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“Enhancing Cultural and Linguistic Competence and Responsiveness to Minority Communities in the Philadelphia Department of Public Health”
Introduction
Over the past few decades, the role of public health services in city government has expanded to include the provision, either directly or through community- based agencies, of a wide variety of basic health and human services to an increasingly poor and disenfranchised constituency. In Philadelphia, as a result of demographic shifts in population and a variety of other factors, this has meant that the constituencies of most services funded by the Philadelphia Department of Public Health are communities of color.
However, while the population served with city funds is largely comprised of racial and ethnic minority people, there are relatively few providers of these services which are minority- operated or which have historical roots in the communities they target. Additionally, relatively few minority staff hold leadership positions in the management and administration of Health Department agencies, and while there have been efforts to expand the capacity of the systems of care to include more minority providers, these efforts have not been organized, have not received much in the way of real financial resources, and have rarely met with much success.
The reasons for these failures are many, and the responsibility for them is widely shared. But the Transition Subcommittee believes that the Street Administration should consider a renewed effort to build the capacity of the city’s communities of color to respond to the many challenges to their health, and dedicate specific, targeted resources to this initiative. It is our belief that the long- term positive outcomes for which our public health service system is organized cannot be achieved unless new priority is given to developing a more diverse and responsive system of public health care in our city.
Short Term Recommendations for Minority Health/ Cultural Competency:
1. The Philadelphia Department of Public Health, including the Behavioral Health System, must engage in a strategic planning process involving consumers, providers and community representatives, to set specific, achievable goals in the following areas:
a) Identifying measurable goals for increasing the number of cultural and linguistic minority providers of behavioral health, AIDS, maternal and child health, and other services. These goals should be time- specific and specific strategies to achieve them should be developed and financed.
b) Financing must be made available to provide training, technical assistance, and start- up funding
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to qualified minority agencies seeking to become part of the public health system of care.
Rationale
"Cultural incapacity" in this sense refers to a set of attitudes, policies and practices that promote racially based stereotypes and ignorance about the pivotal role that race and culture play in public health crises. The net effect is to convey, overtly or covertly, the message that low- income people of color are not valued or particularly welcomed in the system.
"In describing this factor, Roizner, Roizner, Monica, Ed. D., A Practical Guide for the Assessment of Cultural Competence, Judge Baker Children's Center, 1996. writes:
"Culturally blind systems often see themselves as unbiased and responsive to ethnically and culturally diverse clients. Their lack of information and adaptation to diversity, however, tends to render their practices as ethnocentric and virtually useless to all but the most assimilated people of color."
2. The Health Department should create an office with the specific and ongoing purpose of assuring cultural and linguistic competence among its own staff and among provider agencies it supports with public funds.
a) This office should establish standards of performance in the area of cultural and linguistic competence, including but not limited to empowerment of minority personnel in decision making capacities, sensitivity to race, class spiritual, gender, sexual identity and other realities of their clientele, involvement in other ways in the communities the serve, etc., and enforce such standards in Health Department procedures and policies and in contracts for services with community agencies.
b) This office should conduct public information campaigns on the importance of recruiting people of color for public health service, support training and educational programs (perhaps in conjunction with the city’s wealth of educational institutions and the School District), to develop a consistent stream of qualified minority staff, and monitor the employment of minority staff in both high- level and line staff position of the Health Department and community agencies supported with public funds.
Rationale
A large body of research exists which indicates that public health services can be improved, and more people helped, through the development of culturally competent interventions provided by agencies and
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organizations with a historical base in the communities being served. Study after study indicates, in most areas of public health service, that a true commitment to indigenous services and cultural competence leads to better compliance with treatment, better access to services, and increased effectiveness and consumer satisfaction.
The Health and Wellness Transition Subcommittee believes that the city government needs to accept the challenge to improve the capacity of communities of color to develop and support services in their own communities and cultural competence in public health service delivery. A system that turns a blind eye to the socio- economic realities of race, poverty and racial discrimination in our city, or refuses to discuss rationally these issues is, we believe, one which is destined to fail.
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3. The City of Philadelphia should begin immediately to fully enact Philadelphia’s standing Public Access Law. a) The City of Philadelphia should move immediately to establish a nonprofit corporation mandated in the Public Access Law to operate the Public Access System. b) The Board of the nonprofit corporation should include public Health experts, members of the city Health Department, and members drawn from community- based organizations, particularly those serving peoples of color, cultural and linguistic minorities, and other special needs populations.
