The ETHNICS Framework: A Clinical Tool For Ethnogeriatric Education

1. The ETHNICS Framework: A Clinical Tool For Ethnogeriatric Education Fred Kobylarz, M.D. M.P.H. Assistant Professor

2. Objectives • State and describe four rationale for providing culturally appropriate geriatric care. • Define the concept of cultural competence and describe three techniques that can reduce racial and ethnic health disparities. • State the seven domains of the ETHNICS framework and describe challenges implementing its use.

3. Rationale • Responding to demographic changes • Eliminating disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds • Improving the quality of services and outcomes • Meeting legislative, regulatory, and accreditation mandates Cohen E, Goode T. Policy Brief 1: Rationale for cultural competence in primary health care. Georgetown University Child Development Center, The National Center for Cultural Competence. Washington, D.C., 1999. http://gucchd.georgetown.edu/nccc/nccc6.html

4. Demographics Source: Dept. of Health & Human Services Administration on Aginghttp://www.aoa.gov/prof/statistics/census2000/census2000.asp

5. Demographics Source: Dept. of Health & Human Services Administration on Aginghttp://www.aoa.gov/prof/Statistics/profile/profiles2002.asp

6. Within - Group Diversity is often greater than Between - Group Diversity

7. There is no “cookbook approach” in caring for patients

8. Avoid stereotyping and overgeneralization

9. Eliminating Disparities • Healthy People 2010 contains objectives that apply to older adults. • Evidence of disparities http://www.healthypeople.gov/ http://www.iom.edu/report.asp?id=4475

10. Improving Outcomes The knowledge and interpersonal skills that allows providers to understand, appreciate, and work with individuals from cultures other than their own. It involves acceptance of cultural differences; self awareness; knowledge of the patient’s culture; and adaptation of skills. Cultural Competency as a Strategy Davis BJ, Voegtle KH. Culturally Competent Health Care for Adolescents: A Guide for Primary Health Care Providers. Chicago, IL: American Medical Association, 1994.

11. Interpreter services Recruitment and retention of minority staff Cultural competency training Coordination with traditional healers Use of community health workers Culturally competent health promotion Involving family and/or community members Immersion into another culture Administration and organizational accommodations Improving Outcomes Cultural Competency Techniques Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model, Medical Care Research and Review, Vol. 57 Supplement 1, (2000) 181-217.

12. Meeting Mandates Federal Register • National Standards on Culturally and Linguistically Appropriate Services in Health Care (CLAS) http://www.omhrc.gov/clas/ • Policy Guidance on the Prohibition Against National Origin Discrimination as it Affects Persons with Limited English Proficiency (LEP) http://www.hhs.gov/ocr/lep/guide.html/

13. Meeting Mandates Cultural Competency Training • Liaison Committee on Medical Education http://www.lcme.org/functionslist.htm#educational%20objectives • American Council for Graduate Medical Education http://www.acgme.org/outcome/comp/compMin.asp • Professional Medical and Interdisciplinary Organizations For example http://www.stfm.org/corep.html

14. Ethnogeriatric Education • Ethnogeriatrics is defined as healthcare for elders from different culture • Core Curriculum in Ethnogeriatrics is proposed at every level of healthcare professional http://www.stanford.edu/group/ethnoger/

15. The ETHNICS Framework • Concept of the illness explanatory model developed by Kleinman • Does not replace standard medical history- taking process • Framework to facilitate communication during the clinical encounter • Designed to be integrated into the routine 15-minute visit • Each letter represents a cross cultural domain to explore

16. The ETHNICS Framework E : Explanation T : Treatment H : Healers N : Negotiate I : Intervention C : Collaborate S : Spirituality Kobylarz FA, Heath JM, Like RC. “The ETHNIC(S) Mnemonic; A Clinical Tool for Ethnogeriatric Education,” Journal of the American Geriatrics Society 2002, Sep: 50(9): 1582-9

17. Explanation Treatment ETHNICS Healers Negotiate Intervention Collaborate Spirituality

18. Application • Who can use ETHNICS? • Physicians (medical students, residents, and practicing) • Interdisciplinary (nursing, social work, physical/occupational therapy, and others) • Where can ETHNICS be used? • Ambulatory, hospital, home health, and nursing home settings

19. Translating Into Practice • Focuses on the acute and chronic visit • Awareness of cultural issues on • Establishing treatment priorities • Influencing adherence • Addressing end-of-life care • And others

20. Challenges • Systemic, institutional, interpersonal barriers • Disability related issues • Communication impairments (common in older adults) • Hearing, language, and cognitive barriers

21. Conclusion “Developing cultural competence is an ongoing, life-long journey for individuals, families, organizations and communities.” • Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health And Human Services. Cultural Competence: a Journey.

