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Introduction for Healthcare Professionals: Why was this tool kit created? How can it help my practice? This set of materials was produced by a nation-wide team of healthcare professionals who, like you, are dedicated to providing high quality, effective, and compassionate care to their patients. Because of changes in demography, in our awareness of differences in individual belief and behavior, and new legal mandates, we are constantly presented with new challenges in our attempts to deliver health care to a diverse patient population. The material in this tool kit will provide you with resources to address the very specific operational needs that often arise in a busy practice because of the changing service requirements and legal mandates. The tool kit contents are organized into four sections, each containing helpful background information and tools that can be reproduced and used as needed. Below you will find a list of the section topics and a small sample of their contents. Interaction with a diverse patient base: encounter tips for providers and their clinical staff, a mnemonic to assist with patient interviews, help in identifying literacy problems, and an interview guide for hiring clinical staff who have an awareness of diversity issues. Communication across language barriers: tips for locating and working with interpreters, common signs and common sentences in many languages, language identification flashcards, and language skill self-assessment tools. Understanding patients from various cultural backgrounds: tips for talking with a wide range of people about sex, pain management across cultures, and information about different cultural backgrounds. References and resources: some key legal requirements, a summary of the fiCulturally and Linguistically Appropriate Service (CLAS) Standards,fl which serve as a guide on how to meet legal requirements, a bibliography of print resources, and a list of internet resources. We consider this tool kit a work in progress. Patient needs and the tools we use to work with those changing needs will continue to evolve. We understand that some portions of this tool kit will be more useful than others for individual practices or service settings, after all, practices vary as much as the places where they are located. We encourage you to use what is helpful, disregard what is not, and, if possible communicate your reaction to the contents to the ICE Cultural and Linguistics Workgroup at: On behalf of the ICE Cultural and Linguistic Workgroup, Margie Akin, Ph.D. Molina Healthcare, Inc. Research Anthropologist University of California, Riverside Diana Carr, MA Health Net of California, Inc. Medical Anthropologist Peggy Payne, MA SCAN Health Plan Certified Gerontologist Certified Diabetes Educator

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Better Communication, Better Care: Provider Tools to Care for Diverse Populations Section Document A RESOURCES TO ASSIST COMMUNICATION WITH A DIVERSE PATIENT POPULATION BASE 01 A Guide to Information in Section A 02 Working with Diverse Patients: Tips for Successful Patient Encounters 03 Partnering with Diverse Patients: Tips for Office Staff to Enhance Communication 04 Nonverbal Communication and Patient Care 05 fiDiversefl: A Mnemonic for Patient Encounters 06 Tips for Identifying and Addressing Health Literacy Issues 07 Interview Guide for Hiring Office/Cl inic Staff with Diversity Awareness B RESOURCES TO COMMUNICATE ACROSS LANGUAGE BARRIERS 01 A Guide to Information in Section B 02 Tips for Communicating Across Language Barriers 03 10 Tips for Working with Interpreters 04 Tips for Locating Interpreter Services 05 Telephonic Interpreting Companies 06 Language Identification Flashcards 07 Common Signs in Multiple Language s (English-Spanish-Vietnamese-Chinese) 08 Common Sentences in Multiple Language s (English-Spanish-Vietnamese-Chinese and English-Spanish-French Creole) 09 Employee Language Skills Self-Assessment Tool C RESOURCES TO INCREASE AWARENESS OF CULTURAL BACKGROUND AND ITS IMPACT ON HEALTH CARE DELIVERY 01 A Guide to Information in Section C 02 Let™s Talk About Sex 03 Pain Management Across Cultures 04 Cultural Background: Information on Special Topics D REFERENCE RESOURCES FOR CULTURAL AND LINGUISTIC SERVICES 01 A Guide to Information in Section D 02 Title VI of the Civil Rights Act of 1964 03 Standards to Provide fiCLASfl Culturally and Linguistically Appropriate Services 04 Executive Order 13166, August 2000 05 Bibliography of Major Sources Used in the Production of the Tool Kit 06 Cultural Competence Web Resources 07 Acknowledgement of Contributors from the ICE Cultural and Linguistic Workgroup

