Culturally Effective Pediatric Care in a Community-based Health Program April 7, 2011 -Denice Cora-Bramble MD, MBA, FAAP -Dodi Meyer MD, FAAP.
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Culturally Effective Pediatric Care in a Community-based Health Program April 7, 2011
-Denice Cora-Bramble MD, MBA, FAAP -Dodi Meyer MD, FAAP
Webinar Objectives:
1. Understand the American Academy of Pediatrics’ definition of culturally effective care.
2. Learn about the Culturally Effective Care Toolkit and how to apply concepts from the toolkit to a community-based health program.
3. Learn how a current Healthy Tomorrows grantee is addressing low health literacy levels through their Healthy Tomorrows project.
American Academy of Pediatrics’ Culturally Effective Care Toolkit
Denice Cora-Bramble, MD, MBA Lead Author, AAP Culturally Effective Care Toolkit Senior Vice President, Children’s National Medical Center Goldberg Center for Community Pediatric Health Professor of Pediatrics, George Washington University
Overview
Culturally Effective Care AAP toolkit development Website architecture Case studies & application of toolkit resources Q&A
Case Study to Frame the Discussion
Your last case of the day is a 6 y.o. Hispanic male referred by the school nurse because of a fever of 40 0 C. His mother accompanies the patient but does not speak English. The patient speaks and understands both English & Spanish. Your only on-site trained interpreter left for the day and you only know a few words in Spanish. What are your next steps?
Culturally Effective Care
Culturally Effective Care
“The delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of cultural distinctions. Such understanding should take into account the beliefs, values, actions, customs and unique health care needs of distinct population groups. Providers will thus enhance interpersonal and communication skills, thereby strengthening the physician-patient relationship and maximizing the health status of patients”. AAP Committee on Pediatric Workforce: Ensuring Culturally Effective Pediatric Care: Implications for Education and Health Policy
Pediatrics
2004;114;1677-1685
Safety Effectiveness Patient centeredness Timeliness Efficiency Equity
Quality of Care
EQUITY
No variations in the quality of care according to patients’ personal characteristics, including race and ethnicity Institute of Medicine.
Crossing the Quality Chasm: a New Health System for the 21 st Century.
Washington, DC: National Academies Press, 2001
Diversifying U.S. Population
Estimates of US Population 2000 to 2050 (U.S. Census Bureau)
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 69.4
12.6
2.5
3.8
12.7
2000 65.1
15.5
3.0
4.6
13.1
2010 61.3
57.5
17.8
3.5
5.4
13.5
20.1
4.1
6.2
13.9
2020 Year 2030 53.7
22.3
4.7
7.1
14.3
2040 50.1
24.4
5.3
8.0
14.6
2050 .White alone, not Hispanic .Hispanic (of any race) .All other races .Asian Alone .Black alone
How do these changes impact the clinical setting?
