Training and Assessing Internal Medicine Residents to Deliver Culturally Competent Care: Getting from Gestalt to Granular

Transcription

1 Training and Assessing Internal Medicine Residents to Deliver Culturally Competent Care: Getting from Gestalt to Granular Lucien Cardinal Jose Cortes Fredie Diaz Ethan Fried Maria Garcia Maria Maldonado 2016 APDIM SPRING MEETING AAIM s Diversity & Inclusion Committee This workshop is an outgrowth of the activities of the committee Serves to advocate for underrepresented and disempowered groups in the physician workforce and patient population

2 Workshop Agenda Presentation by presenters on their institution s or program s experience with: Practical strategies to assess and meet the needs of the local community Policy at the institutional level A program level tool and an educational technique for introducing cultural competency Breakout sessions Report Back dissemination of CC Toolbox APDIM Spring Conference Workshop Why am I involved and Why am I here? Caring for Underserved Communities is a privilege

3 Cultural Competency We need ways to become Culturally Competent and to assure shared decision-making Challenge for Health Care Providers How to become: Culturally Competent Culturally Sensitive Education Tools Assessment

4 Cultural Competence in Healthcare definition the ability to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients social, cultural, and linguistic needs. Betancourt, J., Green, A. & Carrillo, E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. The Commonwealth Fund. Disparities in Healthcare definition variation in rates of disease occurrence and disabilities between socioeconomic and/or geographically defined population groups

5 Disparities in Healthcare Differences in facilities and services: Access Availability ACGME Requirements related to Cultural Competency : Program Requirements Milestones CLER

6 Internal Medicine Program Requirements Residents are expected to demonstrate: sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. (outcome) Professionalism IV.A.5.f).(5) ACGME IM Milestones PROF3 Professionalism Seeks to fully understand each patient s unique characteristics and needs based upon culture, race, ethnicity, gender, religion and personal preference of the patient/caregiver Modifies care plan to account for a patient s unique characteristics and needs

7 PROF1 Professionalism Is available and responsive to the needs and concerns of the patient Emphasizes patient autonomy in all interactions ICS 1 Interpersonal & Communication Skills therapeutic relationship with patients and caregivers, including persons of different socioeconomic and cultural backgrounds Incorporates patient-specific preferences into plan of care

8 ICS 3 Interpersonal & Communication Skills Engages the patient in shared decisionmaking Incorporates patient specific preferences into the care plan SBP2 Systems Based Practice Recognizes the potential for error within the system

9 CLER: 6 Focus Areas Clinical Learning Environment Review Healthcare Quality (HQ) Patient Safety Care Transitions Supervision Duty Hours/Fatigue Management & Mitigation Professionalism (Selected Topics) HQ Pathway 5 Resident/fellow and faculty member education on reducing health care disparities Residents/fellows and faculty members receive training in cultural competency relevant to patient population served by clinical site

10 HQ Pathway 5 Formal educational activities that create a shared mental model with regard to health care quality-related goals, tools, and techniques are necessary for health care professionals to consistently work in a wellcoordinated manner to achieve a true patient-centered approach that considers the variety of circumstances and needs of individual patients HQ Pathway 6 Resident/fellow engagement in clinical site initiatives to address health care disparities Experiential learning is essential to developing the ability to identify and institute sustainable systemsbased changes to address health care disparities. Residents/fellows are engaged in QI activities addressing health care disparities for the vulnerable populations served by the clinical site.

11 HQ Pathway 6 Resident/fellow engagement in clinical site initiatives to address health care disparities 2014 APDIM PD Survey Milestone 18 Responding to patients unique characteristics and needs Difficult to assess

12 AAIM s D&I Committee PD Survey 35% thought that faculty are competent to train residents in CC care 25% thought that faculty are competent to evaluate residents on their ability to practice CC care Culturally Competent Care at Stamford Hospital Focus on LEP Maria Maldonado, M.D APDIM Spring Meeting

13 GME Demographics Community hospital, university affiliated 21 IM residents (1 to 2 prelim PGY 1 residents) No fellows Other programs: OB/GYN, FM, Surgery 62 residents total Strong faculty resident ratio Demographics of Stamford, CT 122,643 residents 46.7% non white or Latino 10.2% living in poverty Low income residents report lack of access to specialty care 36% foreign born, 42.4% spoke a language other than English at home

