SHIELD Your Patients Health Addressing Health Care Disparities for People with Physical Disabilities

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SHIELD Your Patients Health! Addressing Health
Care Disparities for People with Physical
Disabilities

• Suzanne L. Groah, MD, MSPH
• Brenda Gilmore, BFA
• National Rehabilitation Hospital
• Washington, DC

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• I make no claim, as other people with a
  disability might,
• that the essence of what I experience is
  inherently incommunicable to the able-bodied
  world.
• I do not believe that there is anything in the
• nature of having a disease or disability that
• makes it unsharable or even untellable.
• (Irving Zola, 1935-1994)

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The ProblemHealth Maintenance and Health
Promotion
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Demographics of Disability

• SIPP
• 1 in 5 Americans has a disability
• 53 of disabled are female

• NHIS
• 15.4 of women have activity limitations
• 14.6 of men have activity limitations
• Womens higher longevity affects results

and these numbers will be increasing with the
aging of the population
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Etiology of Activity Limitations

• Women
• Spine/back disorders
• Arthritis
• Heart disease
• Asthma
• Orthopedic
• Mental disorders
• Diabetes
• Learning disability/MR

• Men
• Spine/back disorders
• Heart disease
• Orthopedic
• Arthritis
• Asthma
• Learning disability/MR
• Mental disorders
• Diabetes

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Secondary Conditions

• 40 of people with disabilities have associated
  secondary conditions

• Heart disease
• Arthritis
• Hip fracture
• Diabetes
• Stroke
• COPD
• Visual impairment
• Osteoporosis

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Background

• People with physical disabilities have the same
  or higher risks for being affected by preventable
  health conditions than the general population
• People with physical disabilities have less
  access to and lower utilization rates of primary
  preventive services when compared to the general
  population

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Background

• Receipt of preventive health care services among
  people with physical disabilities remains below
  targets set forth in Healthy People 2010
• Gaps in access and utilization need to be closed
  through targeted, community-based intervention
  strategies

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Background

• Current research indicates that
• Adults with physical disabilities are less likely
  to receive many recommended preventive health
  care services
• Adults with physical disabilities who do receive
  these services often do not get them at the
  recommended times

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Health Care Services

• Women with disabilities report
• Inaccessibility in health care settings
• Health care providers lack knowledge of
  disability
• Perception of lower quality health care

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Health Care Services

• National survey of disabled women
• 39 were not spoken to directly by physician
• 31 had been refused care by a physician

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Health Care Services

• Reproductive health care
• 26 believe the physician is not well-informed
• 36 had difficulty finding a physician to manage
  pregnancy
• 56 reported hospital could not accommodate
  disability-related needs

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Health Care Services

• Sexuality
• Social barriers
• Limited opportunities to gain knowledge through
  experience
• Attitudinal barriers
• Presumption of asexuality
• Mental Health
• Substance and alcohol abuse

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Health Care Services

• Persons with disabilities consume a larger share
  of health care services

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Health Care Services

• Using the spinal cord injured population as the
  model
• Mobility/activity limitation
• Frequent secondary complications
• Osteoporosis
• Early CVD
• Bladder cancer
• Respiratory insufficiency
• Shoulder injuries/overuse
• Substance abuse
• Depression
• Altered body composition

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Osteoporosis

• Universal after SCI
• Primarily due to immobility?
• Bone resorption biomarkers evident within days
• 30-50 BMD loss by 6 months post-injury
• Bone loss predominates around knee
• Spine BMD often normal or elevated
• Impact heightened screening required
• Use of WHO guidelines for osteoporosis likely not
  applicable to these selected populations

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Bladder Cancer

• Associated with the use of indwelling catheters
• Greater predominance squamous cell
• Mortality exceedingly high
• Relative risk increased 5-fold
• Controlling for smoking, gender
• Impact
• Selective and aggressive screening in people
  utilizing indwelling catheters gt 5 years

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Cardiovascular Disease

• Using NCEP Guidelines, 75-80 of males with
  paraplegia (avg age 35 years) required treatment
• Disease occurs early and is often silent
• Low HDL
• Altered body composition
• Elevated post-prandial lipemia
• Elevated risk hyperglycemia
• Impact earlier screening required
• BMI tables not applicable

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Bridging the Gap
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Bridging Health Promotion and Primary Health Care

• Education of health care professional
• Identify and address barriers to health care
• Addressing the whole person
• Education of consumer
• Components of health promotion
• Periodic screening

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Addressing the Barriers to Health Care Identified
by People with Disabilities
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Part I Access Barriers for People with Mobility
Impairments

• A Primer for Health Care Professionals

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Goals

• To identify access barriers commonly encountered
  by people with physical disabilities/mobility
  impairments
• To discuss how these barriers can cause negative
  health consequences
• To present strategies for overcoming or removing
  these barriers

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Access Barriers

• Environmental
• Structural
• Attitudinal
• Combined or alone, these can cause
• negative health consequences for individuals
  with mobility impairment

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Environmental Barriers

• Physically inaccessible environments (e.g.,
  stairs, narrow doorways)
• Transportation
• Inaccessible equipment (e.g., high exam tables,
  mammogram equipment)

