Barriers to Care: Lack of Community Based Oral Health Care July 30, 2014

The Washington Dental Access Campaign is a group of health care associations, consumer advocates, dentists, dental

hygienists, senior groups, Tribal governments and educational institutions supporting new mid-level dental providers as part of

the solution for improving access to care. www.wadentalaccess.com

Presenters:

Sam Watson-Alvan is the State Office of Primary Care Manager for Washington State. The mission of the Office of Primary Care is to strengthen access to underserved populations and communities. Sam has 20 years of experience in in state government and holds a Masters Degree in Social Ecology from The Evergreen State College. Julie R. Severson, Ph.D., J.D. is the healthcare policy analyst at Neighborhood House, one of King County’s largest and oldest human services organizations serving low-income and immigrant/refugee communities. Julie has worked in healthcare administration, policy, program management, and academia, and specializes in in social justice policy strategies designed to improve not only access to but the quality of healthcare. Marguerite J. Ro, MPH, DrPH, is the Chief of the Assessment, Policy Development, and Evaluation Unit of Public Health-Seattle & King County where she leads the department’s work in community health assessment and evaluation. Dr. Ro has long been a leader in developing and implementing innovative health programs that address health disparities among our nation’s most at risk populations.

S

Cultural “Competence” in Oral Healthcare: The Issues & Impact of Humility

July 30, 2014

Children’s Alliance Webinar

Julie R. Severson, Ph.D., J.D. | Neighborhood House

Learning Objectives

Understand That Washington residents experience disparities in oral health and

access to oral healthcare, and that these disparities often reflect race, ethnic, primary language spoken, and economic status (among others).

That a lack of cultural and linguistic “competence” constitute a barrier—among others—to quality oral healthcare in Washington State for these populations.

What cultural “competence” means, and what its limitations are.

The utility of a cultural humility framework for addressing these limitations.

What linguistic competence means.

How cultural humility and linguistic competence can together help further racial equity goals, and

improve health outcomes.

Washington State Hospital Association ____________________________________________________________

Study on ER overuse for dental issues reflects access problem for low-income populations.

January 2008 – June 2009, 54K dental care visits = over $36M

#1 reason uninsured adults sought care from ERs/EDs

Medicaid recipients and uninsured = 2/3 of all dental related ER/ED visits

Health Disparities & Barriers to Care ____________________________________________________________

Reflect race, ethnicity, primary language, income, etc.

“Racial and ethnic minorities make up roughly one-fifth (18%) of the State of Washington’s population. Yet their disease burden is significantly higher. For some ethnic groups, the incidence of a particular disease may be five times the rate for Caucasian residents. The infant mortality rate for African Americans and American Indians/Alaskan Natives in Washington, for example, is twice what it is for Caucasians”.

http://sboh.wa.gov/OurWork/CurrentProjects/HealthDisparities.aspx

Unpacking the Issue of Access

Cost & Workforce Barriers (covered elsewhere during this webinar series)

Provider shortage Rural patients must travel long distances for care,

which is not only inconvenient but adds to cost (lost wages, gas, etc.)

Low reimbursement rate 20% of dentists accept Medicaid (i.e., Washington

Apple Health, or WAH)

Low-income populations (LIPs) ineligible for WAH may not have dental coverage QHPs and QDPs are sold separately on the Exchange,

and while medical coverage is mandated, dental coverage is not.

Antiquated health plans offering poor coverage (barrier to high quality care) Unnecessary extractions common, particularly among

low-income patients. This practice results in a two-tiered standard of care disadvantaging LIPs.

Cultural & Language Barriers

When providers and healthcare institutions:

Fail to offer helpful information in the most appropriate format and language;

Are ill-equipped to tailor their practices in a way that respects cultural differences; and/or

Place judgment on their patients

Patients’ experiences may discourage them from seeking care in the future—if they even sought it in the first place.

Culture ____________________________________________________________

Relates to oral health...

Culture shapes: How we think about our health and

health practices,

How we think about the causes of disease,

What we consider a priority health issue, and

What we do (and expect) once a health issue occurs.

Some cultural elements that can affect oral health: Eating habits and diet preferences,

Understanding of what healthy teeth and gums look like,

Perception of time, and

Gender roles.

Culture __________________________________________________________________

Informs prejudices & stereotypes in the oral healthcare setting

Patients may be seen as: Noncompliant, or as never following

the dentist's recommendations;

Incapable of helping themselves because they are uneducated; and/or

In some way deserving of their pain because they appear to not care about their oral health.

Providers may: Dismiss the importance of cultural and

linguistic differences when it comes to providing oral care, educating patients, and engaging in decision-making;

Be unwilling to learn about the impact their assumptions, communication styles, etc. have on their patients experiences of their healthcare; and/or

Experience personal difficulty providing care to patients who present with significant decay or other oral problems.

Cultural Competency

What it is:

Valuing diversity,

Learning about your own culture and other cultures,

Avoiding stereotypes,

Gaining cultural experiences, and

Engaging with your local communities.

Cultural competence is the ongoing capacity of healthcare systems, organizations and professionals to provide for diverse patient populations high quality care that is safe, patient- and family-centered, evidence-based, and equitable.

