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What is cultural competence? Why is it important to have diverse physicians? What is patient-centered care? How can you provide culturally competent care?
Our guest is Leong Koh, MD, president and CEO of Northwest Permanente. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Leong Koh, MD, president and CEO, Northwest Permanente
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about culturally competent care and the steps that one health system is taking to deliver it. Our guest today is Dr. Leong Koh, president and CEO of Northwest Permanente in Portland, Oregon. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Koh, welcome.
Dr. Koh: Thank you so much, Todd. And thank you for having me.
Unger: Well, before we discuss the ways that you're delivering culturally competent care, why don't we just start by having you tell us a little bit about your organization's commitment to it and the role that it's been playing in your work?
Dr. Koh: Thanks so much, Todd. We, at Kaiser Permanente—actually, our model was actually built on the premise of equitable care. And our founder, Sidney Garfield, Dr. Sidney Garfield and Henry J. Kaiser first met in the early 1930s when they were caring for workers building the Colorado aqueduct in southern California. And later on, Dr. Garfield and Henry J. Kaiser again teamed up in the shipyards that built liberty ships for World War II in Oakland and actually in Portland and on Vancouver area here.
And Dr. Garfield and his team, on the premise of prepaid medicine, took care of workers and their families regardless of race and ethnicity. When Kaiser Permanente actually was formed after the war, Mr. Kaiser himself declared that our hospitals would not be segregated. And we were one of the systems that had hospitals that were unsegregated.
And however, despite the foundation and a long-standing commitment to equitable care, care gap still exists for patients of color. And this is something that we take, obviously, very seriously. And I'm very pleased to say that, over the last couple of decades, Kaiser Permanente has made great strides in closing these care gaps.
And one such example is blood pressure. We know that there is a gap between whites and Blacks and African Americans, and we've been able to close that gap by over 50%. But a gap still exists, so we still have a lot of work to do.
The other thing I want to mention, Todd, is that we also have to be careful and care for our background of pipeline of physicians that are coming through. And I'm proud to serve on the board of directors for the Kaiser Permanente Bernard J. Tyson school of Medicine in Pasadena, California.
And in that role, I do serve as a trusted steward of the school's vision to graduate a diverse community of compassionate leaders, lifelong learners, and have the courage to change the profession and in society. And this is evidenced also by the makeup of the class, which we're very proud of. 40—I'm sorry, 29% identified as LGBTQ+. 18% are actually first-generation students. 41% come from ethnic backgrounds that are underrepresented in medicine relative to the numbers in the general population. And finally, 30% of the class comes from socioeconomically disadvantaged backgrounds.
And we've been able to do this by tuition-free medical education for the first five years at the school. And we hope to continue this work in making sure that we have this pipeline of medical professionals coming into the field of medicine.
Unger: Well, those are already a couple of great examples. First of all, I love the founding story, and it's clear that culturally competent care has just been built in from the start at Permanente. I'd love you to talk a little bit more in detail about some of the initiatives that you are in process with right now to improve delivery of culturally competent care.
I know you've got three big ones that are in process right now. Tell us more about them.
Dr. Koh: I'd love to tell you about them. And first, one of the more mature, what we call Gender Pathways Clinic, which is the hub for our patients receiving gender-affirming care, is something that we're very proud of. One of the unique features of this Gender Pathways Clinic is that it also allows access for clinicians who are not surgeons to care for our patients who are seeking gender-affirming care.
And these include primary care physicians, such as myself. I'm a family physician. And we really wrap our hands around—arms around all the patients and care for not only what they're seeking but also their preventative care.
What's great about this is after—if they do decide to go with a surgical procedure, after it's done, many of these patients have established relationships with the primary care doctors. And guess what? I become their new PCP, and I care for them lifelong as long as they have their care with us.
Another such example is our salud and Español model of culturally and linguistically inclusive care for our Spanish-speaking patients. This is where our physicians, our medical assistants, our nurses all fluently speak Spanish, and we care for our Hispanic, Latino population. And we've done some very innovative approaches here, like, for example, group visits for our patients with diabetes. Our physicians are really improving that care experience for our patients. And we've seen some fantastic outcomes in A1C control and also nutritional status as well.
And finally, this fall, our third example here is our Center for Black Health and Wellness is opening with the goal of delivering, again, culturally competent care for our Black members. And data has shown that, when a clinician looks like you and understands your culture and history, it really does have a significant impact not only on lifespan but also adopting that preventive practice, that proactive care that we're all seeking here. And so this will have emphasis on screening and prevention with the goal of care not only for about our patients, but we want to spread the best practices throughout the entire community as well, too.
And the Black Center for Black—the Center for Black Health and Wellness is not only open for Black and African American patients. They're open to all Kaiser Permanente patients as well, too.
Unger: Now, these seem like pretty significant shifts and undertakings for any organization, especially when they're happening all at the same time. I'm curious, why did you choose to take this kind of approach? And how is that kind of playing out at the organization?
Dr. Koh: Yeah, so health care and the way we deliver care cannot be static. And otherwise, if we're expecting different results, like the disparity in care gaps, we're never going to—we're never going to realize these. And so how we arrived at this was that, well, we asked our patients, and we asked our communities.
And through advisory—member advisory councils, our patients have actually told us what they wanted, what they needed. They—Black community members and community leaders have actually told us how, where and from whom they want to receive care. And so as a health care delivery organization, we need to be focusing on what our members want and what our members need and not what we want and what we need.
