The ETHNICS Framework: A Clinical Tool For Ethnogeriatric Education Fred Kobylarz, M.D. M.P.H. Assistant Professor Directions for using this PPT Some slide have additional information in the notes section that include both content and facilitation notes. Slides 17 and 23 contain hyperlinks.

Objectives State and describe four rationale for providing culturally appropriate geriatric care. Define the concept of cultural competence and describe three techniques that can reduce racial and ethnic health disparities. State the seven domains of the ETHNICS framework and describe challenges implementing its use.

Rationale Responding to demographic changes Eliminating disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds Improving the quality of services and outcomes Meeting legislative, regulatory, and accreditation mandates Content Notes: Other rationale discussed in this reference include gaining a competitive edge in the market place and decreasing the likelihood of liability/malpractice claims. Click on the link provided to further explain each of these points. Facilitation Notes: Consider probing with learner each rationale and asking for specific examples before moving to the next few slides. Cohen E, Goode T. Policy Brief 1: Rationale for cultural competence in primary health care. Georgetown University Child Development Center, The National Center for Cultural Competence. Washington, D.C., 1999. http://gucchd.georgetown.edu/nccc/nccc6.html

Demographics Content Notes: Click on the link provided to get further demographic data that may be more specific to your state. Facilitation Notes: Consider having learner interpret this slide before discussing. Source: Dept. of Health & Human Services Administration on Aging http://www.aoa.gov/prof/statistics/census2000/census2000.asp

Demographics Content Notes: Click on the link provided to get further demographic data that may be more specific to your community. Facilitation Notes: Consider having learner interpret this slide before discussing. Source: Dept. of Health & Human Services Administration on Aging http://www.aoa.gov/prof/Statistics/profile/profiles2002.asp

Within - Group Diversity Between - Group Diversity is often greater than Between - Group Diversity

There is no “cookbook approach” in caring for patients

Avoid stereotyping and overgeneralization

Eliminating Disparities Healthy People 2010 contains objectives that apply to older adults. Evidence of disparities http://www.healthypeople.gov/ Content Notes: Click on the link provided to see online versions of these texts. Facilitation Notes: Consider having learner give an example in each. http://www.iom.edu/report.asp?id=4475

Improving Outcomes Cultural Competency as a Strategy The knowledge and interpersonal skills that allows providers to understand, appreciate, and work with individuals from cultures other than their own. It involves acceptance of cultural differences; self awareness; knowledge of the patient’s culture; and adaptation of skills. Content Notes: This is the American Medical Association definition of cultural competency. Facilitation Notes: The term is confusing. Others may use “culturally appropriate,” “culturally sensitive,” consider exploring with your learners. Davis BJ, Voegtle KH. Culturally Competent Health Care for Adolescents: A Guide for Primary Health Care Providers. Chicago, IL: American Medical Association, 1994.

Improving Outcomes Cultural Competency Techniques Culturally competent health promotion Involving family and/or community members Immersion into another culture Administration and organizational accommodations Interpreter services Recruitment and retention of minority staff Cultural competency training Coordination with traditional healers Use of community health workers Content Notes: Listed are techniques or strategies for cultural competency. Reference on this slide provides examples and gives detailed information on each of these. Facilitation Notes: Consider exploring the interpreter issues further which continues on the next slide. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model, Medical Care Research and Review, Vol. 57 Supplement 1, (2000) 181-217.

Meeting Mandates Federal Register National Standards on Culturally and Linguistically Appropriate Services in Health Care (CLAS) http://www.omhrc.gov/clas/ Policy Guidance on the Prohibition Against National Origin Discrimination as it Affects Persons with Limited English Proficiency (LEP) http://www.hhs.gov/ocr/lep/guide.html/ Content Notes: Click on the links provided to see online versions of these mandates. Facilitation Notes: Consider exploring these further asking for specific examples..

