caring for vulnerable patients in the era of health … for vulnerable patients in the era of health...

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Caring For Vulnerable Patients in the Era of Health Reform

Dean Schillinger MD, UCSF Professor of Medicine in ResidenceChief, Division of General Internal Medicine

Director, Health Communications Research ProgramUCSF Center for Vulnerable Populations @ SF General Hospital

Objectives Review impact of ACA on underserved populations

Deconstruct the construct of vulnerable populations

Present an integrated approach to vulnerable patients

Provide 3 examples of social vulnerabilities & impactsLimited health literacyFood insecurity Intimate Partner Violence (IPV)

Find joy and a feeling of alignment in one’s work

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ACA reduced uninsured by

50% and increased

Medicaid by 36%

Drops in the uninsured rolls much greater for minorities

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Drops in the uninsured rolls much greater for the poor

Vulnerable Populations Defined

Vulnerable Populations are subgroups of the larger population that, because of social, economic, political, structural and historical forces, are exposed to “greater risk of risks”, and are thereby at a disadvantage with respect to their health and health care.

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Exemplar Case Ms J is a 57 yo English-speaking Latina,

mother of 5, with 3 grandchildren, withHTN, depression, DJD and IDDM with A1c of8.6%. She presents for the first time afterhaving been hospitalized for 3 days forhypoglycemia. The inpatient service wasunable to identify a trigger for thehypoglycemia.

Question for you is WHY?

Mnemonic Devices Can Make you a Better Clinician!

My Neurons Erase Memory. Only Names Improve Cognition

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Common Social Vulnerabilities

iolenceninsurediteracy and Languageeglectconomic hardship/food insecurityace/ethnic discordance, discriminationddictionrain disorders, e.g. depression, dementiammigrantegal statussolation/Informal caregiving burdenransportation problemsllness Modelyes and Earshelter

Schillinger 2007

VULNERABILITIES

What are We Up Against?Reversing The Inverse Care Law

“Access to and quality of healthcare is inversely proportional to the needs of the population”

- Tudor-Hart, 1971

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Jerry Garcia

“Somebody has to do something, and it's just incredibly pathetic that it has to be us.”

3 Mechanisms Whereby Vulnerability is Associated with Poor Health

Schillinger et al 2007

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Finding the Sweet Spot for Effective Intervention with

Vulnerable Patients

This approach uniformlyallows a clinician to navigate the social distance and create the human connection that underlies therapeutic relationships

Eliciting the Patient’s Story:Reveals Hidden Treasures

that Humanize

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Finding Resilience Religion Expertise/Employment Social support & Network Intimates Laughter Institutions Energy & Enthusiam Navigate Life’s Difficulties Cultural Assets Entertainment/Enjoyment



Schillinger 2007

VULNERABILITIES

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What is Health Literacy?

“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make [informed] health decisions.”

3 domains: oral (speaking, listening); written (reading, writing); numerical (quantitative)

?Web? Patient portals?

Capacity/Preparedness Demand Mismatch

Schillinger Am J Bioethics 2007

Percentage of adults in each health literacy level, by race/ethnicity, 2003

14 924

4113 25

9

2219

3425

1823

28

53 58

41 31

5245 59

12 142 4

18 7 3

0%

20%

40%

60%

80%

100%

Total

Whi

te

Black

Hispan

icAPI

AI/AN

Mul

tirac

ial

Proficient

Intermediate

Basic

Below Basic

Prevalence & Disparities in Limited Health Literacy

Source: NAAL

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Patients with Diabetes and Low Literacy Less Likely to Know Correct Management

0 20 40 60 80 100

Percent

Need to Know:symptoms of low blood sugar (hypoglycemia)

Need to Do:

correct action for hypoglycemic symptoms

*Williams et al., Archive of Internal Medicine, 1998

Low

ModerateHigh

LowModerate

High

Health Literacy is Associated with Glycemic Control, N=408

0

10

20

30

40

50

1st Quartile 4th Quartile

% o

f pat

ients

Inadequate

Marginal

Adequate

(Tight Control: HbA1c7.2%) (Poor Control: HbA1c>9.5%)

Adjusted OR=0.57, p=0.05Adjusted OR=2.03, p=0.02

Schillinger JAMA 2002

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Complication n** AOR 95% CI

Retinopathy 111 2.33 (1.19-4.57)

Nephropathy 62 1.71 (0.75-3.90)

Lower Extremity Amputation

27 2.48 (0.74-8.34)

Cerebrovascular Disease 46 2.71 (1.06-6.97)

Ischemic Heart Disease 93 1.73 (0.83-3.60)

Lower health literacy is associated with diabetes complications (N=408)

Schillinger JAMA 2002

Limited Health Literacy Patients Experience More Serious Hypoglycemia/year N>14,000

0%

2%

4%

6%

8%

10%

12%

14%

16%

Problems learning

Help reading Not confident with forms

Adequate

Limited

P for all<0.001Sarkar, Adler, Schillinger, JGIM 2010

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“The problem with communication is the assumption that it has occurred.”

