Panel Discussion: Working with Diverse Populations
William C. Hsu, MD
Lorena Drago, MS, RD, CDN, CDE
Lenore T. Coleman, PharmD, CDE, FASHP
Sunday, February 19, 2017
10:15 a.m. – 11:30 a.m.
William C. Hsu, MD
It does not take long for a health care provider to realize that changing patient behavior is one of
the most challenging aspects in clinical medicine. While there are a dozen effective medication
choices at our disposal for the treatment of diabetes, an improvement in clinical outcomes can
only come about when patients are actively engaged in the self-management of diabetes. In
ethnic populations, many factors affect an individual's ability to self-manage diabetes, including
cultural beliefs, immigration experience, language abilities/health literacy, educational
background, employment, and accessibility of healthcare services. Cultural values regarding
health and healthcare offer another layer of complexity that affects an individual's perception
and management of a disease. We will explore how behaviors arose from an individual’s
cultural values and ultimately explanatory models for diseases. As a next step, we will use
examples illustrating the integration of this understanding in our approach to behavior
modification.
References:
1.
Tseng, J. Halperin , Ritholz MD, Hsu WC Perceptions and management of
psychosocial factors affecting type 2 diabetes mellitus in Chinese Americans, Journal of
Diabetes and Its Complications (2013), 2013 Jul-Aug;27(4):383-90
2.
Gutiérrez RR, Ferro AM, Caballero AE (2015) Myths and Misconceptions about Insulin
Therapy among Latinos/Hispanics with Diabetes: A Fresh Look at an Old Problem. J
Diabetes Metab 6: 482.
3.
Ho EY, Chesla CA, Chun KM. Health communication with Chinese Americans about
type 2 diabetes. Diabetes Educ. 2012 Jan-Feb;38(1):67-76.
Lorena Drago, MS, RD, CDN, CDE
1. Cultural competency?
2. How to become more culturally competent?
a. Awareness
b. Knowledge
c. Skills
3. Distribution of US population by Race/Ethnicity 2010
4. Racial Ethnic Differences in Diagnosed Diabetes over age 20, 2010-2012
5. Culturally Specific Communication Tools
a. LEARN
b. BATHE
c. ETHNIC
6. Tool for providers to elicit patient’s health beliefs and perceptions
7. Foods in health and disease
8. Teach-Back
References:
1.
2010 Census. http://www.census.gov/2010census/ Accessed 1/11/17. National Diabetes
Statistics Report, 2014.
2.
http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
Accessed 1/11/17
3.
Campinha-Bacote J. The Process of Cultural Competence in the Delivery of Healthcare
Services: A Model of Care. J Transcult Nurs. 2002;13:181-184.
4.
Goody C., Drago L. Using cultural competence constructs to understand food practices
and provide diabetes care and education. Diabetes Spectrum. 2009; 22(1):43-47.
5.
Berlin EA, Fowkes Jr, WC. A Teaching Framework for Cross-cultural health care. The
Western Journal of Medicine. 1983;139:934-938
6.
Stuart, M.R. and Lieberman, J.A. III. "The Fifteen Minute Hour: Practical Therapeutic
Interventions in Primary Care" 3rd Edition. Philadelphia: Saunders, 2002
7.
Levin SJ, Like RC, Gottlieb JE. ETHNIC: a framework for culturally competent clinical
practice. In: Appendix: Useful clinical interviewing mnemonics. Patient Care
2000;34(9)188-9
8.
Kleinman A (1988) The illness narratives: Suffering, healing, and the human condition.
New York: Basic Books
9.
Goyan Kittler, P. Sucher, K. Nelms, M. 2012. Food and Culture. 6th edition. Belmont,
CA: Wadsworth, Cengage Learning.
10.
Cavanaugh K, Wallston KA and Rothman R. Addressing literacy and numeracy to
improve diabetes care. Diabetes Care 32:2149-215.
