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CCHAP Newsletter Ten

August 2007

Case Presentation, Cross-Cultural Health Care Case

How I Learned To Treat My Bias

Washington Post Article By Manoj Jain MD

Integrating Developmental Screening In A Pediatric Practice

Immunization Handouts In Spanish

Care Coordination For Children with Special Health Care Needs

Practice Liaison Teleconference

Medical Spanish For Office Staff

Print Newsletter Ten:  

Case Presentation
Cross-cultural Health Care

Your next patient, Holly, is a 4-year old African-American girl, whom you have seen once before for asthma.   When you saw her 3 months ago, she was coughing nearly every day with exercise and at bedtime.  She was wheezing at least 3 times a week.  You started her on an inhaled steroid and continued her prescription for an Albuterol inhaler.  You asked them to follow up with you in a couple of weeks.  You have not seen her until today. 

The chart shows that Holly has been to the emergency room for asthma three times in the past month.  In the ER notes,  it says she was not taking her medications.   You are frustrated: “Why can’t these parents give their kids the medicine like they’re supposed to?”  

When you go in to the room, you can see that Holly has very slight retractions and on auscultation she is wheezing mildly.  You ask Holly’s mother if Holly is taking her meds and she says “No.”   How would you proceed?

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The natural response is to explain to the mother that Holly needs the inhaled steroids everyday to prevent wheezing. Or you might ask her mother why she wasn’t giving Holly the medication, to which she answers “It doesn’t work”. And if you asked how long she tried it, she would answer “a week.” When you explain the medication has to be used daily for the long term, you can tell by her look that she is ambivalent about using the inhaled steroid.

(Hint: The mother has a foreign sounding accent.)

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In previous articles, we have shared an approach taught in medical schools and residencies these days, which uses a set of questions to help health care professionals understand health beliefs, practices and concerns that may create barriers to good health outcomes. These questions are called the Cross-Cultural Review of Systems. (click here to view previous article)

In Holly’s case the Cross-Cultural ROS easily identifies the underlying issues. The questions and answers are listed below. They fall into three categories: 1) cross-cultural issues; 2) the meaning of the illness in the family; and 3) the social context.

   
 
Core Cross-Cultural Issues

Specific culture
          “Please tell me a little about where your family comes from originally.”
          Mother emigrated with her husband and her mother from Somalia 7 years 
          ago. Educated in an American missionary school in a small village. 

Cultural Healing Traditions, Customs
          “Who have you seen (talked to) for help with this problem?”   
          No one, but asked child’s grandmother for advice.  
 
          “What have you tried (want to try)?”
          She has given a hot tea that is traditionally used for asthma in her culture, she 
          does not know the ingredients.

          “What were you hoping we would be able to do at the visit today?”
          “You’ve got to give me something to cure it, doctor.” 
          “I can’t stand to hear Holly suffer so much when she’s trying to breathe.”
          “The medicines you prescribed before did not make the asthma go away.”

Decision-making
          “How (and by whom) are decisions made?”  
          “Is there someone else who should join us?”
          The child’s father was killed during a trip back to Somalia two years ago. 
          Mother listens to grandma and is not likely to go against grandma’s opinion.

Meaning of the Illness

          “What do you worry about the most?” 
          “I am afraid she is going to die.”   
          If you ask the mother for more information you will learn that a cousin  
          died of asthma in Somalia. The cousin breathed a medicine from a local  
          healer and died shortly thereafter.

          “What do you think seems to cause the problem / illness? Why did it start when it did?”
          “I clean houses and Holly comes with me. She was with me at work one day, and I let her play 
          outside. When I went to check on her, her breathing was so bad that I took her right to the 
          emergency room. So playing outside is bad for her.”
  
          “What problems has the illness/problem caused?” 
          Mother doesn’t let her go outside to play because she coughs or wheezes. 
          Holly goes to work with mother and often stays in the basement of the  house  
          that mother is cleaning. When they go to certain houses, she wheezes a lot.
 

