Skip Navigation
Events & Podcasts >
March 2010
Ensuring Cultural Competence Across Care Settings
AHRQ's Health Care Innovations Exchange held a Web Seminar on Ensuring Cultural Competence Across Care Settings on March 18, 2010.

Moderator:


Julia Puebla Fortier, Founder and Executive Director, Resources for Cross Cultural Health Care

View Slides

Listen to the Audio File

Read Transcript
Panel Slides

Jump to Slides:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

Slide 1

Text Description Follows

Ensuring Cultural Competence Across Care Settings

Web Event March 18, 2010

Back to top

Slide 2

Text Description Follows

What Is the Health Care Innovations Exchange?

Searchable database of service innovations

  • Includes successes and attempts
  • Wide variety of sources – including unpublished materials
  • Vetted for effectiveness and applicability to patient care delivery
  • Categorized for ease of use: extensive browse and search functions
  • Innovators’ stories and lessons learned
  • Expert commentaries

Learning opportunities

  • Learning Networks: A chance to work with others to address shared concerns
  • Educational content
  • Web Events featuring innovators, experts, and adopters

Back to top

Slide 3

Text Description Follows

AHRQ Health Care Innovations Exchange Webinar Series

How to find Archived Materials

Next Event

  • Web event in April on pharmacy-related innovations

    -- Date to be determined

Evaluation

  • At the end of this web event, please complete the evaluation

Back to top

Slide 4

Text Description Follows

Housekeeping

  • No phone is necessary for this event
  • You may just stream the audio over the web through the speakers on your computer
  • For help, notify the Vcall team through the Q&A window
  • To refresh your screen, hit f5
  • Visit www.innovations.ahrq.gov for a transcript of this webinar and the PowerPoint slides

Back to top

Slide 5

Text Description Follows

Submitting Questions

  • When: Any time during the presentation
  • How: Send a written question through the “Q&A Center”

screenshot of Q&A Center

Back to top

Slide 6

Text Description Follows

Today’s Event Moderator

Resources for Cross Cultural Health Care

Photo Julia Puebla Fortier

Back to top

Slide 7

Text Description Follows

Our Innovators

Children's Mercy Hospitals and Clinics Kansas City, MO

Photo Meredith Dreyer

Photo Sarah Hampl

Back to top

Slide 8

Text Description Follows

Our Innovators

Central Valley Health Policy Institute Fresno, CA

Photo John Capitman

Photo Alicia Gonzales

Photo Tania Pacheco

Back to top

Slide 9

Text Description Follows

Culture, as it Relates to Health

Culture defines how health care information is received, how rights and protections are exercised, what is considered to be a health problem, how symptoms and concerns about the problem are expressed, who should provide treatment for the problem, and what type of treatment should be given.

In sum, because health care is a cultural construct,arising from beliefs about the nature of disease and the human body, cultural issues are actually central in the delivery of health services treatment and preventive interventions.

(From the National CLAS Standards)

Back to top

Slide 10

Text Description Follows

Types of Cultural Competence Interventions

Culturally Sensitive Interventions

  • Cultural competence education
  • Race, ethnic and linguistic concordance
  • Community health workers and culturally competent health promotion

Language Assistance

  • Bilingual services
  • oral interpretation
  • translated written materials

Back to top

Slide 11

Text Description Follows

Types of Cultural Competence Interventions

Organizational Supports for Cultural Competence

  • Management and policy strategies
  • Community engagement
  • Information and data for planning and evaluation
  • Appropriate ethics and conflict resolution processes

Back to top

Slide 12

Text Description Follows

Why do Health Organizations Take Action on this Issue?

  • Access to care (civil rights/advocacy)
  • Legal and quasi-legal (requirements/liability avoidance)
  • Business case (cost effectiveness, ROI)
  • Quality improvement (process)
  • Does it make a difference (outcomes)

Back to top

Slide 13

Text Description Follows

The Evidence Base for Cultural Competence – Does it Matter?

  • Patients often have access and health status deficiencies that need to be addressed
  • It’s not business as usual for providers and organizations
  • It requires additional time, effort, and resources
  • Policymakers and payors want results

Back to top

Slide 14

Text Description Follows

Addressing Cultural and Socioeconomic Issues in the Promoting Health in Teens and Kids (PHIT Kids) Weight Management Program

Sarah Hampl, MD
Meredith Dreyer, PhD
Children’s Mercy Hospitals and Clinics
Kansas City, MO
Logo - PHIT Kids
Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 15

Text Description Follows

PHIT Kids Program

  • Intensive, family-based multidisciplinary behavioral treatment program for children 9 and older
  • Patients are seen by medical provider, psychologist or social worker, dietitian, and physical therapist
  • PHIT Kids evening groups are led by team of 6 Health Educators

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 16

Text Description Follows

PHIT Kids Team

Photo - PHIT Team

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 17

Text Description Follows

Program Details

  • 185 subjects
  • Mean age=12.0 years (SD=2.3)
  • 60.5% Female
  • Race/Ethnicity

    -- Caucasian 29.7%

    -- African American 45.4%

    -- Hispanic 26.1%

    -- Other 3.2%

  • 41.4% Medicaid recipients
  • 7.7% self-pay or financial assistance

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 18

Text Description Follows

Program Details

  • Active treatment phase = Multidisciplinary clinic visits + group education (24 weeks)

    -- 2 groups divided by age

    ---- 9-12 year-olds and parents

    ---- 13-18 year-olds and parents

  • Maintenance phase = monthly group education and periodic clinic visits (18 months)
  • Team also includes administrative and research staff
  • Total treatment period = 24 months

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 19

Text Description Follows

Process of addressing cultural and socioeconomic issues

  • Importance highlighted by participants, families, staff, community partners
  • Initial consultation with local clinics, Alianzas, Black Health Care Coalition
  • Major themes identified
  • Subsequent consultation with national experts—review of curriculum, program materials, meetings, training with staff

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 20

Text Description Follows

Two Dimensions of Cultural Sensitivity*

  • Surface structure=matching intervention materials and messages to observable characteristics of a target population
  • Deep structure=incorporating the cultural, social, historical, environmental and psychological forces that influence the target population’s health behavior into the intervention

*Resnicow K, Baranowski T, Ahluwalia J, & Braithwaite R. (1999)

