Medical Care of Vulnerable and Underserved Populations February 28- - - PDF document

Presented by the Zuckerberg San Francisco General Division of General Internal Medicine And Center for Vulnerable Populations University of California, San Francisco School of Medicine

Medical Care of Vulnerable and Underserved Populations

February 28- March 2, 2019 Holiday Inn Golden Gateway San Francisco, California Course Directors: Dean Schillinger, MD Margaret Wheeler, MD

University of California, San Francisco School of Medicine

University of California, San Francisco School of Medicine Presents

The 4thAnnual Medical Care of Vulnerable and Underserved Populations program is dedicated to the memory of

• Dr. Rick Haber

Richard "Rick" Haber was the pioneering founder of Zuckerberg San Francisco General Hospital's Division of General Internal Medicine and its primary care residency track of the UCSF internal medicine residency. Dr. Haber was a tireless teacher of primary care and clinical general internal medicine, with a focus on both medical student and resident

• learners. After a stint in the Public Health Service, he dedicated his career to this work,

teaching young people how to practice good medicine for the underserved. Thanks to his vision, energy and spirit, we continue to have a unique residency training program that trains physicians for careers in caring for underserved and vulnerable patients. He was a teacher among teachers and cherished among learners, faculty, and house staff. With the support of Rick’s family, faculty at Zuckerberg San Francisco General Hospital and many other donors, the Division of General Internal Medicine at ZSFG established the annual Richard J. Haber, MD Memorial Lectureship. The lectureship was created both to honor his memory, as well as inspire sustained commitments to teaching primary care in the safety net setting. Every year the Division of General Internal Medicine invites an nationally recognized teacher in primary care to give a grand rounds talk at ZSFG and mentor faculty, residents, and medical students. We have named Dr. Christine Cassel and Dr. Chip Thomas as the Rick Haber Lecturers of the 2019 CME course. We look forward to meeting you, hearing your stories and getting your feedback! Dean Schillinger, MD Margaret Wheeler, MD

To be of use

BY MARGE PIERCY

The people I love the best jump into work head first without dallying in the shallows and swim off with sure strokes almost out of sight. They seem to become natives of that element, the black sleek heads of seals bouncing like half-submerged balls. I love people who harness themselves, an ox to a heavy cart, who pull like water buffalo, with massive patience, who strain in the mud and the muck to move things forward, who do what has to be done, again and again. I want to be with people who submerge in the task, who go into the fields to harvest and work in a row and pass the bags along, who are not parlor generals and field deserters but move in a common rhythm when the food must come in or the fire be put out. The work of the world is common as mud. Botched, it smears the hands, crumbles to dust. But the thing worth doing well done has a shape that satisfies, clean and evident. Greek amphoras for wine or oil, Hopi vases that held corn, are put in museums but you know they were made to be used. The pitcher cries for water to carry and a person for work that is real.

University of California, San Francisco School of Medicine Presents

Medical Care of Vulnerable and Underserved Populations

After years of documenting disparities in health and health care based on race, ethnicity, gender, education, and socioeconomic status, the medical community has shifted its focus to pursuing health equity or “striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions.” (Braveman, 2014) With publicly insured and uninsured patients making up about half of all

• utpatient visits in the US, and millions of previously uninsured patients continuing to access health

care through Medicaid expansions, becoming an expert in caring for the complicated medical and social needs of vulnerable and underserved patients is crucial to every healthcare provider. World-class experts and front-line practitioners from the Zuckerberg San Francisco General and the UCSF Center for Vulnerable Populations will present approaches to mitigate the challenges in caring for vulnerable populations and enhance the profound joy clinicians can experience when engaging with patients in greatest need. Topics to be covered will include updates in a broad range

• f diseases that disproportionately affect vulnerable patients, such as HIV, depression, PTSD,
• besity, hepatitis and substance use. In addition, we discuss how clinicians can address social

factors that complicate the management of medical illness, such as homelessness, school suspension, a history of trauma or of incarceration and food insecurity, etc. Each day we will feature a nationally renowned figure in the field of the care of vulnerable populations who will deliver pearls and impart wisdom with respect to how to stay engaged, connected, and inspired in this work.

