For the best outcomes, consider patients' culture
Knowledge, understanding help ensure adherence
In an increasingly diverse society, case managers must be aware of the cultural beliefs and practices of the people they serve in order to effectively coordinate their care and help patients or clients adhere to their treatment plan, says Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy & Associates, a case management training and consulting company.
"Cultural competency is essential to close the widening gaps of disparities in health care. When providers are knowledgeable, respectful, and responsive to the issues surrounding cultural diversity, positive outcomes are much more likely to occur," Mullahy says.
Refugees and immigrants cannot be expected to give up their cultural and religious beliefs when they come to this country, points out Lucy Ricketts, director of public affairs and cultural and linguistic services for Passport Health Plan, a member of the AmeriHealth Mercy family of companies.
"It's all about negotiation. We can't force our members to shift their attitudes about health care, but we can negotiate and educate them so they receive quality care," she adds.
For instance, the Louisville, KY, area, where Passport Health Plan has its headquarters, also is home to a number of agencies that resettle refugees and immigrants, according to Estes.
In fact, students in the public school system of Louisville speak more than 100 languages.
"We have great relationships with the resettlement agencies and work closely with them, so when they tell us which new group of people [is] coming into the area, we start doing research on the practices and beliefs of that culture," Estes says.
The Louisville area has had a huge influx of Somali families in the past two years, Estes adds.
"We found out that the local obstetricians were having difficulty understanding Somali women and their feelings about labor and delivery and prenatal care. We did a lot of research on our own and sought the assistance of experts in the area to help the obstetricians come up with strategies for caring for these women," Estes says.
The health plan partnered with a local Somali-Bantu women's empowerment group to gain the trust of the women, learn about their religious and cultural beliefs related to labor and delivery, and share information about the American approach to pre- and post-natal care.
For instance, the Somali women were upset, because when they were admitted to the hospital for delivery, they didn't receive a meal.
"They told us that in Africa, it was very important to eat a large meal during labor so you'd have the strength to deliver," Estes says.
The health plan shared the information with the obstetricians in person during the health plan's annual cultural competency conference and in the plan's provider newsletter.
Passport Health produced audio and hard-copy versions of its booklet "Mommy & Me Basics" in the Somali-Bantu language and instituted a pilot project to educate the Somali-Bantu women on Western medicine standards of care. The women and a facilitator from the health plan read sections of the book and had an open discussion on the cultural differences in prenatal care, labor, and delivery.
Being aware of a member's cultural background helps case managers, disease management nurses, and health coaches come up with effective strategies to keep the member healthy, says Trish Nguyen, MD, senior medical director of medical operations.
For instance, while Vietnamese eat a lot of vegetables, they also enjoy salty soups and fatty foods such as pork legs, says Nguyen, who is Vietnamese.
"When the health coaches work with our Vietnamese members to help them manage their chronic illness, they are aware that although Vietnamese and others in the Asian culture tend to eat a diet high in fruits and vegetable, those fatty, salty soups could be interfering with their treatment plan," she says.
"This is very important, because they can use key words and messages that will resonate with that member. Telling them just to eat more fruits and vegetables is a very 'vanilla' message, and it may not be effective," she says.
Although Vietnamese tend to be thin, many also have abdominal fat that makes them more likely to become diabetic or die at an early age from heart disease, she points out.
"If our health coaches were not aware of this, they might take it for granted that since the clients are thin, they don't need to modify their diet," she says.
One of the keys to coordinating care with people of different cultures is to understand their beliefs and practices, so you can determine what will resonate with them, Nguyen says.
"Understanding a member's cultural beliefs and practices is important, because it impacts health outcomes. If a care manager doesn't understand the person's cultural background, they will have difficulty engaging with that person, whether it's on the telephone or face to face, and they may not be able to help the person modify his or her behavior," she says.
For instance, health care professionals who are trying to communicate something of importance to patients may infer that patients are resistant to the information, embarrassed, or even depressed if they don't make eye contact. However, in some cultures, direct eye contact is perceived as threatening and case managers should be aware of this, Mullahy points out.
"In some cultures, Asian and Christian African-American populations among them, pain and suffering are believed to redeem and purify. Understandably, therefore, a patient may be unable or unwilling to provide a truly accurate assessment of his pain," Mullahy says.
Native Americans consider wellness as harmony and balance among mind, body, and spirit, Mullahy adds.
"That kind of belief may present a challenge for a diabetic patient facing amputation of a limb. How can he be whole in his afterlife if he is buried without his leg?" Mullahy says.
Mullahy relates that in the case of the diabetic man who was reluctant to lose his leg, practitioners made arrangements to ensure that the limb would be buried in the same place as the patient after his death.
Latino patients tend to resist home health services because of a tradition that all of the elders' needs should be taken care of by family members, adds Janice Crist, RN, PhD, associate professor at the University of Arizona College of Nursing.
Case managers shouldn't think that their Latino clients are non-compliant if they refuse home health services or it doesn't work out, Crist says.
Crist has received a grant from the National Institutes of Health to produce a short film that can be used to educate Latino families about the benefits of home health care.
Crist advises case managers and home health nurses to spend part of each visit or conversation getting to know their Latino clients before starting care.
"One of the most important things that health care providers can do when working with the Latino population is to talk things over in a personal way, instead of being official and impersonal like they would be with patients in the Anglo culture," she says.
Achieving cultural competency is not easy, and while your organization may provide information, individual case managers should assume some of the responsibility for learning about and understanding the populations they serve, Mullahy says.
"Fortunately, much of this information is a mouse-click away," she adds.
Care managers should ask open-ended questions, rather than just telling the member what he or she should be doing, Nguyen adds.
"Care managers need to be able to engage and have rapport with the members. When they ask open-ended questions, the member's cultural beliefs and perceptions come out and can be addressed," she says.
For instance, the case manager may ask members to name their favorite foods, then they ask about what is in their diet to isolate and understand where to begin working with the member on healthy eating habits.
"People in certain cultures have menus in their diet that are high in fat and calories. The health coaches and care managers can help them find healthy alternatives to some ingredients, so the food tastes the same but is healthier," she says.
For instance, if a member with hypertension eats a lot of chicken noodle soup out of a can, the health coach knows that it is high in sodium and can work to find alternative foods, she says.
"These open-ended questions can help the care coordinator or health coach discover the member's beliefs and understand why he or she isn't compliant," she says.
In an increasingly diverse society, case managers must be aware of the cultural beliefs and practices of the people they serve in order to effectively coordinate their care and help patients or clients adhere to their treatment plan, says Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy & Associates, a case management training and consulting company.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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