Caseworker Cultural Mediator Involvement in Neurocritical Care for Patients and Families With Non-English Language Preference: A Quality Improvement Project

Objective To describe Harborview Medical Center's experience with the involvement of caseworker cultural mediators (CCM) for patients requiring neurocritical care. Methods Using univariate and multivariate analysis (model adjusted for age, Glasgow Coma Scale score (GCS), Sequential Organ Failure Assessment (SOFA) Scores, mechanical ventilation, transition to comfort measures only (CMO), and death by neurologic criteria), we examined CCM team members' involvement in the care of Amharic/Cambodian/Khmer/Somali/Spanish/Vietnamese patients admitted to our neurocritical care service between 2014-2022, factors associated with CCM utilization, and changes in CCM utilization after a QI initiative was implemented in 2020 to encourage healthcare providers to consult the CCM team. Results Compared to eligible patients (n=827) who did not receive CCM referral, patients with CCM involvement (n=121) were younger (49 [interquartile range, IQR 38,63] vs. 56 [IQR 42,68] years, p = 0.002), had greater illness severity (admission GCS 8.5 [IQR 3,14] vs. 14 [IQR 7,15], p < 0.001, SOFA scores (5 [IQR 2,8] vs. 4 [IQR2,6], p = 0.007), and more frequently required mechanical ventilation (67% vs. 40%, odds ratio, OR 3.07, 95% CI 2.06,4.64), with higher all-cause mortality (20% vs. 12%, RR 1.83, 95% CI 1.09, 2.95), and with a higher rate of transition to CMO (11.6% vs. 6.2%, OR 2.00, 95% CI 1.03;3.66). The CCM QI initiative was independently associated with increased CCM involvement (aOR 4.22, 95% CI [2.32;7.66]). Overall, 4/10 attempts made by CCMs to reach out to the family to provide support were declined by the family. CCMs reported providing cultural/emotional support (n=96, 79%), end-of-life counseling (n=16, 13%), conflict mediation (n=15, 12.4%), and facilitating goals of care meetings (n=4, 3.3%). Conclusions Among eligible patients, CCM consultations appeared to occur in patients with higher disease severity. Our QI initiative increased CCM involvement.


Introduction
Patient-centered care (PCC) is essential to improving patient experiences and care quality, as it considers individual patient preferences, needs, and values. Cultural differences and language barriers in acutely hospitalized patients can result in multiple challenges in patient care and communication, rendering patients and their families more vulnerable at a critical time. Medical interpretation alone may not always sufficiently address the complex needs of members of immigrant communities [1]. Increasing evidence suggests that our effectiveness as physicians is related to our ability to understand and connect with our patients, including their language and cultural and religious aspects [2].
At our institution, culturally competent care of our increasingly diverse patient population, responsiveness to patients' value-based needs, and a patient-centered approach to care are crucial aspects of high-quality care. The primary mission of Harborview Medical Center is to provide healthcare for the most vulnerable residents of King County, including immigrant communities and populations with Non-English language preference (NELP) [3]. Our institution utilizes a Caseworker Cultural Mediator (CCM) program to bridge care and communication gaps for these populations [4]. This CCM service serves NELP populations in five languages (Amharic, Cambodian/Khmer, Somali, Spanish, and Vietnamese: i.e., CCM consultation eligible patients).
In addition to medical interpretation, CCM provides patient, healthcare provider, and community support. CCM contributes to the well-being and support of immigrant and refugee patients, families, and communities through a partnership that promotes culturally sensitive care by 1) providing interpretation services, 2) forming and maintaining partnerships with patients and their families, and facilitating their interactions with hospital staff, 3) providing information about cultural norms [5] and perceptions around health, illness, and community resources to healthcare providers, 4) advocating for patients and their families and their needs in the healthcare setting, and 5) community outreach to provide healthcare-related education. CCM services have important goals: a) supporting patients and their families during their hospitalization, b) facilitating therapeutic relationships and trust between patients, families, and the healthcare team [6]. Their involvement may benefit patients and the healthcare system and may be helpful to hospitals that care for socially and culturally diverse populations [7]. While there is data on the successes of cultural case workers in community outreach programs, specifically in increasing prenatal visits and reduction in HbAIc levels due to educational visits by bicultural/bilingual community health workers [8], there are no studies examining the involvement of CCMs in neurocritical care (NCC).
When faced with acute neurological emergencies and life-or-death decisions facing prognostic uncertainty, it is critical to consider cultural norms and perceptions while communicating with patients and families [9]. Based on two index cases involving NELP patients' families and surrogate decision-makers experiencing conflict, leading to emotional distress for both the families and neurocritical care providers, a 3-phase quality improvement (QI) project was implemented in 2020 to 1) identify deficiencies and inconsistencies in end-of-life care and then to 2) develop and implement a consensus-based initiative to incorporate CCM involvement on our neurocritical care service. This article describes our experience developing and implementing the initiative to provide culturally sensitive care and examines the effect of a QI process on CCM involvement. We also aimed to characterize practice patterns and the impact of CCM consultation by assessing characteristics associated with CCM involvement and the impact of CCM involvement.

