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OCR for page 180
Interventions: Systemic Strategies
The preceding analysis of sources of racial and ethnic disparities in
healthcare reveals that many participants including patients, their pro-
viders, utilization managers, and health system administrators make
decisions on a daily basis that contribute to gaps in care. These individu-
als operate within many contexts, including clinical care settings and
health system settings that set policies for access to and utilization of ser-
vices, and at a larger level, are affected by laws and policies regulating the
healthcare industry. Given the role of patient, provider, and contextual
factors in shaping the quality of patient care, systemic interventions di-
rected at multiple levels offer promise to modify conditions in which
healthcare disparities occur.
Systemic interventions to improve healthcare delivery for diverse
populations include organizational accommodations that may promote
equity in healthcare, policies that reduce administrative and linguistic
barriers to care, and practices that enhance patients' knowledge of and
roles as active participants in the care process. These efforts are likely to
be most effective when applied in a systematic, simultaneous, multi-level,
coordinated fashion, and follow a well-developed strategic plan that has
support and "buy-in" from all actors involved in healthcare, including
patients, their families, and the communities in which they live; clinicians;
administrative staff; and health systems leadership. Systemic interven-
tions also include changes to healthcare law and policy that promote
equality of healthcare delivery.
There are many reasons why health systems may choose to adopt
comprehensive strategies to eliminate racial and ethnic disparities in
180
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INTERVENTIONS: SYSTEMIC STRATEGIES
181
healthcare. First, they may react to comply with growing state and fed-
eral guidelines that encourage, and in some cases, mandate greater re-
sponsiveness on the part of health systems to the growing diversity of the
U.S. population (Brach and Fraser, 2000~. Second, they may view such
strategies as integral to help achieve the U.S. Department of Health and
Human Services' goal of eliminating racial and ethnic disparities in health
(U.S. DHHS, 2000~. Third, health systems may find that developing and
implementing culturally competent systems of care are consistent with
the "business case" of increasing market share among racial and ethnic
minority populations (Brach and Fraser, 2000~. Increasingly, health plan
purchasers are also finding that health system responsiveness to the needs
of racial and ethnic minority patients makes good business sense. Given
that over 2 of every 5 new workers is a racial or ethnic minority, many
employers find that health plan efforts to improve services for these popu-
lations and narrow the healthcare gap can attract better workers and in-
crease employee productivity (Washington Business Group on Health,
2001~.
Many of these system-wide intervention objectives are reflected in
the culturally and linguistically appropriate services standards (CLAS)
for healthcare issued by the U.S. DHHS Office of Minority Health (OMH)
in December 2000 (U.S. DHHS, 2000~. These standards, which are listed
in Box 5-1, are primarily directed at healthcare organizations, but OMH
encourages individual providers to familiarize themselves with the stan-
dards and incorporate them into their practices.
Further, while the standards are intended to help improve care for
racial and ethnic minority populations, by implication they suggest that
greater attention to the importance of culture and language in healthcare
settings will improve the quality of care for all populations. Noting that
culture and language define how healthcare information is given and re-
ceived and shape the expression and understanding of health and illness,
the agency states that "healthcare is a cultural construct, arising from be-
liefs about the nature of disease and the human body," and that "cultural
issues are . . . central in the delivery of health services treatment and pre-
ventive interventions" (U.S. DHHS, 2000, p. 80863~.
A significant evidence base has accumulated for many aspects of
health systems-level interventions that may improve the quality of care
for minority patients. The remainder of this chapter explores several such
strategies.
LEGAL, REGULATORY, AND POLICY INTERVENTIONS
As noted in Chapter 3, institutional design and legal and regulatory
governance will not eliminate racial and ethnic disparities in healthcare,
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UNEQUAL TREATMENT
but institutions and law make a large difference, in that they exert a broad
influence over the kinds of conditions that may foster healthcare dispari-
ties. In this section, the committee suggests how healthcare institutions,
legislators, and regulators might respond pragmatically to the problem of
racial and ethnic disparity even as they pursue other important policy
goals.