And so we do need to adjust our current practices and establish new ones. And this is also part of the equation of building trust in our members because, if we ask our members what they want and then we keep doing exactly the same thing that we're doing and we keep scratching our heads saying, why are their care gaps and disparities, then I think we're just living in a fantasy world that we're going to be making a change on this. And we have to be willing to train ourselves and be able to take care of our patients in this culturally responsive way that they are telling us how they want it.
Unger: Now, it's interesting. In my role as a chief experience officer, when I hear you talk about this, I call it very customer-centric, in your case, very patient-centric. Do you think that that's kind of a unique way of thinking in health care today? And why aren't more people doing it?
Dr. Koh: Well, I'll tell you that we have long talked about listening to our patients, and we have long talked about doing what's right for our patients. But putting it to practice requires a different type of thinking.
And it requires innovation. It requires courage to think differently in moving things forward. And I think you need to have right leadership in place. You need to have right alignment of goals and outcomes that we want to achieve. And therefore, coming together and wanting the outcomes to close those disparities of care gaps that we have for different populations is something that health systems have to have conversations, honest conversations, about and to see whether they're willing to change the paradigm of how they receive care.
It's much more comfortable to give care the way that you've always given care. So I think that it's an important aspect to make sure that your leadership is aligned together with your care delivery team.
Unger: Now, I guess very importantly, you make a lot of changes like this. Are you starting to see the impact on patients and their outcomes?
Dr. Koh: Absolutely. So one of the things that we have done, Todd, is, on top of opening these types of centers, we've actually really worked with screening out patients for social determinants of health. And we have universal screening in our organization.
And I'm really proud to say that I recently went to a video visit with my primary care doctor. And before my video visit, I was actually screened for my social determinants of health. If I was actually screened as positive, I would be contacted by a member of the team, and this is another innovation that we've done, where we've developed high-functioning community health workers to take care of high-intensity needs that I may have.
And we basically hook folks up with community resources that are needed. And these community health workers basically interview patients, understand their strengths, goals, unmet social needs. And then basically they base it on the personal goals of the patients, and then they develop that tailored action plan.
And the results we're seeing with this intervention has been phenomenal. We've touched over 5,000 patients since we've launched this in 2020. And one of the things that we've seen is an actual decrease in hospital use in all populations that we've intervened in and even higher in communities of color by getting our members to care and the right care at the right time and how they want it as well, too.
And so one of the things we've seen here is triple-digit reduction in hospital days per 1,000 members, 171 days at six months. But what's even more impressive, Todd, is that, after nine months and 12 months, we've been able to maintain the triple-digit reduction in hospital days. That is at 124 days and 109 days, respectively. And you can see how that in of itself is keeping folks out of the hospital, in their homes, where they can thrive better and have a better experience from that. So we are seeing some tremendous benefit here and some tremendous outcomes that we're very proud of.
Unger: Well, two things I love about what you just said. Number one, it just illustrates how nimble operationally you need to be to be able to put some of these new procedures into action. And then second, of course, is those results are—they're incredible. Did you think that that was going to be that big a change?
Dr. Koh: Well, we studied this, and this is one of those things when you bring initiatives into this is we don't go blindly into these initiatives with, really, just theories. We study what's in the literature out there, and there have been studies that actually show, when we have community health navigators and workers, that these types of things, when implemented at the right fidelity and with the right training, we can impact this.
And so we look very carefully at the evidence out there. We look at the—we do our due diligence and look at randomized controlled trials and whatnot. And we've been able to replicate some of the—some of these outcomes out there.
The unfortunate thing is that I just wish that there were more of this, these types of programs out there. And I think that the nation is starting to see this. But I think it's going to take some time for us to fully realize this because, again, it's different and a paradigm shift.
So were we expecting to see this much a difference? I would say yes because I think that we're very careful on how we implement things, and we want to do things right.
Unger: To your point about wanting to see this kind of approach more widespread, how would you advise other folks out there at different health systems about either challenges or opportunities based on what you've learned?
Dr. Koh: Yeah, I'd say that, first of all, you got to know your data. You got to take a look at it and have honest conversations with what you see there in terms of health equity. And many times, when you look at your data, you'll see a lot of process measures or like quality screening measures. And we just mentioned blood pressure, for example.
But you also have to look at the experience. And Todd, I know that you'll identify with this as the chief experience officer here, that care experience, I believe, is equally, if not as, important as those quality measures. How we actually care for our patients and how they experience the care is what embodies that trust between that care team and health care clinician and the patients.
And we all know that when that experience is optimal, you're going to build that trust, which then they're going to do what we would love them to do—adhere to the medications. Go do those preventative screenings. Take care of themselves, and care for themselves and their families. And so you got to have a honest conversation with your data.
And then the second portion of that is, are you willing to make changes based, again, on what your patients tell you and how they want their care, where they want their care, who do they want to get—who do they want their care given by. Those are the things that you got to keep your ears open. And then finally, your willingness to do tests of change and implement those.
Unger: Well, this has just been such a great conversation and so inspiring. Dr. Koh, thank you so much for joining us. The work that you're doing is so important, and it's just a great example of how to really deliver culturally competent care out there in the real world.
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That wraps up today's episode, and we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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