Mnemonic Devices Can Exemplar Case Make you a Better Clinician! Ms - PowerPoint PPT Presentation

Finding the Sweet Spot Disclosures When Caring for Vulnerable Patients  While I am a deeply conflicted person, I have no conflicts of interest to disclose Dean Schillinger MD, UCSF Professor of Medicine in Residence Chief, Division of General Internal Medicine Director, Health Communications Research Program UCSF Center for Vulnerable Populations @ SF General Hospital Objectives Vulnerable Populations Defined  Deconstruct the construct of vulnerable populations  Vulnerable Populations are  Present an integrated approach to vulnerable patients subgroups of the larger population  Demonstrate the importance of eliciting the patient’s that, because of social, economic, narrative, assessing for vulnerabilities and identifying political, structural and historical points of resilience forces , are exposed to “greater risk  Provide 3 examples of social vulnerabilities & impacts of risks”, and are thereby at a ♦ Limited health literacy disadvantage with respect to their ♦ Food insecurity health and health care. ♦ Intimate Partner Violence  Find joy and a feeling of alignment in one’s work 1

Mnemonic Devices Can Exemplar Case Make you a Better Clinician!  Ms J is a 57 yo English-speaking Latina,  My mother of 5, with 3 grandchildren, with  Neurons HTN, depression, DJD and IDDM with A1c of 8.6%. She presents for the first time after  Erase having been hospitalized for 3 days for  Memory. hypoglycemia. The inpatient service was  Only unable to identify a trigger for the hypoglycemia.  Names  Improve  Question for you is WHY?  Cognition What are We Up Against? Common Social Vulnerabilities Reversing The Inverse Care Law V iolence & Trauma U ninsured L iteracy and Language  “Access to and quality of healthcare is N eglect E conomic hardship/food insecurity inversely proportional to the needs of the population” R ace/ethnic discordance, discrimination A ddiction B rain disorders, e.g. depression, dementia - Tudor-Hart, 1971 I mmigrant L egal status I solation/Informal caregiving burden T ransportation problems I llness Model E yes and Ears S helter Schillinger 2007 2

3 Mechanisms Whereby Vulnerability is Associated with Poor Health “Somebody has to do something, and it's just incredibly pathetic that it has to be us.” Jerry Garcia Schillinger et al McGraw-Hill 2017 Finding the Sweet Spot for Eliciting the Patient’s Story: Effective Intervention with Reveals Hidden Treasures Vulnerable Patients that Humanize This approach uniformly allows a clinician to navigate the social distance and create the human connection that underlies therapeutic relationships 3

Common Social Vulnerabilities Finding Resilience  Religion V iolence & Trauma U ninsured  Expertise/Employment L iteracy and Language  Social support & Network N eglect E conomic hardship/food insecurity  Intimates R ace/ethnic discordance, discrimination A ddiction  Laughter B rain disorders, e.g. depression, dementia  Institutions I mmigrant L egal status  Energy & Enthusiam I solation/Informal caregiving burden  Navigate Life’s Difficulties T ransportation problems I llness Model  Cultural Assets E yes and Ears  Entertainment/Enjoyment S helter Schillinger 2007 Patients with Diabetes and Low Literacy What is Health Literacy? Less Likely to Know Correct Management  “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make [informed] Need to Know : health decisions.” Low symptoms of low blood Moderate sugar (hypoglycemia)  3 domains: oral (speaking, listening); written High (reading, writing); numerical (quantitative) Need to Do : Low  ?Web? Patient portals? Moderate correct action for High  Capacity/Preparedness  Demand Mismatch hypoglycemic symptoms 0 20 40 60 80 100 Percent *Williams et al., Archive of Internal Medicine, 1998 Schillinger Am J Bioethics 2007 4