Educational Objectives An attendee completing this course should be able to:

• Review the latest updates in research on health disparities and health equity;
• Describe an approach to considering social vulnerability in medical care;
• Review the care of transgender patients;
• Recognize the effect of food insecurity and homelessness on patient outcomes;
• Describe what is meant by Trauma Informed Care;
• Review the complexities and ways to enhance End-Of-Life discussion in patients with low literacy;
• Review updates in cervical cancer screening;
• Review updates on the treatment of patients with latent tuberculosis;
• Describe an approach to caring for immigrant patients;
• Discuss issues in prostate cancer diagnosis in the African American community;
• Describe prevention of suspension in school children as a medical issue.

Accreditation The University of California, San Francisco School of Medicine (UCSF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. UCSF designates this live activity for a maximum of 24.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This CME activity meets the requirements under California Assembly Bill 1195, continuing education and cultural and linguistic competency. American Board of Internal Medicine (ABIM) MOC: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 24.25 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC)

• program. Participants will earn MOC points equivalent to the amount of CME credits

claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Geriatric Medicine: The approved credits shown above include 3.75 credits toward meeting the requirement under California Assembly Bill 1820, Geriatric Medicine. Pain Medicine The approved credits shown above include 2.25 Pain Credits towards meeting the requirement under California Assembly Bill 487, Pain Management and Care for the Terminally Ill. Nurses: For the purpose of recertification, the American Nurses Credentialing Center accepts AMA PRA Category 1 Credits™ issued by organizations accredited by the ACCME. Physician Assistants: AAPA accepts category 1 credit from AOACCME, Prescribed credit from AAFP, and AMA PRA Category 1 C Credits™ from organizations accredited by the ACCME. Pharmacy: The California Board of Pharmacy accepts as continuing professional education those courses that meet the standard of relevance to pharmacy practice and have been approved for AMA PRA Category 1 Credits™. Family Physicians: This Live activity, Medical Care of Vulnerable and Underserved Populations, with a beginning date of 02/23/2017, has been reviewed and is acceptable for up to 17.75 Prescribed credit(s) by the American Academy of Family

• Physicians. Physicians should claim only the credit commensurate with the

extent of their participation in the activity.

General Information

Attendance Verification/Sign-In Sheet / CME Certificates

Please remember to sign-in on the sign-in sheet when you check in at the UCSF Registration Desk on your first day. You only need to sign-in once for the course, when you first check in. After the meeting, you will receive an email from Qualtrics@ucsf.edu with a link to complete your online Course Evaluation/ Electronic CME Certificate. Please make sure that you add this email to your safe senders list. The Qualtrics system will send you reminders to complete your CME Certificate Claiming until you complete it. Upon completing the Electronic CME Certificate, your CME certificate will be automatically generated to print and/or email yourself a copy. For smartphone users, you may want to take a photo of your certificate as some settings prevent you from emailing the certificate. The link will be available for 30 days after the last day of the course. However, after that date the link will expire and you will no longer be able to claim your credits online. You must then contact the Office of CME at registration@ocme.ucsf.edu to receive your certificate and a $15 administrative fee may be applied. Speaker Survey

Your opinion is important to us – we do listen! On the first morning of the conference you will

receive a link via email for the speaker survey. Please be sure to complete your speaker evaluation online at the conclusion of the course as we appreciate your feedback and use it to plan future courses. ABIM MOC Credit: This course offers an MOC Part II self-assessment for the ABIM diplomats. If interested, you will provide your Name, ABIM # and Date of Birth. The Office of CME will report your claim for MOC Part II Credits to the ABIM on your behalf 45 days post course. Security We urge caution with regard to your personal belongings and syllabus books. We are unable to replace these in the event of loss. Please do not leave any personal belongings unattended in the meeting room during lunch or breaks or overnight. Final Presentations A link to PDF versions of the final presentations will be sent via e-mail approximately 2-3 weeks post course. Only presentations that have been authorized for inclusion by the presenter will be included.

