Transcript Community Plunge - National AHEC Organization

Community Plunge:
A Tool for Increasing Cultural Understanding
in Health Care
Jennifer Casey, MBA.
Cheryl Alberty, MBA, MHA
National AHEC Organization Conference
Las Vegas, Nevada
June 24, 2010
Presentation Overview
• Health disparities in North Carolina
• The role of cultural competence in addressing
health disparities
• What is Community Plunge?
• Northwest AHEC Community Plunge
– Rationale
– Methods
– Results
• Conclusions
What is a Health Disparity?
• “Differences in health status among distinct
segments of the population including differences
that occur by gender, race or ethnicity, education
or income, disability, geographic location, or
sexual orientation.“ – NC 2010 Health Objectives
• “A population-specific difference in the presence
of disease, health outcomes, or access to care.”
- Health Resources and Services Administration
(HRSA)
Disparities in Deaths from Heart Disease
Source: NC Office of Minority Health and Health Disparities and State
Center for Health Statistics, “Racial and Ethnic Health Disparities in NC:
Report Card 2006.”
Disparities in Deaths from Diabetes
Source: NC Office of Minority Health and Health
Disparities and State Center for Health Statistics, “Racial
and Ethnic Health Disparities in NC: Report Card 2006.”
Disparities in Deaths from HIV Disease
Source: NC Office of Minority Health and Health
Disparities and State Center for Health Statistics,
“Racial and Ethnic Health Disparities in NC: Report
Card 2006.”
Infant Mortality Disparities
4.5
Source: NC Office of Minority Health and Health
Disparities and State Center for Health Statistics,
“Racial and Ethnic Health Disparities in NC: Report
Card 2006.”
Why do these disparities exist?
 There is no singular cause, but rather the
interaction of many factors!
We need to consider:
 Social and environmental factors, including SES
 Access to care
 Stress
 Differences in quality of care received
 Genetics and biology
 Behavioral factors
The Importance of Cultural Competence
• Health care must be adapted to meet the cultural and
linguistic needs of an increasingly diverse patient
population
• Cultural competence is critical in understanding these
needs
• Change must start in health professional schools
• Starts with knowledge of disparities, communication with
patients, and sensitivity
Teaching Cultural Competence
• “The curriculum should require a focus on the
reality of evidence-based health disparities
among racial and ethnic minority populations,
importance of providing culturally competent
care and communication to meet the health
needs of diverse patient populations, and
exposure to cultural diversity.”
Source: Shaya, FT; Gbarayar, CM. (2006)
The case for cultural competence in health
professions education. Am J Pharm Educ;
70(6): 124.
Socio-Ecological Framework
(Graphic borrowed from the Centers for Disease Control and Prevention)
What is Community Plunge?
• Experiential learning opportunity that connects
participants (providers and students) with the
strengths & needs of the communities they serve
• Understand patients’ life experiences in the larger
social context of health
• 3 components:
– Windshield tour
– Focus group
– Debriefing session
Windshield Tour
• Route within affluent and poor segments of the
Winston-Salem community
– Poorer areas have a much higher percentage of minority
residents
• Narrated (standardized guide for each department)
• Emphasis on:
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Revitalization efforts
Community assets
Public housing projects
Historical landmarks
Key health and human service agencies
Focus Groups
• Providers listen to clients tell their stories
• Uses standardized focus group guide
• Clients have included:
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Elderly
Low-income African American & Hispanic parents
Parents of children with special needs
Teenage mothers
Community members living with substance abuse or
mental health concerns
– Other vulnerable populations
Debriefing Session
• Providers meet to discuss their experiences
• Complete post-plunge survey
– Most beneficial aspect of the plunge
– Things I SAW that made the biggest impression on me
– Things I HEARD that made the biggest impression on
me
– What I want to remember when caring for clients
– Suggestions for improving the plunge
Northwest AHEC’s Plunge
• Faculty serve as facilitators to guide residents
• Piloted with pediatric residents in 2002
• Now includes 5 departments:
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Pediatrics
Family and Community Medicine
Psychiatry and Behavioral Medicine
Internal Medicine
Physician Assistant Studies
• Financially supported by Northwest AHEC ($4,400
allocated per department)
Data Analysis Methods
• Reviewed post-plunge surveys (n=250)
• Assigned codes to every phrase in each response
– Examples:
• Barriers to care
• Communication
• Disparities
• Organized codes into themes
• Selected quotations to go along with the themes
to tell a story
What was the most beneficial aspect
of the community plunge?
