LeadingAge Magazine · May/June 2014 • Volume 04 • Number 03

Caring for People From Many Cultures

May 14, 2014 | by Dianne Molvig

Providers face the challenges and joys of serving diverse consumers in culturally competent ways.

The face of America is changing as it becomes a more culturally and ethnically diverse nation. This trend is evident among older Americans, as well.

In 2008, 20.3% of adults age 65 and over were non-Caucasians, according to the U.S. Census Bureau, which predicts that this proportion will climb to 24.4% by 2020 and 29.4% by 2030. By 2050, four out of 10 Americans age 65-plus will be non-Caucasians, according to the Census Bureau’s projections.

Aging-services organizations must keep in step with these shifting demographics. Many providers already see tremendous cultural and ethnic diversity among the older adults they serve every day.

Here we’ll look at what a few of these organizations are doing to make all residents or clients feel welcome and comfortable, no matter what their origins may be.

When you walk into one of the TELACU senior apartment buildings in Southern California, “you can smell the different flavors—the Korean kimchee along with the Armenian dishes,” says Jasmine Borrego, president of TELACU Residential Management, an affiliate of TELACU, a community development corporation formed after the Los Angeles Watts riots in 1965.

TELACU has 33 low-income senior apartment communities, totaling 2,999 units, located across four Southern California counties. Any specific apartment community may be culturally homogenous or diverse.

“It could be anything from a building with 100% Chinese residents,” Borrego explains, “to one that’s 30% Chinese, 40% Hispanic and the rest a mix of others.”

The biggest challenge in serving multicultural residents, Borrego says, is communication, which relies on hiring staff who can speak all the residents’ languages. That can be difficult, considering that some 200 different languages are spoken in Southern California, she points out. When necessary, TELACU supplements staff language capabilities by hiring outside translators to help in certain situations.

Language capability is one necessity; another is cultural awareness. For instance, “We have to know what the Chinese New Year is versus the American New Year,” Borrego says, “and that there’s a Mexican Mother’s Day and an American Mother’s Day.” The TELACU staff celebrates various holidays with residents, depending on the demographic makeup of a particular building.

Learning about cultural differences is critical for all staff. Even maintenance personnel, for instance, must know the signs of behavioral or emotional problems, which may manifest differently in people from different cultures. Cultural differences also may impact certain behaviors, such as some people avoiding eye contact as a sign of respect. “We make sure our staff is sensitive to such things,” Borrego says.

With a waiting list for its apartments, TELACU has little need for marketing. It is, however, in the process of spreading the word about a new building to open later this year. It will have 32 units for people who are chronically homeless or have HIV, and are age 62 or older.

To reach these potential clients, “We can’t just send out flyers and then they will come,” Borrego says. “We’re talking to about 25 agencies in the area. We have to build strong relationships.”

The ACC Senior Services Center’s reputation for “culturally sensitive services,” as its website states, draws people from far and wide. “There are people who drive or send their mom on Paratransit to come to our center, bypassing other centers along the way,” says Linda Revilla, program director. “We are the major provider of diverse senior services in the county.”

ACC Senior Services Center, a part of ACC Senior Services in Sacramento, CA, aims to promote health, wellness and independence for older adults and their caregivers through various programs. Some 2,000 older adults use the Center’s day services in any given year.

A key element in being culturally sensitive, Revilla says, is having staff who speaks the languages of clients who come from diverse ethnicities: Filipino, Hmong, Vietnamese, Korean, Laotian, Japanese, Hispanic, Chinese (speaking Mandarin, Cantonese and other languages), African American and Caucasian.

“If we have two candidates for a staff position,” Revilla says, “and their qualifications are equal, we will hire the person who can speak another language” besides English.

About 160 volunteers who speak multiple languages help out in various programs, such as social day respite, transportation, class instruction and more. “Volunteers are our ace in the hole,” Revilla says. “They greatly expand our language capacity.”

The Center for Elders' Independence (CEI), Oakland, CA, says it is the most diverse PACE in California. That’s saying something, considering the demographics of one of the nation’s most diverse states.

