Objectives Cultural competencies, accommodations, and adaptive - PowerPoint PPT Presentation

Objectives • Cultural competencies, accommodations, and adaptive Disability, Health, and How strategies We Can Better Care for - Visual impairments Patients with Functional Impairments - Mobility Impairments - Deaf and Hard-of-Hearing Nathaniel Gleason, MD Associate Professor of Clinical Medicine Division of General Internal Medicine Self-identify as “disabled” — a spectrum Objectives • Challenges commonly encountered Identifies as a person with a disability. Chronic disease with an evolving by people with disabilities in clinical Often knows more than we do. care Unaware / Unacknowledged. functional impairment. Declining function. • New understanding of prevalence • Disparities in care • What can disability advocates teach us about our broader patient population?

Cultural Competency is a good fit Self-identify as “disabled” — a spectrum for those who self-identify “People with disabilities do have a distinctive Unaware / unacknowledged gait Spinal cord injury at age 20 Bilateral knee OA at age 70 culture, founded on their shared history of discrimination and common experiences of Full independence impairment and fall risk Frustrating. Engaged. stigmatization, poverty, social isolation, lack of self determination” –Woodard, Havercamp, Zwgart & Perkins (2012) The “sighted-guide” Blindness and Visual Impairment technique

The “sighted-guide” technique Cultural Competencies Announce yourself • Announce your departure • The group conversation • Be precise with directions • - The clock face Announce physical contact • Getting to know your patient Adaptive strategies for reading • Blind does not mean total loss of • Digital Magnification vision • Closed circuit television (CCTV) • “Legal blindness” tells us fairly little • Adaptive computer software - 20/200 or field < 20 degrees • Large print • Method of reading? • Audio • Orientation and mobility? - Bookshare

Adaptive strategies for Orientation and Mobility “Orientation and Mobility” “The white cane tells me everything I need to know about my surroundings.” “It represents independence.” “A signifier that does the explaining” Language • Evolving - Handicap - Disabled - People with disabilities - Visually impaired, low-vision, legally blind partially sighted, totally blind

Cultural Competencies • A wheelchair is considered personal space • Place yourself at the patient’s Mobility Impairments eye level when talking for more than a moment. • Is a transfer to the exam table necessary? Language • Wheelchair bound • Confined to a wheelchair • Wheelchair user The Deaf and Hard of Hearing • Mobility

Getting to know your patient Clinical Accommodations • Age at onset • Reduce background noise • Educational history • Face the person - Understanding of written English • Speak naturally but clearly. 
 Don’t shout or exaggerate • Cultural identification • Ask the patient how best to - Raised with ASL? communicate • Preferred communication modality • If an interpreter is used, talk to the deaf person, not to the interpreter Adaptive Strategies and Devices • TTY (teletypewriter) systems - Relay operator — dial 711 • Email / Text messaging • Video calls • Video ASL Interpreters

Language Common Themes • Is the patient’s disability relevant to • Hearing impaired the visit? • Hard of hearing • Omissions • Deaf with a capital D ‣ Drugs • Disabled? ‣ Sex ‣ Employment 2011 HHS standard for defining disability in Disability public health surveys Deaf or serious di ffi culty in hearing • Pathology Impairment Disability Functional Blind or serious di ffi culty in seeing, even when wearing • Limits glasses Serious di ffi culty walking or climbing stairs • Macular Decreased Can’t read Can’t read degeneration visual acuity small type Rx on bottle Di ffi culty dressing or bathing • Because of a physical, mental, or emotional condition, • do you have serious di ffi culty in concentrating, remembering, or • Disability is a complex interaction between the health making decisions condition of the individual and the contextual factors di ffi culty doing errands alone such as visiting a • of the environment. -WHO doctor’s o ffi ce or shopping

