Seeing Race in Healthcare
Ignoring race in an attempt to be 'sensitive' to your patients can lead to poor outcomes.
Posts from the ‘health disparities’ Category
Jan 16
Schooling Me
Last week, I wrote about a study that revealed an astonishing fact: Poor, Black people have worse home health outcomes. I surmised that we really didn’t have time to do a full literacy assessment; nor did we have the skills to do so. Oops. A reader, Kyandra commented that there is a Single Question Literacy assessment and that prompted a day long journey into Health Literacy on the internet. Some of the information I found truly was surprising – and frankly, embarrassing to us as a nation.
The statistics are wide and varied. One study estimates that one in three adults does not have the literacy skills to understand written health materials. Most health materials are written at an 8th grade level but the average reading level of adults is closer to the 5th grade level. Older Americans (i.e. Medicare Beneficiaries) are more likely to be unable to read or comprehend written materials. Accidents happen, hospitalizations increase and preventative care decreases with an increase in health literacy skills that are basic or less than basic.
Should health literacy statistics bore you, know that effective January 1, you are mandated to have a working knowledge and use it.
From the new Conditions of Participation:
The agency must provide information about rights and responsibilities verbally and in writing in a manner the patient can understand. There must be documentation that the agency has complied in the chart.
This is not new. It has always been a part of the Civil Rights Act section 504 which applies to all government contractors (yes, you are a government contractor ever since your agency entered into a provider agreement with CMS). Now it is part of the CoPs.
Finally, patients and/or their families have sued successfully when they were unable to understand consents or other forms given to them. Judges think that a patient who cannot understand the information cannot give informed consent. I agree.
During my rambling search, I found one video by the AMA that explains the problem much better than I do and also offers solutions. If I ran an agency, I would play this video at a mandatory inservice for all employees.
After watching the video, consider using a single question literacy screen that has been proven to be fairly accurate in determining health literacy in adults as suggested by Kyandra.
“How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”
- never
- Rarely
- Sometimes
- Often
- Always
Although the assessment is determined to be only moderately effective in research, there’s a good chance that a patient admitting to having difficulty reading medical instructions needs more than a standard teaching guide and I’m pretty sure that creative nurses will be able to accommodate those needs.
Nicole White from Chicago commented that she used a sheet of paper handed to her patients. It had several goals written in a font similar to that found on medication bottles. She asked them to choose a couple of goals they would like to achieve. If they couldn’t read the sheet, she asked if she could fetch their reading glasses from another room. She assessed patient specific goals, vision and literacy without adding time to her assessment.
Nobody is in a better position to dance around problems with literacy than home health employees. We are in the homes where patients are typically more comfortable. We get to the know the patients (which may suggest the need for a second screening after a few visits). We may have more than one person to teach and we can truly give the patient our full attention watching for indications that they are not understanding. And we can solicit questions.
Agencies can lower hospitalizations, prevent medication and other errors, save a life or two, comply with the new CoP’s, reduce risk and save Medicare millions of dollars when they take health literacy seriously. And it only costs the time it takes to play a YouTube video and let your nurses and therapists loose to find creative, patient specific solutions. If nurses can devise a plan to use pool noodles in their care, I’m pretty sure they can use those same skills to meet the needs of their patients.
Please share how you work with patients with limited English proficiency or literacy skills by commenting below or emailing me.
Oct 17
Poor, Black People Have Worse Home Health Care Outcomes
An article came across my desk last week suggesting that Poor and Racial Minorities have Worse Home Health Care Outcomes. If this surprises you, please stop reading and surrender your nursing license now.
If you read further, the article clarifies the Racial Minorities as Black even though the OASIS data set collects information on American Indians, Alaska Natives, Asians, Hispanic and Latinos, Native Hawaiian or Pacific Islanders as well as white patients. So essentially, what the article is stating that if you are Black or poor, your health outcomes are worse.
Nurses know that African Americans are predisposed to certain diseases and conditions. Hypertension and diabetes come to mind immediately. Nearly 42% of Black men and more than 45% of Black women aged 20 and older have high blood pressure.