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 21

Text Description Follows

Socioeconomic Considerations: Recognize and Respect Families’ Hierarchy of Needs

  • Families’ basic needs and daily struggles must be addressed 1st and followed up on
  • Housing and food insecurity
  • Unemployment, lack of health insurance
  • Immigration and deportation issues
  • Transportation and communication barriers
  • Neighborhood safety, limited safe play places
  • Limited access to grocery stores
  • Easy access to convenience stores, fast food

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 22

Text Description Follows

Modifications for African American Families

Characteristic Modification
Collectivism Include extended family in sessions; child, parent and family goal-setting; Reward parent-child and family accomplishments
Respect for elders Limited portions of energy-dense foods at family gatherings

Learning via oral and visual instruction

Interactive discussions; videos as conversation-starters
Group Participation Group PA: slides, hip-hop, cultural dance, exercise videos
Family rewards Cultural cookbooks, graduation prizes
Ethnic cooking Healthy recipe modifications
Authoritarian parenting styles Multiple sessions on effective parenting skills, interactive discussions

Back to top

Slide 23

Text Description Follows

Modifications for Latino/a Families

Characteristic Modification
Child-centered, paternalistic family Expand parenting skills training; parents set supporting goals; empower moms in parenting
Ethnic cooking, showing love w/food Capitalize on healthy aspects of native diet; modify recipes; add F/V; teach through storytelling
Clean your plate, do not waste food Split entrees; use smaller plates, cups
Incidental eating, parties Eat in 1 place at home; emphasize that all calories count
Meal patterns Limit small meals
Whole milk more nutritious Show whole and nonfat milk nutrition facts together; taste-test; mix whole and nonfat milk

Back to top

Slide 24

Text Description Follows

Putting it together

  • Assimilated community and expert opinion
  • Identified major themes
  • Revised curriculum and program materials
  • Initiated ongoing evaluation of impact of cultural/socioeconomic modifications

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 25

Text Description Follows

Overall outcomes

  • For program completers:

    ---- Significant decrease in BMI z-score and age/sex adjusted BMI percentile

    ---- Significant improvements in triglyceride and HDL cholesterol levels

    ---- Many significant improvements in health behaviors, like sweetened drink consumption and TV watching, and psychosocial measures

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 26

Text Description Follows

Outcomes following modifications

  • No significant differences among completers thus far (n=36 before; n=57 after) in empirical measures of weight status or overall program satisfaction
  • Anecdotal evidence of increased confidence by health educators
  • After completing our program changes, we have surveyed families about whether staff, lessons and program materials demonstrated an understanding of their race/ethnicity and financial circumstances

More than 2/3 of surveyed respondents had very favorable responses to these questions

Logo - PHIT Kids

Logo - Children's Mercy Hospital and Clinics

Back to top

Slide 27

Text Description Follows

A Promotora Health Education Model for Improving Latino Health Access in California’s Central Valley

In association with:

Logo - Central Valley Health Policy Institute

Logo - Fresno Latino Center

Made possible by a grant from:

Logo - CMS Centers for Medicare & Medicaid Services

Back to top

Slide 28

Text Description Follows

Background

  • In 2006, the UCSF-Fresno Latino Center for Medical Education and Research (LaCMER) received a Centers for Medicare and Medicaid (CMS) HBCU/HSI Health Services Research Grant
  • Collaboration to examine the effectiveness of using trained Promotoras de salud to deliver an educational intervention to low-income Latinos in California’s Central Valley.
  • Promotora de salud: Commonly referred to as Community Health Worker

    ---- People from and working for their own community

Back to top

Slide 29

Text Description Follows

Context

  • Higher proportion (40%) of Latinos compared to state
  • Higher uninsured rate (33%) than any other racial/ethnic groups
  • Medically underserved area
  • High rates of poorly managed chronic conditions and avoidable hospitalizations and ER use.
  • Need cultural and linguistically competent (CLC) services and interpersonal interventions

Photo Map of California

Source: www.cvhpi.org

Back to top

Slide 30

Text Description Follows

Study Goals

  • Examine the effectiveness of using trained Promotoras de salud to deliver an educational intervention to low-income Latinos in California’s Central Valley
  • Increase healthcare access to Central Valley immigrant elders and adults

    ---- Health Insurance

    ---- Medical Home

    ---- Preventive Service/Physical

    ---- Self-efficacy

Back to top

Slide 31

Text Description Follows

Training

  • Modules

    ---- Four modules: 1) Background 2) Promotora Role 3) Motivational Interviewing 4)Importance of Access 5)Health Insurance Programs

Photo PHIT Team

Trainers

-- Suzanne Kotkin-Jaszi, DrPH

-- Alicia Gonzalez

-- Helda Pinzon-Perez, PhD

Back to top

Slide 32

Text Description Follows

Resource Manual

  • Unique, targeted, and specific

    -- Contact Information

    ---- Spanish Speaking Contacts

    -- Eligibility Rules

  • Varied Resources

    -- Health Insurance to Transportation

  • Accessible

    -- Ready to use tool for all, easier than a phone book!

Back to top

Slide 33

Text Description Follows

Methodology

  • Exploratory pilot project
  • Evaluation of development and implementation of Promotora training module
  • Quantitative and qualitative data
  • Non-randomized one-group study design

    -- Target sample: 400 (with 50% age 64+)

    -- Latino; adult; income <250% FPL; permanent legal resident or U.S. citizen; Fresno County

    -- 10 Adults and 10 Elders per Promotora (20)

  • Participant recruitment through Promotoras’ networks and community groups (snowball method)

    -- Ready to use tool for all, easier than a phone book!

Back to top

Slide 34

Text Description Follows

Intervention

  • Baseline Survey (pre-test)

    -- Demographics, access barriers (qualitative data); four indicators of access to health care services:

    1. Insurance coverage

    2. Source of care

    3. Receipt of Physical

    4. Self-Efficacy when seeking health care services

  • Promotoras developed plan of health care access
  • Case management (follow-up calls, home visits, 5 hours/client)
  • 3-Month follow-up survey (post-test)
  • Second follow-up

Back to top

Slide 35

Text Description Follows

Respondent’s Barriers Based on Promotoras

This chart is based on the qualitative analysis of Promotora interviews. The promotoras believe that their clients experience both systems and personal/attitudinal barriers to service use. They believe that personal and community experiences with the system barriers is a major determinant of the personal/attitudinal barriers. Examples of system barriers include eligibility rules, language incompetence, and poor service access and quality even if insured. Personal barriers include lack of trust in health care programs and the personal and financial considerations that drive reluctance to follow- through on recommended health actions.

