The Culture Paradigm
Business is always brisk at Bazaar, a small food store in Brookline, Massachusetts. One of the main local purveyors of Russian and Eastern European staples, Bazaar offers delicacies that appeal to the local Russian-speaking community, especially the older crowd. Bilingual sales staff offer expertise on the subtle differences between a dozen different kinds of lox, caviar, and salami that a native Russian might have savored in the old country. Part of a growing number of businesses nationwide catering to New Americans from around the world, the store was founded 25 years ago in response to the influx of immigrants from the former Soviet Union. As much as the new arrivals loved their new country’s religious and political freedoms and economic opportunities, they sorely missed the food they’d grown up on.
Much like food, health care is a vital aspect of life in that it addresses both our physical and emotional needs. Having someone familiar to talk to in a clinical setting can make all the difference. For older New Americans in particular, the ability to discuss health concerns with a medical professional who speaks their native language and understands where they are coming from — both literally and figuratively — is especially important. This is why providers and organizations that offer health care services that meet the social, cultural, and linguistic needs of diverse patients are referred to as culturally competent.
There is a growing recognition on the part of the health care industry that culturally competent care is necessary to reduce health disparities, increase health equity, and improve outcomes. As a result of The Joint Commission’s recommendation to demonstrate cultural expertise as part of the certification process, and in response to the growing diversification of the U.S. population in terms of ethnicity, language, culture, and shared experience, health care organizations have started to establish new programs that target the needs of distinct populations. Such culturally competent programs provide care while using the prevailing cultural and/or linguistic idioms of each given group.
One example of a culturally competent program is Fenway Health, a health care, research, and advocacy organization that has addressed the unique needs of Boston’s LGBT (lesbian, gay, bisexual, and/or transgender) population since the early 1970s. Similar dedicated health clinics have now been established in 47 of 50 states.
The “Invisible” Immigrants
Older non-English speaking immigrants are a specific population that until recently has not been a focus of the health care industry. There are currently >4.5 million documented immigrants over the age 65 years living in the U.S. and speaking languages as diverse as Spanish, Chinese, Hindi, Haitian Creole, Portuguese, and Russian. This number is projected to reach 16 million by the year 2050.
Such trends notwithstanding, the specific health care needs of these seniors — referred to by the New York Times as the “invisible immigrants” — have frequently remained unaddressed. While at least one-half of this population qualifies for government programs such as Medicare and Medicaid, data suggest that they are significantly less likely to use common health care services, including primary care, and are more likely to use emergency services for non-emergent indications than their U.S.-born counterparts.
Cultural and Historical Considerations
Cultural and historical considerations should inform anyone caring for immigrant seniors. These considerations are often specific to the immigrants’ countries of origin, cultural roots, religious practices, and reasons for immigration. Some of the common factors to consider are:
- Language Skills: Many immigrant seniors, particularly recent arrivals, do not possess sufficient English skills to engage with the American health care system in a meaningful way.
- Preventive Care: Preventive care, particularly when it involves invasive diagnostics, vaccines, or medications, may be an unfamiliar concept, especially when the senior subjectively feels well. The utility of periodic health examinations may need to be explained to many immigrant seniors.
- Specialist Care: Certain immigrant groups, especially patients from Eastern Europe and East Asia, may be used to seeing specialists first. Thus, the role of a primary care provider who can frequently address their issues may need to be explained.
- Family Expectations: There may be an expectation by the family to live with and care for elders at home when they can no longer live independently.
- Underreporting of Symptoms: Conversely, we have sometimes observed reluctance on the part of immigrant seniors to place the burden of care on the younger members of the family, lest it interfere with their ability to “advance” in their new homeland. As a result, they may underreport symptoms and the severity of their condition may go under-recognized.
- Underuse of Long-Term Care: Long-term care, a concept that may be either unfamiliar or firmly associated with “abandonment,” is frequently underused.
- Palliative Care: Palliative care is a field that is only beginning to gain acceptance in many origin countries, and in our experience, there is often a higher barrier for immigrant seniors to engage with the palliative care providers when indicated, or to accept hospice services. This is especially the case when hospice services are used for diagnoses other than cancer.
As a result of these multiple challenges, seniors frequently postpone using health care services until they are in a crisis, increasing the likelihood of serious chronic illness, frequent emergency room visits, unplanned hospitalizations, and ICU admissions, all of which negatively affect the seniors’ quality of life, increase caregiver stress, and increase health care costs.
Bringing Down the Barriers
To reduce the likelihood of such outcomes, many organizations in areas with high concentrations of immigrant seniors have introduced interpreter services, multilingual patient care navigators, and staff training on cultural diversity. Some organizations have gone a step further and have begun to establish add-on ambulatory and specialty clinics, visiting nursing services, dedicated units in skilled nursing facilities, and hospice programs that target immigrant seniors. Specific examples are discussed below.
Beth Israel Deaconess (Medical Center)
Under the auspices of Beth Israel Deaconess Medical Center in Boston, one of the authors (E.G.) helped to establish two specialized cardiovascular clinics — one targeting immigrants from the former Soviet Union and the other, immigrants from Latin America. These clinics serve >3,000 patients and operate largely in the patients’ native languages, with a range of culturally competent services provided by bilingual cardiologists, nurse practitioners, cardiology fellows, and administrative assistants.
