| By The Innovations Exchange Team The Innovations Exchange Team: Tell us a little about who you are and what you do at AHRQ?
Cecilia Rivera Casale: I serve as the Senior Advisor for Minority Health in the Division of Priority Populations Research, which resides within the Office of Extramural Research, Education, and Priority Populations (also known as OEREP). In this role, I seek to reduce health and health care disparities by improving access to quality health care services for racial/ethnic minority populations, and ensure that the needs of racial/ethnic priority populations1 are addressed in all the agency's research activities, programs, policies, budget decisions, and funding opportunities. In addition, I represent the Priority Populations Division to the Senior Leadership Team, which includes AHRQ's Office, Center Directors, and Portfolio Leads.
What are some of AHRQ’s recent initiatives on patient-centered care and how will they benefit priority populations?
Under the Prevention and Care Management Research Portfolio, AHRQ has several initiatives that focus on patient-centered care that should have a positive impact on priority populations. The first is a series of grants to help primary care practices transform themselves into patient-centered medical homes. The goal is to understand the "natural experiments" that primary care practices undergo as they make this transformation. The grants support the evidence base for and implementation of activities to improve primary care and clinical outcomes through health care redesign, clinical–community linkages, self-management support, integration of health information technology, and care coordination.
Although this initiative does not specifically target priority populations (because most patients are not being served well today in primary care), many members of priority populations will be positively affected as the solo and small practitioners located in the primary care practices that serve them become more connected to the rest of the health care system. As the program progresses, moreover, some of the AHRQ-funded research will likely target specific priority populations.
A second, recent initiative is being funded through the Prevention and Care Management portfolio. This research will support organizations in becoming a Research Center for Excellence in Clinical Preventive Services, with a focus on three programmatic areas. One of these areas is health equity, including improving access, delivery and outcomes of clinical preventative services in priority populations. (The others are patient safety and health care system implementation.) The goal is to foster innovative, targeted research on clinical preventive services for priority populations. This program represents a major investment and commitment from AHRQ to support a patient-centered approach to preventive services. AHRQ recently announced funding awards for this program, with most being for a 3-year period plus option years. This research should yield specific innovations and interventions that will improve care for priority populations.
Another example is AHRQ's support of the Extension for Community Healthcare Outcomes or ECHO project (Click here to read more about project ECHO). Under the Health IT Research Portfolio, AHRQ funded researchers at the University of New Mexico to find effective ways to improve and build capacity and effectiveness of primary care doctors in rural and underserved areas. The ECHO model involves use of technology to connect urban medical center disease experts with rural general practitioners and community health representatives over a telehealth network.
This model enables the specialists to train primary care doctors to treat patients on site who would otherwise have to travel to urban health care facilities for specialty treatment. The initial application of ECHO was for patients with hepatitis C in rural parts of New Mexico. But the approach has enormous potential as an affordable health care intervention in rural communities where certain chronic diseases have reached epidemic levels and health care resources and personnel are scarce. It can also likely work in inner-city areas facing shortages of specialists.
In what areas of cultural and linguistic competence would you like to see future program development?
We need to develop innovative methodologies for including priority populations in research. Although still in its early stages, the newly created Patient-Centered Outcomes Research Institute or PCORI (an independent, nonprofit organization authorized and funded by the Patient Protection and Affordable Care Act) will have the opportunity to work with researchers to develop methodologies for addressing the specific needs of priority populations that traditionally have not been the focus of randomized controlled trials. This work is part of a more general effort to develop more pragmatic, less time-consuming research methods appropriate for these populations.
Additionally, patient–provider communication represents another area in need of more attention as part of the patient-centered care movement. Effective communication requires more than just overcoming language barriers, because many underserved individuals speak the same language as their provider(s). However, they often lack adequate levels of education and health literacy to communicate their needs effectively or understand the prescribed treatment and followup, including how to take medications appropriately.
Providers need to learn to communicate effectively with patients and in many cases with family members as well. Many providers (including but not limited to doctors) lack an understanding of their patient’s language and culture. Going forward, they need to be more responsive to where their patients are in terms of education and comprehension.
AHRQ has already done some important work in this area through its health literacy initiative, which is part of a national effort to make health information more straightforward and understandable. To that end, AHRQ has developed tools to help doctors and office staff improve communication with all patients so they better understand their medical condition and treatment regimen. Some of this work focuses on helping providers do a better job of collecting information on the populations they serve. Large variations exist with respect to how well providers know who they are serving.
Some organizations are creating new methods for collecting data that go beyond the traditional approach of voluntary self-reporting. For example, software programs can collect secondary data that can be used to determine a patient’s ethnicity in cases where such information cannot be collected from the patient. Understanding the patient population being served is the first step for providers in building cultural and linguistic competence.
Are there any “best practices” you can highlight with respect to cultural and linguistic competence or serving priority populations?
In general, decisions about health care and related priorities need to rest within local communities. So rather than prescribing practices, the best approach is to create programs and support research activities that help communities to identify and address their own needs.
AHRQ-sponsored efforts in this area have been quite successful. For example, several agencies within the Department of Health and Human Services (HHS) participated in the HHS Hispanic Elders Health Initiative, which involved eight communities with a high proportion of low-income, elderly residents of Hispanic descent.
Led by the Administration on Aging with support from AHRQ and other agencies, this program promoted local collaboration among community-based organizations. AHRQ’s role was to provide these communities with drill-down data at the county and city level (data included in the National Healthcare Disparities Report, but at a local rather than national or state level). Providing such granular data allowed these communities to identify the most prevalent health care conditions and develop programs to address them. Overall, six of the eight communities chose to focus on diabetes, while the other two decided to tackle cardiovascular disease.
The Federal government’s role in this project was to provide the tools and resources that communities requested, along with technical assistance on how to use them. Many communities are home to talented professionals who have linguistic and cultural concordance with the target population. Armed with the right information and tools, they can develop and execute well-received programs that produce results.
About Cecilia Rivera Casale, PhD
Cecilia Rivera Casale, PhD, serves as Senior Advisor for Minority Health at AHRQ. Before joining AHRQ, Dr. Casale served as Acting Branch Chief, Senior Project Officer, Team Leader, and Acting Minority Health Director for the National Child Traumatic Stress Initiative as well as Acting Minority Health Director in the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration. In these roles, she provided leadership, programmatic management, and oversight of ongoing grant and contract projects. Before that, she served as the Director of the Family Connections Division at the Latin American Youth Center in Washington, DC, where she gained significant experience in community health, health services research, and health care disparities. Dr. Casale has a Bachelor of Arts degree in Sociology, a Master of Social Work degree in Planning and Research, and a Doctor in Social Welfare and Public Policy degree from Brandeis University.
Suggested Readings
Institute of Medicine. Health Literacy Implications for Health Care Reform: Workshop Summary. Available at: http://www.iom.edu/Reports/2011/Health-Literacy-Implications-for-Health-Care-Reform.aspx.
Institute of Medicine. Focusing on Children's Health, Community Approaches to Addressing Health Disparities: Workshop Summary. Available at: http://www.iom.edu/Reports/2009/FocusChildrensHealth.aspx.
National Institutes of Health. Principles of Community Engagement, (2nd ed). NIH Publication No. 11–7782. Available at: http://www.atsdr.cdc.gov/communityengagement.
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