effective patient centered efficient..and equitable

Transcription

1 Sunita Mutha, MD University of California, San Francisco January 25, 2013 Understand cultural competency from viewpoint of individual clinician vs. organization Give examples of effective strategies clinicians ca use to improve care for diverse populations Give examples of effective organizational strategies Identify the organizational case and imperative for focusing on cultural competency Discuss the pitfalls of using untrained medical interpreters safe effective patient centered timely efficient..and equitable White Black Latino Asian Other

2 Demographic trends Health care disparities Mistrust Communication gaps Health beliefs Use of CAM Biases & stereotypes Linguistic barriers Cultural competence Patient-centered care tailored to meet linguistic and cultural needs Communication Patient satisfaction Adherence Health outcomes Institute of Medicine 2003

3 Here for f/u after new dx high blood pressure Despite a long discussion at the last visit, she is taking her hypertension meds intermittently Another non-adherent patient Patient- and familycentered care Ask questions Listen with empathy to pt's perception Explain your perceptions Acknowledge & discuss differences and similarities Recommend treatment Negotiate agreement What does it mean high blood pressure mean to you? High blood pressure too much or too thick blood; made worse by rich diet, red meat, and best treated by medication Hyper-tension acute condition due to blood rising rapidly to head; caused by anxiety or nervousness and not affected by medication

4 Indications that an encounter is becoming more complex & specialized interpreter services might be required: 1)Word finding: you cannot think of a good word to describe a concept 2)Rephrasing: patient displays lack of understanding during a teach-back communication and you cannot rephrase the concept or instruction in a different way 3)Emotional disconnect: the patient displays an emotional response that does not seem to match the content of the conversation 4)Patient editing: needs to edit what s/he says or speaks noticeably more slowly than normal, to make it easier for the clinician to understand 5)Novel topic or issue: the encounter turns to a subject that is unusual, novel, or something the physician does not usually handle 6)Confusing answer: patient's description or answer to a question does not make sense and requires repeated clarifications 7)Confusing question: patient asks a question that is confusing or seems to be out of context College Level + With the onset of nausea, diarrhea, or other gastrointestinal disturbances, consult your physician immediately. 4 th Grade If you start having an upset stomach, loose bowel movements, or other problems, call your doctor right away. Regenstein M, Andres E, Wynia MK JAMA. 2013;309(2):

5 I want to make sure I did a good job explaining this to you Can you tell me what problems can happen with this surgery? Can you show me how you will take this medicine? Can you tell me how you will check to see if your asthma is getting better? When you go home after this procedure, can you tell me what symptoms will you be watching for tonight? Reducing health care disparities can improve: Quality Safety Risk management Patient- and familycentered care

6 Disparities in preventive care Adapted from Pletcher MJ et al JAMA 2008;299(1):70-78

7 Toolbox includes: Focus attention on disparities Stratify data Share results & stories Use QI approaches & tools Disease management Literacy interventions Language assistance Beach MC, et al BMC Public Health Apr 24;6:104.

8 31 errors/encounter - 63% clinically significant Examples Omitting questions about drug allergies and past history instructions about antibiotic use Omitting patient s description of symptoms Adding instructions about treatment planning that physician didn t include Editing physicians instructions to patient regarding follow-up visit Answering questions for the patient without asking patient Interpreting for mother during visits. Assumed to be doing a good job Consultant found that information was incomplete. Pt did not tell mother about liver cancer It has never been a problem, because when I interpreted, I only told my mother what I wanted her to know, and only told the doctor what I wanted him to know. Better understanding Improved use of services (preventive, ED) Better diabetes outcomes (e.g., A1c) Better patient satisfaction Minimize risk and liability Tailoring aspects of care Who delivers information? How is information delivered? What information is delivered? Patient activation Increased activation could reduce gap by 50-88% Karliner et al. Health Serv Res Fisher TL et al. Med Care Res Rev 2007 Hibbard JH et al. Health Affairs, 2008

9 How confident are you filling out medical forms by yourself? Extremely Quite a bit Somewhat at risk A little bit Not at all at high risk % of Asian pts receiving treatment to prevent blood clots within 24hrs before or after selected surgeries. Weinick RM et al. Creating Equity Reports, 2008 Equity is essential part of quality Role for clinicians Role for organizations and systems Measure it Share the information Ask questions Take action Integrate into QI Allocate resources for infrastructure Set the vision and accountability sunita.mutha@ucsf.edu

10 AMA Literacy Toolkit Beach MC et al. BMC Public Health Apr 24; 6:104. Review Fisher TL et al. Med Care Res Rev Oct;64(5 suppl):243s- 82S. Health Disparities Toolkit Improving Quality and Achieving Equity: A Guide for Hospital Leaders.(2008) Institute of Medicine. Crossing the Quality Chasm Institute of Medicine. Unequal Treatment Institute of Medicine. Toward health equity and patientcenteredness Karliner LK. Health Serv Res Apr;42(2): Lieu TA, et al. Pediatrics May; 109(5): Literacy and Health Outcomes National Health Disparities Report (2008) Powers BJ et al JAMA 2010;304(1):L76-84 Weinick RM et al. Creating Equity Reports