What is Culturally Competent Brain Injury Rehabilitation?!

Transcription

1 What is Culturally Competent Brain Injury Rehabilitation?! Carlos Marquez de la Plata, PhD Director of Rehabilita8on Research Clinical Neuropsychologist Pate Rehabilita8on March 9, 2018

2 Learning Objectives! 1. Participant will be able to define cultural competence!! 2. Participant will be able to describe three steps to becoming culturally competent!! 3. Participant will be able to list one thing they can do to increase their knowledge regarding a different culture!! 4. Participant will be able to describe one thing they can do or say to a brain injury survivor to communicate they respect their values even if they don t agree with them.!!

3 Ethnoracial Minori8es in the U.S.

4 Health Dispari8es Defined Gaps in the quality of health and health care across racial, ethnic, and socioeconomic groups. U.S. Dept. of Health and Human Services Unequal burden in disease morbidity and mortality rates experienced by ethnic/racial groups as compared to the dominant group. Healthy People 2010 Initiative Differences in quality of health care that are not due to access-related factors or clinical needs, preferences or appropriateness of interventions Institute of Medicine s 2002 Report Population-specific differences in the presence of disease, access to health care, health outcomes. Health Resources and Services Administration

5 What Explains Dispari8es?

6 Ethnoracial Dispari8es in Stroke Acute Characteris1cs Con1nuum of Care Outcomes Incidence Type of Stroke Comorbidi8es tpa Access to rehabilita8on Quan8ty of rehab svcs Mortality Severe disability Efficiency of Rehab Ethnicity Insurance

7 Ethnoracial Dispari8es in TBI Acute Injury Characteris1cs Con1nuum of Care Outcomes Incidence Cause of injury ED disposi8on Length of acute hospitaliza8on Access to rehabilita8on Quan8ty of rehabilita8on services Ethnicity Mortality Severe disability Dependence on others Insurance

8 Causes of TBI Injury TBIMS centers Retrospec8ve BurneX et al., 2003

9 Limited Access to Post-Acute Rehabilita8on Minorities more likely to be uninsured Greater rate of admission for non- Hispanic Whites Lowest rate for Hispanics Minorities = 15% less likely to receive rehab Even after controlling severity and insurance % Non-Hispanic White (Reference) Rehabilita1on Placement NTDB (n = 58,729) 20% * African American 16% * Hispanic Shafi et al., 2007

10 Race & Insurance Dispari8es in Discharge to TBI Rehab Odds Ra1o Na8onwide Inpa8ent Sample (NIS) data ( ) 96% of U.S. hospital discharges Dispari8es in where minori8es w/ TBI are discharged to aeer hospital Asemota et al., 2013 Even among insured minori8es

11 Race & Insurance Dispari8es in Discharge to TBI Rehab (Cont.) Odds of DC to higher level of rehabilita1on From Acute Hospital To: Inpatient Rehabilitation Skilled Nursing Facility Home Health w/ Rehab Svcs Home NTDB ( ) Minori8es are less likely to receive higher level rehab LOS in ICU and acute care increase likelihood Ins coverage not explain it Odds of DC to higher level of rehabilita1on for TBI >65yo with Medicare Meagher et al., 2015

12 Limited Financial Resources CDC Data (2016) The poor frequently do not have health insurance African Americans and Hispanics have lower rates of insurance than Whites

13 WHAT IS CULTURAL COMPETENCE?

14 Culture Known mediators of performance on cogni8ve outcomes aeer ABI Ethnicity Language Na8onality Accultura8on Socioeconomic status Hays (2008) ADDRESSING Model Age and genera8onal influences Developmental Disability Religion Ethnicity and race Social status (e.g., Socioeconomic, educa8on, rural vs. urban, etc.) Sexual orienta8on and gender iden8ty Indigenous background Na8onal heritage Gender and sex

15 Becoming Culturally Competent AKA: Learning to Develop Rela8onships

16 A Culturally Competent Psychologist Has: Cultural Awareness Self-aware Ethnocentricity Cultural Knowledge Health beliefs/behaviors Health inequali8es Psych and biological understanding of health Cultural Sensi8vity Empathy, trust, acceptance, respect (Sue & Sue, 2008)

