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From the Samuel U. Rodgers Health Center, Kansas City, MO.
Abstract
- Objective: To describe the application of the Health Home model in a center that provides care for a culturally diverse patient population.
- Methods: The initiative serves 300 Medicaid beneficiaries, providing intense primary care and behavioral health services for patients with 2 or more chronic diseases. The program addresses multicultural issues and health literacy in addition to assessing patients’ physical and mental health issues and basic needs. It builds upon the patient-centered medical home model, employing a team-based, holistic approach that integrates a behavioral health component to encompass the needs of the whole person, including psychosocial requirements.
- Results: Implementation has led to improved clinical outcomes, including lower A1c levels in our diabetic patients and fewer emergency department visits and hospitalizations.
- Conclusion: The Health Home model has improved our ability to provide high quality, culturally competent health care to our diverse patient population.
Samuel U. Rodgers Health Center (SURHC) has a long and proud history in Kansas City. It was founded in 1967 and incorporated in 1968 as the fourth federally qualified health center in the United States and the first in Missouri. SURHC provides comprehensive primary and urgent care to persons of all ages in the areas of adult and senior medicine, obstetrics/gynecology, pediatric and adolescent health, behavioral health, and dental health services for our community’s most medically vulnerable families, regardless of their ability to pay or health insurance status.
SURHC has a New Americans program in partnership with the Jewish Vocational Immigration Intake Center, in which all newly arrived refugees come to SURHC to receive their physical health exam and be brought up to date with necessary vaccinations. A large proportion of SURHC’s patients are refugees from war-torn and famine-impacted countries, many of which lived in refugee camps with inconsistent access to health care. Some arrive feeling hopeless, fearful, and drained while others have been tortured, maimed, and/or raped. Given these extraordinary circumstances, many patients come to us without a clear understanding of their illness or what constitutes a healthy lifestyle, including diet and exercise, preventive health screenings, and immunizations. Assistance is often required for behavioral health issues associated with acculturation stress, migration, and resettlement in addition to medical care.
Our refugees come from culturally diverse populations and may have limited literacy rates, be impacted by race-related health disparities, and be non-English speaking. Twenty-nine percent of SURHC’s total patient population and 43% of our patient population at our primary downtown campus location are non-English speaking refugees and/or immigrants. Within our chronic disease population, 68% require interpreter services. The health center employs interpreters for English, Somali, Spanish, Arabic, Burmese, and Vietnamese, but for languages less commonly used in the clinic—such as Karen, Nepalese, and Swahili—phone language interpreter services are used.
One problem we identified while working with our unique patient population was the lack of appropriate educational materials. As a result, the “traditional” method of working with patients would not be effective, necessitating a new approach to meeting the needs of our patients if there was to be any impact on their health outcomes or quality of life or provision of cost savings to the health care system. We recognized the need to address multicultural issues involving health literacy levels in addition to assessing the patient’s physical and mental health issues and basic needs before confronting their chronic disease. The stress produced from these concerns was notably interfering with the patient’s ability to focus on their overall health. We describe our approach to addressing these issues in this article.
Approach to Care
SURHC has been successful in fully integrating behavioral health care with primary care as part of our participation in the Missouri Medicaid primary care Health Home (PCHH) initiative. Our PCHH participation began in 2012 and provides SURHC with the opportunity to benefit from a fully integrated model of care. The initiative serves 300 Missouri Medicaid beneficiaries, providing intense primary care and behavioral health services for patients with 2 or more chronic diseases. The patient centered medical home laid the foundation for PCHH, which relies on a team-based care approach. PCHH employs a holistic approach similar to the medical home model and includes behavioral health as part of the front-line interventions to manage physical and mental health issues, including the determinants of health factors that may be influencing the ability of the patient to adhere to the treatment plan and live a healthy life.
Working with multiple cultures involves developing a staff that is culturally competent. This includes education on the values and beliefs of different cultures which enhances staff’s ability to understand, communicate with, and create an effective learning experience for the patient. Evidence shows that understanding someone’s culture aids in developing trust between patient and team member. This relationship greatly contributes to successful results and the reaching of patient self-management goals.
Working with different cultures also necessitates a multidisciplinary team, comprising a care coordinator, behavioral health consultant, and an RN care manager. The multidisciplinary team works in coordination with the primary care provider, LPN, and medical assistant to address the physical, mental, and social needs of the patient.
