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

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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
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Disclosures

• 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.

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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

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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
http//childstats.gov/americaschildren/glance.asp
March 2009 CPS, estimates by Pew Hispanic
Center, www.pewhispanic.org US Census Bureau.
Middle Series, 20162020. Washington, DC.
National Center for Health Statistics NCHS,
2007 Childrens Defense Fund http//www.childrens
defense.org/policy-priorities/childrens-health/rac
ial-ethnic-disparities/
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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
patients?
n278
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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
  outcomes.
• 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
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Communicating with Diverse Populations
Diane Dooley, MD, FAAPContra Costa Health
ServicesMartinez, California
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Contra Costa Health Plan

• Medicaid Managed Care Health Plan
• Covers 110,000 low income children, mothers and
  adults
• Majority of services provided at Contra Costa
  Regional Health Center Clinics

58 of parents report not speaking English very
well 50 prefer Spanish
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Pediatric Obesity A Disparity Emerges
Pediatric Nutrition Surveillance 2009Contra
Costa BMI-for-age gt 95ile
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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
Lens
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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
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Measurement Chart reviews

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

272 Charts reviewed June 2010 March 2011
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Measurement Patient survey

• Literature review and clinical queries regarding
  important aspects of care
• Satisfaction, counseling, intended changes,
  respect, health education, language use,
  comprehension
• 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
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Baseline Chart Review
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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

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Provider focus groups

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

Questions were asked about the certification
process
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
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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
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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
  clinics.

http//www.hcin.org/index.php/resources-video/
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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

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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

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Improvements in Care
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Conclusions
Language and culture are critical components of
care in pediatrics

• Language concordance is difficult to measure and
  document
• 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

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Resources

• Kaiser Permanente Clinical Cultural and
  Linguistic Assessment www.altalang.com/language
  -testing/ccla.html
• RWJ Roadmap to Reduce Disparitieswww.solvingdisp
  arities.org/tools/roadmap
• Health Care Interpreter Networkwww.hcin.org
• References available on PubMedwww.ncbi.nlm.nih.g
  ov/sites/myncbi/collections/public/1Zuqdiw6uFmOYYX
  721hwJ2KQ4/?sortdatedirectionascending

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Dwight Yoder, MD, FAAPPediatric Partners of
Mobile, Alabama
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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

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Welcome to Mobile

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

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Vietnamese in Mobile

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

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Vietnamese in Mobile

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

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Vietnamese in Mobile

• Community Broadly Organized Around Faith Based
  Groups
• Buddhist
• Catholic
• Evangelical Christian

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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
  constraints
• Mental Health takes a back seat

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My Introduction to the Vietnamese Community

• National Service Corps in Bayou la Batre
  2000-2003
• Large Vietnamese population includes many new
  arrivals
• 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

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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

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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

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The Engineering Solution

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

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The Market Solution

• Technical non-Technical approach
• No restrictions or requirements placed on
  provider behavior the market will find a
  solution
• 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
  community

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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
  (engineering)?
• Will the changes need to be incentivized
  (marketing)?

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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

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Can We Create New Assets?

• Language Learning as a viable alternative for
  most physician encounters with non-English
  speaking patients

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Motives for Language Learning in the Patient
Care Setting

• Better quality overall communication
• Improved relationship with patients and their
  families
• Learning about different cultures
• Overcoming privacy problems

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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

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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!

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Pitfalls of Language Learning Solution

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

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Benefits of Language Learning

• Increased patient confidence
• Improved community credibility
• Improved provider satisfaction

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Language Learning as part of the Medical Home
Concept

• Becoming a community asset
• Providing comprehensive, culturally appropriate
  services
• Enhanced reimbursement already starting to see
  this in global fee increases

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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

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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
  reasons

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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

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Conclusion

• 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

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Additional Resources

• National Center for Cultural Competency
• http//nccc.georgetown.edu/
• National Center for Medical Home Implementation
• Cultural Effectiveness Spotlight Issue
• Health Resources and Services Administration
  Resources
• http//www.hrsa.gov/CulturalCompetence/index.html
• American Academy of Pediatrics Health Equity
  Resources
• http//www2.aap.org/commpeds/resources/health_equi
  ty.html
• American Psychological Association Health
  Disparities
• http//www.apa.org/topics/health-disparities/index
  .aspx

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Questions?
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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
(AAP).