To improve care of patients, become culturally competent

Work around beliefs to solve treatment problems

As our society becomes increasingly diverse, case managers need to be aware of the cultural beliefs and practices of the people they serve to effectively coordinate their care and help them adhere to their treatment plan.

"Healthcare providers have been emphasizing patient-centered care in recent years, but care can't be patient centered unless the patient's cultural beliefs and practices are taken into account." Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN, president of Transcultural C.A.R.E. Associates, a Cincinnati-based cultural competency consulting firm says,

Patient-centered care and cultural competency are two sides of the same coin, Campinha-Bacote says. "Both aim to improve healthcare quality, but each emphasizes different aspects of quality. It has to do with individualizing patient care," she says.

Culture and language may influence health; healing and wellness belief systems; the perception of illness, disease and their causes by patients; attitudes toward providers; and the delivery of services by providers who tend to view the world through their own experiences and values, says Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy and Associates, a case management consulting firm based in Huntington, NY. "We as case managers need to be prepared to meet the needs of all our patients and family members, not just those who look like us, speak like us, and share our beliefs, values, and customs," she says.

The United States is becoming increasingly multicultural, Mullahy points out. Some individuals immerse themselves in American culture and language and decide to embrace all this country has to offer, including healthcare. Others do not have a comfort level with the healthcare system, but they still need care.

Bria Chakofsky-Lewy, RN, nurse supervisor for the House Calls program at Harborview Medical Center in Seattle says: "The problem is not the culture of some patients. The issue is that there are different lenses with which people look at the same situation. Providers have to be able to understand the other person's viewpoint in order to negotiate a successful outcome." (For details on the program, see related article, below.)

Understanding the cultural beliefs and practices of your patients or clients is important because it impacts health outcomes, Mullahy adds. If case managers don'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 might not be able to help the person modify his or her behavior or adhere to the treatment plan. (For tips on avoiding stereotyping when you work with multicultural populations, see related article, below.)

How do you provide patient-centered care when the patient's health beliefs, practices, and values are in direct conflict with medical guidelines? Chakofsky-Lewy says: "Establishing a respectful relationship is the first step toward providing culturally competent care." Develop questions that are culturally sensitive, she suggests. "Listen to what the patient is telling you, then share your suggestions. Acknowledge where there are differences and where there are similarities with your recommended plan of care, then work with your patient to come up with a plan that he or she can and will follow," she says.

Campinha-Bacote suggests asking leading questions rather than direct questions. "People's cultural beliefs are so ingrained they can't articulate them," she says. Ask open-ended questions such as: "Tell me what brought you here." "Tell me what you do to stay healthy." "What treatments do you think you should be having here?" "Some people may go to a doctor or a nurse when they are sick. Others may call their pastor or their mother for advice. What do you do when you are sick?" Identify treatments that the patient has used, including herbs and home remedies.

"Even though you may know what needs to be done for the patient, let the patient tell you. Find out his goals, and integrate what they say into the treatment plan," Campinha-Bacote says.

For example, the case manager might ask the member to name their favorite foods, and then they keep asking about what is in their diet to isolate and understand where to begin working with the member on healthy eating habits. Chakofsky-Lewy says, "When they work with multicultural patients, clinicians may know what will improve the patient's condition, but they also need to determine what is getting in the way of the patient adhering to the treatment plan. If the patient's views can be elicited and heard respectfully, the case manager will establish a basis for working with the patient to come up with a plan that will work."

Incorporating a patient's cultural beliefs into a treatment plan often is a win-lose/win-lose situation, Campinha-Bacote says. The case manager wins a little and loses a little, and so does the patient. "When a patient's beliefs and practices conflict with standards of care, we have to look for the bridge between what they believe and what we believe needs to be done for the patient," she says.

For example, some Southeast Asian cultures practice "coining" a treatment for a variety of illnesses that involves rubbing coins on the skin, which sometimes leaves an abrasion. Suppose you are coordinating care for a sick child and see marks on his back. You question the mother, who tells you that it is coining and that she has done this healing practice to bring down her child's fever.

