Striving for Cultural Competence in an HIV Program: The Transformative Impact of a Microsystem in a Larger Health Network

With increasing U.S. population diversity, it is paramount for health care professionals to provide high-quality medical services that are not only accessible, but also culturally appropriate for their patients. Social workers can be at the forefront of the process of developing and implementing practice-based, patient-centered approaches that are both medically sound and culturally sensitive. An example of such an approach is described in this case study, which examines how an HIV/AIDS hospital-based outpatient program, the AIDS Activities Office (AAO) of Lehigh Valley Health Network (LVHN), designed and implemented programming to ensure the provision of culturally and linguistically appropriate care for its Latino patients in Allentown, Pennsylvania. MICROSYSTEM APPROACH The focus on the clinical microsystem in this case study illustrates how clinicians and social workers can respond to the increasing diversity of their service areas by developing unit-based innovations that, in time, will diffuse to the larger, surrounding health care system. Using a holistic perspective, social workers interact with the multiple dimensions of individuals, including their ethnic, cultural, religious, and gendered traditions and preferences. Nelson et al. (2002) used the example of clinical microsystems to describe the diffusion of systemwide patient-centered quality care from a small functional unit to the larger hospital. Clinical microsystems can be defined as "the small, functional, front-fine units that provide most health care to most people" (Nelson et al., 2002, p. 473). Therefore, any program or process could be considered a microsystem based on how it fits within these concepts of the patient experience at the micro level. This concept is helpful in understanding development of the AAO cultural competency program at the microsystem level, as the program provides a framework that was modeled at an organizational level. SERVICE POPULATION Latinos are the largest and fastest growing ethnic minority group in the United States, constituting 15 percent of the total U.S. population (Bernstein, 2008). The Latino population in Allentown, Pennsylvania, has more than tripled since 1990, and accounted for 34 percent of the city's population in 2006 (U.S. Census Bureau, 2006) (see Table 1). Furthermore, among the more than 25 percent of Allentown residents age 5 and over who speak a language other than English at home in 2000, the majority (70 percent) reported that language as Spanish (U.S. Census Bureau, 2000). Latinos are disproportionately affected by the HIV/AIDS epidemic. In 2006, Latinos accounted for 19 percent of people living with AIDS in the United States and the District of Columbia, even though they represented 15 percent of the U.S. population (Centers for Disease Control and Prevention, 2008). In the six-county region of mideastern Pennsylvania in 2006, the proportion of Latinos riving with AIDS was 5.4 times greater than their overall representation in the regional population (AIDSNET, 2007). AAO CULTURAL COMPETENCY PROGRAM Established in 1989, the AAO initially provided social case management to facilitate end-of-life support for the community's almost 100 HIV-infected patients. Over the next two decades, in response to changing patient needs, the office became the region's largest HIV service provider (with more than 500 patients), offering longitudinal primary care, social case management, mental health counseling, nutrition services, patient education, adherence support, prevention services, on-site clinical trials, and HIV counseling and testing. In response to the region's growing Latino population, the AAO strengthened its capacity to deliver linguistically and culturally sensitive care to this client group. Relationship Building To ensure awareness of and access to its services, the AAO formalized relationships with community-based organizations, local leaders, and other care providers who serve members of the Latino population in Allentown. …