When working with patients from different ethnic backgrounds, it's important that nurses be culturally competent.
Part two of a two-part series. Read part one here.
HealthLeaders continues our conversation with Allison Squires, PhD, RN, FAAN, an associate professor with the New York University Rory Meyers College of Nursing who is lead author of a recent study that found that having a home health nurse who speaks the same language can help prevent hospital readmissions for non-English speaking patients.
The following transcript has been edited for clarity and brevity.
HealthLeaders: How do interactions in the same language affect the quality of care you're able to provide?
Allison Squires: I would get a lot of great information, but then I would also be playing catch-up because oftentimes there would need to be an additional referral, another consultation, a social worker, a mental health professional. You get so much more out of the patient when they know you speak their language.
On the other side, when you have an interpreter, if you become good at establishing relationships, people will share more with you. That consistent relationship certainly helps because people have had a variety of healthcare experiences in their lives.
If they have come from another country, their healthcare experiences will be informed by what their experiences were in their home country, which may or may not have had health services. There's a lot of different things that inform healthcare experience.
The more consistently you can engage with someone, the more likely you are to be able to help them and meet their healthcare needs whenever they happen to be.
HL: How do you navigate the cultural differences in your conversations and interactions with patients?
Squires: It's an approach that, over my professional career, was initially called trying to respond in a "culturally competent" way, then became a "culturally sensitive" way, and now it's phrased as "culturally humble."
The idea is that if you work in a place like New York City, there's no way you're going to be culturally competent in all of the cultures, backgrounds, and languages. Increasingly in the rest of the country, the populations are becoming more diverse in terms of the immigrant profile, so there's no way to be culturally competent for one single group.
To be culturally humble, you have to realize there are going to be beliefs across cultures that are going to affect how people make decisions about their healthcare. These might be beliefs around food, around religious or spiritual practices, and certainly around their previous experiences with healthcare. You're meeting the person where they are in that healthcare encounter and not making judgments about their choices in terms of their health that may be culturally driven.
HL: How important is it that home-based healthcare professionals be knowledgeable of cultural competencies and meet patients where they are?
Squires: Good quality home care organizations will already be doing this and should have already been doing this for many years, so that type of training should be in place already.
It needs to respond to whatever the changing local demographics are, and this is especially because the Medicare population will be getting more diverse as time goes on. The diversity of the market that home care agencies are going to be serving moving forward is going to increase.
Most people don't know you have to work 10 years in the U.S. to become eligible for Medicare and Social Security, so even if you're not a citizen, you can still receive Medicare as a green card holder if you've worked for the eligible amount of time. That's something that's going to also help contribute to shifting the demographics of who's being served by Medicare, who home care will be attending to, and who home health agencies will be serving now.
HL: How can younger generations of healthcare professionals understand the importance of cultural competency throughout the healthcare continuum?
Squires: Interestingly, nursing assistants are more likely to come from the same background as foreign patients. They may themselves be immigrants, and some of them may have even been trained as nurses in their home countries.
They're just not eligible to get credentialed here in the U.S. for a variety of reasons.
When we're looking at nursing aides, especially for home health care aides, you know that training has multiple nuances, and it really depends on who they're working with.
There's also an accountability on the patient part where nursing assistants may very well experience racism and discrimination because of their identity from the patients, and home care agencies also need to be prepared to respond to that, because that culturally humble approach to that patient provider relationship, no matter what the level is, needs to be productive for everyone to be effective.
Beyond interpreters, bilingual or nurses that speak the same language as patients can foster better health outcomes.
Part one of a two-part story.
Having a nurse who speaks the same language can help prevent hospital readmissions among home health patients who don't speak or know very little English, says a new study out of New York University Rory Meyers College of Nursing.
For that reason, home health agencies should try to hire and retain nurses who speak the same languages as their patients, according to Allison Squires, PhD, RN, FAAN, an associate professor with the college and lead author of the study.
Unfortunately, there aren't enough nurses to meet this specific demand, Squires said
HealthLeaders spoke to Squires about her intentions for the study, her experience as a bilingual nurse, and how healthcare should support non-English speakers and their treatment.
