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Reducing Health Disparities Through HRSA Center of Excellence

Last month we joyfully celebrated the award of a Health Resources and Services Administration (HRSA) Hispanic Center of Excellence (COE) Grant to the only school of medicine that is immediately adjacent to the US-Mexico border, the Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. During the celebration, I noticed that a significant number of allied health, nursing and physician colleagues asked: "What is a COE and what does it mean to us”? "What is the impact of a COE on professional healthcare educators and healthcare in the US”? These questions prompted me to analyze the HRSA COE’s in relation to healthcare education and the potential impact of COE’s on healthcare in the US.

The HRSA COE’s Program provides financial support for designated health professions schools under Section 736 of the Public Health Service Act to schools that meet the required general conditions to include: 1) certain Historically Black Colleges and Universities, 2) Hispanic individuals, 3) Native American individuals, and 4) enrollment of underrepresented minorities above the national average for such enrollments of health professions schools. The financial support must be used to: 1) to establish, strengthen, or expand programs to enhance the academic performance of the underrepresented minority students attending the school; 2) to improve the capacity of such schools to train, recruit, and retain underrepresented minority faculty including the payment of stipends and fellowships; 3) to carry out activities to improve the information resources, clinical education, curricula, and cultural competence of the graduates of the schools as it relates to minority health issues; 4) to facilitate faculty and student research on health issues, particularly affecting underrepresented minority groups; 5) to carry out a program to train students of the school in providing health services to a significant number of underrepresented minority individuals through training provided to such students at community based health facilities that provide such health services and are located at a site remote from the main site of the teaching facilities of the school; (6) to provide student stipends; and 7) to develop a large competitive applicant pool through linkages with institutions of higher education, local school districts, and other community based entities and establish an educational pipeline for health professions. These activities of COE’s have a tremendous potential to impact the persisting racial and ethnic disparities in healthcare that are increasingly being documented.

There is increasing evidence that, after taking access to care and other socioeconomic conditions into consideration, race and ethnicity remain significant predictors of the quality of healthcare received. This mounting evidence appears in the many critiques of the Nation’s healthcare delivery system to include the following: 1) In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce (2004), 2) Crossing the Quality Chasm: A New Health System for the 21st Century (2001), and 3)Missing Persons: Minorities in the Health Professions, A Report of the Sullivan Commission on Diversity in the Healthcare Workforce (2004). The most compelling evidence is summarized by the Institute of Medicine in its 2003 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The IOM summary includes the following critical findings:

  1. Racial and ethnic disparities in healthcare occur within the context of broader historic and contemporary social and economic inequality in many sectors of American life.
  2. Many factors, including health systems and healthcare providers may contribute to racial and ethnic disparities in healthcare.
  3. Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.

One of the primary recommendations that the IOM makes in relation to these findings is the use of cross-cultural education of healthcare providers to reduce racial and ethnic disparities in healthcare. This is supported by a significant body of literature defines and supports the importance of cross-cultural education for healthcare professionals. The HRSA COE’s have historically supported this vitally-needed cross-cultural education for healthcare educators and professions.

In 1991, HRSA instituted the COE Program. The COE Program was designed to support programs of excellence in health professional education for underrepresented minorities (URM) in professional schools of medicine, dentistry, pharmacy, and mental health. The COE Program was among the earliest federal grantee projects that required recipients to address the cultural and linguistic competency training of individuals in their respective schools. The COE Program was established to be a catalyst for institutionalizing a commitment to URMs and to serve as a national resource and educational center for diversity and minority health issues.

The goals of the initial COE Program include the following:

  1. Demonstrate institutional commitment to URM populations with a focus on minority health issues and eliminating health disparities.
    2. Develop and test innovative methods to strengthen or expand educational programs to enhance academic performance of URM students.
  2. Increase the presence of culturally competent health professions educators, students, and graduates.
  3. Promote the development and implementation of models of URM faculty development and retention, multicultural curricula, and faculty and student research in relation to minority health issues.

When the first COE’s opened, the directors and staff of the centers immediately understood the tremendous challenge of the cultural and linguistic competence mandate. Among the COE’s there was a paucity of underrepresented minority faculty recruitment and development programs and a limited number of recognized programs related to cultural and linguistic competency knowledge, skills, and expertise. As a result, the faculty and administration of the COE’s have taken modest incremental steps over the past fourteen years to develop and teach cultural and linguistic competency.

The majority of COE’s began offering elective courses to those students who had an interest in this area. COE Programs were attempting to do little more than "preach to the choir”. However, over the past decades, as educational healthcare institutions began to understand the COE initiative and purpose, COE’s became better positioned within their organizations. This improved positioning enabled the faculty of some COE’s to implement cultural and linguistic competency programs and activities that positively affected individual students and, in some cases, faculty.

Today, healthcare professionals and educators in COE’s understand that developing a COE requires making a strong commitment to addressing health disparities in a way that many institutions have not yet fully embraced. Professionals and educators must be willing to break down the barriers that exist in institutions, groups, and among individuals, and they must recognize the opportunities that exist in accepting cultural and linguistic competency as a critical component of quality care. Additionally, they must also accept the challenge of promoting their cultural and linguistic competency efforts so that they can help others learn the lessons they have learned in the process of developing such competency. Some of these lessons can be gleaned from the annual HRSA COE Uniform Progress Reports, which COE’s grantees complete annually.

The 2001-2002 Uniform Progress Report included 29 COE’s: ten were Hispanic/Latino Centers of Excellence, three were African American, four were American Indian, one was Native Hawaiian, and eleven were "Other”. Some of the most salient lessons that all disciplines can learn from the 2001-2002 Uniform Progress Report include the following:

  1. All educational offerings devoted to cultural and linguistic competency should be a broad and inclusive definition of cultural and population diversity, including considerations of race, ethnicity, class, age, gender, sexual orientation, gender identity, disability, language, religion, and other indices of difference.
  2. Training efforts should be incremental. Institutions may start simply by including cultural and linguistic competency training as a specific area of study, but should advance to complex, integrated, and in-depth attention to cultural issues in later stages of professional education.
  3. Trainees should be expected to become progressively more sophisticated in understanding the complexities of diversity and culture as they relate to the care of patients and to the delivery of healthcare services.
  4. Cultural and linguistic competence training is best integrated into numerous courses, experiential, clinical, evaluation and practicum activities as they occur throughout an educational curriculum.
  5. Cross-cultural training is best achieved within an interdisciplinary framework that draws upon a variety of skills and knowledge in the field, such as medical anthropology, medical sociology, epidemiology, pharmacology, and human genetics.
  6. Both instructional programs and student learning should be regularly evaluated in order to provide feedback to the ongoing development of educational programs. Students should be involved in their own evaluation as well as the evaluation of the curricula.

These are valuable lessons for all healthcare educators and providers. An analysis of the history and progress of HRSA COE’s overwhelmingly revealed that COE’s have evolved into pace-setting entities that provide an opportunity for the development and implementation of cross-cultural education in a safe, non-judgmental, supportive environment. This HRSA COE-rooted cross-cultural education has great potential to reduce ethnic and cultural disparities in healthcare in the US.

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