Lenore T. Coleman, PharmD, CDE, FASHP
African American and Latino populations have a higher risk of diabetes compared to
Caucasians (77% higher). In addition, African Americans with diabetes were 1.5 times more
likely to be hospitalized and 2.3 times more likely to die from diabetes than Caucasians.1 The
healthcare industry continues to spend millions of dollars per year to treat the complications of
diabetes rather than focus on prevention and education . Healing Our Village has developed an
interactive model of care that supports strong collaborative links between the patient’s primary
care provider and two additional healthcare team members: Pharmacists and Wellness
Coaches. The core components of the model include: Comprehensive patient interview /
assessment; Individualized Patient Education; Clinical Follow Up; Specialty Training; and
Pattern Management using a “talking” blood glucose monitor. Our program has been able to
demonstrate the following clinical outcomes:
•
•
•
•
•
•
50-60% reduction in emergency room and urgent care visits in patients with diabetes;
50% reduction in hospital admissions for Diabetic Ketoacidosis (DKA); significant
reduction in hemoglobin A1C (decrease of 1.6% over 8 months);
30% increase in overall knowledge of the disease process;
reduction in both systolic and diastolic blood pressure of 10-13 mmHg;
increase in participants’ consumption of fruits and vegetables by 40%;
increase in physical activity by participants by 20%.
The success of the program is based on understanding the learning styles of diverse
populations and ways to use culturally sensitive communication techniques that prove to be
effective. Utilization of appropriate strategies and tactics can ultimately change patient
behaviors related to lifestyle and medication usage.
References:
1.
Chow, EA, Foster, H, Gonzalez V. The Disparate Impact of Diabetes on Racial/Ethnic
Minority Populations. Clinical Diabetes, 30(3):130-133, 2012.
2.
AOA Health Watch – Overcoming Barriers in Treating African Americans. Dos against
Diabetes, January 2011
3.
Tripp-Reimer, T, Choi, E, Kelley, S. Cultural Barriers to Care:Inverting the Problem.
Diabetes Spectrum. 14(1):13-22, 2001
4.
Peek, M, Harmon, S, Scott, S. Culturally tailoring patient education and communication
skills training to empower African-Americans with diabetes. TBM. 296-308.
Presenter Disclosure Information
Working with Diverse Populations
William C Hsu, MD
Joslin Diabetes Center
Boston, MA
In compliance with the accrediting board
policies, the American Diabetes Association
requires the following disclosure to the
participants:
William C. Hsu, MD
Disclosed no conflict of interest.
The Rising Tide of Diabetes Worldwide at
the Turn of the Millenium
Time Magazine
Age-adjusted prevalence of obesity, by sex
and race and Hispanic origin, among adults
aged 20 and over: United States, 2011–2012
Prevalence of and Trends of Diabetes
Among Adults in the U.S 1988-2012
Total
2011- 2012 NHANES
November 5, 2001
JAMA. 2015;314(10):1021-1029
ADA Position Statement
Sensitivity at Selected BMI Cut Points, by
Asian-American Subgroup
Areneta MR, et al. Diabetes Care. 2015 May;38(5):814-20.
Understanding Patient’s Explanatory
Models of Disease
7
What’s Most Important?
Knowledge
Attitude
Tseng, J., et al., Perceptions and management of psychosocial factors affecting type 2 diabetes
mellitus in Chinese Americans. J Diabetes Complications 2013
Skill
Which Foods do you?
Working with Diverse Population:
Cultural Competency in Diabetes
Education
• Eat?
• Stay healthy?
• Cold?
• Avoid?
Lorena Drago MS RD CDN CDE
www.lorenadrago.com
[email protected]
February 19, 2017
Distribution of U.S. Population by
Race/Ethnicity 2010
Based on the 2000 U.S. standard population. Source: 2010–2012 National Health Interview Survey and 2012 Indian Health Service’s National Patient Information Reporting System
What is Cultural Competency?
“Provide effective,
equitable,
understandable, and
respectful quality care and
services that are
responsive to diverse
cultural and
How to Become More Culturally Competent
health beliefs and
practices, preferred
languages, health literacy,
and other communication
needs.”