14

15 Precipitators for Curriculum Patient population GME Resident Survey revealed that only 19% of residents surveyed utilized formal interpretation for LEP patients 100% of the time, and only 38% informed patients of the right to formal interpretation when family member/friend present Planetree Designation Planetree Beliefs Caregiving is best achieved through kindness & compassion Focus on patient centered care Access to understandable health information can empower individuals to participate in their health

16 Cross Cultural Care: A Patient Based Approach Objectives Appreciate that cultural competence is important to delivery of high quality health care Define the social and cultural issues most relevant in the care of diverse populations Communicate effectively across cultures Develop appropriate management strategies that take cultural perspectives/preferences into account

17 Core Values of Cross Cultural Care 1. Curiosity 2. Respect 3. Empathy Cross Cultural History Taking: Cross Cultural Issues Customs, spirituality, diet Styles of communication (stoic, confrontational, deferent) Decision making Mistrust: prior experience with healthcare Sexuality and gender issues

18 Evaluation Checklist: Resident Date Brief description of the patient s presentation and presenting issue that needs to be negotiated with patient: Did the resident restate his/her understanding of the patient s perspective? Yes No Comments: Did the resident highlight those issues that were at odds with his/her (medical) perspective? Yes No Comments: Did the resident explain his/her perspective by providing evidence for it clearly, understandably and with humility? Yes No Comments: Did the resident acknowledge any differences in opinion? Yes No Comments: Was the resident able to demonstrate acceptance of difference, and identify areas for reconciliation? Yes No Comments: Was the resident able to create common ground? Yes No Comments: Did they ask the patient what he/she was willing to do and to give them the support they need to do it? Yes No Comments: Were the patient and resident able to settle on a mutually acceptable plan? Yes No Comments: Was the resident able to identify any hesitation, notice non-verbal cues of the patient? Did the resident openly acknowledge the hesitation, and did he/she readdress any concerns? Yes No Comments: Is the resident able to negotiate management options with indirect supervision? Independently?

19 Strengths On line curriculum allowed for efficient training of both residents and core faculty Easy model to implement Heightened awareness of best practices for caring for patients with LEP Dovetails with Planetree philosophy an example of aligning education with institutional initiatives Challenges Not everyone got trained No stick, no carrot

20 Lessons Learned: CLER Report 47% of residents, 54% of faculty and all PDs reported that they knew hospital s priorities with regard to addressing disparities We don t appear to have a systematic approach to identifying variability in the care provided to or clinical outcomes of their known vulnerable patient populations Generic cultural competency training Addressing Health Care Disparities and Resident Engagement in Clinical Site Initiatives: CLER Health Quality Pathway 6 MARIA M. GARCIA MD, MPH, FACP ASSOCIATE PROFESSOR OF MEDICINE ASSOCIATE PROGRAM DIRECTOR AAIM DIVERSITY AND INCLUSION COMMITTEE

21 UMASS INTERNAL MEDICINE RESIDENCY PROGRAM new Interns/ Prelim 21 PGY PGY 3 Who We Serve Worcester County 750,000 patients Catchment Area >1.5 million patients Internal Medicine Residency Program

22 Our Patients Diverse 15% Non-English speaking 60% White 20% Hispanic 14% African American 6% Asian Large West African, Albanian and Hispanic populations Designated refugee area Large underserved community in Worcester 14% of families and 18% of individuals below poverty line White Asian African American Hispanic Internal Medicine Residency Program OUR SCHEDULE -OUTPATIENT Continuity clinic (4) Sub specialty longitudinal clinic (2) Didactic sessions Independent learning and quality improvement sessions Internal Medicine Residency Program

23 AMBULATORY DIDACTICSESSIONS Topics: Health Disparities Implicit (Unconscious Bias) Implicit Association Test (IAT) tool Complete prior to session INDEPENDENTLEARNING ANDQUALITY IMPROVEMENT PROJECTS Lean Training expected Peer Teaching Presentation to Faculty, Grand Rounds HQ Pathway 6: Health Care Quality: Experimental learning is essential to developing the ability to identify and institute sustainable systems-based changes to address health care disparities Scholarly: Poster Clinical Learning Environment Review (CLER). ACGME

24

25

26

27

28

29 RESULTS Patient Satisfaction survey showed predominance of preference for language concordance encounters Guzman-Suarez, et al Poster