CEI serves about 600 seniors at four sites. Unlike some members with diverse clienteles, CEI does not have much trouble recruiting staff. “The folks looking for work mirror those we serve,” says President and CEO Linda Trowbridge. “The challenge for some programs elsewhere is that people tend to coalesce in one site. But we don’t; all four of our sites have a very mixed group of folks.”

CEI engages with contract agencies to help with on-site interpretation, and CEI has staff that interpret as well; it also uses language lines. As Trowbridge notes, “We don’t get more capitation” just because of the extra expense of translation services. “We’re trying to be cost-effective without making too much of a tradeoff. It’s more than language, I think: For health care in general, it’s important to be culturally competent.”

PACE providers, by their very nature, have to become expert at working with other providers of all sorts. CEI is working on a partnership with a large group that owns a couple of HUD affordable housing properties with Latino clients. There has been talk with a Vietnamese cultural center that might bear fruit.

Asked about serving such diverse people, Trowbridge rejects any talk of “challenges.”

“These things aren’t problems,” she says. “This enriches the program. Just last Thursday we had what we call the Pan-Asian Fashion Show in one of our most diverse centers where we have African Americans, Caucasians, Koreans and Chinese. Some are monolingual. Ladies came in their cultural dress and did a fashion show in front of the whole group. Things like that really break down barriers that we’ve had our whole lives.”

CEI has created an outstanding introductory video that epitomizes outreach to consumers.

ElderServe Health in the New York City metropolitan area, a managed long-term care program, serves a wide demographic mix of seniors. Camille Sands, R.N., assistant vice president, says her clients are about half Russian, 20% Chinese-speaking, 18% Spanish-speaking, and 5-6% Korean-speaking. In all, ElderServe’s clients, drawn from an eight-county area in and around New York City, speak 25 languages, and its staff speaks about 20.

“Among our challenges, language is probably the greatest,” Sands says. The organization tries to use multilingual phone operators, who also have access to language line translators. Because many clients are elderly and sick, callers are not asked to make choices from a voice menu.

When consumers represent so many cultures, sensitivity to cultural differences is imperative. Knowing that East Asian clients like access to fresh produce, ElderServe organizes shopping trips from social day centers in Westchester County to a Korean market in Queens for its frail and elderly members. In serving Chinese clients, understanding the Chinese calendar and celebrations is a must. “We learned the hard way that a white flower means death in Chinese culture,” says Sands. A home-care aide was taught how to maintain a kosher kitchen, to better serve Jewish clients.

Another interesting moment of cultural education, she adds, occurred when Chinese clients tried to celebrate the Chinese New Year by giving little red envelopes with money in them to staff. “That gesture confers good luck on the giver,” says Sands, “but we have a firm rule that no staff can accept any gifts whatsoever.” The ensuing awkwardness led to a special rule for Chinese New Year: Staff can accept the little red envelopes as long as they contain no more than $1.

“The cultural end of [our work] is very important,” Sands says. “Our 2014 calendar has pictures of patients and staff, all different ethnicities, and the cover has pictures of our staff. There’s a lot of education required but also a lot of modeling. We provide mandatory training in diversity [to staff] and they come with great experience working with diverse populations.”

- Gene Mitchell

Some 90 volunteers assist in the transportation program that takes clients to various locations. “If you have mild cognitive impairment,” Revilla explains, “and you don’t understand why you’re on the bus and don’t recognize anyone, it makes an incredible difference if your escort speaks your language.”

Catering to food preferences and celebrating multiple holidays also are part of being culturally competent, Revilla points out. Understanding behavior differences stemming from cultural roots is also important. For instance, people in some cultures typically may speak at a louder volume in normal conversation than Caucasians do. “We talk about such things in our staff meetings,” she says.

To build community awareness, staff members from ACC Senior Services Center attend numerous community events, such as church health fairs, the Filipino Fiesta, the Pacific Rim Festival and more. “Last year we went to 32 different events, large and small,” Revilla says. “We do a lot of outreach.”

In northern Minnesota, built in the shape of an eagle in flight, is Biimaadiiziiwiin, a 30-unit affordable housing community serving older adults of Chippewa heritage. It’s a project of Marion, OH-based United Church Homes, which also operates a 15-unit affordable housing community in Nebraska, home to older adults from the Omaha tribe.