• Gain new perspective: see firsthand how
clients live
– Poverty
– Lack of resources
– Poor housing conditions
“Being able to visualize where my clients
live, work, and access
care/training/services really helps me
tailor their care/education.”
• Impacts how providers plan to care for their
clients and understanding of the resources
available to them in their community
“Helps me to see some of the resources
that I will refer clients to and
understand better how they help.”
• Provides a firsthand opportunity to hear
clients discuss their viewpoints concerning
positives and negatives of care
– Frustrations with health care system
– Expectations of providers
“Speaking with families of patients, you
get information that no book will tell
you.”
What did you SEE that made the
biggest impression on you?
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Low-income housing
Government renovation projects (+ and -)
Squalor and poverty
Disparities in finances and resources
Segregation
“. . . the difference between the haves
and have-nots, and the big lack of
people in the middle.”
• Lack of community resources that others take for
granted
– Transportation
– Food resources
– Pharmacies
“. . . the lack of convenient grocery stores with
variety to provide fruits/vegetables.”
“I was amazed by how far people have to travel
on public transportation.”
What did you HEAR that made
the biggest impression on you?
• Bad or “negative” care received from
providers
– No further information or health education
– No referrals
– Inferior care at low-cost clinics
“People felt doctors were not treating
them like people.”
• Expectations clients have for their providers
– Good personality
– Time
– Compassion
– Listening and trying to understand
“All patients prefer an average doctor
instead of a smart jerk.”
• Barriers to obtaining care
– Access (to providers, medications, etc.)
– Transportation
– Financial barriers
– Cultural / linguistic barriers
– Navigating the system
“One patient refused a pay raise so that
she could still qualify for the free
health care.”
• Racial & ethnic segregation and discrimination
“ . . . hearing the conditional fear of
immigration from patients that were
undocumented and worry of being
taken advantage of.”
Based on what you experienced on
the plunge, what is the one thing
you want to try to remember when
taking care of clients?
• Communication with clients is critical
– Active listening
– Discussing & explaining
– Building rapport
– Involving clients in their care
– Trying to understand clients’ perspectives
“Let people know you are glad they
came to see you.”
• Respect and compassion
– Non-judgmental
– Open-minded
– Treat everyone equally
– Understand their backgrounds
– Treat him/her like a whole person
“Treat them the same way I would want
myself or a loved one to be treated.”
• Keep in mind clients’ backgrounds and
perspectives
– See things from their point of view
“There is a lot more to someone than what is
written in the chart: their real, everyday life
experience.”
“Each client has a different perspective on life
and what is important. For some, compliance
with meds does not compare to finding a
meal.”
What are your suggestions for
improving the plunge?
• Allow more time/interaction with clients.
• Provide exposure to more than one group of
clients.
• Provide a community resource guide.
• Make the windshield tour longer to see more
communities and resources.
• Shorten the windshield tour to have more
time with community members.
• Do walking tours (versus driving) of the
treatment facilities/community resources.
Summary: Key Themes
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Communication
Lack of access to resources
Poverty
Barriers to care
Racial and ethnic differences / disparities
Understanding clients’ perspectives
Limitations
• Generalizability
• Cannot really compare across departments or
disciplines
– Windshield tour scripts differed by departments
– Different departments visited different areas of
the city as appropriate for their needs
Strengths
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Adaptability
Usefulness in promoting cultural competence
Community-centeredness
Has potential to influence community leaders
and policymakers
Future Directions
• Measuring actual behavioral changes in
providers over time
• Solicit input from community members
regarding how plunge should be conducted
• Facilitate interaction between providers and
their clients during the plunge
Conclusion
• Community plunge is a useful, cost-efficient,
and adaptable tool for increasing cultural
competence among health care providers.
Acknowledgement
• This study was supported by Northwest AHEC
generated revenue funds. We would like to
acknowledge the investigators for this study as
well as the ongoing commitment and hard
work of all faculty and staff in the
departments at the Wake Forest University
School of Medicine associated with the
community plunge.
Study Team
• Principal Investigator: Michael Lischke, EdD,
MPH
• Co-Investigators:
– Jennifer Casey, MBA
– Jane Foy, MD
– Jaimie Hunter, MPH, CHES
– Anita Pulley, RN, MSN
• Study Coordinator: Nancy Cox, MSW
Questions?
Contact Information
Jennifer Casey, MBA
336.713.7705
[email protected]
Cheryl Alberty, MBA, MHA
336.713.7719
[email protected]
Northwest AHEC fax: 336.713.7701