The care coordinator maintains current insurance status on patients. Specific doctor-prescribed medical supplies go through the coordinator to be pre-certified through our Cyber Access (electronic health record). The coordinator completes our measures report for meaningful use. The care coordinator answers patient calls and schedules and redirects calls as needed. A newsletter is created and mailed out monthly to our patients.
The behavioral health consultant addresses the mental processes of the patient. An assessment may include an evaluation of the patient’s emotional and spiritual needs as well as possible behavioral modification. The behavioral health consultant also addresses smoking cessation, stress reduction, and exercising. Assessment of motivation and readiness is evaluated to assist the patient in setting goals for the self-management of chronic diseases. The behavioral health consultant and RN care manager work closely together by integrating the behavioral health with the primary medical care of the patient.
The RN care manager sees patients when they come in for appointments with their primary care provider (PCP). The RN uses this time to answer patient questions regarding chronic disease, to check if patients know which medications they are taking and why, and for following up on any previous chronic disease teaching or hospital visits they may have had. This team member also coordinates with other specialists and agencies outside of the clinic to assure the patient is followed up with.
Self-Management Support
The ultimate goal in educating a multicultural patient is to wean them from hands-on support provided by the multidisciplinary staff to be able to effectively self-manage their disease. With effective self-management, the patient understands his or her condition, how it affects the body, and can monitor the condition in order to make any necessary changes to stay healthy.
Health literacy plays a significant role in educating the patient about their chronic disease. It is important to measure each patient’s ability to read and write—not only in their native language, but in English as well. This assessment enabled the multidisciplinary team to create new methods of working distinctively with each individual to support their self-management.
One of the self-management techniques that has helped patients and staff track their progress is the use of wall calendars. Our practice provides a wall calendar for interested patients to help track daily fasting, blood glucose, blood pressure, medications taken, etc. The patient can track times they took their medications by using stickers to indicate if they have taken their morning, noon, or evening medications. Our practice supplies the patient with stickers of their choice to use. These wall calendars are helpful for providing daily and monthly accounts of self-management activitites and patients are encouraged to bring them to their appointments. Future appointments can be added to the calendar before the patient leaves the doctor’s office.
Having on-site, professionally certified interpreters greatly improves the education and learning-time for non-English speaking patients. These team members are crucial for their abilities to visually assess the patient’s understanding of teaching materials and interpreting if the patient is showing signs of confusion. The interpreter is also helpful in re-labeling prescription bottles in the patient’s language or with stickers to help them understand how to take the medication correctly. Interpreters have also helped in creating new patient information tools written in different languages for patients that are literate. We have also noted that patients appear more comfortable in the learning environment when a personal interpreter is present as opposed to a telecommunication service.
Scheduled appointment times are set for the patient to meet one-on-one with the nurse care manager or behavioral health consultant for education during which 1 or 2 main points relating to their chronic disease is discussed. This strategy, called “chunking,” breaks the content down into bite-sized segments, helping the patient to learn and retain the information presented. These sessions are good times to work on specifics of the individual’s lifestyle and history and allow time for the patient to ask questions. Most information on a chronic disease can be given in 2 to 4 sessions, with an hour allotted for each one. Follow-up can be done as needed for each patient.
Teaching patients how to read nutrition labels is another useful skill. This is helpful for patients that have diabetes, hypertension, and/or hyperlipidemia. Our staff has collected empty food containers, snack packages, and drink bottles of different ethnic foods. Patients are taught how to read the nutrition labels to help them make healthy choices; for instance, a patient with diabetes is taught to read the serving size and then assess the carbohydrate amount. When comparing foods of the same kind, patients then know to choose the one with less carbohydrates per serving for the healthiest choice. A patient with hypertension would look at serving size and sodium content whereas a patient with hyperlipidemia would learn to pay attention to the serving size, fats, and cholesterol amounts. Using actual food containers as props has been an eye-opening experience for many of patients and those that understand and follow instructions on how to read nutrition labels have higher success rates in their self-management.