It is the sequelae of those illnesses that disproportionately affect the black community. This is where economics comes in and skews the healthcare received by Black people to an unacceptable degree. Specifically, consider the following statistics:
- Blacks are up to 2.5 times more likely to suffer a limb amputation and up to 5.6 times more likely to suffer kidney disease than other people with diabetes.
- Strokes kill 4 times more 35 to 54-year-old black Americans than white Americans. Blacks have nearly twice the first-time stroke risk of whites
- Cancer treatment is equally successful for all races. Yet Black men have a 40% higher cancer death rate than white men. Black women have a 20% higher cancer death rate than white women.
Additionally,
- Black Americans are half as likely to get flu and pneumonia vaccinations as white Americans. See last week’s blog post.
This information is obtained from an article on WebMD
There are so many reasons for these disparities that the study is almost useless to the home health industry. So maybe the answer is to do what we always done – assess the individual needs of our patients and plan care accordingly. But sometimes in our effort to be ‘color blind’ factors are overlooked that are closely correlated with being Black and poor in the USA.
About 24 percent of Black people cannot read past a basic level compared to 14 percent White people. This information is not part of the OASIS dataset and probably shouldn’t be because the time and skills to assess reading ability are not available to us. There are ways around illiteracy as most nurses know but they take time. Take your time and be creative. Send us an account of how your teach patients who cannot read.
Patients younger than 62 who are referred to you may have Medicaid as a primary payor. In some states, Medicaid provides second rate health care encouraging the use of Emergency Room services when the patient is unable to wait for an appointment set in the distant future. Medicaid approvals for some medications take time. We can’t do anything about how the Medicaid system works but we can help the patients navigate the maze. The truth is that we should be able to treat patients the same regardless of payor source but that ship sailed a long time ago. If you want to be effective, you must know how the Medicaid system in your state functions.
Poverty and crime have an enduring relationship that isn’t likely to end soon. Even though you are Wonderwomen and Supermen, you are not able to flash your badge and arrest the bad guys. Consider the constant stress of living in a home where violent crime is common and how that might affect a patient. When family members are addicts, patient medications may be diverted leaving a patient in pain unless they want to report a loved one to the police. I have seen doors with multiple locks leaving me to wonder if there is an escape route in the event of a fire.
In rural areas, crime may not be a problem but the expense of getting to a physician’s office may be out of reach. Family members may be willing to drive the patient but if they work, they might lose an entire day’s wages. In these cases, it is possible that truly diligent assessments along with detailed reports to the physician may occasionally eliminate the need for an office visit.
Cheap food is frequently not on cardiac or diabetic diets. Plus it adds body weight complicating pretty much every disease or condition. The fact is that poor people eat cheap food and patients who cannot read are unable to follow that food list you gave them, anyway.
As much as we would like to, we cannot teach the world to read, fix Medicaid or reduce crime. Driving patients to the physician’s office is impractical and basically a bad idea for reasons that would fill another blog post. You can’t even plant a garden in their backyard to provide vegetables.
We have to look for allies. Every agency should have a list of community services that can assist us in improving our patient’s’ chances of becoming a little more independent. It should be reviewed regularly and distributed to all nurses. Meals on Wheels isn’t the only service available.
We also need to realize that while outcomes are important, there are some things we cannot control. When someone has untreated hypertension resulting in a stroke prior to admission, it is unreasonable to expect the same good outcomes that result when a patient is referred after being diagnosed with hypertension before a stroke occurs. That doesn’t mean that we shouldn’t try our best.
The bitter pill to swallow is that our best may not be good enough. But, it could be better. Your personal best may be to spend an extra ten minutes with a patient so your functionally illiterate patient can understand the education you provided. An agency may adopt a policy where breaking even financially on poor and Black patients is acceptable and schedule a few more visits. Case managers could supplement visits with regular phone calls. Safety for nurses and patients may be enhanced by an inservice from local law enforcement.
The value of a life is constant throughout races and economic status. As Malcomb Forbes once said, “You can easily judge the character of a man by how he treats those who can do nothing for him.” But you may be surprised. The people who appear to be able to do nothing for you often do the most.