30 HEALTH DISPARITIES QI PROJECT Lessons Learned Small interventions could create big difference for patient care and satisfaction To create sustainable change all members of the staff should be involved and motivated Challenges Retention and sustainability of diverse faculty in the primary care clinic Departure of 4 Spanish speaking Senior residents Completion of longitudinal QI projects considering residents have a finite amount of time spent on this rotations Challenge of implementing change Guzman-Suarez et al Poster

31 WIPIC Cultural Competency Exercise Pronounced - We Pick Cultural Competency And Shared Decision Making Lucien Cardinal, M.D., Fredie Diaz, M.D. Cultural Competence in Healthcare definition the ability to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients social, cultural, and linguistic needs. Betancourt, J., Green, A. & Carrillo, E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. The Commonwealth Fund.

32 Cultural Competency Cultural competency lies at the interface between the caregiver and the patient during the shared decision making process that is essential to quality healthcare Cultural Competency and Shared Decision Making

33 Where is our institution with regards to cultural competency? Cultural Competency Self-Assessment IM and TY Residency Programs Strengths Openness of administration to initiatives Good diversity mix in terms of gender Good Hispanic representation

34 Cultural Competency Self-Assessment IM and TY Residency Programs Weaknesses Competing priorities in the start-up years Need for tools to assess and train staff and residents What action can we take to move toward a culturally competent clinical environment?

35 Initiate a conversation about the importance of culture in shared decision making Develop a case-based tool that will facilitate this conversation WIPIC Learning Goals and Objectives Goal: The participant will gain insight into how to engage in culturally sensitive shared decision making. (Learn how We Pick a care plan together.)

36 WIPIC Review Matrix Wide-Frame Inter-Personal Inter-Cultural Cultural and Personal Characteristics and how it may impact healthcare Conceptual Frame-Work Narrow-Frame Focus Patient Wide-Frame Focus Patient and Caregiver

37 Objective 1. Culture is multi-dimensional and overlapping All of the following (and more) Hispanic (Ethnicity) Black (Race) Female (Gender) Lesbian (Sexuality) Catholic (Religion) Soldier (Occupation) Objective 2: Cultural identity is distinct from cultural background Cultural Background Hispanic, Black, Female, Lesbian, Catholic, US Soldier Cultural identity: American Soldier Hispanic Black female Catholic Lesbian American

38 Objective 3: Personal choices are distinct from cultural identity A catholic couple who choose to use condoms for contraception despite church prohibition A Jehovah s Witness who chooses blood transfusion in a non-life threatening situation WIPIC Exercise A scenario consists of 3 parts Characteristics of a medical case Cultural characteristics of a patient Cultural characteristics of a caregiver

39 A Model for Teaching LGBT Cultural and Clinical Competency in Post Graduate Medical Education José A Cortés, MD, FACP APD- Mount Sinai Beth Israel Department of Medicine Who are we? Mount Sinai Beth Israel in Lower East side of Manhattan, New York City Icahn School of Medicine at Mount Sinai Beds: 825 Ambulatory Encounters: Inpatient Medicine discharges: 14,669 (2014) Total Hospital discharges 39,568 (2014) IM Residency Program 119 residents (105 categorical and 14 preliminary) 3 Ambulatory Clinics (One Federally Qualified, Two Institution owned) Inpatient/Outpatient System (6+2) Academic half day Ambulatory residents from our 3 sites Two hours of learning each Tuesday morning after GR

40 Why did we do this? It was and continues to be the right thing to do - Increase in LGBT Patients Patient complaints, Transgender Residents / Staff struggling (walking on eggshells) Catalysts Our location Closure of St. Vincent s Medical Center Formal LGBT Resident Elective 2012 ACGME CLER Hospital Medical-Home Demonstration Grant ACA / Patient Centered Medical Home CHALLENGES Time and Competing Priorities PGY 1, 2 and 3 Faculty Training- development Institutional Support Medical Home Demonstration Project Dates: 5 Sessions in September and October, 2013, 4 Follow-Ups In April-June, Full sessions 2015 Duration: 2.5 hours ( academic half day )

41 FOCUSING IN Part I Cultural competency, interview, and physical exam Key concepts : health disparities, key health concerns, minority stress, and evidence based guidelines Small group case vignettes Part 2 Population specific clinical concerns in response to post-presentation survey results In-depth case discussions: videos, role plays, actual experiences Morning Report- case presentations Best Practices in LGBT Culturally Competent Healthcare for IM Residents, Part 1 Curriculum Content: Overview of LGBT demographics and health disparities NYS and NYC Laws, Joint Commission guidelines CMS regulatory practices and medical ethics guidelines MSHS LGBT policies Welcoming environment, data collection and privacy/confidentiality concerns Patient provider relationship and shared decision making

