Lecture on the components of patient centered care for all health care providers.

1. Patient-Centered Care II – Behavioral Medicine in Primary Care
MSPAS/MPH Program – Class of 2017 Fall 2014
Ana Maldonado MPH, DHSc, PA-C

2. • Demonstrate an understanding of the
manner in which people of diverse
cultures and belief systems perceive
health and illness and respond to
various symptoms, diseases, and
treatments.

3. • Demonstrate knowledge, respect, and
validation of differing values, cultures, and
beliefs, including sexual orientation, gender,
age, race, ethnicity, and class
• Demonstrate understanding of language
barriers and working with interpreters
• Define the scope of the health literacy problem
• Recognize health system barriers faced by
patients with low literacy

4. • Implement improved methods of verbal
and written communication.
• Incorporate practical strategies to create a
shame-free environment.
• Identify the influences and common
barriers that patients and providers
encounter in regards to patient
adherence.

5. • Identify the impact that non-adherence
to therapies has on patients, the
healthcare industry and the population
• Develop diagnosis, management, and
patient-adherence skills leading to
patient compliance

6. A. Age
B. Gender
C. Race/Ethnicity
D. Socioeconomic Status
E. Health Literacy
F. Physical health
G. Mental Health
H. Religion and/or Spiritual beliefs
I. Sexual Orientation
Therefore take into consideration the multiplicity of factors that
shape the patient’s life sitting or lying before you in the medical
environment.

15.  What is it?
 Why do we need it?
 What does it do?
 Who is responsible?

16.  “An integrated pattern of human behavior that
includes thoughts, communications, languages,
practices, beliefs, values, customs, courtesies,
rituals, manners of interacting and roles,
relationships and expected behaviors of a racial,
ethnic, religious or social group; and the ability
to transmit the above to succeeding
generations.”

17. Cultural Considerations: Primary and
Secondary Dimensions of Diversity
Employment
Community
Networks
Geographic
Location
Family/Extended
Family
Immigration
Status
Marital
Status
Military
Experience
English
Language
Proficiency
Spiritual
Beliefs
Class
Income
Economics
Political
Context
Parental
Status
Education
Literacy
Country
of Origin
Sexual
Orientation
Race
Ethnicity
Language
Cultural + Historical
Knowledge/Experience
Perceptions of
Physical Qualities
Physical
Abilities
Gender
Age
Primary dimensions
influence “who” an
individual is.
Secondary dimensions
influence an individual’s
participation.
(adapted from Rasmussen, 1996)

18. YOU ARE

19. “The ability to think, feel, and act in
ways that acknowledge, respect,
and build upon ethnic, sociocultural,
and linguistic diversity.”
Lynch & Hanson 1998

20.  Understanding
 Culturally And Linguistically
Diverse (CLD) Patients

21.  Skills
Communication
Providing Assessment And
Intervention Services

22. We see and treat an
increasingly diverse patient
population with different
beliefs about healthcare and
how it should be practiced
on them

23. Ethnic & Racial Minorities
 Less access to, & availability of health
care services
 Less likely to receive needed health care
services
 Less likely to receive high quality health
care services
 Experience a greater burden of
disability
Surgeon General's Report 2001

24.  Lack of it results in:
 Patient-provider miscommunication
 Patient-provider misunderstandings
 Misunderstanding and/or ignorance of
culturally based health beliefs and
practices

25. “ . . . a disturbing new study by the Institute of
Medicine has concluded that even when
members of minority groups have the same
incomes, insurance coverage and medical
conditions as whites, they receive notably
poorer care.
Biases, prejudices and negative racial
stereotypes, the panel concludes, may be
misleading doctors and other health
professionals.”
"Subtle Racism in Medicine",
NY Times

26.  Benefits patient care by improving
cross-cultural communication and
ensuring that consultation,
intervention, and assessments are
appropriately designed to meet
patient and family needs

27.  Little attention or skill in dealing
with patients from diverse
sociocultural backgrounds leads to
poor communication and
uncertainty with regard to clinical
outcomes

29. If medication non-adherence
was a disease, it would be an
epidemic.
Anonymous

30. Nearly half of all American adults
– 90 million people – have
difficulty understanding and acting
upon health information
Health Literacy, A Prescription to End
Confusion, IOM, 2003

31. •Assessment tools
•Provider’s intervention strategies
To Learn:
•Factors affecting medication adherence
and the relationship to health literacy
•Definitions and statistics of medication
adherence and health literacy

32. MEDICATION
• Adherence – the extent to which a person
takes medications as prescribed
• Compliance – passive following of clinician’s
orders
• Persistence – a person’s ability to continue
taking medications for the intended course of
therapy

33. Health Literacy – the degree to which
individuals have the capacity to obtain,
process and understand basic health
information and services needed to make
appropriate health decisions
(Ratzan and Parker, 2000) (presented by the National Library of
Medicine, used in Healthy People 2010).

