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Service Delivery Innovation Profile

Insurer's Multifaceted Approach Facilitates Cultural and Linguistic Match Between Patient and Mental Health Provider, Leading to Higher Member Satisfaction


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Snapshot

Summary

CIGNA uses a multifaceted approach to facilitate culturally appropriate behavioral health care for members. The organization collects information about culture, language, and other characteristics from practitioners, and then refers members to providers with the same characteristics when requested. Members can also search this information and read provider self-introductions on CIGNA’s provider Web directory. As part of this effort, CIGNA maintains open access to behavioral health care, focuses on recruiting diverse practitioners, and emphasizes cultural awareness in provider communications. The program enhanced the diversity of the behavioral health practitioner network, encouraged more members to use the online search capability to find a culturally appropriate provider, and increased satisfaction among members using behavioral health services.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after implementation comparisons of key outcomes measures, including the number of online searches, practitioner diversity, and member satisfaction.
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Developing Organizations

CIGNA
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Patient Population

Vulnerable Populations > Mentally ill; Non-english speaking/limited english proficiency; Racial minoritiesend pp

Problem Addressed

Significant racial and ethnic disparities exist with respect to the availability of and access to mental health services.1 Accommodating patient requests for a provider with the same cultural and ethnic background could play a role in addressing these disparities, but few organizations have the ability to accommodate such requests.
  • Striking racial and ethnic disparities: Compared to Caucasians, racial and ethnic minorities have less access to mental health services; are less likely to get needed care; receive poorer quality care; and are underrepresented in mental health research.1 For example, the percentage of African Americans who receive mental health care is half that of the Caucasian population, and fewer than 1 in 11 Hispanic Americans with mental health problems have contacted a mental health specialist.1 As a result, racial and ethnic minorities experience a greater disability burden from unmet mental health needs.1
  • Inability to accommodate requests for ethnic and/or cultural match with provider: A provider's views about mental health and mental health care, which are often influenced by ethnic and cultural background, may differ from those of patients from different backgrounds.2 While ensuring the availability of providers who share a patient's cultural and ethnic background may help to reduce disparities,2 relatively few organizations have the capabilities to do so. For example, CIGNA’s behavioral health staff noted that many individuals calling for a behavioral health referral specified preferences for practitioner characteristics such as race, religion, age, gender, and language, but staff did not always have adequate information to accommodate those requests.2

What They Did

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Description of the Innovative Activity

CIGNA uses a multifaceted approach to facilitate culturally appropriate behavioral health care for members. The organization collects information about culture, language, and other characteristics from practitioners, and then refers members to providers with the same characteristics when requested. Members can also search this information and read provider self-introductions on CIGNA’s provider Web directory. As part of this effort, CIGNA maintains open access to behavioral health care, focuses on recruiting diverse practitioners, and emphasizes cultural awareness in provider communications. Key program elements include:
  • Collection of providers’ cultural and linguistic information: CIGNA’s behavioral health team requests cultural and linguistic information from practitioners, who then choose whether to provide any or all of the following information: gender, age, race/ethnicity, language(s) spoken, sexual orientation, substance abuse recovery status, religion, veteran status, and disabilities. Approximately 35 to 40 percent of practitioners provide some or all of this information.
  • Matching patients to providers with desired characteristics: Staff use a software system to search the information whenever a member requests particular provider characteristics, thus facilitating a cultural and linguistic match between patients and providers.
  • Searchable Web directory of practitioner information: Using CIGNA’s Web-based provider directory, CIGNA members can create a customized list of behavioral care practitioners who meet their needs.
    • Criteria-based searches: Members can search on various criteria, including language, gender, ethnicity, age of the patients served, and clinical specialty. Members cannot access more sensitive characteristics (e.g., sexual orientation, substance abuse recovery status, religion, veteran status, and disability status) online, but can call a behavioral health staff member to identify practitioners with desired attributes in these areas.
    • Provider self-introductions: Directory profiles include a one-paragraph description of each behavioral health provider and his or her practice, including specialties/areas of interest, populations served, languages spoken, and treatment approach. Providers may opt to include a photograph as well. This information allows some members to make a judgment about the potential cultural fit with a provider.
  • Open access to behavioral health care: Because some members may perceive preauthorization to be a barrier to care, CIGNA maintains an open access model for routine outpatient behavioral care, thus allowing members to access network providers without prior authorization. Although cultural sensitivity was not the only factor driving the shift to an open-access model, behavioral health staff believe that the open-access model removes a potential barrier for members from certain cultures.
  • Recruitment to achieve practitioner diversity: CIGNA reviews market characteristics using U.S. Census data, and then actively recruits a diverse group of behavioral health practitioners so that the network reflects the cultural diversity and language needs of the market. Recruitment strategies include (but are not limited to) referrals from primary care physicians and other network behavioral health providers, and a review of practitioner use by employees of new CIGNA employer clients. Recruiting goals are typically set based on languages spoken (e.g., Chinese, French, German, Spanish, American Sign Language), culture (e.g., Asian American, Cuban American, Latin American, Mexican American, Pacific Island Descent), religion (Buddhist, Christian, Hindu, and Muslim), and whether the practitioner is in substance abuse recovery.
  • Communication surrounding cultural awareness: CIGNA sends periodic communications to behavioral health practitioners to promote cultural awareness and encourage the submission of voluntary information. Communications typically occur through the quarterly CIGNA newsletter for network providers. Diversity, cultural sensitivity, and awareness, including nuances related to working with particular patient populations, are common themes woven into newsletter topics and stories. The newsletter also describes how the provider-submitted information will be used, which sometimes prompts providers to submit that information as a way to attract referrals.