In California, Latino children comprise the largest group of children US Census Bureau, 2000 By the year 2020, an estimated 1 in 5 children in the US will be Latino
Changing America: Indicators of Social and Economic Well-Being by Race and Hispanic Origin
; Council of Economic Advisors for the President’s Initiative on Race, 1998
AAP Toolkit Development
Toolkit Development Team
Lead Author: Lead Staff:
Denice Cora-Bramble, MD, MBA, FAAP Regina M. Shaefer, MPH
Review Group
– Julio Bracero, MD, Section on Medical Students, Residents, and Fellowship Trainees – – Colleen Kraft, MD, FAAP, Council on Community Pediatrics Alice Kuo, MD, PhD, MEd, FAAP, Council on Community Pediatrics – – Dennis Vickers, MD, MPH, FAAP, Medical Home Initiatives William Zurhellen, MD, FAAP, Section on Administration and Practice Management,
Practice
– –
Management Online
Editorial Board Mary Brown, MD, FAAP, American Academy of Pediatrics Board of Directors
Culturally Effective Care Toolkit Needs Assessment Results
September 2009
Do questions regarding the delivery of culturally effective care (such as language/interpretive services, traditional practices, cross-cultural communication) arise as you are caring for patients? No, 4.7% n=278 Yes, 95.3%
80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Culturally Effective Care Toolkit Needs Assessment Results
September 2009
Which specific delivery mechanisms for culturally effective care resources would be most useful for you? (check top 3 delivery mechanisms) 74.1% 74.1% 26.6% 32.3% 10.3% 11.0% 25.1% Web-based Resources Patient Materials in Other Languages Topic specific CME 55.1% Best 10 Articles Annotated Bibliography DVD/Video Loan Library Interpretive Services Information Culturally Effective Care Manual n=263
Culturally Effective Care Toolkit Needs Assessment Results
September 2009
Which specific topics would be most helpful for a culturally effective care toolkit to include? (check top 3 tools) 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 58.9% 47.5% 41.8% 30.8% 22.8% 35.7% 14.8% 58.2% Conducting cultural interview Using interpreter services Presentation f or of f ice/clinical staf f Conducting organization cultural comp assessment Conducting individual cultural comp assessment Literacy assessment Cost analysis of interpretive services Accessing community resources n=263
Website Architecture
Case studies & application of toolkit resources
Case Study #1
Your last case of the day is a 6 y.o. Hispanic male referred by the school nurse because of a fever of 40 0 C. His mother accompanies the patient but does not speak English. The patient speaks and understands both English & Spanish. The only on-site trained interpreter left for the day and you only know a few words in Spanish. What are your next steps?
Linguistic Barriers
Studies have documented the multiplicity of adverse effects that language barriers have in health care including: – Impaired health status, nonadherence to medication regiments, higher resource use for diagnostic testing and others Flores G:
Dolor Aqui? Fiebre?:
Arch Pediatr Adolesc Med; Vol156, 638-640; 2002
Linguistic Barriers
One study identified language problems as the single greatest barrier to health care access for Latino children.
Flores G and Abreau M:
Access Barriers to Health Care for Latino Children;
Arch Pediatr Adolesc Med, Vol 152(11), 1119-1125; 1998
Interpretive Services
Medical interpreter as an essential component of effective communication between the limited English proficient (LEP) patient and health care provider Professional in-house, ad hoc, untrained family member, non-clinical hospital employee, stranger Untrained commit many errors Flores G et at.:
Errors in Medical Interpretation and Their Potential Clinical Consequences.
Pediatrics; Vol 111(1); 6-14; 2003
Clinically Significant Medical Errors
Omissions – – – Drug allergies Past medical history Chief complaint Substitutions – – Abx for 2 days instead of 10 HC to entire body instead of lesion Flores G et at.:
Errors in Medical Interpretation and Their Potential Clinical Consequences.
Pediatrics; Vol 111(1); 6-14; 2003
Toolkit Resource: Interpretive Services Section
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Options for providing interpretive services Pros & cons associated with different options Cost & payer payment Integrating interpretive services into office systems & practice What to look for in hiring/contracting for interpretive services Pitfalls to avoid Tips for working effectively with interpreters Assessing the need for interpretive services
Case #2
You have been treating a 7 year old with severe and poorly controlled asthma. The parents refuse to use the inhaled steroids as prescribed and continue to rely on traditional medicine. What are the next steps in managing this patient?
Asthma Disparities: More than Access Barriers
African American and Latino children enrolled in Medicaid managed care had worse asthma status and were less likely to be using
preventive
asthma medications than White children. This disparity persisted after adjusting for socioeconomic status.
Lieu T et al.:
Ethnic Variation in Asthma Status and Management Practices Among Children in Managed Medicaid;
Pediatrics 109(5); 857-865; 2002
Sociocultural Determinants of Health
Parental and child health beliefs Knowledge of asthma and asthma management Competition with other basic life needs Environmental factors – Can parents afford to control the environmental triggers?
Mansour M et al.:
Barriers to Asthma Care in Urban Children: Parent Perspectives.
