Care of the Disadvantaged Patient

Transcription

1 Care of the Disadvantaged Patient Anita Palepu, MD, MPH, FRPC, FACP Professor of Medicine University of British Columbia Rocky Mountain Internal Medicine/ACP Meeting November 16, 2013

2 Care of the Disadvantaged Speaker Anita Palepu, MD, MPH, FRPC, FACP Professor of Medicine University of British Columbia

3 Disclosures No competing interests Acknowledge Dr. Jacques Bédard: 3-minute empowerment Dr. Harvey Chochinov: Dignity in Care Dr. Nadia Khan and Dr. Peter Dodek RMIM/ACP Annual Organizing Committee

4 Learning Objectives 1) Identify the various ways patients are disadvantaged in their/our community 2) Understand the principles of motivational interviewing and other communication strategies to better care for them 3) Identify some of the key social determinants of health that affect our patients and advocate for them

5 Competencies Medical Expert Communicator Collaborator Health Advocate

6 Who is disadvantaged?

7 Who is disadvantaged?

8 Who is disadvantaged?

9 Who is disadvantaged?

10 Access to care barriers Poverty Addiction Mental health disorders Low health literacy Culture and language Unstable housing Social isolation Multi-morbidity Frailty Disadvantage

11 People are complicated Their lives are complicated Competing interests and priorities What knowledge and skills do we need as general internists to care for our patients? How can we approach our patients in a more effective manner?

12 3-minute empowerment J Bedard

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14 The secret of the care of the patient is in the caring for the patient. Dr. Frances Peabody, 1925 Care refers to EBM practices for disease-specific states Caring refers to our relationship with patients

15 We manifest our caring through communication with our patients

16 Importance of caring Patient disclosure lacking Missed diagnoses Medical errors Lost opportunities Patient safety Patient complaints to the College More often due to a failure to communicate Absence of caring

17 From: Relationship, Communication, and Efficiency in the Medical Encounter: Creating a Clinical Model From a Literature Review Arch Intern Med. 2008;168(13): doi: /archinte Rapport building Agenda setting Acknowledgement of patient s social and emotional clues Studies Linking Communication Quality and Efficiency Date of download: 11/7/2013 Copyright 2012 American Medical Association. All rights reserved.

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19 Motivational Interviewing A collaborative, person-centered form of guiding to elicit and strengthen motivation for change Collaborative vs. Confrontation Evocation vs. Imposing Ideas Autonomy vs. Authority

20 Motivational Interviewing Principles Express empathy Support self-efficacy Roll with resistance Develop discrepancy

21 Prochanska s Stages of Change PROS<CONS DENIAL PROS=CONS AMBIVALENCE TRAPS AND STRATEGIES PROS>CONS DETERMINATION BARRIERS AND STRATEGIES BARRIERS AND STRATEGIES

22 CONVICTION CONVICTION Perceiving the benefits that would result from a behaviour change PROS>CONS Low conviction patient sees either no advantage or abstract advantages Moderate conviction appreciates theoretical advantages High conviction appreciates advantages at a cognitive level but also at a personal, highly emotional level (That is key!)

23 CONFIDENCE Feeling capable of changing a behaviour Explore with open-ended questions You want to work on increasing CONVICTION FIRST

24 Benefits Barriers Kellar VF et al. JCOM 1997;4: Miller & Rollnick s Model

25 ACTION 3-minute empowerment J Bedard

26 3-minute empowerment Dr. Jacques Bédard, Sherbrooke Stage What do you think about changing your? Conviction If you decided to.. how would that benefit you? Confidence If you really decided to. Do you think you could do it?

27 Case Mr U. is a 60 year old retired construction worker and married man with COPD, Type 2 DM, HTN, PAD and depression He has smoked 1 ppd since age 14 You are seeing him in follow-up after an admission for COPD exacerbation He is prescribed: ASA, metformin, ramipril, ipatroprium, salbutamol and fluticasone inhalers He is feeling better but is smoking ½ ppd since discharge

28 Open-ended questions What would you think about quitting smoking? Explore PROS and CONS If you decided to quit smoking, how would that benefit you? CONVICTION If you decided to quit smoking, do you think you could do it? CONFIDENCE

29 3-minute empowerment J Bedard

30 Conviction If you decided to quit smoking, how would that benefit you? Listen for the expression of personal benefits and rephrase & reinforce these benefits as they have strong emotional content Provide information on benefits of changing the behaviour (with empathy) 3-minute empowerment J Bedard

31 Confidence If you really decide to quit smoking, do you think you could do it? Open-ended questions: What would prevent you from quitting smoking? xxx How do you think you could address xxx? 3-minute empowerment J Bedard

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33 Report: What makes us sick? Income inequality Lack of affordable housing Lack of early childhood development Lack of access to nutrition and food security Low education levels and low health literacy

34 Income Inequality

35 Access to care barriers Poverty Addiction Mental health disorders Low health literacy Culture and language Unstable housing Social isolation Multi-morbidity Frailty Disadvantage

36 Learning Objectives 1) Identify the various ways patients are disadvantaged in their/our community 2) Understand the principles of motivational interviewing and other communication strategies to better care for them 3) Identify some of the key social determinants of health that affect our patients and advocate for them

37 Thank you for your attention

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