System to reduce health disparities in community

Approach works to improve provider-patient trust

When Adventist HealthCare Inc. of Rockville, MD, asked community leaders what the health care system could do to better serve the community's needs, the answer was to form a center on health disparities.

So in late 2006, the health system opened the Center on Health Disparities, with the goals of assessing health care access among various demographic groups and assisting in improving health care access where it's needed, says Marcos Pesquera, RPH, MPH, executive director of the new center.

National numbers on health care disparities are available, but there's very little data at the local and county level, Pesquera says.

"We don't have data about what's happening in our backyard, and that's where the disparities are having a big impact," he says.

Too often, health care professionals will see the national data about minorities and ethnic groups and health care access, and they'll say that this problem isn't happening in their own community, Pesquera notes.

But when someone actually studies the issue of disparity at the local level, the numbers tell a different story, he adds.

"We're working on a disparities report card, and we're looking at data available throughout the county," Pesquera says.

For example, Pesquera looked at all of the hospitals in the county, reviewing their data on HIV/AIDS diagnoses, and he found that 75 percent of the patients discharged with HIV/AIDS diagnoses were African Americans.

"So we look at a county that's only 15 percent African American and see that 75 percent of the HIV/AIDS discharges are African Americans, then we know there's a disconnect," Pesquera explains. "The data tell us we need to come up with some program around HIV/AIDS education specifically geared to the African-American community."

The report will have useful information for health care facilities and research institutions, particularly when recruitment disparities are encountered.

"By creating this report and distributing it locally, we'll identify and put a light on areas we need to work on," Pesquera says.

For instance, there are clinics where Adventist HealthCare has a partnership with the county for prenatal care and child care, he says.

"When I sit in the exam rooms, I realize the majority of their patients are in the immigrant community, and there's very little data around immigrant health," Pesquera says. "So I will do a chart review one-by-one in terms of prenatal care."

Pesquera will review the different rates of gestational diabetes, infant mortality, and co-morbidity among the patients seen at the clinics. He'll also collect information about when, in their pregnancies, they first seek prenatal care.

"I'll do a manual chart review to get those data," he says.

Through this type of community-based research, he plans to look at the public health issues impacting various ethnic and minority groups and look at strategies for improving health care where disparities exist, Pesquera says.

"We're trying to improve the quality of care," he says. "We firmly believe that by improving the patient-provider relationship, that health care outcomes will improve."

When patients and providers have better communication and relationships, then trust develops, and patients are more likely to follow treatment recommendations and become enrolled in clinical research, Pesquera notes.

"The trust has to be there as a baseline so the patient will say, 'I'll join that research trial,'" Pesquera says.

Once the center has built a foundation in its work to increase patient trust and reduce care disparities, then investigators can build on that foundation for their work, he says.

"If you're my doctor and you trust me fully and I trust you, and you say, 'We need more Latinos for XY study, and you are a perfect candidate,' then I'm going to enroll in the trial," Pesquera says. "But if I don't trust you, I won't."

By providing education to health care providers about the disparities that exist in their own communities and how they can help improve the quality of culturally, competent care, then they'll be able to build that trust, he adds.

The center's educational program will start with three modules about how to provide culturally competent care, Pesquera says.

These are as follows:

1. Health care disparities: "We want to make sure providers understand what is going on in disparities, what the diseases are, and what the issues that different communities have are," Pesquera explains. "This is not only in health care, but in the provision of health care too."

This module will focus on the local counties and their data regarding the languages residents speak and how to provide interpretation for them.

"We'll focus on how many encounters we have in health care with people who require Spanish interpretation or Mandarin or other languages," Pesquera says. "We need to make people realize the high numbers of our patients who request over-the-phone interpretation.'

2. Racial ethnicity of the county: This module will look at the countries patients come from and will help providers of care understand the health beliefs and practices of this population, Pesquera says.

