Cultural Competency and Health Literacy in Home Health Care

1. Goldie Burnham, RN, MS, CNS, CDEProject Manager – Underserved/Task 1d2South Dakota Foundation for Medical CareSeptember 25, 2007 Cultural Competency and Health Literacy in Home Health Care

2. Landmark Study • 2002 • IOM commissioned by US Congress to study differences in kind and quality of healthcare provided for racial and ethnic minorities. • Institute of Medicine. Board on Health Sciences Policy. Unequal Treatment: Confronting • Racial and Ethnic Disparities in Health Care. 2002. Available at: • http://www.nap.edu/openbook.php?isbn=030908265X.Accessed August 30, 2007.

3. Identified Barriers • Cultural • Linguistic • Patient Preferences • Refusal of Treatment • Poor Adherence Institute of Medicine. Board on Health Sciences Policy. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002. Available at: http://www.nap.edu/openbook.php?isbn=030908265X.Accessed August 30, 2007

4. Factors Contributing to Unequal Treatment • Clinical Encounter Provider: Stereotypes Biases Uncertainty All contribute to unequal treatment Institute of Medicine. Board on Health Sciences Policy. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002. Available at: http://www.nap.edu/openbook.php?isbn=030908265X.Accessed August 30, 2007.

5. Condition of Clinical Encounter • High time pressure • Cognitive complexity • Pressure for cost-containment Institute of Medicine. Board on Health Sciences Policy. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002. Available at: http://www.nap.edu/openbook.php?isbn=030908265X.Accessed August 30, 2007.

6. CLAS StandardsCulturally and Linguistically Appropriate Services • National Standards for Culturally and Linguistically Appropriate Services in Health Care www.thinkculturalhealth.org • Standards were developed by the OMH in December 2000 as a means to correct existing inequities in health services Office of Minority Health, U.S. Department of Health and Human Services. (2000).National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. Available at: http://www.omhrc.gov/clas/finalcultural1a.htm. Accessed August 30, 2007.

7. Culture • Determines how we perceive our world • Shapes personal and group values and attitudes • Determines what does and what does not make sense Institute of Medicine. Board on Health Sciences Policy. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002. Available at: http://www.nap.edu/openbook.php?isbn=030908265X

8. Cultural Disregard “Not knowing what one does not know.” Coleman-Miller, B; A Physician's Perspective on Minority Health. Health Care Financing Review, Summer 2999, Vol. 21(4).

9. Barriers to Care • Embarrassment • Position of power for provider • Health literacy • Self-esteem issues • Self-perceived “intelligence” factor • Language differences Coleman-Miller, B; A Physician's Perspective on Minority Health. Health Care Financing Review, Summer 2999, Vol. 21(4).

10. Factors Affecting Cultures • Educational level • Income level • Geographic residence • Identification with community groups • Religious, professional, community service etc. • Individual experiences • Length of residency in US • Place of birth • Age Administration on Aging.US Department of Health and Human Services. January 2001. Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and Their Families. Available at: http://www.aoa.dhhs.gov/prof/adddiv/cultural/addiv_cult.asp. Accessed August 30, 2007.

11. Problem Solving A patient’s culture may dictate how a health problem is solved.

12. Cultural Knowledge If healthcare providers cannot understand their patient’s language, they will not know their cultural beliefs or how these beliefs may impact their health outcomes.

13. Health Literacy Comes from a convergence of educational, cultural and social factors and health services. Institute of Medicine. Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. April 2004. Available at http://books.nap.edu/catalog.php?record_id=10883#toc. Accessed August 30, 2007.

14. Cultural Differences Related to Health Literacy • Eye contact • Touching • Personal space Even though not following cultural norms may be unintentional it may signal disrespect and hinder communication. Andrus, M.R. and Roth, M.T. Health Literacy: A Review. Pharmocotherapy.2002;22 (3): 282-302

15. Health Literacy Definition The National Institutes of Health have defined health literacy as: “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” Healthy People 2010. National Institutes of Health. Department of Health and Human Services. Available at: http://www.healthypeople.gov/document/HTML/Volume1/11HealthCom.htm. Accessed August 30, 2007.