To further encourage healthy eating, with the help of our international interpreters we took pictures of prepared foods from different countries. Each picture was then placed on a red, yellow, or green sheet of paper (the stop light method) based on the ingredients in the food depicted. When a patient comes for teaching, we have them go through the pictures and pull out the ones they recognize and consume. We then teach the patient that foods depicted on green paper may be consumed as much as desired, foods on the yellow paper should be limited in the quantity, and foods on the red sheets represent the unhealthiest choices. Time is spent teaching patients how they can make these red-sheet dishes in a healthier manner.
Outcomes
Although SURHC’s patient population faces many challenges in achieving and maintaining control over their health, we are having success in improving clinical outcomes resulting from the implementation of the PCHH model. For example, within a 6-month period, 80% of our patients with an A1c > 8% saw a reduction in their A1c level. In addition, we found emergency room visits and hospitalizations dropped from 332 in December 2012 to 176 in August 2013. This reflects a 53% decrease in visits, for a conservative estimate of over $327,600 in savings to the health care system.
Discussion
Our outcomes support the fact that interventions and one-on-one work with patients have been helpful. The PCHH model provides personal attention to the patient—such as individually-structured teaching plans to assist in setting and attaining goals—which makes patients more accountable for self-management of their health. The use of interpreters in the education process was key to successful goal management and outcomes as they provided the bridge for patients to learn how to set and reach their goals. This model also integrates a behavioral health component to encompass the needs of the whole person, including psychosocial requirements.
Health literacy is an important factor in working with our multicultural population. It is important to provide literate patients with information in their native tongue, which can help teach them more about their chronic disease. We found some helpful educational handouts online in different languages. We also have used our onsite interpreters to help us in creating new educational handouts. In addition, we developed videos that feature our health center’s personal interpreters providing information in 6 languages about “Medications” and “What do I need to bring to my appointment?” The medication video explains the importance of taking the prescribed medicine every day or as the provider orders, and how to refill medications. The other video explains the need to bring all medications, glucose or blood pressure readings, etc, to appointments. These multilingual videos play in the waiting room throughout the day. Seeing employees on the video helps draw the patients into listening and learning the information provided.
We found that we needed to address the basic needs of the patient before confronting their chronic disease. This process sometimes involved finding beds or providing food for the patient. Many had dental issues that needed to be addressed before we could work with them on their diabetic diet issues or other contributing chronic issues. If these needs are met, it can ameliorate stress, which can have negative effects on their health.
On review of current A1c findings, there was a decrease in the percentage of patients who showed improvement. This is reflective of the most challenging patients we continue to work with. Moving forward, as more refugees representing increasingly diverse cultures come to our clinic, greater understanding of cultural nuances remains a challenge. Additional work is necessary to produce and accumulate more diverse educational materials to meet the health literacy needs of each patient.
Samuel U. Rodgers Health Center has earned the trust of our diverse communities and we are confident and proud of our ability to provide high quality, culturally-competent health care to our diverse patient population.
Corresponding author: Robyn McCright, RN, 825 Euclid Ave., Kansas City, MO 64124, rmccright@rodgershealth.org.
Financial disclosures: None.
From the Samuel U. Rodgers Health Center, Kansas City, MO.
Abstract
- Objective: To describe the application of the Health Home model in a center that provides care for a culturally diverse patient population.
- Methods: The initiative serves 300 Medicaid beneficiaries, providing intense primary care and behavioral health services for patients with 2 or more chronic diseases. The program addresses multicultural issues and health literacy in addition to assessing patients’ physical and mental health issues and basic needs. It builds upon the patient-centered medical home model, employing a team-based, holistic approach that integrates a behavioral health component to encompass the needs of the whole person, including psychosocial requirements.
- Results: Implementation has led to improved clinical outcomes, including lower A1c levels in our diabetic patients and fewer emergency department visits and hospitalizations.
- Conclusion: The Health Home model has improved our ability to provide high quality, culturally competent health care to our diverse patient population.
Samuel U. Rodgers Health Center (SURHC) has a long and proud history in Kansas City. It was founded in 1967 and incorporated in 1968 as the fourth federally qualified health center in the United States and the first in Missouri. SURHC provides comprehensive primary and urgent care to persons of all ages in the areas of adult and senior medicine, obstetrics/gynecology, pediatric and adolescent health, behavioral health, and dental health services for our community’s most medically vulnerable families, regardless of their ability to pay or health insurance status.
