883818

research-article2019
HHCXXX10.1177/1084822319883818Home Health Care Management & PracticeNarayan

Original Article

Home Health Care Management & Practice

Cultural Competence in Home

2020, Vol. 32(2) 76­–80
© The Author(s) 2019
Article reuse guidelines:
Healthcare Nursing: Disparity, sagepub.com/journals-permissions
DOI: 10.1177/1084822319883818
https://doi.org/10.1177/1084822319883818

Cost, Regulatory, Accreditation, journals.sagepub.com/home/hhc

Ethical, and Practice Issues

Mary Curry Narayan, MSN, RN, HHCNS-BC, CTN-A1

Abstract
Home healthcare patients, who are members of minority, marginalized, or vulnerable patient populations, are at risk for
healthcare disparities. Inadequate attention to the needs of the many different types of diverse patient populations seen by
home health agencies could compromise an agency’s outcome indicators, reimbursement in value-based payment programs
and responsibility to deliver equitable quality care. Culturally competent home health nurses may have a role in decreasing
disparities and improving patient outcomes. This article discusses the incidence of disparities in home health care and
highlights literature about the economic, regulatory, accrediting, policy, social justice, and ethical issues surrounding disparate
and inequitable care for home healthcare patients. Patients in need of culturally competent care include those characterized
by diversity related to race, ethnicity, language, religion, socioeconomic status, sexual orientation, gender identification,
mental and physical disabilities, and stigmatized diagnoses (e.g., obesity and substance abuse). Home healthcare nurses who
strengthen the cultural competence of their care may be able to decrease the incidence of disparate outcomes. By investing
in the cultural competence of their home healthcare nurses, agencies may strengthen their commitment to their missions
and the financial health of their agencies.

Keywords
cultural competence, culturally competent care, disparities, diversity, home health care, home health nurses, social justice,
value-based purchasing