16. Low Health Literacy The majority of adults that have limited literacy levels are English speaking, white, native-born Americans over the age of 65. Institute of Medicine. Committee on Health Literacy. Health Literacy: A Prescription of End Confusion. April 2004. Available at http://books.nap.edu/catalog.php?record_id=10883#toc. Accessed August 30, 2007.

17. Low Health Literacy – Cont’d • Increasing Racial and Ethnic Diversity - 2000 U.S. Census data indicated that 75.1% of the U.S. population was Caucasian - By 2050 this percentage will drop to 47.2% - US is popular immigration destination Office of Minority Health. Department of Health and Human Services. 2007. Available at : https://ccnm.thinkculturalhealth.org/GUIs/GUI_CEU_info.asp. Accessed August 30, 2007.

18. Cost of Low Health Literacy Weiss BD, Palmer R. Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population. J Am Board Family Pract. 2004:17;44-47.

19. Manifestations of Poor Health Literacy • Missed appointments • Unable to navigate health system • Less knowledge about disease with more difficulty managing symptoms Edlin, Mari. Health Understood: New awareness reduces ramifications of poor health literacy. Managed Healthcare Executive, Dec.1, 2004. Available at: http://www.managedhealthcareexecutive.com/mhe/Special+Report/Health-understood/ArticleStandard/Article/detail/136684. Accessed August 31, 2007

20. Manifestations of Poor Health Literacy – cont’d • Less likely to receive diagnostic screenings, follow medical regimens and seek help. • More likely to have chronic disease but less likely to enroll in self-management program Edlin, Mari. Health Understood: New awareness reduces ramifications of poor health literacy. Managed Healthcare Executive, Dec.1, 2004. Available at: http://www.managedhealthcareexecutive.com/mhe/Special+Report/Health-understood/ArticleStandard/Article/detail/136684. Accessed August 31, 2007.

21. Manifestations of Poor Health Literacy – Cont’d • Less exposure to newer alternatives • Use of wrong medication • Inability to understand: treatment instructions, consent forms and insurance forms. Edlin, Mari. Health Understood: New awareness reduces ramifications of poor health literacy. Managed Healthcare Executive, Dec.1, 2004. Available at: http://www.managedhealthcareexecutive.com/mhe/Special+Report/Health-understood/ArticleStandard/Article/detail/136684. Accessed August 31, 2007.

22. Assessment of Patient The patient’s story that she/he shares with the initial assessment will bring cultural values and beliefs. If there is little understanding of the culture, there will not be congruence between patient and provider. Part of the story will be missed. Perloff, R. et al. American Behavioral Scientist, Vol. 49, No. 6, 835-852 (2006)

23. Newest Vital Sign Tool developed to assess health literacy level Clear Health Communication Initiative. Available at www.clearhealthcommunication.org. Accessed September 6, 2007.

24. Remember: Communication skills do not equate with intelligence!

25. Elderly Patients As age increases so do deficits in literacy due to: • Decreased levels of cognition • Increased time since formal education • Decreased sensory abilities • Safeer, R and Keenan, J. Health Literacy: The Gap Between Physicians and Patients.American Family Physician. August1, 2005; Vol 72 (3)

26. Combined Factors • Increase in elderly population • Increase in longevity • Increase in number of co-morbidities • Increase in number of specialist referrals • Increased complexity of medical information

27. Low Health Literacy • The effects of low health literacy hit hardest in the elderly when accompanied by failing eyesight, decreased hearing, and decreased feeling and flexibility in fingers. • This is also the time that the these adults become more dependent on medical care, due to chronic conditions. Parker, Ratzan and Lurie Health literacy, a policy challenge for advancing high-quality health care. Health Affairs, 2003;22:147-153.