Campinha-Bacote suggests that you tell the mother, "I respect this treatment to heal your child and would like to add that when you leave a scrape on your child's skin, there is a chance that bacteria or germs can enter into that cut and cause an infection. Also, if we as healthcare providers notice any marks or scrapes on a child's body that were caused by a parent, we must consider child abuse."

Tell the mother that you realize that in her case it is not child abuse but rather a treatment to help the child. "Add, 'We must consider everyone's concerns as we make a plan to treat your child.' Then discuss with the mother alternative ways to coin on the child's back that do not leave a mark or abrasion," Campinha-Bacote advises.

Achieving cultural competency is not easy. While your organization provides information, individual case managers should assume some of the responsibility for learning about and understanding the populations they serve, Mullahy says. "It may be difficult to give culturally competent care when the beliefs of the case manager are very different from the beliefs of the patient," she points out.

Make it a point to know a little about the cultural beliefs and practices of your patients' cultures. Be patient and keep the lines of communication open, she says.

(For links to information about achieving cultural competency, see resource box, below.)


For more information contact:

  • Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN, President of Transcultural C.A.R.E. Associates, Cincinnati, OH. E-mail:
  • Bria Chakofsky-Lewy, RN, Nurse Supervisor, Community House Calls, Harborview Medical Center, Seattle. E-mail:
  • Catherine M. Mullahy, RN, BS, CRRN, CCM, President and Founder of Mullahy and Associates, Huntington, NY. E-mail:

Avoid stereotypes in treatment plans

Culture extends beyond ethnicity, country

As soon as you make an assumption about a particular culture, you are likely to find that many people from that culture don't fit into that particular stereotype, says Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN-A, FAAN, president of Transcultural C.A.R.E. Associates, a Cincinnati-based cultural competency consulting firm.

"You may have two different people from the same culture with the same condition or disease and come up with different strategies for managing it," Campinha-Bacote says.

For example, Campinha-Bacote's family came to America from the Republic of Cape Verde three generations ago. "While I'm Cape Verdean, I am much different from a Cape Verdean who immigrated this year. We would have different ways of looking at disease and managing it," she says.

Cultural groups extend beyond ethnicity or country of origin, Campinha-Bacote says. "You can't just say something is true for Hispanics. Someone from Colombia could be very different from someone from Ecuador or Peru," she says.

Bria Chakofsky-Lewy, RN, nurse supervisor for the House Calls program at Harborview Medical Center in Seattle, cautions case managers to avoid stereotyping their patients because they look a certain way or belong to a certain ethnic group. "As a clinician, it's very important to remember that the person you're working with may or may not ascribe to the beliefs that you have learned about that culture. There is a tremendous amount of intra-cultural variation. People vary as much within cultural groups as they do across cultural groups," Chakofsky-Lewy says.

A comprehensive cultural assessment should involve more than just the person's ethnic background. Culture is more than just ethnicity. It also involves age, gender, sexual orientation, religious beliefs, disability, socio-economic status, occupational status, geographical location, and other factors, Campinha-Bacote says.

If you work in an area where there are ethnic communities, it's your obligation to have information about that community, Chakofsky-Lewy says. Research the literature to learn about the cultures of the patients you encounter, but don't stop there, she suggests.

There are a plethora of cultural assessment tools available in the literature, Campinha-Bacote points out. "My advice for case managers would be to become familiar with some of these tools and incorporate them into the patient history and case management assessment," she says.

"It's the encounters that help us with cultural competency. The more encounters you have with a patient, the more you can learn about that culture. However, case managers may be at a disadvantage if they see someone only once or twice and some healthcare providers get just one shot. The bottom line is that you just do the best you can in making the patient feel respected, supported, and understood," she says.

