Q: My agency is accepting more referrals for immigrants and patients who do not speak English. I know that I should provide "culturally competent care," but exactly how do I do this?

You have already taken the first step to being a culturally competent home healthcare clinician by recognizing that you need to adapt care to meet the needs of your culturally diverse patients. Research indicates that racially/ethnically diverse patients are at risk for health disparities (Agency for Healthcare Research and Quality, 2015). A recent systematic review of the home healthcare literature found that racially/ethnically diverse home care patients have poorer clinical, functional, and patient satisfaction outcomes compared with White home care patients (Narayan & Scafide, 2017). Culturally competent care is basically "patient-centered care" (meeting patient needs and preferences as defined by the patient) for culturally/linguistically diverse patients.

One of the challenges in providing care across cultures is that "good health" and "good care" are defined differently by different cultural groups. Etiquette norms (the way we show respect for one another) and ethical norms (the way we do the "right" thing) vary across cultures. The kinds of foods one eats and the kinds of treatments one believes promote health also vary by culture. Although it is impossible to be an expert in the norms of all cultures, you can learn about the beliefs, values, and practices of the patient populations you most frequently encounter through Internet resources and other sources of knowledge, including cultural community leaders. However, relying solely on cultural knowledge, without asking patients about their preferences, can lead to stereotyping, imposing on patients' beliefs, values, or practices they do not hold.

Here are some principles I keep in mind: 1) If the patient does not speak English well, work with a medical interpreter when performing comprehensive assessments or providing education. 2) Perform culturally sensitive assessments, identifying how the patient's culture affects their care preferences. Ask how their health problems affect them, what they think is wrong, and how the problem is most likely to be helped. What kind of diet would be helpful? What do they think of the medications/treatments the physician has recommended? 3) Adapt the care plan to the patient's cultural preferences identified during your assessment. I recommend an Encourage-Accommodate-Negotiate framework for developing the care plan. You will discover that many cultural norms, based on current evidence, are more health-promoting than many Western/American norms. You will also discover that many cultural norms are "neutral," neither helpful or harmful from a Western biomedical perspective. Accommodate them and include them in the care plan. When cultural norms are harmful (e.g., a high-fat, high-salt diet), negotiate with your patients to change behaviors, using health-coaching techniques.

One last recommendation. Encourage your agency to support your efforts at providing culturally competent care by implementing the National Standards for Culturally and Linguistically Appropriate Services in Health Care (Office of Minority Health, Department of Health and Human Services, 2013). Strategies for implementing these standards specifically within home care agencies are available in the home healthcare literature (Narayan, 2016, 2017).

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