Report on 2014 Needs Assessment at Grace Care Center in Sri Lanka. Background: Devika Bagchi and Kashif Ahmed, two UM medical students working under

Transcription

1 Report on 2014 Needs Assessment at Grace Care Center in Sri Lanka Background: Devika Bagchi and Kashif Ahmed, two UM medical students working under the supervision of Dr. Naresh Gunaratnam, traveled to Grace Care Center (GCC) in Trincomalee, Sri Lanka in August 2014 to conduct an onsite needs assessment. While staying at GCC, the medical students had the opportunity to get to know the GCC children, elders, and staff and develop a deeper understanding of their needs. Medical interviews: Before traveling to Sri Lanka, the medical students worked with Dr. Patricia Pasick, an Ann Arbor- based psychologist with extensive experience working with children in developing nations, to design protocols for interviewing children at GCC. Dr. Pasick and the students selected screening questions from validated culturally- sensitive mental health assessments that focus on depression, anxiety, PTSD and other mental health issues. While onsite at GCC, the students conducted medical interviews and completed mental health screenings for 18 of the 31 children. Each child was interviewed individually by one of the medical students accompanied by the GCC director, Angela Vigneswaran, who is a mother figure to the children and also served as a translator. As an exception to this protocol, three pairs of sisters were interviewed in tandem as per their preferences. Each interview lasted between 30 minutes and an hour. The medical students elicited information about the circumstances surrounding each child s arrival at Grace Care Center. These social histories were the most time- intensive sections of the interview process. In addition, the students recorded information about any present illnesses, past medical/surgical histories, dietary habits, sleep patterns, exercise regimens, and academic performance. The children were then screened for depression, anxiety, PTSD, and other mental health conditions. The interview concluded with several open- ended questions in which the children were asked to share their thoughts on the positive and negative aspects of life at GCC, what improvements could be made to the care they receive, and the biggest challenges they face physically, psychologically, socially, and academically. Results & follow- up: Some pervasive trends emerged from these medical interviews. Many children reported feeling sleepy during the day due to inadequate sleep at night. A significant segment of them also reported that they frequently feel orthostatic due to dehydration. The majority of children suggested that additional tutoring options would be of tremendous academic benefit to them. In their social histories, all of the interviewed children reported significant traumatic events regarding their family life before coming to GCC. About one- third of the children reported symptoms that merit further workup for anxiety, depression, and/or PTSD. We were able to follow up on these findings by reaching out to Dr. Alan Krohn, an Ann Arbor- based psychologist who has visited and taught in Sri Lanka several times before. Dr. Krohn was able to visit GCC in November 2014 and individually interview the four children we had identified as most in need of psychiatric counseling. His reports have helped our team develop long- term treatment plans for those particular girls. Furthermore, he has researched local Tamil- speaking child counselors and invited one, Dr. Arumathurai, to

2 work longitudinally with the girls. Dr. Krohn has offered to pay Dr. Arumathurai s fees for visiting GCC every Saturday and working with the girls individually and in group settings. Elder care: While no formal medical interviews were done with the 26 elders at GCC, the students were able to spend significant time getting to know them, allowing for some informal observations to be made. Many of the elderly men suffer from significant mental health disorders. Two gentlemen display evidence of schizophrenic symptoms and another gentleman has frequent seizures, which were observed by one of the medical students. Because of the frequency of mental disorders among the men, they tend to be far less social than the women, who regularly talk and exercise together. Dermatologic conditions like eczema are frequent among the elders and there are a handful of staff members and elders with varicose veins. Possible interventions to address these findings will be discussed at the end of this report. Lab testing: The students obtained medical lab tests for all children at GCC; measured values included serum electrolytes (Na, K, Cl, Ca), hemoglobin, fasting blood sugar, albumin, white blood cell count, platelets, hematocrit, and mean corpuscular volume. Upon analysis of the values, the students identified two areas of concern: anemia (present in all children except two) and hypocalcemia (five children). To address these concerns, the children with low hemoglobin levels were started on daily iron supplements and the children with low calcium levels are receiving modified meal plans to ensure adequate calcium intake. All children will have their lab values reassessed in six months. The students also obtained lab results for all GCC elders: measured values included fasting blood sugar, creatinine, bilirubin (total, direct, and indirect), AST and ALT (for liver function), alkaline phosphatase, albumin, ferritin, serum electrolytes (Na, K, Cl), total cholesterol, HDL, LDL, triglycerides, white blood cell count, hemoglobin, platelets, and blood picture. While no generalizable trends were identified in the elder population, there were specific areas of concern for individual patients. One woman with elevated total cholesterol and LDL levels received a dose adjustment for atorvastatin as per recommendations from Dr. Gunaratnam. Other patients with abnormal values received follow- up care from Dr. Ganakabahu, a local physician who has agreed to see GCC patients as needed. Establishing relationships: The medical students met with members of the local GCC advisory board: Dr. Gunalan, a physician and local medical superintendent; Mr. Raja Rammohan, a businessman who manages GCC s finances; Mr. Jayaratnam, a businessman and the head of the local board; and Mr. Selvajodi, a businessman with a very active presence at GCC. Meeting with these board members and getting to know them personally allowed the students to better understand the role of the advisory board in daily GCC operations. The students also met with the medical assistants who work at GCC daily and with the healthcare provider who provides onsite healthcare to GCC residents for 1 hour a month. Furthermore, they met with the superintendent of Trincomalee General Hospital and other local physicians. By developing these connections, the UM students gained an understanding and deeper appreciation of the complexities of the local healthcare infrastructure.

