Disparity in Care: A Problem with a Solution

1. Disparity in Care: A Problem with a Solution Presented by Marcy Donley Healthcare Communications Consultant

2. 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.

3. 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.

4. Reasons for Inequalities (cont.) • A healthcare professional’s 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.

5. 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.

6. “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

7. 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.”

8. 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?lvl=2&lvlid=15 • Executive Summary • http://www.omhrc.gov/assets/pdf/checked/executive.pdf

9. Healthcare Disparities Report • The Agency for Healthcare Research and Quality’s 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

10. 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/special needs).

11. 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.

12. 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.

13. 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.

14. Health Literacy

15. 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: IOM’s Health Literacy: A Prescription to End Confusion)

16. 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

17. 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.

18. 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

19. Low Literacy/Limited English Proficiency

20. 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.

21. Myths About Low Literacy (cont.) • Myth: People will tell you if they can’t 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 “I’ll have to take this home for my husband (or wife) to see it first.”

22. 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.

23. 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

24. 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.

25. 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.

26. Speaking for Low Literacy • Avoid jargon and use everyday examples to explain technical or medical terms. • “Read” written instructions out loud. • Speak slowly (don’t shout). • Draw pictures; use posters or models; use video or audio.

27. $50,000 Words • A television news anchor asked a physician on air about a celebrity’s 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.

28. 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.

29. 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

30. Cultural Competency

31. 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

32. 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 • Don’t interrupt or be offended by interruption Source: Industry Collaboration Effort

33. 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.

34. 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 patient’s 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 person’s cultural and personal background.

35. Cultural Considerations (cont.) • Communication Style  English predisposes us to a direct communication style, however other languages and cultures differ. • Formal or informal?If the patient’s 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.

36. 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

37. 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

38. 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

39. Resources

40. Assessment Tools • Organizational • Policy • Health Practitioner • http://www.hrsa.gov/culturalcompetence/

41. 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

42. Cultural Competency Resources (cont.) • National Center for Cultural Competence • http://www11.georgetown.edu/research/gucchd/nccc/

43. Health Literacy Resources • NIH “Clear Communication” Health Literacy Initiative • http://www.nih.gov/clearcommunication/index.htm

44. Low Literacy Resources • MedlinePlus Easy to Read Brochures by Health Condition • http://www.nlm.nih.gov/medlineplus/easytoread/easytoread_a.html

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

46. In-Language Resources • National Network of Libraries of Medicine Health Brochures in Other Languages • http://nnlm.gov/outreach/consumer/multi.html#A2#A2 • Healthy Roads Media (Health resources in many languages and multiple formats. • http://www.healthyroadsmedia.org/index.htm

47. 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/

48. 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/

49. 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.

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