Medical Leadership Council Proceedings 2006-2008 by Catherine Direen

Language Access, Cultural Proficiency & Health Care Workforce Diversity

Resources from the Medical Leadership Council on Cultural Proficiency

Proceedings from 2006, 2007 & 2008 Meetings May 10, 2006 November 15, 2006 May 30, 2007 November 28, 2007 May 28, 2008 November 12, 2008

Sponsored by The California Endowment Convened by the California Academy of Family Physicians

Contents Introduction

Medical Leadership Council Overview

Member Organizations 7 Charter & Operating Principles 8 Guiding Principles - State & Federal Policy 10 Policy Background 14 State Policy Updates 17

MLC Areas of Focus: Increasing Language Access, Cultural Proficiency & Workforce Diversity in Health Care

Panel Discussions & Project Summaries 20 Language Access & Cultural Proficiency 20 Workforce Diversity 28 Projects by Other Organizations 32 Other Work by The California Endowment 35 MLC Resources 37 Appendix: Description of MLC Member Organizations 40

contents

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You can’t provide quality care and you can’t connect with a patient unless you can communicate with that patient about his or her needs in a comfortable way. Robert K. Ross, MD – President and CEO, The California Endowment

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Medical Leadership Council on Cultural Proficiency

Introduction Language access can be a matter of life and death in health care. It is critical that providers and patients are able to discuss symptoms and remedies in a language each can understand. To be effective, health care must also be delivered in a manner that respects patients’ cultural perspectives and practices.

Recognizing the urgency and the widespread need, The California Endowment’s Medical Leadership Council on Cultural Proficiency (MLC) has been meeting since 2002 to find ways to improve language access, cultural proficiency, and workforce diversity in health care. The Council also works to eliminate health disparities based on race and ethnicity. This set of Proceedings reports on Council meetings held in 2006, 2007 and 2008.

Together, the physician and staff leaders of California’s medical specialty societies, county medical associations, and some hospitals and health systems have met regularly with experts and advocates to learn more and, in turn, do more to improve health care in this state where one in five residents speaks English with limited proficiency.

The Council, a unique and powerful group represented by its diverse and geographically dispersed members, has worked to improve hospital and health system policies and practices and to increase physician and medical staff awareness and effectiveness in providing culturally proficient care. In addition, many MLC members have taken this expertise and advocated for improved policies and regulations related to cultural proficiency.

The following summary presents the MLC’s Policy Principles, the group’s recommendations for shaping a health care system that serves all Californians well. It also outlines relevant federal and state legislation crafted to ensure language access is more widely and effectively guaranteed. Other sections describe in-the-field projects MLC members are conducting to find ways to deliver and pay for interpreter services, increase physicians’ ability to deliver culturally proficient care, and mentor the next generations of physicians and other health care professionals to create a workforce that mirrors the state’s ethnic and racial diversity.

Knowing there still is much work to be done, Council members can take this opportunity to reflect on the accomplishments of the past several years and draw from those the inspiration and commitment to continue.

Special thanks to Robert K. Ross, MD, President and CEO of The California Endowment, and Ignatius Bau, Director of Health Systems at the foundation, for their leadership. Special thanks also to Leonard Fromer, MD, Past President, California Academy of Family Physicians, and Susan Hogeland, CAE, Executive Vice President of the Academy, for their contributions representing the lead administrative organization for the Council.

introduction

Medical Leadership Council on Cultural Proficiency

Medical Leadership Council Overview Member Organizations Charter & Operating Principles Guiding Principles - State & Federal Policy Policy Background State Policy Updates

medical leadership council overview

“

It’s one thing to provide a service, but if you’re not providing a quality service, you’re really doing a disservice to the patient. Traci Van – Sutter Health

Medical Leadership Council on Cultural Proficiency

”

Member Organizations Medical Leadership Council on Cultural Proficiency Alameda-Contra Costa Medical Association

Los Angeles County Medical Association

American Academy of Pediatrics, District IX (CA)

Napa County Medical Society

American College of Emergency Physicians, CA Chapter

Native Wellness & Advocacy/Association of American Indian Physicians

American College of Obstetricians and Gynecologists, District IX (CA)

Orange County Medical Association

American College of Physicians, CA Chapter Asian and Pacific Islander American Health Forum California Academy of Family Physicians

Riverside County Medical Association St. Joseph Health System San Bernardino County Medical Society San Francisco Medical Society

California Association of Public Hospitals and Health Systems

San Joaquin County Medical Society

California Hospital Association

San Mateo County Medical Association

California Latino Medical Association

Santa Clara County Medical Association

California Medical Association

Scripps Health

California Medical Association Foundation

Sierra Sacramento Valley Medical Society

California Primary Care Association

Solano County Medical Society

Catholic Healthcare West

Sonoma County Medical Association

Fresno Madera Medical Society

Stanislaus County Medical Society

Golden State Medical Association

Sutter Health

Kern County Medical Society

Wellpoint

Member Organizations

Charter & Operating Principles Charter The California Endowment’s Medical Leadership Council on Cultural Proficiency Name: The California Endowment’s Medical Leadership Council on Cultural Proficiency

Charge: Convene the key stakeholders of medical and health organizations in California to educate, build capacity and engage their memberships on issues of racial and ethnic health disparities by: n

educating physicians and other health care providers on health disparities, language access, cultural proficiency and health workforce diversity issues;

developing tools and resources for provider groups to assess and improve their memberships’ ability to provide culturally proficient and linguistically appropriate health care services;

exploring development, improvement and promotion of efficient and easily accessible local interpreter resources and services;

examining and developing solutions to the problem of limited diversity in the physician and health care workforce as one means of addressing disparities in the provision of health care services;

examining and addressing other barriers to care that result in racial/ethnic disparities in health care and health status.

explore development, improvement and promotion of efficient and easily accessible local interpreter services.

Goal One: Eliminate barriers to health care caused by Limited English Proficiency.

Goal Two: Improve cultural proficiency in the medical practice.

Goal Three: Develop policies that establish sustainable financing mechanisms for providers, health systems, hospitals, health plans and qualified health care interpreters engaged in the delivery of language assistance services.

Goal Four: Examine barriers and means to improve entry into the medical and other health professions by members of California’s underrepresented minority and underserved populations and undertake efforts to increase diversity representative of California’s population in the physician and health care workforce.

Goal Five: Examine barriers to health care and disparities that result from race or ethnicity, including those related to ethnopharmacology, and evaluate and adopt best practices for eliminating such barriers.

Operating Principles The Medical Leadership Council on Language Access (MLC) was convened by The California Endowment (TCE) in 2002 as a council of medical and specialty societies, with additional representation from health plans and other organizations interested in language access. The MLC has served as a forum for educating physician leaders about barriers to care resulting from Limited English Proficiency and sharing best practices to reduce such barriers. Council member organizations have developed a statement of policy principles regarding language

Medical Leadership Council on Cultural Proficiency

access to serve as guidance for their respective organizations’ public policy and educational activities. Beginning in 2005, the MLC will expand its charge to include other issues of racial and ethnic health disparities related to cultural proficiency and health workforce diversity. n

MLC is funded by TCE and convened by the California Academy of Family Physicians (CAFP). Meetings are co-chaired by TCE President and CEO Robert Ross, MD and CAFP Past President Leonard Fromer. TCE and the CAFP jointly schedule meetings and establish agendas for the MLC meetings.

The MLC itself does not make decisions or adopt positions. Discussion and dialogue is encouraged during meetings but there are no formal Rules of Order.

Work groups comprised of volunteers have been utilized for development of such documents as the Public Policy Principles for Language Access and Interpreter Services in California, which are then circulated among the MLC’s member organizations for review and adoption. Each member organization may adopt such principles or not, as it sees fit and according to their respective internal process for adopting policy positions.

The MLC is based on concepts of collaboration and partnership, and all participants are encouraged and provided incentives to work in concert; sharing best practices and programs and resources. Each member organization is expected to participate consistently and contribute its own experiences and expertise to the MLC. In turn, TCE, through CAFP, provides stipends for participation. TCE also has made direct grants to member organizations for research, educational and implementation projects related to the MLC charge and priority issues.

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When people of different ethnic groups have similar insurance as Caucasians, they still tend to get a different level of service. We think that a lot of that disparity is because of cultural and linguistic differences. Susan Hogeland, CAE – California Academy of Family Physicians

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Membership: Membership in the MLC is at the invitation of TCE and the CAFP. Membership is open to physician and health care provider organizations and health care systems that agree to the charge, goals and operating principles of the MLC. Member organizations are expected to be represented by their executive staff and leadership—influential leaders willing to champion these issues, participate consistently, and actively educate and engage their memberships or organizations in the issues discussed by the MLC. Currently, membership is comprised of 10 county medical societies, one state medical society, one foundation, three state health associations, three ethnic medical societies, one advocacy organization, five specialty societies and six health plans.

Current Membership Roster: The current membership roster is available from CAFP.

Frequency of Meetings: The MLC meets twice a year. Member organizations are expected to continuously educate and engage their membership or organization on these issues in between meetings and report back on their activities to the MLC. The CAFP and TCE will continue to identify and provide resources to facilitate this education and engagement among member organizations. For example, extensive resources are available at www.MedicalLeadership.org, MLC’s own Web site, including a county-by-county interpreter services guide.

