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Culturally Effective Pediatric Care in a Community-based Health Program

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.

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Culturally Effective Pediatric Care in a Community-based Health Program

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  1. Culturally Effective Pediatric Care in a Community-based Health Program April 7, 2011 -Denice Cora-Bramble MD, MBA, FAAP-Dodi Meyer MD, FAAP

  2. 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.

  3. 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

  4. Overview • Culturally Effective Care • AAP toolkit development • Website architecture • Case studies & application of toolkit resources • Q&A

  5. 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?

  6. Culturally Effective Care

  7. 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

  8. Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC: National Academies Press, 2001 Quality of Care Safety EQUITY No variations in the quality of care according to patients’ personal characteristics, including race and ethnicity Effectiveness Patient centeredness Timeliness Efficiency Equity

  9. Diversifying U.S. Population

  10. 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

  11. AAP Toolkit Development

  12. 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

  13. Culturally Effective Care Toolkit Needs Assessment ResultsSeptember 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? n=278

  14. 74.1% 74.1% 80.0% 70.0% 55.1% 60.0% 50.0% 40.0% 32.3% 26.6% 25.1% 30.0% 20.0% 11.0% 10.3% 10.0% 0.0% Web-based Resources Patient Materials in Other Languages Culturally Effective Care Manual Topic-specific CME DVD/Video Loan Library Interpretive Services Information Best 10 Articles Annotated Bibliography Culturally Effective Care Toolkit Needs Assessment ResultsSeptember 2009 Which specific delivery mechanisms for culturally effective care resources would be most useful for you? (check top 3 delivery mechanisms) n=263

  15. Culturally Effective Care Toolkit Needs Assessment ResultsSeptember 2009 Which specific topics would be most helpful for a culturally effective care toolkit to include? (check top 3 tools) n=263

  16. Website Architecture

  17. Case studies & application of toolkit resources

  18. 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?

  19. 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

  20. 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

  21. 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

  22. 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

  23. Toolkit Resource: Interpretive Services Section • 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

  24. 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?

  25. 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

  26. 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

  27. 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

  28. 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.

  29. 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

  30. 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

  31. Culturally Effective Toolkit: Health Beliefs and Practices • 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

  32. Culturally Effective Care Toolkit: What Is Culturally Effective Pediatric Care?

  33. 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

  34. 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 dcorabra@cnmc.org

  35. HEALTH 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 AlianzaDominicana

  36. 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

  37. 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.

  38. 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

  39. 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 medication administration

  40. 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.

  41. HEAL: Principles Used • Partnership model • Participatory, collaborative process • Link to existing coalitions, organizations

  42. Target Population • All patients in community based-hospital affiliated practices • Clients served by a Home Visiting Program ( Best Beginnings/ AlianzaDominicana)

  43. 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

  44. 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: Training driven by patient interest and prior knowledge Information conveyed in a non didactical method

  45. 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

  46. 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

  47. 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

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