Transcript Framework for Overcoming Barriers to Latinos’ Access to

Barriers to Health Care Access in the
Latino Community: Communication,
Satisfaction and Adherence
J. Emilio Carrillo, M.D., M.P.H.
Montefiore Medical Center
August 2, 2005
► Poor
health outcomes and disparities are a
result of multiple socioeconomic, demographic,
environmental and other social and cultural
factors
► Barriers
to healthcare access are a significant
contributor to poor health outcomes and
disparities
Barriers to healthcare access contribute to
Latinos’ poor health outcomes and disparities:
Primary Access Barriers
Health Insurance
Lack of insurance, underinsurance, and inability to pay for
care or treatments
Secondary Access Barriers
Organizational and systems of care
All barriers encountered between home and providers’ office:
availability of care, transportation, childcare, waiting times,
etc.
Tertiary Access Barriers:
Communication between Provider and Patient
When language and culture hinder the provider-patient
communication
Primary
Access
Barriers
Trends in number of Hispanics without
Coverage
1989
1999
Change in Number
uninsured
1989-1999
(thousands)
% Increase in
Unisured
Race/Eth
Non-
19,190 21,370
2,180
+11%
Blacks
5,840 7,240
1,410
+24%
Hispanics
6,930 10,950
4,020
+58%
Hisp.Wht.
- Hispanics who make up 11% of the US population in 1999
accounted for 50% of the increase in the uninsured from 89-99
Source: Carrasquillo O. et al, Am J Pub Health 1999, 2000 CPS data
Health insurance among Latino/Caribbean Immigrants
% with Private
Health Insurance
% With Gov.
Insurance
% Uninsured
Cuba (N=950,000)
48%
35%
25%
Domin. Republic
(N=700,000)
32%
33%
38%
El Salvador (N=750,000)
36%
8%
58%
Guatemala (N=350,000)
38%
13%
50%
Haiti (N=400,000)
60%
10%
37%
Mexico (N=7,850,000)
35%
14%
53%
Country
(N=number of
immigrants)
Secondary
Access
Barriers
The Problem
► Patients
at risk who access the health
care system face organizational and
structural barriers to care
 Organizational->leadership/workforce
 Structural->systems of care
► Results:
decreased medical screening,
later stage of presentation, and
insufficient treatment
Organizational Barriers:
Leadership and Workforce
Research supports important role of minority
representation in leadership and workforce
 Minority providers:
► care
for more minority and underserved patients
► are preferred
► score higher on patient-rated quality and satisfaction
 Latinos are underrepresented:
► on
health professional school faculty
► in city/county public health positions
► in the health professional workforce
18
Leadership
17
16
16
14
12
10
%Minority
Professional
Representation
8
6
3
4
2
0
Med S chool
Faculty
Workforce
6
Pub Health
Faculty
6
5
5
3.8
4
%Latino
City/County
Health Officials
3.2
2.9
3
2
1
0
Source: BHP
Physicians
Dentists
Pharmacists
Optometrists
Nurses
Structural Barriers
Extramural
Door-->Clinic
►
►
►
►
►
►
►
Availability of providers
Proximity of Healthcare facilities
(HCF)
Operating hours of HCF
Transportation to HCF
Telephone access to providers
Knowledge of available
resources
Lack of child care resources
Intramural
Clinic-->Doctor Office
►
►
►
►
►
►
►
Bureaucratic intake procedures
Long waiting time for
appointments
Lack of interpreter services
Difficult referrals to test and
specialists
Language-appropriate signage
Language-appropriate health
education
Poor continuity of care
Structural Barriers:
Extramural and Intramural
► Extramural
 Patients at risk disproportionately reside in MUA and
HPSA, have little choice where to go for care, and
use ER’s and OPD’s as main source
► Intramural
 Patients at risk face bureaucratic intake processes,
long waiting times, limited access to specialists, less
continuity of care, and significant language barriers
in health care facilities
25
22
20
16
15
%Reporting
8
10
5
0
Latinos
Structural
Barriers
Blacks
Whites
Difficulty Accessing Specialists
50
45
40
35
46
39
26
30
25
%Reporting
20
15
10
5
0
Latinos
Source: Commonwealth Fund
Blacks
Whites
Don’t have a regular doctor
Tertiary
Access
Barriers
What are tertiary barriers?
► Rooted
in the provider-patient interaction
differences  barriers to
effective care due to:
► Sociocultural
 poor communication
 different beliefs about illness and treatment
 poor adherence to therapeutic plan
 limited health education
 provider bias and stereotypes
Major Considerations
► Heterogeneity
of Patients at risk population
► Acculturation,
SES
► Risk
of stereotyping
► Tertiary
barriers less concrete
► Address
provider/patient perspectives
Primary, Secondary and Tertiary access
barriers impact on Latinos’ health through
various intermediary factors:
A. Less screening and preventive care
B. Late presentation to healthcare
C. Less treatment or no treatment
Intermediary Factors
Associated with Disparities
1o, 2o, 3o
Access
A.
*
Barriers
* Evidence Based
Screening
B. Late
Presentation
To Care
C. No Rx or Rx
*
POOR
HEALTH
OUTCOMES
D
I
S
P
A
R
I
T
I
E
S
What is Patient Based
Cross-Cultural Care?