3 Medical assistant training: While staying at GCC, the students observed at length the daily schedule of the three medical assistants who work at Grace. They trained the medical assistants on the proper use of donated wireless blood pressure monitors and on entering data into electronic health record systems. The students also met with the elders and explained the rationale for the hypertension project. They obtained consent forms for the 18 elders who decided to participate in the hypertension program and were able to consent. Capacity- building: The students connected with local internet provider representatives to procure a more robust internet connection for a discounted price. This will help with the weekly videoconferencing that is an integral part of the telemedicine program. This enhanced internet connectivity will also help the children access online educational materials and improve their digital literacy. Since returning from Grace, the medical students have been able to Skype with the children once a week and have been receiving s from the children regularly. Possible future interventions: Based on the needs assessment, the medical students identified a few possible areas of intervention: 1. Mental health - Based on the August/September medical interviews, we identified several at- risk children who were then individually interviewed by Dr. Krohn in November As of December 2014, Dr. Arumathurai will be working with the children every Saturday. This will ensure that the girls receive face- to- face longitudinal psychiatric care in their own language. Dr. Arumathurai, Dr. Krohn, Dr. Pasick, and other members of our team are developing plans to complete the other remaining tasks regarding mental health; screening must be conducted for the remaining 13 children who did not undergo the medical interviews during the needs assessment. Additionally, the gentlemen who exhibited clear symptoms of schizophrenia would also benefit from reevaluation by a psychiatric professional. Although a few are currently taking psychiatric medication, regular followup has not yet been established. The same applies to the elderly man who regularly suffers from seizures despite his seizure medication. 2. Lifestyle interventions - A significant portion of children reported daytime sleepiness and orthostasis. An onsite intervention in collaboration with Grace staff focused on evaluation and modification of their daily schedule, which could significantly improve their sleep habits and nutritional status. Addressing these issues will lead to downstream improvements in their psychological well- being, activity level, and academic performance. Another point of consideration is the prevalence of iron deficiency among the children. Although this is now being addressed with daily iron supplements, it is worth investigating whether dietary inadequacies are to blame for their initial iron deficiency. Finding cost- effective ways to improve their nutritional status via dietary changes may be more beneficial in the long run than relying on daily iron tablets. 3. Teledermatology - Skin conditions, which are prevalent among the Grace elders, could be examined via the existing videoconference and cloud- based EHR model. Dr. Tejasvi of the

