Abstract
Racial/ethnic disparities have long persisted in the United States despite concerted health system efforts to improve access and quality of care among African Americans and Latinos. Cultural competence in the health care setting has been recognized as an important feature of high-quality health care delivery for decades and will continue to be paramount as the society in which we live becomes increasingly culturally diverse. Unfortunately, there is limited empirical evidence of patient health benefits of a culturally competent health care workforce in integrated care, its feasibility of implementation, and sustainability strategies. This article reviews the status of cultural competence education in health care, the merits of continued commitment to training health care providers in integrated care settings, and policy and practice strategies to ensure emerging health care professionals and those already in the field are prepared to meet the health care needs of racially and ethnically diverse populations.
Keywords: Cultural Competency, Integrated Care, Provider Education, Mental Health
Introduction
Racial/ethnic health disparities in behavioral health have persisted in the United States, despite the development of health care strategies to address these disparities. Results of a national survey of more than 200,000 individuals, comparing disparities between Whites, African Americans, Asian Americans and Hispanics reported that Black-White differences in mental health care increased from 8.2% to 10.8% and Hispanic-White differences increased from 8.4% to 10.9%.1 Contributing factors include lower access to behavioral health care,2 lower mental health help-seeking,3 and lower likelihood of receiving evidence based mental health treatments.4 Further, racial/ethnic minorities are overrepresented among low socioeconomic populations, experience racism and bias, and cultural mistrust of the health care system, which place additional burden on access to care and health care outcomes.5 In addition to behavioral health disparities, racial/ethnic minorities suffer disproportionately from cardiovascular disease, diabetes, and cancer, conditions that are largely preventable and are overrepresented among individuals with behavioral health conditions.2,6 Contributing factors to these conditions are similar to those related to poor behavioral health, including inadequate access to health care resources such as lack of health insurance, limited income, language barriers, transportation barriers and poor health care quality.2
Integrated Care
Integrated health care, particularly primary care and behavioral health integration, is an evidence-based health care strategy designed to improve health care outcomes among individuals with multiple health care needs through the systematic coordination of services, such as those for physical and behavioral health.1 While there are various models of integrated care, key features include some co-location of services, multidisciplinary teams, funding and resource sharing, and data integration. There is extensive research on the benefits of integrated care, including the improvement of mental health outcomes and other chronic health conditions among racial/ethnic minorities (eg, lower reported mental distress); and integrated care has been described as a key health care practice in reducing behavioral health disparities.7 However, there is limited research exploring how cultural considerations may impact physical and behavioral health outcomes among African Americans and other people of color in integrated care settings.6,8,9 As integrated care continues to grow as a strategy to address behavioral health disparities, health care systems must be prepared to provide quality behavioral health care services to their racial/ethnic minority patients, particularly in a society that is becoming increasingly diverse.
Cultural competence in the health care setting has been recognized as an important feature of high quality health care delivery, contributing to improved knowledge and attitudes among health professionals and increased patient satisfaction.10 There is a wide array of research literature on the value of cultural competence in primary care settings.10 Unfortunately, there is limited empirical evidence on the impact of culturally competent care in integrated care settings and how this may contribute to improved access and quality of care and improved health outcomes.5,10 Further, while there are many resources on the relevance of cultural competence in integrated care, there are no reported studies that examine how to implement cultural competence training and education for health care professionals in integrated care settings or the impact of such training.10 It is critically important to address this gap in the literature given the potential impact of a culturally competent health care workforce on improving the health care experiences and outcomes of diverse, underserved populations in integrated care.6 In this article, we 1) present some of the features of cultural competence education and training in health care; 2) explore barriers to curriculum development and implementation; and 3) present opportunities to strengthen the cultural competence of health care providers in integrated care settings.
Culturally Competent Care and Behavioral Health Equity
The health equity issues specific to behavioral health are similar to those for physical health but may include additional barriers. Through cultural competency training, providers are trained to meet the needs of racial/ethnic minority patients experiencing barriers, such as delayed treatment and diagnosis and continued engagement in treatment. This training also provides guidance on how to communicate with patients in a culturally competent way, not highlighting or exacerbating potential stigmas that may serve as barriers to care. Cultural competence education acknowledges the importance of the social determinants of health that may be particularly powerful in shaping the health outcomes of underserved populations. This may prompt providers to link racial/ethnic minority patients to other care services, including a behavioral health specialist or a social worker (for housing or health insurance, faith-based communities near their homes, or to a community navigator who can assist with obtaining a GED or job training programs).