Federal and State Law Regarding Linguistic Access and Services for Limited English Proficient Persons I. Purpose. This document is intended to satisfy the requirements set forth in California Business and Professions code 2190.1. California law requires physicians to obtain training in cultural and linguistic competency as part of their continuing medical education

• programs. This document and the attachments are intended to provide physicians with

an overview of federal and state laws regarding linguistic access and services for limited English proficient (“LEP”) persons. Other federal and state laws not reviewed below also may govern the manner in which physicians and healthcare providers render services for disabled, hearing impaired or other protected categories II. Federal Law – Federal Civil Rights Act of 1964, Executive Order 13166, August 11, 2000, and Department of Health and Human Services (“HHS”) Regulations and LEP Guidance. The Federal Civil Rights Act of 1964, as amended, and HHS regulations require recipients of federal financial assistance (“Recipients”) to take reasonable steps to ensure that LEP persons have meaningful access to federally funded programs and

• services. Failure to provide LEP individuals with access to federally funded programs

and services may constitute national origin discrimination, which may be remedied by federal agency enforcement action. Recipients may include physicians, hospitals, universities and academic medical centers who receive grants, training, equipment, surplus property and other assistance from the federal government. HHS recently issued revised guidance documents for Recipients to ensure that they understand their obligations to provide language assistance services to LEP persons. A copy of HHS’s summary document entitled “Guidance for Federal Financial Assistance Recipients Regarding Title VI and the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons – Summary” is available at HHS’s website at: http://www.hhs.gov/ocr/lep/ . As noted above, Recipients generally must provide meaningful access to their programs and services for LEP persons. The rule, however, is a flexible one and HHS recognizes that “reasonable steps” may differ depending on the Recipient’s size and scope of

• services. HHS advised that Recipients, in designing an LEP program, should conduct

an individualized assessment balancing four factors, including: (i) the number or proportion of LEP persons eligible to be served or likely to be encountered by the Recipient; (ii) the frequency with which LEP individuals come into contact with the Recipient’s program; (iii) the nature and importance of the program, activity or service provided by the Recipient to its beneficiaries; and (iv) the resources available to the Recipient and the costs of interpreting and translation services. Based on the Recipient’s analysis, the Recipient should then design an LEP plan based

• n five recommended steps, including: (i) identifying LEP individuals who may need

assistance; (ii) identifying language assistance measures; (iii) training staff; (iv) providing notice to LEP persons; and (v) monitoring and updating the LEP plan. A Recipient’s LEP plan likely will include translating vital documents and providing either

• n-site interpreters or telephone interpreter services, or using shared interpreting

services with other Recipients. Recipients may take other reasonable steps depending

• n the emergent or non-emergent needs of the LEP individual, such as hiring bilingual

staff who are competent in the skills required for medical translation, hiring staff interpreters, or contracting with outside public or private agencies that provide

interpreter services. HHS’s guidance provides detailed examples of the mix of services that a Recipient should consider and implement. HHS’s guidance also establishes a “safe harbor” that Recipients may elect to follow when determining whether vital documents must be translated into other languages. Compliance with the safe harbor will be strong evidence that the Recipient has satisfied its written translation obligations. In addition to reviewing HHS guidance documents, Recipients may contact HHS’s Office for Civil Rights for technical assistance in establishing a reasonable LEP plan. III. California Law – Dymally-Alatorre Bilingual Services Act. The California legislature enacted the California’s Dymally-Alatorre Bilingual Services Act (Govt. Code 7290 et seq.) in order to ensure that California residents would appropriately receive services from public agencies regardless of the person’s English language skills. California Government Code section 7291 recites this legislative intent as follows: “The Legislature hereby finds and declares that the effective maintenance and development of a free and democratic society depends

• n the right and ability of its citizens and residents to communicate

with their government and the right and ability of the government to communicate with them. The Legislature further finds and declares that substantial numbers of persons who live, work and pay taxes in this state are unable, either because they do not speak or write English at all, or because their primary language is other than English, effectively to communicate with their government. The Legislature further finds and declares that state and local agency employees frequently are unable to communicate with persons requiring their services because of this language barrier. As a consequence, substantial numbers of persons presently are being denied rights and benefits to which they would

• therwise be entitled.