"De-Fragmentation" of Healthcare Financing and Delivery
Many of the studies cited earlier in this report have not taken detailed
account of variations among health plans, and therefore the dispropor-
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INTERVENTIONS: SYSTEMIC STRATEGIES
183
tionate presence of members of disadvantaged minority groups in lower-
end health plans may be a major source of disparities in healthcare provi-
sion. As noted in Chapter 2, some racial and ethnic minorities are dispro-
portionately represented in publicly financed health insurance programs
(Phillips et al., 2000~. And even within a broad federal program such as
Medicare, for example, tiers of health systems exist (e.g., more than 60%
of Medicare beneficiaries possess supplemental coverage), with minori-
ties typically congregated at lower levels. Further, as noted in Chapter 3,
low per capita resources associated with lower-end plans may result in
differences in the intensity of care between lower and higher end health
plans. Studies consistently demonstrate an association between insur-
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84
UNEQUAL TREATMENT
ance status and use of healthcare resources. For example, patients seen in
emergency departments following head injury are more likely to be ad-
mitted to the hospital and have a longer length of stay if they are privately
insured, rather than publicly insured or uninsured (Svenson and Spurlock,
2001), and Medicare patients without supplemental coverage are approxi-
mately 10% less likely to have influenza vaccination, cholesterol testing,
mammography, or Pap smears than those with supplemental coverage
(Carrasquillo, Lantigua, and Shea, 2001~. Fragmentation also engenders
different clinical cultures, with different practice norms, tied to varying
per capita resource constraints. The relationship between racial and eth-
nic maldistribution in tiered health plans, differences in the intensity and
the quality of care provided by these plans, and clinical outcomes should
be a national research priority (see Chapter 8~. Until such research is con-
ducted, it is reasonable to surmise that efforts to reduce the socioeconomic
segmentation of the medical marketplace would help to diminish racial
and ethnic disparities in healthcare provision (Bloche, 2001~.
Equalizing access to high-quality plans can limit fragmentation. Pub-
lic healthcare payors such as Medicaid should strive to help beneficiaries
access the same health products as privately insured patients. This rec-
ommendation is reflected in the IOM Crossing the Quality Chasm report's
strategies for focusing health systems on quality, in its call to "eliminate
or modify payment practices that fragment the care system" (IOM, 2001a,
p. 13~. Expanding access for publicly funded beneficiaries to high-quality
health plans will be expensive. Rising healthcare costs, however, threaten
to increase the likelihood of fragmentation, and subsequently threaten to
increase the racial and ethnic gap in healthcare.
Recommendation 5-1: Avoid fragmentation of health plans along
· · ~
socloeconomlc 1nes.
Medical care financing arrangements should discourage fragmen-
tation of healthcare provision into separate tiers of providers who
adhere to different standards of care and disproportionately serve
separate racial and ethnic minority segments of American society.
Medicaid and other government programs that mandate enrollment
of beneficiaries in managed care should be prepared to pay plans at
rates that give Medicaid enrollees access to the same health plan
products serving substantial proportions of privately insured pa-
tients.
Strengthening Doctor-Patient Relationships
Several lines of research suggest that the consistency and stability of
the doctor-patient relationship is an important determinant of patient sat-
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INTERVENTIONS: SYSTEMIC STRATEGIES
185
isfaction and access to care. Having a usual source of care is associated,
for example, with use of preventive care services. In addition, having a
consistent relationship with a primary care provider may help to address
minority patient mistrust of healthcare systems and providers, particu-
larly if the relationship is with a provider who is able to bridge cultural
and linguistic gaps (LaViest, Nickerson, and Bowie, 2000~. Further, as
noted in Chapter 3, several lines of evidence suggest that a patient's ac-
cess to clinical resources within a hospital or health plan may partly re-
flect his or her doctor's stature, skill, and commitment as an advocate.
This suggests that minority patients may benefit from stronger bonds with
physicians who understand the cultural and linguistic barriers to care
faced by many minority patients navigating through health systems, and
who are positioned and willing to play the advocate's role vigorously.
Health systems should attempt to ensure that every patient, whether in-
sured privately or publicly, through Medicare or Medicaid, has a sus-
tained relationship with an attending physician able to help patients navi-
gate the healthcare bureaucracy effectively (e.g., to help patients obtain
referral and secure appropriate specialty care). This is not meant to imply
that physicians should navigate health systems for their patients; rather,
it is an acknowledgement that primary care providers sometimes wield
great influence and leverage in helping their patients to access specialty
care, clinical trials, and other healthcare resources.
Several strategies can help to promote the stability of patient and pro-
vider relationships in publicly funded health plans. Federal and state
performance standards for Medicaid-managed care plans, for example,
should include guidelines for the stability of patients' assignments to pri-
mary care providers and these providers' accessibility. These guidelines
should also encourage reasonable patient loads per primary physician and
time allotments for patient visits. Regulations governing health plans'
participation in Medicare should include similar guidelines, as should
private accrediting bodies' prerequisites for all health plans (Bloche, 2001~.
Recommendation 5-2: Strengthen the stability of patient-provider
relationships in publicly funded health plans.
Policies that strengthen provider-patient relationships in publicly
funded health plans and that promote the consistency of these rela-
tionships should be adopted. These include guidelines for:
· the stability of patients' assignments to primary care providers
and these providers' accessibility;
· reasonable patient loads per primary physician; and
· reasonable time allowances for initial and follow-up patient vis-
its (and health providers' flexibility to take additional time when
needed to communicate adequately).