Adopted November 17, 2005

Charter & Operating Principles

Guiding Principles: State & Federal Policy Medical Leadership Council on Cultural Proficiency Statement of Policy Principals The members of the MLC—leaders of medical specialty societies, county medical associations, health systems and hospitals—have agreed on a set of Policy Principles for Improving Cultural Proficiency and Care to Minority and Medically Underserved Communities. With the goal of expanding consensus among the statewide organizations and their national counterparts, each group is seeking official organizational endorsement on this range of recommendations in areas including language access, cultural competence, provider education, workforce recruitment and training, and payment for interpreter services. The principles are posted at www.MedicalLeadership.org

Public Policy Principles for Improving Cultural Proficiency & Care to Minority & Medically Underserved Communities Adopted November 2005 / Updated May 29, 2007

1. Introduction: Importance of Improving Cultural Proficiency in the Delivery of Health Services n

The organizations that comprise The California Endowment’s Medical Leadership Council on Cultural Proficiency are committed to promoting access for limited English proficient (LEP) patients, cultural proficiency, expanded health workforce diversity, and reduced health disparities in the provision of medical care to California’s Limited English Proficient and racial/ethnic medically-underserved populations. All persons, regardless of race, ethnicity or primary language deserve access to high quality health services. Cultural proficiency is defined as a set of congruent behaviors, attitudes and policies that come together in a system, agency or among health professionals that enables work in cross-cultural situations. A culturally proficient organization values diversity; conducts cultural selfassessments; is conscious of and manages the dynamics of difference; institutionalizes cultural knowledge; and adapts services to fit the cultural diversity of the community served. n

“

You have to learn that the grief process is very different in different cultures … you have to be very careful. There is no

2. Organizing Principles

course in medical school

Provider Education

that teaches you these things. Satya Chatterjee, MD – Sierra Sacramento Valley Medical Society

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Medical Leadership Council on Cultural Proficiency

Medical societies and provider associations should work with their members to educate them about cultural proficiency, health disparities among racial and ethnic medically-underserved populations, and the impact on health outcomes of limited English proficiency. These organizations should make available information, trainings, and other resources so that physicians and other health care providers n

may continually improve access to quality care and reduce health disparities. n

Health professionals should be aware of, and sensitive to, the cultural and ethnic diversity of patients they serve so they can develop and implement best practices such as providing interpreter services and culturally proficient care in their offices. Health professionals should be aware of the connection between good cross-cultural communication and ensuring patient safety.

The Office for Civil Rights should disseminate information and provide technical assistance about best practices in the provision of culturally, ethnically, and linguistically sensitive care delivery.

Workforce Issues n

The State of California should encourage the racial, ethnic, religious, and linguistic diversity of its health care workforce to reflect the needs of the population it serves.

Medical and other health professional schools should increase efforts to recruit and retain minority faculty and promote minority faculty into leadership positions.

Cultural proficiency training should be incorporated into residency programs in every specialty and should be available as part of the continuing professional development of health professionals.

To meet the needs of LEP patients, the State of California should provide incentives for the development of a trained interpreter workforce.

Medical school admissions policies should reflect the importance of increasing the representation of underrepresented minority students.

Language Access n

Language assistance services, including, but not limited to, bilingual providers and staff, dedicated staff interpreters, contract interpreters, telephonic and video language services, translated written materials, and translated signage, are an essential element of delivering culturally proficient care, particularly to LEP, racial and ethnic medically-underserved communities.

Any language access requirements placed on physicians and other health care providers must recognize the logistical difficulties in the provision of interpreter services for unusual/rarely encountered languages and in urgent/emergent situations, and provide exemptions and additional assistance for these situations, as appropriate.

State, regional and local systems of language assistance service should take into account the limited capabilities and resources of health plans, hospitals, clinics, health departments, medical groups, physician practices and other health professionals. To the extent possible, there should be efforts to collaborate, coordinate and centralize the provision of language assistance services to increase efficiencies and minimize costs and administrative burdens to health professionals.

Payment for interpreter services in both publicly- and privately-funded health care systems must be the responsibility of the insuring or purchasing entity.

Guiding Principles: State & Federal Policy

Research and Data Collection n

Health insurers and health care plans should be required to collect and/or report socio-cultural health information (e.g., patientâ&#x20AC;&#x2122;s race and ethnicity, including subpopulations, primary language, etc.) to assist physician offices, while respecting the individual privacy of patients. This data collection shall not be delegated to the treating physician without an explicit paid, contractual agreement.

Culturally and ethnically diverse populations must be fully represented in clinical studies supported by both private and public sector funds. Researchers from minority communities must be trained to conduct research and clinical trials.

Diseases and conditions disproportionately affecting LEP, racial and ethnic medically- underserved populations should be adequately investigated. Research on specific populations should be conducted to document health issues and successful interventions.

Health Care Financing n

The availability of, and access to, quality, affordable health insurance is integral to eliminating disparities among LEP, racial and ethnic medically-underserved populations.

Public insurance programs should promote access for beneficiaries by advertising availability, providing applications and other documents in other languages, and reviewing application processes to see what barriers may exist for eligible populations.

Written Resources n

The state and other interested stakeholders should examine the feasibility of statewide or local clearinghouses for translated or in-language materials that could increase access to quality health education, medication information, and other health-related information.

Quality Assessment n

Quality indicators that measure cultural proficiency should be developed.

A review of current quality assessment measures should be conducted to identify areas for integration of cultural proficiency measures and make appropriate recommendations.

Payment n

Payment for interpreter services in both publicly- and privately-funded health care systems must be the responsibility of the insuring or purchasing entity.

The primary financial entity (State, insurance company, or managed care company) should contract with and pay interpreters directly unless medical groups or physicians explicitly choose to accept risk for such services in their contracts. Health professionals, including medical groups, shouldnâ&#x20AC;&#x2122;t unwillingly bearing the burden or expense of providing interpreter services.

There should be consideration of reimbursement of physician office bilingual staff who serve as interpreters, as long as they have been trained and assessed for linguistic competency. There should be consideration of compensation for bilingual physicians who would otherwise require an interpreter, provided they have been assessed for linguistic competency.

3. Policy Options

Medi-Cal/SCHIP/Medicare n

The State of California should work with the Centers for Medicare and Medicaid Services (CMS) and the State Health Insurance Program (SHIP) to ensure the cultural and linguistic proficiency of their respective

Medical Leadership Council on Cultural Proficiency

staffs. Materials used to detail Medicare services, in particular Medicare-covered preventive care, should meet the language and health literacy levels of the beneficiaries they serve. CMS should evaluate the materials and strategies used by SHIPs to reach the LEP, racial and ethnic populations they serve. n

The State of California should work with CMS to ensure that reliable and comprehensive data are collected and reported with regard to beneficiaries’ race, ethnicity, and primary language, while respecting the individual privacy rights of beneficiaries.

The State of California should work with CMS to ensure that any program developed by CMS that bases a payment, bonus or reward on quality measures, includes quality measures of care for minority beneficiaries.

The State of California should seek federal matching funds for the provision of interpreter services for patients in the Medi-Cal and Healthy Families programs; the State should also address funding issues within the Workers’ Compensation program.

The State of California and Council members should work with federal policy makers to ensure that language services are a covered benefit under the Medicare program.

Ideally, the State or federal government would organize a centralized service for interpretation that can be accessed easily by physicians. Models with significant promise include that in place in Washington State and the national telephonic interpreting service in Australia. The State of California should support a regional pilot project to test delivery models for such a service.

Managed Care/Health Plans n

Managed care/health plan organizations, including public and private HMO’s, should work with physician and other health provider organizations to ensure the development, evaluation, and diffusion of curricula, training, and education programs that address cultural proficiency, medically underserved communities, and health disparities.

“

Infant mortality rates in our county show that we do worse than maybe a Third World country. That tells us we need to change the way we’re doing things.

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Eric Ramos, MD – Stanislaus County Medical Society

Managed care organizations/health plans should use cultural proficiency as an indicator of access and quality.

Both public and private HMOs and health plans should be asked to take explicit responsibility for paying and arranging for interpreter services as a covered benefit for members with the caveat that such services are the responsibility of the primary financial entity (HMO or purchaser) and are not to be born by fiscal intermediaries such as local medical groups or physicians and other providers, unless physicians/groups/ other providers have explicitly contracted for the provision of such interpreter services.

Managed care organizations/health plan organizations should negotiate with both public and private payors for adequate reimbursement to cover the expenses of interpreter services so that they can establish services without burdening physicians.

Private Industry n

Private industry should be engaged by medical organizations and patient advocacy groups to consider innovative ways to provide interpreter services to both employees and the medically underserved.

Guiding Principles: State & Federal Policy

Policy Background Mandates & Encouragement: Laws, Regulations, and Policies Physicians and other health care professionals place patient health and well-being above all else. To support this goal, a variety of federal and state laws govern the provision of interpreter and translation services to patients with limited English proficiency (LEP). Following is a summary of these requirements.

