Cultures of Health

FOR HOSPITALS AND CARE GIVERS, HEALTHCARE EQUITY MEANS BETTER RESULTS

BY NOUR HABIB

Years ago, Paula Smith met someone who had had an organ removed in a medical procedure, but didn’t know which organ. That’s when Smith was struck by the need for better interpretation services in healthcare.

“So we started the interpretation training program, so that we could build capacity within the hospitals and healthcare systems,” she says.

Smith is the longtime director of Southern New Hampshire Area Health Education Center, which provides workforce development for current and future health professionals.

Language and communication access is considered one of the basic elements of providing culturally effective healthcare. Culturally effective healthcare organizations are institutions working to implement various practices that can improve care and reduce health disparities among a diverse patient population.

Trinidad Tellez, former director of the Office of Health Equity for the NH Department of Health and Human Services, co-authored an issue brief in 2015 that created a framework to help healthcare organizations become more culturally effective. The brief was published in partnership with Brandeis University’s Institute on Assets and Social Policy.

Tellez, who is a physician, says the framework draws from recommendations and best practices established by several healthcare standard-setting organizations, but offers a more “digestible” roadmap for providers who are new to the work and trying to figure out how to make their organizations more equitable.

Tellez also facilitates a work group through the New Hampshire Equity Collective that is trying to teach people about the framework and encourage organizations to implement it.

“We’re the shepherds of the work,” Tellez says about the group. “The goal is that organizations understand how helpful it is to use the framework as the way to begin to think about operationalizing systems and processes so that they’re moving towards equity.”

“(The framework) helps organizations build capacity, so that they can serve everyone, no matter what dimension of identity they may bring,” she says.

Those doing work around cultural effectiveness say it is about responsiveness to all types of diversity, whether related to race, religion, disability, age, immigration status, sexual orientation or something different.

Paula Smith

Trinidad Tellez

And Tellez says creating a culturally effective organization is about much more than just having the individuals who make up the organization be culturally competent.

“This cultural effectiveness framework is about, what are all the many things that need to be operationalized so that the organization can serve everyone?” says Tellez.

In addition to language and communication access and staff cultural competence, other elements of culturally effective healthcare organizations include: leadership buy-in, institutional policies and procedures that formalize an organization’s commitment to cultural effectiveness through written goals and practices, workforce diversity and inclusion, community engagement, and data collection and analysis.

Tellez notes that, while the framework was derived specifically from and for a healthcare context, the work group has found that it is useful for people-serving organizations in varied sectors, including human and social service, education and child abuse prevention.

Cultural competence in practice

Amoskeag Health in Manchester has been working to implement culturally effective healthcare practices for years, and is championing the framework. Officials at Amoskeag have created a toolkit to help other organizations implement the framework.

Betsy Burtis, the Chief Officer for Integrated Health Services at Amoskeag, said the early days of the organization’s cultural effectiveness journey were primarily focused on interpretation and making sure that patients would understand and be understood by their providers. But that was just the beginning. “I think what sets us apart is that we take culturally effective care far beyond language access,” Burtis says.

She says though Amoskeag has a diverse staff and is working to actively make sure its workforce reflects the patient population, that’s not enough to ensure cultural effectiveness.

“You can’t make the assumption that everybody understands what that means to work with somebody of a totally different culture,” says Burtis.

And so Amoskeag diligently collects data and tries to engage and collaborate with different community groups to improve the quality of care. These practices are among the elements listed in the framework that the organization champions.

“We continually work on our policies and procedures to make sure that they align with where our vision and mission are for this work, and that they are not disproportionately hurting any population,” Burtis says. “One of the things that I always stress is, Amoskeag Health has come a long way, but the work is never done. As the state becomes increasingly diverse, we are always trying to learn and grow and trying to be humble about what we know and what we don’t know.”

Community health workers

Smith, who runs the workforce training center, says her organization has always been committed to providing training that improves cultural competence. Recently, they established the Center for Cultural Effectiveness, which encompasses several different programs, including one to train community health workers.

Smith says she thinks of community health workers as a “bridge” between the community and the health system.

“They do peer education, they do individual and community needs assessment, they do a lot of linkage to services,” Smith says.

Employing community health workers is one of the ways healthcare organizations can implement the community engagement and workforce diversity elements of cultural effectiveness, says Tellez.

“In health systems, sometimes patients have a lot of needs related to the ‘social determinants of health,’” Tellez says. “(That’s) what we call the environments where people live, learn, work, play and pray.”

People may be having a housing crisis, which can lead to destabilized health, or experience food insecurity that they don’t know how to navigate. Community health workers can often step in to provide resources and education in those instances.

“So community health workers are just really important for historically excluded populations and BIPOC communities,” Tellez says.

Because they are already trusted members of the community that they work within, community health workers often have more success connecting people with physical or mental health services that they need.

Nelly Gachohu

Nelly Gachohu is a community health worker with the City of Nashua Public Health Division.

Gachohu, who is from Kenya and speaks Swahili, says her background is an asset to the department when they are trying to reach out to the Black or brown communities in Nashua, and specifically the African population in the city.

Gachohu says her role is to build trust and understand the needs of the people she serves. As an example, much of her recent work has revolved around COVID-19. She has held teaching and listening sessions to try to understand why many people in the BIPOC community she serves have not been vaccinated.

“We are not rushing to get arms and vaccinate,” she says. Instead they want to hear the worries and concerns of the community, many of which are valid.

When people feel heard, and receive answers to their specific concerns, some are more willing to receive the vaccines, she notes.

Gachohu says mobilizing community health workers is part of the work of making healthcare more equitable, through addressing many of the social determinants of health.

“Sometimes you’re born into something, or a situation, that allows you to thrive or not,” she says. “And we’ve seen this evidently, throughout the years, that in the BIPOC population, those things are not well distributed.”

Gachohu also works to make resources and all elements of the healthcare system more accessible for the people she works with. Some of the people she serves may not seek medical treatment because they can’t afford to, and they don’t always realize there are resources and options that can help them financially.

Alongside her work as a community health worker, Gachohu is studying public health at Regis College. She says when she learned about public health, she felt it would be a good fit for her.

“I just wanted to be that essential person that is working to improve access in a way, some way,” Gachohu says.

Making good care universal

Essentially, creating culturally effective healthcare organizations is about making sure everyone gets the same level of good-quality care.

“If you take that culturally effective part out, it’s no different than any one of us wants to be treated in healthcare,” Burtis says. “We want to be treated like a better person, we want to be asked about what matters to us and where things hurt. And so, while you have to pay special attention to make sure that you are providing that level of care to every person, the basics of what is good care really is universal.

“We just have to make sure we’re applying it and giving it universally,” says Burtis.