Patient engagement and empowerment: Strategies to improve the chronic disease control among Ethnical Minority Patients in the primary care Dr. Catherine Chen Dept. of FM and GOPC, KCC
Background Hong Kong is Asia s World City with multi-culture and diversity. Ethnic minorities constitute an important component of the HK population. According to census in 2011, about 95% of the local inhabitants are ethnic Chinese; the remainder are mainly from South Asia (India, Philippines, Nepal, Pakistan, and Indonesia). Yau Ma Tei Jockey Club GOPC locates at Central Kowloon, where most of the South Asian minorities including Indians, Nepalese, and Pakistanis reside. The attendance from the Ethnical Minority Groups (EMGs) accounts for about 10-15% of overall yearly attendance at YMTJC GOPC. Source: Hong Kong 2011 Population Census Thematic Report : Ethnic Minorities. Census and Statistics Department. Hong Kong Special Administrative Region. http://www.census2011.gov.hk/pdf/em.pdf
Culture disparity and its clinical impact Previous studies have shown that chronic disease, i.e. DM and HT affect certain EMGs differently. South Asians are at higher risk for T2DM by up to 4 to 6 fold compared with other ethnic groups, probably due to a combination of genetic and environmental factors. In addition, South Asians have a much higher prevalence of T2DM with cardiovascular disease that occurs at an earlier age and is associated with higher morbidity and mortality. Differences in health care systems, limited access to health services, and social deprivation can further compound the risk of developing diabetes and its complications. Reference: Abate N, Chandalia M. The impact of ethnicity on type 2 diabetes. J Diabetes Complications 2003;17:39-58. Gholap N, Davies M, Patel K, Sattar N, Khunti K. Type 2 diabetes and cardiovascular disease in South Asians. Prim Care Diabetes 2011;5:45-56.
Our mission To provide comprehensive programs that facilitate access for all, including EMGs, to the public health care system. To promote that all individuals enjoy equality of health and guard against discrimination. 4
Clinical audit on chronic disease control among EMG patients: methodology Study subjects: EMG patients with chronic disease (DM or HT) and had been regularly FU in YMTJC GOPC of KCC for chronic disease control. The first cycle was carried out from 01/01/2013 to 31/12/2013 with deficiencies of chronic disease control identified. Implementation of change: 01/01/2014 to 31/12/2014 The second cycle was carried out from 01/01/2015 to 31/12/2015. Patients demographics, blood pressure (BP) and biochemical parameters were retrieved from the Clinical Management System (CMS) and the clinical outcome between the first and second cycle were compared. Student s t-test was used for analyzing continuous variables and Chisquare test for categorical data. All statistical tests were two-sided, and a p-value of < 0.05 was considered significant.
Clinical audit on chronic disease control among EMG patients: 1 st cycle Results Compared with Chinese diabetes and hypertension patients, those patients from the EMGs were much younger and more obese. Deficiencies existed in the comprehensive management of chronic diseases, particularly with respect to glycemic control and blood pressure control. During the first cycle, it was found that compared with Chinese hypertensive patients, EMG hypertensive patients have higher systolic and diastolic BP (both P < 0.001), and had a much lower proportion with BP adequately controlled (68% versus 80%, P < 0.001). Within lipid profile, high density lipoprotein (HDL) level was lower while triglyceride level higher in EMGs (P < 0.001). Similarly, the glycemic control was poorer in EMG diabetes patients than their Chinese counterparts (HbA1c 7.8 ± 1.7% vs 7.5 ± 1.4%; P=0.006), with a much lower proportion being adequately controlled metabolically (Hba1c <7%, 48% versus 60%, P<0.001).
Clinical audit on chronic disease control among EMG patients: 1st cycle Results % of HT patient with satisfactory BP control P<0.001 % of DM patient with satisfactory HbA1c control P<0.001
Clinical audit on chronic disease control among EMG patients: improvement strategies Culture competence: defined as the level of knowledgebased skills required to provide effective clinical care to patients from a particular ethnic or racial group. We strive to enhance the culture competence among patients from EMGs and to reduce the ethnic health disparities. Major improvement strategies: Internet resources for health information in multi-languages Interpreter services Training, coordinating with traditional healers Use of community health workers Culturally competent health promotion, including family/community members
Resources for Multi-language Service at government website 1. http://www21.ha.org.hk/smartpatient/tc/empowerment_activities.html 2. http://www.gov.hk/en/theme/multilanguage/mlp/ 3. http://www.chp.gov.hk/en/view_content/22550.html
Interpreter Service in HA
Workflow for Calling Interpreter Service in KCC GOPC Chronic Patients with next follow up appointment Episodic cases Attend Nurse Station Approach the counter desk in Shroff Office Clerical staff identify patient s language Direct to nurse station for further arrangement Nurse identify the language that the patient is needed Nurse confirm patient s needs and ask clerical staff to book the appointment as required Fill the Service Request Form and fax to HKTS, #24286708 Call the Hotline Centre at 24235100 to confirm the delivery of the facsimile The Hotline Centre reply for the Service Reference Number and Interpreter Code Number Nurse keep the booking record till patient s next appointment day for further follow up action
Convenient and coordinated medical care to minority patients (1): Doctor s assessment
Convenient and coordinated medical care to minority patients (2): Nursing Care
Convenient and coordinated medical care to minority patients (3): Allied Health Physiotherapy & Occupational Therapy
Convenient and coordinated medical care to minority patients (4): Ethnical diet education by dietitian
Diet sheets for ethnic minorities: Hindi, Nepali, Urdu, Indonesian, Thai
Sharing of studies on EMGs at various platforms HA convention 2014 KCC convention 2015
Sharing of studies on EMGs at various platforms Reference: Chen XR, Chan KH. Type 2 diabetes management in Hong Kong ethnic minorities: what primary care physicians need to know? HK Med J 2014 Jun; 20(3): 222 8
Community School Outreach Program: To schools with predominately minority students (2015)
Clinical audit on chronic disease control among EMG patients: 2 nd cycle result After two yrs of implementations of the above improvement strategies, the KPI of chronic disease control including BP control rate among HT cases, HbA1c capture rate and control rate among diabetes cases were all significantly improved among EMG patients. HT patients with satisfactory BP control among EMGs DM patients with satisfactory metabolic control among EMGs P<0.001 P=0.006
Working and recognitions from NGOs Awards from Indian Association, Hong Kong
Video clip sharing Mr. Mohammad from Pakistan. He has known history of DM, HT, hyperlipidemia, obesity and has been FU in our clinic since 2012. Latest DMCS reports have shown that his BP, glycemic and lipid control were satisfactory. He will share with us his experience about treatment in HA
Conclusion Deficiencies existed in the comprehensive management of chronic diseases, particularly diabetes and hypertension, among EMG patients. Through a team approach including a closer collaboration with different NGOs and further enhanced culturally competent health promotion and culturally tailored health care interventions, their chronic disease control has been significantly improved.
Way forward To closely collaborate with different NGOs and further enhance culturally competent health promotion, including family/community members To intensify culturally tailored health care interventions, i.e. to widen the service scope and frequency in delivery Ethnical diet education; To set up special clinic for poorly controlled chronic disease patients from Ethnical Minority Groups. 24
Acknowledgements I would like to extend my gratitude to Dr. King Chan for his continuous inspirations and support during this study. I would also like to thank all medical and nursing staff of Dept. of FM & GOPC,KCC and the clinical effectiveness subcom. members for their great effort and support in providing quality primary care to the EMGs.
Bring better health to the community!