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UNEQUAL TREATMENT
Strengthening patient and provider relationships will also benefit
from greater racial and ethnic diversity in the health professions. Racial
concordance of patient and provider is associated with greater patient
participation in care processes, higher patient satisfaction, and greater
adherence to treatment (Cooper-Patrick et al., 1999~. In addition, racial
and ethnic minority providers are more likely than their non-minority
colleagues to serve in minority and medically underserved communi-
ties (Komaromy et al., 1998b). Evidence of these benefits of diversity in
health professions fields weighs in favor of robust commitment to affir-
mative action in medical school admissions, residency recruitment, and
professional specialty training. This is not intended to suggest, how-
ever, that racial concordance of patients and providers should be en-
couraged as a matter of policy. Rather, it is expected that the benefits of
diversity in the health professions will accrue broadly, as this diversity
helps to expand the disciplines' ability to conceptualize and respond to
the health needs of increasingly culturally and linguistically diverse
populations.
Recommendation 5-3: Increase the proportion of underrepresented
U.S. racial and ethnic minorities among health professionals.
To the extent legally permissible, affirmative action and other ef-
forts are needed to increase the proportion of underrepresented U.S.
racial and ethnic minorities among health professionals.
Patient Protections
Much of the political focus on Capitol Hill in the summer of 2001 was
devoted to managed care regulation. To one extent or another, the vari-
ous bills debated all would extend protections to enrollees in private man-
aged care organizations, providing avenues for appeal of care denial deci-
sions, improving access to specialty and emergency department care, and
providing other legal remedies to resolve disputes. These bills were
crafted on the assumption that due process protections of patient choices
were necessary, despite a lack of empirical evidence that overall quality of
care is inferior in managed care plans relative to fee-for-service systems.
Extensive reviews of the literature do not establish whether the quality of
care provided within managed care plans is worse (or better) than other
health systems. However, there is some evidence that managed care may
provide better care for some patient populations. For example, results of
a review by Miller and Luff (1997) suggest a significantly better quality of
care for some subsets of managed care enrollees, such as patients in the
intensive care unit, elderly Medicare patients, and patients with acute
appendicitis or cancer.
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INTERVENTIONS: SYSTEMIC STRATEGIES
187
As discussed in Chapter 3, however, there are reasons and empirical
evidence to be concerned about how financial incentives and decision-
making within managed health plans may differentially affect racial and
ethnic minority groups. Some evidence indicates that low-income and
ethnic minority patients enrolled in managed care plans are less likely to
have a regular provider than similar patients in fee-for-service plans
(Leigh, Lillie-Blanton, Martinez, and Collins, 1999), are more likely than
whites to be denied claims for emergency department visits (Lowe et al.,
2001), and are less satisfied with many aspects of the care they receive in
managed care settings (Phillips et al., 2000~. Other studies find that the
intensity of care is lower for some populations within managed care set-
tings relative to other care systems. Tai-Seale, LoSasso, Freund, and
Gerber (2001), for example, found that prenatal care use was lower among
women enrolled in Medicaid managed care systems relative to women in
fee-for-service systems.
Given that many minorities are disproportionately represented
among the publicly insured who receive care within managed care orga-
nizations, extending the same due process protections proposed in cur-
rent legislation may help to address these disparities. Other factors, how-
ever, may also justify extending the same protections, regardless of payor
source. Extending legal protections only to those enrolled in private man-
aged care plans raises concerns about the unequal application of law. As
Hashimoto (2001) writes, "The [current proposals'] emphasis on indi-
vidual choice, due process protections, and limiting its jurisdiction to pri-
vate health plans will result in an important regulation that largely ben-
efits the employed middle class . . . it is unfair to guarantee special legal
protections to members of private managed care plans while failing to
provide these same guarantees to members of publicly financed managed
care programs" (Hashimoto, 2001, pp. 83-84~.
Recommendation 5-4: Apply the same managed care protections to
publicly funded HMO enrollees that apply to private HMO enrollees.
Civil Rights Enforcement
The committee believes that education and training of healthcare pro-
viders, administrators, and consumers is an important first step as part of
a comprehensive, multi-level intervention strategy to address racial and
ethnic disparities in healthcare. Enforcement of regulation and statute is
also an important component of such a strategy, but unfortunately has
been too often relegated to low-priority status. The U.S. DHHS Office for
Civil Rights (OCR) is charged with enforcing several relevant federal stat-
utes and regulations that prohibit discrimination in healthcare (principally
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UNEQUAL TREATMENT
Title VI of the 1964 Civil Rights Act). The agency, however, has suffered
from insufficient resources to investigate complaints of possible violations,
and has long abandoned proactive, investigative strategies (Smith, 1999~.
