The University Health Truman Medical Center, affiliated with the University of Missouri-Kansas City established a bilingual and bicultural care team that consists of a peer educator, case manager, and clinician. The care team provides clients with culturally responsive care and links them to external community resources. Hispanic and Latina(o/x) clients served by the bilingual and bicultural care team experienced greater retention in care and improved viral suppression rates.
Kansas City, MO
Hispanic and Latina(o/x) communities often face higher rates of HIV and more barriers to high quality health care than non-Hispanic whites, resulting in disparities in health outcomes. Prior to the intervention, Truman Medical Center did not employ Spanish-speaking staff despite the substantial and growing Hispanic and Latina(o/x) client population. Clients were also randomly assigned to a provider regardless of the provider’s level of cultural responsiveness.
The bilingual and bicultural care team consists of a peer educator, case manager, and clinician (nurse practitioner). Together, they provide clients with HIV and primary care, referrals to specialists, HIV education, adherence counseling, and linkage to support services.
The team members play the following roles:
- Peer educator: Checks in with clients at least monthly to provide education and adherence support.
- Case manager: Conducts initial needs assessment and home visits to better understand and meet clients’ clinical and social needs; links clients to social supports.
- Clinician: Provides primary and HIV care including prescribing antiretroviral therapy (ART); refers clients to specialty care; provides education on HIV disease progression and importance of medication adherence; assesses adherence through lab monitoring.
“HIV care services should be representative of and sensitive to the complex needs of the communities that are being served.”
Truman Medical Center developed a structured care provision process, which outlined the key steps and activities of each member of the care team:
- Initial outreach and enrollment: An outreach worker typically contacts the clients to schedule initial meetings with the case manager for program enrollment.
- Clinical appointments: Clinicians are flexible with their appointment times to accommodate clients’ work and other commitments. They immediately inform the case manager of needed follow-up items (e.g., connection to social supports) or if a client misses an appointment.
- Medical chart review: Prior to each appointment, the care team reviews the client’s medical chart to identify medical and social supports that should be provided during the visit.
- Lab result review with clients: The entire care team reviews lab results with clients to discuss progress and adherence issues.
- Pharmacy navigation: The peer educator and case manager play a crucial role in orienting clients about medication prescriptions and refills, helping them identify the right pharmacy, and addressing any adherence issues. If a client chooses to receive pharmacy services at Truman Medical Center’s onsite pharmacy, the case manager or peer educator accompanies the client to the pharmacy to meet staff and learn firsthand about the process.
The care team connects clients to culturally responsive services offered by a network of community partners that work extensively with Hispanic and Latina(o/x) people. These organizations also play an important role in referring Hispanic and Latina(o/x) clients to Truman Medical Center, providing feedback on the care model, and expanding the reach of and generating trust in the program.
Truman Medical Center evaluated the program after initiation, comparing key measures for enrolled individuals during the year before (2005) and the year after (2007) the intervention. The 38 individuals first enrolled experienced greater engagement in medical care and were more likely to be virally suppressed.
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- Assessment of staff resources and gaps. Truman Medical Center reviewed the linguistic and cultural competencies of Truman Medical Center staff. The gap analysis focused on staff language skills, cultural backgrounds, lived experience, and previous training, in addition to the availability of interpretation services at the clinic.
- New staff recruitment. To build out the bilingual and bicultural care team capacity, Truman Medical Center needed to hire additional staff. This required leadership buy-in to use existing Ryan White HIV/AIDS Program (RWHAP) Part A resources to hire new staff members. In addition, Truman Medical Center partnered with a community organization, the Guadalupe Center, to support recruitment efforts by identifying applicants who already had connections and trust in the community.
- Bidirectional staff training. New staff received training to ensure they were familiar with clinic operations and the role of the care team. New staff, in turn, shared their relevant lived experience with existing staff, so all Truman Medical Center staff were familiar with structural barriers that Hispanic and Latina(o/x) people face in accessing services. This bidirectional training supports staff to provide more culturally responsive care.
- Community partnerships. The hospital created referral partnerships with community-based organizations that serve Hispanic and Latina(o/x) populations to provide clients with services not available at the Truman Medical Center.
"Staff should be aware of the intersecting identities of the Hispanic and Latina(o/x) population and how these identities relate to social and structural barriers to accessing care.”
The annual cost of the eight staff involved in the care team and program management was approximately $300,000 a year (in 2007 dollars). Truman Medical Center uses RWHAP Part A funding, an ongoing funding source, to support the initiative.
- The bilingual and bicultural care team should include members who share similar lived experience with their clients and are familiar with structural barriers to care in addition to community assets.
- Healthcare programs that are not able to recruit bilingual and bicultural clinicians should consider using a case manager or peer educator to serve as liaisons in appointments.
- Peer educators with limited professional experience may need additional training and support to better integrate into the clinic environment. Quarterly team and skills building training sessions may be more effective than weekly meetings. Finally, programs should identify and help support the long term career goals of peer educators.
- Training opportunities should always be seen as a learning exchange, where individuals with lived experience, especially peer educators, share their expertise with other clinic staff, so everyone is familiar with culturally responsive practices.
- While some clients are referred from external sources, many may join the program through an in-reach approach (i.e., engaging eligible clients already being seen at the clinic). In-reach reduces the resources required for client recruitment.
