Barriers to Health Care Access in the Latino Community: Communication, Satisfaction and Adherence

1. 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

2. 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

3. 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

4. Primary Access Barriers

5. Trends in number of Hispanics without Coverage - 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

6. Country (N=number of 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% Health insurance among Latino/Caribbean Immigrants

7. Secondary Access Barriers

8. 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

9. 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

10. Leadership %Minority Professional Representation Workforce %Latino Source: BHP

11. 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

12. 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

13. %Reporting Structural Barriers Difficulty Accessing Specialists %Reporting Don’t have a regular doctor Source: Commonwealth Fund

14. Tertiary Access Barriers

15. What are tertiary barriers? • Rooted in the provider-patient interaction • Sociocultural differences  barriers to effective care due to: • poor communication • different beliefs about illness and treatment • poor adherence to therapeutic plan • limited health education • provider bias and stereotypes

16. Major Considerations • Heterogeneity of Patients at risk population • Acculturation, SES • Risk of stereotyping • Tertiary barriers less concrete • Address provider/patient perspectives

17. 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

18. Intermediary Factors Associated with Disparities D I S P A R I T I E S Screening A. 1o, 2o, 3o POOR HEALTH OUTCOMES * * B. Late Presentation To Care Access Barriers C. No Rx or Rx *Evidence Based

19. 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)

20. EVERY INDIVIDUAL IS UNIQUE Cultural Social Unique Individual Constitutional (Carrillo, Green, Betancourt ‘99)

21. Disease vs. Illness I D (Carrillo, Green, Betancourt ‘99)

22. How do we provide Patient Based Cross-Cultural Care ? 1. Language interpretation and translation 2. Avoid cultural categorization 3. 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)

23. How do we provide Patient Based Cross-Cultural Care ? 1. Language interpretation and translation 2. Avoid cultural categorization 3. 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)

24. 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)

26. Carlos Gutiérrez, United States Secretary of Commerce

28. Cameron Diaz, Actress

29. How do we provide Patient Based Cross-Cultural Care ? 1. Language interpretation and translation 2. Avoid cultural categorization 3. 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)

30. Identify and address areas of cross-cultural sensitivity • Every culture has areas of sensitivity • Sometimes sensitivities clash in the cross-cultural encounter • Patients • Staff • Be alert to these sensitive areas (Carrillo, Green, Betancourt ‘99)

31. 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

32. How do you know?SIMPLY ASK! Respect Curiosity Empathy (Carrillo, Green, Betancourt ‘99)

33. How do we provide Patient Based Cross-Cultural Care ? 1. Language interpretation and translation 2. Avoid cultural categorization 3. 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)

34. Explore the patient’s perspective • What does the illness or the symptoms mean to the patient? (Carrillo, ‘04)

35. Picture….

36. Why is it important to explore the meaning of the illness? • To facilitate diagnosis • To enhance patient satisfaction • address patients’ expectations, fears • earn patient’s trust • strengthen doctor-patient relationship • To promote adherence to therapeutic plan

37. Explore the patient’s expectations • What does the patient expect? • Patient’s social context (Carrillo, ‘04)

39. Explore the patient’s expectations • What is at stake for the patient? (Carrillo, ‘04)

40. 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.

41. Engage the patient, Earn the trust • Acknowledge • Explain • Negotiate (Carrillo, ‘04)

42. How do we provide Patient Based Cross-Cultural Care? • Recognize Our Personal Perspective • Patient’s Perspectives • What does it mean? • What is expected? • What is at stake? • Engage the patient, Earn the trust • Acknowledge • Explain • Negotiate • Patient’s Sensitivities • Identify Sensitive • Areas • Simply Ask Language (Carrillo, ‘04)

43. PATIENT BASED CROSS-CULTURAL COMMUNICATION CAN SERVE AS AN ADJUNCT TO TREATMENT ADHERENCE EFFORTS

44. Screening for Adherence RiskDidactic Acronym • Meaning Concordance • Apprehension and concern about treatment • Playback of negotiated treatment plan • Social barriers to treatment adherence (Carrillo, ‘04)

45. What do you think • is going on? • What do you expect? • What’s at stake? • What’s wrong? • What will happen? • What can I do? Patient Provider Acknowledge Present Bio-Med Model (Syntonic) Negotiate Mutual Accord M. A. P. S. Adherence  Satisfaction (Carrillo, ‘04)