Background Report.15 Using many types of health indicators in many

Healthcare disparities undermine the health and well-being
of individuals who are members of minority, marginalized,
stigmatized, and vulnerable populations. According to the
Institute of Medicine’s 2003 report, Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care—
“Racial and ethnic minorities tend to receive a lower quality
of healthcare than non-minorities . . .”1 Health disparities
refer to the substandard health outcomes that not only racial/
ethnic minority groups experience but also the inequities that
other minority groups experience when compared to
America’s “normative” populations.
Disparities are associated with differences in language,1
religion,2,3 socioeconomic status,4,5 age,6 gender,7 sexual ori-
entation/gender identification,8,9 mental and physical dis-
abilities,10,11 stigmatized diagnoses (e.g., HIV, obesity,
mental illness, and substance abuse),12-14 and other ways in
which patients differ from societal norms. Each year, the
Agency for Healthcare Research and Quality (AHRQ) com-
piles the National Healthcare Quality and Disparities
types of settings; the AHRQ reports repeatedly show that dis-
parities persist among different types of minority groups.
These disparities are associated with increased morbidity/
mortality and adverse events and in decreased patient satis-
faction with care. From a social justice perspective, these
disparities are unacceptable. From an economic perspective,
disparities cost the American health system millions of dol-
lars in excessive morbidity and substandard outcomes.16
This article discusses the incidence of disparities in home
health care and why home health nurses need to help prevent
these disparities. It highlights literature about the economic,
regulatory, accrediting, policy, social justice, ethical, and
practice issues surrounding disparate and inequitable care for
home healthcare patients.
1George Mason University, Fairfax, VA, USA
Corresponding Author:
Mary Curry Narayan, School of Nursing, George Mason University, 4400
University Avenue, MS: 3C4, Fairfax, VA 22030, USA.
Emails: mnarayan@gmu.edu; marycnarayan@gmail.com
Narayan 77
Home Healthcare Disparities
Disparities occur in home health care. For instance, Narayan
and Scafide17 performed a systemic review of home health-
care outcomes for the federally defined race/ethnicity groups,
published between 2003 and 2015. Although they only found
seven studies that met their criteria, all seven studies found
that racial/ethnic minority patients suffered disparate out-
comes in comparison to their non-Hispanic White counter-
parts. Brega and colleagues18 found that minority groups had
significantly inferior functional outcomes compared to non-
Hispanic White patients. In a secondary analysis of Outcomes
and Assessment Information Set (OASIS) data, Davitt19 found
that minority patients’ functional outcomes deteriorated in
home health care. Madigan,20 Ryvicker et al,21 and Fortinsky
et al22 found that non-White patients were more likely to
experience adverse events, such as hospitalization or emer-
gency department visits. The AHRQ 2014 National
Healthcare Disparities Report included home healthcare
outcome measures from the OASIS data set, which found
disparities in the ability to ambulate, the ability to manage
medications and in improvement of dyspnea, especially sig-
nificant among Black and Hispanic patients.23 Smith et al24
performed a secondary data analysis of the Home Health
Consumer Assessment of Healthcare Providers and Systems
(HH-CAHPS) finding that minority patients are less satisfied
with their home health care than non-Hispanic Whites.
Since the Narayan and Scafide systematic review, Chase
et al25 performed a study, using OASIS data, to determine if
there were disparities in patients’ ability to perform activities
of daily living at discharge from home care. They found that
Asian, African American, and Hispanic patients experienced
significantly less improvement compared with non-Hispanic
Whites. In another study, Chase et al26 discovered that
African American and Hispanic patients were more likely
than White patients to need hospitalization and emergency
department visits during their stay in home care. Using
Medicare claims data, Joynt Maddox and colleagues16 found
that Black home healthcare patients and patients living in
low socioeconomic neighborhoods had higher rates of
adverse clinical outcomes. They also pointed out that organi-
zations that do not address these disparities in the patient
populations they serve are likely to be at risk in a value-based
reimbursement system.
Cost of Disparities
Although no studies could be found about the cost of dispari-
ties in home health care, LaVeist and colleagues27 used
Medicare data from 2003 to 2006 to determine that ethnic/
racial disparities alone cost the United States $230 billion in
direct medical costs, and 1 trillion in indirect costs, related to
premature death and lost productivity, during that time
period. They also estimated that 30.6% of direct medical
costs for the care of Asian, Hispanic, and African Americans
were excess costs related to health inequities. An article in
the Harvard Business Review reported that racial health dis-
parities cost $35 billion in excess healthcare costs per year.
These costs to the American healthcare system suggest that
home health agencies also suffer negative economic conse-
quences when their clinicians do not provide equitable qual-
ity care.
Regulatory, Accrediting, and Ethical
Implications of Healthcare Disparities
All healthcare providers—including home health nurses—
have a legal and ethical obligation to alleviate patient dis-
parities.28,29 Healthcare disparities are not acceptable because
they deprive patients of health and well-being and because
healthcare disparities can be an indicator of discriminatory
practices, even though unintended. Multiple federal laws
make discrimination, even unintentional discrimination, ille-
gal. For instance, the 1946 Hill-Burton Act,30 1964 Civil
Rights Act,31 1990 Americans with Disabilities Act,32 1996
Health Insurance Portability and Accountability Act,33 and
the 2010 Patient Protection and Affordable Care Act34 all
contain provisions that make discriminatory healthcare prac-
tices illegal.
Standards of care addressing the cultural needs and pref-
erences of minority and vulnerable patient populations have
been articulated by regulatory, accrediting, and quality of
care organizations. The U.S. Department of Health and