Figure 1. Disability Prevalence by Age : 1997 (Percent with specified level of disability) Any disability Severe disability Age Under 15 7.8 years 3.8 10.7 15 to 24 5.3 13.4 25 to 44 8.1 22.6 45 to 54 13.9 35.7 55 to 64 24.2 44.9 65 to 69 30.7 46.6 70 to 74 28.3 57.7 75 to 79 38.0 80 years 73.6 and over 57.6 Source: U.S. Census Bureau, 1996 Survey of Income and Program Participation: August - November 1997. Walker DK,et al. Persons With Disabilities as an Unrecognized Health Disparity Population. Am J Public Health. 2015;105(S2):S198-S206 Functional Impairment: age 50-64 Cumulative incidence of first ADL impairment Health and Retirement Study • Patients 50-56 at enrollment with no ADL or iADL • limitations (n=6874) Interviewed every 2 years through age 64 • 46% women, 80% white, stratified by SES, 
 • 29% HTN, 25% OA, 16% depression Brown RT, Diaz-Ramirez LG, Boscardin WJ, Lee SJ, Steinman MA. Functional Impairment and Decline in Middle Age: A Cohort Study. Ann Intern Med. 2017;167(11):761-768

Cumulative incidence of first ADL impairment Brown RT, Diaz-Ramirez LG, Boscardin WJ, Lee SJ, Steinman MA. Functional Impairment and Decline in Middle Age: A Cohort Study. Ann Intern Med. 2017;167(11):761-768 Disparities in Care Cumulative incidence of first i ADL impairment 77% of adults with disabilities describe • physical or program barriers that limited access to local health programs 47% experienced delays in primary and • preventive care Increased susceptibility to secondary • health problems Poorer health outcomes • Important intersection with poverty • Brown RT, Diaz-Ramirez LG, Boscardin WJ, Lee SJ, Steinman MA. Functional Impairment and Decline in Middle Age: A Cohort Study. Ann Intern Med. 2017;167(11):761-768 National Health Interview Survey (NHIS), CDC, 2011

Strongest predictors of ADL impairment Low income • Stroke • Arthritis • Chronic medical conditions • Sensory impairment • Depression • Obesity • Infrequent physical activity • Lack of health insurance • Residence in a neighborhood with fair or poor safety. • Brown RT, et al, Functional Impairment and Decline in Middle Age Minkler et al, Gradient of Disability across the Socioeconomic Spectrum in the United States. NEJM. 2006 “The real problem of blindness is Identifies as a person with a disability. not the loss of eyesight. The real Chronic disease with an evolving Often knows more than we do. problem is the misunderstanding Unaware / Unacknowledged. functional impairment. and lack of information that exist. If Declining function. a blind person has proper training and opportunity, blindness can be reduced to a physical nuisance.” -National Federation of the Blind

Visual Impairment: re-approaching Visual Impairment: re-approaching the patient with evolving vision loss the patient with evolving vision loss focus on • - reading - orientation & mobility Tools: magnification, large print, • audio, adaptive software Resources: • - Lighthouse for the Blind - Independent living skills centers Re-approaching the patient with loss of mobility

Screening Mobility Aids “Timed Up and Go” (TUG) Test • Improve safety a. rise from chair • Decrease pain b. walk 10 feet • Decrease energy expenditure c. turn around • Restore independence d. return to seated position >12 seconds = risk of falls Canes Standard cane Offset cane Quad cane

Proper fitting of canes & walkers • Align with the wrist crease 
 (with arm relaxed at side), wearing typical shoes • Elbow flexed 15-30 degrees while walking Social stigma & mobility aids • Reframe the issue - Describe the aids as tools - “increased mobility” - “maximize potential” • Not all or nothing.

Re-approaching the patient with evolving hearing loss Medi-Cal study of 2389 
 primary care facilities in 2010 Mudrick, et al. Physical accessibility in primary health care settings: Disability and Health Journal 2012 5, 159-167 Hearing Aid Revolution Clinical Accommodations • Reduce background noise • 20% of with hearing loss have a hearing aid • Face the person • Many of those don't use it regularly • Speak naturally but clearly. 
 - ambient noise, discomfort, symbolism Don’t shout or exaggerate • New devices - Interface via bluetooth ‣ Phone calls. Tailoring to environment ‣ Small and discrete

Take home Disability = Functional Limit + Environment • Address disability independent of pathology • e.g. add mobility to the problem list - Cultural competencies exist and are commonly • cited by patients who identify with “disability” Most patients will not self identify, unlike other at- • risk groups, but you have many tools, accommodations, insights, and resources to o ff er