Federal & National Polices 1964: Title VI of the Civil Rights Act of 1964 and subsequent regulations prohibit not only intentional discrimination based on race, color or national origin in any program or activity that receives federal funding, but also policies and practices that may appear neutral but have the effect of such discrimination. This is the section of law under which language-access complaints are filed and its requirements govern areas including health care, where most providers and facilities receive some form of federal reimbursement. 1974: A 1974 U.S. Supreme Court decision (Lau v. Nichols) established that Title VI prohibits discrimination based on limited English proficiency. The DHHS Office of Civil Rights is charged with enforcing Title VI, and when the department receives complaints staff members investigate. Based on policy guidance issued by the Department of Justice (2002, below), four main factors are considered when evaluating compliance: a) the proportion of LEP patients served; b) the frequency of contact with LEP patients; c) the importance of the program; and d) the resources available. The Office works with physicians and others to resolve complaints, and has brought only one action in the past 20 years to a hearing. 1998: President Bill Clinton and Secretary of Health and Human Services Donna Shalala launch the federal Initiative to Eliminate Racial and Ethic Disparities in Health Care, which since has focused attention on improving the health status of people of color nationwide. This initiative focuses on six areas: infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection/AIDS, and immunizations. 2000: The Clinton Administration issues Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency,” affirming the 1974 prohibition (above) and outlining the requirement of equal access to federally funded health care and services for LEP patients. 2000: Office of Civil Rights releases the “Title VI Prohibition Against National Origin Discrimination As It Affects Persons with Limited English Proficiency: Policy Guidance.” 2000: The Department of Health and Human Services Office of Minority Health issues “National Standards on Culturally and Linguistically Appropriate Services in Health Care—Final Report,” now commonly called the CLAS standards. In addition, JCAHO Accreditation and NCQA (HEDIS measures) both added interpreter/language services as a reporting requirement. 2002: The Department of Justice re-affirms Executive Order 13166 and issued policy guidance. 2002: The federal Centers for Medicare and Medicaid Services issue a final regulation for Medicaid managed

Medical Leadership Council on Cultural Proficiency

care programs that includes a requirement for language access. 2003: U.S. Department of Health & Human Services Guidance: The federal guidelines for services to Limited English Proficiency persons is re-published, remaining similar to those released previously. The National Health Law Program (NHeLP) develops a document, “Side-by-Side: Comparison of HHS Aug. 2000/Feb. 2002 LEP Guidance to DOJ June 2002 and HHS Aug. 2003 Guidance,” which can be ordered by calling NHeLP at 202/2897661. 2006: Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) Standards The new standard (as of 2006) requires Joint Commission-accredited hospitals to document patients’ language and communication needs. A report, funded by The California Endowment, Hospitals, Language, and Culture: A Snapshot of the Nation, describes a three-year study analyzing 60 hospitals across the country in their efforts to offer culturally competent care. The Joint Commission report makes recommendations to hospitals and policymakers and shares best practices for health care for diverse populations. 2006: NCQA HEDIS Measures In September 2006, the National Committee on Quality Assurance (NCQA) issues the HEDIS 2007 Vol. 2 Technical Update, which includes voluntary reporting in 2007 on two HEDIS measures: (1) Race/ Ethnicity Diversity of Membership; and (2) Language Diversity of Membership.

State of California Medi-Cal managed care contracts, CA Department of Health Services (DHS) policy letters, Healthy Families contracts, and the CA Health and Safety Code in a section governing acute care hospitals all establish requirements for oral interpretation and written translation. 1973 The Dymally-Alatorre Act requires language access services for State and local government agencies that serve a “substantial number of non-English-speaking people.” 2002 The Oakland Health Department begins providing language access services, observing a 10,000 LEP population threshold. In San Francisco, the threshold is 5 percent or 10,000 LEP population per supervisorial district. 2002 AB 982 becomes law, designed to increase the number of primary care physicians and dentists practicing in historically underserved areas by providing grants to help pay for the high cost of attending medical or dental school. Some $6 million over three years will come from the Medical and Dental Boards toward educational loan repayments for practitioners working in underserved areas. The program, administered by the Office of Statewide Health Planning and Development, will give priority to applicants who speak Medi-Cal threshold languages, and will consider applicants’ economic status as well.

Policy Background

2002 The Department of Consumer Affairs (DCA) and DHS form a Task Force on Culturally and Linguistically Competent Physicians and Dentists, which holds public hearings, consults experts, and adopts recommendations for continuing education and cultural competence certification. 2003 The Department of Managed Health Care and Office of Patient Advocate issue a Consumer Report Card in October that includes data voluntarily reported on LEP-related services. Language access questions are included on the Consumer Assessment of Health Plans Survey. CA DHS and the Managed Risk Medical Insurance Board (MRMIB) are monitoring language access services in Medi-Cal managed care and the Healthy Families program. 2004 State Senate Bill SB 853 —Healthcare Language Assistance—clarifies that Knox-Keene health plan licensure standards include requirements for health plans to provide access to culturally and linguistically appropriate health care services, such as trained interpreters and translated documents. The law will go into effect in 2008. 2007 Department of Managed Health Care in March issues regulations for implementation of SB 853 in the California Language Assistance Program. Health plans had until July 1, 2008 to provide in writing their proposed standards in four areas: enrollee assessment, provision of language access services, staff training, and compliance monitoring. 2008 To prepare for implementing SB 853 requirements by January 1, 2009, health plans were required to complete enrollee assessments, quality assurance amendments, and policies and procedures. 2009 Health plans were required to meet SB 853 requirements for Health Maintenance Organizations beginning January 1.

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About 40% of Californians report speaking a language other than English at home and of those, half report being limited English speaking. Census 2000

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Medical Leadership Council on Cultural Proficiency

STATE Policy Updates 2006-2008 California Health Care Reform Proposals As a whole, the Council does not take positions on legislation nor does it advocate for specific policies or regulations. The largest health policy development in the state in 2007 and 2008 was the Legislature’s consideration of several reform proposals. Ultimately, no reform measure passed, but MLC member organizations and advocates spent considerable time and energy working to ensure that the Council’s priorities were addressed in reform proposals that aimed to increase health care coverage.

By late 2008, most policy considerations were severely hampered by the State’s—and the nation’s—growing fiscal crisis. Calling on California legislators and the Governor to pass health care reform, Robert K. Ross, President and CEO of The California Endowment said, “It’s wrong to say health care reform can’t proceed because of the State’s budget problems. Leaving millions of people uninsured will just add to the problems.”

2008 Individual MLC organizations supported bills that would have addressed health care disparities and increased language access, but none of the bills passed. The Legislature again revisited health care reform but passed no proposals. The main issue facing the Governor and legislators was a growing budget deficit.

2007 MLC members supported bills aimed at increasing language access for both students and parents in the State’s educational system, improving language access services in the courts, and assuring the needs of LEP people were considered when the State creates emergency and disaster plans, but none of these bills passed. MLC members also advocated for language access, cultural proficiency and physician workforce diversity as the Governor and Legislature considered health care reform plans, which also did not pass.

2006 CA Assembly Bill 2283: Requires the Medical Board of California to annually compile data on physician ethnicity and foreign language proficiency by zip code and post the information on the Board’s Web site by October 1 each year. Signed by the Governor. (Chapter No. 512)

CA Senate Bill 1405: Would have required the Department of Health Services to create a Task Force on Reimbursement for Language Services to find ways to leverage federal matching funds from the Centers for Medicare and Medicaid Services to pay for language assistance services and to assess model practices in other states.

CA Cultural and Linguistic Competency of Physicians Act of 2003: In 2006 the Medical Board of California was deciding how to implement this law, which charges the Board with overseeing county medical societies in developing educational classes on foreign languages and cultural practices and beliefs that impact health care.

STATE Policy Updates 2006-2008

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Disparities in outcomes in health care based upon race or ethnicity are a violation of someone’s civil rights. Leonard Fromer, MD – California Academy of Family Physicians

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Medical Leadership Council on Cultural Proficiency

MLC Areas of Focus: Increasing Language Access, Cultural Proficiency & Health Care Workforce Diversity Panel Discussions & Project Summaries Projects by Other Organizations Other Work by The California Endowment MLC Resources

Mlc areas of focus:

Panel Discussions & Project Summaries Several panel presentations, project summaries, and roundtable discussions comprise the agenda at each of the biannual MLC meetings. These range from policy updates to briefings on the findings of in-the-field research projects, to strategic conversations about the best ways to improve language access, cultural proficiency, and workforce diversity in health care.

The following section provides summaries of panel discussions and overviews of research and improvement projects undertaken by MLC member organizations and other groups funded by The California Endowment. Copies of several speakers’ slides and links to related publications are available on the MLC Web site: www.MedicalLeadership.org.

Language Access & Cultural Proficiency November 2008 Meeting MLC member organizations reported on a variety of Endowment-funded projects in progress.

Providing Interpreter Services: The Alameda Contra Costa Medical Association has led the development of the Alameda County Coalition on Language Access in Healthcare (ACCLAH), a coalition of agencies, organizations and individuals invested in making interpreting services available to physicians, other health care professionals and institutions.

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The mission of ACCLAH is to drive collaborative solutions to countywide needs for effective, efficient, patientcentered and culturally proficient language access services in the Alameda County health system. ACCLAH is supporting a variety of collaborative demonstration projects to pilot new methods of delivering interpreting services to primary care physicians who have traditionally been left out Everybody should have of established language support networks.

equal access to care,

regardless of their ability to speak the language.

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William Guertin – Alameda-Contra Costa County Medical Association

Fluency, Inc. was awarded subcontractor status for ACCLAH and was working on the Alameda County Language Access Portal, which will provide the first public/private approach to managing the dispatch of face-to-face interpreters throughout a highly diverse, urban California county for a variety of public and for-profit healthcare customers.

Medical Office Staff Training: Executive Director Dolores Green from the Riverside County Medical Association and Executive Director Linda Stratton from the San Bernardino County Medical Society described trainings their organizations developed in which physicians teach medical office staff about language access needs and solutions. Five hundred physician assistants, nurse practitioners, medical assistants, office managers, and receptionists have been invited to the educational series. An evaluation of the pilot and future recommendations will be developed in early 2009.

Medical Leadership Council on Cultural Proficiency

Regional Solutions for Interpreter Services: The San Francisco Medical Society (SFMS) hosted a two-part “Language Solutions Stakeholders Meeting” in April 2008 to develop a consensus about the best way to provide interpreter services at the regional level. In this project, outlined by SFMS consultant Diana Lau, RN, CNS, 17 stakeholders— including physicians, Independent Practice Associations (IPAs), HMOs, language policy experts and others— determined that a centralized language broker would be the best solution. Participants agreed that a “centralized collaborative language portal model” could best address current needs, including consistent interpreter standards, research to validate standards, interpreter evaluations, and a computer-based scheduling system.

