Marsha Regenstein

Race/Ethnicity and patient confidence to self-manage cardiovascular disease.

Background:Minority populations bear a disproportionate burden of chronic disease, due to higher disease prevalence and greater morbidity and mortality. Recent research has shown that several factors, including confidence to self-manage care, are associated with better health behaviors and outcomes among those with chronic disease. Objective:To examine the association between minority status and confidence to self-manage cardiovascular disease (CVD). Study Sample:Survey respondents admitted to 10 hospitals participating in the “Expecting Success” program, with a diagnosis of CVD, during January–September 2006 (n = 1107). Results:Minority race/ethnicity was substantially associated with lower confidence to self-manage CVD, with 36.5% of Hispanic patients, 30.7% of Black patients, and 16.0% of white patients reporting low confidence (P < 0.001). However, in multivariate analysis controlling for socioeconomic status and clinical severity, minority status was not predictive of low confidence. Conclusions:Although there is an association between race/ethnicity and confidence to self-manage care, that relationship is explained by the association of race/ethnicity with socioeconomic status and clinical severity.

What The Affordable Care Act Means For People With Jail Stays

About one in six people expected to enroll in Medicaid under health reform expansions and nearly one in ten expected to enroll in qualified health plans through the health insurance Marketplaces will have spent some time in jail during the past year. People who have spent time in jail frequently cycle in and out of incarceration; have high rates of chronic physical, mental health, and substance use conditions; and historically have been uninsured and without access to continuous health care. The Affordable Care Act may not change the quality of health care in jails, but its provision of better access to care before and after people are incarcerated could have positive long-term effects on both the health of those individuals and overall health care costs. Achieving these results will require careful planning and coordination among jail health care programs, Medicaid, and Marketplace health plans. The use of electronic health records by jails and community providers could help ensure that treatments are consistent no matter where a patient resides. Policy makers and health plans could also ensure continuity of care by including in their networks some of the same safety-net providers that are under contract to furnish care to jail inmates.

Challenges in Language Services: Identifying and Responding to Patients’ Needs

Objective Identify characteristics of hospital-based language services (LS), and describe practices of identifying patients with limited English proficiency (LEP) and interpreter training. Participants Seventy-one hospitals applied to participate in a national initiative. Applicants were non-federal, acute care hospitals with substantial LEP populations, at least 10,000 discharges, and in-person interpreters. Methods Descriptive statistics were generated on language, collection of language data, LEP volume and service utilization, staffing and training requirements and organizational structure. The relationship between admissions and encounters was analyzed. Results Ninety percent of hospitals collect primary language data. Spanish is the most common language (93% of hospitals). We found no statistically significant correlation between admissions and encounters. Eighty-four percent require training. Eighty-nine percent have a designated LS department but no clear organizational home. Conclusions Hospital-based LS programs are facing challenges identifying patients with language needs, staffing and training a workforce, and creating an organizational identity. Need is not associated with utilization, suggesting that LS are not reaching patients.

Reducing hospital readmissions among medicaid patients: a review of the literature.

Reducing hospital readmissions is a key approach to curbing health care costs and improving quality and patient experience in the United States. Despite the proliferation of strategies and tools to reduce readmissions in the general population and among Medicare beneficiaries, few resources exist to inform initiatives to reduce readmissions among Medicaid beneficiaries. Patients covered by Medicaid also experience readmissions and are likely to experience distinct challenges related to socioeconomic status. This review aims to identify factors related to readmissions that are unique to Medicaid populations to inform efforts to reduce Medicaid readmissions. Our search yielded 254 unique results, of which 37 satisfied all review criteria. Much of the Medicaid readmissions literature focuses on patients with mental health or substance abuse issues, who are often high utilizers of health care within the Medicaid population. Risk factors such as medication noncompliance, postdischarge care environments, and substance abuse comorbidities increase the risk of readmission among Medicaid patients.

Underserved patients' perspectives on patient-centered primary care: does the patient-centered medical home model meet their needs?

The patient-centered medical home (PCMH) has gained significant interest as a delivery system model that can improve health care quality while reducing costs. This study uses focus groups to investigate underserved, chronically ill patients’ preferences for care and develops a patient-centered framework of priorities. Seven major priorities were identified: (a) communication and partnership, (b) affordable care, (c) coordinated care, (d) personal responsibility, (e) accessible care, (f) education and support resources, and (g) the essential role of nonphysician providers in supporting their care. Using the framework, we analyzed the PCMH joint principals as developed by U.S. medical societies to identify where the PCMH model could be improved to better meet the needs of these patients. Four of the seven patient priorities were identified as not present in or supported by current PCMH joint principles. The study discusses how the PCMH model can better address the needs of low-income, disadvantaged patients.

