culturally effective pediatric care in a community-based health program april 7, 2011 -denice...
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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, MBALead Author, AAP Culturally Effective Care Toolkit
Senior Vice President, Children’s National Medical CenterGoldberg 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 400C. 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
Quality of Care
Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC:
National Academies Press, 2001
Safety
Effectiveness
Patientcenteredness
TimelinessTimeliness
EfficiencyEfficiency
EquityEquity
EQUITY
No variations in the quality of care according to patients’ personal characteristics,
including race and ethnicity
Estimates of US Population 2000 to 2050(U.S. Census Bureau)
13.1 13.5 13.9 14.3 14.6
3.8 4.6 5.4 6.2 7.1 8.02.5 3.0 3.5 4.1 4.7 5.312.615.5
17.820.1
22.324.4
69.465.1 61.3 57.5 53.7 50.1
12.7
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2000 2010 2020 2030 2040 2050
Year
Pe
rce
nt
of
Po
pu
latio
n
.White alone, not Hispanic
.Hispanic (of any race)
.All other races
.Asian Alone
.Black alone
Diversifying U.S. Population
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: Denice Cora-Bramble, MD, MBA, FAAP Lead Staff: 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
No, 4.7%
Yes, 95.3%
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?
n=278
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)
n=263
74.1% 74.1%
26.6%32.3%
10.3% 11.0%
25.1%
55.1%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%
Web-based Resources
Patient Materials in Other Languages
Topic-specific CME
Best 10 Articles
Annotated Bibliography
DVD/Video Loan Library
Interpretive Services Information
Culturally Effective Care Manual
Culturally Effective Care Toolkit Needs Assessment Results
September 2009
58.9%
47.5%
41.8%
30.8%
22.8%
35.7%
14.8%
58.2%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Conductingcultural
interview
Usinginterpreterservices
Presentationfor
off ice/clinicalstaff
Conductingorganizationcultural compassessment
Conductingindividual
cultural compassessment
Literacyassessment
Cost analysisof interpretive
services
Accessingcommunityresources
Which specific topics would be most helpful for a culturally effective care toolkit to include? (check top 3 tools)
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 400C. 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 errorsFlores 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. Options for providing interpretive servicesII. Pros & cons associated with different optionsIII. Cost & payer paymentIV. Integrating interpretive services into office
systems & practiceV. What to look for in hiring/contracting for
interpretive servicesVI. Pitfalls to avoidVII. Tips for working effectively with interpretersVIII. 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. Clinic and Emergency Department UseII. Pain and AnalgesiaIII. Traditional Practices, Alternative Medicine
and Indigenous HealersIV. Bed Sharing and SIDSV. Birth and Early InfancyVI. Death and DyingVII. Role of WomenVIII. 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
Dodi Meyer, MD, Emelin Martinez, Marina Catallozzi, MD, Rosa Morel
Community PediatricsAmbulatory Care Network- New York Presbyterian,
Columbia University Medical CenterAlianza Dominicana
HEALTH EDUCATION & ADULT LITERACY PROGRAM
Bridging the Communication Gap Between Medical Providers and Patients
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 LiteracyModeled 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 medicationadministration
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
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:Training driven by patient interest and prior knowledge
Information conveyed in a non didactical method
Curriculum Development
48
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.
49
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
FOCUS GROUPS FINDINGS
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
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:TylenolMotrin (> 6 months old)
DO NOT use:Vicks Vapor Rub Pediacare productsRobitussin productsTriaminic products Dimetapp productsOther medications in a the store
Ages 2 to 6 years:
DO use as directed:TylenolMotrin
Use ONLY after talking to a doctor:Pediacare productsRobitussin productsTriaminic productsDimetapp productsVicks Vapor Rub and Vicks products
HOW DO I CHOOSE AN OVER THE COUNTER COLD MEDICINE?
Uses: Tells you what it treats. Do you have these symptoms?
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.
Warnings: Reasons not to use or stop using the 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.
Purpose: The type of medicine.
The following label is the most recent U.S, Food & Drug Administration approved over-the-counter drug label format.
TOOLS TO MEASURE WITH:
OralSyringe
Dosage Cup
Tablespoon
Teaspoon
Dropper
• 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
Converting Units of Measurement
5 cc = 5 ml = 1 teaspoon (tsp)
=
Measuring Liquid Medicines
+ +
=
5 ml = 1 Teaspoon
15 ml = Tablespoon
5 ml = 1 Teaspoon
5 ml = 1 Teaspoon
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.
60
TRAINING
• Physicians– Pediatric residents– General Pediatric Faculty
• Medical students• Volunteers (from surrounding colleges)
• Family Support Workers
• Waiting Rooms at community based-hospital affiliated practices
• Clients’ homes enrolled in home visiting program
CURRICULUM IMPLEMENTATION
Evaluation
• Process
• Outcome
Caregivers Encountered in Waiting Rooms with HEAL Curriculum
609
502
0
100
200
300
400
500
600
700
Total Caregivers Approached Total Caregivers Interested inCurriculum
Rate of HEAL Topics Discussed
Topics Discussed in Waiting Room Patient Encounters
24%
18%
17%
12%
16%
10% 3%Preparing For A Visit
OTC
Prescription Medications
Medication Management
Home Remedies
The Cold & Flu
Use of Antibiotics
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
62%
38%Caregivers w ho w erecomfortable readinglabel and using OTC
Caregivers w ho haddiff iculties readinglabel and using OTC
34%
66%
Caregivers WhoDemonstratedDiscomfortReading Label
Caregivers WhoDemonstratedComfort ReadingLabel
0
50
100
150
200
250
300
1
Inc idences ofHome RemediesTopic Discussed
Patient uses homeremedies
Disc loses the Useof Home Remediesto Doctor
Understanding Prescribed Medication Labels.
Understanding OTCMedication Labels.
Use of Home Remedies.
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 ResearchMelissa 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
TrainingPediatricians,
residents, CHWs
ServiceIndividual patient encounters
with pediatricians and residents in waiting room and individual client encounters
with CHWs
Direct service: ACN Clinics & CBOs
Community-engaged research
Head Start/Early Head Start
/ER /CBO home visit
OutcomesHealth practices
ER use
HE
AL Curriculu
mFocus groups to
inform development and implementation
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
Healthy TomorrowsMaternal Child Health Bureau
in partnership with theAmerican Academy of Pediatrics
FUNDING PROVIDED BY:
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