Training & Competency Testing: Sutter Health adopted a competency testing process for bilingual staff and followed that up with an interpreter skills training program. In addition, the health system has developed a strategic plan to infuse cultural competence into its priority areas to help ensure quality care for all patients and an inclusive work environment for staff.

May 2008 Meeting Videoconferencing Medical Interpretation (VMI): San Francisco General Hospital’s (SFGH) State-of-the-Art Services The SFGH Interpreter Services Department receives between 80,000 and 90,000 requests for interpreters each year. About half of these are handled using VMI. The Medical Leadership Council met at SFGH for its May 2008 meeting to watch VMI in action and hear from hospital and program leaders about how services are delivered.

Hospital presenters: Gene O’Connell, CEO; Alice Chen, MD, MPH, Medical Director, General Medicine Clinic; Alicia Fernandez, MD, Associate Professor, University of California, San Francisco; David Minh Dao, Supervisor, Interpreter Services Department; Bruce Occena, VMI Coordinator

SFGH is a public teaching hospital where approximately 20 percent of patients do not speak English. Through presentations and then clinic and interpreter-office tours, Medical Leadership Council members observed firsthand how SFGH provides Videoconferencing Medical Interpretation (VMI) and other language access services in outpatient settings.

The Interpreter Services Department receives between 80,000 and 90,000 requests for interpreters each year. About half of these are handled using VMI. The hospital employs 34 staff interpreters who provide VMI, in-person, and telephone interpreting in 22 languages on-site; 11 on-call interpreters who provide interpretation in an additional 9 languages; two outside agencies that provide telephone interpreting in 170 languages; and an outside agency that provides American Sign Language interpreting. SFGH strives to use staff interpreters whenever possible.

Mlc areas of focus: panel discussions & project summaries

The department, housed in two office locations, provides interpreter services throughout the clinics and the hospital 16 hours a day, 7 days a week.

VMI is the preferred method for providing interpreter services in the outpatient clinics, though in-person and telephone interpreting are also provided when a physician or other provider requests them because the specifics of a patient visit make one of these methods a better choice. (VMI is not used for inpatient services. Speakerphones are a better option because of hospital wiring challenges.)

Video interpreting is provided using a video monitor on a rolling cart, which can easily be moved to different exam rooms and is operated using just two buttons - ‘on’ and ‘off.’ SFGH uses 25 of these monitors for doctors/ patients in the outpatient clinics. During consecutive interpreting, the interpreter appears on the monitor as a third party in the exam room. A live image of the interpreter fills the screen and a small live image of the patient and physician appears in a small box at the top corner of the screen so they can see what the interpreter is seeing. For the interpreter the images are reversed, with the physician’s and patient’s images filling the screen and the interpreter’s own image appearing in the small corner box. As in most videoconferencing set-ups, the camera can be temporarily blocked in case the physician-patient encounter requires temporary visual privacy.

SFGH has realized tremendous efficiencies using VMI, an effort that began in pilot projects in 2003. In earlier days, in-person interpreters usually were able to handle at best two requests an hour and the wait time for a patient and physician to meet with an interpreter was an average of 40 minutes. Today, using VMI, four to five requests can be met per hour and the average wait time is just 20 seconds. Because this allows for more effective use of the interpreter staff, the wait time for in-person services has also been decreased to nine minutes.

Telephone interpreting also is state-of-the-art, provided via speakerphones and, in areas with no wiring for phones, cordless Polycom speakerphones on rolling carts, which facilitates clear, volume-controlled communication among a patient, physician and interpreter. SFGH uses four of these set-ups.

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Latinos are 1.8 times as

Physicians and patients alike rate VMI and SFGH’s overall interpreter services highly.

likely, non-Hispanic Blacks are 2.7 times as likely, and American Indians are 3 to 4 times as likely as whites to undergo lower-limb amputations. Kaiser Family Foundation

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Ensuring Interpreter Services Are Integrated into Medical Practice Demonstrating that the capacity to provide interpreter services works only as well as the medical staff are trained to use these services, Alicia Fernandez, MD presented the published results of a study at SFGH showing that hospitalized patients who do not speak English are less likely to have documentation of informed consent in their medical charts.

The study compared the charts of 74 Mandarin/Cantonese/ Chinese- and Spanish-speaking LEP patients who received a thoracentesis, paracentesis, or lumbar puncture with 74 English-speaking patients who underwent the same procedures, on the same date, on the same hospital service.

Medical Leadership Council on Cultural Proficiency

Researchers found that the charts of English-speaking patients were more likely than those of LEP patients to contain full documentation of informed consent (53% vs. 28%), and were more likely to contain a signed consent form (85% vs. 70%). These differences could result from several factors. Researchers believe the low rates of documented interpreter use (fewer than one-third of LEP patients had documentation of interpreter services in the process of informed consent), combined with fewer signed consent forms, is due to an under-use of interpreters, resulting in inadequate or absent informed consent.

This under-use occurred despite legal requirements for informed consent and the legal standard of a signed consent form. This is in addition to federal and state laws that require providers to use interpreters and SFGH policy that requires documentation. In response, hospital CEO Gene O’Connell championed the results as an example of valuable quality improvement information and a good assessment of disparities.

SFGH has since developed a new consent form that: (1) can be understood by patients with lower-level reading skills; (2) prompts physicians to call interpreters and assess patients’ comprehension; and (3) is printed in English, Spanish, Russian, Chinese, Vietnamese, and Tagalog. In addition, a new qualitative study is under way to examine medical residents’ decision-making on interpreter use.

May 2008 Meeting The Role of Solo and Small Group Practice Physicians in Serving Underserved and Diverse Patient Populations Three projects examined ways to support solo and small practices providing much needed care to underserved patients.

Funded by The California Endowment, the California Medical Association Foundation (CMA-F) has undertaken projects aimed at improving care for diverse populations. Elissa Maas, MPH, CMA’s Vice President for Programs, outlined three recent efforts. In one, the CMA-F served as the lead organization for an NCQA pilot project to understand and address barriers to care for minority patients in small primary care practices, and to provide demonstration grants to solo and small group practices to improve care for these same patients. Lessons learned included: Quality improvement takes longer than a year to achieve; smaller practices have fewer resources to devote to a change process, making it difficult to address information technology and quality improvement at the same time; and effective physician-staff communication is essential for success.

Another project examined ways physicians in 42 solo and small practices in Santa Clara County were providing language access. Findings included: Wide variations exist between physicians’ own assessment of how well they can accommodate patients with LEP and how confident they were that they communicated with LEP patients effectively; quality of care issues arose more frequently with LEP patients; and few physicians used trained interpreters.

Resulting recommendations include: Exploring ways medical school curricula can include training about multilingual and multicultural medical practice; publicizing health plan compliance plans in response to Department of Managed Health Care and other language access regulations; and supporting increased opportunities for healthcare interpreter training.

Mlc areas of focus: panel discussions & project summaries

The third project looked for ways to support the sustainability of primary care ethnic physician solo and small practices to ensure safety net patients’ access to care. The study focused on the Bay Area, Los Angeles County, the Central Valley, and San Diego County and included focus groups with more than 200 physicians, discussions with more than 80 health care consumers, 40 physician office site visits, and a literature review. Resulting recommendations included: Increasing awareness about the role played by this segment of physicians; increasing Medi-Cal and other payments for these physicians; strengthening office infrastructure and medical office staff performance; and developing partnerships at the community level to bring these primary care physicians together with other safety net providers to improve access to care.

May 2007 Meeting Research on the Value of Language Access: Interpreters a critical resource Several recent studies show that providing language access improves patients’ quality of care, and not providing access seriously compromises care.

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Alice Huan-mei Chen, MD, MPH, medical director of the General Medicine Clinic at San Francisco General Hospital, presented research she and other physicians conducted showing the positive impact the use of professional interpreters has on clinical outcomes, and calling for well structured research to learn more. The medical literature also shows that use of professional interpreters appears to increase the quality of care for Limited English Proficient patients to nearly that of patients without Thinking back seven language barriers.1

years ago, these issues were really not on a lot of people’s radar screens. Alice Hm Chen, MD, MPH – San Francisco General Hospital

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Another study found that “about 49.1 percent of LEP patient adverse events involved some physical harm, whereas only 29.5 percent of adverse events for patients who speak English resulted in physical harm.”2

Elizabeth Lyster, MD, MPH, FACOG of the American College of Obstetricians and Gynecologists (ACOG), District IXCalifornia, presented a new publication, Language Access Solutions for OB/GYN Medical Practices, which provides a summary of research documenting the need for language access, a chart outlining and evaluating methods of providing it, practice recommendations (including eliminating the use of children as interpreters) and policy recommendations.

Karliner, L.S., Jacobs, E.A., Chen, A.H. & Mutha, S. “Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency? A Systematic Review of the Literature.” Health Services Research 42:2 (April 2007). 1

Divi, C., Koss, R.G., Schmaltz, S.P., & Loeb, J.M.: “Language Proficiency and Adverse Events in U.S. Hospitals: A Pilot Study.” International Journal for Quality in Health Care (February 2, 2007). 2

Medical Leadership Council on Cultural Proficiency

November 2006 Meeting MLC member organizations focused on projects that could increase language access in a variety of health care settings.

Statewide Database: The California Academy of Family Physicians unveiled a new, searchable, statewide database, funded by The California Endowment, listing interpreters, patient education information in languages other than English, local nonprofit organizations offering services in languages other than English, and other resources available to physicians, medical office staff, patients and the public. See www. MedicalLeadership.org.

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It can’t be done overnight, but we’ll get there.

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Frank Staggers, MD – Alameda-Contra Costa County Medical Association

How Family Physicians’ Offices Meet Language Access Needs: California Academy of Family Physicians representatives visited physicians’ offices in a pilot project to learn first-hand how they meet patients’ language access needs. The findings are published in the report Addressing Language Access in Your Practice— On-Site Assistance Pilot Project Report, available at www.MedicalLeadership.org.

