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March 19, 2008
FOCUS Multicultural Healthcare, March 2008, Volume 4, Issue 1

Multicultural health has become an increasingly important area of study, and some states have established themselves as more proactive than others by enforcing mandates that require physicians to complete specific courses.

Multicultural health has become an increasingly important area of study, and some states have established themselves as more proactive than others by enforcing mandates that require physicians to complete specific courses focusing on culturally and linguistically appropriate services (CLAS) before gaining licensure. For instance, New Jersey implemented such a mandate in March 2005, when then-governor Richard J. Codey signed a law stating that “doctors must take cultural competency training before they can get medical licenses” and that the “30,000 physicians who already have a license will have to complete the training to renew their licenses.”

In addition, California has also established itself as a state dedicated to making sure its healthcare providers demonstrate proficiency in cultural competence, calling for physicians to complete training courses in this area, as well as linguistic training.

With more mandates on cultural competency comes more attention, and with more attention come more programs designed to help everyone from the solo physician to the group practice on becoming better acquainted with this developing area of study. One such emerging program is the National Committee for Quality Assurance’s (NCQA) Technical Assistance Project (TAP). This program, supported by The California Endowment, “provides demonstration grantsto small physician practices to undertake new efforts to improve care for minority patients” to help “reduce health care disparities.”

Although the NCQA has administered physician-recognition programs on specific conditions in the past, this is the first program they have created that focuses specifically on culturally and linguistically appropriate services, and if all goes well, the NCQA is looking to expand the program into larger scale projects. Sepheen Byron, Assistant Director of Performance Measurement for the NCQA, explained that the NCQA has been “exploring this area of culturally and linguistically appropriate services for a while,” and that it fell “right in line with our mission of improving quality and improving healthcare.” The first step of the program was to award grants of up to $25,000 to 20 small practices in California and New Jersey; these practices were then instructed to implement a focused, 12-month project that would seek to improve care for minority patients. For example, the McKinley Medical Clinic in California chose to implement a program called Empowering Patients through Access to Medical Information, which aimed to create personal medical records for its Latino patients with diabetes.

The AIA Wellness Center in New Jersey used their grant money to institute a program to increase annual screening mammogram rates in Asian and African American patients by “implementing culturally appropriate educational materials, physician counseling, and educational classes in preferred languages. The other 18 practices launched similar programs that were dependent upon the ethnic population of their patients (see examples on next page). The idea behind these programs is to, as Byron states, teach “methods such as small tests of change [and] do something on a small scale at first; evaluate it; see if it works; and then do it on a larger scale for the whole practice.” By providing these practices the liberty of zoning in on a specific area of study (eg, hypertension, diabetes, depression) in specific populations (eg, African American, Latino, Asian), the TAP program sought to collect a great deal of data on the numerous studies, so that they could begin to implement strategies and methods that would be conducive to improving minority health.

By agreeing to take part in the program, practices were required to spend part of their grant funds to send a physician and office staff member to attend a full-day, local, project-launch training workshop. This kick-off meeting was locally held, and introduced the program’s participants to CLAS, as well as healthcare disparity issues and quality improvement methods. Models for delivering culturally appropriate healthcare, quality improvement framework, and how to conduct “small tests of change” were some of the topics that were covered in this meeting. Additionally, Byron explained that the NCQA had project leaders “partake in an online module on CLAS and conduct a brief chart review exercise,” at which point “project champions “completed either A Physician’s Practical Guide to Culturally Competent Care, developed by the Office of Minority Health, or Quality Interactions, developed by leading researchers in CLAS” (see the “Spotlight On” feature in this issue for more information about this program). Once this initial task was completed, participants were then required to attend a monthly, hour-long, Web-assisted conference call for technical assistance; complete practice and staff assessments; submit a project plan and budget, along with quarterly progress and budget reports; and use part of the grant funds to attend a national conference to share completed project findings with peers.