Meeting Mandates Cultural Competency Training Liaison Committee on Medical Education http://www.lcme.org/functionslist.htm#educational%20objectives American Council for Graduate Medical Education http://www.acgme.org/outcome/comp/compMin.asp Professional Medical and Interdisciplinary Organizations For example http://www.stfm.org/corep.html Content Notes: LCME – for example, educational objective 21, ACGME – for example, competency E on professionalism, Professional organization – for example, Society for Teachers of Family Medicine Recommended Core Curriculum Guidelines on Culturally Sensitive and Competent Health Care The following specialty groups have published guidelines and/or policies relating to the care of culturally diverse populations: Society of Teachers of Family Medicine American Academy of Family Physicians American Academy of Pediatrics American College of Obstetrics and Gynecology American Psychiatric Association American College of Emergency Physicians

Ethnogeriatric Education Ethnogeriatrics is defined as healthcare for elders from different culture Core Curriculum in Ethnogeriatrics is proposed at every level of healthcare professional Content Notes: Click on the link provided to see online versions of the core curriculum in ethnogeriatrics.. http://www.stanford.edu/group/ethnoger/

The ETHNICS Framework Concept of the illness explanatory model developed by Kleinman Does not replace standard medical history- taking process Framework to facilitate communication during the clinical encounter Designed to be integrated into the routine 15-minute visit Each letter represents a cross cultural domain to explore Content Notes: Broadened from the original version (ETHNIC) to include “S” for spirituality Levin SJ, Like RC, Gottlieb JE. ETHNIC: A framework for culturally competent clinical practice. In Appendix: Useful clinical interviewing mnemonics. Patient Care 2000;34:188 - 189.

The ETHNICS Framework E : Explanation T : Treatment H : Healers N : Negotiate I : Intervention C : Collaborate S : Spirituality Kobylarz FA, Heath JM, Like RC. “The ETHNIC(S) Mnemonic; A Clinical Tool for Ethnogeriatric Education,” Journal of the American Geriatrics Society 2002, Sep: 50(9): 1582-9

ETHNICS Explanation Treatment Healers Negotiate Intervention Collaborate Spirituality Click on each of the circles in the figure representing the components of the ETHNICS framework to view sample direct questions that can be asked when interacting with patients. To progress to the next slide simply click anywhere on the slide not occupied by an ETHNICS domain. Content Notes: The ETHNICS Framework does not have to be followed in a linear fashion!

Application Who can use ETHNICS? Where can ETHNICS be used? Physicians (medical students, residents, and practicing) Interdisciplinary (nursing, social work, physical/occupational therapy, and others) Where can ETHNICS be used? Ambulatory, hospital, home health, and nursing home settings Content Notes: The ETHNICS Mnemonic is not limited to just physicians but can be used by any health care professional in any setting.

Translating Into Practice Focuses on the acute and chronic visit Awareness of cultural issues on Establishing treatment priorities Influencing adherence Addressing end-of-life care And others Content Notes; These are fully explained in article. Refer to Kobylarz FA, Heath JM, Like RC. “The ETHNIC(S) Mnemonic; A Clinical Tool for Ethnogeriatric Education,” Journal of the American Geriatrics Society 2002, Sep: 50(9): 1582-9.

Challenges Systemic, institutional, interpersonal barriers Disability related issues Communication impairments (common in older adults) Hearing, language, and cognitive barriers Content Notes: Examples include poverty, racism, and other forms of bias, prejudice, and discrimination. Facilitator Notes: Consider exploring examples with learners.

Conclusion “Developing cultural competence is an ongoing, life-long journey for individuals, families, organizations and communities.” Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health And Human Services. Cultural Competence: a Journey.

Conclusion “Maintaining cultural humility, avoiding stereotyping, engaging in mutually respectful communication, and fostering empowerment in relationships are critical” Tervalon M, Murray-Garcia J: “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education, “Journal of Health Care for the Poor and Underserved 1998; 9(2):117-124.

Self-check What are four rationale for providing culturally appropriate geriatric care? Answer What is cultural competence and what are three techniques that can reduce racial and ethnic health disparities in older adults? Answer What are the seven domains and challenges of implementing the ETHNICS framework? Answer This self-check is designed to reinforce the objectives of this presentation. Click on the link called “Answer” that is located after each question to view the slides with the answer to that question. To progress to the next slide simply click anywhere on the slide not occupied by an Answer link. After viewing the answer slide for a question, click on the link located on the bottom of the answer slide called “Back to Self-check” to return to this self-check. Note that link on some answers will occur on two slides, and in these cases you will see a link called “See rest of answer” for viewing the second answer slide. In these cases, the second answer slide will contain the link called “Back to Self-check.”

Thank you for your attention! Any Questions? Thank you for your attention!