Cultural Competence Training and Education
There has been a growing appreciation for and understanding of the need to have a culturally competent health care workforce, thus the need to educate and train medical students and practicing physicians. By 2045, Whites will no longer be a majority compared with the non-White population in the United States, suggesting a need for a health care workforce capable of meeting the health care needs of a racially and culturally diverse population.11,12 While some research has concluded that racial/ethnic concordance is a weak predictor for patient outcomes, such as dropout rates, a majority of the evidence indicates that racial/ethnic minority patients report more communication challenges, lower patient satisfaction, and less decision making power than White patients, when treated by clinicians of different races.13 This provides additional support for continuing efforts to increase diversity among the health care workforce.
In 2000, the Liaison Committee for Medical Education (LCME) introduced a standard related to cultural competence, requiring faculty and students to demonstrate knowledge and an understanding of the role of culture in health care.14 The American Association of Medical Colleges (AAMC) recognizes that effective implementation of cultural competence curriculums requires institutional and community resources.15 It also requires the support of leaders, faculty, and students, integrated educational programming matched to learners, and clear accountability and evaluation processes.15 Integrating cultural competence curricula into the education of emerging health care professionals is a key strategy in reducing racial/ethnic health disparities. These curricula should also educate learners about the role of integrated care in removing barriers to implementing culturally competent care and reducing racial/ethnic health disparities while simultaneously acknowledging the need for additional research on effective strategies for providing cultural competence education and training to providers in these settings.
Cultural competence models and curricula in health care are designed to ensure that learners acquire attitude, knowledge and skills to deliver effective, quality health care to diverse populations. In their Cultural Competence Education report (2005), the AAMC provided a few examples of evidence-based cultural competence training tools for practicing health care professionals, with most models developed for medical schools and other training programs.15 Several curricula and tools provided in the literature assist with incorporating features and elements of cultural competence in clinical practice.14,15 Rust and colleagues created the CRASH Course in Cultural Competence, which is a mnemonic to guide practitioners: C, consider culture; R, show respect; A, assess and affirm differences; S, show sensitivity and self-awareness; H, and, do it all with humility.16 The goal of this course is to provide medical professionals with a core set of cultural competence skills and to enhance provider confidence in effective communication with racially and ethnically diverse patient populations.16 Betancourt and colleagues describe a model for assessing changes in knowledge, attitude, and skill among medical students who have received cultural competence education5; this may be useful for training in integrated care settings. For example, the educational approach to attitude is teaching students to communicate empathy and respect during cross-cultural encounters; assessment activities that might be a good fit for integrated care settings might include presentation of clinical cases during team meetings and individual self-awareness assessments.5 Further, standardizing evidence-based cultural competence training in medical settings can lend credibility to cultural competence that some consider to have evolved from “weak science” and tying cultural competence strategies to quality improvement projects, will further efforts to institutionalize cultural competence in settings where health professionals practice.
Barriers to Implementing Cultural Competence Training
Cultural competence education and training of health care professionals practicing in integrated care settings will require different strategies and approaches to be effective. Barriers to the uptake of cultural competence training in health care across settings have been cited as limited evidence of its impact on patient outcomes and low feasibility of training implementation, leading to poor buy-in from providers.10 A systematic review of 34 studies, which included studies targeting practicing physicians and pre-professionals, found evidence of cultural competence impact on patient satisfaction and patient outcomes, which is vital to a strong rationale for cultural competence education and training.10,17 Yet, this review also substantiates the need for evidence of the effectiveness of an integrated care approach in addressing the health outcomes of culturally and linguistically diverse populations experiencing disparities.10 Perhaps practitioners in integrated care settings, particularly those who serve ethnically diverse and underserved populations, are more apt to appreciate the importance of providing culturally competent care given the frequency of clinical encounters that require them to demonstrate cultural knowledge and skills. However, they may also feel that, since they regularly engage these populations and are caring and sensitive physicians, additional training is not needed. Additional studies are needed to explore the impact of cultural competence training on patient outcomes and to address the challenges around integrating cultural competence training within busy practice environments with limited time resources.
