Patient-Centered Care II – Behavioral Medicine in Primary CareMSPAS/MPH Program – Class of 2017 Fall 2014Ana Maldonado MPH, DHSc, PA-C

• Demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.

• Demonstrate knowledge, respect, and validation of differing values, cultures, and beliefs, including sexual orientation, gender, age, race, ethnicity, and class

• Demonstrate understanding of language barriers and working with interpreters

• Define the scope of the health literacy problem• Recognize health system barriers faced by

patients with low literacy

• Implement improved methods of verbal and written communication.

• Incorporate practical strategies to create a shame-free environment.

• Identify the influences and common barriers that patients and providers encounter in regards to patient adherence.

• Identify the impact that non-adherence to therapies has on patients, the healthcare industry and the population

• Develop diagnosis, management, and patient-adherence skills leading to patient compliance

A. AgeB. GenderC. Race/EthnicityD. Socioeconomic StatusE. Health LiteracyF. Physical healthG. Mental HealthH. Religion and/or Spiritual beliefsI. Sexual Orientation

Therefore take into consideration the multiplicity of factors that shape the patient’s life sitting or lying before you in the medical environment.

What is it? Why do we need it? What does it do? Who is responsible?

“An integrated pattern of human behavior that includes thoughts, communications, languages, practices, beliefs, values, customs, courtesies, rituals, manners of interacting and roles, relationships and expected behaviors of a racial, ethnic, religious or social group; and the ability to transmit the above to succeeding generations.”

Cultural Considerations: Primary and

Secondary Dimensions of Diversity

Employment

Community

Networks

Geographic

Location

Family/Extended

Family

Immigration

Status

Marital

Status

Military

Experience

English

Language

Proficiency

Spiritual

Beliefs

Education

Literacy

Parental

Status

Class

Income

Economics

Political

Context

Country

of Origin

Sexual

Orientation

Race

Ethnicity

Language

Cultural + Historical

Knowledge/Experience

Perceptions of

Physical Qualities

Physical

Abilities

Gender

Age

Primary dimensions

influence “who” an

individual is.

Secondary dimensions

influence an individual’s

participation.

(adapted from Rasmussen, 1996)

YOU ARE

Lynch & Hanson 1998

“The ability to think, feel, and act in ways that acknowledge, respect, and build upon ethnic, sociocultural, and linguistic diversity.”

Understanding

Culturally And Linguistically Diverse (CLD) Patients

Skills

Communication

Providing Assessment And Intervention Services

We see and treat an increasingly diverse patient population with different beliefs about healthcare and how it should be practiced on them

U.S. Census 2000

Of the 281 million people 5 and older in the United

States in 2007, 55.4 million individuals — or 20 percent

— reported speaking a language other than English at

home.

While the Census Bureau codes 381 detailed languages,

data tabulations generally are not available for all of

those detailed groups. Instead, the Census Bureau

collapses them into smaller sets of “language groups.”

Surgeon General's Report 2001

Ethnic & Racial Minorities Less access to, & availability of health

care services Less likely to receive needed health care

services Less likely to receive high quality health

care services Experience a greater burden of

disability

Lack of it results in:

Patient-provider miscommunication

Patient-provider misunderstandings

Misunderstanding and/or ignorance of culturally based health beliefs and practices

"Subtle Racism in Medicine", NY Times

“ . . . a disturbing new study by the Institute of Medicine has concluded that even when members of minority groups have the same incomes, insurance coverage and medical conditions as whites, they receive notably poorer care.

Biases, prejudices and negative racial stereotypes, the panel concludes, may be misleading doctors and other health professionals.”

President's New Freedom Report 2003

“The system has neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages and value systems of culturally diverse groups.”

Benefits patient care by improving cross-cultural communication and ensuring that consultation, intervention, and assessments are appropriately designed to meet patient and family needs

Little attention or skill in dealing with patients from diverse sociocultural backgrounds leads to poor communication and uncertainty with regard to clinical outcomes

Schyve, 2002

“The delivery of health care services in a manner that is respectful and appropriate to an individual’s language and culture is more than simply a patient’s right, but is, in fact, a key factor in the safety and quality of patient care.”

If medication non-adherence was a disease, it would be an epidemic.

Anonymous

Nearly half of all American adults– 90 million people – havedifficulty understanding and actingupon health information

Health Literacy, A Prescription to End Confusion, IOM, 2003

•Assessment tools•Provider’s intervention strategies

To Learn: •Factors affecting medication adherence and the relationship to health literacy•Definitions and statistics of medication adherence and health literacy

MEDICATION• Adherence – the extent to which a persontakes medications as prescribed• Compliance – passive following of clinician’s orders• Persistence – a person’s ability to continue taking medications for the intended course of therapy

Health Literacy – the degree to whichindividuals have the capacity to obtain,process and understand basic healthinformation and services needed to makeappropriate health decisions

(Ratzan and Parker, 2000) (presented by the National Library of Medicine, used in Healthy People 2010).