Defined by the National Standards for Culturally and Linguistically
Appropriate Services (CLAS) in Health and Health Care
Culturally Specific Communication Tools
• L.E.A.R.N. MODEL
LEARN: Guidelines for Health Practitioners
L:
Listen with sympathy and
understanding to the patient’s
perception of the problem
E:
Explain your perceptions of the
problem
Acknowledge and discuss the
differences and similarities
Recommend treatment
Negotiate agreement
• Guidelines for Overcoming Obstacles in
Cross-Cultural Communication with
Patients
• B.A.T.H.E. MODEL
• Eliciting the Psychosocial Context
• E.T.H.N.I.C. MODEL
• Framework for Culturally Competent
Clinical Practice
Berlin EA, Fowkes Jr, WC. A Teaching Framework for Cross-cultural health care. The Western Journal of Medicine. 1983;139:934-938
A:
R:
N:
Berlin and Fowkes 1983, 934-938
Stuart, M.R. and Lieberman, J.A. III. "The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care" 3rd Edition. Philadelphia: Saunders, 2002.
Levin SJ, Like RC, Gottlieb JE. ETHNIC: a framework for culturally competent clinical practice.
In: Appendix: Useful clinical interviewing mnemonics. Patient Care 2000;34(9)188-9
B.A.T.H.E.
• Background: A simple question, "What is going on in your
life?" elicits the context of the patient's visit.
• Affect: (The feeling state) Asking "How do you feel about
what is going on?" or "What is your mood?" allows the patient
to report and label the current feeling state.
• Trouble: "What about the situation troubles you the most?"
helps the physician and patient focus, and may bring out the
symbolic significance of the illness or event.
• Handling: "How are you handling that?" gives an assessment
of functioning and provides direction for an intervention.
• Empathy: "That must be very difficult for you." legitimizes
the patient's feelings and provides psychological support.
ETHNIC MODEL
The ETHNIC model can be effective
in identifying patient’s explanation
of illness, treatment, and
traditional treatment practices
accepted in the patient’s culture.
This model can also help negotiate
the treatment options, determine
the appropriate intervention, and
collaborate with patients and family
members.
ETHNIC: A Framework for Culturally Competent Clinical
Practice
ETHNIC
E: Explanation
T: Treatment
What do you think may be the reason you have these symptoms?
What do friends, family, and others say about these symptoms?
Do you know anyone else who has had or who has this kind of
problem?
Have you heard about/read/seen it on TV/radio/newspaper?
(If the patient cannot offer an explanation, ask what most concerns
them about their problems).
H: Healers
Developed by: Steven J. Levin, M.D.
Robert C. Like, M.D., M.S., Jan E. Gottlieb, M.P.H.
Department of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
What kinds of medicines, home
remedies or other treatments have you
tried for this illness?
Is there anything you eat, drink or do
(or avoid) on a regular basis to stay healthy? Tell
me about it.
What kind of treatment are you seeking from me?
Have you sought any advice from alternative/folk
healers, friends or other people (non-doctors) for
help with your problems? Tell me about it.
ETHNIC
N: Negotiate
I: Intervention
C: Collaboration
Tool for Providers to Elicit Patient’s Health Beliefs
and Perceptions
Negotiate options that will be
mutually acceptable to you and
your patient and that do not
contradict, but rather incorporate
your patient’s beliefs.
Determine an intervention with your
patient. May include incorporation
of alternative treatments,
spirituality, and healers as well as
other cultural practices (e.g. food
eaten or avoided in general and
when sick).
Collaborate with the patient, family
members, other health care team
members, healers and community
resources.
The Explanatory Models Approach
•
•
•
•
•
•
•
•
What do you call this problem?
What do you believe is the cause of this problem?
What course do you expect it to take? How serious is it?
What do you think this problem does inside your body?
How does it affect your body and your mind?
What do you most fear about this condition?
What do you most fear about the treatment?
How long will this problem last?
Kleinman A (1988) The illness narratives: Suffering, healing, and the human condition. New York: Basic Books
Foods in Health and Disease
Teach Back/Show Me Method
• Can you explain in your own words what I said?
• Which foods do you eat to stay healthy?