Pediatrics 106(3);512-519
Sociocultural Determinants of Health
Racial and ethnic differences in health beliefs and concepts of disease Differences in beliefs about the value of prevention Fears about steroids Lack of regularity in the life of the family Lieu T et al.:
Ethnic Variation in Asthma Status and Management Practices Among Children in Managed Medicaid;
Pediatrics 109(5); 857-865; 2002
Understanding Pediatric Asthma Disparities
While the control and treatment for asthma is primarily based on medications, some parents have strong personal and cultural beliefs against the use of medications.
Belief Systems and Asthma
60% of Dominican mothers believed that their child did not have asthma in absence of symptoms 88% thought that medicines are overused in the US 72% did not use prescribed medicines but substituted traditional practices instead Bearison DJ et al.:
Medical Management of Asthma and Folk Medicine in a Hispanic Community.
J Pediatr Psychol; 24(4);385-392;2002
Traditional Practices Used in the Treatment of Asthma
Ethnomedical therapies – Prayer – Vicks VapoRub or “alcanfor” – “Siete jarabes” – “Agua maravilla” – “Te de manzanilla” Pachter L et al.:
Ethnomedical (Folk) Remedies for Childhood Asthma in a Mainland Puerto Rican Community.
Arch Pediatr Adolesc Med, Vol149(9);982-988;1995
Culturally Effective Toolkit: Health Beliefs and Practices
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Clinic and Emergency Department Use Pain and Analgesia Traditional Practices, Alternative Medicine and Indigenous Healers Bed Sharing and SIDS Birth and Early Infancy Death and Dying Role of Women Role of Family
Culturally Effective Care Toolkit: What Is Culturally Effective Pediatric Care?
Final Thoughts
“But culture in all its richness, does not simply explain health behaviors, nor does sensitivity to culture solve health disparities. Rather, culture works dynamically, in conjunction with economic and social factors, to affect health behaviors and to alleviate or exacerbate health disparities.” Gregg J, et al: Loosing Culture on the Way to Competence: The Use and Misuse of Culture in Medical Education.
Academic Medicine;2006;81(6);542-547
Contact Information
Please submit your questions via the question pane.
Denice Cora-Bramble, MD, MBA Professor of Pediatrics, George Washington Univ.
Senior Vice President Children’s National Medical Center Goldberg Center for Community Pediatric Health 111 Michigan Ave., N.W.
Washington, D.C. 20010 (202) 476-5857 [email protected]
HEAL
TH EDUCATION & ADULT LITERACY PROGRAM
Bridging the Communication Gap Between Medical Providers and Patients Dodi Meyer, MD, Emelin Martinez
,
Marina Catallozzi, MD, Rosa Morel Community Pediatrics Ambulatory Care Network- New York Presbyterian, Columbia University Medical Center Alianza Dominicana
Practice Setting
•
Community based, hospital affiliated primary care practice in Northern Manhattan
•
Faculty run, resident integrated practice
•
11,000 visits per year representing approx 5000 patients
Patient Population
• • • •
Mostly Latino: Dominican, Mexican Low SES: 73.3% born into poor families Limited English Proficiency : 40% children have LEP Health Literacy Level: 83.8% ranging from limited to possibly limited HL using NVS
• U.S. Census 2000. Manhattan, New York Community District 12. Retrieved from http://www.infoshare.org
.
Citizen Committee for Children, NYC 2005 Personal communication: Larson, Nevarra 2011.
Impact of Low Health Literacy
• • • •
Health outcomes Healthcare costs Quality of care Medication administration practices
Health Literacy Interventions and Outcomes: An Updated Systematic Review, Structured Abstract. Agency for Healthcare Research and Quality, March 28, 2011 Yin, et al. Parents medication administration errors: Role of dosing instruments and health literacy. Arch Pediatric Adolesc Med 2010; 164 (2): 181-186.
Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.) (2004).