The prime challenge in serving these residents is understanding that “they place a different value on time” than most Caucasians do, says Cheryl Wickersham, vice president of housing services. For instance, once a prospective resident decides to move in, it may be several months before he or she actually does so. “We have to make many phone calls and perhaps visits to those applicants,” Wickersham says. “We must be patient.”

Explaining the financial side also can get tricky. A rent equal to 30% of income sounds like a lot of money to prospective residents. They may have paid a much lower rent before, Wickersham explains, “but the utilities ate them up. It’s a challenge to educate them.”

Both the Minnesota and Nebraska communities have Native American staff. “That makes a difference in helping people to decide to move in,” Wickersham says. “They’re more likely to trust a Native American who says, ‘Yes, this is a good decision for you.’ After all, this is a culture that has been taken advantage of for generations.”

Once they’ve settled in, however, the cultural background of staff seems less critical to residents, Wickersham adds. “After they move in,” she says, “and see they’re being treated fairly, they’re happy.”

United Church Homes also operates a 39-unit affordable housing community in Immokalee, FL, that’s home to Haitian older adults, mostly former farmworkers. The main challenge there is to explain the concept of a waiting list to people who want to move in.

In the Native American communities, United Church Homes does outreach by advertising in tribal newsletters and on tribal radio stations, attending the summer powwow and other key events, and hosting an annual craft fair. At the Florida community, United Church Homes works with the local Catholic church and also has a wellness clinic on site. “We have a doctor who makes house calls and is Haitian,” Wickersham says. “Our residents trust him.”

At GuildCare Manhattan, each day begins with announcements delivered in multiple languages. “We don’t want any of our clients to miss anything,” says Karen McCauley, program director. “We’re in Midtown Manhattan, so serving diverse cultures has always been the norm here.”

GuildCare Manhattan is one of five adult day health programs operated across the state of New York by Lighthouse Guild, formerly called Jewish Guild Healthcare. McCauley reports that more than half of the Manhattan day center’s clients are age 60 or older, and about 75% have visual impairments. Ethnic makeup is 35% Hispanic, 43% African American, 8% Asian, 14% Caucasian, 4% Russian and 3% Polish.

The center offers a variety of daytime activities, with a focus on cultural inclusiveness. Employees speak many languages, and meals consist of foods that will appeal to people from multiple cultures. “We also highlight special events for different cultures throughout the year,” McCauley says.

For instance, Chinese entertainers come in to help celebrate the Chinese New Year. During Hispanic Heritage Month there’s a parade at which people wear garb related to their cultural roots. “Many clients who are not Hispanic also like to dress up and participate,” McCauley says.

She notices a lot of curiosity and sharing among clients about cultural traditions. A Tai Chi class, for example, proved to be extremely popular, and not only with Chinese clients. People also trade a bit of language instruction.

“It’s terrific to see them teaching each other how to say ‘Hello, how are you today?’ in each other’s languages. There’s definitely an interest in finding out more about different cultures,” McCauley says.

GuildCare Manhattan has a full-time recruiter on staff who connects with targeted community organizations to build awareness about the adult day program. The agency also does some advertising, such as on city buses and on the radio.

Local health fairs are another key way to reach out to potential clients. Staff who attend these fairs speak the languages prevalent in a particular neighborhood. People also can pick up GuildCare Manhattan brochures available in multiple languages. “It’s very important for us to attend these events,” McCauley says, “because our potential clients are right there.”

Two vital ingredients enter into being a culturally competent or culturally sensitive organization, says Nancy Spring, president of CARING Housing Ministries, El Monte, CA. First, you have to want to make the effort to honor diversity, and second you need strong leadership.

“If you want to do this and your leadership wants to do this,” Spring says, “then it’s a natural thing to do. It’s expected that everyone will treat residents with dignity and respect. The fact that residents come from different places just doesn’t matter.”

CARING Housing Ministries operates 10 housing communities (one in Arizona and nine in California) serving low-income older adults. The company is a wholly owned subsidiary of Front Porch, a not-for-profit organization based in Glendale, CA.

The ethnic mix varies from one community to another, but the entire population of older adult residents includes people having Chinese, Korean, Russian, Polish, Persian, Hispanic, African American, Caucasian and other ethnic origins.