SURHC has a New Americans program in partnership with the Jewish Vocational Immigration Intake Center, in which all newly arrived refugees come to SURHC to receive their physical health exam and be brought up to date with necessary vaccinations. A large proportion of SURHC’s patients are refugees from war-torn and famine-impacted countries, many of which lived in refugee camps with inconsistent access to health care. Some arrive feeling hopeless, fearful, and drained while others have been tortured, maimed, and/or raped. Given these extraordinary circumstances, many patients come to us without a clear understanding of their illness or what constitutes a healthy lifestyle, including diet and exercise, preventive health screenings, and immunizations. Assistance is often required for behavioral health issues associated with acculturation stress, migration, and resettlement in addition to medical care.
Our refugees come from culturally diverse populations and may have limited literacy rates, be impacted by race-related health disparities, and be non-English speaking. Twenty-nine percent of SURHC’s total patient population and 43% of our patient population at our primary downtown campus location are non-English speaking refugees and/or immigrants. Within our chronic disease population, 68% require interpreter services. The health center employs interpreters for English, Somali, Spanish, Arabic, Burmese, and Vietnamese, but for languages less commonly used in the clinic—such as Karen, Nepalese, and Swahili—phone language interpreter services are used.
One problem we identified while working with our unique patient population was the lack of appropriate educational materials. As a result, the “traditional” method of working with patients would not be effective, necessitating a new approach to meeting the needs of our patients if there was to be any impact on their health outcomes or quality of life or provision of cost savings to the health care system. We recognized the need to address multicultural issues involving health literacy levels in addition to assessing the patient’s physical and mental health issues and basic needs before confronting their chronic disease. The stress produced from these concerns was notably interfering with the patient’s ability to focus on their overall health. We describe our approach to addressing these issues in this article.
Approach to Care
SURHC has been successful in fully integrating behavioral health care with primary care as part of our participation in the Missouri Medicaid primary care Health Home (PCHH) initiative. Our PCHH participation began in 2012 and provides SURHC with the opportunity to benefit from a fully integrated model of care. The initiative serves 300 Missouri Medicaid beneficiaries, providing intense primary care and behavioral health services for patients with 2 or more chronic diseases. The patient centered medical home laid the foundation for PCHH, which relies on a team-based care approach. PCHH employs a holistic approach similar to the medical home model and includes behavioral health as part of the front-line interventions to manage physical and mental health issues, including the determinants of health factors that may be influencing the ability of the patient to adhere to the treatment plan and live a healthy life.
Working with multiple cultures involves developing a staff that is culturally competent. This includes education on the values and beliefs of different cultures which enhances staff’s ability to understand, communicate with, and create an effective learning experience for the patient. Evidence shows that understanding someone’s culture aids in developing trust between patient and team member. This relationship greatly contributes to successful results and the reaching of patient self-management goals.
Working with different cultures also necessitates a multidisciplinary team, comprising a care coordinator, behavioral health consultant, and an RN care manager. The multidisciplinary team works in coordination with the primary care provider, LPN, and medical assistant to address the physical, mental, and social needs of the patient.
The care coordinator maintains current insurance status on patients. Specific doctor-prescribed medical supplies go through the coordinator to be pre-certified through our Cyber Access (electronic health record). The coordinator completes our measures report for meaningful use. The care coordinator answers patient calls and schedules and redirects calls as needed. A newsletter is created and mailed out monthly to our patients.
The behavioral health consultant addresses the mental processes of the patient. An assessment may include an evaluation of the patient’s emotional and spiritual needs as well as possible behavioral modification. The behavioral health consultant also addresses smoking cessation, stress reduction, and exercising. Assessment of motivation and readiness is evaluated to assist the patient in setting goals for the self-management of chronic diseases. The behavioral health consultant and RN care manager work closely together by integrating the behavioral health with the primary medical care of the patient.
The RN care manager sees patients when they come in for appointments with their primary care provider (PCP). The RN uses this time to answer patient questions regarding chronic disease, to check if patients know which medications they are taking and why, and for following up on any previous chronic disease teaching or hospital visits they may have had. This team member also coordinates with other specialists and agencies outside of the clinic to assure the patient is followed up with.
Self-Management Support
The ultimate goal in educating a multicultural patient is to wean them from hands-on support provided by the multidisciplinary staff to be able to effectively self-manage their disease. With effective self-management, the patient understands his or her condition, how it affects the body, and can monitor the condition in order to make any necessary changes to stay healthy.