22. Conclusion “Maintaining cultural humility, avoiding stereotyping, engaging in mutually respectful communication, and fostering empowerment in relationships are critical” Tervalon M, Murray-Garcia J: “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education, “Journal of Health Care for the Poor and Underserved 1998; 9(2):117-124.

23. Self-check • What are four rationale for providing culturally appropriate geriatric care? Answer • What is cultural competence and what are three techniques that can reduce racial and ethnic health disparities in older adults? Answer • What are the seven domains and challenges of implementing the ETHNICS framework? Answer

24. Any Questions? Thank you for your attention!

26. Explanation • Direct question to be asked: • Why do you think you have this… (use the patent’s phrase for their) symptom/illness/condition?” • Probe Questions: • 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/Internet? • If patient cannot offer an explanation, ask what concerns them about their problems? Back to ETHNICS

27. Treatment • Direct question to be asked: • What have you tried for this… (use the patent’s phrase for their) symptom/illness/condition?” • Probe Questions: • What kind 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 treatments are you seeking from me? Back to ETHNICS

28. Healers • Direct question to be asked: • “Who else have you sought help from for this… (use the patent’s phrase for their) symptom/illness/condition?” • Probe Questions: • Have you sought help from alternative or folk healers, friends, or other people who are not doctors for help with your problems? Back to ETHNICS

29. Negotiate • Direct question to be asked: • How best do you think I can help…(use the patient’s phrase for their) symptom/illness/condition? • Try to find options that will be mutually acceptable to you and your patient and that do not contradict but rather incorporate your patient’s beliefs. Back to ETHNICS

30. Intervention • Direct Statement: • This is what I think needs to be done now. • Determine an intervention with your patient, which incorporate alternative treatments, spirituality, and healers as well as other cultural practices (e.g., foods eaten or avoided in general and/or when sick). Back to ETHNICS

31. Collaborate • Direct question to be asked: • “How can we work together on this and with whom else?” • Collaborate with the patient, family members, healers, and community resources. Back to ETHNICS

32. Spirituality • Direct question to be asked: • “What role does faith/religion/spirituality play in helping you with this…(use the patient’s phrase for their) symptom/illness/condition?” • Probe Questions: • Tell me about your spiritual life. How can your spiritual beliefs help you with this? Back to ETHNICS

33. Answer to Self-check question 1 • Responding to demographic changes • Eliminating disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds • Improving the quality of services and outcomes • Meeting legislative, regulatory, and accreditation mandates Back to Self-check Cohen E, Goode T. Policy Brief 1: Rationale for cultural competence in primary health care. Georgetown University Child Development Center, The National Center for Cultural Competence. Washington, D.C., 1999.

34. Answer to Self-check question 2 The knowledge and interpersonal skills that allows providers to understand, appreciate, and work with individuals from cultures other than their own. It involves acceptance of cultural differences; self awareness; knowledge of the patient’s culture; and adaptation of skills. Cultural Competency as a Strategy See rest of answer Davis BJ, Voegtle KH. Culturally Competent Health Care for Adolescents: A Guide for Primary Health Care Providers. Chicago, IL: American Medical Association, 1994.

35. Interpreter services Recruitment and retention of minority staff Cultural competency training Coordination with traditional healers Use of community health workers Culturally competent health promotion Involving family and/or community members Immersion into another culture Administration and organizational accommodations Answer to Self-check question 2 Cultural Competency Techniques Back to Self-check Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model, Medical Care Research and Review, Vol. 57 Supplement 1, (2000) 181-217.

36. Answer to Self-check question 3 E : Explanation T : Treatment H : Healers N : Negotiate I : Intervention C : Collaborate S : Spirituality See rest of answer Kobylarz FA, Heath JM, Like RC. “The ETHNIC(S) Mnemonic; A Clinical Tool for Ethnogeriatric Education,” Journal of the American Geriatrics Society 2002, Sep: 50(9): 1582-9

37. Answer to Self-check question 3 • Systemic, institutional, interpersonal barriers • Disability related issues • Communication impairments (common in older adults) • Hearing, language, and cognitive barriers Back to Self-check