17 Developmental Model of Intercultural Ethnocentric Ethnorela8ve Stage Descrip1on Typical Statement Denial There is no difference All big ci8es are the same lots of buildings, too many cars, McDonald s, etc. Defense Defending against the difference My culture should be a model for the rest of the world Minimiza8on Minimizing the difference No maxer what the culture, people are prexy much mo8vated by the same things Acceptance Accep8ng a new way of seeing Where can I learn more about Mexican culture to be effec8ve in my communica8on? Adapta8on Adap8ng a new way of ac8ng To solve this dispute, I m going to have to change my approach. Integra8on Competence (Adapted from Bennet, 1993) Harmonious sharing of various cultural backgrounds and values In an intercultural world, everyone needs to have a mul8cultural mindset

18 Cultural Awareness and Knowledge of Self and Others Guideline #1: Psychologists are encouraged to recognize that, as cultural beings, they may hold artudes and beliefs that can detrimentally influence their percep8ons of and interac8ons with individuals who are ethnically and racially different from themselves. Mainstream U.S. values individuals who are independent own goals Certain cultures value interdependence with others and subordina8on of own goals to those of the group APA Guidelines on mul8cultural educa8on, training, research, prac8ce, and organiza8onal change for psychologists 2002

19 Understand Others Worldview Guideline 2: Psychologists are encouraged to recognize the importance of mul8cultural sensi8vity/responsiveness, knowledge, and understanding about ethnically and racially different individuals. gain a bexer understanding and apprecia8on of the worldview and perspec8ves of those racially and ethnically different from themselves APA, 2002

20 CLIENT CENTERED PRACTICE: A Framework for Cultural Competence Collabora1on 4,5 Autonomy 3, 6 Empowerment 4,5 Partnership 1 Independence as a goal Enable Respec8ng differences between client and therapist 2 Client-driven choices Create opportuni8es Sharing power and responsibility 3,4 Self-determined Therapist-facilitated Cita8ons: 1. Armstrong, J. (2008). 2. Wong-Hernandez, L., Wong, D.W. (2002). 3. Papadimitriou, C., Carpenter, C. (2013). 4. Bright, F.A., Boland, P., Rutherford, S.J., Kayes, N.M., McPherson, K.M. (2012). 5. Abreu, B.C., Zhang, L., Seales, G., Primeau, L., Jones, J.S. (2002) 6. Levack, W.M.M, Dean, S.G., McPherson, K.M., Siegert, R.J. (2006)

21 How To Be Client-Centered (Papadimitriou & Carpenter 2013; Bright et al., 2012; Armstrong, 2008; Law et al., 1995; Wong-Hernandez & Wong, 2002; Doig et al., 2011; Leach et al., 2010; Maitra & Frances, 2006) Show respect for clients : Values Beliefs Preferences Environment Culture Flexible in approach CCP Provides structure and guidance throughout treatment Promotes mo8va8on for pa8ent and team Client-centered outcomes means involving clients and family in all phases, including problem iden8fica8on and agreement, goal se(ng and evalua8on

22 Get to Know the Client (Abreu et al., 2002; Niemeier et al., 2016) Assessment Strengths and weakness from a mul8disciplinary approach (evalua8ons and record review) Biopsychosocial factors (interview) Psychosocial uniqueness interview with client and family frequent family conferences Assess accultura8on Tradi8onal cultural group New host cultural group Independent Blending to varying degrees

23 Get to Know the Client s Culture Create mul8ple opportuni8es to invite client and family to par8cipate in psychosocial interviews, family conferences, teleconferences, training, home evalua8ons, etc Ask family to share about their culture (i.e., preferences, values, etc.) Allow 8me for ques8ons Assess language preferences. Use interpreter consistently, even if some English is spoken. Ask about their culture and go learn about their culture Facilitate good partnership with the team Make yourself available. Call family or significant others as oeen as they would like to update and give encouragement

24 How to Gain Cultural Awareness & Knowledge Go out to eat and learn about the culture of the food. Google ask the waiter See a movie from a different culture Google or read a book on life in that culture Build a cultural network Gather materials on cultural competence (APA) INTENTIONALLY EXPERIENCE SOMETHING NEW from a different culture