Health literacy plays a significant role in educating the patient about their chronic disease. It is important to measure each patient’s ability to read and write—not only in their native language, but in English as well. This assessment enabled the multidisciplinary team to create new methods of working distinctively with each individual to support their self-management.
One of the self-management techniques that has helped patients and staff track their progress is the use of wall calendars. Our practice provides a wall calendar for interested patients to help track daily fasting, blood glucose, blood pressure, medications taken, etc. The patient can track times they took their medications by using stickers to indicate if they have taken their morning, noon, or evening medications. Our practice supplies the patient with stickers of their choice to use. These wall calendars are helpful for providing daily and monthly accounts of self-management activitites and patients are encouraged to bring them to their appointments. Future appointments can be added to the calendar before the patient leaves the doctor’s office.
Having on-site, professionally certified interpreters greatly improves the education and learning-time for non-English speaking patients. These team members are crucial for their abilities to visually assess the patient’s understanding of teaching materials and interpreting if the patient is showing signs of confusion. The interpreter is also helpful in re-labeling prescription bottles in the patient’s language or with stickers to help them understand how to take the medication correctly. Interpreters have also helped in creating new patient information tools written in different languages for patients that are literate. We have also noted that patients appear more comfortable in the learning environment when a personal interpreter is present as opposed to a telecommunication service.
Scheduled appointment times are set for the patient to meet one-on-one with the nurse care manager or behavioral health consultant for education during which 1 or 2 main points relating to their chronic disease is discussed. This strategy, called “chunking,” breaks the content down into bite-sized segments, helping the patient to learn and retain the information presented. These sessions are good times to work on specifics of the individual’s lifestyle and history and allow time for the patient to ask questions. Most information on a chronic disease can be given in 2 to 4 sessions, with an hour allotted for each one. Follow-up can be done as needed for each patient.
Teaching patients how to read nutrition labels is another useful skill. This is helpful for patients that have diabetes, hypertension, and/or hyperlipidemia. Our staff has collected empty food containers, snack packages, and drink bottles of different ethnic foods. Patients are taught how to read the nutrition labels to help them make healthy choices; for instance, a patient with diabetes is taught to read the serving size and then assess the carbohydrate amount. When comparing foods of the same kind, patients then know to choose the one with less carbohydrates per serving for the healthiest choice. A patient with hypertension would look at serving size and sodium content whereas a patient with hyperlipidemia would learn to pay attention to the serving size, fats, and cholesterol amounts. Using actual food containers as props has been an eye-opening experience for many of patients and those that understand and follow instructions on how to read nutrition labels have higher success rates in their self-management.
To further encourage healthy eating, with the help of our international interpreters we took pictures of prepared foods from different countries. Each picture was then placed on a red, yellow, or green sheet of paper (the stop light method) based on the ingredients in the food depicted. When a patient comes for teaching, we have them go through the pictures and pull out the ones they recognize and consume. We then teach the patient that foods depicted on green paper may be consumed as much as desired, foods on the yellow paper should be limited in the quantity, and foods on the red sheets represent the unhealthiest choices. Time is spent teaching patients how they can make these red-sheet dishes in a healthier manner.
Outcomes
Although SURHC’s patient population faces many challenges in achieving and maintaining control over their health, we are having success in improving clinical outcomes resulting from the implementation of the PCHH model. For example, within a 6-month period, 80% of our patients with an A1c > 8% saw a reduction in their A1c level. In addition, we found emergency room visits and hospitalizations dropped from 332 in December 2012 to 176 in August 2013. This reflects a 53% decrease in visits, for a conservative estimate of over $327,600 in savings to the health care system.
Discussion
Our outcomes support the fact that interventions and one-on-one work with patients have been helpful. The PCHH model provides personal attention to the patient—such as individually-structured teaching plans to assist in setting and attaining goals—which makes patients more accountable for self-management of their health. The use of interpreters in the education process was key to successful goal management and outcomes as they provided the bridge for patients to learn how to set and reach their goals. This model also integrates a behavioral health component to encompass the needs of the whole person, including psychosocial requirements.