• Which foods do you avoid?
• Which foods do you eat more of now that you have
this medical condition?
• Which of these recommended foods contradict your
beliefs?
• We all take remedies or certain foods when we are
sick, which ones do you use?
Summary
•
•
•
•
How do you become culturally competent?
Which tools can you use?
Ask the right questions
Use Teach-Back
Thank YOU
Lorena Drago MS RD CDN CDE
www.lorenadrago.com
[email protected]
Working with Diverse Populations:
Presenter Disclosure Information
Lenore T. Coleman, Pharm.D. CDE
President and Founder, Healing Our Village of Maryland, Inc.
Atlanta Georgia
Lenore T. Coleman
Research Support: Acurian, Inc.
Consultant: Speaker ‐ Merck Pharmaceuticals
Distributor – Glucocard Expression
NO OTHER CONFLICTS
Why do I care??
• More than 9000 lower extremity amputation per year
• More than 4000 new cases of end‐stage renal disease per year
• More than 3000 new cases of blindness per year
• More than 400,000 hospitalizations per year (115,000 due to CVD)
Cultural Barriers and Differences in Diverse Populations
Empowering patients to modify their behavior to effectively manage their chronic diseases Myths about Minorities with Diabetes Myths about Minorities with Diabetes • Highly Educated patients have a high Health Literacy ‐ TRUE FALSE • Standardized Diabetes Education Programs are equally effective in Caucasians and Minority patients – FALSE
• Poor educated patients cannot understand complex information TRUE FALSE
– FALSE
• Patients are not willing to PAY CASH for Diabetes Education and Diabetes Supplies TRUE FALSE – FALSE
• Minority populations are not interested in improving their diabetes control ‐ Competing priorities – NEED to SHOW VALUE
TRUE FALSE
– False ‐ Enjoy Less Structure ‐ Informality, and flexibility to adjust to various conditions/situations
• African Americans have a fear of needles and do not like to take insulin shots TRUE FALSE
– True (Especially Men)
• Benefit more from individual counseling – T or F
– False: Enjoy small groups versus one‐on‐one • Spirituality does not play a factor in glycemic control TRUE FALSE
African American Cultural Norms
Hispanic Culture
**Hispanic Culture ** African American Culture
• Strong extended family system more pronounced than other ethnic groups**
• Respect for the elderly and their role in the family**
• Use of Ebonics and use of slang in some subgroups
• Do not necessarily believe EDUCATION is the key to a better life
• Direct eye contact when speaking, less eye contact when listening
• Independent, competitive, and achievement oriented (pride in overcoming obstacles and barriers to success)
• Communicating with passion, expression, spontaneity, and animation – PATIENT IS NOT UPSET
• Personal and interpersonal relationships highly valued and come first **
• Commitment to the Spanish language
• Direct physical contact expected, affectionate hugging and kissing on the cheek are acceptable for both the same sex and opposite sex
• Become relaxed with time
• Strong religious beliefs (primarily Catholicism)**
• Tendency toward more traditionally defined family structure (father as head of house) and more defined sex roles
Build TRUST FIRST!!
Cultural Sensitivity
• Creating an atmosphere of understanding, respect, and support. Evaluate your clinic environment. IS IT USER FRIENDLY
• Establishing meaningful connections. DO NOT HAVE AN AGENDA
• Knowledge of the history, culture, traditions, customs, language or dialect, values, religious or spiritual beliefs, art, music, learning styles
• Written information and visual aids must reflect the population served (content and design)
Barriers to Shared Decision Making in Minority Populations
• Patient Identified Barriers
– Familial experiences, Self Efficacy
• Physician Identified Barriers
– Interpersonal skills, accessibility, availability
• Patient/Provider imbalance
– Physician bias/ discrimination
– Cultural discordance (less likely to share test results)
– Lack of Trust ‐ negative attitudes / internalized racism = patient is less forthcoming with information and less likely to adhere to therapy
Shared Decision Making (SDM)
• Studies have found that engaging diabetes patients in shared decision making can results in better control of diabetes and hypertension, higher ratings of self‐reported health, and shorter hospitalizations.
