Welcome to the training on Advancing Health Equity in Texas through Culturally Responsive Care provided by Texas Health and Human Services (HHS) and the Texas Department of State Health Services (DSHS).
This module does not currently offer CE credit. An updated version that will offer CE credit is in development.
The goal of this module is to provide physicians and other health-care professionals with practical guidance about how to advance health equity by adopting and implementing the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care.
Texas Health Steps providers and other interested health-care professionals.
Specific Learning Objectives
After completing the activities of this module, you will be able to:
- Specify an individual-level poor health outcome in Texas that correlates to health disparity.
- Given a case study, recommend the most appropriate action to provide culturally responsive care.
- Select one purpose of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care.
- Select one benefit to health-care providers and organizations of implementing CLAS standards.
- Specify the reason that providing equitable care is the basis by which CLAS standards operate.
- Given a case study, select one strategy that supports a diverse workforce.
- Determine two ways to provide communication and language assistance to patients and their families.
- Specify one way to provide patient-centered care with help from community resources.
Please note this module expires on 12/18/2017.
One of the requirements of continuing education is disclosure of the following information to the learner:
- Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
- Create a Texas Health Steps account.
- Complete on-line registration process.
- Thoroughly read the content of the module.
- Complete the on-line examination.
- Complete the evaluation.
- Commercial Support.
The THSTEPS Web-based Continuing Education Series has received no commercial support.
- Disclosure of Relevant Financial Relationships.
The THSTEPS Continuing Education Planning Committee and the authors of these modules have no relevant financial relationships to disclose.
- Non-Endorsement Statement.
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
- Off-Label Use.
Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).
The following are policies and definitions of terms related to continuing education disclosure:
The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.
All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.
Glossary of Terms
Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.
Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.
Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).
- Agency for Healthcare Research and Quality. (2002). Expanding Patient-Centered Care To Empower Patients and Assist Providers.
- American College of Physicians. (2010). Racial and Ethnic Disparities in Health Care, Updated 2010. Philadelphia: American College of Physicians; 2010: Policy Paper.
- Anand, R., & Lahiri, I. (2004). Intercultural competence in health care: Developing skills for interculturally competent care. In DK Deardorff (Ed.). The SAGE Handbook of Intercultural Competence (2009). SAGE Publications, Inc., 387-402.
- Anand, R. (2004). Cultural Competency in Healthcare: A Guide for Trainers (3rd ed.). National MultiCultural Institute.
- Association of American Medical Colleges. (2005). Cultural Competence Education.
- Belle Brown, J., Stewart, M., & Weston, W. (2002). Challenges and solutions in patient-centered care: A case book. Oxford: Radcliffe Medical.
- Bhui, K. and Bhugra, D. (2004). Communication with patients from other cultures: the place of explanatory models. Advances in Psychiatric Treatment, 10, 474-478.
- Brach, C., & Fraser, I. (2002). Reducing disparities through culturally competent health care: An analysis of the business case. Quality Management in Health Care, 10(4): 15-28.
- Campinha-Bacote, J. (2009). A culturally competent model of care for African Americans. Urologic Nursing, 29(1).
- Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 12(3): 181-184.
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- Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a Culturally Competent System of Care: Volume 1. Washington, DC: Georgetown University Child Development Center.
- Dahlgreen, G. & Whitehead, M. (1991). Policies and strategies to promote social equity in health. Background document to WHO — Strategy paper for Europe.
- Epstein, R. M., & Street, R. L., Jr. (2007.) Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. National Cancer Institute, NIH Publication No. 07-6225.
- Frieden, T. R. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4): 6.
- Green, A. R., Carrillo, J. E., & Betancourt, J. R. (2002). Why the disease-based model of medicine fails our patients. Western Journal of Medicine. 176(2): 141—143.
- Haidet, P., O’Malley, K. J., Sharf, B. F., Gladney, A. P., Greisinger, A. J., & Street, R.L. (2008). Characterizing explanatory models of illness in healthcare: development and validation of the CONNECT instrument. Patient Education and Counseling, 73(2): 232-39.