It is the intention of the Legislature in enacting this chapter to provide for effective communication between all levels of government in this state and the people of this state who are precluded from utilizing public services because of language barriers.” The Act generally requires state and local public agencies to provide interpreter and written document translation services in a manner that will ensure that LEP individuals have access to important government services. Agencies may employ bilingual staff, and translate documents into additional languages representing the clientele served by the agency. Public agencies also must conduct a needs assessment survey every two years documenting the items listed in Government Code section 7299.4, and develop an implementation plan every year that documents compliance with the Act. You may access a copy of this law at the following url: http://www.spb.ca.gov/bilingual/dymallyact.htm

Faculty List Dean Schillinger, MD Professor of Medicine Chief, Division of General Internal Medicine Director, Health Communications Program Zuckerberg San Francisco General UCSF Center for Vulnerable Populations Margaret Wheeler, MD Professor of Medicine Division of General Internal Medicine Zuckerberg San Francisco General Steering Committee Gerri Collins-Bride, RN, MS, FAAN Clinical Professor and Vice Chair for Faculty Practice, Community Health Systems and the School of Nursing Susan Fisher-Owens, MD, MPH Clinical Champion, CareLinkSF Associate Clinical Professor of Pediatrics; Associate Clinical Professor of Preventive and Restorative Dental Services Shira Shavit, MD Director, Transitions Clinic Network Associate Professor, Department of Family and Community Medicine Course Co-Chairs

Faculty: (University of California, San Francisco unless indicated) *- Rick Haber Lecturer Joan Addington-White, MD Professor of Medicine Residency Director Zuckerberg San Francisco General Primary Care Internal Medicine Training Program Soraya Azari, MD Assistant Professor of Medicine Associate Director, Primary Care Residency Program Zuckerberg San Francisco General Rachel Baden, MD Associate Professor of Medicine Chair, Department of Internal Medicine Highland Hospital Oakland, CA Jessica Beaman, MD, MPH Assistant Professor of Medicine Zuckerberg San Francisco General *Christine Cassel, MD (Rick Haber Lecturer) UCSF Presidential Chair Department of Medicine Diana Coffa, MD Associate Professor of Medicine Zuckerberg San Francisco General Matthew Cooperberg, MD, MPH Associate Professor of Urology Triveni Defries, MD, MPH Clinical Fellow Addiction Medicine Fellowship Zuckerberg San Francisco General Madeline Deutsch, MD, MPH Associate Professor Department of Family Community Medicine Camila Cribb Fabersunne, MD, MPH Clinical Instructor, Department of Pediatrics Medical Education Alicia Fernandez, MD Professor of Medicine Attending Physician, General Medical Clinic & the Medical Wards, Zuckerberg San Francisco General Course Faculty (University of California, San Francisco unless indicated)

Nathaniel Gleason, MD Associate Professor of Medicine Medical Director for Practice Innovation for UCSF Health Michelle Guy, MD Professor of Medicine Liz Imbert, MD, MPH Assistant Clinical Professor HIV, Infectious Diseases, and Global Medicine Zuckerberg San Francisco General Vivek Jain, MD, MAS Associate Professor of Medicine and Infectious Diseases Division of HIV, Infectious Diseases and Global Medicine Zuckerberg San Francisco General Chris Keh, MD Assistant Professor of Medicine Director of Tuberculosis Clinic at San Francisco Department of Public Health Zuckerberg San Francisco General Elaine Khoong, MD, MS Clinical Fellow Division of General Internal Medicine Zuckerberg San Francisco General Leigh Kimberg, MD Professor of Medicine Director, UCSF PRIME-US San Francisco Department of Public Health Suneil Koliwad, MD, PhD Associate Professor of Medicine UCSF Diabetes Center Margot Kushel, MD Professor of Medicine Director of the Primary Care Research Fellowship Zuckerberg San Francisco General Dannielle McBride, MD Resident, Department of Pediatrics Medical Education Maureen McGrath, RN, MS, PNP Associate Professor Department of Family Health Care Nursing Ashley McMullen, MD Chief Resident Department of Medicine