Human Services’ Office of Minority Health has issued the
2013 National Standards for Culturally and Linguistically
Appropriate Services in Health and Health Care.29 The Joint
Commission,35,36 the Community Health Accreditation
Program,37 and the Institute of Healthcare Improvement38,39
urge health providers to evaluate and address disparities,
including in their own personal practices. Healthy People
2030 envisions America as “a society in which all people can
achieve their full potential for health and well-being” and
specifically states that one of their top five goals for the next
10 years is to “Eliminate health disparities and achieve health
equity . . . to improve the health and well-being of all.”40
Nursing standards also require respect for the cultural
needs and preferences of minority and vulnerable patient
populations. The Code of Ethics for Nurses28 specifically
addresses nurses’ ethical responsibility to patients who are
members of culturally diverse minority and vulnerable
groups. Provision 1 requires nurses to treat all patients with
compassion, respecting them as individuals with a need for
equitable care. Provision 3 emphasizes nurses’ obligation to
uphold patients’ rights including the right to health and health
care, and Provision 8 states that nurses have an obligation to
reduce health disparities. In the Scope and Standards of
Nursing, 3rd edition,41 the eighth standard is “The registered
nurse practices in a manner that is congruent with cultural
diversity and inclusion principles.” In addition, the Scope
78 Home Health Care Management & Practice 32(2)
and Standards of Home Health Nursing Practice42 specifi-
cally identify culture-sensitive assessments and care plan-
ning as essential home health nursing competencies.
Practice Issues
Healthcare providers, including home health nurses, despite
being committed to equitable care for all, may be contribut-
ing to these disparities. According to the 2003 Institute of
Medicine report,1 disparities can be traced to three main fac-
tors: (1) systemic/environmental factors, such as those
related to the social determinants of health, including educa-
tional/economic opportunities and access to affordable health
care;43 (2) patient factors, such as cultural norms, health lit-
eracy, and differences in health-illness paradigms44; and (3)
provider/clinician factors.
Provider/clinician factors could contribute to health dis-
parities in multiple ways. For instance, various researchers,
policy makers, and thought leaders have discovered or sug-
gested factors that could be associated with clinician contri-
bution to patient disparities, including (1) prejudice and
discrimination,45 (2) implicit (unconscious) bias resulting in
unintentional discriminatory practices,46-48 (3) a lack of
awareness or knowledge about how to address the needs and
preferences of individuals within certain cultural groups,49 (4)
a lack of commitment to culturally competent care,50 (5) a
lack of commitment to patient-centered care,51,52 and (6) a
lack of skill at assessing patients in culture-sensitive/patient-
centered ways so culturally congruent care plans can be
developed.50,53-55 If and how these factors influence the care
home health nurses provide to culturally diverse minority and
vulnerable patients is currently unknown.
Among the ways these provider/clinician factors could
compromise home health nurses’ ability to promote cultur-
ally competent care is nursing programs that rely on cultural
encounters to teach cultural competence, which is only the
first step in developing cultural competence skills. Even
when home health nurses develop these skills, they may
encounter barriers to practicing culturally competent care
when agencies are understaffed, and high caseloads preclude
practicing many of the patient-centered elements of cultur-
ally competent care. Nurses complain of a lack of resources—
interpretation/translation services, inservices and resources
focused on the needs of the culturally diverse populations
they serve, and knowledgeable support from supervisors—
which leaves them feeling they are unable to meet the needs
of their culturally diverse patients.56
Cultural Competence of Home Health
Nurses
Cultural competence is widely accepted as the standard of
care for meeting the needs of diverse and vulnerable patient
populations. But to what degree do home health nurses
incorporate the principles of culturally competent care into
their practice and to what degree are home health agencies
providing support and resources to facilitate this practice?
Although there are a handful of studies and expert opinions
that attempt to answer pieces of these questions,56-58 the cur-
rent state of knowledge about how cultural competence is
incorporated into home health nursing is unknown. Research
is currently being conducted to answer these questions. In
the meantime, nurses can enhance their cultural competence
by mitigating their implicit biases,47 practicing mindfulness
during patient encounters59,60 developing therapeutic rela-
tionships with their patients61,62 and by incorporating prin-
ciples of patient-centered care63,64 and culturally competent
care into their practice. 53,54,65-68 Home health agencies can
use the National Standards for Culturally and Linguistically
Appropriate Services in Health and Healthcare to guide
their efforts to enhance quality equitable care and to decrease
disparities.29,69
Conclusion
By incorporating cultural competence principles into their
practice, home health nurses may be able to provide more
effective care for culturally diverse patient populations. For
instance, if nurses assess patients for the factors that put their
patients at risk for disparities, they may be able to plan inter-
ventions that mitigate the risk that these factors potentiate.
Providing nurses with additional knowledge about how to
incorporate cultural competence care principles into their
practice could help home health nurses provide higher qual-
ity equitable care. By investing in cultural competence edu-
cation and resources, home health agencies who support the
cultural competence of the nurses they employ, may prevent
disparities and achieve a good return on their investment in a
value-based payment model.
Acknowledgments
The author thanks Dr. R. Kevin Mallinson, PhD, RN for his guid-
ance with her dissertation out of which this paper grew.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Mary Curry Narayan https://orcid.org/0000-0003-1348-3905
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