Complaints to the agency have increased in recent years, while funding
has remained constant in actual dollars but has decreased in fiscal year
2000 to less than 60% of fiscal year 1981 funding, after adjusting for infla-
tion (U.S. Commission on Civil Rights, 2001~. This decrease in spending
power has severely and negatively affected OCR's ability to conduct civil
rights enforcement strategies, such as on-site complaint investigations,
compliance reviews, and local community outreach and education. The
agency should be equipped with sufficient resources to better address
these complaints. In addition, OCR should resume the practice of peri-
odic, proactive investigation, both to collect data on the extent of civil
rights violations and to provide a deterrent to would-be lawbreakers. As
will be discussed in Chapter 7, LaVeist and Gibbons (2001) suggest a two-
tiered strategy in which routine data collection and monitoring can be
used to identify health systems that display persistent disparities, fol-
lowed by field investigations possibly by trained, paired testers. While
audits of healthcare facilities are largely untested and methodologies must
be developed for fair and appropriate assessment of discrimination in
healthcare settings, such a strategy offers a promising "last line" of de-
fense against civil rights violations.
Recommendation 5-5: Provide greater resources to the U.S. DHHS
Office for Civil Rights to enforce civil rights laws.
Congress and the U.S. Department of Health and Human Services
should provide adequate funding to the U.S. DHHS Office for Civil
Rights to expand the agency's capabilities to address civil rights
complaints and carry out its oversight responsibilities.
HEALTH SYSTEMS INTERVENTIONS
Research suggests that a variety of interventions applied at the level
of health systems may be effective as a part of a comprehensive, multi-
level strategy to address racial and ethnic disparities in healthcare.
iPaired testing strategies, in which auditors of differing race, ethnicity, or gender are
matched for a variety of socioeconomic and personality characteristics, have been used suc-
cessfully to identify discrimination in housing, employment, and mortgage lending prac-
tices. This strategy is discussed in Chapter 2.
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INTERVENTIONS: SYSTEMIC STRATEGIES
Evidence-Based Cost Control
189
As discussed in Chapter 3, medical science has made tremendous ad-
vances that have transformed clinical practice. Many innovations are
available to healthcare providers, and the use of evidence-based practice
guidelines to improve and standardize care has increased. Despite these
developments, variations in practice patterns are still observed across geo-
graphic areas and types of healthcare institutions, and utilization manag-
ers still exert considerable discretion in making decisions regarding
healthcare resource allocation. To the extent possible, given the gaps in
knowledge about medical care's efficacy and the difficulty of anticipating
all clinical contingencies, clinical practice and utilization decisions should
be based on evidence-based guidelines. Such application of evidence to
healthcare delivery can help to address the problem of potential underuse
of services resulting from capitation or per case payment methods, as
noted in the IOM Quality Chasm report (IOM, 2001a). Practice guidelines
may be a useful tool in the effort to eliminate racial and ethnic disparities
in healthcare, given the advantages of guidelines over general, discretion-
ary standards including consistency, predictability, and at least the ap-
pearance of objectivity.
A pragmatic balance must be sought, however, between the advan-
tages and limitations of guidelines. The goal of standardized care must be
weighed against the need for clinical flexibility. One means to address this
balance disclosing health plans' clinical protocols would aid both pri-
vate sector and public efforts in balancing the virtues of rules and discre-
tion. Private accrediting entities and state regulatory bodies could require
that health plans' clinical practice protocols be published with supporting
evidence and thus open them to professional and consumer review.
Clinical guidelines that are not backed by evidence and argument
should not be entitled to deference in administrative or legal proceedings
that involve challenges to health plans' application of such guidelines.
But where guidelines do have empirical support, even if the evidence is at
best debatable, administrative and legal decision makers should give sub-
stantial weight to the social importance, in a racially and culturally di-
verse nation, of making allocative choices in a manner that achieves some
consistency in appearance and practice (Bloche, 2001~.
Recommendation 5-6: Promote the consistency and equity of care
through evidence-based guidelines.
To the extent possible, medical care allocative decisions should be
driven by evidence-based clinical guidelines to insure consistency
of care. These guidelines should be published, along with their
supporting evidence base, to allow public and professional scru-
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UNEQUAL TREATMENT
tiny, and used to examine the quality of care for racial and ethnic
· · ~
m~nor~hes.
