Community Plunge: A Tool for Increasing Cultural Understanding in Health Care

1. Community Plunge:A Tool for Increasing Cultural Understanding in Health Care Jennifer Casey, MBA. Cheryl Alberty, MBA, MHA National AHEC Organization Conference Las Vegas, Nevada June 24, 2010

2. Presentation Overview • Health disparities in North Carolina • The role of cultural competence in addressing health disparities • What is Community Plunge? • Northwest AHEC Community Plunge • Rationale • Methods • Results • Conclusions

3. What is a Health Disparity? • “Differences in health status among distinct segments of the population including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation.“ – NC 2010 Health Objectives • “A population-specific difference in the presence of disease, health outcomes, or access to care.”- Health Resources and Services Administration (HRSA)

4. Disparities in Deaths from Heart Disease Source: NC Office of Minority Health and Health Disparities and State Center for Health Statistics, “Racial and Ethnic Health Disparities in NC: Report Card 2006.”

5. Disparities in Deaths from Diabetes Source: NC Office of Minority Health and Health Disparities and State Center for Health Statistics, “Racial and Ethnic Health Disparities in NC: Report Card 2006.”

6. Disparities in Deaths from HIV Disease Source: NC Office of Minority Health and Health Disparities and State Center for Health Statistics, “Racial and Ethnic Health Disparities in NC: Report Card 2006.”

7. Infant Mortality Disparities 4.5 Source: NC Office of Minority Health and Health Disparities and State Center for Health Statistics, “Racial and Ethnic Health Disparities in NC: Report Card 2006.”

8. Why do these disparities exist? • There is no singular cause, but rather the interaction of many factors! We need to consider: • Social and environmental factors, including SES • Access to care • Stress • Differences in quality of care received • Genetics and biology • Behavioral factors

9. The Importance of Cultural Competence • Health care must be adapted to meet the cultural and linguistic needs of an increasingly diverse patient population • Cultural competence is critical in understanding these needs • Change must start in health professional schools • Starts with knowledge of disparities, communication with patients, and sensitivity

10. Teaching Cultural Competence • “The curriculum should require a focus on the reality of evidence-based health disparities among racial and ethnic minority populations, importance of providing culturally competent care and communication to meet the health needs of diverse patient populations, and exposure to cultural diversity.” Source: Shaya, FT; Gbarayar, CM. (2006) The case for cultural competence in health professions education. Am J Pharm Educ; 70(6): 124.

11. Socio-Ecological Framework (Graphic borrowed from the Centers for Disease Control and Prevention)

12. What is Community Plunge? • Experiential learning opportunity that connects participants (providers and students) with the strengths & needs of the communities they serve • Understand patients’ life experiences in the larger social context of health • 3 components: • Windshield tour • Focus group • Debriefing session

13. Windshield Tour • Route within affluent and poor segments of the Winston-Salem community • Poorer areas have a much higher percentage of minority residents • Narrated (standardized guide for each department) • Emphasis on: • Revitalization efforts • Community assets • Public housing projects • Historical landmarks • Key health and human service agencies

14. Focus Groups • Providers listen to clients tell their stories • Uses standardized focus group guide • Clients have included: • Elderly • Low-income African American & Hispanic parents • Parents of children with special needs • Teenage mothers • Community members living with substance abuse or mental health concerns • Other vulnerable populations

15. Debriefing Session • Providers meet to discuss their experiences • Complete post-plunge survey • Most beneficial aspect of the plunge • Things I SAW that made the biggest impression on me • Things I HEARD that made the biggest impression on me • What I want to remember when caring for clients • Suggestions for improving the plunge

16. Northwest AHEC’s Plunge • Faculty serve as facilitators to guide residents • Piloted with pediatric residents in 2002 • Now includes 5 departments: • Pediatrics • Family and Community Medicine • Psychiatry and Behavioral Medicine • Internal Medicine • Physician Assistant Studies • Financially supported by Northwest AHEC ($4,400 allocated per department)

17. Data Analysis Methods • Reviewed post-plunge surveys (n=250) • Assigned codes to every phrase in each response • Examples: • Barriers to care • Communication • Disparities • Organized codes into themes • Selected quotations to go along with the themes to tell a story

18. What was the most beneficial aspect of the community plunge?

19. Gain new perspective: see firsthand how clients live • Poverty • Lack of resources • Poor housing conditions “Being able to visualize where my clients live, work, and access care/training/services really helps me tailor their care/education.”