34. • 90% of Medicare beneficiaries take
prescription medications
• Nearly half use five or more different
medications
• 55% do not follow medication
regimen
Amaral, 1986

35. • 25% do not fill new prescriptions
• 39% unable to read prescription label
• 67% do not fully understand information
given to them
AARP, 2004
Moisan, 2002

36. Medication non-adherence accounts for:
• More than 10% of older adult hospital
admissions
• Almost one-quarter of nursing home
admissions
• 20% of preventable adverse drug events
• 125,000 deaths annually
• $300 billion in health care costs annually
1 –Vermiere, 2001 2 – Strandberg, 1984
3 – Gurwitz, 2003 4– McCarthy, 1998

37. Many Americans Disregard Doctors’
Course of Treatment:
• 44% of Americans ignored a doctor’s
course of treatment
• 27% left a prescription unfilled
• 43% believe doctors over treat patients
Wall Street Journal
March 15, 2007

38. Adherence is determined by interplay of
five factors:

39. Health system related factors:
1. Quality of provider-patient relationship
2. Level and quality of communication
3. Access to providers (physical/geographic,
ease of appointments)
4. Access to medications (cost)
5. Continuity of care
6. Formulary changes and restrictions

40. Condition related factors:
1. Asymptomatic Chronic Disease
2. Mental health disorders

41. Patient related factors:
1. Physical impairments: cognitive,
vision, hearing, dexterity, mobility
2. Psychological/behavioral: anger,
stress, anxiety; low self efficacy;
substance abuse

42. Therapy related factors:
1. Complexity of medication regimen: number
of meds; number of daily doses
2. Duration of therapy
3. Therapies that are inconvenient or interfere
with a person’s lifestyle
4. Medications with social stigma attached
5. Medication side effects

43. Social/economic related factors:
1. Low health literacy, limited English language
proficiency
2. Lack of health insurance; barriers to access to
care
3. Cost of medications
4. Burdensome work schedule

44. Social/economic related factors:
5. Poor social support
6. Homelessness or unstable living
conditions
7. Cultural beliefs and attitudes

45. Relationship Between Health
• Limited research about causal relationship
between health literacy and health
outcomes
• Limited published information regarding
role of health literacy in the medication
adherence process

46. Relationship Between Health
• Inadequate functional health literacy, a
barrier to assessing medication adherence
• Adults with limited health literacy have less
knowledge of disease management

47. • No gold standards
• Most commonly used:
– Pill counts
– Refill records
– Patient self report
– Drug therapeutic levels
• Indirect:
– Clinical outcomes

48. • Validated scale designed to estimate the risk
of medication non-adherence
• Cited in over 70 articles since its
publication 1986
Morisky DE, Green LW, Levine DW. Concurrent and predictive
validity of a selfreported measure of medication adherence. Medical
Care 1986;24:67-74

49. • Used for many different disease such as
HTN, hyperlipidemia, asthma and HIV
• Score based on patient responses to four
Yes or No questions
Yes = 0 No = 1
Morisky DE, Green LW, Levine DW. Concurrent and predictive validity of a self-reported
measure of medication adherence. Medical Care 1986;24:67-7

50. Four is the highest level of medication adherence, while
zero is the lowest level.

51. Most tools cannot differentiate among:
• Reading ability
• Lack of background knowledge in
health
• Lack of familiarity with language and
types of materials
• Cultural differences

52. Commonly used tools in health services
research:
• Wide Range Achievement Test (WRAT)
• Rapid Estimate of Adult Literacy in
Medicine (REALM)
• Test of Functional Health Literacy in Adults
(TOFHLA)

53. Screening questions for use in clinical practice:
1. How often do you have problems learning
about your medical condition because of
difficulty understanding written
information?
2. How often do you have someone help you
read hospital materials?
Wallace, et al. Screening Items to Identify Patients with Limited Health Literacy Skills. J Gen
Intern Med 2006; 21 (8): 874-877

54. Screening questions for use in clinical
practice:
3. How confident are you filling out medical
forms by yourself?
Wallace, et al. Screening Items to Identify Patients with Limited
Health Literacy Skills. J Gen Intern Med 2006; 21 (8): 874-877

55. Intervention Strategies Targeting Health
Literacy:
• Routinely assess patient’s health literacy level
and medication adherence
• Improve written prescription information
• Improve verbal communication
• Use effective patient adherence tools
Improving Use of Prescription Medication: A National Action Plan NQF, 2005

56. • Simplify reading level to grade 5
• Offer all written prescription medication
information in foreign language and large
print
• Use standardized, universal symbols
(simple, explicit icons)

57. • Use plain language always
• Use teach back and show back techniques
• Limit information to two or three important
points at a time
• Use drawings, models or devices to
demonstrate points
• Encourage patients to ask questions

58. Steps:
I. Explain/demonstrate the new concept
A. Explain the rationale
B. Provide complete instructions
C. Explain likely benefits
D. Explain likely side-effects
II. Assess patient’s recall and comprehension:
ask patient to demonstrate

59. III. Clarify and tailor the explanation
IV. Re-assess patient’s recall and
comprehension: ask patient to
demonstrate
V. Patient recalled and
comprehended/demonstrated mastery

60. Effective Patient Adherence Tools
Medication Organizers
Medication organizers such as weekly pill boxes and others are effective
tools to improve medication adherence.

61. Electronic Pagers/Timers

62. Simplify Medication Regimen
Complex medication regimen can be simplified as much as possible
by using longer acting drugs or drug combination whenever
appropriate.

63. • Medication non-adherence is a significant
Problem
• Health Literacy is an important
contributing factor to medication nonadherence
• Interventions targeting health literacy in
medication adherence process – need to be
multi-layered

64. https://www.youtube.com/watch?v=cGtTZ_vxjy
A
http://www.youtube.com/watch?v=sMb43pMfsM
k
Brown, M. T. & Bussell, J. K. (2011)
Medication Adherence: Who Cares? Mayo Clinic
Proceedings. 86(4):304-314.
Article is posted on Blackboard
http://www.healthlitt.org/TalkingTouchscreen/Pa
ges/default.aspx

65. Questions and Answers