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Structural Barriers

• Health plan limitations and restrictions
• Office/health plan procedures (e.g., referrals,
  short appointment times)
• Health care costs

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Attitudinal Barriers

• Lack of knowledge about disability on the part of
  health care providers
• Always treating the patients disability as the
  primary health care issue
• Communication issues

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Strategies to Address Environmental Barriers

• Make sure front office staff, including the
  appointment desk, advise patients with disability
  of the accessibility limitations of the
  office/building environment
• Clear hallways, waiting areas, and rooms of extra
  clutter and/or chairs
• Reserve exam rooms with accessible tables for
  individuals with an SCI
• Be flexible if a patient is late for a scheduled
  appointment

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Strategies for Addressing Structural Barriers

• Allow patients with a disability extra time
  during their office visit (for un/dressing, using
  the restroom, discussing health care issues)
• Be cognizant of the logistics and costs of
  requiring multiple visits in order to address all
  of their health care issues

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Strategies for Addressing Attitudinal Barriers

• Be willing to learn about the specific disability
  from your patient he or she may know more about
  it than you do
• A person with a disability has the same
  preventive health care needs as someone without a
  disability (e.g., cholesterol and blood pressure
  checks, weight, flu shots) and are often
  physically and sexually active as well

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Consequences of Access Barriers

• Delayed or no receipt of health care services
• Diminished health and function
• Loss of faith and trust in the health care system
• Decreased independence and self-direction

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Little Changes Go a Long Way

• Allow extra time for an individual with physical
  disability
• Determine if exam rooms are truly accessible
• For the OB/Gyn and FPs, consider investing in an
  accessible exam table
• If patient weight is routinely obtained, consider
  investing in a wheelchair scale

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Bridging Health Promotion and Primary Health Care

• Education of health care professional
• Identify and address barriers to health care
• Addressing the whole person
• Education of consumer
• Components of health promotion
• Periodic screening

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Part II Project SHIELD

• A Primer for the Consumer with a Physical
  Disability

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Purpose of Project SHIELD Benefits for Consumers

• Increase access to primary preventive health care
  services among adults with physical disabilities
• Improve the health of adults with physical
  disabilities through education and empowerment

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Purpose of Project SHIELD Address Barriers to
Care

• Heighten health care provider awareness of the
  barriers to receipt of preventive health care
  experienced by adults with physical disabilities
• Develop strategies to address provider and
  environmental barriers to preventive care

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Project SHIELD Goals

• Year 1 Use a Participatory Action Research model
  to
• Develop health promotion materials for adults
  with physical disabilities
• Year 2 Hands-on evaluation of the Preventive
  Services Resource Kit
• Year 3 Dissemination
• Including alternative formats

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Focus Groups

• 5 focus group meetings, 36 participants
• Identify barriers to preventive services
• Consumer input on overcoming barriers
• Collect ideas on format/presentation of
  information

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Preventive Services Resource Kit (PRSK) Data
Sources

• Consumer Feedback
• Community Steering Committee
• Data from 5 focus groups
• NRH Research Publications
• Writings of June Kailes
• Internet Resources
• Government agencies
• Non-Profit Organizations
• Health Care provider organizations

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Content Areas for Preventive Services Resource Kit

• Information on staying healthy with a disability
• Information and tools to help adults with
  physical disabilities identify and address their
  health risks

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Content of Preventive Services Resource Kit

• Information about routine preventive screenings
• General screenings
• Gender-based screenings
• Immunizations
• Lifestyle counseling
• Tools for creating an individualized plan to get
  needed preventive care

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Content of Preventive Services Resource Kit

• Information and tools for becoming an active
  health care consumer, including strategies for
• Planning for a doctor visit
• What to do during the visit
• Follow-up after the visit
• Methods of effective communication with health
  care providers

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Content of Preventive Services Resource Kit

• In-depth information to learn more about
  preventive health care and why it is important
• Organizations and websites
• Tips for health care professionals who provide
  preventive care for adults with disabilities

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Primary Preventive Service Areas

• General Screenings
• Physical Exam (every 1 to 2 years)
• Blood pressure check
• Cholesterol check
• Blood stool test (age 40 and older)
• Height and weight measured
• Bone mineral density screening
• Gender-Based Screenings
• Pap smear (all sexually active women or women 18
  and older)
• Breast exam (women 18 and older)
• Mammogram (women 30 and older frequency depends
  on age and history)
• Dr. discuss prevention of bone loss
• Prostate exam (men 50 and older)

• Immunizations
• Flu shot (annually)
• Pneumonia shot (once in lifetime)
• Tetanus shot (every 10 years)
• Health Behavior Assessment
• Dr. asked about diet and eating habits
• Dr. asked about physical activity
• Dr. asked about smoking
• Dr. asked about alcohol consumption
• Dr. asked about birth control
• Dr. asked about drug use
• Dr. asked about sexually transmitted diseases

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For more information, contact Matthew.E.Kehn_at_Meds
tar.net, BrendaGilmore_at_Comcast.net,Suzanne.L.Groa
h_at_Medstar.net
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Thank You