critical access hospital clas perspectives from the c-suite
DESCRIPTION
Purpose This descriptive, survey-based study extends earlier research by exploring how Critical Access Hospitals (CAHs) across the nation provide Culturally and Linguistically Appropriate Services (CLAS) for their patients. Methods Personal emails announcing a national electronic survey of CAHs in 45 states were sent to 968 of the 1,329 CAHs in the United States (73%). The survey was completed by 137 of the 1,329 CAHs (14.15% participation rate, 10.3% of all CAHs). Findings CAHs with larger non-White or non-English speaking patient populations had a greater variety and more frequent use of language services than CAHs that served less diverse populations. CAHs that collected cultural and linguistic information from patients were significantly more likely to have mechanisms in place to ensure this information followed the patient throughout the continuum of care. CAHs that collected cultural and linguistic information from patients offered significantly more mechanisms to address their patients’ cultural and linguistic needs. CAHs with larger non-White or non-English speaking populations were significantly more likely to employ FTEs related to CLAS than CAHs that served less diverse populations. CAHs with larger non-White or non-English speaking populations were not significantly more likely to provide CLAS training than CAHs that served less diverse populations. Conclusions Collection of patient demographic information may relate to use of that information in the patient’s healthcare encounter. Location in a diverse population may not be an indicator of the CAHs provision of CLAS services.TRANSCRIPT
SHEILA KELTY, DHA, FACHE
Critical Access Hospital CLAS perspectives from the C-
Suite
Brought to you by:
WWW.NCIHC.ORG
Background
The United States Supreme Court has interpreted Title VI of the Civil Rights Act of 1964 to mean that all healthcare providers who accept Medicare and Medicaid must provide culturally and linguistically appropriate services (CLAS) for their patients.
The United States Department of Health and Human Services’ Office of Minority Health issued a set of national standards for CLAS to “ensure that all people entering the health care system receive equitable and effective treatment in a culturally and linguistically appropriate manner
Sources: Youdelman, 2008 ; United States Department of Health and Human Services Office of Minority Health, 2001.
Necessity for CLAS
Increase in diverse populations in rural areasNo reimbursement for CLAS expensesImmigrants have higher rates of infectious diseases
than established US populationsPhysicians order more diagnostic testing when there
is a language barrierLower patient satisfaction scores and decreased
patient compliance when there is a language barrier without language services
Use of a professional trained interpreter results in less diagnostic testing, lower cost & shorter length of stay.
Sources: Johnson, 2012; Armanda & Hubbard, 2010; Whitman & Davis, 2008; Hampers, Cha, Gutglass, Binns, & Krug, 2009
Language Services
Types of language services Trained vs. Untrained On-site vs. Off-site Language concordant
Availability vs. Use Clinical staff not encouraged to use language services Depend on their own limited foreign language skills Time and inconvenience
Sources: Hudleson & Vilpert, 2009; Diamond, Schenker, Curry, Bradley, & Fernandez, 2009.
Culture
Required collection: Race Ethnicity Primary Language
Cultural health disparities affect outcomes
Need for education, awareness and understanding of cultures in the patient population and community
Sources: Graves, Like, Kelly, & Hohensee, 2007
Research Questions
1) Do CAHs that collect cultural and linguistic information from patients upon admission have more mechanisms in place to meet these cultural and linguistic needs than CAHs that do not collect cultural and linguistic information from patients upon admission?
Research Questions
2) Do CAHs that collect cultural and linguistic information from patients upon admission have more mechanisms in place to ensure this information follows the patient throughout the continuum of care than CAHs that do not collect cultural and linguistic information from patients upon admission?
Research Questions
3) Do CAHs that have larger non-white and non-English speaking populations have a greater number of CLAS specific employees and provide more training than CAHs that have smaller non-white and non-English speaking populations?
Research Questions
4) Do CAHs that have larger non-English speaking populations have a greater variety of language services available and use them more often than CAHs that have smaller non-white and non-English speaking populations?
Research Questions
5) Do CAHs that have written policies and procedures for CLAS allocate money to CLAS related services more often than CAHs that do not have written policies and procedures for CLAS?