Rationale Public Health: Ethnic communities are the most at- risk for public health problems and have the lowest access to information. Public Access can carry messages that are culturally and linguistically specific and bypass cultural stigmas surrounding discussion of health issues. Public Access can provide alternative programming that would counteract the irresponsible messages about sexual behavior found on commercial television. Minority Representation: Commercial media continually ignores or misrepresents minority communities. There is very little programming for or about African Americans, Latinos, Asians, sexual minorities, women, or elderly communities. Public Access would allow minority communities to generate positive images of themselves, tell their own stories, and represent themselves in an honest and real manner. |
Long Term Recommendation for Minority Health/ Cultural Competency:
4. The newly established Office of Policy and Planning should establish a mechanism for
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reviewing the performance of the Health Department in increasing the number of minority provider in its various systems of care.
a) .The Office of Policy and Planning should develop a mechanism that will address the perception that the Health Department treats minority providers in a discriminatory manner
b) This office should further conduct an analysis of employment patterns and salary structures to for advancement, etc, which are equivalent to the patterns in non- minority provider agencies.
Rationale
In many areas of health services supported with Health Department funding, there is an obvious lack of qualified minority community- based providers because of historical discrimination in the development of such services. However, few financial resources have been allocated by the Health Department aimed at developing this capacity in minority communities, and the lack of minority providers is usually used as an excuse for why non- minority organizations must be utilized to provide these services.
In some agencies of the Health Department, in particular the Behavioral Health System, tens of millions of dollars in Aprogram funding@ has for many years been allocated to long existing, usually non- minority, provider agencies. This more flexible funding has, therefore, been unavailable to newer minority providers, providing a special barrier to the development of indigenous minority community service agencies.
While virtually all Health Department activities formally recognize the need to increase the number and type of minority provider agencies, the Department has not set specific goals with regard to the number of such agencies or the dollars allocated to support them.
XII. Insurance Eligibility
Statement of the Problem:
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While exact numbers are not known, upwards of 20% of people in Philadelphia have no health insurance. In addition, thousands of others are eligible for current programs (Medical Assistance (MA) and CHIP), but are not enrolled. The consequences for individuals living without health insurance and their providers are far reaching:
1. Individuals who lack health insurance often receive less care than those with insurance, and that care is often provided later than is medically desirable and is of lesser quality. (Kaiser Project on Incremental Health Reform). In addition, they may needlessly suffer pain and physical discomfort because of delay in receiving care.
2. For individuals in poor health and with chronic illness, timely and regular access to medical care is crucial. According to recent Kaiser Project these individuals “experience preventable hospitalizations, more disability and even shortened life spans.”
3. Many individuals living without health insurance suffer indignities when they do seek out care. In addition, they often live in fear that if they or a loved one become ill they will not know where to get medical care, or how to pay for it.
4. MA greatly increases access to care. For example, studies show that low income seniors with MA coverage are much more likely to have a regular medical care provider, visit their doctor and are less likely to put off medical care, than their peers without MA who have only Medicare (Families USA).
5. The City’s Health Care Centers, which provide comprehensive medical and dental care to all Philadelphians regardless of their insurance status, are an important safety net. However, rising costs associated with uncompensated care, and a rising number of uninsured patients, may ultimately impact the ability of the Health Centers to provide comprehensive, state- of- the- care.
This report, then, makes two fundamental recommendations: 1) Enhance efforts to ensure that Philadelphia children and adults who are eligible for current insurance plans are enrolled as promptly as possible (and providers have the capacity to bill accordingly); 2) Enhance efforts and collaborations to improve healthcare insurance coverage for individuals who are currently ineligible for any insurance plan.
Long Term Recommendations Related to Enhancing MA and CHIP Enrollment of Children:
1. The Health Department should work to enhance enrollment of children in Pennsylvania’s MA
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or CHIP program.
Rationale
Most children in Philadelphia qualify for MA or the Children’s Health Insurance Program (CHIP), comprehensive health insurance programs that provide a wide range of medical services for children. However, as many as 40,000 eligible children in Philadelphia are currently not enrolled in either program. In the past three years alone, (1996 to 1999), there has been a decline of 19,000 children enrolled in MA. While the number of new children enrolled in CHIP has grown by 7,000 during this period, this has not offset reductions in MA enrollment. The number of eligible but uninsured children remains large.
Uninsured children receive no healthcare, or healthcare that is provided later than medically desirable and sometimes of lesser quality than their peers who are insured. Current initiatives to improve children’s health insurance enrollment must be supported and enhanced.
Best Practices
Under the leadership of the Philadelphia Citizens for Children and Youth, Community legal Services and the Pennsylvania Health Law Project and others, significant efforts have already been implemented to improve children’s enrollment in MA and CHIP. In addition, models around the nation have been developed and assessed. These efforts need to be expanded.
