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Warrior Centric Healthcare Training (WCHT)®

“The Need for Cultural Competency Training for Military and Veteran Communities”

Evelyn L. Lewis, MD, MA, FAAFP Ronald J. Steptoe, CMR

The Steptoe Group

You Must Know Me To Treat Me®

Video

Please visit the following url after the webinar to view the above mentioned video.

http://youtu.be/NxsqWXLNDVE

Demographics of Today’s Veterans

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Did you know? 74% are Wartime Veterans

Remember: 60% are NOT registered with the VA

Who is treating them??

Problem – Solution - Outcome

Vietnam Studies Rand Report – “Invisible Wounds” Steptoe Group – Market Study (National Capital Area) Joint Commission - (JCAHO) – new standards National Standards on Culturally and Linguistically Appropriate Services (CLAS) Accreditation Council for Graduate Medical Education (ACGME) Integration of military culture, cultural competency and patient-centric communications into treatment methodologies Providers who are better trained to accommodate the unique and evolving needs of culturally diverse service members, veterans, and their families impacted by war and service.

Problem -

Solution –

Outcomes -

Recommendations On Care Management Of Mental And Behavioral Health Conditions

Research findings from the Rand Report-Invisible Wounds of War (2008)

Final Report of the Defense Task Force on the Prevention of Suicide by Members of the Armed Services (2010)

DoD Recovering Warrior Task Force Report (2011)

Army’s Generating Health and Discipline in the Force Ahead of the Strategic Reset (2012)

The Joint Commission (2012) recommendations

Substance Use Disorder – Institute of Medicine Report on the DoD (2012).

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Research findings from the Rand Report-Invisible Wounds of War (2008)

Healthcare and service support providers - demonstrate requisite knowledge of unique military culture, military employment, and issues relevant to veterans.

Establishing regional training centers for joint training of DoD, VA, and civilian providers in evidence-based care for PTSD and major depression.

Linking certification to training to ensure that providers not only receive required training but also are supervised and monitored to verify that quality standards are met and maintained over time.

Final Report of the Defense Task Force on the Prevention of Suicide by Members of the Armed Services (2010)

Ensure all “helping professionals” are trained in competencies to deliver evidence based care for the assessment, management, and treatment of suicide related behaviors (Strategic Initiative 3E – recommendation 61)

The Joint Commission – New Requirements (2012) – New Requirements

Patient Centered Communication – training to advance: 1) effective communication, 2) cultural competency, 3) patient and family centered care

Substance Use Disorder – Institute of Medicine Report on the DoD (2012).

The increased prevalence of co-morbid behavioral health diagnoses necessitates access to providers with advanced levels of training rather than certified counselors or peer support by individuals in recovery.

WHO ARE THE 21.8 MILLION

U.S. VETERANS?

http://www.census.gov/how/infographics/veterans.html# The 2010 American Community Survey is a survey and its estimates are subject to sampling error.

http://www.census.gov/how/infographics/veterans.html#

BREAKDOWN BY GENDER

The 2010 American Community Survey is a survey and its estimates are subject to sampling error.

http://www.census.gov/how/infographics/veterans.html#

The 2010 American Community Survey is a survey and its estimates are subject to sampling error.

Post-traumatic Stress Disorder • Detachment and estrangement from loved ones • Insomnia, fatigue, irritability, poor concentration • Hypervigilance and exaggerated startle response • Intrusion (memories of the trauma, “flashbacks”) • Avoidance (avoiding situations that are reminders) • Hyperarousal (feeling constantly threatened,

suddenly irritable or explosive) • Persistent and distorted blame of self or others; and,

persistent negative emotional state * • reckless or destructive behavior * * New DSM 5 revisions

Determinants of Mental Health

• Individual Biology • Individual Behavior • Social Environment • Physical Environment • Access to Quality Care • Policies & Interventions

Influence of Culture on Mental Illness and Mental Health

• How patients communicate • How patients manifest symptoms • How patients cope • Range of family and community

support • Willingness to seek treatment • Moral Injury

U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001

Factors in Mental Health, Mental Illness and Service Use

• Economic impoverishment • Mistrust • Fear • Cultural and social influences • Biological, psychological and environmental

factors • Discrimination

U.S. Dept. of Health and Human Services Office of the Surgeon General, SAMHSA August 2001

Differences in Seeking Mental Health Care

African Americans: more likely to use emergency services or primary care providers than mental health specialists. (Surgeon General, 2001)

Asian Americans: Only 4% would seek help from mental health specialist vs. 26 percent of whites. (Zhang et al., 1998)

Latinos: < 1 in 11 with mental disorders contact mental health specialists, & < 1 in 5 contact primary care providers. (Surgeon General, 2001)

Native Americans: 44% with a mental health problem sought any kind of help--and only 28% of those contacted a mental health agency. (King, 1999)

Mental Health Disparities

• Underdiagnosis and undertreatment of anxiety and mood disorders

• Differential prescribing patterns • Lower metabolism of certain

psychotropic medications • More side effects and less adherence • More seclusion and restraint

Ethnocultural Influences on Mental Health Care Outcomes

Direct influence: • Cultural beliefs and preferences • Pathoplasticity (predisposing or

provoking agents) • Ethnopsychopharmacology

Ethnocultural Influences on Mental Health Care Outcomes

Indirect influence: • Bias and stereotyping • Misinterpretation of behavior and belief • Lack of symptom recognition • Misdiagnosis and inappropriate

treatment • Ignorance of ethnocultural issues

Other factors in a combat situation that may contribute to PTSD and other mental health issues

•What the individual does in the war

•The politics around the war

•Where the fighting takes place

•Type of enemy faced (National Center for PTSD 2009)