Exemplar Case: Limited Health Literacy Patients Experience Clearly this was More Serious Hypoglycemia/year N>14,000 Limited Health Literacy, right? 16% 14%  Ms J is a 57 yo English-speaking Latina, mother of 5, with 12% 3 grandchildren, with HTN, depression, DJD and IDDM with A1c of 8.6%. She presents to you for the first time 10% Adequate after having been hospitalized for 3 days for 8% Limited hypoglycemia. The inpatient service was unable to 6% identify a trigger for the hypoglycemia. 4% 2% 0% Problems Help reading Not confident learning with forms P for all<0.001 Sarkar, Adler, Schillinger, JGIM 2010 Common Social Vulnerabilities The Old Face of Hunger V iolence & Trauma  The uneasy or painful sensation caused by lack of food, U ninsured L iteracy and Language or the recurrent and involuntary lack of access to food. N eglect E conomic hardship/ food insecurity R ace/ethnic discordance, discrimination A ddiction B rain disorders, e.g. depression, dementia I mmigrant L egal status I solation/Informal caregiving burden T ransportation problems I llness Model E yes and Ears S helter Schillinger 2007 5

The New Face of Cycles of Food Food Insecurity Adequacy & Inadequacy Wreak Havoc  The limited or uncertain ♦ availability of nutritionally adequate and safe foods or ♦ ability to acquire acceptable foods in socially acceptable ways Hyperglycemia Hypoglycemia Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9. Life Sciences Research Organization Hypoglycemia & Food Cycles of Food Insecurity Adequacy & Inadequacy Wreak Havoc  Patients with diabetes in a safety net hospital ♦ 1/3 of those who reported hypoglycemia attributed it to the inability to afford food  Primary care patients with diabetes at community health centers (38% food insecure) ♦ Blood sugar ever gotten too low because you couldn’t afford food? (33% FI vs. 5% FS) ♦ Ever been to the ER because your blood sugar was Hyperglycemia Hypoglycemia too low? (28% FI vs. 5% FS) Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9. Nelson, JAMA, 1998; Seligman, JHCPU, 2010. 6

Risk Factors for Exemplar Case: Clearly this was Severe Hypoglycemia Food Insecurity, right?  Ms J is a 57 yo English-speaking Latina, mother of 5, with 3 AOR grandchildren, with HTN, depression, DJD and IDDM with A1c Food Insecurity 3.0 (1.5-5.9) of 8.6%. She presents to you for the first time after having been hospitalized for 3 days for hypoglycemia. The inpatient Alcohol abuse 2.2 (1.1-4.5) service was unable to identify a trigger for the hypoglycemia. Comorbid illnesses 1.5 (1.1-2.0) Obesity 0.3 (0.1-0.7) Seligman, Arch Int Med , 2011 What is intimate partner Common Social Vulnerabilities violence (IPV)? V iolence & Trauma U ninsured PATTERN of abusive behaviors L iteracy and Language  including physical, sexual, verbal, emotional, economic, N eglect and/or psychological abuse E conomic hardship/food insecurity R ace/ethnic discordance, discrimination  Includes interfering with medical care A ddiction B rain disorders, e.g. depression, dementia  used by adults or adolescents I mmigrant L egal status  against current or former intimate partners, and I solation/Informal caregiving burden sometimes against other family members T ransportation problems I llness Model  in ANY intimate relationship: LGBTQ/straight/all gender E yes and Ears identities S helter Schillinger 2007 7

Exemplar Case: Clearly this was Where Have We Been? Intimate Partner Violence, right?  Deconstruct the construct of vulnerable populations  Ms J is a 57 yo English-speaking Latina, mother of 5, with 3  Present an integrated approach to vulnerable patients grandchildren, with HTN, depression, DJD and IDDM with A1c of 8.6%. She presents to you for the first time after having been hospitalized for 3 days for hypoglycemia. The inpatient  Demonstrate the importance of eliciting the patient’s service was unable to identify a trigger for the hypoglycemia. narrative, assessing for vulnerabilities and identifying points of resilience  Provide 3 examples of social vulnerabilities & impacts ♦ Limited health literacy ♦ Food insecurity ♦ Intimate Partner Violence  Find joy and a feeling of alignment in one’s work Care of Vulnerable Patients TWO DEAD MEN A POEM….  “ There needs to be a little Don Quixote in all health One: a refugee from Cuba. practitioners… locked in Always in white, on the mission, Skin black and smooth, undaunted by the The other: tall, lanky, Fitting the mold from bottom top: doubters and the half- Happy and old. White leather shoes, hearted ” A former ball player White pants, In the West Coast Negro League. White linen shirt,  Fitzhugh Mullan, MD Pitched for the Sea Lions Crowned with a Havana, Until he threw his shoulder Of course. Out of its socket, And could throw no more. 8