The National Quality Forum

Cultural Competency

Cultural competency assumes:

Objectivity, or cultural neutrality, of the practitioner;

Cultural groups are monolithic (which can inadvertently reinforce stereotypes, even “positive” or “harmless” ones);

Understanding cultural difference is a finite process, and—at some point—practitioners can achieve the threshold “competence” needed to provide quality care; and

Practitioners don’t need to cultivate self-awareness, or challenge their own assumptions, during their learning.

Cultural competence terminology/language can become institutionalized and pro-forma.

Pitfalls of a culturally “competent” framework.

An Alternate Framework: Cultural Humility

What it is:

Valuing diversity,

Learning about your own culture and other cultures,

Avoiding stereotypes,

Gaining cultural experiences, and

Engaging with your local communities.

Assumes:

Everyone has cultural biases, but that with the proper work, practitioners can not only come to understand how those biases contribute to barriers to care, but how to minimize their impact on their practice and patients.

Cultural groups are not monolithic. Cultural humility emphasizes the need to develop honest and open relationships that allow for individual variation in a judgment free environment.

That learning about cultural differences is a lifelong undertaking.

Practitioners need to cultivate self-awareness, and challenge their own assumptions, during their learning.

In practicing cultural humility, rather than learning to identify and respond to sets of culturally specific traits, the culturally competent provider develops and practices a process of self-awareness and reflection.

Melanie Tervalon, M.D., M.P.H &

Jann Murray Garcia, M.D., M.P.H.

Cultural Humility

“In this model, the most serious barrier to culturally appropriate care is not a lack of knowledge of the details of any given cultural orientation, but the providers' failure to develop self-awareness and a respectful attitude toward diverse points of view.”

California Health Advocates

Linguistic Competency

Includes

Providing information, whether verbal or written, in a way that individuals from culturally diverse groups can easily understand.

Especially important when working patients:

who are limited in their English proficiency (LEP),

who have little or no literacy skills,

who live with disabilities, and

those who are Deaf/deaf or heard of hearing.

All of these patient populations may experience difficulty with making/keeping appointments, understanding their health coverage (if they have it), following risk/benefit discussions (particularly if providers overuse clinical terminology), etc.

Implementation options:

Interpreter services,

Community Health Workers / Patient Navigators,

Increasing the number of providers who come from the communities (e.g., the mid-level dental provider).

The ability to communicate effectively with patients at every point of contact.

Cultural Humility & Linguistic Competence ____________________________________________________________

Dismantling Barriers & Providing a Path Towards Health Equity

The health equity model assumes that affirmative changes must be implemented to ensure equal access to populations currently experiencing disparities in both their health and access to quality care.

These affirmative changes include, but are not limited to, cultural humility and linguistic competence. When implemented well, these models can remove a variety of obstacles in accessing and receiving care.

Helpful Resources

U.S. Dept. of Health and Human Services, Office of Minority Health

http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15

Georgetown University’s National Center for Cultural Competence

http://nccc.georgetown.edu

The California Endowment

http://www.calendow.org/uploadedFiles/principles_standards_cultural_competence.pdf

Washington State Department of Health, Health Education Resource Exchange

http://here.doh.wa.gov/professional-resources/health-equity-competency

Marguerite Ro, DrPH

Chief, APDE/PC2

Creating a culture of oral health – non dental oral health champions

Diversifying the oral health workforce

Triple Aim as applied to oral health

Improving the patient experience of care

Improving the health of populations

Reducing the per capita cost of health care

Quality oral health care

Equitable oral health

outcomes

Accessible and affordable quality oral health services

Conditions associated with poor oral health: premature and low birth weight, diabetes, cardiovascular disease, stroke, HIV/AIDS

Impact on well-being: loss school or work days, career opportunities, social stigma, preventable visits to the emergency department

Demonstrating cultural humility in developing oral health strategies ◦ Acknowledging cultural and environmental factors

Engaging non-dental oral health champions ◦ Community organizations, schools, health and

social services

Integrating oral health services with primary care and preventive services

Change public or institutional policy to support the financing and delivery of oral health services

Improved access to high-quality care for the dentally underserved;

Greater patient choice and satisfaction;

Better patient-practitioner relationships and communication;

Increased likelihood of patients receiving and accepting appropriate oral health care; and, ultimately,

Improved health.

The development of a health care workforce that is representative and reflective of the communities served is vital for health care reform to achieve its potential to serve a diverse and growing minority population and to create an affordable and sustainable health care system that produces positive health outcomes.

Health care professional schools must be affordable and must reflect the diverse communities they serve. Their curricula must promote a trans- and multi- disciplinary, team-oriented, and community-responsive approach to teaching, training, mentoring, and matriculating to ensure the availability of health care providers necessary to implement comprehensive health care reform.

The development of diverse executive leadership and governance bodies of the health care system as well as diversity of faculty and leadership in K-16 and health care professional schools are essential for implementing effective health care reform that meets the needs of a diverse minority population and works toward eliminating health disparities/inequities.

Accrediting and licensing agencies should include strong and robust requirements, benchmarks, and oversight processes for ensuring the provision of patient-centered, culturally and linguistically sensitive/competent training and care in all health care settings. This includes, at a minimum, meeting the National Standards on Culturally and Linguistically Appropriate Services (CLAS).These benchmarks must ensure a diverse health workforce including diverse executive leadership and governance.

“Diversity and excellence are not mutually exclusive. They go hand-in-hand. We need to address this like we do all issues – with passion, determination, and persistence – with our ultimate goal to be world class.”

~ Dr. Rubens J. Pamies