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Advocacy, understanding are keys to success
Trained staff, translators work with members
People who are publicly insured need more advocacy than other populations, and the problems they face negotiating the health care system can be compounded when they don’t understand the language, points out Pamela Persichilli, RNC, director of clinical operations for Horizon NJ Health, a Trenton, NJ-based managed care organization for the publicly insured.
All staff in Horizon NJ Health’s Care Coordination Unit for the special needs population participate in cultural diversity training to learn to be sensitive to the cultural aspects of the population the plan serves.
"The multicultural aspect of our program is very important. It’s hard enough for someone who is Latino or Vietnamese to cope with multiple specialty needs, but when they don’t understand the language and our health care system, it’s really traumatic," Persichilli says.
The health plan contracts with certified translators whom the care managers can use during their telephone conversations with members and who will accompany the member to the physician, the physical therapist, the occupational therapist, or other providers.
"We have to be sensitive about a member’s cultural beliefs and family dynamics," Persichilli says.
For instance, in some cultures, the oldest male is the person with whom to speak on health care matters. Case managers need to take these customs into account.
"People who are publicly insured need more advocacy and more help in negotiating the health care system than other populations. We believe in the 50-50 role. If we advocate and teach and show, all of a sudden the member and the member’s caregivers grow wings and can take on the role of advocate for themselves," Persichilli says.
For instance, the care managers will put the members in touch with the American Cancer Society or American Lung Association programs that can make their life easier.
Unless the special needs members have a strong advocate at home, they may not get a lot of services they need, she points out.
The caregivers often are so involved in taking care of the everyday living needs of these members that they may be overwhelmed by what it takes to get them through the health care system, she says.
"Our advocacy takes some of the pressure off the caregiver, who now has a partner they can call to either help them and make the call for them or if it’s something they want to do themselves to guide them through the process," she says.
Many of the members are surprised at the level of services they receive when they join Horizon NJ Health, Persichilli says.
"We offer coordination, structure, collaboration, and advocacy — not what they got under fee-for-service," she says.
"When you have fee-for-service, there is nobody to call to ask how you get occupational therapy or with questions about a new medication, or to find out where you can get orthotics for your shoes. We coordinate all the care these members need and get them in touch with the right person and the right time to get what they need," Persichilli adds.