conversation with patients who might have mental issues or need marriage counseling and similar services. I think in terms of cultural competency and bridging the gap, mental health access is where you really rely on community engagement. This means leveraging faith-based organizations and pulling in the help of pastors to provide some social network around mental health.
At least they have a person they can vent to and trust that it stays anonymous with them. If a mental health patient can connect with someone on a more personal level, it can begin to break down these barriers and allow for a healthier, more purposeful relationship between the patient and the person they're confiding in. I think that's a point of where we can leverage community engagement to be able to break down that stigma of being afraid to share and not trusting the person you're venting to.
Telehealth in mental health service delivery
What are effective ways to train providers in cultural competency, going beyond webinars that providers may just click through? How can a health system/provider group train staff in cultural competency in the way that it is meaningful and has an impact on care?
Telehealth can help. Where I'm from there are spots where there is no internet connectivity. Since the Covid-19 pandemic, a lot of things have transitioned and now we are more open to telehealth and to having conversations via Zoom or video call. I do think there is opportunity to leverage telehealth with mental health services, especially in places where we don't have mental health providers.
However, for it to be culturally competent, that provider should be trained in methods like motivational interviewing where they approach the interaction open-minded and listening. They let the patient lead the discussion and then facilitate and give basic alternatives of what should be done: “Here's the advantage and disadvantage of this and this is what I think might be helpful and aligning that to your wants and needs."
Examples of successful efforts of cultural competency
What are some examples of successful efforts to address cultural competency in the health care setting? Are they being replicated? What is driving these efforts and what challenges lie ahead?
The NQF, National Quality Forum, has this framework around how to integrate cultural competency and what kind of measures around culturally competent care there should be, such as built-in tools to start collecting data and information around race and ethnicity. There are some organizations that are behind collecting that kind of data, but I think one of the first steps in reporting on cultural competency is highlighting where there are these disparities, where there are these gaps. And once we know where these gaps are and where these populations- or who these populations are that have the gaps, once we can define and quantify those, then we can begin to close and mitigate that.
It's important that organizations mirror the populations in which they serve. The more diverse a population is, the more diverse an organization should be, because you do not want a very diverse population but a very homogenous group of providers providing care. To get around that, you must put more emphasis on culturally competent care. You need to understand what this diverse population looks like by collecting data around quality outcomes and stratifying it, so providers understand what they're up against, what gap they need to close, and the populations in which they need to target and spend more time and resources on.
Data collection shines light on health inequities
Are there any specific outcomes you would mention where collecting the data has really shone a light on these disparities? When it comes to cultural competency, what types of patient-centered metrics, process measures and outcome measures should health systems/provider/hospital groups be tracking/following for their own internal cultural competency work? What about patient care metrics?
It's important that we stratify data by geography, by region-colored maps or heat maps of outcomes by geography or region so that we can see what areas need more targeted interventions. And remember, geography can vary. You can have a county level and a ZIP code level, and there's lots of variation in both. I think it needs to be more granular where you get down to Census tract, which is more of a community level. Reporting outcomes by community level and mapping it out at the community level to kind of see and understand, “Here's where there's a gap, here's where we need to spend a little bit more time." That can be very helpful for healthcare systems to identify that where we need to spend a little bit more time.
We know that there's evidence suggesting that where you grow up has an impact on your health. Health systems should be collecting this data and reporting to their leaders on this. If we want to get to a point where healthcare is more equitable for all populations, we must collect the data and report on it, because if we don't, we're not acknowledging that it exists. And once we collect and report, add on to it. See where we can close and how we mitigate and where is those opportunities to mitigate those gaps are.
Serve patients objectively
What lessons did vaccine outreach efforts have in understanding/addressing culturally sensitive approaches to health care?
The Covid-19 pandemic was a testament to the challenges within the healthcare system as a whole and the challenges that healthcare leaders and experts, including providers and even scientists like myself, face regarding providing equitable care and culturally competent care. There was a big backlash to vaccine uptake. Even amid scientific evidence, methodologically sound and rigorous evidence that was promising and showed there's protective benefits against severe outcomes, like hospitalizations and even mortality if you receive vaccines from Pfizer or Moderna or Johnson & Johnson. There was just severe backlash against the vaccine uptake, even among some medical providers.
Some of the backlash is rooted in political differences, political views, political opinions. Also religious beliefs. And a lack of trust in science. The pandemic brought science and the practice of epidemiology to the spotlight. And living in a more connected world where there's countless outlets for people to voice and share their opinions just created this huge waterfall of opinions that sometimes overshadowed experts and evidence-based information that is not opinionated or subjective.