Methods
Population: 1,329 Critical Access Hospitals located in the United States As designated by Centers for
Medicare and Medicaid ServicesConnecticut, Delaware, Maryland,
New Jersey, and Rhode Island do not have CAHs.
Methods
Web-based Electronic Survey (Qualtrics)Invitation through National Rural
Health Association e-newsletter (December 2012 & January 2013)
Emails to CEOs, CNOs, or other executives at 1,116 CAHs
Reminder emails sent 10 days after original email
Methods
Each CAH was asked questions about CLAS in their facility that corresponded to the following categories: Collection of cultural and linguistic information from patients Mechanisms in place to meet cultural and linguistic needs Mechanisms in place to ensure cultural and linguistic
information follows patient throughout continuum of care Percentage of race/ethnicity and primary languages of patient
base Established multicultural services departments and human
resources/employee training in CLAS Variety of language services available and frequency of use Written plans and policies for CLAS Funding for CLAS
Results
270 CAHs opened the survey
183 CAHs responded to the first question
137 CAHs completed the survey (10.31% of U.S. CAH population; 14.15% of contacted CAHs)
All of the survey questions were answered by 78 of the CAHs (8.06% participation rate, 5.87% of all CAHs)
Results
Less than 10% of the patients served by the CAHs responding to the survey have a primary language other than English
Less than 20% of the patients served by the CAHs responding to the survey are not white
Results
85.5% of the CAHs participating in the survey have a written patient care policy addressing provision of language services
51.3% of the CAHs participating in the survey have a written patient care policy addressing provision of culturally appropriate services
68.0% of the CAHs participating in the survey are certified by their State Department of Health, 22.7% are certified by The Joint Commission
Results
0.00%2.00%4.00%6.00%8.00%
10.00%12.00%14.00%16.00%18.00%
CAHs that always use interpreter, by interpreter type and patient population
CAHS with higher percentage of pa-tients who don't speak English (> 8.00% , median n=62)
CAHS with lower percentage of pa-tients who don't speak English (> 8.00% , median n=76)
Results
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
CAHs that never use interpreter, by interpreter type and patient population
CAHS with higher percentage of pa-tients who don't speak English (> 8.00% , median n=62)
CAHS with lower percentage of pa-tients who don't speak English (> 8.00% , median n=76)
Results
1) Do CAHs that collect cultural and linguistic information from patients upon admission have more mechanisms in place to meet these cultural and linguistic needs than CAHs that do not collect cultural and linguistic information from patients upon admission?
There is a significant positive relationship between collecting cultural and linguistic information from patients and the availability of mechanisms to address the cultural and linguistic needs of the patients.
Results
2) Do CAHs that collect cultural and linguistic information from patients upon admission have more mechanisms in place to ensure this information follows the patient throughout the continuum of care than CAHs that do not collect cultural and linguistic information from patients upon admission?
There is a significant positive relationship between collection of cultural and linguistic information from patients and having mechanisms in place to ensure this information follows the patient throughout the continuum of care.
Results
3a) Do CAHs that have larger non-white populations have a greater number of employees with CLAS specific duties than CAHs that have smaller non-white and non-English speaking populations?
There is a significant positive relationship having a larger non-white populations and having a greater number of employees with CLAS specific duties than CAHs that have less diverse populations.
There is a significant positive relationship having a larger non-English speaking populations and having a greater number of employees with CLAS specific duties than CAHs that have less diverse populations.
Results
3b) Do CAHs that have larger non-white populations provide more CLAS specific training than CAHs that have smaller non-white and non-English speaking populations?
There is not a significant relationship having a larger non-white populations providing more CLAS specific training than CAHs that have less diverse populations.
There is not a significant relationship having a larger non-English speaking populations and providing more CLAS specific training CAHs that have less diverse populations.
Results
4) Do CAHs that have larger non-English speaking populations have a greater variety of language services available and use them more often than CAHs that have smaller non-English speaking populations?
There is a significant positive relationship between having a larger non-English speaking populations and having a greater variety of and more frequent use of language services.
