A bill awaiting Gov. Jared Polis’ signature that would fund training for Colorado health care providers to help them better work with diverse populations is a good start, but it won’t address all the ways the system leaves some people out, advocates say.
HB22-1267, which cleared the legislature on the penultimate day of the session, would create a $900,000 grant program to hire contractors to train health care providers on how to provide culturally responsive care to “priority populations.” Polis hasn’t said if he will sign the bill.
The definition of priority populations is broad, including people of color; veterans; LGBTQ people; people who are homeless or in the criminal justice system; people who have HIV or AIDS; older adults; “children and families”; and people with disabilities.
While the boards overseeing medical licensing would be ordered to encourage providers to complete the training, there’s no penalty to providers that don’t.
Interest in how to better serve different patients seems to growing, especially since the pandemic highlighted existing health disparities, said Robert King, vice president of diversity, equity and inclusion at Colorado Access, which manages care for a portion of Colorado’s Medicaid members and purchased some lessons from an outside vendor to offer providers.
Training can cover issues like bias, privilege and how the way systems failed people of color — or actively harmed them — in the past influences whether they trust medical providers today.
“Training itself will not get to sustainable outcomes, but it is a necessary ingredient,” King said.
In a September 2020 poll by the Pew Research Center, about 76% of Black respondents thought they were less likely to be treated fairly in medical settings than white people. The majority of white respondents didn’t believe Black people were more likely to face unfair treatment. The poll didn’t ask whether other groups were treated unfairly.
Interactions between providers and patients can be intimidating, especially if there’s a difference in culture or social class, said Robert Friedland, director of the Center on an Aging Society at Georgetown University. Knowing that patients from other communities may have different ideas than their doctors, such as whether a brain-dead person should be considered dead if their heart hasn’t stopped beating, can help set up better conversations, he said.
“I think a lot of this centers around the issue of communication and understanding,” he said. Cultural responsive care is “a package of tools and sensitivities.”
Typically, medical students get a few days of training about communicating with diverse patient groups, and they may take occasional continuing education courses on the subject as providers, Friedland said. Usually, the training focuses on people of different ethnicities or religions, though sometimes training about LGBTQ people and people with varying disabilities is available, he said.
When patients trust their doctors, they’re more likely to follow medical advice, whether that’s getting a vaccine or taking steps to manage their chronic conditions, King said. And they’re more likely to trust providers who understand where they’re coming from and are trying to meet their needs, he said.
“When you look at (COVID) vaccine adoption rates… the key factor is trust,” Friedland said.
A better relationship with patients is only one part of the solution, though, King said. Patients won’t get better care if the office is only open when they’re at work, isn’t accessible for people with disabilities and doesn’t offer help navigating the complex systems surrounding elder care, he said.
“Training is about 20% of the equation,” he said. “If the system doesn’t change, if the structure doesn’t change… any effect is going to be marginal.”
Cultural gaps in vaccine rollout
Maria Gonzalez, CEO of Commerce City-based Adalante Community Development, said the need for cultural competency became clear during the pandemic.
The state and local health departments’ initial efforts to get COVID-19 vaccines out didn’t focus on the Latino community’s needs, and asking for identification at some sites raised suspicion among people who didn’t trust the government with health information or were worried about their immigration status, she said.
Some sites didn’t have bilingual staff who could answer people’s questions, and it could be difficult to even find Spanish versions of the forms that vaccine recipients fill out, Gonzalez said.
In the first months of the vaccine rollout, recipients were disproportionately non-Hispanic white Coloradans, though the disparity has narrowed somewhat since then as the state hosted clinics in underserved areas. People of color were disproportionately likely to catch COVID-19 and die of it nationwide, though it’s difficult to know to what extent Colorado saw the same pattern, because so many cases lacked data on race and ethnicity.
“There have been so many barriers,” she said.
Practical considerations, like whether a medical site is as accessible, has convenient hours and offers interpretation services at every point in the interaction can be as important to cultural competency as having a well-trained staff, according to guidance from Georgetown University’s Health Policy Institute. So can working with people who know a community well, whether that’s staff members who share the patient’s background, community health workers or traditional healers (when possible without compromising care).
Adalante normally doesn’t get involved with health issues, focusing on economic development and assisting Latino business owners. But the staff is part of the community and knew how to talk to people about their concerns, Gonzalez said, estimating they facilitated about 15,000 shots through a partnership with Colorado Access, which provided staff and funding.
They also knew that setting up at the weekly Mile High Flea Market and at apartment and mobile home complexes would bring in people who weren’t opposed to being vaccinated but hadn’t been able to get the shot easily, she said.
“We didn’t have to beg,” she said.
Patients who feel supported seek more care
While race and language come up most often in discussions of cultural competency, some of the biggest supporters of the bill to fund the training are organizations representing the LGBTQ community.
In a 2018 survey commissioned by One Colorado, about one-third of people identifying as LGBTQ said they didn’t have adequate access to health care providers who understood their needs, and 36% said they weren’t open about their gender identity or sexual orientation because they worried about discrimination in the provider’s office.
Dr. Jude Harrison, a recently retired family medicine physician in Durango who identifies as transgender, said even having options other than “male” and “female” for patients to mark on their intake forms can be helpful.
So can getting rid of gendered language when it’s not necessary, such as asking about the patient’s parents, rather than mother and father, when taking their health history. With a few exceptions, a relative’s sex doesn’t matter when figuring out if family history puts a patient at risk for an illness, he said.
“A lot of it comes down to practices not assuming that someone is heterosexual and cisgender,” he said. “When people are treated respectfully… that significantly increases the odds that someone will seek care and they will seek it promptly.”
Transgender people have a particularly difficult time getting health care, even when the reason they’re seeking care has nothing to do with their gender identity, Harrison said. It doesn’t matter if a patient is transgender if they have strep throat or a broken wrist, but a significant percentage of providers still say they can’t treat those patients, he said.
The One Colorado survey found that when respondents thought their health care provider understood and was supportive of LGBTQ people, they were more likely to have had a medical visit in the past year, and to have received routine care like flu shots and cancer screenings. About 78% of people who said their provider understood their needs had a primary care visit in the previous year, compared to 52% of those who didn’t feel comfortable with their provider.
“You don’t have to comprehend someone’s sexual orientation or gender identity to treat them with compassion and respect,” Harrison said.