Epidemiology of PTSD in Diverse Populations

• African Americans had more exposure to war stresses and more predisposing factors which when controlled for, differences from Whites disappeared

• Among Hispanics disparity in PTSD compared to Whites remained even after controlling for greater exposure to war stresses

National Center for PTSD, www.ncptsd.va.gov, accessed 2/16/09

Steptoe Group’s - Medically Accredited Warrior-Centric Healthcare Training(WCHT)® System Session #1: Military and Veteran Culture In the

Clinical Setting • Contrast explicit and implicit characteristics of military

and veteran culture • State relevancy of cultural competency communication

training for patient-provider interactions Session #2: Cultural Competency In Military and

Veteran Communities • Determine the relevancy of cultural communications

training • Demonstrate comprehension of cultural competency

during interactive case studies • Identify personal cultural biases and beliefs Session #3: Neurobiology of PTSD and TBI • Review the characteristics of PTSD and TBI • List areas of neuropsychological assessment • Discuss pharmaceutical and therapeutic interventions Session #4: Patient-Provider Communication In the

Military and Veteran Communities • Execute communication strategies that enhance

targeted outcomes • Build cultural communication strategies into

clinical practice

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2011 Choice Award, Excellence in a Medical Specialty

2010 Winner , Veteran Braintrust Award

2010, National Medical Accreditation Awarded

A CULTURE WITHIN CULTURES

•The Military is a distinctive culture with distinguishing signs and symbols.

•However, each warrior belongs simultaneously to many additional cultures as well.

•Understanding the interplay between and among the co-existing cultures of a warrior is critical to establishing tailored and effective healthcare services and outcomes.

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TBI/PTSD Link and the Military

• TBI: 19% of all those returning from OEF/OIF (RAND)

• 44% returnees from Iraq who reported TBI with LOC and post concussive symptoms 3 to 4 months after re-deployment met criteria for PTSD

• 27% with altered consciousness met criteria

• 16 % with other injuries met criteria

• 9% no injuries met criteria

Hoge CW, Goldberg HM, Castro CA. Care of war veterans with mild traumatic brain injury—flawed perspectives. N Engl J Med. 2009; 360(16): 1588-1591.

Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist

Recovery. 2008, RAND Corporation: Washington, DC.

Rates of Psychiatric Illness after TBI

• 12 months after the event: 31% • 22% suffered disorders they never had before • PTSD, anxiety disorders, depression • Progressive dementia, Alzheimer’s (10x risk) • Progressive rates of CVD, CA, DM have also been noted

Bryant RA, O’Donnell ML, Creamer M, McFarlane AC, Clark CR, Silove D. The psychiatric sequelae of traumatic injury. Am J

Psychiatry. 2010 Mar; 167(3): 312-330. Mayeux R, Ottman R, Maestre G, et al. Synergistic effects of traumatic head injury and apolipoprotein-epsilon 4 in patients with

Alzheimer’s disease. Neurology. 1995; 45(3 Pt 1): 555-557.

Figure 1. Two or more chronic conditions among men aged 25–64, by age group and veteran status: United States, 2007–2010

NOTE: Conditions include diabetes, hypertension, heart disease, cancer (excluding nonmelanoma skin cancer), stroke, chronic bronchitis, emphysema, asthma, and kidney disease. SOURCE: CDC/NCHS, National Health Interview Survey, 2007–2010.

FACTORS THAT IMPACT EFFECTIVE COMMUNICATION

• Trust • Health Literacy • Language Access • Bias, Stereotyping, and “isms” • Culture

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SO WHAT! WHAT DO I DO NEXT?

“ MENTAL CHECKLIST”

L.E.A.R.N. Listen

Explain Acknowledge

Recommend Tx Negotiate Agreement

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Importance of Patient-Provider Communications E.T.H.N.I.C.

Explanation Treatment

Healer Negotiate

Intervention Collaboration

B.A.T.H.E. Background

Affect Trouble

Handling Empathy

Active Listening, Encouragement, and Legitimization Berlin E. A. and Fowkes, W.C. Jr: A Teaching Framework for Cross-Cultural Health Care, Western Journal of Medicine of Medicine 1983, 139:934-938

Levin, S.J., Like, R.C., and Gottlieb, J.E. (2000) ETHNIC: A framework for culturally competent clinical practice. In Appendix: Use clinical interviewing mnemonics. Patient Care, 34 (9): 188-189

Stuart, M.R. and Lieberman, J. A III. The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care, 3rd Edition. Philadelphia, PA: Saunders, 2002

EXPLANATORY MODEL OF ILLNESS 1. People from different cultural backgrounds often have very different ways

of understanding illness, its consequences, and how best to treat it – a different explanatory model.

2. Every culture uses some element or version of an explanatory model for the origins of disease/illness.

3. Beliefs regarding disease causality tend to be consistent with cultural and personal values and behavior, and social training.

4. In addition to culture, education and socioeconomic factors influence beliefs regarding disease.

5. Health care providers can best individualize care when they understand how the patient and family experience health and illness.

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Hallenbeck J, Goldstein MK, Mebane EW. Cultural considerations of death and dying in the United States. Clinics in Geriatrics. 12(2); 1996:393-406. Kleinman A. Culture, illness and cure: Clinical lessons from anthropologic and cross-cultural research. Annals Int Med. 1978; 88:251-258.

Substance Abuse

Poor Physical Health STIs, DM, CAD, CA, etc

Poverty, Homelessness, Unemployment

Unmet Mental Health Needs

Violence, Trauma and Incarceration

Vicious Cycle

Used and Adapted with permission from Dr. Annelle Primm, MD

Resources

• You Must Know Me to Treat Me video® – http://youtu.be/NxsqWXLNDVE

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Q & A