Financial Incentives in Healthcare
As discussed in Chapter 3, financial factors, such as capitation and
plan incentives to providers to practice frugally, can pose greater barriers
to racial and ethnic minority patients than for whites, even among pa-
tients insured at the same level. Low payment rates inhibit the supply of
physician (and other healthcare provider) services to low-income groups,
disproportionately affecting ethnic minorities. Inadequate supply takes
the form of too few providers participating in plans serving the poor, and
provider unwillingness to spend adequate time with patients. In Chapter
4, the committee linked this time pressure to the underlying problem of
poor information exchange between physicians and members of minority
groups. Where employers have an interest in providing an attractive ben-
efit package, market forces protect middle and upper income groups
against health plans "going too far" in rationing care. These protections
are not available to all low-income groups, who must rely on balanced
public policy to induce adequate supply of care.
More finely crafted provider incentives can have a positive role in ef-
forts to reduce disparities in care. Greater economic rewards for time spent
engaging patients and their families can contribute to overcoming barriers
of culture, communication, and empathy. Payment schemes that reward
providers for high scores on measures of patient satisfaction would further
encourage the bridging of barriers related to racial and ethnic difference.
Incentives to adhere to evidence-based protocols for frugal practice and to
engage in age- and gender-appropriate disease screening would generally
encourage efficient, quality care and penalize deviations regardless of race
or ethnicity. Further, payment linked to favorable clinical outcomes, where
reasonably measurable (e.g. control of diabetes, asthma, and high blood
pressure), would provide additional such encouragement. Industry move-
ment toward more nuanced incentive schemes along these lines could be
catalyzed by private accrediting bodies, encouraged by business and pro-
fessional leaders, and even initiated by public payers. Again, this recom-
mendation is consistent with the IOM Quality Chasm report, which called
for healthcare organizations, clinicians, purchasers, and other stakeholders
to "align the incentives inherent in payment and accountability Processes
with the goal of quality improvement" (IOM, 2001a, p. 10~.
J 1
Recommendation 5-7: Structure payment systems to enhance avail-
able services to minority patients, and limit provider incentives that
may promote disparities.
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INTERVENTIONS: SYSTEMIC STRATEGIES
191
Payment systems to providers should ensure an adequate supply of
services to racial and ethnic minority patients. Financial incentives
to restrict care and pass liability to providers should be limited, to
reduce conditions in which racial and ethnic stereotypes and biases
may be exacerbated or reinforced.
Recommendation 5-8: Enhance patient-provider communication
and trust by providing financial incentives for practices that reduce
barriers and encourage evidence-based practice.
Economic incentives should be considered for practices that en-
hance provider-patient communication and trust, and that reward
appropriate screening, preventive, and evidence-based clinical care.
Interpretation Services
As noted in Chapter 2, nearly 14 million Americans are not proficient
in English. In 1995, the Commonwealth Fund estimated that language
differences are problematic for 21% of racial and ethnic minority group
members who receive healthcare (Commonwealth, 1995~. This percent-
age is almost certainly higher today given recent increases in immigration
to the U.S. from many parts of the world. Language barriers may affect
the delivery of adequate care through poor exchange of information, loss
of important cultural information, misunderstanding of physician instruc-
tion, poor shared decision-making, and ethical compromises, such as dif-
ficulty obtaining informed consent (Woloshin et al., 1995~. In addition,
low English reading proficiency may disproportionately and negatively
affect many racial and ethnic minority patients' ability to read and under-
stand written material from health plans and healthcare providers if ap-
propriate translation is not provided. As discussed in Chapter 3, there is
significant evidence that language affects variables such as follow-up com-
pliance and satisfaction with services (Carrasquillo et al., 1999~. Linguis-
tic difficulties may present a barrier to the use of healthcare services
(Derose and Baker, 2000), decrease adherence with medication regimes
and appointment attendance (Manson, 1988), and decrease satisfaction
with services (Carrasquillo et al., 1999; David and Rhee, 1998~. For ex-
ample, a recent survey of Spanish-speaking Latinos and English speakers
of varying ethnicities who used emergency department services found
that among patients who reported at least one physician visit in the previ-
ous three months, Latinos with fair or poor English proficiency reported
22% fewer visits than English-speaking non-Latinos, after controlling for
reason for the visit (Derose and Baker, 2000~. These associations were
similar for patients in poor health, those with no usual source of care, and
those without insurance. Other investigators have found independent
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UNEQUAL TREATMENT
effects of language concordance on health outcomes, such that having a
physician who spoke Spanish resulted in higher ratings of physical and
psychological well being, higher health perceptions, and lower percep-
tions of pain (Perez-Stable, Napoles-Springer, and Miramontes, 1997~.