Thomas Neylan, MD Professor In Residence Department of Psychiatry Director of the Posttraumatic Stress Disorders (PTSD) Clinic and the Stress and Health Research Program at the San Francisco Veterans Affairs Medical Center Tung Nguyen, MD Stephen J. McPhee, MD Endowed Chair in General Internal Medicine, Professor of Medicine Nynikka Palmer, DrPh, MPH Division of General Internal Medicine Zuckerberg San Francisco General Urmimala Sarkar, MD, MPH Associate Professor of Medicine UCSF Center for Vulnerable Populations Zuckerberg San Francisco General George Sawaya, MD Professor of Medicine Department of Obstetrics, Gynecology and Reproductive Sciences Hilary Seligman, MD, MAS Associate Professor of Medicine and

• f Epidemiology and Biostatistics

Center for Vulnerable Populations Zuckerberg San Francisco General Christy Soran, MD, MPH Clinical Fellow Addiction Medicine Fellowship Zuckerberg San Francisco General Scott Steiger, MD Associate Professor of Medicine Zuckerberg San Francisco General Rebecca Sudore, MD Professor of Medicine Director, Innovation and Implementation Center in Aging and Palliative Care, San Francisco VA Health Care System *Chip Thomas, MD (Rick Haber Lecturer) Physician of Family Medicine and Artist Indian Health Service Tuba City, AZ Juan Vasquez Medical Student, UCSF

The following faculty speakers, moderators, and planning committee members have disclosed they have no financial interest/arrangement or affiliation with any commercial companies who have provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity:

Disclosures

Joan Addington-White, MD Soraya Azari, MD Rachel Baden, MD Jessica Beaman, MD, MPH Diana Coffa, MD Triveni Defries, MD, MPH Camila Cribb Fabersunne, MD, MPH Alicia Fernandez, MD Nathaniel Gleason, MD Michelle Guy, MD Liz Imbert, MD, MPH Vivek Jain, MD, MAS Chris Keh, MD Elaine Khoong, MD, MS Leigh Kimberg, MD Margot Kushel, MD Dannielle McBride, MD Maureen McGrath, RN, MS, PNP Ashley McMullen, MD Thomas Neylan, MD Tung Nguyen, MD Nynikka Palmer, DrPH, MPH George Sawaya, MD Dean Schillinger, MD Hilary Seligman, MD Christy Soran, MD, MPH Scott Steiger, MD Rebecca Sudore, MD James Edward “Chip” Thomas, MD Juan Vasquez, MD Margaret Wheeler, MD

The following faculty speakers have disclosed a financial interest/arrangement or affiliation with a commercial company who has provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity. All conflicts of interest have been resolved in accordance with the ACCME Standards for Commercial Support: Christine K Cassel, MD Honor Inc Youscript Inc Wellsheet Advisor or Reviewer Board Member Advisor or Reviewer Matthew R Cooperberg, MD, MPH Astellas Dendreon Bayer MDx Health Consultant Consultant Advisor or Reviewer Advisor or Reviewer Madeline B. Deutsch, MD, MPH Gilead Consultant Suneil K. Koliwad, MD, PhD Amma Therapeutics Eli Lilly Gilead Suggestic YES Health Consultant Grant/Research Support Grant/Research Support Stock Shareholder/Consultant Stock Shareholder/Consultant Urmimala Sarkar, MD, MPH Genentech Spouse (Employee) This UCSF CME educational activity was planned and developed to: uphold academic standards to ensure balance, independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and, include a mechanism to inform learners when unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced. This activity has been reviewed and approved by members of the UCSF CME Governing Board in accordance with UCSF CME accreditation policies. Office of CME staff, planners, reviewers, and all