The following transcript has been edited for clarity and brevity.
HealthLeaders: What information were you hoping to find with the study?
Allison Squires: We were looking at the idea of using the nursing role as an intervention in home health care.
If you are working with patients with limited English proficiency, would having the same nurse be as effective as having a nurse who speaks your same language? We looked at this in terms of language concordance: if you had a nurse with the same ethnic background and spoke the same language, or if you had several nurses who knew how to speak your language, because there's a lot of interest in this notion of concordant care in healthcare and languages.
The trouble with languages is we don't have enough people in the U.S. who speak other languages to meet the demand, especially among Spanish speakers, and so we needed an alternative intervention to look at in terms of what might make a difference in terms of home health outcomes.
I'm not Latina, but I've worked in Mexico, so I have an above-average understanding, certainly of Mexican culture, but also of Latin American culture, in addition to being fluent. There have been moments in my time working clinically as a nurse for a decade that having a nurse who spoke the same language made a difference.
As I developed into a health services researcher and understood workforce interplays, I also know that having language-concordant providers is not necessarily realistic for a lot of organizations.
When I began working with the Visiting Nurse Service of New York around 2011, they had the data that we could use to do this analysis and determine these types of effects. They had a large enough data set because of the size of the organization and the clientele that they serve to be able to study this.
The last couple of years and the pandemic has certainly sensitized the broader healthcare community to the needs of non-English speakers when seeking healthcare.
And it goes beyond just using an interpreter; if just using an interpreter worked, then there shouldn't be any disparities in health outcomes when controlling for all other types of things.
HL: Being bilingual, is Spanish something you picked up specifically to help you as a nurse?
Squires: No, I started studying Spanish in junior high school and found that I was good with languages, so I continued it while I was in university studying to be a nurse, and just happened to have the opportunity to study abroad in Mexico.
Since I graduated university in 1995, it happened to be a very good time to graduate and be a bilingual nurse speaking Spanish.
It's always a good time to be a bilingual or speaking Spanish, but back then there were even fewer of us who spoke Spanish.
HL: How do you think Hispanic patients perceive you when speaking to them one-on-one?
Squires: When I was working as a staff nurse, and even now when I volunteer, and I'm able to speak Spanish, usually what happens is people work with interpreters and they tend to sort of curtail the information that they share because it is the best option for communication.
It also makes everything take longer, given time constraints in healthcare delivery.
When I would work with patients who had been working with interpreters or didn't have a family member around or whatever reason, oftentimes you'd start speaking and they'd be like, "Oh my God. Do you speak Spanish?" And then suddenly, all this other stuff would come out and it would give answers as to a lot of the issues that we're coming up around specific patient in terms of what their health needs were.
The private duty sector is booming post-COVID, so small agencies and franchises alike must be strategic with their growth efforts.
Much like home health, the private duty sector has seen substantial growth over the last few years. With 20% of the nation's population anticipated to be at or over the age of 65 by 2030 and potentially in need of caregiving services, it's important that agencies be strategic in their growth and marketing efforts and adapt quickly to change.
Here are recent HealthLeaders stories featuring business insights from private duty executives and franchisees:
Nicole Haney, owner and founder of Papa's Place Adult Day Center, had no intentions of entering the home care space, but when COVID hit, it was a necessary change that ultimately paid off.
Once they began offering home care services, the business took off, according to Haney. Despite a small marketing budget, Papa's Place was able to build on its consistency with clients to build a reputation.
"It literally made the difference for us," she said. "Everything that we've built has been organic."
Within the first quarter of 2023, Seniors Helping Seniors opened six new locations, completed eight agreements to establish a presence in 14 new territories, and they're just getting started.
The key to their growth strategy has been finding franchise owners with "a passion and energy to deliver high-quality care to seniors," according to franchise consultant, Dave Wagner.
Dadong Wan is one of those people, having opened his franchise location in April. Having previously worked as a technology consultant, he was inspired to enter home care after struggling to find a reliable caregiver for a loved one.
For others who may be interested in becoming a home care franchise partner, he advises that they find the right system with the right model for them.