• 90% of Medicare beneficiaries takeprescription medications• Nearly half use five or more different medications• 55% do not follow medication regimen

Amaral, 1986

• 25% do not fill new prescriptions• 39% unable to read prescription label • 67% do not fully understand information given to them

AARP, 2004Moisan, 2002

Medication non-adherence accounts for:• More than 10% of older adult hospitaladmissions• Almost one-quarter of nursing homeadmissions• 20% of preventable adverse drug events• 125,000 deaths annually• $300 billion in health care costs annually

1 –Vermiere, 2001 2 – Strandberg, 19843 –Gurwitz, 2003 4– McCarthy, 1998

Many Americans Disregard Doctors’ Course of Treatment:

• 44% of Americans ignored a doctor’s course of treatment• 27% left a prescription unfilled• 43% believe doctors over treat patients

Wall Street JournalMarch 15, 2007

Adherence is determined by interplay of five factors:

Health system related factors:1. Quality of provider-patient relationship2. Level and quality of communication3. Access to providers (physical/geographic,ease of appointments)4. Access to medications (cost)5. Continuity of care6. Formulary changes and restrictions

Condition related factors:1. Asymptomatic Chronic Disease2. Mental health disorders

Patient related factors:1. Physical impairments: cognitive,

vision, hearing, dexterity, mobility

2. Psychological/behavioral: anger, stress, anxiety; low self efficacy; substance abuse

Therapy related factors:1. Complexity of medication regimen: numberof meds; number of daily doses2. Duration of therapy3. Therapies that are inconvenient or interferewith a person’s lifestyle4. Medications with social stigma attached5. Medication side effects

Social/economic related factors:

1. Low health literacy, limited English language proficiency2. Lack of health insurance; barriers to access to care3. Cost of medications4. Burdensome work schedule

Social/economic related factors:5. Poor social support6. Homelessness or unstable living conditions7. Cultural beliefs and attitudes

Relationship Between Health

• Limited research about causal relationship between health literacy and health outcomes• Limited published information regarding role of health literacy in the medication adherence process

Relationship Between Health

• Inadequate functional health literacy, abarrier to assessing medication adherence

• Adults with limited health literacy have less knowledge of disease management

• No gold standards• Most commonly used:

– Pill counts– Refill records– Patient self report– Drug therapeutic levels• Indirect:– Clinical outcomes

• Validated scale designed to estimate the riskof medication non-adherence• Cited in over 70 articles since itspublication 1986

Morisky DE, Green LW, Levine DW. Concurrent and predictive validity of a selfreported measure of medication adherence. Medical Care 1986;24:67-74

• Used for many different disease such as HTN, hyperlipidemia, asthma and HIV• Score based on patient responses to four Yes or No questions

Yes = 0 No = 1

Morisky DE, Green LW, Levine DW. Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care 1986;24:67-7

Four is the highest level of medication adherence, while zero is the lowest level.

Most tools cannot differentiate among:• Reading ability• Lack of background knowledge in health• Lack of familiarity with language and types of materials• Cultural differences

Commonly used tools in health services research:

• Wide Range Achievement Test (WRAT)• Rapid Estimate of Adult Literacy inMedicine (REALM)• Test of Functional Health Literacy in Adults (TOFHLA)

Screening questions for use in clinical practice:1. How often do you have problems learningabout your medical condition because ofdifficulty understanding writteninformation?2. How often do you have someone help youread hospital materials?

Wallace, et al. Screening Items to Identify Patients with Limited Health Literacy Skills. J Gen Intern Med 2006; 21 (8): 874-877

Screening questions for use in clinicalpractice:

3. How confident are you filling out medicalforms by yourself?

Wallace, et al. Screening Items to Identify Patients with LimitedHealth Literacy Skills. J Gen Intern Med 2006; 21 (8): 874-877

Intervention Strategies Targeting HealthLiteracy:

• Routinely assess patient’s health literacy level and medication adherence• Improve written prescription information• Improve verbal communication• Use effective patient adherence tools

Improving Use of Prescription Medication: A National Action Plan NQF, 2005

• Simplify reading level to grade 5• Offer all written prescription medicationinformation in foreign language and largeprint• Use standardized, universal symbols(simple, explicit icons)

• Use plain language always• Use teach back and show back techniques• Limit information to two or three important points at a time• Use drawings, models or devices todemonstrate points• Encourage patients to ask questions

Steps:I. Explain/demonstrate the new concept

A. Explain the rationaleB. Provide complete instructionsC. Explain likely benefitsD. Explain likely side-effects

II. Assess patient’s recall and comprehension: ask patient to demonstrate

III. Clarify and tailor the explanationIV. Re-assess patient’s recall andcomprehension: ask patient to demonstrateV. Patient recalled andcomprehended/demonstrated mastery

Effective Patient Adherence ToolsMedication Organizers

Medication organizers such as weekly pill boxes and others are effective tools to improve medication adherence.

Electronic Pagers/Timers

Simplify Medication Regimen

Complex medication regimen can be simplified as much as possible by using longer acting drugs or drug combination whenever

appropriate.

• Medication non-adherence is a significantProblem

• Health Literacy is an importantcontributing factor to medication nonadherence

• Interventions targeting health literacy inmedication adherence process – need to bemulti-layered

https://www.youtube.com/watch?v=cGtTZ_vxjyA

http://www.youtube.com/watch?v=sMb43pMfsMk

Brown, M. T. & Bussell, J. K. (2011)Medication Adherence: Who Cares? Mayo Clinic

Proceedings. 86(4):304-314.

Article is posted on Blackboard

http://www.healthlitt.org/TalkingTouchscreen/Pages/default.aspx

Questions and Answers