Scatter Plot of Correlation betweenLanguage Services & Non-English Speaking
Population
Median 1 2 3 4 5 6 7 8 9
1. Collect
cultural &
linguistic info 7.00
1
131
.330**
124
.408**
129
.090
130
-.021
129
.202*
116
.104
87
.410**
129
.108
131
2. Meet
cultural &
language
needs 1700
1
141
.351**
139
.250**
128
.290**
127
.331**
118
.185*
87 .543**130
.860**
141
3. Follow
continuum of
care 2.00
1
150
.093
135
.060
134
.191*
125
.132
87
.513**
137
.281**
150
4. Serve non-
white
population 10.00
1
138
.751**
137
.217**
121
.045
87
.131
134
.306**
137 5. Serve non-English population 4.00
1
137
.173*
120
-.012
87
.242**
133
.371**
136
6. Employ
CLAS FTEs0.05
1
128
.074
78
.266**
124
.247**
128
7. Provide
CLAS training8.00
1
89
.398**
88
.137
89
8. Maintain
written
policies for
CLAS 6.00
1
139
.387**
139
9. Offer
language
services 8.00
1
179
Results Descriptive statistics (M & SD) and inter-correlations
Notes: * p >0.05; ** p > 0.01
Limitations
Sample sizeResponse rateCAHs may not be representative of other
larger or non-rural hospitals
Conclusion & Discussion
There is a positive correlation between CAHs that gather information regarding race, ethnicity, and language from the patient CAHs that have more mechanisms in place to meet the CLAS needs of patients.
There is a positive correlation between CAHs that gather information regarding race, ethnicity, and language from the patient and CAHs who pass this information on throughout the continuum of care within their facility. This could be due to the use of electronic health records.
Conclusion & Discussion
There is a positive correlation between CAHs with larger non-white or non-English speaking patient populations and CAHs who provide more language services for their patients.
There is no significant correlation between CAHs with larger non-white or non-English speaking patient populations and CAHs who provide more CLAS training for their employees. This could be because many hospitals do not use their own staff to provide language services.
Conclusion & Discussion
CAH executives should review how they use the race, ethnicity, and language information they are collecting from their patients to determine how they could use this information to better meet the CLAS needs of these patients
CAH executives should review the mechanisms in place for meeting CLAS standards and determine how to implement more mechanisms to better meet the CLAS needs of their patients.
CAH executives should review the need to offer more CLAS education provided to their employees and determine how to measure CLAS competency of their staff.
References
Armanda, A.A., & Hubbard, M.F. (2010) Diversity in healthcare: Time to get REAL! Frontiers of Health Service Management, 26(3), 3-17.
Diamond, L.C., Schenker, U., Curry, L., Bradley, E. H., & Fernandez, A. (2009) Getting by: Underuse of interpreters by resident physicians. Journal of General Internal Medicine, 24(2), 256-262.
Graves, D. L., Like, R. C., Kelly, N., & Hohensee, A. (2007) Legislation as intervention: A survey of cultural competence policy in healthcare. Journal of Health Care Law & Policy, 10, 339-361.
Hampers, L.C., Cha, S., Gutglass, D.J., Binns, H.J., & Krug, S.E (1999) Language barriers and resource utilization in a pediatric emergency department. Pediatrics, 103(6), 1253-1256.
Hudelson, P., & Vilpert, S. (2009). Overcoming language barriers with foreign-language speaking patients: a survey to investigate intra-hospital variation in attitudes and practices. BMC Health Services Research, 9(187).
Johnson, K. M. (2012). Rural demographic change in the new century: slower growth, increased diversity. The Carsey Institute at the Scholar's Repository, (159).
United States Department of Health and Human Services Office of Minority Health (2001). National standards for culturally and linguistically appropriate services in health care: Final report. Retrieved June 13, 2010 from http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf
Whitman M.V., & Davis, J.A (2008). Cultural and linguistic competence in healthcare: The case of Alabama general hospitals. Journal of Healthcare Management, 53(1), 26-40.
Youdelman, M.K. (2008). The medical tongue: U.S. laws and policies on language access. Health Affairs, 27(2), 424-443.
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Sheila Kelty, DHA, FACHE
LinkedIn: http://www.linkedin.com/pub/sheila-kelty/19/4a8/47
Email: [email protected]
WWW.NCIHC.ORG