A clinician's biases can alter care decisions for their patients, negatively affecting health outcomes.
A clinician's bias toward their patients can negatively affect the quality of care home health clinicians provide, says a recent study from the Columbia University School of Nursing.
Using data from an urban home health organization, results found that home health clinicians spend less time with patients "for whom they document the language of judgment"—words like "adamant," "apparently," "claims," and "insists"—which allows them to distance themselves from the source of knowledge and question the speaker's credibility.
"Although quality of care is affected by numerous factors, a [home health] clinician's biased behavior towards patients can affect quality of care," the study stated.
An example would be evaluating one racial or ethnic group negatively in comparison to another.
Such biases, it explained, affect the home health clinicians' behaviors and care decisions regarding their patients, which then impact how patients comply with their treatment and ultimately affect their health outcomes.
Results showed that judgment language was used for just over 17,000 patients—38% of the overall sample—with 10% of all clinical notes found to have judgment language.
Judgment language was more frequently documented in clinical notes referring to Black or Hispanic patients, with these two groups having up to 9% higher odds of this occurring than White patients.
The study considers a few explanations to describe the difference, including how home health clinicians' personal biases might show up in written documents. The analysis also shows how some home health clinicians are more likely to use judgment language than others.
Conversely, the research team noted that judgment language may not be the result of biases but influenced by specific circumstances of the patient-provider interaction. The use of judgment language may even increase in reference to patients with more complex health conditions.
As more patients prefer receiving care in the home and older adults choose to age in place, the demand for home health services has grown exponentially over the last few years. According to the study, around 200,000 home health clinicians—this estimation includes RNs, physical and occupational therapists, and social workers—treat over five million patients each year.
Around 25% of home health patients are part of racial or ethnic minority population, such as Black or Latinx groups, which is why the movement to diversify clinicians is crucial to better healthcare.
Diverse home care clinicians bring shared life experiences with their patients and the ability to understand the culture and establish partnerships and communication with their minority patients, studies have indicated
Rafael Fantauzzi, chief diversity, equity, and inclusion officer for AccentCare, a home health provider, is working to increase diversity among his company’s clinicians.
Following the formula of belongingness + uniqueness = inclusion, and releasing a breakdown of the organizational demographic data, Fantauzzi's goal is to set an example for the home health space for its workforce to reflect the patients they care for.
"I think it's an encouragement to my counterparts in other organizations for us to work together toward trying to increase the workforce pipeline," he said. "But also, to elevate the quality of service because when we are intentional about including folks that are in our communities, we will service them better."
The foundation hopes to attract more workers to the home care space by showing them a career pathway.
To elevate the importance of caregiving and those who do the demanding work, the Jean Griswold Foundation recently awarded 18 scholarships totaling $44,200 to caregivers to help them pursue or continue education in related fields.
Michael Slupecki, CEO of Griswold Home Care, had the idea to direct the charitable efforts of the foundation, which operates as a separate entity, to focus on caregivers.
"A lot of our [recipients] simply want to get a certified nurse assistant (CNA) designation," he told HealthLeaders. "But we have several recipients that want to pursue a nursing degree."
Some scholarship recipients, he added, were even pursuing their Doctor of Medicine degree.
Bettina Conde, part of the latest round of scholarship recipients, has spent the last 15 years in healthcare, primarily as an emergency medical technician (EMT).
Conde will be putting her scholarship toward tuition and fees for nursing school, easing the financial burden and allowing her to focus on her studies.
"As the first in my family to pursue higher education, I've embraced the opportunity with determination and excitement," she said. "While navigating the complexities of academia, I've been motivated by the change to set a precedent for my family and future generations."
As a child, Conde immigrated to the United States from the Dominican Republic with her family. Within six months, she and her siblings were fluent in English and translating for family members. She immediately noticed how language barriers created a disconnect and lack of understanding between the public and resources available.
"I believe that my calling in life is to help others and help them avoid the struggles that my family went through," she told HealthLeaders.
As rewarding as caregiving can be as an occupation, , caregivers often are not paid enough, Slupecki said. Despite this, he finds that many caregivers continue their work because they feel called to what they're doing.
