Medical Home in Pediatrics: The HOW TO Webinar Series brought to you by the National Center for Medical Home Implementation - PowerPoint PPT Presentation

1 / 51
About This Presentation

Medical Home in Pediatrics: The HOW TO Webinar Series brought to you by the National Center for Medical Home Implementation


Pediatric Partners of Mobile, Alabama March 27, 2013 ... A Disparity Emerges Pediatric Nutrition Surveillance 2009 Contra Costa ... – PowerPoint PPT presentation

Number of Views:226
Avg rating:3.0/5.0
Slides: 52
Provided by: medicalho8


Transcript and Presenter's Notes

Title: Medical Home in Pediatrics: The HOW TO Webinar Series brought to you by the National Center for Medical Home Implementation

Medical Home in Pediatrics The HOW TO Webinar
Seriesbrought to you by the National Center for
Medical Home Implementation
How To Enhance Care Delivery for Diverse Patient
PopulationsDiane Dooley, MD, FAAPContra Costa
Regional Medical Center, California Dwight
Yoder, MD, FAAPPediatric Partners of Mobile,
AlabamaMarch 27, 2013
  • We have no relevant financial relationships with
    the manufacturers(s) of any commercial
    products(s) and/or provider of commercial
    services discussed in this CME activity.
  • We do not intend to discuss an
    unapproved/investigative use of a commercial
    product/device in my presentation.

Webinar Objectives
  • By the end of this webinar, the participant will
    be able to
  • Review the importance of effective provision of
    comprehensive care for patients and families who
    are vulnerable and/or medically underserved
  • Explore specific strategies to deliver pediatric
    care in a culturally competent manner
  • Highlight practical tools that can be used to
    assess patient and family needs in a culturally
    competent manner

Did You Know
  • The portion of US children who are minorities has
    grown substantially
  • By the year 2020, 44.5 of American children 0 to
    19 years of age will belong to a racial or ethnic
    minority group
  • Hispanic children represent 1 out of 4 births
  • Almost 1 in 4 parents in the US are immigrants
  • 73.9 of Hispanic and 67 of non-Hispanic, black
    children did not meet all of the criteria used to
    measure quality of care, compared to 51.3 of
    white children
  • Children and youth with special health care needs
    who were Hispanic (32.2) or non-Hispanic Black
    (36.8) were far less likely to have families who
    reported that they had a medical home than White,
    non-Hispanic children (52.8)
  • Minority children have high rates of unmet mental
    health needs 88 of Latino children have unmet
    mental health needs while black children are more
    likely to be sent to the juvenile justice system
    for behavioral problems than placed in
    psychiatric care.

References America's Children in Brief Key
National Indicators of Well-Being, 2012
March 2009 CPS, estimates by Pew Hispanic
Center, US Census Bureau.
Middle Series, 20162020. Washington, DC.
National Center for Health Statistics NCHS,
2007 Childrens Defense Fund http//www.childrens
Culturally Effective Care Toolkit Needs
Assessment Results (September 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
Culturally Effective Care
  • Culturally effective care is the delivery of care
    within the context of appropriate physician
    knowledge, understanding, and appreciation of
    cultural distinctions leading to optimal health
  • Culture is used to signify the full spectrum of
    values, behaviors, customs, language, race,
    ethnicity, gender, sexual orientation, religious
    beliefs, socioeconomic status, and other distinct
    attributes of population groups.

Ensuring Culturally Effective Pediatric Care
Implications for Education and Health Policy,
Pediatrics 20041141677
Communicating with Diverse Populations
Diane Dooley, MD, FAAPContra Costa Health
ServicesMartinez, California
Contra Costa Health Plan
  • Medicaid Managed Care Health Plan
  • Covers 110,000 low income children, mothers and
  • Majority of services provided at Contra Costa
    Regional Health Center Clinics

58 of parents report not speaking English very
well 50 prefer Spanish
Pediatric Obesity A Disparity Emerges
Pediatric Nutrition Surveillance 2009Contra
Costa BMI-for-age gt 95ile
Causes of Health Disparities
  • Community level factors
  • Healthcare system-level factors
  • Care Process-Level variables
  • Clinical uncertainty
  • Clinical concerns regarding efficacy
  • Limited resources for language
  • interpretation, translation
  • Time Pressure