Health literacy: A prescription to end confusion
. Washington, DC: National Academies Press. Healthy People 2010: Health communication. 2000: 11-20. Office of Disease Prevention and Health Promotion
HEAL: Health Education Adult Health Literacy Modeled after the Health Education and Literacy for Parents Project at Bellevue Hospital, NYC
Goal: Improve health literacy of the population served with a focus on medication administration
HEAL
• • •
Educational interventions can improve health knowledge, behaviors and use of healthcare resources among patients with low health literacy (HL).
Interventions must integrate HL with cultural and linguistic competency Interventions must address service needs of patients and training needs of providers
Yin, H. S., Dreyer, B. P., van Schaick, L., Foltin, G. L., Dinglas, C., & Mendelsohn, A. L. (2008). Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children.
Arch Pediatr Adolesc Med
, 162(9), 814-822.
Paasche-Orlow, M. K., Wolf, M. S. (2007). The causal pathways linking health literacy to health outcomes.
Am J Health Behav
, 31, S19 –S26.
HEAL: Principles Used
•
Partnership model
•
Participatory, collaborative process
•
Link to existing coalitions, organizations
Target Population
•
All patients in community based hospital affiliated practices
•
Clients served by a Home Visiting Program ( Best Beginnings/ Alianza Dominicana)
HEAL Program Objectives
•
Objective 1: To develop culturally responsive health education material regarding medication administration using the basic tenets of health literacy
•
Objective 2: To train pediatric providers, family support workers, and volunteers to appropriately address low health literacy in different health care settings
•
Objective 3: Implement the HEAL curriculum in health care organizations and community based organizations serving the Northern Manhattan population
Curriculum Development
Purpose of Curriculum: Increase patient’s involvement in planning care Enhance patient’s understanding of medication use Improve patient’s adherence to medical instructions Teaching Methodology: T raining driven by patient interest and prior knowledge Information conveyed in a non didactical method
Curriculum Development: Focus Groups
•
Three focus groups in community setting (two in Spanish/one in English)
•
22 participants
•
Domains: communication, medications, expectations, physician qualities, clinic qualities and home remedies.
48
FOCUS GROUPS FINDINGS
• •
Communicating with Doctors
Explain specific ailments verbally, not with handouts.
Outline a treatment plan for the family and ask for the family’s input. Give the family several options • • • •
Medications
General distrust of medications. Fear of overdose and side effects. When they don’t want to give medicine and use something else instead, they don’t tell the doctor. Want accurate instructions that include a visual and tsp/ml conversion for oral syringes.
When they pick out OTCs they ask friends or use previously used OTCs When they go to the doctor for a sick visit they expect medication • •
Home Remedies
For some, a secondary healing source after western medicine does not work. Others use when children too small for OTCs Some don’t tell doctor about home remedies because it would insult the doctor/patient relationship. Others don’t tell the doctor because they fear a negative response 49
Components of the HEAL Curriculum
• • • • •
PREPARING FOR A VISIT TO THE DOCTOR
–
Preparations Prior to a Medical Visit
– –
My Child’s Medical History Medical Words That You May Hear or See PRESCRIBED MEDICATION
–
Understanding Prescribed Medication Labels OVER-THE-COUNTER MEDICINE
–
Understanding OTC Medication Label
–
Selecting OTC Medications for Children Over 6 MEDICATION MANAGEMENT
–
How to Give Medicine
–
Medication Logs HOME REMEDIES
–
Common Home Remedies Used in the Community
–
Disclosing Use of Home Remedies to Medical Providers
HOW DO I CHOOSE AN OVER THE COUNTER COLD MEDICINE?
Over the Counter Cold Medicines should NOT be given to children under the age of 2. For children between the ages of 2-6, talk to your doctor first! Children over the age of 6 can use Over the Counter Cold Medicines.
Newborn to 2 months old:
A baby under 2 months with cold symptoms should be seen by a doctor.
NO MEDICATIONS ARE SAFE!