Back to top

Slide 36

Text Description Follows

Promotoras’ Role and Impact

This chart is based on qualitative analysis of Promotora interviews. The promotoras see themselves as facilitating attitude change in their clients through showing them that services are available, by devoting time and attention--communicating real understanding and concern for their situation, and by being able to identify with the individual's situation and help the individual recognize that positive outcomes are possible.

Back to top

Slide 37

Text Description Follows

Lessons for Implementation

  • Findings of pilot research project demonstrate effectiveness of utilizing Promotoras in a new and innovative role such as agents in improving health care access for low-income Latinos in Central Valley.
  • Unique, personalized service, availability of Promotoras resulted in significant difference in improving main outcome indicators from baseline to follow-up.
  • Relate to clients, language, trust

Back to top

Slide 38

Text Description Follows

Lessons for Implementation

  • Choose a project coordinator who knows the community
  • Recruit experienced Promotoras
  • Provide ongoing support for Promotoras
  • Emphasize importance of data collection
  • Advocate for policy change to establish long-term funding

Back to top

Slide 39

Text Description Follows

Contact

Julia Puebla Fortier, Executive Director
DiversityRx: Resources for Cross Cultural Health Care
rcchc@aol.com
www.diversityRx.org

Back to top

Slide 40

Text Description Follows

Contact

Promoting Health in Teens and Kids (PHIT Kids) Program
Sarah Hampl, MD
jcapitman@csufresno.edu
Meredith Dreyer, PhD
mldreyer@cmh.edu

Back to top

Slide 41

Text Description Follows

Contact

Central Valley Health Policy Institute
John Capitman, PhD, Executive Director
jcapitman@csufresno.edu
Report available at: www.cvhpi.org

Back to top

Listen to the Audio File

Audio File (MP3)
Transcript

Operator

Good afternoon and welcome to the AHRQ Health Care Innovations Exchange Web Event Conference Call. All participants will be on a listen-only mode. Should you need assistance, please signal the conference specialist by pressing the * key followed by 0. Please note this event is being recorded.

I would now like to turn the conference over to Judy Consalvo. Please go ahead, ma'am.

Judy Consalvo – AHRQ Center for Outcomes and Evidence – Program Analyst

Thank you. Good afternoon, everyone. On behalf of the Agency for Healthcare Research and Quality, I'd like to welcome you to our Web event entitled Ensuring Cultural Competence Across Care Settings. My name is Judy Consalvo and I'm a Program Analyst in AHRQ's Center for Outcomes and Evidence. We're very excited about today's topic and glad to see that you share our enthusiasm. We will be polling you in a few minutes to get a better feel for who has joined us today.

And some of you may be new to AHRQ's Health Care Innovations Exchange, I'll take just a minute or two to give you an overview before I introduce today's moderator.

The Health Care Innovations Exchange is a comprehensive program designed to accelerate the development and adoption of innovations in health care delivery. This program supports the agency's mission to improve the safety, effectiveness, patient centeredness, timeliness, efficiency, and equity of care with a particular emphasis on reducing disparities in health care and health among racial, ethnic, and socio-economic groups.

The Innovations Exchange has the following components: Searchable innovations which are profiles of successful and attempted innovations that describe the innovative activity, its impact, how the innovator developed and implemented it, and other useful information for deciding whether to adopt the innovation. There are now over 350 profiles within our database. New profiles and content are added every two weeks.

We have searchable QualityTools. The innovations exchange presents... posts over 400, excuse me, 1400 tools; practical tools that can help you assess, measure, promote, and improve the quality of health care. New tools are also added every two weeks.

We have learning opportunities. Many resources describe the process of innovation and adoption and ways to enhance your organization's receptivity to innovative approaches to care. Resources include expert commentaries, articles, perspectives, and adoption guides.

We also have networking opportunities. You can interact with innovators and organizations that have adopted innovations to learn new approaches to delivering care and developing effective strategies and share information. Posting comments on specific innovations is one way to connect with the innovators. Types of comments include asking questions or responding to questions about how an innovation works and mentioning additional resources and lessons learned from adopting, implementing, and sustaining an intervention.

This Web event is part of the series of participatory learning events to support you in developing and adopting innovations in health care delivery. We invite you to take a look at archived materials from our most recent Web event on Clinical Nurse Leaders as Quality Champions. It could be found on our Web site which is www.innovations.ahrq.gov and we hope you'll join us for future events that will be announced on the Health Care Innovations Exchange Web site. Stay tuned for a Web event in April on pharmacy related innovations.

We also welcome your thoughts on other topics we could address with you. At the end of today's event, you will be asked to complete a brief evaluation form. Your comments will help us to plan future events that meet your needs and you can also e-mail your comments and ideas to us at info@innovations.ahrq.gov.

So let me just go over a few housekeeping details. While we don't anticipate any technical problems, I'd like to give you a few tips in case you experience any. First, no phone is necessary for this event. You may just stream the audio over the Web through speakers on your computer. If you experience any difficulty with the sound coming through your computer speakers, please notify the Vcall attendant via the Q&A window.

If you have any trouble with the slides or your connection to the Web event, try pressing F5 to refresh your screen. We are recording this event so that anyone who couldn't make it today or needs to leave the Web event early can listen to the recording or read through the transcript. You'll be able to find links to a downloadable recording, the slides, and a transcript on the AHRQ Health Care Innovations Exchange Web site in just a few days. In fact, if you'd like to download the slides for today's presentation, you can find them through the link at the bottom of the screen or on our website now at www.innovations.ahrq.gov. You may submit questions at any time through the Q&A center as pictured in the screen shot. We will be answering questions between presentations, at least we're going to try and do that, and near the end of the web event. So, okay?

Before we get started, I'd like to give our panelists a sense of who we have in our audience today. You're going to be seeing a polling question shortly and please answer the question that you'll be seeing on your screen. So we are pausing just for a minute or two to give you all an opportunity to respond and here we go.

Okay. So looks like we have some physicians on board, nurses, other clinicians, researchers, and then at about 28% or 29% are policy makers, health administrators, and others seems to be our highest category. So welcome, everyone. I think you're all going to enjoy this today.