Differences in health care outcomes for diverse
populations often result from issues of
communication, culture and context -RWJ Equity
Pediatric Obesity and Disparities
  • Language concordance between physicians and
    patients increases the quality of care,
    compliance with treatment and follow up and
    increases patient satisfaction.
  • Hispanic families are more likely to report that
    clinicians did not spend enough time discussing
    physical activity quality of nutrition and
    physical activity advice rated poor or fair
  • California State law and Title VI of the Civil
    Rights Act require that health systems provide
    interpretation and translation services to
    limited English proficient patients

Medical Literature
Measurement Chart reviews
  • Identified evidence-based practice guidelines,
    MediCal Managed Care measurements and
  • Develop chart tool
  • Serial chart audits with interval feedback and
    query with physician group

272 Charts reviewed June 2010 March 2011
Measurement Patient survey
  • Literature review and clinical queries regarding
    important aspects of care
  • Satisfaction, counseling, intended changes,
    respect, health education, language use,
  • Used some validated questions from CAHPS,
    developed own questions
  • Survey reviewed with promotoras, literacy level
    adjusted, translated

73 Surveys reviewed June 2010 March
2011 Response rate 26
Baseline Chart Review
Language Communication
Survey results and chart reviews showed many gaps
and uncertainties in communication
  • 81 of patients were very satisfied with their
    recent visit. Almost all patients planned to make
    lifestyle changes
  • 85 of Spanish-speaking patients reported that
    their provider either spoke their language or
    used an interpreter
  • 79 of Spanish-speaking families received care
    without documentation of interpreter use or
    provider certification

Provider focus groups
  • Providers reported inadequate resources for
    patient education, group appointments, follow-up

Questions were asked about the certification
Low literacy tools
Latino staff members shared cultural issues
regarding food and obesity
Providers and patients agreed that care should be
provided in the familys preferred language
Many providers commented that they did not feel
comfortable with the use and availability of
interpreter devices
Language Access Supports
System policies regarding identification of race,
ethnicity, language preference
Identification of need
Ongoing recruitment of bilingual staff, stipend
for bilingual status, requirement for hiring in
certain positions
Bilingual staff
Interpreter access
Health Care Interpreter Network available, along
with ad-hoc interpreters
Health Care Interpreter Network
  • The Health Care Interpreter Network (HCIN) is a
    cooperative of California hospitals, and clinics
    sharing trained health care interpreters through
    an automated video/voice call center.
    Videoconferencing devices and all forms of
    telephones throughout each hospital and clinic
    connect within seconds to an interpreter on the
    HCIN system, either at their own hospital and
    clinic or at another participating hospital and

Language Access - Challenges
Time constraints
Provider certification
Interpreter costs and qualifications
  • Resident physicians reported many barriers to
    using interpreters in the clinic setting,
    especially time constraints, convenience,
    normalization of underuse by peers and mentors
  • Objective Spanish-language testing in combination
    with education and enforceable policies may play
    an important role in decreasing non-proficient
    Spanish use and improving care for LEP patients

Language Access - Challenges
Clinic flow and support
Culturally appropriate resources and referrals
  • Patients using some form of interpreter had
    longer mean provider times (32.4 min vs. 28 min)
  • Provider self-perceived cultural competency was
    associated with discussion of sensitive topics,
    parental reports of quality of well child care
    more than language concordance

Improvements in Care
Language and culture are critical components of
care in pediatrics
  • Language concordance is difficult to measure and
  • Systems improve their performance when they move
    from getting by to a culture of equity
  • Access to interpreter services, and increased
    cultural competency improves care, but is
    difficult to accomplish

  • Kaiser Permanente Clinical Cultural and
    Linguistic Assessment
  • RWJ Roadmap to Reduce Disparitieswww.solvingdisp
  • Health Care Interpreter
  • References available on PubMedwww.ncbi.nlm.nih.g

Dwight Yoder, MD, FAAPPediatric Partners of
Mobile, Alabama
What do we do when we have a patient in the
office who does not speak English?
  • Verbal language as a subset of communication
  • Cultural awareness as a tool
  • Patterns of behavior that are evolving

Welcome to Mobile
  • An old city with rich, diverse culture
  • Early French and Spanish culture
  • Recent wave of Asian immigration

Vietnamese in Mobile
  • 2010 Census 8,000 Asian inhabitants in Mobile
  • Majority of Asians from Vietnamese Community
  • These numbers do not include mixed race families

Vietnamese in Mobile
  • Lower Middle Income Shop Owners
  • Variety of Skilled and Unskilled Laborers
  • Some Professionals in Business, Engineering, and

Vietnamese in Mobile
  • Community Broadly Organized Around Faith Based
  • Buddhist
  • Catholic
  • Evangelical Christian