With a predominantly female workforce, he also noted that gender bias may be another factor in lack of respect for caregiving.
"From our view, if we show that upward trajectory, if we show and help in that career path, then we can attract more people in the field of providing care," he explained.
"They can see that starting out in home care and learning just the basics can be a steppingstone to going up the continuum."
Through the scholarship, the foundation also hopes to attract more people to the home care space by showing them a feasible career pathway.
Griswold Home Care and its franchisees assist with fundraising for the scholarships, and the foundation also receives donations from families of clients. For last year's application cycle, the foundation raised over $140,000, a goal set in honor of the 40th anniversary of the home care business.
"I would love to have a million dollars to give away," Slupecki said. "It's the best job in the world to be Santa Claus and see those reactions."
Infection prevention efforts aren't exclusive to COVID and must be made a priority to keep vulnerable patients safe.
The public health emergency (PHE) declaration for COVID-19 ended in May, along with the waivers, flexibilities, and additional funding it enabled. While more attention is being paid to infection prevention efforts in skilled nursing facilities and now home health, there is still much work and education to be done to ensure the safety of residents and patients alike.
Here are recent HealthLeaders stories featuring conversations with Devin Jopp, CEO of the Association for Professionals in Infection Control and Epidemiology, raising awareness for the need for solid infection prevention processes.
Conversations around infection prevention increased over the course of the pandemic, but Jopp explained that it isn't exclusive to COVID. Hospitals, skilled nursing facilities, and home health agencies alike should either have a combination of infection prevention methods in place, staff trained in infection prevention, or at least one full-time infection control specialist on staff.
Compounding the problem is that like the rest of healthcare, there aren't enough specialists to accommodate the need, nor are there many students pursuing that career pathway.
Infection Prevention Efforts in Home Health—Part 1 and Part 2
As more people prefer to receive care in their home, the home healthcare sector is experiencing substantial growth. However, according to Jopp, there are minimal infection prevention practices in place, if any.
Whether it's home health or hospital at home, the lack of oversight and difficult logistics of maintaining a clean, pathogen-free environment for patients in their own home presents a challenge and puts the patient's health at risk.
Jopp provides some recommendations on how to make infection prevention a priority throughout the healthcare continuum, as well as how to address the shortage of infection preventionists.
The specialized and clinical home care provider appointed Paul Mastrapa to succeed former CEO Jennifer Sheets in July.
With 30 years of experience in home care and the home health sector, Paul Mastrapa is in familiar territory as president and CEO of Interim HealthCare and its parent company, Caring Brands International.
Interim HealthCare, a provider offering specialized and clinical home care, announced Mastrapa’s appointment as CEO in July. He succeeds former president and CEO, Jennifer Sheets.
Prior to his appointment, Mastrapa served as CEO of Help at Home, a home care provider, and president and CEO of Option Care, the leading national provider of alternate site infusion services.
He knew early in his career that home care and home health were to be his focus.
"I have the benefit of seeing healthcare longitudinally, and I think that helps give me a lot of perspective," he told HealthLeaders.
Much of what is currently happening in healthcare, calls for reform and increased oversight in different areas, has previously occurred, and it's important that workers and stakeholders advocate for the changes they want to see, according to Mastrapa.
Especially, he noted, with such a high portion of the industry receiving reimbursements from the government.
"[We] know [we] need to make sure that [we're] advocating effectively and educating policymakers about the benefit of the services that [we] provide," he said.
Mastrapa also emphasized the importance of an organization's ability to innovate and scale as it grows—particularly large providers such as Interim HealthCare. Considering the growing demand for aging services and the current reforms organizations and healthcare workers alike are advocating for, having those factors as part of organizational culture is crucial.
"Every organization has wonderful caregivers that do the work they do for personal and noble reasons," he said. Early in his career, he added, he learned that organizations could use that purpose-driven mindset to drive strategies, goals, and outcomes and foster a culture that encourages that.