So today, we do proudly present this Web event because we appreciate the importance of cultural competence. As our nation becomes more diverse and our health care systems serve an increasingly diverse patient population, we recognize that we must be up to the challenge across care settings.

With that very brief introduction, I'd like to introduce our moderator for today's Web event, Julia Puebla Fortier. Julia is an internationally recognized consultant on cultural competence. She is the founder and director of Resources for Cross Cultural Health Care, a non-profit organization that offers policy development, research, and technical support on linguistic and cultural competence in health care. Julia also developed and manages the DiversityRX Web site and co-produces a large national conference series on Quality Health Care for Culturally Diverse Populations which is supported by federal agencies, major foundations, and national organizations.

So Julia, I'm going to turn it over to you.

Julia Puebla Fortier – Resources for Cross Cultural Health Care – Founder and Director

Thank you very much, Judy, and it's a real pleasure to be on this Web event today. I think we've got some terrific speakers and I'm very pleased to be able to introduce them to you. We're going to be having our first presentation delivered by Sarah Hampl and Meredith Dreyer and their presentation will be followed by John Capitman, Alicia Gonzalez, and Tania Pacheco. And before I invite them to get started on their presentations, what I'd like to do is start out with just a brief overview for you of cultural competence, cultural and linguistic competence, I think more accurately stated, because I think if we have a broader understanding of what this can do for us in health care delivery then we'll be able to understand better the kinds of approaches that our presenters have taken in their work.

So culture... and let's just go to the next slide. Thanks. I think that we're all familiar with the fact that when we talk about cultural and linguistic competence, there are two if not more components. The first one, which is more commonly recognized, is the issue of language barriers and how language barriers between consumers or patients and providers can get in the way of real patient-centered communication. It can interfere with people's ability to understand what's going on and to communicate what their needs are.

Culture is something that perhaps we don't think about as much or we're not exactly sure how that might come into play, but I think that this definition from the National CLAS Standards gives you an idea about how we each have culture, no matter where we come from, and our providers come from a variety of cultural backgrounds. And these things do come into play in the decisionmaking process and the communication process.

Next slide please.

So I just want to give you a brief overview of some of the kinds of cultural and linguistic competence interventions. First of all, we have culturally sensitive intervention, which is to say how we specifically bring culture into the background and into the discussion with our patients and this could happen in a variety of different ways. Providers can be trained about cultural competence. We can aim to have a match between the patient and provider with respect to race, ethnicity, or language. And we can design health promotion programs, perhaps using community health workers, that attempt to interject culture into an intervention. Language assistance, of course, may include bilingual services. It can include oral interpretation and the use of translated written materials.

Next slide please.

It can also... we could also look at cultural competence on the level of organizations and what... by this we mean, a variety of different things where an organization takes cultural and linguistic competence issues into its management and policy strategies. They attempt to engage with the community to find out what the issues are. They collect data and do a variety of other information gatherings so that they can effectively plan for the population they're serving and when there are ethics or conflicts that arise, they consider culture as a part of what might be going on and how to address it.

Next slide please.

So I think the important question here is what is it that persuades health care organizations to take action on linguistic and cultural competence and there are a couple of different reasons why they might. First of all, there are many people who'll just say it's the right thing to do. We need to meet the patient where they are and take who they are into account as we are delivering care. This has often been advocated from a civil rights perspective. It's also a good public health reason to do it. There are also legal reasons and sort of quasi-legal reasons, requirements from the accrediting agencies like the Joint Commission or from the Office of Civil Rights.

There are also liability concerns because if these factors come into play then and there's a patient safety issue or some kind of medical error then they can be called into question. There's a business case because health care organizations want to know that the care they are delivering is in fact effective and that they're getting a return on their investments or programs. There's also a quality improvement issue because we want to make sure that we're delivering our care effectively and efficiently. And finally, the other reason that we want to be concerned about this is because we want to make sure that patients have good outcomes and many people are positive that cultural competence can take us along the way to making sure that patients from diverse communities do have positive outcomes.

So let me just close with our next slide by saying that the evidence base for cultural competence is actually important. Because patients have access and health status deficiencies that need to be addressed, providers often have to do this in a way that's different than the way they usually deliver care. It requires an investment of time and effort and resources.

It's not business as usual for health care providers and organizations. And so we want to be able to answer the questions: Did the intervention do what it was supposed to do? Did it affect the processes of care? Did it improve access to service? Did it improve utilization? Does it affect patient satisfaction or health behaviors? Does it affect patient outcomes? And does it improve efficiency and cost effectiveness for the health care organization?

So with those questions in mind, marrying together cultural and linguistic competence with quality, I'd like to turn things over now to our first set of presenters. Sarah is going to lead us off and tell us about a very interesting innovation that addresses health care, particularly obesity issues, with a young population. Go ahead, Sarah.

Sarah E. Hampl, M.D. – Children's Mercy Hospitals and Clinics – Medical Director of Weight Management Services

Thank you, Julia. I'd like to introduce our program called the Promoting Health in Teens and Kids, weight management program, from Children's Mercy Hospitals and Clinics in Kansas City, Missouri.

Next slide please.

We have an issue with overweight and obesity in Kansas City just like the rest of the nation and our general pediatrics clinics as well as really a multi-disciplinary team at our hospital early in this decade realized the necessity of developing a weight management treatment program and we developed a multi-disciplinary clinic which began in 2004 called the PHIT Kids Clinic and in several months into it, really realized that if we're going to be able to help families create a sustainable family-based change that we needed to have a more intensive intervention than just periodic clinic visits and so our group program kicked off in June of 2006 and it is a family-based multi-disciplinary behavioral treatment program for children 9 and older and their parents or caregivers.

And in the clinic where kids are first identified, the children are seen by a medical provider, either myself or a pediatric nurse practitioner, as well as a psychologist or a social worker, a registered pediatric dietician, and a physical therapist and children identified who would like to be part and their family would like to be part of our evening group program then are offered that after several clinic visits and the evening group program is led by a racially and ethnically diverse team of six health educators.

Next slide please.

Next you'll see on our next slide, we have a lot fun in our evening group. Our clinic staff also assists in planning of the evening group sessions, the curriculum, the handouts, other materials, and just the experiences that families get. And we have a good space to be able to do this in the evening.

Next slide please.

