Disparity%20in%20Care:%20%20A%20Problem%20with%20a%20Solution

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Disparity in Care A Problem with a Solution

• Presented by Marcy Donley
• Healthcare Communications Consultant

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Data on Existence of Disparities

• In 2002, the IOM released Unequal Treatment
  Confronting Racial and Ethnic Disparities in
  Health Care.
• It reported evidence of healthcare inequality ?
  irrespective of income, insurance status, or
  education.

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Reasons for Inequalities

• Subtle differences in the way individuals respond
  to treatment.
• Variations in individual help-seeking behavior.
• Barriers in language proficiency, literacy level
  and cultural beliefs.

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Reasons for Inequalities (cont.)

• A healthcare professionals beliefs may
  influence patient interaction.
• The healthcare professional may be limited in the
  amount of time available to gather information.
• An unconscious prejudice or bias may exist.

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Why Is It Important?

• The US Census Bureau estimates that by 2050, one
  in every two Americans will be an
  African/American, Hispanic/Latino, American
  Indian/Alaskan Native, or Native Hawaiian/Pacific
  Islander.

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• Health care providers should be made aware of
  racial and ethnic disparities in health care, and
  of the fact that these disparities exist, often
  despite providers best intentions. In addition,
  all current and future health care providers can
  benefit from cross-cultural education programs.
• Unequal Treatment Confronting Racial and
  Ethnic Disparities in Healthcare
• Institute of Medicine, March 2002

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Title VI -- Civil Rights Act of 1964

• No person in the United States shall, on the
  ground of race, color or national origin, be
  excluded from participation in, be denied the
  benefits of, or be subjected to discrimination
  under any program or activity receiving federal
  financial assistance.

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CLAS Standards

• National Standards for Culturally and
  Linguistically Appropriate Services (CLAS) in
  Health Care Final Report, OMH, 2001
• The Standards
• http//www.omhrc.gov/templates/browse.aspx?lvl2l
  vlid15
• Executive Summary
• http//www.omhrc.gov/assets/pdf/checked/executive.
  pdf

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Healthcare Disparities Report

• The Agency for Healthcare Research and Qualitys
  National Healthcare Disparities Report was one of
  the first efforts (2003) to measure differences
  in health care by various populations.
• An annual report is released along with the
  National Healthcare Quality Report.
• http//www.ahrq.gov/qual/nhdr08/nhdr08.pdf

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Purpose of NHDR

• Identify the differences or gaps where some
  populations receive poor or worse care than
  others and to track how these gaps are changing
  over time.
• Emphasis is on disparities related to race,
  ethnicity, and socioeconomic status.
• Also includes priority populations (women,
  children, older adults, rural, disabilities/specia
  l needs).

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2008 Report Key Findings

• Disparities persist in health care quality and
  access.
• Magnitude and pattern of disparities are
  different within subpopulations.
• Some disparities exist across multiple priority
  populations.

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National Focus on Cultural and Linguistic
Competency

• Since it has been found that cultural
  expectations, assumptions, and language affect
  the quality of care patients receive
• Efforts have focused on improving the skills of
  health care professionals to deliver culturally
  and linguistically competent care for diverse
  populations.

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Goals for Today

• Make you aware that cultural expectations,
  assumptions, and language affect the quality of
  care patients receive.
• Bring you the best of available research, tools
  and resources to improve cultural and linguistic
  competency.
• Encourage self and organizational assessment and
  improvement that facilitates bridging the gap in
  healthcare disparities.

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Health Literacy

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Health Literacy

• Poor health literacy is "a stronger predictor of
  a person's health than age, income, employment
  status, education level, and race. (Source
  AMA)
• 90 million people in the United States (nearly
  half the population) have difficulty
  understanding and using health information.
  (Source IOMs Health Literacy A Prescription to
  End Confusion)

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What is Health Literacy

• Health literacy is the degree to which
  individuals have the capacity to obtain, process,
  and understand basic health information and
  services needed to make appropriate health
  decisions.
• Adopted by the IOM and Healthy People 2010

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More Than Reading or Writing

• Health literacy is the ability to
• Comprehend complex vocabulary and concepts
  including medical terms or probability and risk.
• Share personal information with providers about
  health history and symptoms.
• Make decisions about basic behaviors like healthy
  eating and exercise.