Context of the Innovation

CIGNA is a full-service insurance company covering 47 million individuals in the United States and around the world. CIGNA offers medical, dental, behavioral health, pharmacy, and vision care benefits, along with group life, accident, and disability insurance. Spurred by a U.S. Surgeon General report that outlined striking cultural disparities in mental health care, and the fact that many members in need of behavioral health care requested specific preferences in practitioner characteristics, CIGNA launched several formal initiatives to ensure that that its culturally and linguistically diverse members had access to culturally appropriate mental health care.

Did It Work?

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Results

The program enhanced the diversity of the behavioral health practitioner network, encouraged more members to use the online search capability to find a culturally appropriate provider, and increased satisfaction among members using behavioral health services.
  • More diverse practitioners: Between 2001 and 2006, CIGNA increased the number of African-American and Spanish-speaking practitioners in its network by more than 80 percent. In the four states with a large proportion of Spanish-speaking residents (California, Arizona, Texas, and New Mexico), the percentage of practitioners speaking Spanish now exceeds the percentage of the general population that speaks Spanish. Over the same time period, CIGNA also increased the number of Jewish and gay/lesbian practitioners by 36 percent and 68 percent, respectively.
  • More online searches: Between 2004 and 2006 (most recent data available), the number of CIGNA members using the behavioral health practitioner search capability roughly tripled, from 3,043 to 9,174. Program developers believe that open access and the increased availability of information on selected practitioner characteristics have led to increased use of the search function by members trying to find a culturally appropriate provider.
  • Higher member satisfaction: The program has led to higher satisfaction among members, as outlined below:
    • With regard to cultural needs: A random survey of 400 members who used behavioral services found that, between 2004 and 2006, the percentage of respondents who said that their practitioner met their cultural, language, or specialty needs increased from 19 percent to 26 percent.
    • With regard to access: Between 2003 and 2006, the percentage of African-American and other nonwhite members expressing satisfaction with access to urgent and routine behavioral health care increased, jumping from 36 percent to 55 percent for urgent care and from 73 percent to 82 percent for routine care.
    • With regard to listening skills: The percentage of members stating that their behavioral health providers always/usually listen carefully increased from 81 percent to 89 percent between 2003 and 2006.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after implementation comparisons of key outcomes measures, including the number of online searches, practitioner diversity, and member satisfaction.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Requesting provider information: In 1999, CIGNA behavioral health staff began to request voluntary information from behavioral health practitioners so that they could better respond to members’ requests. CIGNA developed a survey form to allow providers to submit information about their cultural background and personal characteristics. Query fields were added into CIGNA’s Provider Management & Referral System software so that staff could search for providers.
  • Enhancing Web-based provider directory: In 2002, CIGNA created a Web-enabled practitioner search capability to allow members to search for and select their medical and behavioral health practitioners. Selected provider characteristics were included in the search function. In 2004, the CIGNA behavioral health service enhanced its Internet capabilities by implementing the provider self-introductions.
  • Implementing open access: In 2003, CIGNA removed prior authorization requirements for behavioral care to facilitate access to services.
  • Launching recruitment efforts: In 2004, CIGNA behavioral health professional relations staff began actively recruiting diverse providers for the network.
  • Training call center staff: In 2004 and 2005, CIGNA’s behavioral health team trained call center staff to use the practitioner search capabilities, and reminded them about procedures for activating resources such as telephonic translation services.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines. All behavioral health practitioners work under contract with CIGNA.
  • Costs: Data on program costs are unavailable; development costs included technology enhancements to expand searchable fields in the online provider directory and to incorporate the provider self-introductions.
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Funding Sources

CIGNA
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Adoption Considerations

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Getting Started with This Innovation

  • Do not require providers to share information: Because cultural, linguistic, and other information can be sensitive, ask practitioners to provide it on a voluntary basis.
  • Protect privacy of information: Practitioners can be encouraged to share personal characteristics by having appropriate processes in place to ensure the privacy and respectful treatment of the information.
  • Emphasize patient benefits: Practitioners will be more likely to provide information if they understand how the patient will benefit from its availability.
  • Plan for phased implementation: By adding incremental initiatives over time, project developers can better ensure that subsequent enhancements target and meet member needs.

Sustaining This Innovation

  • Continue to promote cultural awareness among practitioners: Continue to highlight the cultural context of care, as many members will continue to see practitioners from a different culture. Practitioners should be reminded to consider their approach to treatment in light of the patient's background, and to identify culturally-specific community resources when working with clients from a different culture.
  • Collect and review data when adding programs: For example, analyses of changes in the diversity of local populations can inform the development of ongoing recruiting goals.

More Information

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Contact the Innovator

Susan Bryant, MS, LPC, CPHQ
Director
CIGNA
11095 Viking Drive
Eden Prairie, MN 55344
Phone: (804) 594-0695
E-mail: Susan.Bryant@CIGNA.com

Innovator Disclosures

Ms. Bryant has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

CIGNA wins award for innovation in multicultural health care from the National Committee for Quality Assurance. November 13, 2007. Available at:
http://newsroom.cigna.com/article_display.cfm?article_id=814

CIGNA: facilitating cultural and language match in behavioral care. CBH Practitioner Connection. Volume XIV, 4th Quarter. September 2008. Available at: http://www.cignabehavioral.com/web/basicsite/provider/newsAndLearning/newsletter/newsletter2007Quarter4/pages/FacilitatingCulturalLanguageMatch.html

Footnotes

1 U.S. Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. Available at: http://profiles.nlm.nih.gov/ps/access/NNBBHS.ocr.
2 Robert Wood Johnson Foundation. CIGNA: facilitating cultural and language match in behavioral care. September 2008. Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2008/09/the-national-health-plan-collaborative-toolkit
/section-5-case-studies.html
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: August 04, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 28, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 20, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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