"If health care providers tell me the majority of the limited-English proficiency patients are from El Salvador, then they can ask that I come up with a module addressing that population," he says. "I'll interview leaders at churches, etc. and come up with modules that help providers understand the patients' practices, beliefs, and health behaviors."

3. Stereotypes, biases, and assumptions: "I go under the assumption that if we live in this world, we all have stereotypes, biases, and assumptions," Pesquera says. "That's the premise I start with in this module."

The purpose of this module is to help people bring to the surface their own hang-ups, he says.

"Sometimes, without our saying a word patients can sense what we're thinking or feeling and what our apprehensions are," Pesquera explains.

Studies involving placing electrodes on people's heads showed that if someone is sitting at a table and someone walks into the room upset, the electrodes show that without either person saying a word, the person who is sitting at the table has the same neurons light up as the upset person, Pesquera says.

"The same thing happens with a happy person," he adds. "If the happy person looks at you in the eyes, then the same neurons in you light up as are in the happy person."

There's a human connection that takes place even without words, and until providers fully understand this, they will not be aware that they can walk into an exam room and jeopardize their relationship with a patient before they even say "Hello," Pesquera says.

The modules are presented as inservices to groups of no more than 20 physicians, nurses, and research professionals and include exercises and discussions.

Pesquera also offers these other suggestions on how to reduce disparities in health care and research:

Hire diverse research and health care staff.

"Our providers of care are quite diverse," Pesquera says. "We have providers from every country you can think of, including nurses from the Philippines and Africa."

Having a diverse group of providers helps to reduce the need for medical interpreters, and it helps build trust more quickly.

"When you look at our staff, we do represent the communities we serve in terms of diversity," Pesquera notes.

Make certain informed consent forms are translated appropriately.

It's best to hire organizations that are well qualified in medical translation to translate informed consent documents, Pesquera advises.

When the translated informed consent documents arrive, the next step is to provide a proper quality process check-up, he says.

"Give the translated document to another translator and have him or her translate it back into English to compare this document to the original English document," Pesquera says. "That's the quality process that will be required for consent forms, and any company that wants to do translations for us will have to use that process."

Use interpreters who are trained in health care jargon and situations:

If an institution has employees or volunteers who are multilingual and who are interested in being interpreters, then it's important to provide them with medical interpretation training, Pesquera says.

"We have a three-day course that trains people to interpret medical skills in the appropriate setting," he says. "They can serve as a conduit between providers and patients, and they could be either volunteers or paid employees."

The training includes information on ethics and medical terminology and how to be transparent in a patient-provider relationship, he says.

One of the biggest complaints providers have of untrained interpreters is that they will develop a relationship with the patient that is independent of the provider, Pesquera says.

"Say we're both Spanish speakers and both from Puerto Rico, then all of a sudden we develop a great relationship in the exam room, and I tell you what my mom did for a cold when I was little, and I forget the doctor is there," Pesquera explains.

"Then we talk again and I'm basically taking history as an untrained physician, and I develop a relationship with you when I have no right to do that," he adds.

So the medical interpreter training teaches interpreters such details as where to stand to minimize interference with the provider-patient relationship, Pesquera says.

"We teach them to look at the floor so they don't have eye contact with the provider or the patient," he adds. "If there was a curtain in the room, we'd have them stand behind that."

When there isn't a curtain, the interpreter should stand in a way that suggests there is a curtain between him or her and the patient.

The goal is to help the provider improve his or her relationship with the patient, and the interpreter can assist by not interfering and by giving the provider information about any hot button cultural issues that arise, Pesquera says.

For instance, if the patient is a teenage girl who sees the doctor with her mother, and there is an issue involving birth control pills, then the interpreter might let the provider know that it would be wise to ask the patient's mother to leave the room so that the girl can speak freely, Pesquera says.

Interpreters who already work in the institution as an employee could be paid a differential for taking on this extra role, but they must know the medical terminology and be fluent in both English and the second language, he notes.

When there are not any local interpreters available, an institution could use a qualified medical interpretation service and have interpreters work via telephone calls.