The population of children and teens that we have served thus far includes 185 youths with the mean age of 12 years. A little over half of our participants are female and the majority are African American followed by Caucasian and Hispanic and about 3% other race and ethnicities. We have a little over 50% of our population either receiving Medicaid or not qualifying for Medicaid in a self-pay status, often times receiving a varying degree of financial assistance from our hospital.

Next slide please.

A few details about our program, we have two phases. The first being an active treatment phase which consists of these multi-disciplinary clinic visits as well as the weekly group education which lasts for two hours at a time that goes on for 24 weeks. And we divide the groups by age so that tweens or the 9 to 12-year-olds are educated by their own health coach. Parents have their own health coach. Spanish-speaking parents have their own health coach. And then finally our teens have their own health coach. And this is following an initial period of group physical activity where we have a number of different options to choose from. And then there's a wrap-up session at the end where everyone does come together again. We invite children and their parents and siblings to come back monthly for group education on a different night and interspersed some periodic clinic visits with that so that the total treatment period is 24 months. After this, we do continue to see the children in clinic as needed. For more details about our program, please see the AHRQ Health Care Innovations Exchange Web site that was mentioned earlier.

Next slide please.

I wanted to detail a little bit about the process of how we've addressed cultural and socio-economic issues in our patients and families. The importance of this really was highlighted early on with our clinic patients and their families and the importance of really developing our evening group program, developing the cultural competence to a greater degree in our evening group program. We got this feedback also from our staff and the community partners that we had although we did our best, we didn't really put a lot of research or thought initially into how we would make special efforts to be as culturally competent as we could, but we did do some consultation with local colleagues, local health clinics that primarily serve Hispanic and African American populations as well as with a Hispanic advocacy group in town and the Black Health Care Coalition and we identified some major themes from that that, again, after sharing our curriculum and program with them, were identified. Following this, we had the opportunity to engage a couple of national consultants actually to review our curriculum, our program materials.

They actually met with us and our staff and subsequently provided some training; one was Donna Matheson who is a researcher from Stanford University Prevention Research Center and the other was Angela Odoms-Young from the University of Illinois, Chicago and we always acknowledged that they really have a great role to play in the development of the innovations that we were able to implement.

I'm going to turn things over now to Dr. Meredith Dreyer.

Next slide please.

Meredith L. Dreyer, Ph.D. – Children's Mercy Hospitals and Clinics – Clinical Child Psychologist

As part of our innovation, as part of that review process, what we learned are that there are two dimensions to cultural sensitivity; one of those being a surface structure level that we, and it's a term from Resnicow and his colleagues, that we are trying to match our intervention innovation to…match our materials and information to key characteristics of the intervention population, so that our materials feature aspects and characters and materials that have African American members and Hispanic Latino members. The other thing that we are trying to go a little bit... dig a little bit deeper and look at the deep structure aspects so that we are attending to and incorporating the multiple levels of factors that actually influence the behaviors of the target population.

Next slide please.

In addition to that, we also wanted to be very sensitive to not just cultural factors but also socioeconomic considerations. So we want to recognize and respect that hierarchy of needs because many times families will show up and they don't have any power at their house. They don't have transportation. So there's a food and security so in addition to our cultural difficulties and cultural variables that play a role, socioeconomic variables play a very big role. As Sarah mentioned, lack of health insurance. We have about 7% of our population who does not have health insurance because they don't qualify for any health insurance. That plays a role and impacts their ability to seek care. Immigration and deportation issues are a concern... they lack health care access. And then for nearly all of our families, neighborhood safety, many of them come from the urban core here in Kansas City and so they have limited safe places to play. They don't have access to grocery stores but they have very ready access to convenience stores and fast food restaurants and so frequent access to things that we don't want them to be having.

Next slide please.

So in looking at the recommendations that Donna Matheson and Angela Odoms-Young suggested was all the research that we were able to come up with. We thought about some various modifications that we need for our African American families. They've done some key characteristics or values that that culture... many members of that culture have such as a significant respect for elders and so we hear frequently that, "I couldn't possibly tell my mother or my grandmother, 'no,' if they make these foods," so how you can take a very small portion of those foods at family gatherings versus having to say you know, "hey, I'm trying to work on this for my son or my daughter," and many times family members live in... because of housing and support, they're living with extended family members and this is across multiple cultures and in particular for our African American and Latino families. They're living with extended family members so we do try to involve many of the family members and we invite the grandma, if possible, to come to the session so that she can…we can dispel any myths that she may have."

We do also try to use a lot of oral and visual instruction when possible because that's a preferred learning method. One of our favorites is the Eat This, Not That... some of the Eat This, Not That quiz games and so forth that we put on.

The value of group participation. We try to do a lot of group physical activity like the Cha Cha Slide. Zumba has been popular among all of our cultural groups actually. The more family-based rewards, honoring the role and the effort that takes place for all of the family members that participate. Some of our more popular recipe modifications that we've made have included how to make collard greens healthy. Our families are like "We've never heard that you can make those healthy!"

And then for our African American families, we know that the authoritarian parenting style is actually healthy and a very protective parenting style whereas it's not very protective for a Caucasian family. So we try to highlight that there are multiple... we do multiple sessions on effective parenting so that families are able to make these types of interactions or interventions, but we suggest that you can do that differently for different types of families.

Next slide please.

For our Latino families, there's a little bit more of a maternalistic family that we tend to see and this has been noted a lot out in Donna Matheson's Stanford program that moms who have male children have a very hard time setting limits and we definitely see that here in our program and so we have worked very hard to empower those moms with the parenting skills education that we do and to help them to figure out how to set those limits with their children regarding food and we know that food is how you show love in many cultures, in particular, in the Latino culture. So we talk about how to show love and to show attention using other ways and we try to capitalize on the good part of the healthy method. The healthy aspects of the diet especially the diet... the native diet is very high in fruits and vegetables and lower in meats and we try to overcome language barriers by... when you're going out to eat, try splitting entrees because most of our families who have language barriers won't ask for a to-go box which is something that we teach other families. "So just ask for to-go box, split it in half when you start with it and don't take it out." Most of our Latino families who don't speak enough English won't do that. They think it's disrespectful. So we've learned to modify the splitting entrees method for those families.

And then we also know that we don't assume that everybody eats three meals and a snack or that they eat the biggest meal at dinner time so we tried to provide various forms of meal planning and addressing different schedules and how you can adapt to those.