Social Context

          “What is a typical day like for Holly?”
          Six days a week, Holly accompanies her mother while she cleans homes. 
          While her mother works, Holly plays quietly hidden in the basements of the 
          houses. If Holly didn’t go with her mother, she would stay with her grandmother.

          Stress – “Are there any problems that the family is going through now?”
          “I had to leave work early the day I took Holly to the ER, so I didn’t get paid, and 
          the car was broken the week before that. I had to spend all my money on the car. 
          If I don’t have my car, I can’t work. We just didn’t have the money to come here. I 
          work hard, but we can’t afford insurance, and doctor bills always put me over the 
          top. The emergency room sends us a bill, but I just tell them we don’t have any 
          money to pay.”
 
          Social support – “Are there people you can depend on for help or support?”
          Mother has no friends and is always working.  Grandmother takes care of Holly.  
          No other family in Denver.

          Resources –“Tell me a little about where you live?”
          Live in a very old apartment with molds and dust. 

          English proficiency – “How well can you understand English?”
          Understands and speaks well

          Literacy - “How well can you read English?”
          Does not read well.  Cannot read the handouts given her at the last visit or  in the ER.

          Understanding – “Do you feel you understand what I have recommended?”
          She doesn’t understand why to give the medication everyday even when Holly is not wheezing.  
          And that she has to give the medicines at the same time everyday?

          Acceptance – “Is there any thing that might make it difficult for you to do as 
          I have recommended?”
          Grandmother feels it is not safe to breathe medicine.

Discussion of the Case

The Cross-Cultural Review of Systems questions are particularly helpful when the provider feels that there are problems in the understanding, compliance or response to treatment, or if the parent is from a culture that is different than the provider’s and the health problem is serious or the treatment is complicated. Holly’s case underscores the importance of not making assumptions about one’s culture or “race.”  It is more effective to ask about the family’s geographic origins than to ask about (or making assumptions about) “race”. The single best question for obtaining helpful information is (no matter what the family’s culture is), “What worries you the most?” and “Why?”  The second best question for all cases is, “Is there any thing that might make it difficult for you to do what I have recommended?”

Strategies for responding to the information obtained in Holly’s case:

• Invite the grandmother to the follow-up visit.
• Give mother an application for CHP+/Medicaid
• Refer the mother to county Medicaid and TANF (welfare) technician.
• Help the mother understand the chronic nature of asthma and the objective of treatment is amelioration of symptoms and acute episodes. Help her understand (and plan how to convince grandmother) that inhaled steroids didn’t cause the cousin’s death and isn’t dangerous for Holly.
• One goal is for Holly to be able to play outside.  Don’t keep her in basements all day.
• Refer to asthma case management nurse with the Department of Pediatrics Pulmonary Medicine for evaluation, education (for patient, mother and grandmother) and phone follow-up.
• Asthma education has to be verbal rather than handouts.
• See if you can find out what is in the tea and if it is not dangerous, accept its use.