The clinics are fostering parallel relationships with other culturally competent programs in the area, including some that focus on diabetes management and mental health, two important health issues for older minority seniors. For the Medical Center, such clinics serve as de facto new portals that welcome large numbers of new, diverse patients, fostering community loyalty and engagement and expanding the customer base.
Royal Braintree Nursing and Rehabilitation Center (Long-Term Care Facility)
Importantly, culturally competent care should extend beyond the realm of acute care hospitals, primary care offices, and subspecialty offices. A number of skilled nursing facilities, visiting nurse associations, and hospice agencies now boast add-on programs as well. The Indian Nursing Home was founded in 2005 in New Jersey and now includes 11 programs that are staffed by Hindi-speaking health care providers, immersing the seniors in a more comfortable, familiar setting. Its motto, “Culture, Comfort, and Care Under One Roof,” succinctly captures the essence of the mission.
Similarly, Royal Braintree Nursing and Rehabilitation Center’s Solnyshko (Sunshine) is a long-term care program for Russian-speaking seniors in the Boston area that was established in 2007 by Zinaida Levin, MD, and Lena Zeliger, a nursing home administrator. Ms. Zeliger had witnessed the challenges faced by immigrant seniors firsthand: her elderly Russian-speaking mother had been a resident of a long-term care facility where she was unable to communicate with the staff, comprehend the contents of the daily menu, or participate in social activities in a meaningful way. With such challenges in mind, Solnyshko offers Russian-speaking staff, home-style meals, and Russian-language TV and activities.
Ms. Zeliger notes that, these amenities notwithstanding, she still had to work hard on getting “buy-in” from many immigrant families who, as discussed above, often equate the idea of placing their loved ones in a nursing home with abandonment. During individual tours of the facility, she makes a point to carefully listen to the families’ concerns, address their apprehensions, and explain the pros — as well as, on occasion, the cons — of placement in specific situations.
Another challenge was finding Russian-speaking staff. To attract the “right” people, Solnyshko offered recent Russian émigrés with medical backgrounds a fast-track CNA (certified nursing assistant) training program with the promise of assistance with future certification in their disciplines. This program has proven to be a win-win, as most of the staff have elected to stay with Solnyshko to this day. The program, which has expanded fivefold since its inception, has consistently had a full occupancy rate — unusual in an industry in which a 10–20% vacancy rate is an assumed norm.
Good Shepherd Community Care (Hospice)
Palliative care and hospice programs have also recognized the need for culturally competent care at a time in a patient’s life when navigating the unfamiliar health care system becomes even more difficult. Good Shepherd Hospice in Boston has dedicated teams of Spanish-, Mandarin-, and Russian-speaking nurses and administrators catering to the needs of their respective communities. Here, too, the program initially had to overcome much skepticism in the target communities, where “hospice care” historically had been a somewhat foreign and widely misunderstood concept, where death and dying were not subjects that were openly discussed, and where most people died in the hospital.
In order to win the hearts and minds of these communities, Good Shepherd had to find a way to address individual families’ fears and concerns in a culturally sensitive way — one that conveyed an understanding of the stigmas, anxieties, and uncertainties not only about hospice, but about death itself. For example, in many Chinese families, there is a superstition that dying at home inevitably will create “bad luck.” Therefore, families frequently wanted to move their loved ones to a hospital as death became more imminent. In contrast, for Russian patients, the obstacle was less about dying at home and more about a need and desire to treat the patient until the very end in hopes of finding a “cure.”
Jennifer Sax, Good Shepherd’s Director of Communications, points out that because the staff members speak the same language as their patients, they are able to help patients and families open up to the idea that, by accepting hospice care, they aren’t “giving up” but rather are changing the course of medical interventions to emphasize care, comfort, and psychosocial and spiritual support. The staff can communicate, in a way that comes across as genuine, that hospice care is a choice, not a death sentence — and that the families can change their minds at any time.
Sax reports that, in the beginning, a high percentage of patients would elect to “revoke” their hospice benefit and would prefer to call 911 and go to the hospital for symptom management. Over time, however, patients have learned that choosing hospice doesn’t change the course of one’s death, only the course of one’s care. By word of mouth, these patients’ families have helped to educate other members of their community. Currently, according to Sax, most patients are cared for in their private homes. Good Shepherd’s Multicultural Hospice Program now consistently constitutes about 30% of their average daily patient census.
Looking to the Future
These early experiences demonstrate that culturally competent add-on programs are an important part of providing patient-centered care for immigrant seniors. While more data are needed to determine how much these programs actually contribute in terms of improved care outcomes and health care savings, they have already shown a strong potential to add value across the continuum of care. Given the demographic outlook that promises increased numbers in this patient population in the decades to come, organizations that develop such programs not only will benefit numerous older patients, but also might secure for themselves an important strategic advantage going forward.
Note: Special thanks to Janice Rogovin and Tamara Cadet for their help with this article.