| By The Innovations Exchange Team The Innovations Team: The U.S. will soon be a country with a “Majority-Minority” population. What demographic shifts are driving this change?
Thomas LaVeist: There is a combination of things behind the demographic shift. There is a rapidly declining white birth rate and higher minority birth rates. In general, minorities have first births at a younger age than whites, meaning they utilize a longer portion of their reproductive years. And, of course, there is immigration—mainly from Latin America and Asia. Looking at the demographic pyramid of the United States, a larger percentage of whites are in their nonreproductive years. And, at the same time the United States is becoming a “browning” nation, it is also becoming a “graying” nation due to an aging population, predominately an aging white population.
What implications does this have for the future of health care?
These two groups that are growing in size are also groups with high health care utilization. Racial and ethnic minorities are in greater need of health services due to suboptimal health status. And, most health care services are devoted to individuals in the last years of their lives. So these trends mean that health care utilization will go up and, obviously, health care costs will go up.
There are well-documented disparities for minorities in quality of care, communication with health care providers, injuries, and accidents. All of these are likely to increase as more minority patients use the health care system. Also, we are becoming a more linguistically diverse nation and language is an important determinant of patient safety and health care quality. As there are more nonnative English speakers, we should expect to see growing problems in these areas. We may also see increased medical liability suits if there is a lower quality of care for these patients and if the quality of the doctor–patient relationship, which is impacted by communication, is predictive of whether or not one sues following an adverse event. These trends are all likely, unless we take action.
You have written that there are six key factors for addressing the health disparities crisis. What are these six factors and how should they inform how innovators think about providing health care today?
These six key factors—socioeconomic conditions, social and physical environments, access to quality care, cultural competency, health literacy, and empowered healthcare consumers—indicate the places where we might be able to intervene to improve health care disparities.
Disparities are produced through a chain of events around a medical encounter. The patient must experience a symptom, identify the symptom and determine that they need to seek help, figure out how to get help, overcome barriers such as transportation and paying for their care, and then get into the health care system—there are several steps a patient must go through even before they get into the health care system. Once they gain entry into the health care system, the questions are: Will the symptoms be identified as a condition requiring medical intervention? Will the diagnosis be appropriate and correct? Will the course of treatment be correct? Will it be administered correctly?
There are so many steps in the process of receiving care and disparities occur around each step. Think of a hose with holes. As water comes out at each hole, people experience disparities in health care at many points. You can plug one hole, but there are many left. You are not going to fix the hose with one patch because there are so many holes that the water will find.
How can an innovator begin to address the many problems associated with health disparities?
A single patch can address a hole, and we do need the holes patched to move forward. Addressing health care disparities can seem overwhelming, but I would tell people that it’s not too much to take on. Focus on a place where you can make an impact. Make your intervention as strong and effective as possible. Do not be concerned that health disparities are amorphous, with many causes outside the health care system. It is helpful to recognize the largeness of the problem, but do not let it be a reason for inaction.
Can you tell us about any innovative or otherwise notable programs that you have seen making an impact in providing culturally and linguistically appropriate care?
There are a few programs, including programs in the AHRQ Innovations Exchange, that are making an impact. However, despite the fact that the concept of cultural competence has been around for a few years, we still are having difficulty getting beyond letters to the editor, essays, and conceptual think pieces. The interventions that are out there tend to be narrow and limited in scope, and focused on language, which is an important area, but just one aspect of cultural competency. There is not a strong evidence base for action around cultural competence, in many areas. We need to know more about actual interventions that could lead to more culturally competent care and better outcomes.
One of the things I’ve been working on at the Hopkins Center for Health Disparities Solutions is called the Cultural Quality Collaborative (CQC), located at: http://www.thecqc.org. Launched in February 2011, it is a collaborative of hospitals around the country that are working on formal assessments of cultural competence programs in hospitals. Our goal is to jump-start the creation of an evidence base. We are identifying problems and coming up with innovative solutions, even if there is no evidence base behind them at first. We will do small scale interventions to see if there is any evidence that it is improving the situation. If that pilot shows promise, we will scale up the program and do formal evaluations to document the changes. Currently there are 10 hospitals, and we are looking to expand the group. We will eventually put together an information exchange and also submit appropriate innovations to the AHRQ Health Care Innovations Exchange.
