Transcript Practical steps and tools for patient navigators working

Engaging Patients:
Real World Problems, Real World Solutions
Marilyn R. Gardner
 What
difficulties do you
have engaging patients?
 What
difficulties do
patients face navigating
the health system?
Patients in the Health Care System
Compliant or Non-Compliant?
 The
problem with labels
 Background:
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1980’s to 1990’s – Using “non-compliant” to label a
patient was used like candy on Halloween
1990’s to 2000’s – A vague discomfort arises in the use
of the term “non-compliant”. We’ve eaten too much
candy
2000 and beyond – Replacing the candy with a
healthier alternative
What we know
 Literature

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
search:
Large body of research
Some research looks at this as a “patient
problem” to be resolved through nursing
intervention
Other research critiques this approach
An alternative approach: Focus on how health
care treatments affect patients’ lives not just
their health
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Cultural Beliefs and Values
Social Determinants
Restructuring care
Real Solutions
 Engaging
Patients through Culturally
Responsive Care
 Engaging
Patients through Social
Determinants of Health
 Engaging
Patients through Collaborations
Engaging patients through culturally
responsive care
Culture is deeply personal
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Respect difference.
Focus is on racial/ethnic cultures.
Distinguish “generalizing” from
“stereotyping.”
Forgive time constraints.
What is culture?
Culture Quiz
. . . with thanks to the University of Toronto
Culture . . . It’s not genetic!

The customary beliefs, values, shared attitudes,
practices and choices of a group.

The learned and shared values, beliefs, norms, and
life view of a group that guide thinking, decisionmaking and action.
Culture is our learned view of
life.
Culture is our lens.
Decor
Souvenir
Place of Prayer
Status
Status
Status
Cultural self-awareness
Communicating Across
Boundaries
A Cultural Passport Exercise
Cultural Competency:
A learning process that enables
individuals and organizations to
respect, value --- and function
effectively in the midst of --cultural difference.
Why do we need cultural competency?
 Increasingly
diverse communities.
 Evidence of health disparities.
 Regulatory and charitable focus.
 Nature of quality care.
The Face of Florida
Total population just over 18
million
Uninsured population – more than
3.9 million, over 21% of the
population (national is 16%)
Black – 2.7 million or 15%
Hispanic – 3.9 or 21%
Asian/American-Pacific Islander –
just over 400,000 or 2%
Face of Florida
 Foreign
born – 19.2%
 Language other than English spoken at home
– 26.6%
 Poverty
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Level
White – 14%
Black – 35%
Hispanic – 31%
 Reducing
Racial and Ethnic Health Disparities
"Closing the Gap" was signed into law on June
8, 2000.
Health Disparities
“Population-specific differences in the
presence of disease and health
outcomes.” . . . Health Resources and
Services Administration
“Health inequalities, across racial,
ethnic and socioeconomic groups.”
. . . Wikipedia
7/20/2015
VNA Care Network & Hospice
Unequal Treatment

Institute of Medicine “Unequal
Treatment: Confronting Racial
and Ethnic Disparities in Health
Care.”

Racial and ethnic minorities in
the U.S. receive lower quality
health care than whites even
when their insurance and income
are the same.
March 20, 2002
Significant racial & ethnic differences in:
 Receipt of appropriate cancer treatment
 Pain control - Minority patients more likely to be undermedicated for pain than white patients (65% vs. 50%),
more likely to have severity of pain underestimated by
physicians
 Mental health services - “plagued by disparities.” One
study indicates 44% of White English speakers to 27.8%
of Blacks received treatment after a diagnosis of
depression.
 Heart procedures – including bypass surgery
 Diabetes – from diagnosis to amputations
 Pediatric Care – Less satisfaction, cite poorer
communication, perception of lack of response
CLAS Standards
National Standards for Culturally and
Linguistically Appropriate Services
in Health Care
Office of Minority Health, 2000
Stages of Cultural Competency
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Stage 1: Awareness
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Stage 2: Sensitivity
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Stage 3: Knowledge
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Stage 4: Adaptability
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Stage 5: Competency
Three attitudes that support
successful cross-cultural encounters
are:
Empathy
Curiosity
Respect
Explanatory models as communication tools:
“It is much more important to know what sort of patient
has a disease, than what sort of disease a patient has”
-William Osler
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The “insiders” view of the world