Medical training programs and hospital systems are recognizing the increasing cultural diversity of the practice environment and are seeking to better prepare their providers. Project THRIVE, a community-based research project implemented at a large public hospital in Atlanta, Georgia, found that African American patients receiving integrated care services wanted to see their providers in their community and wanted health education workshops on stress management to address stressors specific to the African American experience.7 Project THRIVE researchers used qualitative data, previously collected through a series of patient focus groups and provider/administrator key informant interviews, both conducted at a local family medicine practice,7 to develop an online course to deliver culturally relevant, educational resources to health care providers. Transcripts from the focus groups and the key informant interviews were analyzed for key themes related to depression care, perceived unmet cultural needs, and desired adaptations; these findings were used to compile the content of the course. Despite the information provided, no one volunteered to complete the course due, in part, to the challenges with implementing cultural competence education and training within one of the busiest hospitals in the Southeast (A. Belton, oral communication, August 2018). Despite this lack of participation in one setting, a need for strengthening cultural competence within health care settings remains.
Resources to Strengthen Cultural Competence of Health Care Providers
The Annapolis Coalition on the Behavioral Health Workforce (www.annapoliscoalition.org), guided by the Substance Abuse and Mental Health Service Administration’s (SAMHSA) Center for Integrated Health Solutions (CIHS), includes cultural competence and adaptation as one of its core competencies for integrated health care. Components include: a) addressing disparities in access and quality; b) cultural adaptation of services to health care consumers; c) developing collaborative relationships that support meeting the needs of culturally diverse clients; d) adjusting health care delivery according to quality of care among culturally diverse consumers; e) educating health care team members on health experiences of diverse populations; and f) fostering a culturally diverse interprofessional health care team.18 Interviews with cultural competence experts in various work settings acknowledge resistance from providers who may view cultural competence training as a “soft science” and recommend standardization and utilizing evidence-based curricula to garner support and encourage participation.5 Cultural competence training initiatives for integrated care settings must leverage the work of coalitions and governmental agencies (eg, SAMHSA) that can provide technical assistance resources, expert advice and guidance that will encourage adoption by providers and staff.
Practice and Policy Implications
Cultural competence is key for health care professionals to provide quality health care in today’s diverse complex health care systems. Betancourt et al proposed a useful framework for institutionalizing cultural competence throughout a health care organization such that it is reflected on three levels: organizational level, structural level, and the clinical level.5 At the organizational level, there should be a robust effort to ensure a culturally diverse workforce, making it more likely for culturally sensitive policies and practices to be implemented and reflect community needs. Creating organizational policies that strongly encourage or mandate cultural competency training should be accompanied by the time and resources to implement such a rule. For example, at the structural level, guidelines are needed to ensure that culturally and linguistically appropriate services (eg, providing interpreter services) are delivered. At the clinical level, this could mean providing cultural competency training to ensure providers and staff are responsive to a diversity of needs.
Proficiency in culturally competent care especially in an integrated care setting requires monitoring and assessment of provider knowledge, skills and efficacy. To achieve the triple aim in health care of population health, reduced health care costs, and individual experience of health care,19 educational activities and training should both acknowledge and provide ongoing training of health care professionals, including direct feedback and observations to change behavior. Similar to teaching cultural competence in educational systems, it is equally imperative that we educate our health professionals via culturally responsive teaching for self-reflection, understanding, and uptake of the principles and change in provider and staff practice styles.20 Culturally responsive teaching leverages the health care provider’s prior experiences, cultural awareness, and the diversity of health care professional learners to change their practices.20
Research has demonstrated that cultural competence training can improve health care provider knowledge, understanding, and skills in treating patients from diverse socioeconomic, cultural, and linguistic backgrounds.21-23 Training in cultural competent integrated care, through a top-down approach with buy-in and leadership from the federal government through agencies such as SAMHSA, state and local governments, and leadership within hospital systems and clinics, can support the individual provider. This will greatly assist the goal of making cultural competence normative within the practice environment.24 Once leadership buy-in and approval has been obtained, grassroots efforts through ongoing training and feedback involving the frontline health care team can be transformational and key to obtaining buy-in from the bottom up for sustainability from providers.25 Despite cultural competency being well-known in the literature as essential to improving provider-patient relationships and health outcomes specifically in racial ethnic minority populations, many health care systems have not widely implemented this training in these settings.21-23 Cultural competence training in integrated care settings must be incentivized to accomplish these goals. Improved relationships between providers and racial/ethnic minority patients may increase engagement and adherence to treatment recommendations thereby improving health outcomes. If this is achieved, it may lessen the gap between racial/ethnic minorities and Whites regarding quality of behavioral health care, thereby improving behavioral health equity. However, this connection does not have strong empirical support, and should be the focus of additional research.