Institutional review board
This study (STUDY00009382) was approved on March 1, 2022, by the Institutional Review Board of the University of Washington, and a waiver of consent was in place for a retrospective analysis of data gathered between 1/1/2014 and 1/31/2021.

Study design and patient selection
We assessed the involvement of CCM in primarily Amharic/Cambodian/Khmer/Somali/Spanish/Vietnamesespeaking adult patients at a 413-bed, level-I trauma and designated Comprehensive Stroke Center with a 30bed dedicated neurocritical care service. Patients were included and deemed "CCM eligible" if they or their families were identified as members of the respective community. We launched a quality improvement project in January 2019 to raise awareness and encourage healthcare providers to consider CCM referrals. The period of 1/1/2014 to 1/31/2018 was considered the pre-CCM project implementation period, and that between 1/1/2019 to 1/31/2021 was considered the post-CCM project implementation period. At our institution, CCM involvement can occur via 1) a request made by the healthcare team or 2) self-referral from the CCM team member after identifying the patient's preferred language in the electronic medical records (EMR). For this study, we retrospectively identified all potentially eligible patients by electronic chart review and compared clinical characteristics and outcomes between eligible patients who received CCM consultation and those who did not. We also compared CCM referral patterns before and after implementing our QI project.

Outcomes of interest
The primary outcomes were 1) rates of CCM involvement before and after the implementation of the QI project, 2) Differences and outcomes between CCM-eligible patients who received CCM consultation versus those who didn't, 3) Qualitative analysis of the CCM role, concerns shared by patients/families and support offered by the CCM team, which was gathered from CCM progress notes entered in the EMR and direct feedback from the CCM team.

The structure and function of the CCM team
The CCM team comprises hospital employees representing five communities of NELP patients and families: Amharic, Cambodian/Khmer, Somali, Spanish, and Vietnamese. Each representative is proficient in the language, has been born in the respective country, and shares the same cultural background. All CCMs receive advanced training in medical interpretation, cultural mediation, and case management, understand the role of the community advisor as a resource person, understand the resources and roles of the health and social institutions in the local area, interact with health care professionals, and reviewing cases with medical staff [10].
The CCM team is typically available for consultation with medical teams between Monday and Friday during the daytime. While not routinely available on the weekend, exceptions are made for complex cases, and the critical care team may contact the CCM team. As part of the internal CCM self-referral process, the CCM team reviews the list of all hospitalized patients daily to identify patients/families/surrogate decisionmakers they may be able to support.
Following consultation or self-referral, the CCM approaches the patient/families/surrogate decision-maker, provides education regarding the role of the CCM team, and offers involvement of the CCM team. CCMs are responsible for documenting patient encounters in the EMR. Once a referral is received, and the family has agreed to CCM involvement, the CCM will meet with the care team and delineate an individualized plan regarding communication and multidisciplinary family meetings. During these meetings, families receive educational material related to critical illnesses or death by neurological criteria (DNC).
Communication with the care team is essential to CCM workflow. CCM add themselves to the patient's care team list in the EMR and document family meetings and phone calls with patients/families. This establishes continuity of care and informs other healthcare team members about their involvement. The workflow of the CCM encompasses the following standards of practice: Navigation, Case Management, Mediation/Advocacy, Education, and Interpretation. CCM seeks out resources in the patient's community that provide cultural, religious, and social support and often partners with religious leaders. In addition to direct patient contact, CCM interacts with outside hospitals, schools, and social organizations and organizes health fairs in their communities. Thus, the CCMs offer a wrap-around service by connecting patients and families to internal and external resources.  Phase 0 consisted of a review of two index cases involving two patients belonging to NELP and CCM-eligible communities who were declared DNC, resulting in contentious discussions with the care team after the family had a difficult time coming to terms with the medical diagnosis. The CCM was involved late in the process after communication breakdowns had occurred and provided remediation support to healthcare providers and families. This was the first time our neurocritical care team recognized the importance of the CCM team's expertise in supporting NELP patients and mediating conflict.