Now a month into his tenure as CEO, Mastrapa has been spending time in the field with franchises, internal support center staff, and company-owned locations getting acquainted with the different areas of Interim HealthCare. Even as a C-suite executive, he doesn't shy away from learning new things.
"There's a lot of innovation happening in the marketplace. Value based care, I think, is a very large, systemic shift that's changing the relationship between providers and payers," he said. "The system really needs to lean into the way these organizations access patients, provide care, drive their services forward."
"It's becoming less about what you do and more about the impact of what you do, which determines your success."
Mastrapa believes that healthcare is at an inflection point, with technological innovations such as artificial intelligence (AI) and its potential to enable organizations to be more efficient with their workforce, alleviating the strain of the workforce shortage.
Going forward, some of his goals include assessing Interim HealthCare's capabilities against market demands to define a future strategy to accelerate growth.
"I'm very carefully working with the leadership team on where we're headed to drive clear focus, alignment, and investment to help us get there," he said. "Which is what I've tried to do with every organization I've touched."
Facilities negotiated the staffing minimum, but finding staff remains an issue.
A staffing mandate for Pennsylvania nursing homes went into effect in July, and facilities are already feeling the strain.
Former Gov. Tom Wolf proposed a staffing requirement of 4.1 PPD (per patient day) for the state's nursing homes. Many facilities called the proposal untenable, so Wolf's administration struck a compromise: a minimum staffing requirement of 2.87 PPD, in exchange for a $300 million increase in Medicaid funding.
This compromise came with additional accountabilities, said Garry Pezzano, president and CEO of the Pennsylvania chapter of LeadingAge, a community of nonprofit, mission-driven aging services providers.
"One of the accountabilities being that 70% of the Medicaid [funding] spent in skilled nursing facilities would go directly to the bedside," he told HealthLeaders. "And then there was also some very specific staffing ratios that were put into place."
While the compromised staffing ratio decreased from 4.1 PPD to 2.87 PPD, this would be only for the first year—2023, with the mandate going into effect July 1. For the second year—which would be 2024— the PPD will go up to 3.2 PPD, unless another Medicaid increase is approved for that year's budget.
Each sector of healthcare has been affected by the workforce shortage, with aging services like skilled nursing facilities and home health providers struggling even more. A staffing mandate, Pezzano said, is the last thing they need right now.
After polling LeadingAge Pennsylvania's skilled nursing facility members—about 150 in total—34% said they have beds on hold, meaning that they have a certain number of beds available but can't admit residents because they don't have enough staff.
About 55% of members said they were having to turn away hospital transfers. The average length of stay in Pennsylvania's hospitals is increasing by one and two days, according to Pezzano.
"[That’s] significant because it's not the least-restrictive placement for the resident and it's more costly for an older person to be in acute care," he said.
"That means they're not getting the rehabilitation they need. They're not getting the socialization they need and they're not getting the mobility that they need. Then, it's more costly, so it becomes an access issue."
Some 83% of members are using temporary nurses from staffing agencies, which are notoriously expensive. In addition to the mandate compromise, the state's nursing homes were successful in getting legislators to place quality measures over agency staffing, namely by requiring them to register with the state.
However, no changes were made to the pay rates that staffing agencies can charge.
As for how facilities are managing operations with the mandate now in effect, Pezzano said it varies by location. In some areas of the state, they're able to hire the staff they need, and some member facilities have said that they're seeing staff who previously left return to the facility.
"What a mandate does is it treats everyone the same, and not all providers are the same in regard to even their physical space, or their ability to find staff, and most importantly, the acuity of their patients," Pezzano said.
"When you lose that flexibility as a clinical operator, as a clinical team, it kind of forces you into a situation that you know is ultimately going to impact your ability to care for patients."
HealthLeaders has previously reported on the anticipated influx of older adults needing some type of aging service by 2030. With the persisting workforce shortage, strain of staffing minimums, and lack of young healthcare workers interested in working in the post-acute space, there's pressure on skilled nursing facilities to provide the care that people will need.
LeadingAge Pennsylvania began an initiative called Long Term Services and Supports (LTSS) Evolved, where they've begun looking at ways to create more efficiencies in practice by affecting antiquated and more cumbersome legislative health policies. They're also involved in state efforts, urging Gov. Josh Shapiro to create an office of health workforce innovations and reform, and looking at immigration reform to see how foreign workers can bolster their workforce.