Can you identify best practices that focus on culturally and linguistically competent innovations related to: organizational policy, workforce development, environmental enhancements, and/or systems approaches toward service delivery?
It is difficult to provide a comprehensive list, but I can suggest a few best practices. First, organizations need to have an executive level person tasked with making a change regarding health disparities. Instead, many organizations have an “equity” or “diversity” committee made up of staff who have other primary responsibilities. This group is asked to take on cultural and linguistic competence on top of their other work. This is not the way we address any other problem in a hospital. For example, if performance scores went through the floor, a hospital would not create a committee; it would put someone in charge of figuring out the problem and fixing the problem. Hospitals need to take the same approach to health disparities.
Second, leadership needs to make it clear that cultural and linguistic competence and health care disparities are a priority at all levels of an organization. I have developed an assessment tool called COA360* (at http://www.coa360.org) to access the cultural competence of health care organizations. We have been finding, among many of the organizations that take the assessment, that while high level leadership often expresses commitment to addressing disparities, attitudes may not permeate further down the organization. So it’s important to treat reducing disparities as a value; clearly communicate and incentivize and reward staff to produce the desired outcomes.
Third, while health care organizations are becoming more and more data driven, organizations rarely look at their data by subgroups, such as language, religion, race, or ethnicity. For other problems, health care organizations collect and monitor data, make someone accountable, and provide the resources to fix the problem. We need to do the same to address health disparities.
Fourth, there is a growing awareness and interest in engaging communities within the service area. Health care organizations engage the community to identify cultural needs and unique aspects and improve quality and patient outcomes. This is a good trend, and one I hope that continues to grow.
You are involved in reviewing the CLAS standards. Can you give us an idea of what we should expect from the revised standards?
We’re really not far enough along to say. There have been new regulatory findings and regulations have changed, so the standards will be updated to be in compliance with the new regulations. Beyond that, we’re doing a re-imagining of the CLAS standards. Everything is open to change. However, I suspect there won’t be that much that changes because the standards are still relevant.
About Thomas LaVeist, PhD
Thomas A. LaVeist, PhD, is the William C. and Nancy F. Richardson Professor in Health Policy and Director of the Hopkins Center for Health Disparities Solutions at the Johns Hopkins Bloomberg School of Public Health. He received his bachelor degree from the University of Maryland Eastern Shore, PhD in medical sociology from the University of Michigan and postdoctoral fellowship in public health at the Michigan School of Public Health. His dissertation was awarded the 1989 Roberta G. Simmons Outstanding Dissertation Award by the American Sociological Association. He was appointed a fellow at the Brookdale Foundation, awarded the “Knowledge Award” from the U.S. Department of Health and Human Services Office of Minority Health, and the “Innovation Award” by the National Institute on Minority Health and Health Disparities. His research has been funded by the National Institutes of Health, National Center on Minority Health and Health Disparities, Center for Disease Control and Prevention, and the Agency for Healthcare Research. Dr. LaVeist has published numerous articles in leading scientific journals, and authored two books on health disparities.
Disclosure: Dr. LaVeist created the Cultural Competence Organizational Assessment (COA360) and receives financial renumeration each time the assessment tool is purchased.
Suggested Readings
LaVeist TA, Relosa R, Sawaya N. The COA360: a tool for assessing cultural competency of Healthcare Organizations. J Healthc Manag. 2008;53(4):257-66. [PubMed]
LaVeist TA, Gaskin DJ, Richard R. Estimating the economic burden of racial health inequalities in the United States. Int J Health Serv. 2011;41(2):231-238. [PubMed]
LaVeist TA, Thorpe R, Galarraga JE, et al. Environmental and socio-economic factors as contributors to racial disparities in diabetes prevalence. J Gen Intern Med. 2009;4(10):1144-8. [PubMed]
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