A few studies examining the effectiveness of interpretation services
have been conducted, with mixed results. Although mostly uncontrolled,
some studies suggest that the use of interpreters for patients with limited
English skills results in greater satisfaction (as compared to patients who
said an interpreter should have been used; Baker, Hayes, and Fortier, 1998)
and better medical outcomes (Tocher and Larson, 1998~. However, in the
investigation by Baker and colleagues (1998), while patients who used
interpretation services rated their care as better than patients who would
have liked services and did not receive them, they still rated their pro-
vider as less friendly, less respectful, less concerned, and felt less comfort-
able than patients who did not need an interpreter. These results suggest
that interpretation services are necessary, but that both interpreters and
providers should be aware that the mere availability of the service may
not be adequate to improve satisfaction and outcomes. It has also been
suggested that the use of remote language services, in which the inter-
preter is not physically in the room, may be preferable (for both patients
and providers) to in-person interpretation services (Hornberger et al.,
1996~. While outcomes are somewhat variable, it is generally agreed that
professional interpreters are necessary for many patients and that the use
of family members, minors, or friends should be avoided as it may repre-
sent a breach of confidentiality, inhibit the patient from fully express-
ing symptoms or difficulties, or lead to errors in transmitting medical
information.
The importance of interpretation services is underscored in guide-
lines offered by the Office for Civil Rights of the Department of Health
and Human Services (U.S. DHHS) to prevent discrimination against lim-
ited-English proficient persons (U.S. DHHS, 2000~. These guidelines per-
tain to any entity that receives direct or indirect financial assistance from
HHS. Four key elements for compliance with the guidelines include: an
assessment of the needs of the population; comprehensive written poli-
cies on language access (including hiring of bilingual staff and interpret-
ers, arranging for telephone interpreters); training of staff; and monitor-
ing of programs to ensure people with limited English proficiency are
adequately served. Further, if the covered entity/agency suggests, re-
quires, or encourages the use family members, minors, or friends as inter-
preters, it may expose them to liability under Title VI. Similarly, as noted
above, the Office of Minority Health's national standards on culturally
and linguistically appropriate services (CLAS) in healthcare also empha-
size the importance of language access services.
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INTERVENTIONS: SYSTEMIC STRATEGIES
193
An important issue for future consideration is the establishment of
minimum standards for training of translators and interpreters. Signifi-
cantly, the U.S. DHHS and some accreditation bodies are beginning to
assess the feasibility of establishing minimum standards for interpreters
and interpretation services. Selected federal laws and regulations, such
as the Disadvantaged Minority Health Improvement Act, require the de-
velopment of interpreter programs to increase the access of limited En-
glish proficient individuals to healthcare services. In addition, associa-
tions such as the Massachusetts Medical Interpreter Association (MMIA)
in conjunction with Education Development Center, Inc., have published
standards of practice focused on areas of interpretation, cultural interface,
and ethical behavior. The recently established National Council on Inter-
pretation in Healthcare has charged its Standards, Training and Certifica-
tion (STC) Committee to draft standards, recommendations and infor-
mational materials concerning the interpreter role and performance as
well as interpreter services and programs of interpreter education and
assessment. Similarly, the California Healthcare Interpreters Association
(CHIA) has recently released draft standards of ethical principles, proto-
cols, and guidance for healthcare interpreters within the state.
Finding 5-1: As a result of the increasing linguistic diversity in the
United States, professional interpretation services are increasingly
needed to assist low-English proficient racial and ethnic minority
patients in healthcare settings.
Recommendation 5-9: Support the use of interpretation services
where community need exists.
Professional interpretation services should be the standard where
language discordance poses a barrier to care. Greater resources
should be made available by payers to provide coverage for inter-
pretation services for limited-English proficient patients and their
families. Future research should identify best practices where the
availability of interpretation services is limited.
Community Health Workers
Community health workers have been acknowledged participants in
healthcare systems since the 1960s (Witmer et al., 1995~. These individu-
als, often termed lay health advisors, neighborhood workers, indigenous
health workers, health aids, consejera, or promotora, fulfill multiple func-
tions in helping to improve health outcomes. They have been defined as
being "community members who work almost exclusively in community
settings and who serve as connectors between healthcare consumers and
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UNEQUAL TREATMENT
providers to promote health among groups that have traditionally lacked
access to adequate care" (Witmer et al., 1995~. The training of lay health
workers varies and typically depends on the nature of services they will
provide. Generally, the length of training varies from a few weeks to six
months and includes lectures and supervised practical/field experiences
(for review see Jackson and Parks, 1997; Witmer et al., 1995~. One of the
greatest assets of lay health programs is that they build on the strengths of
community ties to help improve outcomes for its citizens.