"We're stepping through this at the moment, but we continue to look at these disruptors and forward-looking ways of solving the workforce crisis because there are not enough people," Pezzano said.
"You're not going to get enough people and there literally is not enough money to throw at it,” he said. “Staffing mandates that are unfunded and unsupported are just making the situation worse."
Aspen Park and Lewiston Transitional Care, both Cascadia Healthcare facilities, were recognized for meeting the rigorous standards of the organization's national quality award program.
"This recognition is a testament to the dedication, compassion, and the tireless efforts over the years by these incredible providers," Cathy Bergland, AHCA/NCAL's national quality award board chair, said in a statement.
"They all deserve to be celebrated for their unwavering focus on delivering high-quality care and outcomes for their residents and staff."
To receive the Gold award, a long-term care facility needs to have previously received the Bronze and Silver awards for commitment to quality and achievement in quality, respectively, which takes several years. Applicants for these awards must adhere to the core values and criteria of the Baldridge Performance Excellence Program, an organizational improvement tool that targets leadership, customer and workforce satisfaction, clinical outcomes, and other factors.
This year’s honorees for the Bronze and Silver awards were recognized earlier in the summer, with 399 providers receiving the Bronze award and 72 receiving the Silver award.
"Congratulations to this year's extraordinary providers for achieving exceptional performance and care outcomes for their residents and staff," Mark Parkinson, president and CEO of AHCA/NCAL, said in a statement.
"Their dedication and commitment to the Quality Award journey to become the best in the nation is inspiring. I am so proud of our members for their hard work and ongoing progress in delivering high-quality care."
Gold, Silver, and Bronze honorees will be presented their awards during Delivering Solutions 23, AHCA/NCAL's annual Convention and Expo, October 1-4, 2023, in Denver, Colorado.
Lack of interest from young professionals stems from lack of exposure.
For Tammy Schmitz, what began with a nudge from her father turned into a nursing career spanning three decades and being named Interim HealthCare's 2023 Nurse of the Year.
In 1989, Schmitz had been working as a bartender when, after a conversation with her father, she began to think about other career options. Some of her customers had wives who were nurses, and speaking with them gave her the push she needed to enroll in a licensed practical nurse (LPN) program.
Years later, having accumulated a wealth of experience in the field and earning her nursing degree, Schmitz joined Interim HealthCare of Lima, Ohio, a home healthcare agency, in 2019 as an RN case manager, right at the onset of the COVID-19 pandemic.
"I was very lucky as an LPN back then," she said. "I could do quite a bit and gather knowledge and build confidence. Then I went back for my bachelor's degree and took off from there to where I am today."
In the aftermath of the pandemic, and aligning with the nation's growing elderly population, healthcare has seen more patients preferring to receive care at home, rather than going into a doctor's office. Yet, due to a workforce shortage exacerbated by the pandemic, there aren't enough nurses, aides, and caregivers to accommodate the demand for services.
The issue goes beyond home health and home care, with all healthcare sectors struggling to hire and retain staff, Schmitz said. When it comes to finding and recruiting young talent, they have little to no interest in working with older populations, which she attributes to a lack of exposure.
As a nursing student, she had the opportunity to work with different populations during her clinical rotations which helped her figure out which patient populations she worked best with. She found that obstetrics and pediatrics weren't for her, but she did discover a preference for working in geriatrics.
"You had all sorts of different age groups in the hospital, so we were exposed for quite a while," she said. "We had nursing home rotations, hospital rotations; we really got a well-rounded education with the school I was at."
Another hinderance to younger healthcare professionals not choosing to work with older patients is ageism—discriminating against older people due to negative and inaccurate stereotypes.
To correct these misconceptions and get future healthcare professionals interested in working with older patients, Schmitz suggested normalizing interactions with older adults from when they're young.
"I think what it takes is just starting people when they're younger, interacting with some of the older generation just so they start getting more comfortable with them," she said.