Ages 2 months to 2 years: DO use as directed:
Tylenol Motrin (> 6 months old)
DO NOT use:
Vicks Vapor Rub Pediacare products Robitussin products Triaminic products Dimetapp products Other medications in a the store
Ages 2 to 6 years: DO use as directed:
Tylenol Motrin
Use ONLY after talking to a doctor:
Pediacare products Robitussin products Triaminic products Dimetapp products Vicks Vapor Rub and Vicks products
Active Ingredient
: The main medicine. If I want to take more than one medication with the same active ingredient I should talk to my doctor first.
Uses
: Tells you what it treats. Do you have these symptoms?
Warnings
: Reasons not to use or stop using the medicine.
The following label is the most recent U.S, Food & Drug Administration approved over-the-counter drug label format.
Purpose
: The type of medicine.
Directions
: How to take, how often and how much medicine to give for a specific age.
Other information
: How to store medicine.
Inactive ingredients
: These ingredients are not the ones that fix you.
TOOLS TO MEASURE WITH:
Dropper Oral Syringe Tablespoon Teaspoon Dosage Cup
Converting Units of Measurement
• • • • • • •
CC stands for cubic centimeters ML stands for milliliters One cc = one ml One teaspoon (tsp) = 5 cc = 5 ml One Tablespoon (Tbl) = 15 cc = 15 ml One Tablespoon = 3 teaspoons One ounce = 30 cc = 30 ml = 2 Tablespoons = 6 teaspoons
Measuring Liquid Medicines
5 cc = 5 ml = 1 teaspoon (tsp) =
5 ml = 1 Teaspoon + 5 ml = 1 Teaspoon + 5 ml = 1 Teaspoon = 15 ml = Tablespoon
Physician Training: Parent/Patient Exit Interviews
• • •
Clinical observation at two randomly selected clinics 20 physicians observed using a checklist Communication issues identified:
• •
Allowing the patient’s parent to describe the problem uninterrupted Asking if the patient’s parent has questions before the end of the visit
• • • • •
Using visual methods Identifying additional resources Knowing and using the teach-back method, particularly regarding medication instructions Asking about the patient parent’s ability to follow treatment plans Using the translator phone when needed
Content of Training for Physicians and FSWs
• • •
Principles of health literacy Communication skills: effectively communicate with families who may have low health literacy levels. Teach back method: identify misunderstandings and allow clients/patients to enhance personal knowledge.
Williams, M. V., Davis, T., Parker, R. M., Weiss, B. D. (2002). The role of health literacy in patient-physician communication.
Fam Med
, 34(5), 383-9.
Andrulis, D. P., & Brach, C. (2007). Integrating literacy, culture, and language to improve health care quality for diverse populations.
American Journal of Health Behavior
,
31
(Suppl 1), S122-133.
Turner, T., Cull, W. L., Bayldon, B., Klass, P., Sanders, L. M., Frintner, M. P.,
et al
. (2009). Pediatricians and health literacy: Descriptive results from a national survey.
Pediatrics
,
124
, S299-S305.
TRAINING
• • • •
Physicians
– –
Pediatric residents General Pediatric Faculty Medical students Volunteers (from surrounding colleges) Family Support Worker s
60
• •
CURRICULUM IMPLEMENTATION
Waiting Rooms at community based hospital affiliated practices Clients’ homes enrolled in home visiting program
•
Process
•
Outcome
Evaluation
Caregivers Encountered in Waiting Rooms with HEAL Curriculum
700 600 500 400 300 200 100 0 609 Total Caregivers Approached 502 Total Caregivers Interested in Curriculum
Rate of HEAL Topics Discussed
Topics Discussed in Waiting Room Patient Encounters
10% 3% 16% 12% 24% 18% Preparing For A Visit OTC Prescription Medications Medication Management Home Remedies The Cold & Flu Use of Antibiotics 17%
People trained
• • • • •
16 pediatric faculty 64 pediatric residents 9 first year medical students 46 Family Support Workers 30 volunteers
Outcome Evaluation
1) Pre-post knowledge test:
–
FSW: significant difference (W=-3.493, p=0.0005)
–
Faculty: No statistical significance 2) Feedback logs: collected in waiting rooms
Feedback Logs
Lessons Learned From Encounters
Understanding Prescribed Medication Labels.