Advocating for Ethnic Physicians: The Network of Ethnic Physicians Organizations is working to improve quality and access to care provided to safety net communities and to advocate for solo and small group ethnic physicians serving these populations.

Improving CME: The Institute for Medical Quality, a subsidiary of the California Medical Association, is providing technical assistance to continuing medical education providers to meet the new State requirement that all CME courses address cultural and linguistic competence in the practice of medicine.

May 2006 Meeting Hospital & Health System Improvements Hospitals and health systems across the state are piloting ways to improve services and care for patients who speak English with limited proficiency.

California Health Care Safety Net Institute (SNI): Wendy Jameson, MPH/MPP, Director, outlined SNI’s statewide activities, which include:

Policy & procedure review: SNI is assisting public hospital systems in improving language access and cultural competency. Three California Association of Public Hospitals (CAPH) member institutions—Kern Medical Center, Riverside County Regional Medical Center, and Rancho Los Amigos National Rehabilitation Center— will participate this year in a Language Access Policy and Procedure Review. Each will receive $10,000 to review SNI model policies and procedures, as well as their own, and develop improvement plans. A subsequent project will allow hospitals that have completed the review process to apply for a $40,000 grant for additional consulting and training support.

Mlc areas of focus: panel discussions & project summaries

Video & phone interpreters: Three public hospitals (San Mateo Medical Center, Contra Costa Health Services and San Joaquin General Hospital) are sharing interpreter services remotely using video and speakerphone. San Francisco General Hospital and Alameda County Medical Center have linked their interpreters via VMI technology. Interest is growing in several Los Angeles county hospitals, other health plans, and private providers, considering the huge boost in productivity possible. At one hospital using all in-person, face-to-face interpreters, five FTEs can handle 45 encounters per day, limited mostly to hospital-based outpatient primary care clinics. At a hospital participating in the Health Care Interpreter Network (HCIN) (three CAPH member hospitals sharing interpreters via remote technology), one fulltime interpreter can handle 45 encounters a day throughout the hospital, including the emergency department.

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Team training: SNI also is helping eight public hospital teams to improve language access and integrate cultural competency principles into administrative and clinical practice, in partnership with the UCSF Center for the Health Professions. The program provides teams with leadership training, educational resources, tools to monitor accountability, and best practices to be shared among public hospital and health systems leaders. Teams this year come from Riverside County Regional Medical Center, Rancho Los Amigos National Rehabilitation Center, Santa Clara Valley Medical Center and San Francisco General Hospital and are focusing their project work on language access, palliative care for Latinos, and diabetic care for African Americans.

Asian American women

Partnership with Kaiser Permanente (KP): SNI and KP are sharing bilingual staff training and assessment tools. KP also has contributed significant funding to a learning partnership with HCIN.

have the lowest cancer screening rates and are usually diagnosed at a later stage compared to other racial and ethnic groups.

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Online resources: Go to www.safetynetinstitute.org to access language access tools and resources, including translated documents and signage.

Catholic Healthcare West (CHW): Eileen Barsi, Director of Community Benefit, discussed ways CHW has enhanced policies for patients with LEP; has developed a new education and training module on cultural competence, open to all employees, focusing on patient diversity and cross-cultural team-building; is developing a dedicated interpreter program; and plans to measure pre-and post-demonstration project outcomes in patient and provider satisfaction and in specific quality of care indicators. CHW also is tracking patients’ language preferences and needs system-wide and now conducts patient surveys by mail in each patient’s language of choice.

Montgomery (MD) County Dept. of Health & Human Services

Kaiser Permanente (KP): Gayle Tang, RN, MSN, Director, National Linguistic and Cultural Programs, outlined KP’s three main language access projects. One was a comparison of KP’s written translation process with that of other vendors. Results: KP’s process had the lowest error rate and a 38 percent lower cost. Another is assessing whether the use of KP qualified/trained interpreters and integrated systems of language access is predictive of better patient outcomes, a study comparing two different groups of 430 Cantonese-speaking patients each and two groups of 800 Spanish-speaking patients each. The third project is developing methods for testing providers’ language proficiency, a project in progress.

Medical Leadership Council on Cultural Proficiency

St. Joseph Health System: Veronica Gutierrez, MPH, Community Outreach Department, explained how her organization is tracking patient languages system-wide using MEDITECH; conducting extensive staff interpreter training; negotiating a system-wide contract for telephonic interpretation; introducing language access coordinators at each facility; conducting patient satisfaction surveys about language access; and including language access and cultural competency in physician grand rounds.

Scripps Mercy Hospital: David Shaw, MD, Director of Medical Education, presented details of a project in which readmissions to the hospital were reduced after staff began using basic medication instructions in English or Spanish at discharge. The project studied 126 patients with cardiovascular diseaseâ&#x20AC;&#x201D;one-half Englishproficient and one-half not. Fifty percent of both groups were medication compliant 48-72 hours after discharge and 35 percent of both groups were compliant 30 days after discharge. The hospital now uses a computerbased form to reconcile pre-and post-admissions medication lists and to provide instructions, and electronically translates the form into Spanish for patients who need it. Results: a 40 percent reduction in admissions for any cause over the six months after discharge and the elimination of readmissions due to medication non-compliance. Scripps Mercy plans to incorporate Vietnamese as the next language for translation.

Montserrat Noboa, Coordinator of the Cultural Competency and Linguistics Program at Scripps Mercy, works to improve employeeâ&#x20AC;&#x2122;s competence in these areas. She delivers a presentation on cultural awareness in all newemployee orientations and explains how to access interpreters for patients; holds a lunch-time multicultural health series; and teaches a brief medical Spanish series (three classes, two hours each) designed to help employees serve patients until an interpreter arrives.

Sutter Health: Maria Moreno, MPH, Health Services Researcher, and Traci Van, Community Benefit Coordinator, reported that Sutter Health has evaluated the language competency of 500 dual-role staff interpreters and is providing interpreter skills training as needed. Also, to increase access to appropriately translated patient education documents and decrease redundancy, the health system partnered with a translation vendor to develop a popular online library with 150 frequently translated patient education documents accessible to all Sutter affiliates.

The health system also will be selecting a single telephone interpreter vendor to provide services system-wide, is completing a cultural competence assessment using the federal CLAS guidelines as a baseline, and will develop improvement plans as necessary.

May 2006 Meeting Identifying Interpreters in Santa Clara County, CA In a Limited English Proficiency project, California Medical Association staff compiled a list of volunteer interpreters, mostly in Santa Clara County, and delivered training to bilingual staff in physician offices and to physicians on how to use interpreters. To design the next stage of projects, CMA staff planned to interview and survey physicians statewide to determine what kinds of efforts would be useful to them.

Mlc areas of focus: panel discussions & project summaries

Workforce Diversity November 2008 Meeting MLC member organizations are increasingly focused on projects to increase physician workforce diversity. Two of the main updates at the November meeting reported progress on the Network of Ethnic Physician Organizations and DECISION Medicine.

Network of Ethnic Physician Organizations (NEPO): Valerie Berry, MPH, director of the Network, discussed recent network activities, including the annual summit. Network activities are based on organizational goals, which include efforts to: support a network of ethnic physician leaders to serve as community health advocates throughout California; strengthen the collaboration between ethnic physician and community-based organizations; deepen the relationship between physicians and community members to improve the health of their communities; and encourage ethnic physician leadership development at the local, regional, and statewide level.

Increasing Physician Workforce Diversity: Currently in California, just 5 percent of the state’s 62,000 licensed, practicing physicians are Latino, though 33 percent of the population is Latino. Just 3 percent of the state’s doctors are black while 7 percent of the population is black. To help increase diversity, the San Joaquin County Medical Society has developed DECISION Medicine, a two-week program designed to encourage local students to consider careers in medicine and to show them such a career is possible. “In July 2008, 24 students received one-on-one mentoring from area physicians and shadowing opportunities in medical practices,” said Executive Director Mike Steenburgh. They also made group hospital visits and took a field trip to UC Davis Medical School.

May 2008 Meeting ‘The Color of Medicine in California: An Analysis of the California Medical Board Survey’ If the goal is to train a physician workforce in which the diversity of the state’s doctors matches the diversity of the state’s population, California has a long way to go. This first-ever comprehensive study of physicians’ ethnicity and language diversity provides the details.

Kevin Grumbach, MD, reported on a study of the ethnicity and language diversity of physicians in the state. Using Medical Board data, this is the first comprehensive study of its kind. Assisted by colleagues at University of California-San Francisco, Grumbach compared physician demographics with those of the state overall, examined the choice of medical specialty by ethnicity, the choice of practice location, languages spoken, and more.

His findings include: The under-representation of Latinos and African Americans in California medicine is “dire”; the state has few physicians of Samoan, Cambodian, Hmong and Laotian ethnicity and these groups should be more actively recruited; minority physicians are much more likely to serve in Medically Underserved Areas, Health Professional Shortage Areas, and minority and low income communities; minority physicians are much more likely to work in primary care; few non-Asian physicians speak Asian languages, though California physicians speak several languages in addition to English; and more.

Medical Leadership Council on Cultural Proficiency

His recommendations include: Investing in the educational pipeline to prepare minority and disadvantaged students for medical and health professions careers; promoting diversity as a key element in expanding medical education in the state; insisting that health professions schools develop a culture that promotes diversity, including recruiting and retaining underrepresented minorities; increasing incentives for physicians to work in underserved areas; and collecting and analyzing more data on California physicians as part of the relicensure process.

The California Endowment and the Statewide Office of Health Planning and Development funded this project.

