Culture Matters:
Improving Cultural Competency in
Minnesota’s Rural Physician Offices
Mary Beth Dahl, Program Manager
Stratis Health
2008 Minnesota CAH and Rural Health Conference
June 24, 2008
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Objectives
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Discuss the changing demographics of rural
Minnesota and the clinics that participated in the
initiative
Describe how Stratis Health worked with the clinics to
promote cultural learning
Share results of the pre- and post-CLAS
assessments
Learn about a DVD series that was created to
educate physician office staff about culture and
health care
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Overview
„
Stratis Health
ƒ Mission: non-profit organization that leads
collaboration and innovation in health
care quality and safety, and serves as a trusted
expert in facilitating improvement for people and
communities.
ƒ Serves as the Medicare Quality Improvement
Organization (QIO) for Minnesota
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Minnesota’s
Changing Rural Demographics
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What does it mean?
ƒ Minnesota’s white population is older on
average and will age rapidly in the coming
years (baby boomer effect).
ƒ Age 65 plus will rise from 13% in 2000 to
23% in 2030.
ƒ African American/Black is the largest
non-white racial group in the state.
ƒ Minnesota has the largest Somali and
Liberian populations in the U.S.
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What does it mean? (cont.)
ƒ Asian population in Minnesota
is projected to grow rapidly
over the coming decades.
ƒ Current age distribution of
Asians is very young.
ƒ In 2000, 31% of Asians
were under age 15.
ƒ Minnesota has the
largest Hmong population
in the U.S.
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What does it mean? (cont.)
ƒ American Indian population is
projected to grow more slowly than
other non-white groups.
ƒ Population growth is mainly the
product of natural increase
(excess of births over deaths).
ƒ Very little net in-migration from
other states.
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What does it mean? (cont.)
ƒ Hispanic/Latino population is
projected to triple by 2030.
ƒ Growth can be attributed to a
combination of:
▫ International migration,
▫ Migration from other states, and
▫ High rate of natural increase.
ƒ Two or more races
ƒ Projected to grow dramatically.
ƒ Younger people are more likely to identify with
two or more races.
Population information derived from “Minnesota Population Projections
by Race and Hispanic Origin 2000-2030,” Minnesota State Demographic
Center
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Culture Matters:
Cultural Competency Initiative
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What was the goal of the initiative?
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To address disparities and to gain a better
understanding of cross-cultural care
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Clinic Participation
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23 clinics in Minnesota completed the initiative
(12 urban and 11 rural)
„ Expectations were established for participating
clinics
„ Representation from seven health systems
„ Participating rural clinics located in northern,
central, and southwestern Minnesota
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Participating Clinics
Urban Clinics
„ CentraCare – Melrose
„ Duluth Clinic – Ely
„ HealthPartners – Como
„ HealthPartners – Maplewood
„ HealthPartners – Riverside
„ HealthPartners – St. Paul
„ North Clinic – Maple Grove
„ North Clinic – Osseo
„ North Clinic – Plymouth
„ North Clinic – Robbinsdale
„ Parkview Medical Clinic
„ Primary Care & Rehabilitation
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Rural Clinics
„ CentraCare – Long Prairie
„ Duluth Clinic – Deer River
„ Mayo Health System – Madelia
„ Sanford Clinic – Adrian
„ Sanford Clinic – Glick
„ Sanford Clinic – Luverne
„ Sanford Clinic – Mountain Lake
„ Sanford Clinic – Tracy
„ Sanford Clinic – Westbrook
„ Sanford Clinic – Worthington
„ Stevens Community Medical
Center
Participating Clinics (cont.)
Clinic - Urban vs Rural
Urban
47.8%
52.2%
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Rural
Who do the participating rural clinics serve?
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Clinics in Northern Minnesota
ƒ Serve many American Indian patients. Deer River’s
population is 12% American Indian.
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Clinics in Central Minnesota (Todd and Stearns counties)
ƒ Serve many different immigrant populations who are moving
to the area to work in the meat processing plants, including
Hispanic, Vietnamese, Cambodian, Laotian, Hmong, Somali,
and Sudanese.
ƒ Population of Todd County is at least 9% Hispanic.
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Who do the participating rural clinics serve?
(cont.)
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Clinics in Southwestern Minnesota (Cottonwood,
Rock, Nobles, Lyon, and Watonwan counties)
ƒ Serve similar immigrant populations as Central
Minnesota with an even higher Hispanic
population
ƒ At least 20% of Worthington’s population is
Hispanic and 7% is Asian.
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Culture Matters:
Stratis Health’s Unique Approach
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Materials Provided to Clinics
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How Stratis Helped
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Demographic reports
ƒ Each clinic had a site visit at the beginning
of the project and were provided with standardized
reports with Minnesota-specific demographic
information
ƒ Customized report for each clinic that
included:
ƒ Demographic change/impact on clinic
ƒ Population projections
ƒ Summary
ƒ At-A-Glance statistics
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How Stratis Helped
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Pre-CLAS assessment
ƒ Clinic staff (physicians,
nurses, front desk staff,
lab staff, clinic
managers, etc.) took a
pre-CLAS assessment
ƒ Results of the pre-CLAS
assessment were
shared at clinic visits
ƒ A gap analysis was
performed and future
strategies and action
steps were shared with
the clinics
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How Stratis Helped (cont.)
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Clinic staff agreed to complete the Office of Minority
Health’s (OMH) online curriculum which included:
ƒ Pre- and post- tests
ƒ Video vignettes that present cross-cultural situations that
doctors, nurses, and other clinic staff may encounter
ƒ Opportunities for learners to respond to each situation
presented
ƒ Many learning points about specific cultures
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Stipends
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How Stratis Helped (cont.)