Outline of the QI project
Phase I consisted of several rounds of discussions between the neurocritical care team and members of the CCM team to delineate synergistic interactions between the CCM and the healthcare team. Initially, the author AVL met with the CCM team to obtain input regarding the perceptions of CCM-eligible patients towards end-of-life care and DNC. Several themes emerged, such as insufficient time between admission and neurological prognostication, insufficient time for the family to process the loved one's condition, and perceived lack of accommodation by the neurocritical care service of the requests by families/surrogate decision-makers towards the continuation of care/somatic support. At the end of these discussions, a plan was made to invite CCM team members to a monthly multidisciplinary neurocritical care service meeting to enhance regular dialogue between the CCM and neurocritical care teams.
Phase II consisted of educational sessions with the CCM team. The neurocritical care service put together a proposal to incorporate the benefits of the CCM team in routine neurocritical care workflow. It was decided that prompt consultation with the CCM team would occur within 24 hours of the patient's admission to the neurocritical care service.
We created flyers that included the project proposal, contact information for the project leads from neurocritical care service and CCM teams, authors AVL and LAM, respectively, and held several educational sessions.
Simultaneously at this time, the hospital's DNC policy underwent a revision. Due to the two index cases, it was decided to include a multidisciplinary huddle before the initiation of DNC determination with the involvement of the CCM team before approaching families/surrogate decision-makers regarding DNC, as outlined in the World Brain Death Project [9].

Phase III
We collected data on the involvement of the CCM team, time from admission to the participation of the CCM team, as well as progress noted by CCM, neurocritical care service, nurses, and social workers.

Data Collection
Patient information and specific data were collected from the EMR and refined via a departmental database, Perioperative & Pain Initiatives in Quality Safety Outcome (PPIQSO). The data points collected were as follows: 1) Patient characteristics: age, sex, admitting diagnosis, race, ethnicity, preferred language, insurance carrier, admitting Glasgow Coma Scale score (GCS), the maximum (SOFA) scores, need and duration of mechanical ventilation, intensive care unit (ICU) and hospital length of stay (LOS), all-cause in-hospital mortality, transition to comfort measures only (CMO) and DNC.
2) Caseworker cultural mediator (CCM) services: We screened the EMR for the consultation notes by members of the CCM team. We noted the date and time the first note was written and calculated the time since admission to the consultation note (in days).
3) Authors AVL and AB met with members of the CCM team over a Zoom TM (San Jose, CA, USA) conference call to obtain insight from CCM team members about a priori selected topics: 1) common concerns voiced by the CCM-eligible patients/families/surrogate decision makers, 2) common requests made by CCM-eligible patients/families as relayed by CCM team members, 3) and discussed proposed solutions. 4) Author AB extracted clinical notes for all CCM and neurocritical care service encounters for the corresponding days from the study participants from the electronic medical record and saved them as Microsoft Word documents.

5)
We examined the notes for follow-up meetings with patients/families or a lack thereof.

Statistical Analysis
The descriptive analysis described the study cohort characteristics. Categorical variables were expressed as counts and percentages. The Shapiro-Wilk test was performed to examine the normality of distribution of continuous variables such as age, intensive care unit, and hospital length of stay expressed as mean+SD or median [interquartile range, IQR]. Differences between patient characteristics in the pre-and postimplementation periods were performed using a two-tailed t-test and Chi-square test and calculated odds ratios and 95% confidence interval (CI). We also compared the patients in whom CCM self-referral led to families declining their request to be involved in the patient's care. We used the Chi-square test to understand the temporal trends in CCM involvement between 2014 and 2021. In multivariate models, we examined characteristics of patients who received CCM among CCM-eligible cases, associations between CCM involvement and transition to CMO, and associations between CCM involvement and ICU LOS after adjusting for age, admission GCS, mechanical ventilation, and maximum SOFA scores. We reported the results as adjusted odds ratios (aOR) and corresponding 95% CIs. Multivariate models were tested for Hosmer-Lemeshow goodness-of-fit test. A Bonferroni-corrected p-value of < 0.05 was considered to be statistically significant. Qualitative analysis pertained to the common themes identified after discussion with CCM team members and after a review of clinical notes. We codified major and minor themes and presented them as counts and percentages. STATA version 15 (StataCorp LLC, College Station, TX, USA)/RStudio 1.554 (R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis [11,12].   Figure 2 represents a run chart of the trends in CCM involvement over the study period.

