Engaging Patients: Real World Problems, Real World Solutions Marilyn R. Gardner

1. Engaging Patients: Real World Problems, Real World Solutions Marilyn R. Gardner

2. The Problem... • What difficulties do you have engaging patients? • What difficulties do patients face navigating the health system?

3. Patients in the Health Care System

4. Compliant or Non-Compliant? • The problem with labels • Background: • 1980’s to 1990’s – Using “non-compliant” to label a patient was used like candy on Halloween • 1990’s to 2000’s – A vague discomfort arises in the use of the term “non-compliant”. We’ve eaten too much candy • 2000 and beyond – Replacing the candy with a healthier alternative

5. What we know • Literature search: • Large body of research • Some research looks at this as a “patient problem” to be resolved through nursing intervention • Other research critiques this approach • An alternative approach: Focus on how health care treatments affect patients’ lives not just their health • Cultural Beliefs and Values • Social Determinants • Restructuring care

6. Real Solutions • Engaging Patients through Culturally Responsive Care • Engaging Patients through Social Determinants of Health • Engaging Patients through Collaborations

7. Engaging patients through culturally responsive care Culture is deeply personal Respect difference. Focus is on racial/ethnic cultures. Distinguish “generalizing” from “stereotyping.” Forgive time constraints.

8. What is culture?

9. Culture Quiz . . . with thanks to the University of Toronto

10. The customary beliefs, values, shared attitudes, practices and choices of a group. The learned and shared values, beliefs, norms, and life view of a group that guide thinking, decision-making and action. Culture is our learned view of life. Culture . . . It’s not genetic!

11. Culture is our lens.

12. Decor Souvenir Place of Prayer

13. Status Status Status

14. Cultural self-awareness Communicating Across Boundaries A Cultural Passport Exercise

15. Cultural Competency: A learning processthat enables individuals and organizations to respect, value --- and function effectively in the midst of --- cultural difference.

16. Why do we need cultural competency? Increasingly diverse communities. Evidence of health disparities. Regulatory and charitable focus. Nature of quality care.

17. The Face of Florida • Total population just over 18 million • Uninsured population – more than 3.9 million, over 21% of the population (national is 16%) • Black – 2.7 million or 15% • Hispanic – 3.9 or 21% • Asian/American-Pacific Islander – just over 400,000 or 2%

18. Face of Florida • Foreign born – 19.2% • Language other than English spoken at home – 26.6% • Poverty Level • White – 14% • Black – 35% • Hispanic – 31% • Reducing Racial and Ethnic Health Disparities "Closing the Gap" was signed into law on June 8, 2000. 

19. Health Disparities “Population-specific differences in the presence of disease and health outcomes.” . . . Health Resources and Services Administration “Health inequalities, across racial, ethnic and socioeconomic groups.” . . . Wikipedia 5/17/2012 VNA Care Network & Hospice

20. Unequal Treatment Institute of Medicine “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” Racial and ethnic minorities in the U.S. receive lower quality health care than whites even when their insurance and income are the same. March 20, 2002

21. Significant racial & ethnic differences in: • Receipt of appropriate cancer treatment • Pain control - Minority patients more likely to be under-medicated for pain than white patients (65% vs. 50%), more likely to have severity of pain underestimated by physicians • Mental health services - “plagued by disparities.” One study indicates 44% of White English speakers to 27.8% of Blacks received treatment after a diagnosis of depression. • Heart procedures – including bypass surgery • Diabetes – from diagnosis to amputations • Pediatric Care – Less satisfaction, cite poorer communication, perception of lack of response

22. CLAS Standards National Standards for Culturally and Linguistically Appropriate Services in Health Care Office of Minority Health, 2000

23. Stages of Cultural Competency • Stage 1: Awareness • Stage 2: Sensitivity • Stage 3: Knowledge • Stage 4: Adaptability • Stage 5: Competency