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Health Literacy Definition (cont.)

• Engage in self-care and chronic-disease
  management.
• Navigate a complex healthcare system ? from
  walking hospital corridors to filling out
  insurance forms.
• Source HHS Office of Disease Prevention and
  Health Promotion

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Low Literacy/Limited English Proficiency

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Myths About Low Literacy

• Myth People who have limited literacy skills are
  dumb and learn slowly, if at all.
• Fact Most people with low literacy skills have
  average IQs and function quite well.

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Myths About Low Literacy (cont.)

• Myth People will tell you if they cant read.
• Fact Since there is a strong social stigma
  attached to limited reading and writing skills,
  nearly all nonreaders or poor readers will seek
  to conceal this fact. They will use ruses such as
  I forgot my glasses or Ill have to take this
  home for my husband (or wife) to see it first.

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Myths About Low Literacy (cont.)

• Myth Years of schooling is a good measure of
  literacy level.
• Fact Years of schooling tell what people have
  been exposed to, not what reading skill they
  acquired. Surveys show that, on average, adults
  currently read three to five grade levels lower
  than the years of schooling completed.

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Writing for Low Literacy

• Organize information so the most important
  behavioral or action points come first
• Break complex information into smaller,
  understandable chunks
• Use simple language or define technical terms

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Writing for Low Literacy (cont.)

• Use short sentences and active voice.
• Design for impact use ample white space, bullets
  for lists/numbers for steps.
• Check reading level (MS Word can check RL and
  grammar)
• Test materials with audience.
• Consider using translated or easy-to-read patient
  materials.

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Reading Level

• Contact your insurance carrier at least 24 hours
  before your planned admission time to obtain
  needed referrals or authorizations. Because many
  insurance companies have strict guidelines about
  covered services, where they can be done and
  which physicians can provide them, your insurance
  company must be involved in your admission to the
  hospital. Even though the hospital's admissions
  office will contact your insurance company, there
  may be information only you can provide.

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Speaking for Low Literacy

• Avoid jargon and use everyday examples to explain
  technical or medical terms.
• Read written instructions out loud.
• Speak slowly (dont shout).
• Draw pictures use posters or models use video
  or audio.

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50,000 Words

• A television news anchor asked a physician on air
  about a celebritys cancer. The doctor stated
  Well, the cancer has metastasized.
• The TV anchor immediately realized that most
  viewers may not understand what the word
  metastasized means. He asked the doctor to
  explain.
• The doctor was quick to say that metastasize
  means the cancer has spread or traveled to
  other parts of the body.

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Teach Back Method

• Ask the patient to restate the conversation in
  their own words. Example Ask them to repeat back
  instructions on taking a prescribed medication.
• When their understanding is not accurate or
  complete, repeat the information until is it
  restated correctly.
• You can also ask the patient to show you how they
  will conduct a process, such as checking and
  recording blood sugar.

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Limited English Proficiency

• Assess percentage of foreign language use in your
  population, consider translating commonly used
  materials
• Consider using professional interpreters assess
  staff capabilities
• Consider offering language translation telephone
  service

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Cultural Competency

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What is Culture?

• Culture refers to integrated patterns of human
  behavior of racial, ethnic, religious, or social
  groups that include
• Language/Communications
• Actions/Customs
• Beliefs/Values/Institutions

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Cultural Considerations

• Style of Speech ? People vary greatly in length
  of time between comment and response, the speed
  of their speech, and their willingness to
  interrupt.
• Tolerate gaps impatience may be seen as rude
• Modify your speech to match that of the other
  person
• Dont interrupt or be offended by interruption
• Source Industry Collaboration Effort

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Cultural Considerations (cont.)

• Eye Contact ? The way people interpret various
  types of eye contact is tied to cultural
  background and life experience.
• Euro-Americans may interpret an indirect gaze as
  a sign of disrespect. Other cultures may see
  direct eye contact as rude.
• If someone seems uncomfortable with direct gaze,
  try sitting next to the person instead of across
  from them.