Leveraging Federal Funds for Language Access in the Medi-Cal Program The California Health Care Interpreting Association (CHIA) reported on the work of the 19-member Medi-Cal Language Access Services Task Force that has been meeting since December 2006. Convened to recommend ways to draw down federal matching funds to help pay for language access for the state’s 2.5 million LEP MediCal beneficiaries, the group included advocacy organizations, ethnic health organizations, representatives of counties statewide, medical associations, and others. Their recommendations include: Creating a hybrid broker/ direct provider billing model in fee-for-service; reimbursing for services performed by interpreters trained in accredited programs; convening a quality assurance board; and starting with a multi-county pilot project.

Elizabeth Nguyen, chair of the CHIA Board of Directors, reported on the planned first meeting of the National Coalition on Health Care Interpreter Certification, which then took place in late May in Chicago. The group, comprised of a broad range of stakeholder organizations, plans to eventually develop a national certification.

November 2007 Meeting Increasing Workforce Diversity While Solving the Physician Shortage Speakers from State government, academia, and organized medicine outlined the escalating shortage of physicians and ways to increase the diversity of California’s health care workforce while working to end the shortage.

Anmol Mahal, MD, past president of the California Medical Association, called for increasing the number of physicians trained in California to help meet the growing need for physicians and to help increase diversity. “Only 25 percent of the physicians practicing in California attended medical school here,” he said. “Fifty percent attended elsewhere in the U.S. and about 25 percent are international medical graduates.”

“California will face a shortage of between 5,000 and 17,000 physicians by 2013,” many of them in primary care, said Angela Minniefield, MPA, deputy director of the Healthcare Workforce Development Division of the Office of Statewide Health Planning and Development (OSHPD). Currently, 7.8 million Californians live in geographic areas officially recognized as Health Care Professional Shortage Areas, where there is at most one physician for every 3,500 residents, she said.

OSHPD administers several programs to help address the physician shortage, including the Song Brown Healthcare Workforce Training Program, the National Health Service Corps/State Loan Repayment Program, and the healthcare professionals Shortage Designation Program. Earlier in 2007 OSHPD also convened the new Health Care Workforce Diversity Advisory Council.

Mlc areas of focus: Workforce Diversity

Better coordination of efforts among the entities training new health professionals and the entities wanting to employ them also would help address the shortage and improve diversity, said Kevin Barnett, DrPH, MCP, a senior investigator at the Public Health Institute in Berkeley, and Jeff Oxendine, MPH, MBA, associate dean for public health practice at the University of California-Berkeley School of Public Health. Their research shows that better links are needed between the “supply” side (state educational agencies; medical, nursing, public health and other schools and programs; undergraduate colleges and universities; and K-12 schools, among others) and the “demand” side (health care delivery systems, public health agencies, health plans, IPAs, PPOs, and others).

May 2007 Meeting Medical Schools Making a Difference: New ways medical schools are increasing physician diversity and cultural competence Three representatives of academic medicine explained ways their medical schools are recruiting more diverse students and ensuring that all future physicians are encouraged to become more culturally competent.

Rosalia Mendoza, MD, MPH, a post doctorate research fellow at the University of California, San Francisco (UCSF) Center for California Health Workforce Studies, reported that the supply of primary care physicians continues to decline, and the race and ethnicity of the physician workforce continue to lack the diversity of the patient population. Underserved communities suffer because of the lack of an adequate number of physicians to provide care, she said. To remedy these trends, the center recommends several approaches, including increasing medical school capacity in California; increasing medical schools’ focus on producing graduates who will care for underserved populations; increasing incentives and supports for physicians to practice in underserved communities; investing in primary care infrastructure and training; and investing in pipeline programs to prepare disadvantaged students for careers in medicine. Studies show that minority students and those from rural backgrounds are most likely to practice in underserved communities.

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Amerish Bera, MD, associate dean for admissions at the University of California, Davis (UCD), said trends at UCD show that physicians of color and those who grew up economically disadvantaged are most likely to provide medical care to low-income communities. He suggested that cultural proficiency may be more important than race or academic standards when selecting medical students likely to eventually work in underserved communities. He also is interested in developing a program in which a fourth year of medical school would be intensive training in primary care.

Workforce diversity has a

lot to do with encouraging people with those language skills, with those cultural beliefs into medical school training.

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Edward Hess, MD, MBA – San Bernardino County Medical Society

Medical Leadership Council on Cultural Proficiency

Donna Elliot, MD, EdD, associate dean for student affairs at the University of Southern California (USC) Keck School of Medicine, discussed USC’s work to recruit underrepresented minority students and provide cultural competence education. Keck conducts substantial outreach to a diverse pool of prospective medical students, providing informational forums and recruitment events throughout Central California at high schools, community colleges, and California State University and UC campuses. Keck also sponsors a high school

mentoring program, diverse student organizations and several minority medical student organizations and activities. As a result, USC’s class of 2010 is 20 percent underrepresented minorities, 49 percent male and 51 percent female.

USC has plans to augment its curriculum to increase cultural proficiency among future doctors through coursework and clinical experience. Changes include teaching about concepts of culture and various cultures’ approaches to health, illness and medical care; health care disparities; using interpreters; population health; and health policy and advocacy. Clinical instructional changes include adding questions about culture to student’s patient interviews, and requiring students to consider issues of health access and the effects of poverty on their patients.

May 2006 Meeting New Network of Ethnic Physicians in California Cultivating the power of numbers, ethnic physician organizations began meeting together as a network.

Arthur Fleming, MD, Chair of the Steering Committee for the NEPO, presented the group’s 2006-2010 Strategic Plan. NEPO is convened by the CMA-F and funded by The California Endowment and The California Wellness Foundation. Members’ work will focus on improving health, reducing health care disparities, and increasing the diversity of those entering medicine as a profession. “More than 10,000 physicians are represented by the 60 organizations in this network,” Fleming said. “They are the invisible face of the safety net—caring for the uninsured and the under-insured while they are un-reimbursed for much of their care.” NEPO’s goal is to serve as a collaborative organization to speak “with one voice” on health policy and health care issues. For more information, see www.ethnicphysicians.org.

“It’s a diverse and important group of physicians,” said NEPO Director Doretha Williams-Fournoy, MS. “They work in universities, large health systems, and also here in Los Angeles at Broadway & 112th Street in small offices, flowing past capacity.” The ongoing deterioration of the safety net and public health resources, low reimbursement rates, and the fragmentation of care for patients in small and solo practices are critical issues for ethnic physicians.

Mlc areas of focus: Workforce Diversity

Projects by Other Organizations At each meeting, MLC members learn from the work of other grantees of The California Endowment.

November 2008 Meeting National Medical Organizations Support ‘Patient Centered Medical Home’ Experts explain ways a patient-centered primary care medical home benefits diverse, low-income patients.

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In the patient-centered medical home—as jointly defined by the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics, and the American Osteopathic Association —each patient has a relationship with a personal physician, who leads a health care team that takes responsibility for delivering primary care and coordinating the patient’s overall care across African Americans with the health care system and in the community. heart disease are less likely This includes care for all stages of life, including preventive, acute, chronic, and end-of-life care. than whites to receive Care also is facilitated by “registries, information diagnostic procedures, technology, health information exchange, and other means to assure that patients get the indicated revascularization procedures care when and where they need and want it in a culturally and linguistically appropriate manner,” and thrombolytic therapy. according to the joint statement. Kaiser Family Foundation

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Data clearly show that this model improves care and reduces health care disparities, said Anne Beal, MD, MPH, of The Commonwealth Fund. Studies indicate that Hispanics and Asians are least likely to report always getting medical care when they need it, for example, but these racial and ethnic differences are eliminated when adults have medical homes. Hispanics and Asian Americans also are less likely to receive a reminder for preventive care visits, but are just as likely as whites to receive the reminders when they have medical homes. Overall, three quarters of adults with medical homes received plans to manage their conditions at home, and adults with medical homes are more likely to report checking their blood pressure regularly and keeping it in control.

The National Committee for Quality Assurance (NCQA) has developed criteria for recognizing patient-centered medical homes. As payers and purchasers conduct pilot projects and consider future scenarios in which primary care practices functioning as medical homes may receive additional payment, agreement on standards is necessary, said Kristine Thurston Toppe, MPH, NCQA’s director for public policy. The current standards evaluate access and communication, patient tracking and registry methods, care management, patient self-management support, electronic prescribing, and four other areas. For more information, visit http://www.ncqa.org/ tabid/631/Default.aspx.

Medical Leadership Council on Cultural Proficiency

Pacific Business Group on Health Examines Potential for Pay for Performance to Address Cultural Proficiency and Health Disparities Researchers find most physicians not addressing key aspects of culturally proficient care.

Roza Do from the Pacific Business Group on Health’s California Quality Collaborative (CQC) presented the results of a recent study assessing the feasibility of addressing cultural proficiency and health care disparities through “pay for performance.” Sunita Mutha, MD, from the UCSF Center for the Health Professions, was the principal investigator and conducted the study with CQC’s Neil Solomon, MD, partnering with the Integrated Healthcare Association.

Interviewing representatives of medical groups and health plans, the researchers learned that 84 percent of physician groups do not “look at differences in quality of care of special populations of patients (e.g., racial/ethnic populations, populations with language barriers)” and 60 percent of physician groups do not collect information about patients’ preferred languages for their health care visits. Most physician group representatives did not think cultural proficiency measures should be added to P4P. The researchers are considering other ways to improve collection and measurement of patient experience as well as to increase physicians’ cultural proficiency.

May 2006 Meeting NCQA Working to End Health Disparities The National Committee for Quality Assurance is working with health plans and medical practices, with an emphasis on primary care, to find ways to reduce health disparities based on race.