In addition to increasing access to services, some evidence suggests
that lay health workers can help improve the quality of care and reduce
costs (Witmer et al., 1995~. Lay workers can facilitate community par-
ticipation in the health system, serve as liaisons between patients and
providers, educate providers about community needs and the culture of
the community, provide patient education, promote consumer advocacy
and protection, contribute to continuity and coordination of care, assist
in appointment attendance and adherence to medication regimens, and
help to increase the use of preventive and primary care services (Brown-
stein et al., 1992; Earp and Flax, 1999; Jackson and Parks, 1997~. Pro-
grams that utilize lay health workers have sought to improve healthcare
delivery for a variety of conditions including stroke and hypertension
(Richter et al., 1974), breast and cervical cancer screening (Brownstein et
al., 1992; Dignan et al., 1998; Earp and Flax, 1999), and the use of prena-
tal services (Meister et al., 1992~. Lay health workers have also been
used to address broader issues such as improving healthcare organiza-
tions' ability to identify needs of the community (Baker et al., 1997) and
improve general wellness through informing community members
about resources and facilitating their access to and negotiation through
services (Rodney et al., 1998~.
During its inception, the concept of using lay health workers included
collaborations between lay health workers and public health departments,
homeless programs, and community health centers (Richter et al., 1974~.
More recently, partnerships have been formed with academic medical cen-
ters (see for example, Levine et al., 1994~. This movement has been ac-
companied by increased efforts to evaluate the effectiveness of lay work-
ers in improving patient satisfaction and increased use of services. Results
indicate that use of lay health workers can increase awareness of and
screening for breast cancer (Bird et al., 1998; Navarro et al., 1998; Slater et
al., 1998) and cervical cancer (Bird et al., 1998; Dignan et al., 1998; Navarro
et al., 1998~. For example, among a population of Vietnamese-American
women in California, the use of lay health workers significantly increased
women's awareness of and utilization of Pap smear and mammography
(Bird et al., 1998~. The use of lay health workers in a diabetes education
program improved completion, regardless of financial status or language
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195
spoken, over conducting the education program without lay health work-
ers (Corkery et al., 1997~. However, the health workers did not have a
significant effect on diabetes knowledge, self-care behavior, or glycemic
control, although the small sample size (n = 64) may have limited the
investigators' ability to find statistically significant relationships with
these outcomes.
In order for community health worker programs to be successful, they
must be designed properly and workers must be adequately trained and
supervised. Barriers to their effective use have included a lack of consis-
tent, widely accepted definition of who they are and what services they
can provide (e.g., scope of practice, qualifications), lack of consideration
by degreed health professionals for their services, and lack of consistent
funding for lay health programs (Witmer et al., 1995~. Some literature
provides guidance regarding the design of community health worker pro-
grams (Brownstein et al., 1992; Giblin, 1989; lackson and Parks, 1997; Rich-
ter et al., 1974; Witmer et al., 1995), but rigorous evaluations of specific
program components and their impact on service utilization are needed.
Finding 5-2: Community health workers offer promise as a commu-
nity-based resource to increase racial and ethnic minorities' access
to heathcare and to serve as a liaison between healthcare providers
and the communities they serve.
Recommendation 5-10: Support the use of community health workers.
Programs to support the use of community health workers (e.g., as
healthcare navigators), especially among medically underserved
and racial and ethnic minority populations, should be expanded,
evaluated, and replicated.
Multidisciplinary Teams
Research demonstrates that multidisciplinary team approaches uti-
lizing physicians, nurses, dietitians, and others have proven effective in
optimizing risk reduction strategies. This effect is found in randomized
controlled studies for patients with coronary heart disease (Multiple Risk
Factor Intervention Trial Research Group, 1982), hypertension (Hyperten-
sion Detection and Follow-up Program Cooperative Group, 1979), and
other diseases (SHEP Cooperative Research Group, 1991; Pedersen et al.,
1994; Treatment of Mild Hypertension Study Research Group, 1993), and
has extended to strategies for reducing risk behaviors such as smoking
and sedentary lifestyle and managing obesity (Hill and Miller, 1996~.
Multidisciplinary teams coordinate and streamline care, enhance patient
adherence through follow-up techniques, and address the multiple be-
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UNEQUAL TREATMENT
havioral and social risks that patients face, particularly racial and ethnic
minority patients. They may save costs and improve the efficiency of care
by reducing the need for face-to-face physician visits and improve pa-
tients' day-to-day care between visits. Further, such strategies have
proven effective in improving health outcomes of minorities previously
viewed as "difficult to serve" (Hill and Miller, 1996~. Multidisciplinary
team approaches should be more widely instituted as strategy for im-
proving care delivery, implementing secondary prevention strategies, and
enhancing risk reduction.
Recommendation 5-11: Implement multidisciplinary treatment and
preventive care teams.
Multidisciplinary teams offer promise as a means to improve and
streamline care for racial and ethnic minority patients, and there-
fore should be more widely implemented.