Health literacy is an important factor in working with our multicultural population. It is important to provide literate patients with information in their native tongue, which can help teach them more about their chronic disease. We found some helpful educational handouts online in different languages. We also have used our onsite interpreters to help us in creating new educational handouts. In addition, we developed videos that feature our health center’s personal interpreters providing information in 6 languages about “Medications” and “What do I need to bring to my appointment?” The medication video explains the importance of taking the prescribed medicine every day or as the provider orders, and how to refill medications. The other video explains the need to bring all medications, glucose or blood pressure readings, etc, to appointments. These multilingual videos play in the waiting room throughout the day. Seeing employees on the video helps draw the patients into listening and learning the information provided.
We found that we needed to address the basic needs of the patient before confronting their chronic disease. This process sometimes involved finding beds or providing food for the patient. Many had dental issues that needed to be addressed before we could work with them on their diabetic diet issues or other contributing chronic issues. If these needs are met, it can ameliorate stress, which can have negative effects on their health.
On review of current A1c findings, there was a decrease in the percentage of patients who showed improvement. This is reflective of the most challenging patients we continue to work with. Moving forward, as more refugees representing increasingly diverse cultures come to our clinic, greater understanding of cultural nuances remains a challenge. Additional work is necessary to produce and accumulate more diverse educational materials to meet the health literacy needs of each patient.
Samuel U. Rodgers Health Center has earned the trust of our diverse communities and we are confident and proud of our ability to provide high quality, culturally-competent health care to our diverse patient population.
Corresponding author: Robyn McCright, RN, 825 Euclid Ave., Kansas City, MO 64124, rmccright@rodgershealth.org.
Financial disclosures: None.
From the Samuel U. Rodgers Health Center, Kansas City, MO.
Abstract
- Objective: To describe the application of the Health Home model in a center that provides care for a culturally diverse patient population.
- Methods: The initiative serves 300 Medicaid beneficiaries, providing intense primary care and behavioral health services for patients with 2 or more chronic diseases. The program addresses multicultural issues and health literacy in addition to assessing patients’ physical and mental health issues and basic needs. It builds upon the patient-centered medical home model, employing a team-based, holistic approach that integrates a behavioral health component to encompass the needs of the whole person, including psychosocial requirements.
- Results: Implementation has led to improved clinical outcomes, including lower A1c levels in our diabetic patients and fewer emergency department visits and hospitalizations.
- Conclusion: The Health Home model has improved our ability to provide high quality, culturally competent health care to our diverse patient population.
Samuel U. Rodgers Health Center (SURHC) has a long and proud history in Kansas City. It was founded in 1967 and incorporated in 1968 as the fourth federally qualified health center in the United States and the first in Missouri. SURHC provides comprehensive primary and urgent care to persons of all ages in the areas of adult and senior medicine, obstetrics/gynecology, pediatric and adolescent health, behavioral health, and dental health services for our community’s most medically vulnerable families, regardless of their ability to pay or health insurance status.
SURHC has a New Americans program in partnership with the Jewish Vocational Immigration Intake Center, in which all newly arrived refugees come to SURHC to receive their physical health exam and be brought up to date with necessary vaccinations. A large proportion of SURHC’s patients are refugees from war-torn and famine-impacted countries, many of which lived in refugee camps with inconsistent access to health care. Some arrive feeling hopeless, fearful, and drained while others have been tortured, maimed, and/or raped. Given these extraordinary circumstances, many patients come to us without a clear understanding of their illness or what constitutes a healthy lifestyle, including diet and exercise, preventive health screenings, and immunizations. Assistance is often required for behavioral health issues associated with acculturation stress, migration, and resettlement in addition to medical care.
Our refugees come from culturally diverse populations and may have limited literacy rates, be impacted by race-related health disparities, and be non-English speaking. Twenty-nine percent of SURHC’s total patient population and 43% of our patient population at our primary downtown campus location are non-English speaking refugees and/or immigrants. Within our chronic disease population, 68% require interpreter services. The health center employs interpreters for English, Somali, Spanish, Arabic, Burmese, and Vietnamese, but for languages less commonly used in the clinic—such as Karen, Nepalese, and Swahili—phone language interpreter services are used.
One problem we identified while working with our unique patient population was the lack of appropriate educational materials. As a result, the “traditional” method of working with patients would not be effective, necessitating a new approach to meeting the needs of our patients if there was to be any impact on their health outcomes or quality of life or provision of cost savings to the health care system. We recognized the need to address multicultural issues involving health literacy levels in addition to assessing the patient’s physical and mental health issues and basic needs before confronting their chronic disease. The stress produced from these concerns was notably interfering with the patient’s ability to focus on their overall health. We describe our approach to addressing these issues in this article.