FIGURE 2: Trends in Caseworker Cultural Mediator Involvement in the Care of Patients Requiring Neurological/Neurosurgical Critical Care
The green line indicates the go-live for the CCM involvement project There was a statistically significant increase in CCM involvement from 2014-2021, a point estimate of 0.    Figure 3, Hosmer-Lemeshow goodness-of-fit test, p = 0.1178).

Cultural Mediator Involvement in Neurocritical Care
ICU: intensive care unit: SOFA: Sequential Organ Failure Assessment

Qualitative analysis of CCM involvement
As Figure 4 shows, there was a proactive approach by the CCM team to educate families about the role of CCM by self-referral (n=91, 75.2%). Only a minority of consultations originated from critical care physicians and nurses (n=28, 23.1%) and families (n=2, 1.65%).

FIGURE 4: Caseworker Cultural Mediator Involvement Referral Patterns in Patients Requiring Neurological/Neurosurgical Critical Care
CCMs reported providing cultural/emotional support (n=96, 79%), end-of-life counseling (n=16, 13%), provided conflict mediation (n=15, 12.4%), and facilitated goals of care meetings (n=4, 3.3%). Specifically, CCMs provided cultural and linguistic care mediation, facilitation of communication within the neurocritical care team and families, provision of resources for rehabilitation and long-term condition management, location of housing and long-term care facilities, providing letters of support for out-of-the-country family members wishing to travel to the United States, and advocating for patient and family wishes. CCMs also assisted with locating legal next of kin and in the determination of childcare for minors.

Eligible Patients/Family and Solutions Proposed by the Caseworker Cultural Mediator Consultation
We present themes and quotes from the CCM progress notes in Table 3, which highlight the common concerns and solutions provided by CCMs in the following areas: language barriers causing anxiety, inadequate housing, emotional distress due to patient's condition, demographic and personal specifics of the patient, cultural values, legal, financial, and next-of-kin mediation, medical procedures, resources for patient families, the impact of COVID-19 visitation rules, and services to assist with external concerns. Assistance with locating legal next of kin; provision of letters of support for Embassies in foreign countries "The family reported being surprised about the autopsy need because they were told he suffered a brain aneurysm and was confirmed brain dead," "they reported the organ procurement staff came and Explanation of care plan;

involvement of
Medical procedures asked about organ donation. At this time, they became mistrustful of the intent of the autopsy", "as a mother, she wanted to watch the autopsy to assure none of his organs were removed. She stated she felt that even though she had refused organ donation, she believed his organs would be taken during the autopsy", "I was able to clarify patient's brain death prognosis, as well as the nature of the neurological tests and ultrasound, performed today," "[patient's husband inquired] about the reason why the tumor was not removed completely," "we will discuss with providers the possible rearrangement of