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Stipend money was used for:
ƒ Bringing speakers from a certain culture into the
clinic to share (invited other community members
such as law enforcement, school employees, etc.)
ƒ Purchased cordless phones for exam rooms
ƒ Medical Spanish classes for clinic staff
ƒ Purchased visual educational tools
ƒ Donated money to community cultural wellness
project
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How Stratis Helped (cont.)
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Provided the clinics with:
ƒ Quarterly Culture Matters newsletters
ƒ Notification of conferences or seminars on
relevant topics
ƒ Educational materials, including:
ƒ Access to the Multilingual Health Resources Exchange
ƒ Educational DVDs in multiple languages with information
about a variety of health care topics such as breast
cancer, diabetes, TB, etc.
ƒ Medica’s “Walking in their Shoes” training kits
ƒ Referrals to speakers and educators to train at their
clinics
ƒ Other information, as requested
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How Stratis Helped (cont.)
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Post-CLAS assessment
ƒ Clinic staff again took the CLAS assessment
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Final Clinic Visits
ƒ Each clinic had a final site visit
ƒ Provided with the post-CLAS assessment results
with a comparison to the pre-CLAS results and a
gap analysis with recommendations
ƒ Certificate of completion
ƒ Program evaluation
ƒ DVD series with CEU certificate
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Final Results . . .
Post-CLAS Assessment Survey
Pre-CLAS vs Post CLAS Standards - Scores
5.00
Scores
4.50
4.00
3.50
3.00
2.50
2.00
Pre-CLAS
Post-CLAS
1.50
1.00
0.50
0.00
1
2
3
4
5
6
7
8
9
CLAS Standards
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10
11
12
13
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Final Results
Pre-CLAS vs Post CLAS Standards - Met or Exceeded
100.0%
90.0%
% Met or Exceeded
80.0%
70.0%
60.0%
Pre-CLAS
Post-CLAS
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
1
2
3
4
5
6
7
8
9
CLAS Standards
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10
11
12
13
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Final Results
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In the pre-CLAS assessment, approximately 7
(30.4%) clinics met only 0-2 of the CLAS
standards, while the post-CLAS assessment
showed that all 23 clinics had met at least 3 or
more of the CLAS standards.
„ In the pre-CLAS assessment, 4 (17.4%) of the
clinics met or exceeded 12-14 of the standards,
while there were 10 (43.5%) clinics in the postCLAS assessment that met or exceeded 12-14 of
the standards.
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Final Results
Most Improved - Top 3 Relative Rate of Improvement from
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pre-CLAS to post-CLAS:
Standard 3 (pre-CLAS score=2.71, post-CLAS
score=3.22, relative % increase=18.8%)
Standard 9 (pre-CLAS score=2.78, post-CLAS
score=3.29, relative % increase=18.3%)
Standard 2 (pre-CLAS score=3.29, post-CLAS
score=3.87, relative % increase=17.6%)
(Note: Standard 3 is the bottom performer for Pre-CLAS
and Post-CLAS but is also the most improved. )
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Culture Matters DVD Series
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Culture Matters DVD Series (cont.)
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Produced three DVDs addressing how to provide culturally-appropriate
care:
ƒ Three major growing populations in state:
ƒ Hispanic/Latino
ƒ Hmong
ƒ Somali
ƒ Three expert speakers with health care background for each population
were chosen:
ƒ Cristina Martinez-Gonzalez
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Attended medical school in Mexico
MPH – U of MN, focus on cultural competency
ƒ Huda Farrah
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Trained in epidemiology
Worked in public health for MDH and Hennepin County
Director of Somali Health Screening Project
ƒ May Hang
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First Hmong Advanced Practice Nurse in MN
Family nurse practitioner focusing on acute common family illness
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Culture Matters DVD Series (cont.)
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Sections addressed include:
ƒ Brief overview of culture and cultural competency
ƒ Cultural background
ƒ History
ƒ Geographic location
ƒ Languages spoken
ƒ Role of religion and health care beliefs
ƒ Social values
ƒ Family structure and impact on health care
ƒ Decision making
ƒ Health care considerations
ƒ Suggestions for health care professionals
ƒ Resources
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Culture Matters DVD Series (cont.)
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Hispanic/Latino DVD clip – Suggestions
for Health Care Professionals
Distribution:
ƒ Provided to clinics in initiative
ƒ CEUs available
ƒ Broader distribution planned
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“It is much more important to
know what sort of a patient has
a disease, than what sort of
disease a patient has.”
- Sir William Osler, 1911
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What Clinics Say About the Initiative
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“Learned that different cultures have
different health care expectations.”
“The importance of providing information in
the patient’s native language.”
“Very good opportunity to learn about
other cultures. Good follow-up with clinics
from Stratis staff. I wouldn’t change
anything.”
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Lessons Learned . . .
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Physician and clinic staff’s time for training and education
is limited.
Clinic resources for training are limited.
Oral Cultures . . . video series.
Incentives (stipends) boost involvement.
All staff need to be involved (especially front-line staff).
Support from “top” is also important.
Awareness of strengths and weaknesses can lead to
change and improvement.
Cultural Competency is a journey – not a destination.
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Contacts
Mary Beth Dahl
Program Manager
952-853-8546
[email protected]
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Stratis Health is a non-profit independent
quality improvement organization that leads collaboration and innovation
in health care quality and safety, and serves as a trusted expert in
facilitating improvement for people and communities.
This material was prepared by Stratis Health, the Medicare Quality Improvement Organization for Minnesota, under a contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS).
The contents presented do not necessarily reflect CMS policy. 8SOW-MN-1d2-08-15
06.2008
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