PATIENT EDUCATION AND EMPOWERMENT
Skill-building and training for providers of healthcare has been a tra-
ditional avenue for helping to improve outcomes (see for example Roter
and Hall, 1994; Roter et al., 1995; Williams and Deci, 2001), increase pa-
tient satisfaction with care (Roter et al., 1996), and decrease the incidence
of lawsuits (Levinson et al., 1997; Mock, 2001~. However, as issues of
improved patient-provider communication/relationship have moved to
the forefront, patient education, participation, activation, and empower-
ment have received more attention. Information that flows in both direc-
tions is deemed important for increasing patient cooperation, engagement,
and adherence to medical regimes (Korsch, 1994~.
Patient education has taken many forms including provision of books,
pamphlets, in-person instruction, CD-ROM, and Internet-based informa-
tion. Books such as that by Korsch and Harding (1998) help guide pa-
tients through typical office visits and provide information about asking
the right questions, communicating with the provider when instructions
are not understood or cannot be followed, and being an active participant
in decision making. The guide also helps patients understand the nature
of medical training and its impact on provider behavior. Other mediums
such as entertainment television (Cooper, Roter, and Langlieb, 2000) and
computer-based education programs (McRoy, Liu-Perez, and All, 1998)
have been initiated. In addition, private and academic institutions offer
information systems to assist patients in navigating healthcare systems.
For example the Bayer Institute has developed a program called PRE-
PARE, a six-step program using a self-administered audiotape and guide-
book to help patients prepare for office visits. Complementary materials
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197
were also developed for use by providers of healthcare to support and
encourage use of the program. In addition, some medical institutions,
such as the Ohio State University Medical Center and Cincinnati
Children's Hospital Center, have established Internet-based programs to
help answer patient questions about topics such as pain management,
medications, medical procedures, nutrition, and health promotion.
As patient education approaches become more widely used, efforts to
evaluate their effectiveness have increased, and have demonstrated posi-
tive results. In one of the earliest papers examining the beneficial effects
of patient education, Roter (1977) assessed the effects of a health educa-
tion intervention to increase patient question-asking during office visits.
In this study, which was conducted with an urban and predominantly
black population, patients were randomly assigned to intervention and
non-intervention groups. There were also two non-randomized control
groups. Results indicated that patients in the intervention group asked
more direct questions and fewer indirect questions than did non-inter-
vention group patients. However, within the intervention group, there
was more negative affect, anxiety, and anger in the patient-provider inter-
action, while in the placebo group, patient-provider interaction was char-
acterized as mutually sympathetic. In addition, the intervention group
patients were less satisfied with care received in the clinic on the day of
their visit than were placebo patients, but they demonstrated higher
appointment-keeping (accounting for average number of appointments
made) during a 4-month prospective monitoring period. These results
suggest that efforts directed at increasing patient activation must also tar-
get physician behavior and how providers receive and respond to pa-
tients' increased participation.
A recently developed CD-ROM reproductive health education pro-
gram for adolescents with diabetes has been evaluated for its effective-
ness in altering knowledge, attitudes, skills, and behaviors. Initial results
indicate that the use of the CD-ROM was associated with changes in
knowledge, attitudes, and beliefs over the use of a self-instruction packet
or standard care. Similarly, an individual education and coaching pro-
gram in pain self-management for cancer patients was demonstrated to
improve ratings of pain severity over patients who did not receive the
intervention. However, no changes were observed in functional impair-
ment resulting from pain, frequency of pain, or pain-related knowledge.
In a review article, Roter and colleagues (1998) summarized results of
153 studies evaluating the effectiveness of interventions to improve pa-
tient compliance. Many of these studies were patient education-based
and included strategies such as individual and group teaching, use of
written and audiovisual materials, mailed materials, and telephone in-
structions. Overall, the most striking results were seen for behavior strat-
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UNEQUAL TREATMENT
egies (e.g., skill building, practice activities, modeling and contracting,
rewards, mail and telephone reminders) and those that combined educa-
tion and behavior strategies. In general, interventions that combined strat-
egies were more successful than single-focus interventions. Significant
results, though varied in magnitude, were found for refill records, pill
counts, utilization, and improved health outcomes. While most studies
cited were not specifically targeted toward communities of color, positive
results from patient education programs offer promise for their use with
racial and ethnic minority patients. However, it is crucial that interven-
tions be adapted with cultural and linguistic considerations in mind and
also address physician responses to their patients' increased activation, to
ensure collaborative interactions.
Finding 5-3: Culturally appropriate patient education programs
offer promise as an effective means of improving patient participa-
tion in clinical decision making and care-seeking skills, knowledge,
and self advocacy.
Recommendation 5-12: Implement patient education programs to
increase patients' knowledge of how to best access care and partici-
pate in treatment decisions.
Culturally appropriate patient education programs tailored to spe-
cific racial and ethnic minority populations should be developed,
implemented, and evaluated.
Representative terms from entire chapter:
health workers