- Kleinman, A. (1978). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88: 251-8.
- LaVeist, T. A., Gaskin, D. J., & Richard, P. (2009). The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies.
- Literacy Coalition of Central Texas.
- Marks, J. (2009). Why Your ZIP Code May Be More Important to Your Health Than Your Genetic Code. Huffington Post.
- Meyer, P. A., Yoon, P. W., & Kaufmann, R. B. (2013). Introduction: CDC Health Disparities and Inequalities Report – United States, 2013.
- Modern Language Association, American Community Survey 5-Year Estimates, Public Use Microdata Sample, 2006—2010. (2010). Most spoken languages in Texas in 2010.
- National Academy of Science, Institute of Medicine. (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press.
- National Center for Education Statistics. 2006. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy. Washington, DC: U.S. Department of Education.
- Public Broadcasting System. 2008. Unnatural Causes: Is Inequality Making Us Sick?
- Ring, J. (2009). Psychology and medical education: collaborations for culturally responsive care. Journal of Clinical Psychology in Medical Settings, 16:120—126.
- Saha, S. (2006). The relevance of cultural distance between patients and physicians to racial disparities in health care. Journal of General Internal Medicine, 21(2): 203—205.
- Saha, S. B. (2008). Patient centeredness, cultural competence/responsiveness, and healthcare quality. Journal of the National Medical Association, 100(11): 1275-85 (abstract).
- Salimbene, S. (2001). CLAS A-Z: A Practical Guide for Implementing the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. Inter-Face International.
- Stanton, Mark. (n.d.). Expanding Patient-Centered Care To Empower Patients and Assist Providers. (n.d.)
- Subramanian, K.I (2004). Income inequality and health: What have we learned so far? Epidemiologic Reviews, 26(1): 787-91.
- Taylor, W. C., Poston, W. S., Jones, L., & Kraft, M. K. (2006). Environmental justice: Obesity, physical activity, and healthy eating. Journal of Physical Activity and Health, 3: S30-S54.
- Tervalon, M, & Murray-García, J. (1998). Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. Journal of Health Care for the Poor and Underserved, 9(2): 117-125 (Article).
- Texas Department of State Health Services, Center for Health Statistics. (2011). Texas Behavioral Risk Factor Surveillance System, 2011.
- Texas Health and Human Services Commission. Frequently Asked Questions About Deaf and Hard of Hearing Issues.
- Texas Department of State Health Services, Center for Health Statistics. (2010). 2010 Mortality.
- Texas Department of State Health Services, Statewide Health Coordinating Council. (2010). Texas State Health Plan 2011-2016: A Roadmap to a Healthy Texas.
- The Henry J. Kaiser Family Foundation. (2012). State Health Facts.
- The Joint Commission. (2014). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.
- The San Antonio Health Literacy Initiative. (n.d.). Resources.
- U.S. Census Bureau. American Community Survey, 2006-2010.
- U.S. Census Bureau. (2013). People Quick Facts–Texas.
- U.S. Department of Health and Human Services. (2014). Federal Poverty Guidelines.
- U.S. Department of Health and Human Services, Office of Minority Health. (2013). National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.
- U.S. Department of Health and Human Services, Office of Minority Health, Center for Linguistic and Cultural Competence in Health Care. (2010). Think-Speak-Act Cultural Health: Part 1.
- U.S. Department of Health and Human Services. (n.d.). Healthy People 2020: Disparities.
- U.S. Department of Health and Human Services. (n.d.). Quick Guide to Health Literacy.
- Weinick, R., Flaherty, K., & and Bristol, S. (2008). Creating Equity Reports: A Guide for Hospitals. The Disparities Solutions Centre, Massachusetts General Hospital.
- World Health Organization, Commission on Social Determinants of Health, Final Report. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health.