Jessica Briefer French, MHSA, senior consultant for research and analysis at NCQA, presented an overview of national Culturally and Linguistically Appropriate Services (CLAS)/Disparities programs. NCQA has looked at health disparities in Medicare, gender disparities in cardiovascular care, and the feasibility of evaluating culturally and linguistically appropriate services (as defined in the federal CLAS guidelines) in health plans. Among the results were findings that disparities persist in health plans, regardless of payer, and that providers are motivated to make improvements but don’t know which interventions are effective.

Mlc areas of focus: projects by other organizations

To address these issues, NCQA now is promoting innovative practices in plans and medical practices by awarding recognition to health plans that demonstrate innovation and improvement; awarding small grants and collaborative support to medical practices to implement quality improvement related to CLAS/disparities; and encouraging a focus on patient-centered care in primary care practices, including developing cultural competence and providing language access for diverse populations.

NCQA is focusing on small, independent, adult primary care practices with a minimum of 35 percent minority patients, and awarding $25,000 to support a variety of quality improvement activities, including staff training, attending collaborative workshops, providing patient education materials, making systems improvements (e.g., developing registries, implementing electronic medical records, completing practice redesign), and hiring interpreters and consultants.

May 2006 Meeting Medicare Provides Funding for Electronic Health Records This federal agency is funding practice improvements to improve patient care.

Ana Perez, MSN, CPHQ, formerly the senior project manager for physician office initiatives at Lumetra, described work Medicare is funding through that organization to assist small- and medium-size practices to implement electronic health record systems to improve patient outcomes. Lumetra, a health care consulting organization, also offers a continuing medical education program on cultural proficiency training based on federal CLAS guidelines for providing culturally and linguistically appropriate services.

Medical Leadership Council on Cultural Proficiency

Other Work by The California Endowment With the goal of developing culturally competent health systems, The California Endowment continued its leadership in 2006, 2007 and 2008 by “advancing the knowledge, attitudes, skills and experience of health providers and health systems to effectively serve California’s diverse communities,” explained Ignatius Bau, JD, Director of Health Systems.

From partnering with advocacy groups like the Asian Pacific Islander American Health Forum and the California Primary Care Association, to encouraging medical and allied health schools to teach cultural competence and increase the numbers of minority students and faculty, to supporting projects by medical specialty societies to improve the cultural competence of their members, The Endowment is working on several fronts to improve care. These include:

Community Organization Support: The Endowment supports community groups that provide effective services to Latino, African American, Asian American and other underserved patients/consumers.

Cultural Competency Education: The Endowment is identifying ways to support cultural competency education in medical schools, residency programs, health departments and public hospitals.

Ending Health Care Disparities: The Endowment also is consulting with large national organizations, such as the American Medical Association, the Institute for Healthcare Improvement, health care purchasers and large employers about ways to improve health care.

Expert Planning: Representatives of The Endowment met with experts including Louis Sullivan, MD and Lonnie Bristow, MD, the chair and co-chair of the Alliance to Transform America’s Health Professions, part of the Joint Center’s Health Policy Institute in Washington, DC. The Alliance is composed of former members of the Institute of Medicine (IoM) panel that examined diversity in the health professions and former members of the Sullivan Commission on Diversity in the Health Care Workforce. Dean of Morehouse School of Medicine, Dr. Sullivan, led the commission that issued the landmark 2004 report, “Missing Persons: Minorities in the Health Professions,” and Dr. Bristow is a member of the IoM.

Joint Commission Support: The Endowment funded research by the Joint Commission on Accreditation of Healthcare Organizations on effective practices at scores of hospitals.

NCQA Support: The Endowment supported NCQA awards to health plans for their improvements in cultural competence.

other work by the california endowment

Nursing School Faculty Support: Because mentoring and role modeling are critical to minority students’ success, The Endowment supports efforts to increase nursing school faculty diversity. Given the nursing shortage and the large number of retiring faculty members, nursing schools have an excellent chance to improve faculty diversity and improve the teaching of cultural competency in their curricula.

Pre-Med Support: The Endowment funded programs at the University of California (Davis, San Francisco and Irvine) to assist under-represented minority (URM) students to prepare for medical school. Working with all five dental schools in the state over three years, The Endowment found such programs effective, as URM students now comprise 10 percent of dental school admissions in California, up from 4 percent at the start of the project.

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Language is one aspect of it but cultural competency is a lot more important than just language access … Each culture has its own things, rooted for thousands of years. Dev GnanaDev, MD – California Medical Association

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Medical Leadership Council on Cultural Proficiency

MLC Resources Medical Leadership Council Web Site with the Language Access Database www.MedicalLeadership.org

The first-if-its-kind language access database lists interpreters, downloadable patient education materials in languages other than English, links to organizations providing services and materials in languages other than English, and resources to learn more about providing culturally proficient health care. The database is searchable by California county, language spoken, and/or type of resource needed.

The full MLC Web site offers a Language Access Toolkit to help physicians provide interpreter services in their offices; Continuing Medical Education courses in print and video; summaries of MLC meetings and copies of presentersâ&#x20AC;&#x2122; slides; a video about the MLCâ&#x20AC;&#x2122;s work; and additional resources to assist physicians and other health care professionals provide language access and culturally proficient health care.

Mlc areas of focus: MLC resources

Publications from The California Endowment www.CalEndow.org

The Publications section of the foundation’s Web site offers hundreds of articles, booklets, DVDs and other resources designed to assist physicians, other health care professionals, hospitals and health plans in providing culturally proficient health care. Below is a sample of resources introduced in 2006, 2007 and 2008—all downloadable from the MLC site.

Interpreter Services Available from Medi-Cal Managed Care and Healthy Families Plans (available in English, Spanish, Chinese, Vietnamese, Hmong and Korean) This guide helps LEP speakers enrolled in the Medi-Cal Managed Care and Healthy Families plans navigate the health system to access care in their own languages. The document serves as a reminder that interpreter services are free and provides contact numbers and information for various health plans.

Language Access Needs in Alameda County In Alameda County, one of the most diverse counties in the state, innovative efforts address residents’ language needs training needs of the health care interpreting workforce. The Endowment commissioned a survey of community-based organizations serving immigrant and refugees in Alameda County. The purpose was to increase The Endowment’s knowledge of existing and emerging language assistance needs, the current capacity of community-based organizations to meet these needs, and to gather community recommendations for improving language access.

Overcoming Language Barriers to Health Care This publication describes policy efforts at the state and federal levels to overcome language barriers to health care faced by non-English speaking patients. This case study demonstrates the critical role that the administrative and regulatory processes play in establishing and implementing public policy. It also describes the interrelationship between state and federal policy. This report identifies ways in which The Endowment—primarily through its support of advocacy and convening—helped raise the visibility of this issue, bring critical stakeholders together, and achieve meaningful progress.

Language Access: Understanding the Barriers and Challenges in Primary Care Settings This report examines language challenges identified by safety net providers in primary health care clinics and the strategies they use to meet the care needs of LEP patients.

Serving Patients with Limited English Proficiency: Results of a Community Health Center Survey In 2007, the National Association of Community Health Centers (NACHC) surveyed its member health centers. The results are reported here.

Medical Leadership Council on Cultural Proficiency

Addressing Language Access Issues in Your Practice: A Toolkit for Physicians and Their Staff Members Prepared by the California Academy of Family Physicians, the toolkit presents a systems approach to redesigning medical office practices to provide the highest quality care possible to LEP patients.

California Speaks: Language Diversity and English Proficiency by Legislative District This publication reports the numerous languages (other than English) spoken at home by nearly 40 percent of Californians. The research and analysis presented here are aimed at raising awareness and informing policy making and long-term planning to meet the needs of these populations.

Hospital Language Services for Patients with Limited English Proficiency Working with the National Health Law Program, the Health Research and Educational Trust released this report on a national survey that examined the barriers some patients may face when trying to obtain quality health care.

Language Access Solutions for OB/GYN Medical Practices The American College of Obstetricians and Gynecologists, District IX California explored approaches employed by its physician members to communicate with patients without English language proficiency. From that project emerged practice and policy recommendations to promote use of language access practices that ensure accurate interpretation, confidentiality and adherence to medical ethics standards, while discouraging use of inappropriate methods.

The Multicultural Health Series This collection of 10 video (and DVD) case studies and training materials was designed for health care professionals who work with ethnically and culturally diverse populations. The curriculum is meant to educate providers about the meaning and importance of cultural competence in health care. Each video case study is accompanied by facilitator notes and participant handouts.

Mlc areas of focus: MLC resources

Appendix: Member Organization Descriptions Alameda Contra Costa Medical Association

www.aacma.org

The Alameda-Contra Costa Medical Association is a professional association of physicians throughout Alameda and Contra Costa Counties dedicated to addressing local health issues of concern to their patients and their profession.

American Academy of Pediatrics, District IX

www.aap-ca.com

The California District of the American Academy of Pediatrics is a group of over 5,000 board-certified pediatrician members from four California regional chapters. Their mission is to promote the health and wellbeing of all California’s children.

American College of Emergency Physicians, California Chapter

www.calacep.org

The California Chapter of the American College of Emergency Physicians includes more than 2,000 California emergency physicians, practicing in a wide variety of settings, including large and small groups, academic centers, and managed care. CAL/ACEP represents and advocates for emergency physicians and the patients they serve. They identify areas of mutual concern and work toward concrete improvements in the practice of emergency medicine at the state and national levels.

American College of Obstetricians and Gynecologists, District IX

www.acog.org

The American College of Obstetricians and Gynecologists is the nation’s leading group of professionals providing health care for women, and today has over 46,000 members. ACOG serves as a strong advocate for quality health care for women; maintains standards of clinical practice and continuing education for its members; promotes patient education, understanding, and involvement in medical care; and increased awareness of changing women’s health care issues.

American College of Physicians, California Chapter

www.acponline.org/chapters/ca

The American College of Physicians is the nation’s largest medical specialty society. Its mission is to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine.