Approach to Care
SURHC has been successful in fully integrating behavioral health care with primary care as part of our participation in the Missouri Medicaid primary care Health Home (PCHH) initiative. Our PCHH participation began in 2012 and provides SURHC with the opportunity to benefit from a fully integrated model of care. The initiative serves 300 Missouri Medicaid beneficiaries, providing intense primary care and behavioral health services for patients with 2 or more chronic diseases. The patient centered medical home laid the foundation for PCHH, which relies on a team-based care approach. PCHH employs a holistic approach similar to the medical home model and includes behavioral health as part of the front-line interventions to manage physical and mental health issues, including the determinants of health factors that may be influencing the ability of the patient to adhere to the treatment plan and live a healthy life.
Working with multiple cultures involves developing a staff that is culturally competent. This includes education on the values and beliefs of different cultures which enhances staff’s ability to understand, communicate with, and create an effective learning experience for the patient. Evidence shows that understanding someone’s culture aids in developing trust between patient and team member. This relationship greatly contributes to successful results and the reaching of patient self-management goals.
Working with different cultures also necessitates a multidisciplinary team, comprising a care coordinator, behavioral health consultant, and an RN care manager. The multidisciplinary team works in coordination with the primary care provider, LPN, and medical assistant to address the physical, mental, and social needs of the patient.
The care coordinator maintains current insurance status on patients. Specific doctor-prescribed medical supplies go through the coordinator to be pre-certified through our Cyber Access (electronic health record). The coordinator completes our measures report for meaningful use. The care coordinator answers patient calls and schedules and redirects calls as needed. A newsletter is created and mailed out monthly to our patients.
The behavioral health consultant addresses the mental processes of the patient. An assessment may include an evaluation of the patient’s emotional and spiritual needs as well as possible behavioral modification. The behavioral health consultant also addresses smoking cessation, stress reduction, and exercising. Assessment of motivation and readiness is evaluated to assist the patient in setting goals for the self-management of chronic diseases. The behavioral health consultant and RN care manager work closely together by integrating the behavioral health with the primary medical care of the patient.
The RN care manager sees patients when they come in for appointments with their primary care provider (PCP). The RN uses this time to answer patient questions regarding chronic disease, to check if patients know which medications they are taking and why, and for following up on any previous chronic disease teaching or hospital visits they may have had. This team member also coordinates with other specialists and agencies outside of the clinic to assure the patient is followed up with.
Self-Management Support
The ultimate goal in educating a multicultural patient is to wean them from hands-on support provided by the multidisciplinary staff to be able to effectively self-manage their disease. With effective self-management, the patient understands his or her condition, how it affects the body, and can monitor the condition in order to make any necessary changes to stay healthy.
Health literacy plays a significant role in educating the patient about their chronic disease. It is important to measure each patient’s ability to read and write—not only in their native language, but in English as well. This assessment enabled the multidisciplinary team to create new methods of working distinctively with each individual to support their self-management.
One of the self-management techniques that has helped patients and staff track their progress is the use of wall calendars. Our practice provides a wall calendar for interested patients to help track daily fasting, blood glucose, blood pressure, medications taken, etc. The patient can track times they took their medications by using stickers to indicate if they have taken their morning, noon, or evening medications. Our practice supplies the patient with stickers of their choice to use. These wall calendars are helpful for providing daily and monthly accounts of self-management activitites and patients are encouraged to bring them to their appointments. Future appointments can be added to the calendar before the patient leaves the doctor’s office.
Having on-site, professionally certified interpreters greatly improves the education and learning-time for non-English speaking patients. These team members are crucial for their abilities to visually assess the patient’s understanding of teaching materials and interpreting if the patient is showing signs of confusion. The interpreter is also helpful in re-labeling prescription bottles in the patient’s language or with stickers to help them understand how to take the medication correctly. Interpreters have also helped in creating new patient information tools written in different languages for patients that are literate. We have also noted that patients appear more comfortable in the learning environment when a personal interpreter is present as opposed to a telecommunication service.