-GB Shaw

Diabetes Patients with Limited Health Literacy Experience Poorer Quality Communication, N=408

0

10

20

30

40

50

%

Doctor Use Words NotUnderstood

Give You Test Resultsw/o Explanation

Confused AboutMedical Care

Doctor UnderstandProblems Doing Rx

Inadequate FHL

Adequate FHL

(Often/Always) (Often/Always) (Often/Always) (Never/Rarely/ Sometimes)

OR=3.2;p<0.01OR=3.3;p=0.02

OR=2.4;p=0.02

OR=1.9;p=0.04

32%

13% 13% 13%

26%21%

33%

20%

Schillinger 2004

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Recommendation #1: Eliminate Jargon (Use “Living Room Language”)

GLUCOMETER

HEMOGLOBIN A1c

DIALYSIS

ANGINA

RISK FACTORS

CREATININE

Jargon Terms…unclarified

Glucometer Immunizations Weight is stable Microvascular complication System of nerves HbA1c EKG abnormalities Dialysis Wide Range Risk factors Kidney function Interact

…clarified Angina Microalbuminuria Ophthalmology Genetic Creatinine Symptoms

…from Patient’s own visit:• benign• blood drawn• blood count

• CAT scan• blood count• correlate• stool was negative• stool• baseline• respiratory tract• polyp

•washed out of your system•receptors•short course•renal clinic•blood cells•increase your R•screening•vaccine

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Provide Health Education

29%

Deliver Test Results24%

Provide Recommendations

37%

Assess Symptoms10%

n = 60

Function of Physician Jargon in Outpatient Visit

Castro, Schillinger AJHB 2007

jpm=0.4

Recommendation #2: Assess comprehension with the “teach-back”

method aka “Closing the Loop”

In this interactive technique, the clinician prioritizes amongst the information exchange and explicitly asks the patient to “teach-back” what he/she has recalled and understood re those high-priority domains.

Similarly, clinicians can use the strategy to assess patient’s perceptions of the information or advice given.

The technique can be used toward the end of a visit or during the course of the visit, so as to tailor communication earlier.

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Closing the Loop: Interactive Communication to Enhance Recall & Comprehension

Re-AssessPatient Recall &Comprehension

Adherence

New Concept:Health Information,

Advice, or Change in Management

Provider Explains New Concept

Patient Recalls and Comprehends

AssessPatient Recall & Comprehension

Clarify & Tailor Explanation

We Rarely “Close the Loop” --But It’s Good When We Do

Physicians assessed recall or comprehension for 15/124 new concepts (12%)

When new concepts included patient assessment, patient provided incorrect response half the time (7/15=47%)

Visits using interactive communication loop not longer (20 min vs. 22 min)

Application of loop associated with better HbA1c (AOR 9.0, p=.02)

Schillinger Arch Int Med 2003

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Exemplar Case: Clearly this was

Limited Health Literacy, right?

Ms J is a 57 yo English-speaking Latina, mother of 5, with 3 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 service was unable to identify a trigger for the hypoglycemia.


iolenceninsurediteracy and Languageeglectconomic hardship/ food insecurityace/ethnic discordance, discriminationddictionrain disorders, e.g. depression, dementiammigrantegal statussolation/Informal caregiving burdenransportation problemsllness Modelyes and Earshelter

Schillinger 2007

VULNERABILITIES

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The Old Face of Hunger

The uneasy or painful sensation caused by lack of food, or the recurrent and involuntary lack of access to food.

The limited or uncertain availability of nutritionally

adequate and safe foods or ability to acquire acceptable

foods in socially acceptable ways

The New Face of Food Insecurity

Life Sciences Research Organization

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Coping Strategies to Avoid Hunger

Eating low-cost foods Eating highly filling

foods Small variety of foods Skipping meals Avoiding food waste Eating less at each

meal Skipping meals

Federal nutrition programs (SNAP, WIC)

Eating with relatives/friends/church

Food pantries or soup kitchens

Shopping in bulk/generic brands/coupons

Putting off other expenses/staggering bills

21 million adults

8.6 million kids

12 million adults

765,000 kids

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Risk Factors (Household-Level)

Children (21%) Children under age 6 (22%) Children with single mother (37%); single father (25%)

Income <185% FPL (35%) Black (25%) or Latino (26%) Smoker in the household

Nearly 50% of US children and 90% of Black children will use Food Stamps at some point during their childhood.