42 Clinical Issues and Best Practices History taking Understanding minority stress Sexual risk General health risk Screenings Health issues: gay men/bisexual (MSM), lesbians (WSW) Transgender related care including hormones and pre/post surgical needs Psychosocial needs, ethical and legal checklists Referrals and community based resources Resources for further learning and handouts Small Group Case Vignettes Example: Talking with LGBT Patients Do not make assumptions about identity or behavior Are you currently in a relationship? What are the genders of your sexual partners? How would you describe your gender identity? Ask yourself if labels around sexuality and gender are clinically important Use the language your patients use for themselves and their partners Husband, wife, partner; gay, straight, bisexual, pansexual 84

43 Example: Talking about trans bodies We are always tempted to use proper medical language when talking about genitals Sometimes this can be alienating Instead, use private parts, or genitals instead of penis and vagina if someone has not had a Gender Conforming Surgical (GCS) procedure For transgender men, it is appropriate to say chest 85 Example: Trans Bodies Privacy during a physical exam does not necessarily mean a private room Bathrooms and other similar spaces Privacy is still very important Expose only the body part that you are examining Remember language tips 86

44 Part 2 Curriculum Content: npep and PrEP including how to decide whether or not to prescribe/discuss with a patient Basics of providing care for transgender people on HRT including effects, common regimens, working with guidelines Lesbian/Bisexual (WSW) health concerns including CAD, cancer screening Larger focus on case studies, presentation of multiple video cases Case Vignettes Example: Jack A 17 year old male you are seeing or the first time for an annual physical. He confides in you as his primary care physician that he is worried about HIV. He is exploring his sexuality and he has had unprotected anal insertive sex with several male partners. Now he is afraid he might be HIV positive. He implores you not to tell his parents as his father has said if he ever found out a child of his was gay, he would disown him. How do you proceed with this patient? What screenings do you conduct and how do you handle his concerns about his parents? What would be the most effective preventive and treatment plan/approach for his care? What potential referrals might you make and where?

45 Examples: Video Cases ( Bad Doc, Good Doc ) Facilitated Video Case Discussions : In the Waiting Room ( transgender woman patient) Dr. Gonzalez ( gay man ) Jill, NP ( transgender man patient) Dr. Golrab ( lesbian patient ) Urgent Care ( Transgender woman being admitted to hospital ) Adolescent (gay teen comes out to family doctor) Facilitator s Guide Measurable Outcomes/ Achievements Knowledge and Skills Survey Patient complaints Number of HIV testing Anal PAP- Colorectal referrals HPV vaccine administration National and Local recognition of Program CLER Report Healthcare Equality Index Leader designation

46 Best Practices in Lesbian, Gay, Bisexual and Transgender (LGBT) Culturally Competent Healthcare: IM Resident Knowledge and Skills Survey, Sept. & Oct., 2013 N = PGY1; 35 PGY2; 18 PGY3 C O N F I D E N C E Demo Policies Welcome Gay Lesbian BI Trans Screen Psysoc Ethics Refer Workshop Pre Testing Avg: Workshop Post Testing Avg: Confidence level: 1- not at all confident 2: somewhat confident 3: moderately confident 4: very confident 5: completely confident Lessons learned Institution- the C-Suite PCMH Initiative GME HCAPS- Patient satisfaction Picking the right setting- venue Academic half day vs Noon Conference Selecting the group of learners Preliminary vs Categorical Heterogeneous group of learners Connect to your LGBT community Patient Panels CBO s (LGBT center, State societies, etc ) Faculty development CQIP model Self assess

47 Barrier to implementing an LGBT curriculum 1. Buy in 2. Expertise- Faculty, staff, etc 3. Developing a curriculum 4. Metrics- (EHR, Surveys, etc ) 5. Expanding project institution wide (Adapting to different areas, Clerks, nursing, security, etc ) 6. Implementing policy changes. Excerpt from our CLER report When queried, most of the residents/fellows, nearly all of the faculty and program directors interviewed reported they knew the medical center s priorities with regard to healthcare disparities mentioning translation services, access to care for LGBTQ patients, the Asian Care Unit, and coordination of care.

48