• African Americans want to participate in SDM but physicians do not offer them the option
Parchman ML, Zeber JE, Palmer RF. Participatory decision making, patient activation, medication
adherence, and intermediate clinical outcomes in type 2 diabetes: a STARNet study.
Annals Fam Med. 2010;8:410-417. Stewart MA.
Effective physician-patient communication and health outcomes: a review. Can Med Assoc J.
1995;152:1423- 1433.
SDM impacts ownership and adherence to treatment plan • Patients should be taught to: – ask more questions ‐ information seeking particularly about the risks/benefits of tests/treatments; – give more detailed information (information provision), especially about lifestyle issues, preferences for quality vs. quantity of life, etc.; – clarify/restate what the practitioner says (Teach –
Teach Back) information verified to ensure full patient understanding;
– share in the decision‐making process by explicitly stating preferences for tests and treatments that reflect lifestyle choices
Culturally Sensitive Diabetes Education via Telehealth Platform
TeleHealth Diabetes Management Program –
Focus on Medication and Pattern Management Outpatient Diabetes Education Program – AADE or ADA Certified
• “Sugar Busters” – Customarily on Saturdays from 10am to 2pm
• “Fit and Fabulous” ‐ Nutrition Support Groups
– Weekdays
– Evenings
• “Choices and Changes” – Prevention and Behavior Change • “Heart of the Matter” – Focus on cardiovascular health –
Hypertension, CAD, Heart Failure • Referrals generated by physician staff, and community based clinics and community outreach
• Individual appointments provided for specialty patients (i.e. newly diagnosed, pediatric, gestational diabetes) 15
Confidential
Medication Reconciliation is the KEY
Seamless Transition between Inpatient and Outpatient Medication Non‐adherence ‐ >50%
Confidential
Medication Therapy Management (MTM)
17
Medication Therapy Management Wellness Coaches =navigators = certified medical assistants) – Home Visits • Customized programs that close the gaps within an integrated health care system – “Medical Home Model”. • HOV trained Wellness Coaches located in
– Hospitals / Emergency Departments
– Clinics
– Physician offices
– Patient’s homes
• Deploy and infuse technology into the system in order to improve access and coordination while capturing clinical and outcome data
• Patients are systematically directed to hospital/clinic/ community based support programs
Confidential
18
Clinical Pharmacist
“Personalized Touch” HOV Solution to Closing the Gaps
• Pattern Management through the use of Talking Meter (English/Spanish) ‐
Patients need to know their numbers
• Medication Therapy Reconciliation– “Specialized” Pharmacists
• Pharmacist provide “live” appointments in physician offices, clinics and via the telephone
• Telehealth appointments using Housecall / HealthEC • Comprehensive Medication Review
– Perform a complete medication history and medication review
– Analyze medication therapy regimen for compliance issues, side effects, inappropriate medication, drug interactions, etc. – Identify all inappropriate medication utilization patterns and recommendations for drug therapy changes
– Provide a Care Plan to the attending physician with all drug related problems and point of care testing results.
– Educate patients via the internet or telephonically regarding medication adherence and provide tools and strategies to improve medication adherence
Confidential
– Adjust diet and medication to match the physiology of the disease
– Understand the importance of postprandial hyperglycemia 19
Diabetes Transitional Care Program
United Medical Center / Department of Health – 9 months • 301 patients with complete pre post data thus far‐ 65% female, 35% male – Mean age 52
• Reduction in Emergency Room Visits – 50% Dr. Lenore T. Coleman Pharm.D. CDE
Healing Our Village
www.healingourvillage.com
800 788 0941 [email protected]
Demographics and Clinical Measures
Averages
Prev 12 months
Post‐
Interven
Difference
A1C 9.6%
7.81%
‐1.79%
BP Systolic
142.4
106.9
‐35.5
BP Diastolic
95.6
82.5
‐13.1
Random BG
271.9
185.6
‐86.3
Weight
222.4lbs
208.3lbs
‐14.1 lbs
Confidential
Questions??
21