• thers in control of content have disclosed no relevant financial relationships

COURSE PROGRAM Thursday, February 28, 2019 8:00 am Introduction & IGNITE: Creating the Context for Care with Vulnerable Populations Dean Schillinger, MD 8:15 Fifteen Years after Unequal Treatment— Where are we Now? Alicia Fernandez, MD 9:00 Substance Use in Adolescence Diana Coffa, MD 9:45 Smarter Screening and Smarter Treatment for Prostate Cancer in High-Risk Populations Nynikka Palmer, DrPH, MPH Matthew Cooperberg, MD, MPH 10:30 Break 10:45 Error Disclosure Urmimala Sarkar, MD, MPH 11:35 IGNITE: Pregnancy and substance use Diana Coffa, MD 11:45 Lunch— On Your Own 1:15 pm Sharing My Journey, Dean Schillinger Interviews a Patient in Recovery 1:30 ART 101 Vivek Jain, MD, MAS 2:20 Disability, Health, and How we can better Care for Patients with Functional Impairments Nathaniel Gleason, MD 3:05 IGNITE: Dealing with the Racist Patient Ashley McMullen, MD 3:15 Care of the Transgender Patient Madeline Deutsch, MD, MPH 4:00 Break 4:15 Reducing the Harm of Substance Use: Interactive Cases Scott Steiger, MD 5:05 pm Adjourn

Friday, March 1, 2019 8:00 am Career Notes from the Safety Net Maureen McGrath, RN, MS, PNP 8:15 GP Chronic Pain Soraya Azari, MD 9:00 Making Advance Care Planning Easier for Vulnerable Populations Rebecca Sudore, MD 9:45 IGNITE: Clinical New Devices to Change DM Maureen McGrath, RN, MS, PNP 9:55 Time for Action: Managing early Pregnancy Loss and Medication Abortion in GIM Jessica Beaman, MD, MPH 10:40 Break 10:55 Updates in Cervical Cancer Screening George Sawaya, MD 11:40 GP Optimizing Care for Patients with Food Insecurity Hilary Seligman, MD, MAS 12:25 pm Lunch-On Your Own 1:30 GP The safety Net: What does Professionalism demand? Christine Cassel, MD 2:20 IGNITE: PreP Liz Imbert, MD 2:30 Breaking Down Walls: Improving Healthcare for Resilient Populations through Stakeholder Engagement? Tung Nguyen, MD 3:15 IGNITE: 5 Diet Industry Myths Michelle Guy, MD 3:25 Break 3:40 G Aging Homeless Populations: What can we Do? Margot Kushel, MD 4:25 Updates on Treatment of Latent TB Chris Keh, MD 5:10 pm Adjourn

SATURDAY, MARCH 2, 2019 8:00 am Art and Health: A Physician’s work with Navajo Nation Chip Thomas, MD 8:50 G Care of the with Posttraumatic Stress Disorder Thomas Neylan, MD 9:35 IGNITE: Care of Patients with Limited English Proficiency Elaine Khoong, MD, MS 9:45 Diabetes Management in the Safety Net: Making Sense of Medication Choices Suneil Koliwad, MD, PhD 10:30 Break 10:45 Care of Patients with Hepatitis B Rachel Baden, MD 11:30 IGNITE: IPV Screening Leigh Kimberg, MD 11:40 IGNITE: Addressing Myths about the Treatment of Alcohol Use Disorder Triveni Defries, MD, MPH 11:50 IGNITE: Cannabis Use: Medicine, Malady, or Neither? Christy Soran, MD 12:00 pm Lunch 1:15 Mentorship in Medicine Juan Vasquez 1:30 Care of the Patient with Hx of Incarceration Joan Addington-White, MD and panel of expert physicians 2:20 G Trauma Informed Care Leigh Kimberg, MD 3:05 Break 3:20 Race, Exclusionary School Discipline, and the Camila Cycle of Trauma – Connecting the Dots Cribb Fabersunne, MD, MPH Dannielle McBride, MD 4:05 IGNITE: Health Literacy Dean Schillinger, MD 4:15 Clinical Care of the Immigrant Patient Margaret Wheeler, MD 5:00 pm Adjourn G • Geriatric Credit P • Pain Credit