Explanation Direct question to be asked: Why do you think you have this… (use the patent’s phrase for their) symptom/illness/condition?” Probe Questions: What do friends, family, and others say about these symptoms? Do you know anyone else who has had or who has this kind of problem? Have you heard about/read/seen it on TV/ radio/newspaper/Internet? If patient cannot offer an explanation, ask what concerns them about their problems? Click on the “Back to ETHNICS” link to continue to the next screen Back to ETHNICS

Treatment Direct question to be asked: What have you tried for this… (use the patent’s phrase for their) symptom/illness/condition?” Probe Questions: What kind of medicines, home remedies, or other treatments have you tried for this illness? Is there anything you eat, drink, or do (or avoid) on a regular basis to stay healthy? Tell me about it. What kind of treatments are you seeking from me? Click on the “Back to ETHNICS” link to continue to the next screen Back to ETHNICS

Healers Direct question to be asked: “Who else have you sought help from for this… (use the patent’s phrase for their) symptom/illness/condition?” Probe Questions: Have you sought help from alternative or folk healers, friends, or other people who are not doctors for help with your problems? Click on the “Back to ETHNICS” link to continue to the next screen Back to ETHNICS

Negotiate Direct question to be asked: How best do you think I can help…(use the patient’s phrase for their) symptom/illness/condition? Try to find options that will be mutually acceptable to you and your patient and that do not contradict but rather incorporate your patient’s beliefs. Click on the “Back to ETHNICS” link to continue to the next screen Back to ETHNICS

Intervention Direct Statement: This is what I think needs to be done now. Determine an intervention with your patient, which incorporate alternative treatments, spirituality, and healers as well as other cultural practices (e.g., foods eaten or avoided in general and/or when sick). Click on the “Back to ETHNICS” link to continue to the next screen Back to ETHNICS

Collaborate Direct question to be asked: “How can we work together on this and with whom else?” Collaborate with the patient, family members, healers, and community resources. Click on the “Back to ETHNICS” link to continue to the next screen Back to ETHNICS

Spirituality Direct question to be asked: “What role does faith/religion/spirituality play in helping you with this…(use the patient’s phrase for their) symptom/illness/condition?” Probe Questions: Tell me about your spiritual life. How can your spiritual beliefs help you with this? Click on the “Back to ETHNICS” link to continue to the next screen Back to ETHNICS

Answer to Self-check question 1 Responding to demographic changes Eliminating disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds Improving the quality of services and outcomes Meeting legislative, regulatory, and accreditation mandates Click on the “Back to Self-check” link to continue to the next screen Back to Self-check Cohen E, Goode T. Policy Brief 1: Rationale for cultural competence in primary health care. Georgetown University Child Development Center, The National Center for Cultural Competence. Washington, D.C., 1999.

Answer to Self-check question 2 Cultural Competency as a Strategy The knowledge and interpersonal skills that allows providers to understand, appreciate, and work with individuals from cultures other than their own. It involves acceptance of cultural differences; self awareness; knowledge of the patient’s culture; and adaptation of skills. Click on the “See rest of answer” link to continue to the next screen See rest of answer Davis BJ, Voegtle KH. Culturally Competent Health Care for Adolescents: A Guide for Primary Health Care Providers. Chicago, IL: American Medical Association, 1994.

Answer to Self-check question 2 Cultural Competency Techniques Interpreter services Recruitment and retention of minority staff Cultural competency training Coordination with traditional healers Use of community health workers Culturally competent health promotion Involving family and/or community members Immersion into another culture Administration and organizational accommodations Click on the “Back to Self-check” link to continue to the next screen Back to Self-check Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model, Medical Care Research and Review, Vol. 57 Supplement 1, (2000) 181-217.

Answer to Self-check question 3 E : Explanation T : Treatment H : Healers N : Negotiate I : Intervention C : Collaborate S : Spirituality See rest of answer Kobylarz FA, Heath JM, Like RC. “The ETHNIC(S) Mnemonic; A Clinical Tool for Ethnogeriatric Education,” Journal of the American Geriatrics Society 2002, Sep: 50(9): 1582-9

Answer to Self-check question 3 Systemic, institutional, interpersonal barriers Disability related issues Communication impairments (common in older adults) Hearing, language, and cognitive barriers Back to Self-check