We've also learn to try to help make label reading and milk buying as easy as "Look for the pink cap," when we convince families to switch to the nonfat or skim milk.

And we also provide our classes in Spanish for the parents.

Next slide please.

And we think about how we'd put it all together. We really did assimilate our community and expert opinions as well as the opinions of, as Sarah mentioned, our diverse staff members to come up with our major themes and then we use all that information to revise our curriculum and program materials so that they meet the surface structure as well as some of the deep structure modifications and then we have initiated ongoing evaluation of the impact of those cultural and socioeconomic modifications.

Next slide please.

In terms of overall outcomes for our program completers, we are seeing significant decreases in their BMI z-score and percentiles, working improvements in their triglycerides and HDL. And then health outcomes like sugar-sweetened beverage consumption and TV watching and weight-related quality of life.

Next slide.

In terms of whether our cultural competency... our cultural modification training and change (inaudible) has made a difference, we haven't seen any differences so far in whether they're losing more weight since we started this, but our health educators have definitely reported that they feel more confident in how our materials feel to them, that they feel like we're doing a better job in addressing some of the issues that have come up in past, and actually, two-thirds of our families have reported that they feel like we are sensitive to their financial difficulties and to their culture and ethnicity, their race and culture and ethnicity that they come from.

So, Julia, that is what we have.

Julia Puebla Fortier – Resources for Cross Cultural Health Care – Founder and Director

Thank you very much both Sarah and Meredith and I'd like to move on now to our second presentation and we're going to start off with John Capitman and he's going to talk about the very interesting program of promotoras in the Central Valley of California and how they are working to improve access to care within the Latino population there. John, why don't you go ahead?

John A. Capitman, Ph.D. – Central Valley Health Policy Institute – Executive Director

Good afternoon. Hi. John Capitman and I'll be speaking along with my colleagues.

The Central Valley Health Policy Institute is at California State University, Fresno and our mission is to improve equity in health care by developing the region's capacity for policy analysis and program changes.

Next slide.

In 2006, we began a partnership with the University of California San Francisco Latino Center for Medical Education and Research. Our collaboration was to study the effectiveness of using trained promotoras de salud to develop an educational intervention to low income Latinos in California's Central Valley. Promotoras de salud, sometimes called community health workers, are people from a community who work with their own community members in a direct way to improve care and improve access to care.

Next slide.

As you may know, typically promotoras are used to assist with service delivery. Our focus was on bringing promotoras to help people get access to care. Our region, as you see, has a high percentage of Latinos, higher than the state as a whole and among the highest rates of uninsured persons in the state and in the nation and also particularly among Latinos. Most of the valley is a medically underserved area with high rates of poorly managed chronic conditions and avoidable hospitalizations, avoidable emergency room use. Part of that reflects the fact that many people who are in the Latino community, even when eligible for services, have trouble getting into the service system because of an absence of culturally appropriate and linguistically competent care delivery.

Next slide.

Our study examines the effectiveness of using promotoras who had some experience, who are trained delivering an educational intervention. What we're hoping to do is to increase health care access and we intended to and tried to measure health care access in terms of whether or not people had a source of insurance, whether or not they had a usual source of care, were getting age appropriate preventive services such as an annual physical, and what was their sense of being able to deal with their health problems on their own.

Now, I'm going to turn it over to my colleague, Alicia Gonzalez.

Alicia Gonzalez – Central Valley Health Policy Institute – Promotora Project Coordinator

Thank you, Dr. Capitman.

The promotora training was developed and delivered by Dr. Suzanne Kotkin-Jaszi and Dr. Helda Pinzon-Perez who are faculty from the Department of Public Health at California State University Fresno and myself, the project coordinator, over the course of two full days. The training was conducted in English and Spanish and it focused on the importance of having health insurance, a medical home, and a primary care provider. The promotoras were paid completing the baseline survey and provided us with valuable feedback on the culture appropriateness, linguistic proficiency, and the educational level of the survey before it was put into use.

The promotoras received training on the eligibility requirements of public health insurance programs like Medicaid, Medicare, and the State Children Health Insurance Program. They learned about age appropriate use of preventive services, appropriate use of emergency hospital services, and patient rights such as the right to have an interpreter. Throughout the project, we consistently emphasized the value of their role and provided continuous training and support which made them feel comfortable in asking questions whenever they needed clarification.

Next slide please.

An especially important component of the project was the use of a localized community health resource guide which was developed to assist the promotoras in providing specific and appropriate referrals to their clients. The guide which was in both English and Spanish included an extensive list of health and social service agencies within Fresno County along with basic descriptions of the services they provide and health insurance eligibility guidelines. But most importantly, the manual had the name of a Spanish-speaking person, for example, at a community health center, an insurance enrollment agency, or public transportation provider who serve as the promotoras direct contact. The promotora communicated and followed up with this contact in resolving a client specific issue or concern.

So the personal aspect of the resource manual is very important because it helps instill trust between the client and the promotera, which made it easier for the client to schedule an appointment on their own because they felt more comfortable knowing that they had the name of a specific person who spoke Spanish and whom the promotora knew. The promotoras also work together and share the resources and contacts with each other.

Next slide please.

Our methodologies summarized on this and... next slide. The methodology slide. So we had a total of 13 experienced promotoras who had existing ties to Latino communities here in Fresno County. Most promotoras were bilingual in English and Spanish and one was bilingual in Spanish and Mixteco, which is an indigenous native language of Mexico. Our final sample size of 313 represented 67% of adults between ages 18 and 64 and 33% were elders over age of 65.

Each promotora recruited adults and elders from their own social and community networks and from a variety of community settings such as health fairs, farmers' market, churches, and senior meal site centers. Word of mouth is very strong within the Latino communities so many participants referred friends and relatives to the promotoras because they had already established a trusting relationship with her and wanted to help their friends get access to health care services, too.

Next slide please.

So the actual intervention consisted of an initial baseline survey that lasted roughly 1 to 1-1/2 hours and it often took place in the client's home.

There are four indicators of health care access that we measured in the baseline and during the followup interviews which are noted on this slide. We asked participants whether or not they had insurance coverage, a resource of care, if they had received a physical in the previous year, and to rate their self-efficacy in navigating the health care system.