(i) The City should work with the State so that it adopts presumptive eligibility for children as nine other states have done.
(ii) The City, in cooperation with community- based agencies and health care providers, should implement activities to inform parents about CHIP and MA coverage and assist with their enrollment. Specifically the Benefits Counselors program at the City’s Health Care Centers should be strengthened, supported and expanded to all Health Centers.
(iii) The City should aggressively pursue its share of the $17 million currently unspent in Pennsylvania’s TANF De- Linking Fund. This fund was created under federal TANF legislation for states to assure that persons who are eligible for MA are enrolled and/ or remain enrolled. These federal matching dollars are available to conduct outreach activities such as “simplifying the application process, updating computer systems, training eligibility workers, etc.” To date, Pennsylvania has only spent a
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very small share of its funding. In addition, the City expenditures in this area are eligible to be matched with federal funds, if the State would cooperate. This would not require an outlay of state funds.
The City should do everything in its power to assure that welfare to work agencies like Greater Philadelphia Works and Philadelphia@ Work ensure that recipients who make the transition to stand- alone Medicaid. This loss of TANF is the main reason for the drop in Medicaid enrollment for both children and adults, both locally and nationally. Stopping it requires working with people at the time of transition from welfare to work.
Long Term Recommendations Related to Enhancing
MA Enrollment of Adults:
1. The Health Department should work to improve enrollment of MA eligible adults in Philadelphia.
Rationale
Thousands of adults living in Philadelphia are eligible for MA but are not enrolled. While we do not have exact numbers, we do know that:
a) Eligibility rules and procedures permitting an adult to receive MA in Pennsylvania are confusing, complicated, cumbersome and seemingly contradictory. There are several programs all with differing eligibility, income and resource limits. The application process itself is fraught with barriers to enrollment.
b) Recent changes in TANF law has resulted in 32,000 persons in Pennsylvania who lost MA when they left TANF. DPW has agreed with advocates to implement several strategies to reinstate these families back on MA. More needs o be done, especially at the local level and in Philadelphia, where a disproportional part of the loss has taken place., according to DPW data.
c) Most MA programs for adults require an assessment by a physician. However, physicians know little about the requirements for MA eligibility, often assuming a more difficult standard than required by law for a patient to become enrolled.
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d) Staff at the Department of Welfare, County Assistance offices who process MA applications are often overworked, overwhelmed. They are unable and often unwilling, to assist applicants to ensure prompt and accurate approval. A large percentage of applicants are wrongly denied or wrongly cut off from coverage because of paperwork errors by the DPW.
e) 64% of patients at the Health Care Centers are uninsured, up from 44% in 1995, yet almost all the patients are poor. 80% of patients live below the Federal poverty level, ($ 13,880 a year for a family of three) with only 2% live above 200% of the poverty level (or $27,760 a year for a family of three).
While poverty alone is no longer sufficient to become MA eligible, there is no doubt that significant numbers of these patients are eligible for MA because they are disabled, are heads of households with children, are blind or 65 or older, or fit into another eligibility category. The challenge is to create programs that facilitate enrollment and do not interrupt or discourage care.
Clearly, efforts are needed to improve MA access for eligible adults. In order to improve rates of enrollment, the Managing Director of Social Services should work to ensure that a coordinated strategy is developed to respond.
Information on Best Practices
(i) Develop creative and effective strategies to identify eligible but unenrolled adults. (E. g., through the Model Court Project, the City’s Health Care Centers, CBH, DHS, schools). Educate them on their options and assist with the application process. Additional funding should be sought to develop and evaluate the best methodology for enhancing enrollment and address obstacles (e. g., cultural sensitivity and language access).
(ii) Train physicians and other medical care providers (nurses and physicians assistants) on the medically based eligibility standards and their role in determining eligibility;
(iii) Strengthen the role of Benefits Counselors to improve their performance with greater supervision and support and train them to counsel on the other available government benefits such as food stamps and SSI.
(iv) Link all City Health Care Centers with neighboring Welfare Department County Assistance
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Offices to establish more effective working relationships. (v) Explore developing a computer- based program to assess a person’s eligibility.
2. he Philadelphia Department of Health or the Mayor’s Office should work more closely with Philadelphia Department of Public Welfare to improve procedures and remove obstacles to expedited enrollment.
Rationale
In order to successfully implement strategies to enhance both adult and children’s MA and CHIP enrollment, cooperation from the Pennsylvania Department of Public Welfare is crucial. To date, staff in the Administrative Office has indicated a willingness to collaborate, and help develop strategies to improve approval rates.