4 University of Michigan Medical School has already expressed significant interest in developing this potential project. 4. EHR development - Currently, our proprietary cloud- based electronic health record system is being used as a data collection tool. In order to increase the efficiency of our telemedicine model and scale up the project, it is vital that we enhance the functionality of the EHR. Specifically, we are building medical management algorithms to transform the EHR from a data- collection system to a data- interpretation tool. This will allow us to make more efficient, data- driven decisions for larger cohorts of patients. 5. Nonmedical projects - Given the academic difficulties of the overwhelming majority of GCC children, Skype- based tutoring programs and other educational enrichment models will be of tremendous value to the children. These interventions will concurrently improve the children s English- speaking abilities, which is critical for their future career prospects. Key considerations for moving forward: Longitudinal relationships between GCC children and visitors: The medical students noted that the Grace children became very emotionally attached to members of the Ann Arbor team who visited GCC. While this high level of trust helped with the medical interviews and other interventions, it may take a severe toll on the children s well- being if they repeatedly experience people leaving their lives within weeks or days of establishing this level of trust. This is particularly resonant given many of the children s struggles with abandonment as noted in their social histories. Any intervention conducted by GCC outsiders should be implemented with this in mind. Care must be taken to ensure that the children will not be subject to a cycle of new visitors who come to GCC for a few weeks in the summer and then are not heard from again. This concern is somewhat mitigated by the longitudinal Skype programs that the medical students and other volunteers participate in but the GCC children deserve to have the agency to decide for themselves whether they would like to see these types of interventions going forward. During the development of any future intervention, careful consideration must be given to ensure that the project is not designed to be an enjoyable voluntourism opportunity for outsiders, but rather a genuine opportunity to sustainably improve the lives of Grace children and elders. Dr. Pasick is willing to help us navigate this issue and find ways to incentivize GCC visitors to participate in longitudinal follow- up exchanges with the children. Enabling local providers: One additional concern is in regard to the sustainability of the project. With the current telemedicine model, the medical students and supervising physicians are in charge of healthcare for the GCC elders and children, while GCC staff and local providers merely play a supplementary, subservient role. Since Grace is a high- needs, low- resource area and Ann Arbor is the opposite, the emergence of the current model is understandable given the lack of better options. Going forward, attention must be given to the empowerment of local providers, either within GCC s compound itself or in the surrounding community. A central value of telemedicine is that it can connect high- needs areas like GCC with high- resource areas like UM, but equally importantly, it can help build resources of high- needs areas so that with time, they no longer need to depend on outside

5 help. This type of vision could make GCC a truly self- sustainable community with a more equal partnership with UM. To accomplish this goal of sustainability via local empowerment, our team can develop innovative ways to gradually include GCC staff and/or local providers in higher- level care as their capacity increases. Given the presence of three committed medical assistants at Grace s staff, one approach could be videoconference training sessions that begin with basic health care, such as measuring health metrics, and progresses to more advanced care- for example, training about the indications, contraindications, and side effects for medications commonly used at GCC. Over time, this may allow Grace medical assistants to gain enough knowledge and confidence to implement rudimentary preventative care practices for the children and elders, with Dr. Gunaratnam and other U.S. providers eventually playing more of a supervising, consulting role. Streamlining healthcare: Additionally, we are looking into opportunities to increase the long- term sustainability of healthcare for GCC residents. A group of Michigan MBA students is traveling to GCC in March and April 2015 to research profit- generating opportunities at GCC. In addition to ideas like building a chicken coop or renting vacant rooms onsite, the students are investigating the feasibility of a healthcare model that takes advantage of our electronic triaging system and Sri Lankan healthcare infrastructure. As described above, our team is developing a virtual triaging system in which medical data such as blood pressure or blood sugar is entered electronically by GCC medical assistants into an electronic spreadsheet. The spreadsheet then automatically parses the data and highlights areas of concern, such as patients with elevated blood pressure. This triaging process allows healthcare providers to avoid manually combing through health metrics and instead allows them to devote their efforts to only the areas of concern. In order to provide substantial financial incentive to healthcare workers, we intend to pay a flat fee for a local physician to assume responsibility for the care of all GCC residents. Using the virtual triaging system, the doctor will not need to see each GCC resident, but instead would devote a much smaller fraction of time to providing more thorough care to only those GCC residents who most need it. This is a tremendous value for the GCC community since all residents are assured of quality healthcare access if necessary, all of which is covered by a flat fee. Furthermore, this paradigm is financially appealing to the physician who is paid for the care of 50 people while only having to actually provide active care to a small fraction. We hope that the March 2015 visit to GCC will allow us to explore the feasibility of this type of healthcare model that would rely on the virtual triaging system and a contracted physician who would assume healthcare responsibility for the GCC residents. Based on previous site visits, one local physician, Dr. Ganakabahu, stands out as an ideal candidate for this proposed model, due to his close relationship with the GCC community, his excellence as a healthcare provider, and his willingness to implement novel best practices. Developing this innovative healthcare paradigm can be a major opportunity to not only ensure long- term, data- driven care for GCC residents, but also to build a more equitable partnership between GCC, local healthcare providers in Trincomalee, and the University of Michigan Medical School.