25 Adapta1on of Skills Guideline #5: Psychologists strive to apply culturally appropriate skills in clinical and other applied psychological prac8ces. It is not necessary to learn all new skills Adapt skill set to the cultures you are trea8ng given your knowledge of the pa8ent Incorporate background Invite helpers culturally relevant to pa8ent (i.e., a cultural broker) APA, 2002

26 Applying Cultural Competency In Rehabilita1on (Smith-Wexler, 2014; Shen & Zuwang, 2015) Iden8fy resources or barriers to outcome related to culture: family, gender, religion, sexual orienta8on, socioeconomic status, life experiences (ADDRESSING) Adapt goals to be congruent with specific culture - use client-centered goals THE ART OF GOAL SETTING During problem solving and when giving feedback engage family in hypothesis tes8ng THE PATIENT/FAMILY IS THE EXPERT ON THEMSELVES

27 SUMMARY: Connect with the Pa8ent Build each rela8onship Iden8fy what the pa8ent wants and/or needs from the interac8on Learn from the pa8ent Frame abili8es and impairments in terms relevant to the pa8ent and family

28 REFERENCES 1. Papadimitriou, C., Carpenter, C. (2013).Client-centered prac8ce in spinal cord injury rehabilita8on: a field guide. Retrieved from hxp:// 2. Bright, F.A., Boland, P., Rutherford, S.J., Kayes, N.M., McPherson, K.M. (2012). Implemen8ng a client-centred approach in rehabilita8on: an autoethnography. Disability and Rehabilita2on 2012;34(12): doi: / Armstrong, J. (2008) The benefits and challlenges of interdisciplinary client-centred, goal serng in rehabilita8on. New Zealand Journal of Occupa2onal Therapy, Law, M., Bap8ste, S., Mills, J. (1995). Client-centred prac8ce: what does it mean and does it make a difference? Canadian Journal of Occupa2onal Therapy, Vol. 62, No. 5: Retrieved from hxp:// 5. Wong-Hernandez, L., Wong, D.W. (2002). The effects of language and culture variables to the rehabilita8on of bilingual and bicultural consumers: a review of literature study focusing on Hispanic families and Asian Americans. Disability Studies Quarterly, Vol. 22, No. 2: Doig, E., Fleming, J., Kuipers, P., Cornwell, P., Khan, A. (2011). Goal-directed outpa8ent rehabilita8on following TBI: a pilot study of programme effec8veness and comparison of outcomes in home and day hospital serngs. Brain Injury, Vol. 25, No. 11: Leach, E., Cornwell, P., Fleming, J., Haines, T. (2010) Pa8ent centered goal serng in a subacute rehabilita8on serng. Disability and Rehabilita2on, Vol. 32, No. 2: Maitra, K.K., Frances, E. ( 2006). Percep8on of client-centered prac8ce in occupa8onal therapists and their clients. The American Journal of Occupa2onal Therapy, Vol. 60, No. 3: Abreu, B.C., Zhang, L., Seales, G., Primeau, L., Jones, J.S. (2002). Interdisciplinary mee8ngs: inves8ga8ng the collabora8on between persons with brain injury and treatment teams. Brain Injury, Vol. 16, No.8,: Shen, Zuwang. ( 2015) Cultural competence models and cultural competence assessment instruments in nursing: a literature review. Journal of Transcultural Nursing, Vol.26, No. 3: Sue, D.W. (2001). Mul8dimensional facets of cultural competence. The Counseling Psychologist, Vol.29, No.6: Smith-Wexler, L. (2014) Cultrual competency in TBI rehabilita8on. American Psychological Associa2on. Retrieved from hxp:// Niemeier, J. P., Keawe aimoku Kaholokula, J., ArangoLasprilla, J. C., & Utsey, S. O. (2016).Effects of accultura8on on neuropsychological rehabilita8on of ethnically diverse persons. In J. M. Uomoto (Ed.) Mul2cultural Neurorehabilita2on, pp New York: Springer Publishing Company.