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A-01-04 (pg. 1 of 1) A Guide to Information in Section A RESOURCES TO ASSIST COMMUNICATION WITH A DIVERSE PATIENT POPULATION BASE We recognize that every patient encounter is unique. Every patient is different in age, sex, ethnicity, religion or sexual preference and will bring to the medical encounter their unique perspectives and experiences. This factor will always impact communication, compliance and health care outcomes. The suggestions presented here are intended to help build sensitivity to differences and styles, minimize patient-provider and patient-office staff miscommunication, and foster an environment that is non-threatening and comfortable to the patient. This information may assist you to: · Improve health care delivery and outcomes · Decrease repeat visits · Decrease unnecessary lab tests · Increase adherence · Avoid Civil Rights Act violations · Identify opportunities to improve office staff cultural and linguistic competency The following materials are available in this section: Working with Diverse Patients: Tips for Successful Patient Encounters A one-page tip sheet designed to help providers enhance their patient communication skills. Partnering with Diverse Patients: Tips for Office Staff to Enhance Communication A one-page tip sheet designed to help office staff enhance their patient communication skills. Non-verbal Communication and Patient Care A two-page overview of the impact of non-verbal communication on patient-provider relations and communication. fiDiversefl: A Mnemonic for Patient Encounters A mnemonic to help you individualize care based on cultural/diversity aspects. Tips for Identifying and Addressing Health Literacy Issues A two-page handout elaborating on the signs of low health literacy and how to address them. Interview Guide for Hiring Office/Clinic Staff with Diversity Awareness A list of interview questions to help determine if a job candidate is likely to work well with individuals of diverse backgrounds.

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A-02-04 (pg. 1 of 1) WORKING WITH DIVERSE PATIENTS: TIPS FOR SUCCESSFUL PATIENT ENCOUNTERS To enhance patient/provider communication and to avoid being unintentionally insulting or patronizing, be aware of the following: Styles of Speech: People vary greatly in length of time between comment and response, the speed of their speech, and their willingness to interrupt. · Tolerate gaps between questions and answers, impatience can be seen as a sign of disrespect. · Listen to the volume and speed of the patient™s speech as well as the content. Modify your own speech to more closely match that of the patient to make them more comfortable. · Rapid exchanges, and even interruptions, are a part of some conversational styles. Don™t be offended if no offense is intended when a patient interrupts you. · Stay aware of your own pattern of interruptions, especially if the patient is older than you are. Eye Contact: The way people interpret various types of eye contact is tied to cultural background and life experience. · Most Euro-Americans expect to look people directly in the eyes and interpret failure to do so as a sign of dishonesty or disrespect. · For many other cultures direct gazing is considered rude or disrespectful. Never force a patient to make eye contact with you. · If a patient seems uncomfortable with direct gazes, try sitting next to them instead of across from them. Body Language: Sociologists say that 80% of communication is non-verbal. The meaning of body language varies greatly by culture, class, gender, and age. · Follow the patient™s lead on physical distance and touching. If the patient moves closer to you or touches you, you may do the same. However, stay sensitive to those who do not feel comfortable, and ask permission to touch them. · Gestures can mean very different things to different people. Be very conservative in your own use of gestures and body language. Ask patients about unknown gestures or reactions. · Do not interpret a patient™s feelings or level of pain just from facial expressions. The way that pain or fear is expressed is closely tied to a person™s cultural and personal background. Gently Guide Patient Conversation: English predisposes us to a direct communication style, however other languages and cultures differ. · Initial greetings can set the tone for the visit. Many older people from traditional societies expect to be addressed more formally, no matter how long they have known their physician. If the patient™s preference is not clear, ask how they would like to be addressed. · Patients from other language or cultural backgrounds may be less likely to ask questions and more likely to answer questions through narrative than with direct responses. Facilitate patient-centered communication by asking open-ended questions whenever possible. · Avoid questions that can be answered with fiyesfl or fino.fl Research indicates that when patients, regardless of cultural background, are asked, fiDo you understand,fl many will answer, fiyesfl even when they really do not understand. This tends to be more common in teens and older patients. · Steer the patient back to the topic by asking a question that clearly demonstrates that you are listening. Some patients can tell you more about their health through story telling than by answering direct questions.