Serving older adults from diverse cultures entails being aware of the role of the elderly in those cultures, Spring says. Some cultures treat their elderly with great respect. “You may have mental health needs among elderly people who had a lot of status in their culture,” she explains, “and now that they’re in this country, they may feel they no longer have that same status.”

Fostering cultural sensitivity amongst residents also can be an issue, she adds. Residents in CARING Housing Ministries communities generally are accepting of each other. But in one long-time predominantly Caucasian community, some residents have displayed biases toward others who don’t speak English.

“They have shown what I call naughty resident behavior,” Spring says. “We meet with those residents and tell them their behavior is unacceptable. We just don’t tolerate it.”

Multilingualism among staff, as well as volunteers, and providing appropriate menus are other key elements in serving older adults from diverse cultures. Cultural awareness also enters into planning programs and activities. For instance, many Asian people place a high value on having a safe place to exercise or a place to grow food.

“You have to know what’s important in a particular culture,” Spring says, “and then willingly embrace providing that to the people you serve. Again, it goes back to wanting to do this.”

“We’ve always believed in providing housing plus services, but we don’t want residents to just be here, we want them to have meaningful lives, and to engage them in different programs and activities, to have a community feeling within and across buildings,” says Mohini Mishra, program director, housing for Selfhelp Community Services, based in Flushing, NY.

Mishra works with 1,200 residents in seven independent living buildings; six are in Flushing, Queens, and the seventh is in Bayside. And it is a diverse group. Thirty-eight percent speak Chinese as a first language; 22%, Korean; 18% Russian; 3% Spanish and 9% English. Twenty-one percent of the residents are Jewish.

The six Flushing communities are within walking distance of each other, so Selfhelp encourages activities and events involving multiple buildings. “The challenge is to get people together, to provide culturally sensitive services but not be in silos. People dress in their native costume, bring things personal to them, and have conversations about it. We talk about languages, music, food, and the trauma in people’s lives. We talk about resiliency.” An active resident council helps welcome new residents and if desired, connects them with other people in their group.

As expected, language issues are always present, but with translation, friendships and understanding grow. The new Charles B. Wang Health Center that will be co-locating in the newest of Selfhelp's affordable residential buildings will be staffed with bilingual (Chinese and English) health professionals and support staff. Educational material for patients and wellness instruction will also be bilingual. An English and a Chinese web portal for patients to have access to their own records, make appointments and keep tabs on progress will enhance convenience and accuracy.

Other multicultural requests are simpler to address, but nonetheless important. For instance, many non-Jewish residents expressed an interest in participating in the Passover Seder. Selfhelp arranged for the Haggadah to be translated into several languages so other residents could learn more about it.

Selfhelp’s culturally competent staff includes bilingual Russian, Korean, and Chinese speakers. Language line services are available in all buildings, so any worker can use it to communicate with any resident. Interns brought in from local schools are, whenever possible, bilingual or multilingual. When funding allowed telehealth kiosks to be brought into one site, Selfhelp arranged for them to offer Chinese, Korean, Russian and Spanish translations.

Learning to Live Together
Translation is also a major challenge for Jewish Community Housing for the Elderly (JCHE), based in Brighton, MA. The organization offers HUD-subsidized low-income housing but also “market rate” housing that is actually below market rate, says Caren Silverlieb, director of strategic planning and partnerships. Resident demographics are very diverse (more than 20 languages are spoken), but there are large numbers of Russian-born (50%) and Chinese-born (23%) residents.

Gaye Freed, executive director of the JCHE Brighton Campus, where two of the three buildings are HUD-subsidized, says “We were able to get resident service coordinator grants, so we’re able to have sufficient staff for our frail population, and staff that speak the languages of [the] residents. But it’s harder to find social workers or resident service coordinators and staff in other departments who speak the languages we need.”

Laura Isenberg, resident services administrator at JCHE’s Golda Meir House, Newton, MA, says translation issues are always present because so many things must be documented. “The timing of getting things translated can put a hold on things,” Isenberg says. “That’s the first major challenge, and then you have to make sure your translations are accurate: Don’t use Google Translate!”