- Wynia, M. K., Ivey, S. L., & Hasnain-Wynia, R. (2010). Collection of data on patients' race and ethnic group by physician practices. New England Journal of Medicine, 362: 846—850.
- Critical MASS Toolkit: Taking community ACTION on health disparities. Designed to help communities and grassroots coalitions mobilize for the elimination of disparities.
- Culture, Language, and Health Literacy materials from the U.S. Department of Health and Human Services. A collection of resources, including toolkits, videos, and workbooks aimed at health-care providers to enable them to better address the cultural, language, and health literacy needs of their patients.
- DiversityRX. An interactive website that provides a clearinghouse of information on model programs, policies, practices, and legal issues related to cross-cultural health.
- FAIR Toolkit. A two-part resource based on the Robert Wood Johnson Foundation’s Finding Answers project focused on reducing racial and ethnic disparities in health care.
- HealthBegins. A “think-and-do-tank” social network founded by doctors and public health innovators to develop and spread activities to address social determinants of health.
- Diversity Training ROI: How to Measure the Return on Investment of Diversity Training Initiatives. A book by Hubbard, E. E. Global Insights, 2010. Available through Amazon.
- Intercultural Communication Institute (ICI). A nonprofit charity with the mission of fostering an awareness and appreciation of cultural differences. It also provides An Introductory Guide to Intercultural Books on its website.
- Cultural Competency and Health Literacy Primer. A teaching resource guide by McCann, M., Carter-Pokras, O., Braun, B., & Hussein, C. Maryland Office of Minority Health and Health Disparities and the University of Maryland School of Public Health, March 2013.
- National Center for Cultural Competence at Georgetown University. Provides training, technical assistance, consultation, and resources to promote cultural and linguistic competency among health- and mental health-care providers and systems.
- National Prevention Strategy: Elimination of Health Disparities. Recommendations from the U.S. Surgeon General’s National Prevention Council.
- Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health. A workbook for public health practitioners and partners interested in addressing social determinants of health in order to achieve equity.
- Regional Disproportionality and Disparities Specialists. Specialists available to address health-related disproportionality and disparities within systems in Texas.
- Roots of Health Inequity. A web-based course presented by the National Association of County and City Health Officials that explores the root causes of inequity in the distribution of disease, illness, and death.
- Think Cultural Health. Develops and promotes culturally and linguistically appropriate services and provides continuing education programs designed to help individuals at all levels and in all disciplines promote health and health equity.
- Toolkit for Community Action. Developed to help individuals, organizations, and policymakers raise awareness of health disparities, engage others in conversation about the problem and solutions, and take action for change.
- Unnatural Causes: Is Inequality Making Us Sick? A seven-part PBS documentary series exploring racial and socioeconomic disparities in health.
The medical definitions in this module were obtained or adapted from the National CLAS Standards Blueprint, the Texas Department of State Health Services, and the U.S. Department of Health and Human Services’ Healthy People 2020 initiative.
Anticipatory guidance—age-appropriate education and counseling—is a required component of every Texas Health Steps preventive medical and dental checkup. Texas Health Steps offers age-appropriate education and counseling topics so providers can assist patients, families, and caregivers to understand growth, development, and healthy practices. Texas Health Steps recommends that health-care providers personalize anticipatory guidance depending on the needs of their patients. Anticipatory guidance topics should be individualized and prioritized based on questions and concerns of the child or adolescent and their parent or guardian. Specific guidance should also be based on findings obtained during the health history and physical exam.
Texas Health Steps offers Anticipatory Guidance-A Guide for Providers, which includes guidance topics for every age group birth through 20 years. It mirrors anticipatory guidance topics included on the Texas Health Steps Child Health Clinical Record Forms.
Families and caregivers of children with chronic medical conditions face complex challenges and extended stress. Providing long-term care for a child with a disability or chronic illness can take a physical, emotional, and financial toll. It also requires a time commitment that can be difficult to achieve.
