Speaking their language: Crossing cultural barriers

Be familiar with practices of populations you serve

Navigating the health care system often is bewildering for people who were born in the United States and speak English; it may be incomprehensible for some of this country's growing immigrant population, who bring their own cultural beliefs and practices with them.

Addressing the needs of this increasingly diverse population has become a major challenge for health plans, clinicians, and health systems, and the job only is going to get more challenging as the immigrant population increases, according to the Agency on Healthcare Research and Quality (AHRQ).

Minority Americans are expected to make up more than 40% of the U.S. population by 2035, according to AHRQ.

"Culturally and linguistically diverse groups and individuals of limited English proficiency typically experience less adequate access to care, lower quality of care, and poorer health status and outcomes," the AHRQ reports.

Managed care plans must become sensitive to the multicultural populations that they serve, says Catherine Mullahy, RN, BS, CRRN, CCM, president of Huntington, NY-based Options Unlimited, a Matria Healthcare company.

This means that case managers should take an active role in improving their own cultural competency and gain an understanding of the beliefs and practices of the populations they serve, she adds.

"We live in such a melting-pot kind of society that it is a challenge for health care to keep up with the changes in the populations they serve. I believe in the value of culturally competent care, and I think managed care organizations have done some good things, depending on where they are located," she says.

Blue Cross and Blue Shield of Minnesota has provided health literacy and motivational interviewing training for its case management staff and provides additional education through its continuing education program, says Jane Cavanaugh, RN, CCM, CPHQ, nurse case manager for the St. Paul-based health plan.

"Our health care demographic has changed, as a non-English-speaking population has moved into the area. When the first influx of immigrants arrived in our area in the 1970s, we were not prepared to deal with the health issue and communications issues that arise when people of other cultures need the services of Western medicine," she recalls.

At the time, health plans and hospitals didn't have interpreters on the staff, Cavanaugh says. "They didn't speak English, and we couldn't understand them. It was a difficult time for us and for the members."

When she began managing the care of the first member who didn't speak English, Cavanaugh began doing research for information on that member's cultural beliefs.

"Case managing someone from another culture means being flexible. You have to respect their ideas and look for ways to meet their needs that still respect their traditional medicine. Some of the traditional techniques we use with American-born members won't work with people from other cultures," Cavanaugh explains.

For instance, when she managed the care of a Vietnamese woman with lung cancer, she learned that the woman would ride in a car only with her husband.

Instead of arranging transportation so the woman could see her physician, she had to arrange the appointments around the husband's work schedule.

"More and more managed care organizations are becoming increasingly sensitive to the multicultural population that they serve," Mullahy says.

For instance, when care coordinators with UCare Minnesota's Minnesota Senior Health Options (MSHO) visit the homes of their clients from other cultures, they often are accompanied by another staff member who is from the same cultural background as the client they are visiting.

MSHO is a health coverage plan created by the Minnesota Department of Human Services and offered through UCare Minnesota.

Case manager Cindy Radke, LSW, and Maiyer Vang, BS, associate case manager, work as a team to coordinate the care of MSHO members from the Hmong community.

"Maiyer is an asset to me. She helps me understand the traditional beliefs of our Hmong members and assists in setting up services. We work as a team to help members get everything they need to remain healthy at home," Radke says.

The UCare population includes Hmong, Somali, Russian, Cambodian, Vietnamese, and Spanish members. Hmong and Somali are among the biggest populations.

If you are serving people from a multitude of backgrounds and cultures, it's a good idea to familiarize yourself with the beliefs and practices of the people whose care you manage, Mullahy suggests.

"Understand the culture you're working with and look for resources to expand your knowledge base so you can meet the needs of your clients," Cavanaugh adds.

There are a multitude of web sites and materials that can help provide insight into diverse populations, she suggests.

Case managers should look to resources in the ethnic communities they serve to learn about what programs are available for members and for information on how to develop materials that are geared to that population, Mullahy suggests.

"It's worth the time and energy to develop materials that are user-friendly for large ethnic populations," she adds.

Most health plans have information available in Spanish, but consider developing educational materials for other ethnic groups if your membership includes a large population, Mullahy says.

Some managed care organizations list physicians who speak a variety of languages on their web site so that speakers of that language can select a physician with whom they can communicate, she says.

Look to the community itself for help in writing the materials and making them user-friendly for your membership, or turn to people on your staff for help.

Recruit nurses from the multicultural communities you serve, Mullahy recommends.

"There is more than one class of people immigrating to this country. A lot of professional people are immigrating here and can be an asset to managed care organizations because they speak the language and they are aware of the cultural beliefs and needs of the community you serve," Mullahy says.

If you have a large number of members from an ethnic group, find a nurse who speaks that language and can be an interpreter.

"One of our biggest assets is having staff members we can call on to find out about the traditional beliefs of each of the cultures we serve," Radke says.

Become comfortable with using a language line and an interpreter service, Cavanaugh suggests.

If you find an interpreter the member is comfortable with, request that interpreter for follow-up calls, she adds.

Make sure an interpreter is available to talk with hospitalized members about their discharge plan, and if you call in a home health agency, make sure it uses an interpreter as well, Cavanaugh says.