Translation becomes an issue in activities as well, though some programs, like art, dance, yoga or tai chi courses, speak a more “universal” language and have served to create common experiences and create bonds among residents. Isenberg says that one-hour resident meetings with the executive director must be repeated three times for three different language groups. On top of that, she adds, a Russian- or Chinese-speaker with dementia or some other condition complicates the story.

Silverlieb also notes that diversity isn’t just about culture or language: “All of our buildings have three or four generations of people [ages from 60 to 100], and four different income levels. That is also diversity.”

A little effort goes a long way. One bilingual administrative assistant is teaching Russian to English speakers. Like Selfhelp, translation by staff helped residents understand the Passover Seder and celebrate Chinese holidays. “We don’t have the attitude that everyone should learn English,” says Isenberg, “but we do temper it with an expectation that people will make an effort. We have a Russian speaker who has taught ESL for 10 years. We have another who does a beginning English class. We think people will still make an effort to at least be able to speak their name, phone number and apartment number.”

JCHE works to be sure all staff become culturally competent in terms of understanding other cultures, how to address people and what the immigrant experience is like. Understanding different standards for behavior across cultures is a learned skill: for instance, how one greets a stranger, when to shake (or not shake) hands and proper demeanor in meetings. There are always issues that arise, as varied as cooking smells, footwear choices or attitudes about learning English.

A Community Center Where Everybody Gathers
Asian cultures are well-known for families’ commitment to caring for aged themselves. Even so, when the founders of Kin On, the nation’s first nursing home operated by the Chinese community, did surveys in the Seattle area they found that there was a need for such a home, which led to its opening in 1987. Kin On’s first location was in a building formerly occupied by another provider, Seattle Keiro, which had been serving Japanese-American seniors since the early 1960s.

“Originally we started with an idea that we wanted to bring our community together, so the nursing home project came to a conclusion that various segments in the community can support,” says CEO Samuel Wan. “At first, some people felt it may not work that well, but about six to seven months after we started serving the community the idea had changed.”

Today Kin On occupies its own site, the 100-bed Kin On Health Care Center built in the 1990s. The organization also offers in-home health and support services, chronic care management, Alzheimer’s and dementia support and hospice services.

Kin On’s residents and clients are almost all Asian, about three-fourths Chinese but including some Southeast Asians as well.

Wan says family involvement is high: “The way we operate, Kin On is more of a community center where everybody gathers. We have organizations from the community [that] come to visit regularly. On a quarterly basis we have some adopted children from China whose parents bring them here—back to the culture. It is basically a community place, and we intended it that way.”

CEO Samuel Wan says this summer will see the groundbreaking for a new expansion to include spaces for a healthy aging program, exercise, trainings and more. Also included will be 22 units for assisted living, and a new model for Kin On, an “adult family home,” with some similarity to the Green House or small house model, and using universal workers.

“We want to try this one first,” says Wan. “We want the adult family home to be connected to the major campus, so we have skilled nursing, assisted living and independent living as a continuum.” Later adult family homes might have somewhat different profiles, depending on where the properties are located.

An Inclusive Environment
For Collington, Mitchellville, MD, a CCRC affiliated with Kendal, residents play an important part in making prospective residents feel welcome. “We don’t do outreach based on ethnicity but on geography,” says Executive Director Marvell Adams, “but a diverse group comes in the door. As we meet prospective residents we will pair them with residents with similar interests if they ask for it.”

“What we try to do, for events small or large, is to have a diverse group of residents at the events,” says Adams. Marketing events are held frequently, and Adams says they try to invite a diverse cross-section of residents, across race, ethnicity and sexual orientation.

For staff, Collington and the Kendal system put a priority on building an inclusive environment. “We don’t want [staff] to feel as if they have to self-segregate. Part of that is being able to have moments that allow individuals to be prideful about their culture; a lot of times that is done around food. Another thing we’ve done as a Kendal system is coming together more to talk about how to share experiences.”

Last year Collington partnered with a national multicultural institute from DC, which did a series of focus groups with staff, board members and residents about how the organization’s diversity efforts are going. Part of the process was a group of “diversity chats,” with residents and staff getting together to talk about their diverse life histories.

- Gene Mitchell