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A-04-04 (pg 1 of 2) NON-VERBAL COMMUNICATION AND PATIENT CARE Non-verbal communication is a subtle form of communication that takes place in the initial three seconds after meeting someone for the first time and can continue through the entire interaction. Research indicates that non-verbal communication accounts for approximately 70% of a communication episode. Non-verbal communication can impact the success of communication more acutely than the spoken word. Our culturally informed unconscious framework evaluates gestures, appearance, body language, the face, and how space is used. Yet, we are rarely aware of how persons from other cultures perceive our non-verbal communication or the subtle cues we have used to assess the person. The following are case studies that provide examples of non-verbal miscommunication that can sabotage a patient-provider encounter. Broad cultural generalizations are used for illustrative purposes. They should not be mistaken for stereotypes. A stereotype and a generalization may appear similar, but they function very differently. A stereotype is an ending point; no attempt is made to learn whether the individual in question fits the statement. A generalization is a beginning point; it indicates common trends, but further information is needed to ascertain whether the statement is appropriate to a particular individual. Generalizations can serve as a guide to be accompanied by individualized in-person assessment. As a rule, ask the patient, rather than assume you know the patient™s needs and wants. If asked, patients will usually share their personal beliefs, practices and preferences related to prevention, diagnosis and treatment. Eye Contact Ellen was trying to teach her Navaho patient, Jim Nez, how to live with his newly diagnosed diabetes. She soon became extremely frustrated because she felt she was not getting through to him. He asked very few questions and never met her eyes. She reasoned from this that he was uninterested and therefore not listening to her.1 It is rude to meet and hold eye contact with an elder or someone in a position of authority such as health professionals in most Latino, Asian, American Indian and many Arab countries. It may be also considered a form of social aggression if a male insists on meeting and holding eye contact with a female. Touch and Use of Space A physician with a large medical group requested assistance encouraging young female patients to make and keep their first well woman appointment. The physician stated that this group had a high no-show rate and appointments did not go as smoothly as the physician would like. Talk the patient through each exam so that the need for the physical contact is understood, prior to the initiation of the examination. Ease into the patients™ personal space. If there are any concerns, ask before entering the three-foot zone. This will help ease the patient™s level of discomfort and avoid any misinterpretation of physical contact. Additionally, physical contact between a male and female is strictly regulated in many cultures. An older female companion may be necessary during the visit.

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A-04-04 (pg 2 of 2) NON-VERBAL COMMUNICATION AND PATIENT CARE (Continued) Gestures An Anglo patient named James Todd called out to Elena, a Filipino nurse: fiNurse, nurse.fl Elena came to Mr. Todd™s door and politely asked, fiMay I help you?fl Mr. Todd beckoned her to come closer by motioning with his right index finger. Elena remained where she was and responded in an angry voice, fiWhat do you want?fl Mr. Todd was confused. Why had Elena™s manner suddenly changed?2 Gestures may have dramatically different meanings across cultures. It is best to think of gestures as a local dialect that is familiar only to insiders of the culture. Conservative use of hand or body gestures is recommended to avoid misunderstanding. In the case above, Elena took offense to Mr. Todd™s innocent hand gesture. In the Philippines (and in Korea) the ficome herefl hand gesture is used to call animals. Body Posture and Presentation Carrie was surprised to see that Mr. Ramirez was dressed very elegantly for his doctor™s visit. She was confused by his appearance because she knew that he was receiving services on a sliding fee scale. She thought the front office either made a mistake documenting his ability to pay for service, or that he falsely presented his income. Many cultures prioritize respect for the family and demonstrate family respect in their manner of dress and presentation in public. Regardless of the economic resources that are available or the physical condition of the individual, going out in public involves creating an image that reflects positively on the family – the clothes are pressed, the hair is combed, and shoes are clean. A person™s physical presentation is not an indicator of their economic situation. Use of Voice Dr. Moore had three patients waiting and was feeling rushed. He began asking health related questions of his Vietnamese patient Tanya. She looked tense, staring at the ground without volunteering much information. No matter how clearly he asked the question he couldn™t get Tanya to take an active part in the visit. The use of voice is perhaps one of the most difficult forms of non-verbal communication to change, as we rarely hear how we sound to others. If you speak too fast, you may be seen as not being interested in the patient. If you speak too loud, or too soft for the space involved, you may be perceived as domineering or lacking confidence. Expectations for the use of voice vary greatly between and within cultures, for male and female, and the young and old. The best suggestion is to search for non-verbal cues to determine how your voice is affecting your patient. 1, 2 Galanti, G. (1997). Caring for Patients from Different Cultures. University of Pennsylvania Press. Hall, E.T. (1985). Hidden Differences: Studies in International Communication. Hamburg: Gruner & Jahr. Hall, E.T. (1990). Understanding Cultural Differences. Yarmouth, ME: Intercultural Press.