Understanding OTC Medication Labels.
66% 34%
Caregivers Who Demonstrated Discomfort Reading Label Caregivers Who Demonstrated Comfort Reading Label
38% 62% Caregivers w ho w ere comfortable reading label and using OTC Caregivers w ho had difficulties reading label and using OTC 300 250 200 150 100 50 0 Use of Home Remedies.
Incidences of Home Remedies Topic Discussed Patient uses home remedies Discloses the Use of Home Remedies to Doctor
1
How program evolved
•
Research need to demonstrate effectiveness of the program
•
H1N1 epidemic:
–
Need to teach patients about emergent virus
–
Treatment of the flu and the common cold
Revised HEAL Curriculum
• • • • • • •
PREPARING FOR A VISIT TO THE DOCTOR
–
Preparations Prior to a Medical Visit
–
My Child’s Medical History
–
Medical Words That You May Hear or See TREATING THE COMMON COLD & FLU
–
What Is a Cold and How to Treat It?
–
Distinguishing Between the Common Cold & Flu
–
How to Treat & Prevent the Flu USING ANTIBIOTICS
–
What Does it Treat?
–
Safe Way to Use Antibiotics
–
Results of Misusing Antibiotics PRESCRIBED MEDICATION
–
Understanding Prescribed Medication Labels OVER-THE-COUNTER MEDICINE
–
Understanding OTC Medication Label
–
Selecting OTC Medications for Children Over 6 MEDICATION MANAGEMENT
–
How to Give Medicine
–
Medication Logs HOME REMEDIES
–
Common Home Remedies Used in the Community
–
Disclosing the Use of Home Remedies to Medical Providers
Implementing HEAL in Research Melissa Stockwell MD MPH, Elaine Larson RN PhD, Dodi Meyer, MD, Marina Catallozzi MD, Anu Subramony MD MBA
•
Appropriate Care of Upper Respiratory Infections (ACURI)
Collaborative and Multidisciplinary Pilot Research Study (CaMPR,
2009) funded by CUMC CTSA
–
Goal: determine impact of 3 health literacy modules with regard to treatment of the common cold in a Latino Head start population
•
Appropriate Care of Upper Respiratory Infections (ACURI) funded by NIH/ NIMHD : Randomized control study to evaluate a health literacy intervention among Latino Early Head Start/Head Start parents.
–
Goals: Increase health literacy levels regarding upper respiratory infections (URI) , decrease pediatric emergency department visits for viral URI, determine the cost effectiveness of this intervention
Implementing HEAL in research Anu Subramony MD MBA, Melissa Stockwell MD MPH, Elaine Larson RN PhD, Dodi Meyer, MD
•
Decreasing Medication Administration Errors: A Health Literacy Intervention Collaborative and Multidisciplinary Pilot Research Study (CaMPR,
2010) funded by CUMC CTSA
–
Goals: decrease medication errors in our community by developing an web based educational module to be implemented at discharge form our emergency room
HEALth Literacy Initiative: Delivery Model
Direct service: ACN Clinics & CBOs Training Pediatricians, residents, CHWs Service Individual patient encounters with pediatricians and residents in waiting room and individual client encounters with CHWs Curriculum Focus groups to inform development and implementation Community-engaged research Head Start/Early Head Start /ER /CBO home visit Outcomes Health practices ER use
Challenges
•
Recruiting volunteers for teaching in the waiting room
•
Assessing long term impact of waiting room education program
Conclusions
•
Patients and clients are receptive to the curriculum
•
Physicians and FSW recognize need for training in this area Developing and Implementing a Culturally-Responsive Health Literacy Program in a Pediatric Immigrant Community (unpublished data)
Conclusions
•
Need to establish a process for HL curriculum development and implementation that is applicable to any community regardless of demographic served, health topic addressed, language used or health belief embraced
FUNDING PROVIDED BY:
Healthy Tomorrows Maternal Child Health Bureau in partnership with the American Academy of Pediatrics