As a pediatric health-care provider, you “have a responsibility to recognize caregiver burden (Adelman, Tmanova, Delgado, Dion & Lachs, 2014). Research has shown that caregivers are at increased risk for depression, anxiety, and other negative health effects of what can be a crushing responsibility. At each pediatric checkup, make it part of your routine to inquire whether family or caregivers have questions or concerns about their roles, their own health, or navigating the health-care system.
The health of your young patients and the health of their caregivers are interwoven.
Caregivers who feel overwhelmed may not be able to provide appropriate care for a child in need. You must be alert to outcries for help or signs of health problems related to caregiving, including loss of sleep and diet imbalance. Open communication allows you to be a sounding board for caregivers who are struggling with their duties. At the same time, be on the watch for signs of fatigue or stress in caregivers who try to project an “all’s well” attitude even when they are having problems.
Your role includes providing practical counseling about stress and offering resources designed to help families and caregivers cope.
Top 10 Caregiver Coping Skills
Sharing this Top Ten list of coping skills can help caregivers learn strategies that may reduce stress:
- Understand your feelings.
- Express your emotions.
- Educate yourself about your child’s illness or condition.
- Keep communications open.
- Talk to other parents.
- Focus on the strengths and goals that are achievable.
- Believe in your child.
- Establish routines.
- Maintain your sense of humor! There is no co-pay for laughter!!
- Remember that taking care of yourself is caring for your family.
Source: Parent to Parent of New York State
Resources to share with families and caregivers
Aging and Disability Resource Centers (ADRCs) operated by Texas Health and Human Services (Texas HHS). The centers are welcoming and offer information about state and federal health benefits as well as local programs and services. The trained staff can connect caregivers with services such as home care, meals, transportation, legal help, attendant care, respite support, and housing. Visit the ADRC website for a list of resource center locations in Texas.
Family Support Services, a program to help families care for children with special health-care needs at home. Services are provided by the Children with Special Health Care Needs (CSHCN) Services Program, a branch of the Texas Department of State Health Services.
Navigate Life Texas, a multilingual website created by parents for parents of children with disabilities and special health-care needs. This unique site offers comprehensive, relevant, and reliable information for families, professionals, advocates, and anyone working with children who have disabilities and their families. Sponsored by the Texas Interagency Task Force on Children with Special Needs.
Take Time Texas, a website offered by Texas HHS that includes a state inventory of respite services.
Texas Parent to Parent offers peer support for parents of children with special health-care needs.
All Medicaid managed care organizations (MCOs) provide case management services (called service management for STAR members with special health-care needs). In the other Medicaid managed care programs, everyone gets some level of case management. Patients should first be referred to the plan’s service coordinator and then referred to Case Management for Children and Pregnant Women if patient needs cannot be met by the plan’s services. Health plans are also required to make appropriate referrals to case management services.
For patients enrolled in STAR Medicaid, STAR Health, or Fee-For-Service (FFS) Medicaid, providers can make a referral by one of these methods:
- Calling 877-847-8377 (877-THSteps).
- Contacting a case manager (“Find a Case Manager” web page accessed from the Resources for this module).
- Submitting the Case Management Referral Form (the form is also accessed from Resources).
For patients enrolled in STAR Kids:
- Health Plan service coordinators and others can refer by submitting the STAR Kids Case Management Request Form (the form is also accessed from Resources).
Early Childhood Intervention (ECI) is a statewide program for families with children birth through 35 months who have disabilities and developmental delays. All health-care providers are required by federal and state regulations to refer children 35 months and younger to the local ECI program as soon as possible but no later than seven days after the suspicion or identification of a developmental delay.
To qualify for ECI services, a child must have:
- A qualifying medically diagnosed condition that has a high probability of resulting in a developmental delay. For more information, visit the ECI Qualifying Diagnosis Search web page.
- An auditory or visual impairment as defined by the Texas Education Agency (TEA) rule at 10 TAC Section 89.1040.