Rank, 2009

About 50% of US adults between the ages of 20 and 65 will receive Food Stamps at some point.

Food Insecurity & Diabetes

Adapted from Seligman & Schillinger

Food Insecurity

-Affordability of healthy foods-Episodic food

availability-Stress

Poor Diabetes Control

Increased Diabetes

Complications

Increased Health Care Utilization & Expenses

Worsening of Competing Demands

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Food Insecurity & Diabetes Prevalence

Seligman, Jl Nutr, 2010.

p=0.03 after adjusting for age, gender, race/ethnicity; p=0.09 after adjusting for above + education + income as continuous variable + income as ordinal variable

Food Insecure Adults with Diabetes Have Higher Average A1c

0

5

10

15

20

25

30

35

40

<=7.0 7.1-8.0 8.1-9.0 9.1-10.0 10.1-11.0 >11

%

HbA1c

Food secure (n=354)

Food insecure (n=296)

Seligman, Diabetes Care, 2012.

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Hunger-Obesity Paradox

Food affordability Episodic food availability Bandwidth

Drewnowski, A. et al. Am J Clin Nutr 2004;79:6-16

Relation between the energy densityof selected foods and energy costs

(¢/MJ)

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Hunger-Obesity Paradox

Food affordability Episodic food availability Stress

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Cycles of Consumption

Food insecurity is cyclical & episodicMonthly SNAP (“The Food Stamp Cycle”) or

pay checksSeasonal variationPeriodic, unforeseen expenditures

Food insecure households are food insecure during 7 months of the year on average

Food Stamp Cycle: More Calories in the 1st week of the month

Wilde, 2000

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Income Shocks Affect the Poor via Food Budget

Adaptation to episodic Food Availability: Binge Eating

“I buy a big five-pound block of cheese twice a month and when that first comes into the house, you know, it’s like everybody’s sort of ravenous after stuff….”

“Towards the first part, the first half of the month they always eat probably more than they should, ‘cause they get so excited.”

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Cycles of Food Adequacy & Inadequacy Wreak

Havoc

Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

Hyperglycemia Hypoglycemia

Cycles of Food Adequacy & Inadequacy Wreak Havoc

Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.

Hyperglycemia Hypoglycemia

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Hypoglycemia & Food Insecurity

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 too low? (28% FI vs. 5% FS)

Nelson, JAMA, 1998; Seligman, JHCPU, 2010.

Risk Factors for Severe Hypoglycemia

AOR

Food Insecurity 3.0 (1.5-5.9)

Alcohol abuse 2.2 (1.1-4.5)

Comorbid illnesses 1.5 (1.1-2.0)

Obesity 0.3 (0.1-0.7)Seligman, Arch Int Med, 2011

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Admissions Attributable And Appendicitis Among Patients Ages Nineteen And Older To

27% increase in rate of hypoglycemia admissions at end of month in low-income

Seligman H K et al. Health Aff 2014;33:116-123

Recommendation #1: Screen for Food Insecurity

Within the past 12 months, we worried whether our food would run out before we got money to buy more.

Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.

Yes=often or sometimes true; no=never true “Yes” to either question: 97% sensitivity, 83%

specificityHager, Pediatrics, 2010

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Recommendation #2 for FI: Nutrition and Medical Counseling

Simple counseling strategiesRecommend Frozen fruits and vegetables Farmers’ markets Nutritionist & SW referral: hunger safety net & federal

nutrition programs (still underutilized)

For patients with diabetesMedication management/titration Expand definition of a “sick day” Individualize A1c goals

Encourage smoking cessation for everyone in household!

Exemplar Case: Clearly this was Food Insecurity, right?


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Schillinger 2007

VULNERABILITIES

What is intimate partner violence (IPV)?

PATTERN of abusive behaviors including physical, sexual, verbal, emotional,

economic, and/or psychological abuse

used by adults or adolescents

against current or former intimate partners, and sometimes against other family members

in ANY intimate relationship: LGBTQ/straight/all gender identities

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Lifetime Prevalence of Rape, Physical Violence, Stalking by Intimate Partner

Lifetime weighted percent

Women Men

Rape 9.4% # not large enough for accurate estimate

Physical violence 32.9% 28.2%Stalking 10.7% 2.1%Rape, physical violence, and/or stalking 35.6% 28.5%

With IPV-related impact—this means that the person experienced some adverse impact as a result of the violence/abuse

28.8% 9.9%

Effects of IPV: Relationships affect health

Injuries and death (femicide) Poor mental health: depression, anxiety, PTSD, suicide Poor physical health

Chronic pain Disability Asthma Stroke Heart disease

STD’s—2-3x risk, HIV risk increased Unwanted pregnancy and abortions Substance addiction (esp ETOH) Overuse of health services , missed appointments ,

obstruction of medical care and self-management

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Recommendation #1: Screen for IPV

At a minimum, screen all women and adolescent girls for victimization

JCAHO requires screening of either all women or all women and men

ACA requires IPV screening for women

CA state law requires IPV programs in clinics

Screening: Framing Questions

I am concerned about my patients’ health andsafety, so I ask all my patients...