Program helps navigate healthcare system

Cultural mediators visit in communities

When immigrants and refugees living in Seattle's diverse multicultural communities seek care at Harborview Medical Center, the hospital's Community House Calls program helps them navigate the healthcare system and overcome linguistic and cultural barriers to care.

Called caseworkers/cultural mediators, the staff members are bilingual and bicultural. They have had the experience of being immigrants and refugees themselves. They all have connections with the communities they serve, and they visit their clients in their homes and in their communities.

A key portion of their jobs is to help clinicians understand patients by providing them with information about their cultural backgrounds, current living situations, and healthcare practices and beliefs, as well as accompanying them into the community to talk with residents, says Bria Chakofsky-Lewy, RN, nurse supervisor for the program.

Patients who come to Harborview Medical Center speak more than 90 languages.

English, then Spanish are the most common languages, followed by Somali and Vietnamese. The hospital has a staff of 50 interpreters, who with telephonic back-up for languages they don't speak, provide interpretation for more than 100,000 patient visits each year.

The House Calls program began 17 years ago by two physicians who thought that to practice good medicine, they needed information about the populations they were serving "They wanted to know the experiences and the expectations of their patients, and what they were doing at home to get well, such as herbal medicine or other practices," Chakofsky-Lewy says. "This allows knowledge of their patient's beliefs and practices and allows providers to negotiate with patients to develop an effective care plan."

The caseworker/cultural mediator's duties include case management services such as advocacy and coordination of care, interpretation, cultural mediation, health education, and assistance in accessing English and citizenship classes.

Patients are referred by physicians and other healthcare providers. Depending on the situation, the caseworker/cultural mediator might visit the patient in the hospital or set up an appointment the next time the patient has an outpatient visit. In some cases, the cultural mediators set up a home visit and might ask a nurse or physician to accompany them. For example, a provider might refer a patient who has repeatedly been scheduled for a mammogram and hasn't had the procedure. "The reason may be transportation, she might have heard misinformation in the community, or it may be that the patient is afraid to have an unfamiliar procedure and needs someone to go with her," Chakofsky-Lewy says. "The case worker/cultural mediator addresses the problem and finds a solution."

The focus for the House Calls program has expanded through the years, she says. When the program started, most of the patients were new immigrants with acute healthcare problems. Now that they are seeing a physician when they have acute problems, the treatment team at Harborview is working with patients on chronic illnesses. "These illnesses are not unique to these populations, but the idea of taking medication every day when you don't feel bad makes no sense to many of our patients," she says.

A common scenario is for the patient to thank the physician for his prescription for hypertension. "Many of our patients have respect for the authority of a provider that precludes them saying anything but 'thank you' for the medication, but then they don't take it," Chakofsky-Lewy says.

During the next visit, seeing no improvement, the physician increases the dosage. If the patient abruptly decided to take the medication, he could have a medical emergency.

Sometimes, the caseworker/cultural mediators take on the role of a health coach to help patients learn to manage their chronic diseases. For example, they might find out what is important to the patient and help them change their behavior by taking their medication or otherwise adhering to their treatment plan so they can meet their goals. "There are a lot of myths about insulin in some communities," she says. "The caseworker/cultural mediators know about these myths and can talk to the patient and the provider to help overcome the patient's misconceptions."

Some of the caseworker/cultural mediators have been with the program since it started 17 years ago. Others have used the position as a career springboard. One is now a nurse in the hospital system. Another is a social worker.

Some patients learn to navigate the healthcare system in a short time. Others have stayed in the program since it began. For instance, one of the first patients referred to the program came to physician appointments many hours early because she couldn't read a clock. When the cultural mediator looked into the situation, she discovered that the patient had cognitive problems that resulted from being tortured in her native country. The caseworker/cultural mediator reminds her of her appointments, makes sure she has transportation, and arranges to be with her during her appointment. As a result, the woman sees her physician regularly and receives the recommended preventive care.

"Our goal is to give people the tools to manage for themselves, but in this case, the person will never be able to be totally self-sufficient, so we continue to support her," she says.