3. The City’s Health Care Centers must maximize MA and CHIP dollars to ensure money is available for uninsured patients.
Rationale
It is absolutely crucial that nothing is done to disturb the District Health Center’s policy to provide primary medical care to all Philadelphia residents regardless of their health insurance status. However, in order to ensure that the Health Care Centers continue to have the capacity to serve those lacking insurance, it is important that the City captures every MA or CHIP reimbursement dollar available.
Best Practices
(i) Develop a process to improve MA approval, and therefore MA reimbursement based on the date of the patient’s first visit to the Health Center.
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(ii) Develop a system to ensure that billing and reimbursement for all MA approved services are done retroactively up to three months as permitted by law.
(iii) Develop a system that ensures that rules for expedited approval of MA is utilized.
Long Term Recommendations to Expand Health Insurance Access for Individuals Ineligible for Insurance
1. The City must aggressively go after state, federal and private funds to expand health care access for uninsured and increase revenue for uninsured medical care provided by the Health Care Centers.
Rationale
Between 15 and 20% of Philadelphians are currently ineligible for any form of health insurance. Some are low- income individuals who are ineligible because of their immigration status, or open criminal record. Others are working in low- income jobs that lack health insurance coverage and are ineligible for Medical coverage because of their income or resources.
Many states are examining innovative ways to expand health care coverage for their uninsured. While much of the leadership must come at the State level, the City should aggressively pursue an agenda in Harrisburg to get more support at the state level for expanded healthcare access. This is especially important in light of Governor Ridge’s recent announcement of his recommendations for the use of Pennsylvania’s share of tobacco money and the pending legislative approval process.
Ideas
There are several initiatives in expand health insurance coverage being considered or implemented in States and Cities across the County. These include 1) tax- based programs to subsidize purchase of health insurance; 2) direct subsidy programs and 3) MA expansions.
In Pennsylvania, among other initiatives, efforts should be made to secure money for Philadelphia from the TANF De- Linking Fund, noted above and the recently announced tobacco money
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2. The City should aggressively seek grant funding to analyze systems weaknesses and strengths to create the organizational improvements and cultural changes to ensure that the City’s Health Care Centers are places poor people want to go to for their health care, even when approved for MA or other insurance.
Rationale
The ability of the City’s Health Care Centers to maximize insurance reimbursement is a product of both of improved availability of MA and other insurance programs for the poor but also continued improvements in the attractiveness of the City’s Health Care Centers, the cultural sensitivity and customer friendliness of the staff and systems.
3. The Health Dept. or the office of the Director for Social Services should establish a dedicated office for the purpose of coordinating efforts to improve rates of MA approval and reimbursement within the Health Care Centers and CBH, and enhancing the amount of federal, state, and philanthropic funding available to expand health insurance access for people who lack insurance.
XIII. Management Information Systems
Long Term Recommendations for MIS:
1. The Health Department should develop a plan for data system acquisition and upgrade to ensure that databases are compatible so that information can be shared across systems in accordance with appropriate confidentiality standards.
Rationale
Incompatible data systems prevent different Health Department units from sharing information and force contract providers to report data in different formats for different units or programs. This incompatibility also requires the expenditure of resources for outside expertise to analyze data comprehensively or draw conclusions across programs. Upgrade of systems would streamline data collection methods and remove some of the burden that impedes effective use of the data.
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2. The Health Department should enhance its capacity for comprehensive data analysis.
Rationale
The Health Department units record an immense amount of data about clients and the services provided to them. Much of this data capture is driven by funder reporting mandates which can impede utilizing this data for actual evaluation of services and their impact on consumers. The analysis of this data is also limited in some part due to a lack of available technical skills in the department. The development of an internal capacity for comprehensive data analysis and the creation of a central data analysis unit in the department, supported by enhanced data systems where needed, would significantly increase the department's ability to use the data collected to support its mission, measure its services and direct its resources most effectively.
3. The Health Department should fulfill the above objectives by completing an inventory and needs assessment of current systems, reviewing systems that other cities are using effectively, and performing a national search for an appropriate person to lead this process.
Rationale
Data integration across departments is complex and expensive. Many cities have expended monies on these projects, but have not achieved their goals. Nevertheless, there are many successful models available in the country. Taking this approach will speed up the process and ensure that the dollars are effectively spent.
XIV. Prison Health Services
Short Term Recommendations for Prison Health Services:
1. The Health Department must take immediate steps to expand the pharmaceutical formulary in the city prison health department for people with mental illness, people with HIV disease, and other chronic diseases including but not limited to as asthma, diabetes, hypertension, and seizure disorders.