Asian & Pacific Islander American Health Forum

www.apiahf.org

The mission of Asian & Pacific Islander American Health Forum is to enable Asian Americans and Pacific Islanders to attain the highest possible level of health and wellbeing. It envisions a multicultural society where Asian American and Pacific Islander communities are included and represented in health, political, social and economic areas, and where there is social justice for all.

California Academy of Family Physicians

www.familydocs.org

The California Academy of Family Physicians has been advancing the cause of family physicians and their patients since 1948. With nearly 7,000 members, including active practicing family physicians, residents in family medicine, and medical students interested in the specialty, CAFP is the largest primary care medical society in California, and the largest chapter of the American Academy of Family Physicians.

California Association of Public Hospitals and Health Systems

www.caph.org

The California Association of Public Hospitals and Health Systems is a statewide trade association representing

Medical Leadership Council on Cultural Proficiency

30 public and not-for profit hospitals, academic medical centers, and comprehensive health care systems working on the front lines of health care in California. Operating in 17 counties, CAPH members assist in meeting the counties’ legal mandate to provide health care to indigent residents, and share a mission to ensure access to a full spectrum of health care services to all persons, regardless of insurance status or ability to pay. Public hospitals deliver care to low-income and uninsured individuals and provide essential community services such as emergency, trauma and burn care and services for special-needs children. As teaching hospitals they train more than half of the new doctors in the state.

California Healthcare Interpreting Association

www.chiaonline.org

The California Healthcare Interpreting Association (CHIA) is a nonprofit organization dedicated to improving the quality and availability of language services in the delivery of healthcare. CHIA members are healthcare interpreters and providers working together to overcome linguistic and cultural barriers to high-quality care. The organization assists students, interpreters, healthcare providers, administrators, and language agencies.

California Hospital Association

www.calhealth.org

Through effective leadership and member participation, the California Hospital Association seeks to develop consensus, establish public priorities, and represent and serve hospitals, health systems, and other health care providers. In concert with its member organizations, CHA is committed to establishing and maintaining a financial and regulatory environment within which hospitals, health systems and other health care providers can continue to provide high-quality patient care.

California Latino Medical Association

www.calma.org

With a membership of more than 3,000 Latino physicians, the California Latino Medical Association is the largest ethnic physician association in the State of California and is committed to providing culturally sensitive health care of the highest quality to Latinos and their families.

California Medical Association

www.cmanet.org

The California Medical Association’s mission is to promote the science and art of medicine, the care and wellbeing of patients, the protection of the public health, and the betterment of the medical profession; to promote similar interests in its component societies; and to unite with similar organizations in other states and territories of the United States to form the American Medical Association.

California Medical Association Foundation

www.calmedfoundation.org

The California Medical Association Foundation champions improved individual and community health through a partnership of leaders in medicine, related health professions, and the community. The CMA Foundation acts as a bridge linking physicians to their communities. It works in collaboration with many partners to achieve significant improvement in key health issues.

California Primary Care Association

www.cpca.org

The California Primary Care Association represents more than 600 not-for-profit community clinics and health centers that provide comprehensive, quality health care services, particularly for low-income, uninsured and underserved Californians. CPCA’s mission is to promote and facilitate equal access to quality health care for individuals and families through organized primary care clinics and clinic networks that, among other things, seek to maintain cost-effective, affordable medical services, as well as meet the linguistic and cultural needs of California’s diverse population.

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Catholic Healthcare West

www.chwhealth.com

Catholic Healthcare West, serving the western United States, strives to be a spiritually- oriented and communityfocused health care system passionate about improving patient care, enhancing work life quality and collaborating with others to create a just health system. Catholic Healthcare West dedicates its resources to delivering compassionate, high quality, affordable health services; serving and advocating for our sisters and brothers who are poor and disenfranchised; and partnering with others in the community to improve the quality of life.

Fresno Madera Medical Society

www.fmms.org

The Fresno Madera Medical Society promotes the art and science of medicine, the care and wellbeing of patients, the enhancement of the publicâ&#x20AC;&#x2122;s health, and the general welfare of the medical profession; to cooperate with organizations of like purpose; and to unite with similar societies in California as component societies of the California Medical Association.

Golden State Medical Association Kern County Medical Society

www.kms.org

The mission of the Kern County Medical Society is to promote the science and art of medicine, the care and wellbeing of patients, the protection of the public health, the betterment of the medical profession, and the welfare of its members.

Los Angeles County Medical Association

www.lacmanet.org

The Los Angeles County Medical Association is a professional association representing physicians in all modes of practice and specialties, including solo practitioners, small- and large-group or hospital-based physicians, and students, interns and residents.

Napa County Medical Society

www.ncms.com

The purpose of the Napa County Medical Society is to promote and develop the science and art of medicine, to protect the public health, and the betterment of the medical profession, to cooperate with organizations of like purposes, and to unite with similar societies of other counties.

Native Wellness & Advocacy (Association of American Indian Physicians) www.aaip.org The AAIPâ&#x20AC;&#x2122;s primary goal is to improve the health of American Indian and Alaskan Natives. Its mission is to pursue excellence in Native American healthcare by promoting education in the medical disciplines, honoring traditional healing principles and restoring the balance of mind, body, and spirit.

Orange County Medical Association

www.ocma.org

The Orange County Medical Association, a non-profit voluntary organization, is designed to promote the science and art of medicine, the protection of public health, and the betterment of the medical profession.

Riverside County Medical Association

www.rcmanet.org

The Riverside County Medical Association is a professional association of Doctors of Medicine that works to promote the science and art of medicine, the care and well-being of patients, the protection of the public health, and the betterment of the medical profession.

Medical Leadership Council on Cultural Proficiency

St. Joseph Health System

www.stjhs.org

St. Joseph Health System is organized into three regions—Northern California, Southern California and West Texas/Eastern New Mexico—and consists of 15 acute care hospitals, as well as home health agencies, hospice care, outpatient services, skilled nursing facilities, community clinics, and physician organizations. St. Joseph’s mission is to extend the Catholic healthcare ministry of the Sisters of St. Joseph of Orange by continually improving the health and quality of life of people in the communities they serve.

San Bernardino County Medical Society

www.sbcms.org

The purpose of the San Bernardino County Medical Society is to promote and develop the art and the science of medicine, to conserve and protect the public health, and to promote the betterment of the medical profession.

San Francisco Medical Society

www.sfms.org

The San Francisco Medical Society advocates for the interests of physicians and their patients in the improvement of public health. The purpose of the Society is to promote and develop the science and art of medicine, to conserve and protect the public health, to promote the betterment of the medical profession, and to cooperate with organizations of like purposes.

San Joaquin County Medical Society San Mateo County Medical Association

www.sjcms.org www.smcma.org

The San Mateo County Medical Association represents, educates and serves physicians and promotes quality medical care for the people of San Mateo County.

Santa Clara County Medical Association

www.sccma.org

The Santa Clara County Medical Association’s mission is to act collectively for its members by promoting excellence in the provision of quality, ethical healthcare; the health of our community; physicians’ personal, social, and professional integrity and well-being; and the common goals of similar organizations.

Sierra Sacramento Valley Medical Association

www.ssvms.org

The Sierra-Sacramento Valley Medical Association is a voluntary, nonprofit organization of medical doctors and doctors of osteopathy. With over 1,200 physician members in active practice and several hundred retired members, they are the largest physician organization in their region. The Association is dedicated to upholding the authority and autonomy of physicians in the delivery of professional and ethical medical care.

Solano County Medical Society

www.solanomedsoc.com

The Solano County Medical Society’s mission is to promote the science and art of medicine, the care and wellbeing of patients, the protection of the public health and the betterment of the medical profession.

Sonoma County Medical Association

www.scma.org

The Sonoma County Medical Association is an organization welcoming all physicians, respecting diverse interests and acting as a unifying force in the community by working to: encourage mutual physician support and understanding; strengthen and expand the role of the physician as patient advocate; enhance physician leadership and success in the health care arena; and improve the health and well-being of the community.

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Stanislaus County Medical Society

www.stanislausmedicalsociety.com

The purpose of the Stanislaus County Medical Society is to promote and develop the science and art of medicine, to conserve and protect the public health, to promote the betterment of the medical profession, to cooperate with organizations of like purposes, and to unite with similar societies from other counties.

Sutter Health

www.sutterhealth.org

Sutter Health is one of the nation’s leading not-for-profit health care organizations. The Sutter Health network consists of some of Northern California’s most respected physician organizations, more than two dozen acute care hospitals, physician and nurse training programs, medical research facilities, region-wide home health, hospice and occupational health networks, and long term care centers. Sutter Health affiliates serve more than 20 Northern California counties. Their mission is to enhance the health and wellbeing of people in the communities they serve, through a not-for-profit commitment to compassion and excellence in health care services.

WellPoint

www.wellpoint.com

WellPoint Health Networks Inc., the nation’s second largest health plan, serves the health care needs of 15.5 million medical members and 46.2 million specialty members nationwide through Blue Cross of California, Blue Cross Blue Shield of Georgia, Blue Cross Blue Shield of Missouri, Blue Cross Blue Shield of Wisconsin, HealthLink and UniCare.

credits Photos and quotes featured in this report appear in a video about the Medical Leadership Council’s work, Meeting the Needs of California’s Diverse Patient Populations, available at www.MedicalLeadership.org. Photographer: Jacqueline Véissid, www.jacquelineveissid.com. Filmmaker: Alicia Dwyer, Veracity Productions. Publication design and production: Candice Jacobus. cj+j design

Medical Leadership Council on Cultural Proficiency

1520 Pacific Avenue San Francisco, CA 94109-2627 415.345.8667 cafp@familydocs.org www.familydocs.org