The promotoras developed an individualized health care access plan together with the participants which addressed specific health care needs. The promotoras then determined where the participants should be referred to depending on where they live and provided them with appropriate contact information using the resource manual. The promotoras provided ongoing assistance to their clients in successfully carrying out the agreed upon plan. And oftentimes, the promotora assisted the clients in checking the status, for example, of a pending insurance application, scheduling lab work for themselves or their family, and in arranging public transportation.

The promotoras made several followup calls or home visits on a bi-weekly basis to motivate their clients following up with their plan. And three months after the baseline survey, the promotoras conducted a post test and then we had a second followup which obtained more specific information about the four indicators which are noted on this slide.

And now, I'll pass it over to my colleague, Tania Pacheco, who will discuss our findings from the evaluation.

Tania L. Pacheco – Central Valley Health Policy Institute – Research Analyst

Thank you.

Next slide.

The promotora intervention showed statistically significant improvement in all four of the indicators for access, health insurance, medical home, receipt of a preventive service, and self-efficacy. This chart that you see here is based on the qualitative analysis of the promotora interview.

The promotoras believe that their clients experience both system and personal attitudinal barriers to service use. These systematic barriers are the major determinant to the personal or attitudinal barriers that community members may face. Examples of these system barriers include stringent eligibility rules, lack of translation or competent personnel to correctly translate, and poor or rude service in the health care setting even if they are insured. As a result, the personal barriers developed including a lack of trust in health care programs but there also existed financial considerations that drove a reluctance to follow through on recommended health actions.

Next slide.

These are just some of the things uncovered in the qualitative analysis about the participants. But we also analyzed what kind of impact using a promotora can have on participants' success to improve his or her healthcare access.

This chart is also based on the qualitative analysis of the promotora interview. The promotoras see themselves as facilitating attitude change in their clients by showing them that services are available by devoting time and attention, communicating real understanding and concern for their situation, and being able to identify with the individual situation and help the individual recognize that positive outcomes are possible.

Next slide.

Remember that a promotora is someone within the community. So as several promotoras said, "We have the same roots. We suffer the same," which led them to "open up."

Our demonstration project showed that using promotoras for other than behavioral modification within vulnerable populations is possible. However, increasing health care access to any community is complex. Promotoras must untangle the web of mistrust that the system has embedded in these individuals over time through poor or inadequate service before the interventions can have a chance for success. Perhaps this is why having someone from the same community to reach out may be one of the best methods of intervention which includes a unique and personalized approach.

In addition, however, there needs to be further inquiry into these systematic barriers. As we understand that these systematic barriers are leading to the personal barriers to system health care, we must study this more closely. At CVHPI, we are currently in the process of combining data from this project and another with families in which at least one of the members is undocumented to explore how poor treatment or malos tratos influences health care access.

Next slide.

We can clearly mark the success and perhaps something that could always be further capitalized on are the trust, availability, and overall ability of the promotoras to relate to their clients.

Now, we will have John Capitman come back to discuss the lessons for implementation.

John A. Capitman, Ph.D. – Central Valley Health Policy Institute – Executive Director

Yes. I think that the major lessons from our project are that in the context of a community to implement a program like this really requires that the coordinator be somebody wonderful like Alicia who knows the community, understands the people, feels a connection, and also has learned about the health care system. It's important to recruit experienced promotoras. Many of the people we worked with had worked for years helping community members and so understood both the community and the needs of the population.

We also attempted to provide ongoing support for the promotoras all throughout the program. People needed help solving problems. I can't get this client in. I can't understand this client's needs. Or I'm having trouble with the forms.

Data collection turned out to be a challenge in our program. We did not spend enough time initially emphasizing the importance of getting solid data so that we could demonstrate the importance of the project and so did a lot more work with the promotoras throughout the study period to make sure that we had full and complete data.

And finally, we've been able to see that the real opportunities to advocate for policy change in California, as in another states, there really isn't a long-term funding stream for promotoras or an established mechanism for certifying or recognizing their skills. And so we've joined efforts in California to advocate for policy change and think that's a necessary part of this work.

Julia Puebla Fortier – Resources for Cross Cultural Health Care – Founder and Director

Great. Thank you very much, John and also to Alicia and Tania. It was an excellent presentation. And now we've got time for some questions and we have some very interesting ones so I'm going to start off by turning to Meredith and Sarah and ask if you would have some recommendations for child health care providers about how they might incorporate cultural competence approaches into their practices and their programs based on your experience.

Sarah E. Hampl, M.D. – Children's Mercy Hospitals and Clinics – Medical Director of Weight Management Services

I think that it's very important as this as it has been highlighted to listen the community and so although there are some... maybe some more general things that can be learned by literature searches and reviews, I think it's important to know what the specific needs that are perceived by the community are and so being able to take advantage of different parent groups in the community both of young children such as parents or teachers at Head Start, parents as well as older kids would be a good way,in addition to surveying their colleagues just about what anecdotal things parents are mentioning to them and that their staff also note. So that would be kind of an initial step. I think again a literature search is a great idea but there's nothing like actually talking with your target population and their constituents to just see what they feel like the most important issues are to be addressed.

Julia Puebla Fortier – Resources for Cross Cultural Health Care – Founder and Director

And so just as a followup to that, looking a little bit more broadly, how did you facilitate the collaboration piece with some of your community partners for this program?

Sarah E. Hampl, M.D. – Children's Mercy Hospitals and Clinics – Medical Director of Weight Management Services

We had some existing community partners from the initial start up of the group program but then we identified others really through the local university here, University of Missouri, Kansas City, and then we were aware of the work of the Black Health Care Coalition in our community as well as we were already in an educational intervention for childhood obesity with the particular clinic that served the majority of Latino and Latino patients and parents. So we used our existing contacts and then asked them for their recommendations.

Julia Puebla Fortier – Resources for Cross Cultural Health Care – Founder and Director

Great. Now just to turn things over to the other team, one of the questions that we got was how have you... you described a very interactive process between promotoras hooking up, getting to know providers and agencies in the community, and then making links for those potential clients. How... if you worked on this at all, how did you sensitize those providers to some of the cultural issues that they might encounter with some of these new clients?

John A. Capitman, Ph.D. – Central Valley Health Policy Institute – Executive Director

It's a great question. As part of the development of the resource manual, we Identified within each agency that we were going to work with somebody who was both a Spanish speaker and who was willing to engage with us about making sure that our clients had access. That's really about what we can say. However, many of the clients report not only policy and program design barriers to receiving care but really rude service in the offices when they contact the social service agencies, when they contact many different places. So there's really an ongoing need to think about introducing more of a culturally appropriate and language competent approach in many of these agencies.