24. Three attitudes that support successful cross-cultural encounters are: Empathy Curiosity Respect

25. Explanatory models as communication tools: “It is much more important to know what sort of patient has a disease, than what sort of disease a patient has” -William Osler • The “insiders” view of the world • Consists of what people in a given setting or culture believe about the nature, cause, prevention, and response to an event • Understanding of the broader beliefs about how the body works and general factors that influence a person’s fate in life

26. Video: Case Study – Alicia Mercado Story • Small group discussion • Report back

27. Culture Shock Culture Conflict Cultural Imposition Ethnocentrism Racism & Discrimination Barriers to effective cross-cultural interactions

28. Communication Tools: • Be aware of your cultural values and beliefs • Understand that limited language proficiency does not mean limited intellectual ability • Use Explanatory Models • Allow the use of storytelling • Rethink your role not only as an expert to the patient or client but also as a student of the patient or client • Seek assistance from bilingual/bicultural co-workers and individuals • Recognize the patient or client may not be the decision maker in the family

29. Steps and Resources to Improve Culturally Responsive Care Be aware of your culture! Identify key cultural informants. Plan with, not for, the community. ASK! Don’t assume. Training – What further trainings/workshops would help you to better care for your patient population Resources: Cultural profiles, articles, books, films, interviewing tools.

30. Questions or Comments?

31. Lunch Break

32. Engaging Patients: Social Determinants of Health • What are the Social Determinants of Health • Why do they matter?

33. Definition: • The conditions in which people are born, grow, live, work and age, as well as the health system • Results in health “inequities” • Systemic and unjust distributions of social, economic and environmental conditions needed for health • Goal is to provide health equity • The opportunity to attain full health potential.

34. Social Determinants of Health • “Unnatural Causes…is inequality making us sick?” PBS special • Much more to wellness than medical care, genetic propensity, and behavior • Social, economic, and physical environments profoundly affect our longevity and health

35. Stress can cause illness

36. Stressors Poverty Immigration Language and cultural barriers Stigma Education Powerlessness Poor access to resources Living in dangerous neighborhoods Job insecurity Illness And the list goes on….

37. Place Matters 29 minute clip ~ Why is your street address such a strong predictor of your health? 

38. Discussion Questions • What health threats does Gwai face that are beyond his individual control? • How do neighborhood conditions, his job and income situation and being an immigrant affect his ability to keep his children out of harm’s way? • How might all of this affect Gwai’s stress level? What options would make things better for his family and others? • What health advantages do residents of wealthier neighborhoods have that are often lacking in neighborhoods like where Gwai lives? • In what ways does a story like this inform and/or impact your work?

39. Engaging patients through best practice models and collaborations • We can’t do it alone! • What ‘Best Practice’ models can we learn from? • How can we use the resources in the community to help patients?

40. Promising Practices • The Clark County Story, Vancouver, Washington • Group visits in prenatal care involving a patient navigator • Case Management and Stanford University Chronic Disease Self Management • Patient Navigation and Colorectal Screening, NYC • Diabetes project, Mass General Hospital

41. Role of Patient Navigator • Works with providers, clinics, and Medicaid office • Assists women with referrals for other needed services – food & cash assistance, child care, transportation, WIC, mental health, dental care, etc. • Bilingual/Bicultural • Acts as cultural broker to aid Case managers in increasing cross cultural understanding

42. Group visits • Initial Problems: • No shows • Difficult to sustain preventive care • Long waits for appointments • Group Visits • Emphasize patient education • Make use of group dynamics

43. Based on today’s discussion: • How do you think cultural values and beliefs affect both access and receipt of care in your patient profile? • How do you think the social determinants of health play into the health behavior of your patients? • What additional resources would you need/want in order to address these significant variables with your patients?

44. Be specific, for example: • Does your assessment need to change? • Do you have adequate interpreter services and do all staff know how to use interpreters? • Are community specific resource guides available for your patients and if so, do they know how to use them? • What culturally specific information on your patient population do you still need in order to provide them the best care possible? • What might be helpful to know about your patient’s neighborhood in order to develop a realistic plan of care for them?

45. Promising Practices • Questions? • Contact: Marilyn Gardner, R.N.| Clinical Liaison Email: marilyn.gardner@state.ma.us