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Cultural Considerations (cont.)

• Body Language ? Sociologists say that 80 of
  communication is non-verbal. Body language varies
  greatly by culture, class, gender, and age.
• Follow the patients lead on physical distance
  and touching.
• Be very conservative in your own use of gestures
  and body language.
• The way that pain or fear is expressed is closely
  tied to a persons cultural and personal
  background.

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Cultural Considerations (cont.)

• Communication Style ? English predisposes us to a
  direct communication style, however other
  languages and cultures differ.
• Formal or informal? If the patients preference
  is not clear, ask how they would like to be
  addressed.
• Patients from other backgrounds may not ask
  questions or answer with narrative.
• Avoid yes/no questions. Ask open-ended questions.

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Culture by Ethnicity - Latino

• Illness may be seen as an imbalance between
  internal and external. (hot vs. cold, natural vs.
  unnatural, etc.)
• Many patients seek care from folk healers.
• The mother decides when to seek medical care, the
  father gives permission.
• La Familia is an important source of emotional
  support.
• Relationships are extremely important.
• Source Culture Clues University of Washington
  Medical Center

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Culture by Ethnicity - Asian

• Health may be viewed as finding harmony between
  complementary energies.
• May use foods to restore yin/yang balance.
• May try traditional approaches first may
  consider Western medicine too strong.
• Emphasis on loyalty to family/traditions not on
  individual feelings.
• Family may not tell patient bad news.
• Source Culture Clues University of Washington
  Medical Center

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Culture by Ethnicity - AI/AN

• A holistic view in which people, community,
  nature, and spirituality are interconnected and
  interrelated.
• Practices may include different rituals and
  ceremonies as well as herbal remedies (sweat
  lodge, talismans)
• Family and community (tribe) may be involved
  and source of support.
• May resist expressions of pain.
• Source Culture Clues University of Washington
  Medical Center

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Resources

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Assessment Tools

• Organizational
• Policy
• Health Practitioner
• http//www.hrsa.gov/culturalcompetence/

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Cultural Competency Resources

• EthnoMed University of Washington Medical
  Center
• Information about cultural beliefs, medical
  issues and other related issues pertinent to the
  health care of recent immigrants.
• http//ethnomed.org

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Cultural Competency Resources (cont.)

• National Center for Cultural Competence
• http//www11.georgetown.edu/research/gucchd/nccc/

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Health Literacy Resources

• NIH Clear Communication Health Literacy
  Initiative
• http//www.nih.gov/clearcommunication/index.htm

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Low Literacy Resources

• MedlinePlus Easy to Read Brochures by Health
  Condition
• http//www.nlm.nih.gov/medlineplus/easytoread/easy
  toread_a.html

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LEP Resources

• Guide to Implementing Language Access Services
• Assists healthcare organizations in planning,
  implementing, and evaluating language access
  services.
• https//www.thinkculturalhealth.org/LanguageAccess
  Services.asp

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In-Language Resources

• National Network of Libraries of Medicine Health
  Brochures in Other Languages
• http//nnlm.gov/outreach/consumer/multi.htmlA2A2
  
• Healthy Roads Media (Health resources in many
  languages and multiple formats.
• http//www.healthyroadsmedia.org/index.htm

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Quality Improvement Resources

• Multicultural Healthcare A Quality Improvement
  Guide (Based on CLAS Standards)
• New resource from the National Committee for
  Quality Assurance, developed in collaboration
  with Lilly USA
• QI initiatives to improve culturally and
  linguistically appropriate services (CLAS) and to
  reduce disparities in health care
• http//www.clashealth.org/

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Continuing Education Resources

• Think Cultural Health -- free online courses
  with continuing education credits for physicians
  and nurses.
• Sponsored by the Office of Minority Health (OMH)
• https//www.thinkculturalhealth.org/

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Conclusion

• The 2008 National Healthcare Disparities Report
  concluded that some Americans receive even worse
  care than other Americans, due in part to
  differences in access to care, provider biases,
  poor provider-patient communication, poor health
  literacy, and other factors.

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Thank you for being part of the growing
nationwide effort to help bridge the gap in
health disparities.