From The Field N O V E M B E R 2 1 , 2 0 1 1 Going Beyond Grants to End Health Disparities KAREN VOCI Executive Director, Harvard Pilgrim Health Care Foundation SHANI DOWD Director, Culture InSight S everal years ago, Hallmark Health System, which tives, the foundation aims to combat health disparities in order includes Lawrence Memorial Hospital of Medford and to improve the health of not only Harvard Pilgrim Health Melrose-Wakefield Hospital and is located north of Care members, but also the many communities we serve. Boston, realized it had a substantial challenge: while its patient population had changed dramatically in terms of language and THE CURRENT STATE OF HEALTH culture, its staff and management had not. Enter Culture DISPARITIES InSight, an operating program of the Harvard Pilgrim Health The consistent increase in the immigrant and minority Care Foundation that was brought in by Hallmark Health to population throughout New England has had significant help facilitate the changes needed to better serve their patients. implications for patients and the health care industry and has Culture InSight’s preliminary survey of Hallmark Health’s led to growing health disparities, including: staff revealed that although there was an overall positive feeling about the services provided at the sites, more work needed to • Organizational Obstacles – Pressure to contain spending be done to ensure that the organization presented a consistent may disproportionally affect patients who are less educated environment that was welcoming to patients of all cultures. or less likely to ask doctors for more services. Additionally, After in-depth meetings with staff at all levels and a full-day many health plans do not offer professional interpretation retreat with managers, Culture InSight developed a strategic or translation services to patients who do not speak English. plan for the organization that outlined the need to embrace Because of this, organizations may have difficulty connect- diversity in the workforce, governance structure, and care of ing with the diverse communities in their service areas. patients in order to provide culturally congruent and compe- • Patients’ Attitudes and Behaviors – Some minority tent care. Through several training courses and consultation patients may put off health care visits because they do not sessions, as well as continuous and consistent support, Culture trust the health care system, reject their doctor’s recommen- InSight was able to help Hallmark Health System better dations, or fail to correctly follow physician instructions. align their goals and improve care for members of ethnic and Provider/patient communication can be negatively affected disadvantaged populations, with a focus on those populations by linguistic and cultural factors. most affected by health disparities. • Unrecognized Biases and Prejudices – Health care Rather than providing direct grants, the Harvard Pilgrim providers’ attitudes and beliefs may influence the quality of Health Care Foundation through Culture InSight, provides care they provide minority patients. These attitudes and cultural competency and medical interpreter training, as well biases are likely unconscious, the result of cultural learning, as consulting and organizational development services to and sometimes reinforced by training. health and human service professionals and their organizations throughout Massachusetts, New Hampshire, and Maine. When large segments of our population suffer an increased When Culture InSight was organized nearly a decade ago, burden of chronic health problems and lack high-quality and there were a number of foundations providing grants that sup- culturally competent health care and health-related informa- ported a variety of projects to end health disparities. There were, tion, it affects all sectors of our community: children have however, few organizations that trained medical and health staff more absences from school, adults are more likely to miss at community clinics, health centers, and small hospitals to work or be less productive in the workplace, and the financial actually address cultural barriers in their individual practices. cost of illness can make individuals and families unable to By providing support for these organizations and their initia- contribute to the success of their community. WHY OUR MODEL WORKS medical interpreting. Several other programs throughout the The goal of Culture Insight is to reduce cultural barriers region have adopted many of the practices, including providing between patients and medical providers, while at the same new interpreters with language coaching by native speakers. time help create organizations that are welcoming for people In Maine, Culture InSight is currently working on the Race, of all cultures, languages, and classes. As a small foundation, it Ethnicity and Language (REL) data collection project by pro- is imperative to maximize the reach and impact of our contri- viding consultation support to a coalition of community-based butions to society – by turning a portion of our funding into organizations working to enhance the collection of REL data services through Culture InSight, we are able to work with a and its utilization in the state. greater number of organizations for longer periods of time. LESSONS LEARNED In Massachusetts we are lucky enough to have a richness of funding for health services, as well as active health departments, • Relationships, relationships, relationships. It takes time community health centers, and public and private agencies, all to develop strong relationships that allow us to be successful; working to provide health care for minority and disadvantaged the partner organization must be a willing collaborator. populations. But there are very few organizations that are able • Quality is critical. We make it a point that our training and to affect change in a substantial way with regards to how consultation services are of the highest quality. We want patients of all cultures receive care. Our services and support people to walk away wanting more. Engage the client ensure that the health organizations and professionals provid- through curiosity. ing care to these specific populations are able to supply the highest-quality, most culturally competent care possible. • Establish credibility with ethnic communities. We are Culture InSight’s unique training format utilizes facilitative, known for our passion and skills in various communities, rather than didactic, lecture-based learning that positions all which allow us to be more effective. participants as learners. Participants bring their unique • Dedication is a must. A dedicated staff brings not only their perspectives to each discussion, while receiving practical, skills, but also a commitment to the programs provided. hands-on experience through a variety of teaching methods, including discussion, role playing, and skill-building activi- • Build long-term, meaningful relationships. Demonstrate ties. Programs, such as neighborhood tours, provide insight a commitment to the field by being a consistent presence in on cultures and customs that shape our communities. Over the community. the years, the program has grown to include consulting ser- vices, medical interpreter training in nine different languages, We foresee the issue of health disparities and cultural compe- and a wide range of educational programs for health care and tency evolving to become much more of a mainstream topic. social service professionals. Culture InSight also publishes And as we continue to witness significant changes in population training materials and reports. across the nation – not just in urban enclaves – the topic of health disparities will be better integrated in the training of CULTURE INSIGHT’S RANGE OF SERVICES medical professionals and discussions surrounding public AND REACH policy. In 20 years, cultural competency will no longer be an add-on to health care but will move to the center of how we Culture InSight has a longstanding relationship with the take care of people in this country. Massachusetts League of Community Health Centers, pro- Often, we at the foundation are asked, “If I am a grantmaker viding cultural competency training for community health without an operating program, what can I do to improve health centers in Massachusetts, free of charge, with the ultimate disparities?” And while answers to that question differ depend- goal of disseminating training to areas outside the urban cores ing on size, budget, and service, a critical point for all funders is of the state. to be more knowledgeable about the diverse communities they In collaboration with Neighborhood Health Plan, Culture serve and build strong relationships within those communities. InSight designed and delivered the region’s first cultural It is not enough to just read the data. Get out of the office and competency training program for pharmacists utilizing the meet community members and leaders. Serve as the bridge train-the-trainer model. Participants in the class are now able to between funders and the ethnic and poor communities. deliver training to additional pharmacists throughout the region. Additional funding and grants are always valued. But Culture InSight provides ongoing consultation and training ultimately, we have made a strong impact because we have support to the Urban Scholars program at Dartmouth developed a specific approach that adds value to all of the Medical School, serving as a bridge between Dartmouth and efforts that take place in the health disparities field, and we various urban medical systems. have stayed with that framing and strategy over the past 10 The program has supplied scholarships to facilitate training years. Our focus and consistency about what we are doing is for bilingual staff of health centers in Massachusetts, includ- what leads to strong patient-provider relationships to improve ing the MetroWest Free Care Clinic. By providing free the quality of health care throughout the region. medical training to volunteers, we have enhanced the quality of care they are able to provide to their large population of limited-English proficient patients. Culture InSight’s Foundations in Medical Interpreting Views from the Field is offered by GIH as a forum program has served as a best practices model in the field of for health grantmakers to share insights and experiences. If you are interested in participating, please contact Faith Mitchell at 202.452.8331 or fmitchell@gih.org.