The other thing that we think is important is that some of the agencies that we... some of the health care providers to which our clients were referred really use promotoras... different promotoras, additional promotoras, as part of the health care team. The promotoras assist people in getting and using services and then understanding and communicating with the physician and making sure that they understand followup. And I think that inclusion of the promotora in the health care team is just an essential kind of piece for making these experiences more accessible and helpful for people.

Julia Puebla Fortier – Resources for Cross Cultural Health Care – Founder and Director

Great. All right. We're getting a lot of questions in now and just to let you know, we won't be able to answer them all during this Web event, but there may be an opportunity for the presenters to be able to address a few of these after the fact. So let me take a look at this question here. This is for John and perhaps, exactly, Tania. What could you tell us about the policy implication for this, you mentioned it briefly, but do you think that there are recommendations that states could take on board with respect to your work and how to improve access to services for culturally diverse populations?

Tania L. Pacheco – Central Valley Health Policy Institute – Research Analyst

Yes. During our interactions with the promotoras after the intervention, we really found that they kind of... they would like more time and they see the ongoing need for their services and so do we. We've done a document in which we have policy recommendations and the overall for the state would be the institutionalization of promotora use within the different health care services at the state level, keeping in mind that these interventions are most successful when they are unique and personalized to each of the county goals or each of the city goals and then translated that down to the personal goals of the client. So definitely having them become, as John mentioned, part of the health care team and providing a sustainable infrastructure for them to exist within this health care team but also keeping in mind that when you start talking about guidelines and things like that that the major drive be a unique personalized approach.

Julia Puebla Fortier – Resources for Cross Cultural Health Care – Founder and Director

Great. Thanks. Now, Meredith and Sarah, I've got two questions here that both address the issue of culture and weight or obesity. One of our participants is saying that when she interprets on childhood obesity issues, she finds that there's often some ignorance on the part of health care providers with respect to the eating habits of other ethnic groups. And so what can be done to bring better awareness to diabetes educators and obesity specialists with regard to eating habits? And then just as a corollary to that, have your educators found that culture plays apart in whether parents see their children as obese or not obese?

Meredith L. Dreyer, Ph.D. – Children's Mercy Hospitals and Clinics – Clinical Child Psychologist

Sure. I think definitely culture plays a role in ideal body size. It's certainly affected... bigger is beautiful is often a theme that we hear among African American girls and we even... some of our teenage girls, their goal weight is much higher than we would like it to be as health care providers and as compared to others. And then among our younger kids, we find that a chubby baby in particular among our Latino families and as among families from many, many cultures who immigrated here and maybe immigrated quite a while ago, there's a perception that you don't want a skinny baby, a skinny baby is a sick baby. And so we see that that affects whether or not they're very worried about their child's weight status.

With regard to trying to better educate the impact of different types of meal patterns for diabetes educators and weight management professionals, I think it's a matter of trying to have people just ask more general global questions about what does eating look like in your family and that something that the interpreters can try to suggest is that here's how... and sometimes you can develop a bit of education yourself as to say, you know, in our family or in our culture, this is more common and so it might be helpful if you just ask them to tell you about their eating style or eating habits for the day. Many times people would do a 24-hour recall of food and that should allow for more flexibility as just describing what you have to eat yesterday.

Julia Puebla Fortier – Resources for Cross Cultural Health Care – Founder and Director

Great. Great. Good answer. I have another question which perhaps either one of you, either one of the teams could answer. Could you elaborate a little bit on the intergenerational interventions utilized in either of your programs?

Sarah E. Hampl, M.D. – Children's Mercy Hospitals and Clinics – Medical Director of Weight Management Services

This is for the PHIT Kids team. I think we try to address this especially well, really with the kids and the parents both, in certain session topics such as a family meals or getting ready for holidays and how you might deal with the fact that multiple dishes may be brought by multiple family members and we also address it in terms our family support sessions and we're usually aware of what the family structure is and who the children are living with and the constraints that they may be observing because the parent may feel like they are not able to have a lot of influence if the parent and the child are actually living under the grandparents' roof. So we try to provide some insight and explanation as to why the grandparent, for instance, may have a certain way of believing or doing things but then also try to provide them with some skills about how to respectfully yet firmly do something or act in a certain way in a more healthy way or how to respectfully kind of bring up the topic with the grandparents. So there are certain sessions that lend themselves more easily when we're talking again about family support or how to really enlist others in the family that perhaps might even be sabotaging the efforts. It's usually kind of again in certain sessions that we address that particular issue.

John A. Capitman, Ph.D. – Central Valley Health Policy Institute – Executive Director

This is John. I think it's important to point out in our context that elders who are documented were not having as much difficulty as younger families in accessing care that they have comprehensive coverage available for them. Medicare program really was facilitating access for people in a way that wasn't going on with the younger people.

We also really found lots of evidence of a kind of a whole family approach to health care access. People were often talking to us about the problems of their child or the problems of the elder in their family as much as their own concerns. So I didn't really have much sense, correct me, colleagues, that intergenerational conflict or lack of communication across generations was really a big part of the access and quality care issues that we were trying to address.

Julia Puebla Fortier – Resources for Cross Cultural Health Care – Founder and Director

Great. Great. So we're coming up here on the closing of the Web event. Before I ask any more questions, I'd just like to ask Judy or Kay from the AHRQ team, is this a good place for us to take a break and do a wrap up?

Judy Consalvo – AHRQ Center for Outcomes and Evidence – Program Analyst

Yes. I'm afraid we're coming to the end of our time and so, yes, we do have to bring the Web event to a close.

And I want to thank our presenters and Julia and our audience. This has been a wonderful very informative learning opportunity for all of us. We do value your feedback and since we're running out of time, if you have more questions and you want to address any of these questions or comments to our innovators, you can go to the Innovations Exchange Web site and on each innovation, there is a comment section. So you can continue, you can make a comment, you can ask a question, and the innovator will get back to you.

And now as we're drawing to a close, we would like to ask you if could stay on a few more minutes and complete the evaluation that's about to appear on your screen and do remember you can also contact us at our Innovations Exchange Web site or at any time at info@innovations.ahrq.gov. Thank you.