Discussion
A single-center quality improvement (QI) project was undertaken to explore and increase the involvement of Caseworker Cultural Mediator (CCM) to provide culturally sensitive care for Non-English Language Preference (NELP) patients requiring neurocritical care, to bridge communication gaps and enhance the bond between NELP-patients, their families, and the medical team. Our main finding was that implementing the QI project was independently associated with increasing CCM involvement. Other results include 1) CCM involvement preferentially occurred in the NELP patients with higher illness severity, 2) CCMs were more likely to be involved with NELP patients undergoing a transition to CMO, and those with longer ICU LOS, however, when adjusted for illness severity, these associations became non-significant, 3) four out of ten attempts made by CCMs to reach out to the family to provide support were declined by the family, 4) CCMs reported providing cultural/emotional support, end-of-life counseling, conflict mediation, and facilitated goals of care meetings.
A multiphase QI project successfully increased the involvement of CCMs in the care of NELP patients. The individualized awareness of and attention to the needs of patients provided with the help of cultural mediators is integral to understanding the unique needs of our increasingly diverse populace. Patient differences in race/ethnicity can affect patient evaluations of care in many ways, potentially resulting in healthcare disparities. In a study comparing patient-centered care from the viewpoint of cancer patients of different ethnicities and races, unmet needs for time to make decisions and provider interaction between visits emerged among Blacks and Caucasian patients. At the same time, value for optimism was observed among Hispanic patients [13]. By creating awareness and bridging gaps in knowledge about the CCM team's role on the part of the healthcare team, we attempted to address the lack of guidelines and protocols regarding CCM consultation triggers and successfully reduced the potential for missed opportunities. However, more work needs to be done in this area. Given the low rate of CCM involvement and a sizeable NELP population that can potentially benefit, we suggest solutions to increase consistency and sustainability in the participation of the CCM team. These solutions are aimed at overcoming communication barriers and bridging cultural gaps. This could be achieved by monthly educational opportunities for neurocritical care healthcare providers, including mandatory virtual/on-demand training, setting up institutional guidelines, and a consultancy request through the EMR, which was not present at the time of the study. Finally, adequate hospital resources should be reserved for the growth and sustenance of the CCM team and for exploring ways to expand services to other NELP communities beyond those currently supported.
Our study finds that CCM involvement was utilized for the sickest NELP patients and end-of-life support, including transitions to CMO and patients with longer ICU LOS. Since prognostication after neurological and neurosurgical emergencies often involves complex and time-sensitive conversations with the patients/families/surrogate decision makers, the CCM team may be seen as a "last resort" or after a communication breakdown with patient/patient families instead of employing a proactive approach to address and overcome language, cultural and religious barriers. This argument is highlighted by the two index cases where the CCM team had to resort to remediation regarding complex medical decision-making.
Our study indicated that CCM involvement was not associated with an increased likelihood of CMO transitions and non-CMO in-hospital mortality when adjusted for illness severity. The project also highlights that within the construct of CMO discussions, without influencing the outcome (CMO or ICU LOS), the involvement of the CCM team may provide opportunities to provide culturally sensitive care to NCC patients in a time-sensitive manner.
The majority of CCM involvements included a proactive approach by the CCM team to identify patients based on their preferred language listed in EMR. The CCM team members introduced themselves to the patients/families, educated them on the support that could be provided, and left their contact information.
In a minority of cases, we found that the social worker/bedside nurse/case manager/primary critical care team members reached out to CCM. The few times the critical care team reached out to CCM were in the context of end-of-life support and DNC. One case of DNC highlighted challenges in the accommodation of family requests after the diagnosis of the DNC was completed by the neurocritical care service. It underlined the importance of a proactive multidisciplinary approach to culturally sensitive care, as highlighted and recommended in the World Brain Death Project [9].
Medical care for NELP patients and families is stressful in various aspects, only one of which is the barrier of language [14]. CCMs likely contribute to their sense of control and support and provide solutions to real problems such as finance and housing. We were surprised to find that 4 out of 10 self-referrals by the CCMs resulted in a lack of a request by the NELP families to seek the support of CCM. The exact reasons for this are unknown, but our study suggests that in patients with high illness severity, families may reach out to CCMs for support when faced with challenges related to end-of-life/goals of care conversations. Future studies may examine why NELP families may not seek CCM support in neurocritical care.

Limitations
Several limitations are apparent, mainly because this was a single-center, nonrandomized quality improvement project with before/after comparison. Most importantly, this project did not examine patient/family-centered outcomes; thus, it was impossible to compare perceptions of the family/surrogate decision-makers towards culturally sensitive care provided with and without the involvement of CCMs. This low rate may be multifactorial such as lack of awareness and participation of CCMs only if there is a conflict between the neurocritical care provider and the families/surrogate decision makers. Another limitation of the current system at HMC for CCMs to know about potential patients/family needing their services (proactive approach) is that the CCMs only know of patients needing their services based on the patient's language as listed in the EMR, which may not always be recorded accurately. It does not factor in their families' preferred language. Unless CCMs get a referral from a critical care team member, the CCM team may be unable to identify these families prospectively. Hence, the results from our study may not be generalizable to adult NCC patients outside our hospital but provide a benchmark for other hospitals and neurocritical care units/services to compare against.

Conclusions
A local QI project rollout increased the involvement of CCMs in neurocritical care. This project attempts to create awareness among neurocritical care healthcare providers on ways to support NELP patients and families of different cultural backgrounds. The study results are encouraging, and there is potential to spread this awareness to other NELP patients/families and contexts other than critical care environments. The lessons learned from this study informed the neurocritical care and CCM team members that 1) NELP patients/families need support in many areas, support that typically is not provided by a medical interpreter, 2) there may be patients/families that may decline to follow up with a CCM team member, 3) high illness severity, end-of-life and goals of care conversations may be seen as triggers for CCM support, and 4) If CCM resources are limited then we may focus attention on these areas of need to maintain the sustainability of CCM team to provide culturally sensitive care. The perceptions of NELP patients/families regarding routine involvement of CCM in neurocritical care and its impact deserve further examination.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. University of Washington issued approval STUDY00009382. This study (STUDY00009382) was approved on March 1, 2022, by the Institutional Review Board of the University of Washington, and a waiver of consent was in place for a retrospective analysis of data gathered between 1/1/2014 and 1/31/2021. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: Abhijit V. Lele declare(s) personal fees from LifeCenter Northwest. Not relevant to submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.