Patient Based Cross-Cultural Care is a
dynamic process of care which focuses on
the unique social and cultural characteristics
of the patient and provides skills to facilitate
communication across social and cultural
boundaries.
(Carrillo, ‘04)
EVERY INDIVIDUAL IS UNIQUE
Cultural
Social
Unique
Individual
Constitutional
(Carrillo, Green, Betancourt ‘99)
Disease vs. Illness
D
I
(Carrillo, Green, Betancourt ‘99)
How do we provide Patient Based
Cross-Cultural Care ?
1.
2.
3.
Language interpretation and translation
Avoid cultural categorization
Identify and address areas of
cross-cultural sensitivity
4.Serve the individual
–
–
–
–
Be aware of you own personal perspective
Explore the patient’s perspective
Explore the patient’s expectations
Engage the patient, Earn the trust
(Carrillo, ‘04)
How do we provide Patient Based
Cross-Cultural Care ?
1.
2.
3.
Language interpretation and translation
Avoid cultural categorization
Identify and address areas of
cross-cultural sensitivity
4.Serve the individual
–
–
–
–
Be aware of you own personal perspective
Explore the patient’s perspective
Explore the patient’s expectations
Engage the patient, Earn the trust
(Carrillo, ‘04)
What is Culture?

Shared system of values, beliefs, and
learned patterns of behavior

Not equivalent to ethnicity or race

Dynamic, not static
(Carrillo, Green,
Betancourt ‘99)
Carlos Gutiérrez,
United States Secretary of Commerce
Cameron Diaz, Actress
How do we provide Patient Based
Cross-Cultural Care ?
1.
2.
3.
Language interpretation and translation
Avoid cultural categorization
Identify and address areas of
cross-cultural sensitivity
4.Serve the individual
–
–
–
–
Be aware of you own personal perspective
Explore the patient’s perspective
Explore the patient’s expectations
Engage the patient, Earn the trust
(Carrillo, ‘04)
Identify and address areas of
cross-cultural sensitivity
•
Every culture has areas of sensitivity
•
Sometimes sensitivities clash in the crosscultural encounter
Patients
– Staff
–
•
Be alert to these sensitive areas
(Carrillo, Green,
Betancourt ‘99)
What are some of these sensitive areas?
•
Styles of communication
–
–
–
Informality may be seen as disrespect
Eye contact
Touch
•
Who’s in charge?
•
Gender of professional
•
Mistrust and Prejudice
•
Food preferences
(Carrillo, Green,
Betancourt ‘99
How do you know?
SIMPLY ASK!
Respect
Curiosity
Empathy
(Carrillo, Green,
Betancourt ‘99)
How do we provide Patient Based
Cross-Cultural Care ?
1.
2.
3.
Language interpretation and translation
Avoid cultural categorization
Identify and address areas of
cross-cultural sensitivity
4.Serve the individual
–
–
–
–
Be aware of you own personal perspective
Explore the patient’s perspective
Explore the patient’s expectations
Engage the patient, Earn the trust
(Carrillo, ‘04)
Explore the patient’s perspective
•
What does the illness or the
symptoms mean to the patient?
(Carrillo, ‘04)
Picture….
Why is it important to explore the
meaning of the illness?

To facilitate diagnosis

To enhance patient satisfaction
 address
 earn
patients’ expectations, fears
patient’s trust
 strengthen

doctor-patient relationship
To promote adherence to therapeutic plan
Explore the patient’s expectations
•
What does the patient expect?
•
Patient’s social context
(Carrillo, ‘04)
Explore the patient’s expectations
•
What is at stake for the patient?
(Carrillo, ‘04)
►45
year old Puerto Rican woman lives
in East Harlem, “El Barrio,” depressed,
adhering poorly to DM and BP
medications. Major concern is
obtaining Public Housing.
Engage the patient, Earn the trust
•
Acknowledge
•
Explain
•
Negotiate
(Carrillo, ‘04)
How do we provide Patient Based
Cross-Cultural Care?
Patient’s
Sensitivities
Language
• Identify Sensitive
Areas
• Simply Ask
Recognize Our
Personal
Perspective
Engage the
patient,
Earn the trust
Patient’s
Perspectives
• Acknowledge
• What does it mean?
• Negotiate
• Explain
• What is expected?
• What is at stake?
(Carrillo, ‘04)
PATIENT BASED CROSS-CULTURAL
COMMUNICATION CAN SERVE AS AN
ADJUNCT TO TREATMENT ADHERENCE
EFFORTS
Screening for Adherence Risk
Didactic Acronym
Meaning Concordance
Apprehension and concern about
treatment
Playback of negotiated treatment plan
Social barriers to treatment adherence
(Carrillo, ‘04)
• What’s wrong?
• What will happen?
Patient
Provider
• What can I do?
• What do you think
is going on?
• What do you expect?
• What’s at stake?
Acknowledge
Present Bio-Med Model
(Syntonic)
Negotiate
Mutual Accord
M. A. P. S.
 Satisfaction
Adherence
(Carrillo, ‘04)