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A-05-04 (pg. 1 of 1) fiDIVERSEfl A MNEMONIC FOR PATIENT ENCOUNTERS A mnemonic will assist you in developing a personalized care plan based on cultural/diversity aspects. Place in the patient™s chart or use the mnemonic when gathering the patient™s history on a SOAP progress note. Assessment Sample Questions Assessment Information/ Recommendations D Demographics- Explore regional background, level of Œacculturation, age and sex as they influence health care behaviors. Where were you born? Where was fihomefl before coming to the U.S.? How long have you lived in the U.S.? What is the patient™s age and sex? I Ideas- ask the patient to explain his/her ideas or concepts of health and illness. What do you think keeps you healthy? What do you think makes you sick? What do you think is the cause of your illness? Why do you think the problem started? V Views of health care treatments- ask about treatment preference, use of home remedies, and treatment avoidance practices. Are there any health care procedures that might not be acceptable? Do you use any traditional or home health remedies to improve your health? What have you used before? Have you used alternative healers? Which? What kind of treatment do you think will work? E Expectations- ask about what your patient expects from his/her doctor? What do you hope to achieve from today™s visit? What do you hope to achieve from treatment? Do you find it easier to talk with a male/female? Someone younger/older? R Religion- ask about your patient™s religious and spiritual traditions. Will religious or spiritual observances affect your ability to follow treatment? How? Do you avoid any particular foods? During the year, do you change your diet in celebration of religious and other holidays? S Speech- identify your patient™s language needs including health literacy levels. Avoid using a family member as an interpreter. What language do you prefer to speak? Do you need an interpreter? What language do you prefer to read? Are you satisfied with how well you read? Would you prefer printed or spoken instructions? E Environment – identify patient™s home environment and the cultural/diversity aspects that are part of the environment. Home environment includes the patient™s daily schedule, support system and level of independence. Do you live alone? How many other people live in your house? Do you have transportation? Who gives you emotional support? Who helps you when you are ill or need help? Do you have the ability to shop/cook for yourself? What times of day do you usually eat? What is your largest meal of the day?

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A-06-04 (pg. 1 of 1) TIPS FOR IDENTIFYING AND ADDRESSING HEALTH LITERACY ISSUES Low health literacy can prevent patients from understanding their health care services. Health Literacy is defined by the National Health Education Standards (*) as “the capacity of an individual to obtain, interpret, and understand basic health information and services and the competence to use such information and services in ways which are health-enhancing.” This includes the ability to understand written instructions on prescription drug bottles, appointment slips, medical education brochures, doctor’s directions and consent forms, and the ability to negotiate complex health care systems. Health literacy is not the same as the ability to read and is not necessarily related to years of education. A person who functions adequately at home or work may have marginal or inadequate literacy in a health care environment. Barriers to Health Literacy · The ability to read and comprehend health information is impacted by a range of factors including age, socioeconomic background, education and culture. Example: Some seniors may not have had the same educational opportunities afforded to them. · A patient™s culture and life experience may have an effect on their health literacy. Example: A patient™s background culture may stress verbal, not written, communication styles. · An accent, or a lack of an accent, can be misread as an indicator of a person™s ability to read English. Example: A patient, who has learned to speak English with very little accent, may not be able to read instructions on a prescription bottle. · Different family dynamics can play a role in how a patient receives and processes information. · In some cultures it is inappropriate for people to discuss certain body parts or functions leaving some with a very poor vocabulary for discussing health issues. · In adults, reading skills in a second language may take 6Œ12 years to develop. Possible Signs of Low Health Literacy Your patients™ may frequently say: · I forgot my glasses. · My eyes are tired. · I™ll take this home for my family to read. · What does this say? I don™t understand this. Your patients™ behavior may include: · Not getting their prescriptions filled, or not taking their medications as prescribed. · Consistently arriving late to appointments. · Returning forms without completing them. · Requiring several calls between appointments to clarify instructions. Tips for Dealing with Low Health Literacy · Use simple words and avoid jargon. · Never use acronyms. · Avoid technical language (if possible). · Repeat important information Œ a patient™s logic may be different from yours. · Ask patients to repeat back to you important information. · Ask open-ended questions. · Use medically trained interpreters familiar with cultural nuances. · Give information in small chunks. · Articulate words. · fiReadfl written instructions out loud. · Speak slowly (don™t shout). · Use body language to support what you are saying. · Draw pictures, use posters, models or physical demonstrations. · Use video and audio media as an alternative to written communications. (*) Joint Committee on National Health Education Standards, 1995

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