28. Informed Consent • Health literacy is a big part of patient safety. • There must be a mutual understanding between the patient and the practitioner regarding the surgical/treatment options.

29. Health Literacy and Numeracy • Prescription Labels • Treatment Regimens • Return Appointments

30. Tips for Practice • Always assess the first language spoken in the home • Always use “living room” language when talking with patient • Break information into small pieces • Speak slowly • Use pictures when possible

31. Tips for Practice – Cont’d • Encourage questions • Have friend or family member present • When using brochures make sure that they have images/symbols from patient’s own culture • Use large print with contrasting colors • Check reading level of materials http://www.harrymclaughlin.com/SMOG.htm

32. Tips For Practice – Cont’d • Create education materials at 5th-6th grade reading level, or even lower if serving a high percentage of patients at risk for low health literacy • Use short sentences • Focus on 2-3 main points at one visit • Only use 2-3 sentences per paragraph in written materials

33. SMOG • SMOG Readability Calculator “SMOG estimates the years of education needed to understand a piece of writing. SMOG is widely used, particularly for checking health messages.” Simple Measure of Gobbledygook (SMOG) Available at: http://www.harrymclaughlin.com/SMOG.htm. Accessed September 6, 2007.

34. Tips for Practice – Cont’d Use “show me” or “teach back” method

35. Healthcare Issue • There are rapid advances being made in medical technology • These advances may be offset by patients with low health literacy that cannot manage their own healthcare due to low health literacy Cutilli, C.Do Your Patient’s Understand: Determining Your Patient’s Health Literacy Skills.Orthopedic Nursing, September/October 2005; Vol 24(5) pp372-377.

36. Educating Patients You can assist the patient by teaching them to ask their providers (doctors, nurses, or pharmacists) 3 questions: • What is my main problem? • What do I need to do? • Why is it important for me to do this? www.askme3.org

37. Minorities Do Not Always Seek Health Care Minorities Tend to seek health care from Community resources, i.e. WIC, local churches, PHNs, CHNs. Health care services must develop community partnerships.

38. Remember: Communication IS Everything Teachback Teachback Teachback

39. Hispanic – Latino Culture http://www.paho.org/English/DD/PIN/Number19_article01.htm Perspectives in Health - The magazine of the Pan American Health Organization Volume 9, Number 1, 2004 http://ohioline.osu.edu/hyg-fact/5000/5237.html Ohio State University: Understanding the Hispanic Culture

40. Hispanic – Latino Culture cont’d http://www.nahnny.com/?q=node/26 Cultural Similarities and Disparities Among Hispanic Populations when Providing Culturally Competent Care Nat’l Association of Hispanic Nurses-New York http://www.culturediversity.org/hisp.htm Transcultural Nursing: The Hispanic American Community

41. http://www.aafp.org/afp/20051201/2267.pdf Cross-Cultural Medicine- Gregory Juckett, M.D., M.P.H.

42. Resources Ask Me 3 website: http://www.askme3.org/ Prevalence Calculator to determine percentage of patients in practice that may have difficulty understanding medical information and instructions: http://www.pfizerhealthliteracy.com/public-health-professionals/prevalence-calculator.html

43. Resources – Cont’d IHA-Institute for Healthcare Advancement http://www.iha4health.org/index.cfm/MenuItemID/124.htm Michigan Adult Learning and Technology Center http://www.malt.cmich.edu/healthlit.htm Ohio State College of Medicine Area Health Education Center: http://medicine.osu.edu/ahec/5838.cfm

44. Resources – Cont’d University of Washington, Harborview Medical Center: http://ethnomed.org/

45. Hmong Health Websites http://www.hmonghealth.org/ http://maclearinghouse.com/CatalogDiabetes.htm

46. Book The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. By Anne Fadiman, 1997. Published by: Farrar, Straus and Giroux This material was prepared by the South Dakota Foundation for Medical Care, the Medicare Quality Improvement Organization for South Dakota, under contract with the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-SD-1b-07-145