Vietnamese in Mobile
  • Vietnamese families that need language assistance
    are in Survival Mode
  • Non-Urgent medical questions not addressed in
    this context due to frustration and time
  • Mental Health takes a back seat

My Introduction to the Vietnamese Community
  • National Service Corps in Bayou la Batre
  • Large Vietnamese population includes many new
  • Minimal staff assistance
  • Vietnamese study with assistance from community
    members and University of South Alabama
  • Patients from this community later followed me to
    my private practice in Mobile

Failure to Communicate
  • Dual problem of verbal and cultural understanding
  • Cultural differences mean that language alone
    would not bridge the communication gap
  • But words are a good starting place

Stocking a Tool Kit
  • Developing a flexible skill set for dealing with
    communication issues
  • Many communication problems require use of
    multiple tools
  • Three main categories
  • Engineering
  • Market
  • Behavioral

The Engineering Solution
  • Technical assumes relatively straightforward
  • Use of Informatics
  • Could be implemented as a requirement
  • Not a complete solution, but better than our
    current paradigm

The Market Solution
  • Technical non-Technical approach
  • No restrictions or requirements placed on
    provider behavior the market will find a
  • Assumes the existence of an economically viable
    solution under current payment system
  • The Race to the Bottom
  • This is the current state of affairs in my

The Behavioral Solution
  • Can we change physician behavior?
  • Can we select for a different set of behaviors at
    the physician training level?
  • Will we need system structure changes
  • Will the changes need to be incentivized

Current Assets
  • Family members as interpreters concerns
    regarding objectivity, privacy, technical
    language, especially when children are used
  • Community members as interpreters privacy,
    competency, reimbursement concerns
  • Technological solutions improving rapidly
  • Professional interpreters vast improvements in
    competency, privacy, objectivity, but costly and
    still time consuming

Can We Create New Assets?
  • Language Learning as a viable alternative for
    most physician encounters with non-English
    speaking patients

Motives for Language Learning in the Patient
Care Setting
  • Better quality overall communication
  • Improved relationship with patients and their
  • Learning about different cultures
  • Overcoming privacy problems

Language Learning Strategies
  • Setting appropriate goals
  • Using a variety of methods written materials,
    recorded materials, online tutoring, local
    teaching when available
  • Monitoring progress fast enough to make
    progress, slow enough to provide reinforcement
  • Employing professional teachers

Limits of Language Learning
  • Time constraints a long term investment, like
    medical training
  • Ability versus Desire Language Learning is
    want to
  • Engineering solution may not solve all of your
    communication problems
  • In the end, some patients will still choose a
  • physician who they cant talk to!

Pitfalls of Language Learning Solution
  • Loss of Objectivity you may become more
    involved in your patients lives than you
  • Patient encounter as language lab
  • Patient encounter as anthropology workshop

Benefits of Language Learning
  • Increased patient confidence
  • Improved community credibility
  • Improved provider satisfaction

Language Learning as part of the Medical Home
  • Becoming a community asset
  • Providing comprehensive, culturally appropriate
  • Enhanced reimbursement already starting to see
    this in global fee increases

Case Presentation Peter (2003)
  • New 12 year old Vietnamese patient with asthma
  • Surprising new role for the physician/interpreter
    father and son cannot communicate
  • Looking for context in religious affiliation

Case Presentation Theresa (2007)
  • New 5 month old Vietnamese infant with fever
  • Absolute respect for authority
  • Falling through the cracks patient referred
    non-Vietnamese speaking physician for insurance

Case Presentation Diem (2011)
  • 4 day old Vietnamese infant
  • Referred by friends due to mothers limited
    English skills
  • Highlights my evolving role in the community
  • Everything for the family

  • Patient/physician communication is very complex
  • Direct communication between patient and health
    care providers is best, however patients will
    choose to access the health care system based on
    many criteria
  • Consider making language learning an integral
    part of physician training

Additional Resources
  • National Center for Cultural Competency
  • http//
  • National Center for Medical Home Implementation
  • Cultural Effectiveness Spotlight Issue
  • Health Resources and Services Administration
  • http//
  • American Academy of Pediatrics Health Equity
  • http//
  • American Psychological Association Health
  • http//

Were Here to Help You!
  • Have a question about medical home?
  • Contact us!
  • Medical_home_at_aap.org800/433-9016 ext 7605

The National Center for Medical Home
Implementation (NCMHI) is a cooperative agreement
between the Maternal and Child Health Bureau
(MCHB) and the American Academy of Pediatrics
Write a Comment
User Comments (0)