I compare it the flu that started off as a pandemic in 1918. The difference between that pandemic versus the Covid-19 pandemic is we did not have the internet; we didn't have social media. I couldn't read an experience from someone who was in a whole other state or country and then, by reading that experience, completely say "Well, I'm going have a negative outlook on it as well." They had to completely rely on experts.
Nurture medical trust with culturally competent care
It really did show that there's a lack of trust. That people have a lack of trust in the government, people have a lack of trust in who the government appoints for crisis management, for the Covid-19 taskforce. Lack of trust in science and research, even though the practice of medicine is based off science and research.
I don't know of a lot of scientists that are Lumbee Indian from Robeson County area. And me being one if not the only epidemiologist from the area, I also wanted to share my take on it being an expert in the field. And I received backlash as well. There were some people who received it very well and decided to get the vaccine. But then there are some who had backlash against it for political or religious reasons.
It's important that we get to a point where we are giving patients the evidence-based, correct, accurate and credible information they need to make an educated decision. We don't want people to make decisions from inaccurate information. We want to arm them with credible evidence-based information so that they can make their own best educated decision on how they want to move forward with things. That's what I try to do as a scientist, and I think that's also what should be done in that patient-provider relationship.
Patient satisfaction and quality outcomes
It's also very important that providers listen to the patient's concerns and goals. I think the patient should share their goals of care and where they see themselves and their process of care. Then the provider as a facilitator says "Okay, this is what can be done. This is the advantages and disadvantages of doing this versus this, and I think that this might be the best thing to align with what you've shared as being your goals." Then deciding together of how to move forward with the best treatment plan. That's how I see a more culturally competent patient-provider relationship.
Role community leaders play in healthy citizens
In terms of training providers in cultural competency what do you think really resonates with people? Have you seen any examples of like training or webinars that work well?
What I've seen back home is that the tribe leader, who is essentially the chief of the tribe, would share information to these larger healthcare systems about the culture of the Lumbee so that these newer physicians coming into the community learn a little bit more about who the Lumbee Indians are. This means the culture of who they are, how they live and how they eat. When they go into these relationships one on one, they're more informed. They're more sensitive to people's culture and to their values and their beliefs.
In that particular example, when the tribal leader would go to these conferences or meetings and present to the providers, they would share historically the context of our religious belief. Lots of us are Methodist and that feeds into our outlook on life in general. They also shared a lot of context around our culture, meaning the kinds of foods that we eat, how we prepare foods. Lumbee Indians are big on farming. Farming is a huge part of the culture, so they touched on how we get food, where we get the food from and how we prepare it.
How children are raised and where children and the social environment around the child is also very important. We are big on raising children in the community type where you let the community help raise the child. If you see this child acting up somewhere else, you have my permission to discipline the child. It's those types of things are important for providers to know.
Serving diverse populations with culturally competent care
If possible, should BIPOC patients see BIPOC providers? Why or why not? What do you think about efforts such as HUED?
I think people of color might feel more comfortable seeing providers who identify as people of color. But I don't think the labor of care should be segregated. That's where cultural competency comes in to ensure that providers of any racial or ethnic background can provide quality care to patients from any racial or ethnic background.
One of the resources, HUED, links Blacks or people of color to providers of color. It's a good resource for patients who want to receive care from people who identify like themselves. However, from a system perspective, I think we need to get beyond that segregated look and get to a point where it doesn't matter your racial or ethnic background, we just want to provide good quality care.
And that's not after they begin practicing. It should be initiated in medical school, I think it should be built into the curriculum. At a broad level, here's how we should be culturally competent as providers. And then when they get to wherever they're going to practice, like part of the residency, they understand the population of the patient. Sitting down to see the breakdown of the patient population which they're serving helps them situate the kind of people that they will be serving. And they are more open minded and adept to handle that going into practicing.
Defining health disparities
What is a health disparity?
AHRQ has a definition of disparity which is a 10 percent unit difference between two groups that you're comparing. For example, if I'm comparing Black African Americans to white Caucasians, if there's a 10 percent unit difference or relative difference between those two groups that can be defined as a disparity. You can adapt that definition of a disparity by applying it to whatever outcomes you are reporting to show that if there is a disparity that exists in outcomes such as like readmissions or mortality.
Balancing ownership of patient care
We must make sure that providers are aware of that shift and change from being more authoritative now to a facilitator. Them acknowledging that that shift has occurred and how that relationship now exists between patient and provider and what it means now I think is very important. We must be able to regain that trust or to get the trust from the patient. Because if the patient cannot trust the system or the patient can't trust the provider, they're going completely forgo seeking care. So that's a very vital, important aspect, is getting the trust of the patient and keeping that trust.