Scheduled appointment times are set for the patient to meet one-on-one with the nurse care manager or behavioral health consultant for education during which 1 or 2 main points relating to their chronic disease is discussed. This strategy, called “chunking,” breaks the content down into bite-sized segments, helping the patient to learn and retain the information presented. These sessions are good times to work on specifics of the individual’s lifestyle and history and allow time for the patient to ask questions. Most information on a chronic disease can be given in 2 to 4 sessions, with an hour allotted for each one. Follow-up can be done as needed for each patient.
Teaching patients how to read nutrition labels is another useful skill. This is helpful for patients that have diabetes, hypertension, and/or hyperlipidemia. Our staff has collected empty food containers, snack packages, and drink bottles of different ethnic foods. Patients are taught how to read the nutrition labels to help them make healthy choices; for instance, a patient with diabetes is taught to read the serving size and then assess the carbohydrate amount. When comparing foods of the same kind, patients then know to choose the one with less carbohydrates per serving for the healthiest choice. A patient with hypertension would look at serving size and sodium content whereas a patient with hyperlipidemia would learn to pay attention to the serving size, fats, and cholesterol amounts. Using actual food containers as props has been an eye-opening experience for many of patients and those that understand and follow instructions on how to read nutrition labels have higher success rates in their self-management.
To further encourage healthy eating, with the help of our international interpreters we took pictures of prepared foods from different countries. Each picture was then placed on a red, yellow, or green sheet of paper (the stop light method) based on the ingredients in the food depicted. When a patient comes for teaching, we have them go through the pictures and pull out the ones they recognize and consume. We then teach the patient that foods depicted on green paper may be consumed as much as desired, foods on the yellow paper should be limited in the quantity, and foods on the red sheets represent the unhealthiest choices. Time is spent teaching patients how they can make these red-sheet dishes in a healthier manner.
Outcomes
Although SURHC’s patient population faces many challenges in achieving and maintaining control over their health, we are having success in improving clinical outcomes resulting from the implementation of the PCHH model. For example, within a 6-month period, 80% of our patients with an A1c > 8% saw a reduction in their A1c level. In addition, we found emergency room visits and hospitalizations dropped from 332 in December 2012 to 176 in August 2013. This reflects a 53% decrease in visits, for a conservative estimate of over $327,600 in savings to the health care system.
Discussion
Our outcomes support the fact that interventions and one-on-one work with patients have been helpful. The PCHH model provides personal attention to the patient—such as individually-structured teaching plans to assist in setting and attaining goals—which makes patients more accountable for self-management of their health. The use of interpreters in the education process was key to successful goal management and outcomes as they provided the bridge for patients to learn how to set and reach their goals. This model also integrates a behavioral health component to encompass the needs of the whole person, including psychosocial requirements.
Health literacy is an important factor in working with our multicultural population. It is important to provide literate patients with information in their native tongue, which can help teach them more about their chronic disease. We found some helpful educational handouts online in different languages. We also have used our onsite interpreters to help us in creating new educational handouts. In addition, we developed videos that feature our health center’s personal interpreters providing information in 6 languages about “Medications” and “What do I need to bring to my appointment?” The medication video explains the importance of taking the prescribed medicine every day or as the provider orders, and how to refill medications. The other video explains the need to bring all medications, glucose or blood pressure readings, etc, to appointments. These multilingual videos play in the waiting room throughout the day. Seeing employees on the video helps draw the patients into listening and learning the information provided.
We found that we needed to address the basic needs of the patient before confronting their chronic disease. This process sometimes involved finding beds or providing food for the patient. Many had dental issues that needed to be addressed before we could work with them on their diabetic diet issues or other contributing chronic issues. If these needs are met, it can ameliorate stress, which can have negative effects on their health.
On review of current A1c findings, there was a decrease in the percentage of patients who showed improvement. This is reflective of the most challenging patients we continue to work with. Moving forward, as more refugees representing increasingly diverse cultures come to our clinic, greater understanding of cultural nuances remains a challenge. Additional work is necessary to produce and accumulate more diverse educational materials to meet the health literacy needs of each patient.
Samuel U. Rodgers Health Center has earned the trust of our diverse communities and we are confident and proud of our ability to provide high quality, culturally-competent health care to our diverse patient population.
Corresponding author: Robyn McCright, RN, 825 Euclid Ave., Kansas City, MO 64124, rmccright@rodgershealth.org.
Financial disclosures: None.