Next Steps
Health systems that welcome cultural competence education do so because their leaders believe such efforts support their mission and vision and meet the needs of their patient populations, including those experiencing behavioral health disparities.26 Increasing provider awareness of research showing that patients have better health outcomes when their care is culturally competent supports increased accountability for the care they deliver.22,26 Pay-for- performance is challenging and often frowned upon among health care providers who serve patients in low socioeconomic populations.26 Despite complicated reimbursement formulas, holding health care providers accountable to the same standards of care without addressing health inequity and addressing their patient’s social determinants of health, makes this model neither feasible nor sustainable.
Conversely, institutionalizing provider education to provide culturally competent integrated care, especially among safety net providers, is important to achieving health equity and reducing health care disparities in resource-poor populations. Organizations should provide educational materials, training opportunities and modules for culturally competent integrated care training. These organizations should ensure that educational materials, modules and training opportunities be made available on their website or upon written request from colleagues, are validated and in place to use with the appropriate interprofessional workforce to provide this team-based care.
Leveraging technology through electronic health records can improve patient adherence to treatment and the monitoring of patient health outcomes,9 including tracking patient health outcomes such as hemoglobin A1c for diabetes, depression severity, blood pressure control, frequency of primary care and mental health visits, emergency department visits, and even screening and addressing the other social health determinants. Monitoring these and other health outcomes among patients whose health care providers have received cultural competence training, compared with those without such training, may provide some evidence of the impact of their training on outcomes. We can then demonstrate not only improvement in physical and mental well-being for our patients but potential fiscal savings as well.1 Additionally, health and lifestyle apps are now becoming the cultural norm and a flexible way for patients to connect to their health care providers without the barriers of needing an appointment, travel, and time off from work. While everyone may not have a mobile phone or may experience connectivity issues, a significant number of individuals, including a majority of those in lower socioeconomic strata do have phones,27 making this a viable option for reaching patients.
As metrics for success in culturally competent care in integrated care settings are not well-elucidated, monitoring health care provider well-being and burnout rates is also vital to the sustainability to culturally competent care in an integrated care setting. Providers, who are unprepared to provide effective, quality health care to patients in a culturally responsive way, may experience frustration with communication barriers and patient dissatisfaction.28 While this has not been studied in integrated care settings, burnout has become an increasingly popular topic of focus for health care professionals and is an emerging area of research internationally.28 Likewise, targeting future health care providers (ie, medical school students, nursing school students, psychiatry residents, and allied health students) and modeling how to communicate and effectively work within interprofessional teams is paramount to preparing the next generation of health care professionals to deliver culturally competent care in an integrated health care setting. This targeted training approach will ultimately, lead to better relationships with patients who feel respected and valued by their providers and the health system overall.29 Interprofessional teams bring distinct skills, training and prior patient experiences which can uniquely address the individual needs of our patients. Finally, the health care delivery system must be reformed to ensure that patient- and family-centered health care is accessible to racial/ethnic minorities and health care providers are equipped with the resources to deliver quality culturally competent care in integrated care settings.
Acknowledgments
Project THRIVE is supported as a subproject in the Morehouse School of Medicine Transdisciplinary Collaborative Center for Health Disparities Research (MSM TCC) (PI: Kisha B. Holden, PhD, MSCR) by a grant from the National Institutes of Health/National Institute of Minority Health and Health Disparities (Grant Number U54MD008173).
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