20. Impacts how providers plan to care for their clients and understanding of the resources available to them in their community “Helps me to see some of the resources that I will refer clients to and understand better how they help.”

21. Provides a firsthand opportunity to hear clients discuss their viewpoints concerning positives and negatives of care • Frustrations with health care system • Expectations of providers “Speaking with families of patients, you get information that no book will tell you.”

22. What did you SEE that made the biggest impression on you?

23. Low-income housing • Government renovation projects (+ and -) • Squalor and poverty • Disparities in finances and resources • Segregation “. . . the difference between the haves and have-nots, and the big lack of people in the middle.”

24. Lack of community resources that others take for granted • Transportation • Food resources • Pharmacies “. . . the lack of convenient grocery stores with variety to provide fruits/vegetables.” “I was amazed by how far people have to travel on public transportation.”

25. What did you HEAR that made the biggest impression on you?

26. Bad or “negative” care received from providers • No further information or health education • No referrals • Inferior care at low-cost clinics “People felt doctors were not treating them like people.”

27. Expectations clients have for their providers • Good personality • Time • Compassion • Listening and trying to understand “All patients prefer an average doctor instead of a smart jerk.”

28. Barriers to obtaining care • Access (to providers, medications, etc.) • Transportation • Financial barriers • Cultural / linguistic barriers • Navigating the system “One patient refused a pay raise so that she could still qualify for the free health care.”

29. Racial & ethnic segregation and discrimination “ . . . hearing the conditional fear of immigration from patients that were undocumented and worry of being taken advantage of.”

30. Based on what you experienced on the plunge, what is the one thing you want to try to remember when taking care of clients?

31. Communication with clients is critical • Active listening • Discussing & explaining • Building rapport • Involving clients in their care • Trying to understand clients’ perspectives “Let people know you are glad they came to see you.”

32. Respect and compassion • Non-judgmental • Open-minded • Treat everyone equally • Understand their backgrounds • Treat him/her like a whole person “Treat them the same way I would want myself or a loved one to be treated.”

33. Keep in mind clients’ backgrounds and perspectives • See things from their point of view “There is a lot more to someone than what is written in the chart: their real, everyday life experience.” “Each client has a different perspective on life and what is important. For some, compliance with meds does not compare to finding a meal.”

34. What are your suggestions for improving the plunge?

35. Allow more time/interaction with clients. • Provide exposure to more than one group of clients. • Provide a community resource guide. • Make the windshield tour longer to see more communities and resources. • Shorten the windshield tour to have more time with community members. • Do walking tours (versus driving) of the treatment facilities/community resources.

36. Summary: Key Themes • Communication • Lack of access to resources • Poverty • Barriers to care • Racial and ethnic differences / disparities • Understanding clients’ perspectives

37. Limitations • Generalizability • Cannot really compare across departments or disciplines • Windshield tour scripts differed by departments • Different departments visited different areas of the city as appropriate for their needs

38. Strengths • Adaptability • Usefulness in promoting cultural competence • Community-centeredness • Has potential to influence community leaders and policymakers

39. Future Directions • Measuring actual behavioral changes in providers over time • Solicit input from community members regarding how plunge should be conducted • Facilitate interaction between providers and their clients during the plunge

40. Conclusion • Community plunge is a useful, cost-efficient, and adaptable tool for increasing cultural competence among health care providers.

41. Acknowledgement • This study was supported by Northwest AHEC generated revenue funds. We would like to acknowledge the investigators for this study as well as the ongoing commitment and hard work of all faculty and staff in the departments at the Wake Forest University School of Medicine associated with the community plunge.

42. Study Team • Principal Investigator: Michael Lischke, EdD, MPH • Co-Investigators: • Jennifer Casey, MBA • Jane Foy, MD • Jaimie Hunter, MPH, CHES • Anita Pulley, RN, MSN • Study Coordinator: Nancy Cox, MSW

43. Questions?

44. Contact Information Jennifer Casey, MBA 336.713.7705 jencasey@wfubmc.edu Cheryl Alberty, MBA, MHA 336.713.7719 calberty@wfubmc.edu Northwest AHEC fax: 336.713.7701