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

Disability, Health, and How We Can Better Care for Patients with Functional Impairments

Nathaniel Gleason, MD

Associate Professor of Clinical Medicine Division of General Internal Medicine

Objectives

• Cultural competencies,

accommodations, and adaptive strategies

• Visual impairments
• Mobility Impairments
• Deaf and Hard-of-Hearing

Objectives

• Challenges commonly encountered

by people with disabilities in clinical care

• New understanding of prevalence
• Disparities in care
• What can disability advocates teach

us about our broader patient population?

Self-identify as “disabled” — a spectrum

Identifies as a person with a disability. Often knows more than we do. Chronic disease with an evolving functional impairment. Declining function. Unaware / Unacknowledged.

Spinal cord injury at age 20 Full independence Bilateral knee OA at age 70

• Frustrating. Engaged.

Unaware / unacknowledged gait impairment and fall risk

Self-identify as “disabled” — a spectrum Cultural Competency is a good fit for those who self-identify

“People with disabilities do have a distinctive culture, founded on their shared history of discrimination and common experiences of stigmatization, poverty, social isolation, lack

• f self determination”

–Woodard, Havercamp, Zwgart & Perkins (2012)

Blindness and Visual Impairment The “sighted-guide” 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

• Blind does not mean total loss of

vision

• “Legal blindness” tells us fairly little
• 20/200 or field < 20 degrees
• Method of reading?
• Orientation and mobility?

Adaptive strategies for reading

• Digital Magnification
• Closed circuit television (CCTV)
• Adaptive computer software
• Large print
• Audio
• 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

Mobility Impairments Cultural Competencies

• A wheelchair is considered

personal space

• Place yourself at the patient’s

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
• Mobility

The Deaf and Hard of Hearing

Getting to know your patient

• Age at onset
• Educational history
• Understanding of written English
• Cultural identification
• Raised with ASL?
• Preferred communication modality

Clinical Accommodations

• Reduce background noise
• Face the person
• Speak naturally but clearly. 


Don’t shout or exaggerate

• Ask the patient how best to

communicate

• 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

• Hearing impaired
• Hard of hearing
• Deaf with a capital D
• Disabled?

Common Themes

• Is the patient’s disability relevant to

the visit?

• Omissions
• Drugs
• Sex
• Employment

2011 HHS standard for defining disability in public health surveys

• Deaf or serious difficulty in hearing
• Blind or serious difficulty in seeing, even when wearing

glasses

• Serious difficulty walking or climbing stairs
• Difficulty dressing or bathing
• Because of a physical, mental, or emotional condition,

do you have

• serious difficulty in concentrating, remembering, or

making decisions

• difficulty doing errands alone such as visiting a

doctor’s office or shopping

Disability

Pathology Functional Limits

Macular degeneration Decreased visual acuity Can’t read small type Can’t read Rx on bottle

Impairment Disability Disability is a complex interaction between the health condition of the individual and the contextual factors

• f the environment. -WHO

Figure 1.

Disability Prevalence by Age : 1997

Source: U.S. Census Bureau, 1996 Survey of Income and Program Participation: August - November 1997.

(Percent with specified level of disability) Any disability Severe disability 80 years and over 75 to 79 70 to 74 65 to 69 55 to 64 45 to 54 25 to 44 15 to 24 Under 15 years 7.8 3.8 10.7 5.3 13.4 8.1 22.6 13.9 35.7 24.2 44.9 30.7 46.6 28.3 57.7 38.0 73.6 57.6 Age

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

• 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

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

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

Cumulative incidence of first iADL 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

• 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

National Health Interview Survey (NHIS), CDC, 2011

Minkler et al, Gradient of Disability across the Socioeconomic Spectrum in the United States. NEJM. 2006

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

Identifies as a person with a disability. Often knows more than we do. Chronic disease with an evolving functional impairment. Declining function. Unaware / Unacknowledged.

“The real problem of blindness is not the loss of eyesight. The real problem is the misunderstanding and lack of information that exist. If 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 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

Visual Impairment: re-approaching the patient with evolving vision loss Re-approaching the patient with loss of mobility

Screening

“Timed Up and Go” (TUG) Test

• a. rise from chair
• b. walk 10 feet
• c. turn around
• d. return to seated position

>12 seconds = risk of falls

Mobility Aids

• Improve safety
• Decrease pain
• Decrease energy expenditure
• Restore independence

Standard cane Offset cane Quad cane

Canes

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.

Mudrick, et al. Physical accessibility in primary health care settings: Disability and Health Journal 2012 5, 159-167

Medi-Cal study of 2389 
 primary care facilities in 2010

Re-approaching the patient with evolving hearing loss Hearing Aid Revolution

• 20% of with hearing loss have a

hearing aid

• Many of those don't use it regularly
• ambient noise, discomfort, symbolism
• New devices
• Interface via bluetooth
• Phone calls. Tailoring to environment
• Small and discrete

Clinical Accommodations

• Reduce background noise
• Face the person
• Speak naturally but clearly. 


Don’t shout or exaggerate

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 offer