Integrating Developmental Screening
In a Pediatric Practice

• The Colorado Assuring Better Child Health & Development (ABCD) project has received a three year grant to provide training and technical assistance to providers to implement a “validated” developmental screening tool into well child visits for infants/toddlers birth to three.
• The ABCD project is partnering with CCHAP to provide training and support to pediatric practices to implement standardized developmental screening into well care checks.
• Medicaid will reimburse $34.00 to providers if you implement validated developmental screening into an EPSDT visit.
• The Colorado Chapter of the AAP supports the ABCD project in implementing enhanced developmental and behavioral screening and surveillance in pediatric practices.
• Early detection and intervention is crucial to improve outcomes.  Many delays in children’s development are missed in the first 4-5 years of life without a standardized, validated screening test. 
• What should providers do? Use a new, brief, accurate, standardized, time-efficient tool for developmental screening.  The most time-efficient tool is one in which the parent completes a questionnaire.
• To comply with 2010 recertification guidelines by the American Board of Pediatrics, documentation will be required to show levels of involvement in practice improvement initiatives. By implementing the use of a “validated” developmental screening with a sensitivity and specificity rating of 70% or greater like the ASQ or PEDS, practices are taking steps to integrate quality improvement into their practices.
• Currently in Colorado, based on December 1, 2006 Child Count Data, only 1.9% of the birth to three population is being identified as eligible for early intervention services. Colorado’s goal by 2010 is 2.5 % which is the national average for identifying birth to three year olds as eligible for early intervention.
• What are providers saying about implementing either the ASQ or the PEDS parent questionnaire developmental screening tool:
• It takes less than a minute of the provider’s time if the MA, LPN or RN scores the questionnaire.
• In many instances, it reduces the length of the visit.
• It helps providers concentrate on what are the concerns/priorities of the caregivers.
• It reduces the doorknob concerns as you are walking out the door of a well care visit.
• It improves patient satisfaction and positive parenting practices.
• It increases provider confidence in decision-making for when to refer a child for further developmental evaluation.
• Eileen Auer Bennett, the Colorado State ABCD Coordinator and her team are available to assist providers in getting started. Training and technical assistance will be provided to practices in the implementation of a standardized tool such as the ASQ or PEDS. Support will also be given to front/back office staff on how to implement the use of a standardized developmental screening tool into the current office work flow.
  

For more information, please contact:
            Eileen Auer Bennett
            720-333-1351
            ileanben@yahoo.com
   

Immunization Handouts
In Spanish

Everything you ever wanted to know about care coordination
For children with special health care needs

1. Proper use of coordination of care codes
2. Identification of Children in the Practice with Special Health Care Needs
3. Care Continuity
4. Continuity across Settings
5. Cooperative Management Between Primary Care Provider and Specialist
6. Supporting the Transition to Adult Health Care Services
7. Family Support
8. Needed forms
9. How to negotiate with public and private insurers
10. Job descriptions and roles of staff
11. Documentation
12. Resources for children with specific conditions
       

Practice Liaison Teleconferences
(Everyone Welcome)

Medical Spanish
For Office Staff

Spanish Interpretation Training for Pediatric Practices

CCHAP offers a convenient, time-efficient, cost-efficient medical Spanish interpretation training program for pediatric office staff and providers.  It is provided as a telephone conference, during practice office hours at lunch time.

Training in medical Spanish interpretation includes:
          Medical (pediatric) terminology
          Subtle differences in the two languages in word selection and grammar
          Culturally appropriate communication skills
          Professionalism and etiquette of interpretation
          Confidentiality and HIPPA issues

Who: This program is for people in the practice who already speak Spanish and English

How: The sessions will be conducted via telephone, using handout materials and the Internet, 
          and will also include role-playing.

When: Wednesdays from 12:15 to 1 pm.  The next session will begin as soon enough people 
          are interested in attending.

How long: 45 minute sessions weekly for 6 weeks

Registration: Email the information below to ilssoto@aol.com.  
          Name of student:
          Job title:
          Pediatric practice name:
          Work phone number:
          Home phone number:
          Is your first language English or Spanish?
          If Spanish is your second language, how long have you been speaking it?
          What time is your usual lunch hour?
          What is your goal in enrolling in this class?

Price: $20 per session.  
          After your registration and start date is confirmed, please send a check for $120, 
          payable to International Language Services 
          12572 West Brandt Place, Littleton CO 80127.

An assessment of each individual’s skill level will be done during a 5-10 minute phone call prior to first telephone conference/class.  Maria will contact you to schedule this initial individual telephone call upon receipt of your registration email.  A certificate of completion will be given after completion of all 6 sessions. The faculty is Maria Soto, a certified Spanish interpreter and trainer with International Language Services.

Contents:

Case Presentation, Cross-Cultural Health Care Case
How I Learned To Treat My Bias
Integrating Developmental Screening In A Pediatric Practice
Immunization Handouts In Spanish
Care Coordination For Children with Special Health Care Needs
Practice Liaison Teleconference
Medical Spanish For Office Staff