- A documented delay of at least 25 percent in one or more of the following areas of skills and development: gross motor, communication, cognition, fine motor, social, emotional, or self-help. Or, a documented delay of at least 33 percent when the delay occurs only in expressive language.
- A qualitative determination of delay, as indicated by responses or patterns that are disordered or qualitatively different from what is expected for the child’s age.
To refer a child, providers should use the ECI Provider Referral and Feedback form. The form, which requires a parent or guardian signature, helps ensure that ECI’s evaluation results and service plan are shared with the referring provider.
To refer families for services, providers can call the local ECI program.
Texas Health Steps requires that all federal- and state-mandated checkup components be documented in the medical record in order for the checkup to be considered complete and to qualify for provider reimbursement. Any checkup component that is not completed must be noted in the medical record, along with the reason it was not completed and a plan to complete it. The medical record must also contain documentation of all screening tools used, screening results, and referrals. Texas Health Steps child health clinical record forms are optional but are recommended to assist providers with documentation of all required checkup components. Providers should be aware that Texas Health Steps checkups are subject to retrospective review and recoupment if the medical record does not include all required documentation.
A medical home is the patient’s primary point of contact when accessing health care. The medical home concept was developed by the American Academy of Pediatrics (AAP) and is promoted by Texas Health Steps. A medical home is defined as one in which care is accessible, family-centered, continuous, comprehensive, compassionate, coordinated, and culturally effective. It is a partnership between a child, the family or caregiver, and the child’s primary health-care setting. The primary health-care setting can be a physician’s office, a hospital outpatient clinic, a school health center, a community health center, or a health department clinic.
Providers who need assistance finding a specialist or subspecialist who accepts patients enrolled in Medicaid can find a specialist or subspecialist by using the Texas Medicaid & Healthcare Partnership (TMHP) Online Provider Lookup or by calling the Texas Health Steps toll-free help line for providers at 800-964-2777 Monday through Friday from 8 a.m. to 6 p.m. Central Time. Select option 3 to speak with a representative.
Providers can access a set of child health clinical record forms to document Texas Health Steps preventive medical checkups. The set includes a form for each checkup under the Texas Health Steps Periodicity Schedule, for patients from up to 5 days old through 20 years. Providers can save or print the forms.
Each form includes the required components for that age’s checkup, along with space for documenting routine, non-required components of a medical checkup. The backside of the form includes a helpful list of suggested anticipatory guidance topics and checklists such as the Hearing Checklist for Parents and Lead Risk Factors.
Texas Health Steps is the preventive care services program for children birth through 20 years who are enrolled in Medicaid. Texas Health Steps provides regular checkups and screenings as part of the Early and Periodic Screening, Diagnosis, and Treatment program, also known as EPSDT.
In Texas, EPSDT is known as Texas Health Steps, which includes the preventive care components—or Early and Periodic Screening (EPS)—of the total EPSDT service. Required medical checkups and preventive care services are provided in accordance with the latest Texas Health Steps Periodicity Schedule, which is modeled after the one developed by the American Academy of Pediatrics (AAP). Additional checkup components are required in Texas to meet federal and state guidelines, and checkups are encouraged as part of the medical home. The Periodicity Schedule specifies when each of the checkup components is due. Providers should always refer to the latest schedule available. To download a PDF of the Periodicity Schedule online, visit the Texas Health Steps Provider Information web page.
The Texas Medicaid & Healthcare Partnership (TMHP) updates the TMPPM monthly. The policy updates are published on the TMHP website and in banner messages, which appear weekly on a provider’s Remittance and Status Report as well as on the website. Providers can find updates on the web page in two ways:
Release Notes—Changes to the TMPPM arranged by date, with most recent at the top of the list.
Change History—Changes to the TMPPM arranged by chapter. (If a chapter has not changed, it will not appear on the list).
NOTE: Providers should always check the TMHP website for the current TMPPM, banner messages, and policy and procedures updates. Archived versions of the TMPPM will remain online for reference purposes.