Consists of what people in a given setting or culture
believe about the nature, cause, prevention, and
response to an event
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Understanding of the broader beliefs about how the body
works and general factors that influence a person’s fate
in life
Video: Case Study – Alicia Mercado Story
 Small
group discussion
 Report
back
Barriers to effective cross-cultural
interactions

Culture Shock
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Culture Conflict
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Cultural Imposition
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Ethnocentrism
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Racism & Discrimination
Communication Tools:
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Be aware of your cultural values and beliefs
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Understand that limited language proficiency does not
mean limited intellectual ability
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Use Explanatory Models
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Allow the use of storytelling
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Rethink your role not only as an expert to the patient or
client but also as a student of the patient or client
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Seek assistance from bilingual/bicultural co-workers
and individuals
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Recognize the patient or client may not be the decision
maker in the family
Steps and Resources to Improve
Culturally Responsive Care
 Be
aware of your culture!
 Identify key cultural informants.
 Plan with, not for, the community.
 ASK! Don’t assume.
 Training – What further
trainings/workshops would help you to
better care for your patient population
 Resources: Cultural profiles, articles,
books, films, interviewing tools.
 Questions
or Comments?
Lunch Break
Engaging Patients: Social Determinants
of Health
 What
are the Social Determinants of Health
 Why do they matter?
Definition:
 The
conditions in which people are born,
grow, live, work and age, as well as the
health system
 Results
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Systemic and unjust distributions of social, economic
and environmental conditions needed for health
 Goal

in health “inequities”
is to provide health equity
The opportunity to attain full health potential.
Social Determinants of Health
 “Unnatural
Causes…is inequality making us
sick?” PBS special
 Much
more to wellness than medical care,
genetic propensity, and behavior
 Social,
economic, and physical environments
profoundly affect our longevity and health
Stress can cause illness
Poverty
Immigration
Language and cultural barriers
Stigma
Education
Powerlessness
Poor access to resources
Living in dangerous neighborhoods
Job insecurity
Illness
And the list goes on….
Place Matters
29 minute clip ~
Why is your street
address such a strong
predictor of your health?
Discussion Questions
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What health threats does Gwai face that are beyond his
individual control?
How do neighborhood conditions, his job and income
situation and being an immigrant affect his ability
to keep his children out of harm’s way?
How might all of this affect Gwai’s stress level? What
options would make things better for his family and
others?
What health advantages do residents of wealthier
neighborhoods have that are often lacking in
neighborhoods like where Gwai lives?
In what ways does a story like this inform and/or impact
your work?
Engaging patients through best
practice models and collaborations
 We
can’t do it alone!
 What ‘Best Practice’ models can we
learn from?
 How can we use the resources in the
community to help patients?
Promising Practices
 The
Clark County Story, Vancouver,
Washington
 Group visits in prenatal care involving a
patient navigator
 Case Management and Stanford University
Chronic Disease Self Management
 Patient Navigation and Colorectal Screening,
NYC
 Diabetes project, Mass General Hospital
Role of Patient Navigator
 Works
office
with providers, clinics, and Medicaid
 Assists
women with referrals for other
needed services – food & cash assistance,
child care, transportation, WIC, mental
health, dental care, etc.
 Bilingual/Bicultural
 Acts
as cultural broker to aid Case managers
in increasing cross cultural understanding
Group visits
 Initial
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No shows
Difficult to sustain preventive care
Long waits for appointments
 Group
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Problems:
Visits
Emphasize patient education
Make use of group dynamics
Based on today’s discussion:
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How do you think cultural values and beliefs affect
both access and receipt of care in your patient
profile?
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How do you think the social determinants of health
play into the health behavior of your patients?
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What additional resources would you need/want in
order to address these significant variables with your
patients?
Be specific, for example:
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Does your assessment need to change?
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Do you have adequate interpreter services and do all
staff know how to use interpreters?
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Are community specific resource guides available for
your patients and if so, do they know how to use them?
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What culturally specific information on your patient
population do you still need in order to provide them
the best care possible?
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What might be helpful to know about your patient’s
neighborhood in order to develop a realistic plan of
care for them?
Promising Practices
 Questions?
 Contact:
Marilyn Gardner, R.N.| Clinical Liaison
Email: [email protected]