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Rationale
The current formularies in the prison health system are inadequate. The recent task force working on mental health in the prisons has identified that the lack of access to appropriate pharmaceuticals has increased the suicide rate and untreated mental illness in the prisons. For people with HIV, inappropriate use of the new drug regimens increases the risk of developing drug resistant strains of the HIV virus. This not only poses a threat to the individual, but poses public health risk as well.
2. The Health Department must take immediate steps to ensure that prisoners with HIV, mental illness, and chronic diseases are provided with a comprehensive plan for their discharge which assures that they receive at least 30 days supply of medications, linkage to ambulatory medical care and/ or mental health care within one week of discharge, and linkage to case management, housing, behavioral health treatment, and other social services.
Rationale
Most prisoners with chronic physical or mental health problems are lost to care upon release. There are a number of reasons for this. While in jail, they are not eligible for health insurance and other benefits and must apply for these upon release, when they are jobless and, often, homeless. In addition, prisoners do not have sufficient supplies of their medications, access to their medical records, or an ongoing relationship with providers of mental health and primary care services. Those with severe mental illness quickly decompensate and are often incarcerated again. Those with HIV/ AIDS experience a rapid increase in their viral load, with the attending health risks noted earlier. Those with diabetes, asthma, and seizure disorders can experience life- threatening episodes within a few days of terminating their medications.
3. The city should continue the work of the task force of the prisons and the prison mental health and physical health providers to improve mental health services in the city jails. After one year, an outside source should be involved in re- evaluating the city’s performance.
Rationale
The number of prisoners with mental illness is growing each year. The suicides of the four inmates last summer drew attention to the lack of adequate care for prisoners with mental illness. The task force identified universal screening and referrals, comprehensive pharmaceutical formularies, drug monitoring,
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and skilled hospital inpatient staffs as the key needs in the prison system.
4. The Health Department must take immediate steps to assure that all HIV+ individuals incarcerated in the Philadelphia County Prison System are receiving HIV- related medical care from trained HIV specialists providing care according to city standards of care, including routine access to all required medications.
Rationale
The treatment of HIV disease is complex and rapidly developing. National studies consistently demonstrate that people living with HIV/ AIDS who are treated by specialists live twice as long as those who are not. Furthermore, inconsistent or inappropriate use of the relatively new drug regimens increases the risk of developing drug resistant strains of the HIV virus, which poses a public health risk.
5. The City should use the policies and procedures developed in response to the Jackson vs. Hendrick lawsuit as a base line for providing physical and mental healthcare for inmates in the Philadelphia County Jail.
Rationale
Both outside experts, and experts retained by the City of Philadelphia have found very serious deficiencies in prison mental and physical healthcare in the County Jail. The City has agreed to implement the policies and procedures from the Jackson vs. Hendrick litigation. These must be implemented in a timely manner.
Long Term Recommendations for Prison Health Services:
6. The city must maintain a rigorous system of outside independent auditing of their system by qualified experts and make whatever changes these experts recommend.
Rationale
Corrections can be a closed system. Because of the broad scope of important improvements needed, it is critical that outside, independent experts are retained and have access to necessary information to review the Jail's system of healthcare on a regular basis and that changes are made in a timely manner in
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response to the experts' recommendations
7. The Director of Social Services should provide supervision and strong oversight over the Philadelphia County Jail.
Rationale
Though the Health Department has oversight, Prison Health Services is operated through a PPS contract. The appointment of a Director for Social Services who is responsible for oversight of both the Health Department and the Department of Prisons, has promise for assuring a more integrated, rational and cost- effective approach to addressing the needs of incarcerated and recently- released people who have medical and behavioral health issues.
8. The City should develop a mechanism for prison public health planning. The City must improve the coordination of behavior and physical health services in the county jails and ensure an open dialogue from physicians of both these services.
Rationale
Many of the challenges of the behavioral and physical health systems parallel each other. In fact, for many consumers, one of the greatest obstacles to care is the lack of coordination between these two systems, as many prisoners are dually diagnosed. Some progress has been made to improve this and should continue. Systems must be developed to improve coordination of medications, to ensure consistent cross referrals when appropriate, and to ensure that adequate nursing and medical skills are available for the increasing number of prisoners who are dually diagnosed.
Section C Appendices - Needs Assessment of Medical Access For African Americans Living With HIV/ AIDS - - Health Policy Recommendations for Children in Substitute Care in Philadelphia -
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- Health and Wellness Committee Meeting Minutes
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For the full report, which is extremely long and does not shed any additional light on Public Access, see http://www.phila.gov/transition/healthwellness.htm.