Because violence and threats are so common in relationships, I ask all my patients. . .

Relate questions to patient’s situation:

“The nurses have noticed that every time your boyfriend comes to visit you in the hospital your asthma gets worse, so I am worried that…”

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Screening tools:

HITS tool (best combo of sens/spec):

Screening: Direct Questions

“Has your partner ever hit you or hurt you or threatened you?”

“Has your partner ever forced you to have sex when you didn’t want to?”

“Has your partner ever tried to interfere with your birth control?”

Avoid value-laden terms like “abuse” or “rape”

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“What everyone needs is a good listening to.”

--Mary Lou Casey

Recommendation #2: Intervene with Skills

17 PC intervention studies-- (beyond screening)

Intervention methods: empowerment/education/referral/home visitation/phone calls/case manager

Benefit: +13/17 studies

Reduction in IPV: +5/11 studies (trend in 6th) (other benefits: improved health/use of resources and referrals, safety-promoting behaviors)

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Recommendation #2: Intervene but Don’t Rescue

Assess safety and use empowering languageProvide validating messages of support to allOffer hotline numbers to allAllow patient to call clinic/hospital if in

dangerOffer safety planning (either on site or in

community agency) and ongoing supportAlways document in chart

Assessment as anEmpowerment Tool

Emphasize unrecognized strengths

“Wow, you are amazingly strong to be caring for your child under such difficult circumstances”

“That was so brave to share with me what is going on”

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SAFETY PLANNING…

Best done by a IPV advocate with participation of behaviorist—but you need to know basics

Explore with patient what creative, customized options there are for safety within the context of a dangerous and abusive relationship

ALWAYS offer patient connection to safety planning experts—community DV agencies (24/7)

Documentation: Can Be Critical for a Legal Case

San Francisco Department on the Status of Women

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IPV Resources

• www.leapsf.org- “how to”, training videos, patient ed materials• http://Futureswithoutviolence.org- clinic materials, policies, fact sheets• www.thehotline.org- national domestic violence hotline

Exemplar Case: Clearly this was Intimate Partner Violence, right?


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Where Have We Been?

Deconstruct the construct of vulnerable populations

Present an integrated approach to care of vulnerable patients

Provide 3 examples of social vulnerabilities & DM Limited health literacy Food insecurity Intimate Partner Violence (IPV)

Find the joy and a feeling of alignment in one’s work

Care of Vulnerable Patients

“There needs to be a little Don Quixote in all health practitioners… locked in on the mission, undaunted by the doubters and the half-hearted”

• Fitzhugh Mullan, MD

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Interrupting the Cycles of Vulnerability & Poor Health

Schillinger et al 2007

TWO DEAD MENA POEM….

One: a refugee from Cuba.

Always in white,

Skin black and smooth,

Fitting the mold from bottom top:

White leather shoes,

White pants,

White linen shirt,

Crowned with a Havana,

Of course.

The other: tall, lanky,

Happy and old.

A former ball player

In the West Coast Negro League.

Pitched for the Sea Lions

Until he threw his shoulder

Out of its socket,

And could throw no more.

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The First: always smiling,Laughing even.

Gold sparkling from a tooth.Bejeweled with blingLike epaulettesFrom his favorite pastime:Reno with Maria

The Second: never sure of his age,

Either 93 or 88,

His Louisiana birth certificate,

Unable to read it,

But he knows it bears false witness.

Keeps his daughter's number safe:

Pearline - on the inside brim

Of his omnipresent

Baseball cap.

The Former: still alive

‘Cause he quit tobacco 25 years ago

After being filleted openTo plumb his heart.Proud of his medical survival skills,

And grateful for his doctor.While smacking his big round belly,Pregnant with hope and worry.

The Latter: still aliveBecause he quit smoking 25 years agoAfter being told his lungs are vanishing.Owe my life to my doctor,So he says and so he believes.Now chained to an oxygen tank,Not sure if it's worth it,Anymore.

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Two Brothers,

Resilient,

Living in parallel,

Struggling in parallel,

Full lives behind them.

Now both suddenly dead,

Within days of each other.

Leaving behind their doctor

How can it be

That these two men,

Bedeviled by society

Could become the favorites

Of their doctor?

What can fill the absences,

When one is robbed of one's favorites

And their love is lost?

END

caring for vulnerable patients in the era of health … for vulnerable patients in the era of health...

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