When asked about how the TAP program went about defining “quality healthcare,” and about the barriers and deficiencies that

have been encountered throughout the program, Byron said that it was “less a focus on clinical outcomes and more of a focus

right now on processes, so if they are able to implement a change and see that they’re able to, for example, collect data on their

outcomes rather than focusing specifically on the outcomes, we view that as a success because a lot of these practices don’t even have the information to make a decision about how they should be caring for their minority patients.” Another problem the TAP program faced was that these participants were a part of smallscale or solo practices, and this created a problem of not being able to spend time with a project like this. “Often, there are only one or two physicians in the whole practice, and they have to focus all their time on caring for patients,” says Byron. “Being able to set aside time, resources, etc. to do some sort of focused project on their patient population is difficult for them.” However, in the end, the practices that took part in this project were able to find ways to help contribute to the program. In fact, many practices (all of which had a fairly substantial minority population) understood the larger implications of this project, and made the time to help the NCQA determine which strategies and processes would lead to better care for these minority populations.

When asked whether she thought programs like the ones initiated by TAP’s grants would catch on across the nation, Byron explained that many of the initiatives to study minority health “were stimulated by the Institute of Medicinereport that came out a few years ago, looking at culturally and linguistically appropriate services. It triggered [the need for such initiatives] in a lot of people’s minds, and now you see it spreading across the country, and with the increasing diversity of the US, we think it’s going to be a very important area.” In this regard, the NCQA’s Technical Assistance Project is carefully constructing a foundation for improvements in minority health, and is helping to present evidence from the anecdotal data that has gone ignored for too long.

The TAP program is now scheduled to undergo a full-scale evaluation, at which point the NCQA will determine which programs initiated by these small practices have shown to be the most successful. Once complete, the NCQA will focus its attention on taking these successful programs to a larger scale, and then, ultimately, will evaluate that step as well. Be sure to look for a comprehensive article in Focus on Multicultural Health later this year, detailing the TAP program’s evaluation, which is scheduled to be released in June/July.

Programs initiated by TAP grants

Practice: Med One Medical Group, Inc. (California)

Project: Adherence to Hypertension Treatment and Measurement Aim: To educate hypertensive patients who speak English, Arabic, or Vietnamese about managing their hypertension and the importance of adhering to treatment recommendations.

Description: The project team is providing understandable patient education materials that describe steps to checking blood pressure and effectively managing hypertension. The team is creating and testing processes to identify and flag patients who prefer materials in Arabic and Vietnamese. Educational materials are available in Arabic, Vietnamese, and English and also take into account the cultural differences of these patient groups. Practice: Practice of M.A. Sarraf, MD (New Jersey)

Project: Tracking HbA1c in Minority Diabetics as a Quality Improvement Process Aim: To measure and record HbA1c levels at set intervals in African American and Latino patients with diabetes.

Description: The project team is implementing a process to identify African American and Latino patients who have diabetes. The team will check for the date of the patient’s last HbA1c measurement and, if one has not been performed in the last quarter, will conduct the test. The team also distributes culturally and linguistically appropriate educational materials to teach patients how to manage their diabetes and about the importance of regular HbA1c testing.

Practice: Clinica Western (California)

Project: Overweight Reduction and Patient Tracking Aim: To improve the health among overweight or obese Latino and Asian patients.

Description: In this project, Latino and Asian patients who are diagnosed as overweight or obese receive education and participate in motivational interviewing techniques to help them achieve a healthier weight. The project team is employing techniques learned through TAP to encourage patients to become involved in their healthcare. In addition, the team distributes patient education materials that are culturally and linguistically appropriate for these two populations.

Practice: California Coast Medical Center

Project: MAGIC — Medication Analysis Generated Into Compliance Aim: To increase medication adherence and patient follow-up using information in English and Spanish.

Description: The project team is educating patients to improve medication management, particularly in Latinos with limited English proficiency. The team approach includes personalized teaching in Spanish, communication tools, and visual aids. The team stresses patient understanding of conditions, knowledge of medications, and the importance of completing treatment and follow-up visits. In this way, the team hopes to increase understanding and decrease missed appointments among Latino patients.