Appropriate Use of Non–English-Language Skills in Clinical Care

AN ESTIMATED 25 MILLION US RESIDENTS HAVE LIMited English proficiency (LEP) and in a 2006 national survey of 2022 internists, 54% reported encountering patients with LEP at least weekly, with many seeing LEP patients every day. Legal guidance related to Title VI of the Civil Rights Act requires that physicians and hospitals take reasonable steps to ensure effective communication with these patients. Hence, when a patient with LEP presents for care, the encounter must either be conducted with a clinician who speaks the patient’s language or indirectly through a trained interpreter. Untrained interpreters, such as patients’ friends or family members, are sometimes used, although this practice is risky for reasons of competence and confidentiality. While no national data are available on physicians’ non– English-language skills, in some local surveys, more than 80 percent of physicians report some proficiency in 1 or more non-English languages. Direct communication between language concordant patients and physicians is associated with improved quality, adherence and satisfaction, and reductions in emergency department utilization and costs. We recently worked with the Commission to End Health Care Disparities to develop a set of recommendations for policymakers, organizations, and clinicians to promote the appropriate use of physicians’ non–English-language skills. The recommendations were based in part on interviews with bilingual physicians in a variety of practice settings and an expert panel review using a patient safety approach to care improvement. The commission recognized that the responsibility for ensuring quality of communication ultimately rests with physicians and encouraged use of their non−English-language skills to interact in the patient’s preferred language, but cautioned against relying on inadequate language skills. The course of this work, however, revealed that language skills are often interpreted for practical purposes as a dichotomous construct—even modest skills are often deemed good enough to “get by.” In contrast, recommendations from leaders in the field have advocated for graduated measures of language proficiency. Physicians’ non–English-language skills are extremely heterogeneous, ranging from those who speak just a few words of 1 or more non-English languages to those who are native speakers and received their medical training in another language. Similarly, the communication demands of certain clinical interactions are greater than others— conversations about end-of-life care or informed consent for surgery implicitly pose greater miscommunication risks compared with more routine encounters. As a result of this variability, some physicians are probably always able to appropriately provide care to patients in languages other than English, others might be able to do so in some circumstances, and others have such limited skill that they never should attempt medical communication without an expert assistant (ie, a trained interpreter). This more nuanced understanding of language proficiency makes it similar in nature to many other skills necessary for the appropriate and effective practice of medicine. Physicians commonly have some level of skill in specific areas (rheumatology, cardiology, surgery, etc) that usually is sufficient for many routine interactions, but they also are prepared to involve an expert consultant if the clinical situation evolves to exceed their skill level. If bilingual physicians should consider trained interpreters as expert consultants, how should physicians decide whether their non–English-language skills are adequate to provide appropriate care in particular situations and when should they call for consultative assistance? This turns out not to be an easy task. A qualitative study of 20 resident physicians found that most overestimated their ability to provide care in another language. Another study of 25 physicians who provide care directly in a nonEnglish language (most often Spanish) based on skills that are frequently inadequate (ie, skills obtained in high school or middle school, “medical Spanish” courses, or during short visits abroad and reinforced only by occasional medical or nonmedical use) found the physicians value direct communication with patients very highly, and believe patients do too. However, these physicians might also underappreciate the value provided by using trained interpreters, and cli-

Medication Information for Patients with Limited English Proficiency: Lessons from the European Union

Misuse or misunderstanding of medication information is a common and costly problem in the U.S. The risks of misunderstanding medication information are compounded for the large and growing population of individuals with limited English proficiency that often lacks access to this information in their own language. This paper examines practices related to translation of medication information in the European Union that may serve as a model for future U.S. policy efforts to improve the quality and availability of medication information for individuals with limited English proficiency.

Assumed equity: Early observations from the first Hospital Disparities Collaborative

&NA; Disparities in healthcare represent a failure in the equity domain of quality. Although disparities have been well documented, little has been written about how hospitals might use improved data collection and quality improvement techniques to eliminate disparities. This article describes early findings from the planning phase of the first hospital‐based disparities collaborative. The authors also discuss the changes in policy and practice that may speed hospitals in placing disparities and equity on their quality agendas.

Health Reform and the Safety Net: Big Opportunities: Major Risks

Bruce Siegel Marsha Regenstein Peter Shin illions ofAmericans are dependent on what is often called the “safety net.” These loosely-organized networks of health M and social service providers serve the many Americans who are uninsured, dependent on public coverage, or for a variety of reasons unable to access other private systems of care. The Institute of Medicine (IOM) repo*AmeriCa’s Health CaTe Safety Net: Intact but E&ngeTed, called attention to both the fragility and the resilience of this health care safety net.’ The IOM report underscored the critical importance of the safety net to the health and well-being of millions of individuals and called for efforts to strengthen it and improve the nation’s ability to monitor its viability? Given this central role, any health care reform efforts need to be fully informed by an understanding of what the safety net includes, how it is financed, and how it is responding to a series of challenges it now faces. They also must consider the nature of the role of the health care safety net in radical health care reform, like universal coverage. As this article discusses, universal coverage would change, not eliminate, the need for the safety net. It may offer opportunities for these providers to better meet their core missions, but such reform potentially poses major risks as well.

Socioeconomic Status and Health Care

There is a vast amount of evidence across countries that the use of health care services (including hospitalizations, physician services, and clinical preventive services) is positively associated with income, education and other markers of socioeconomic position. In some analyses, lower socioeconomic status (SES) is associated with greater physician and hospital use, although it appears that these findings are primarily driven by higher rates of poor health status or medical need in socioeconomically disadvantaged populations. Three general sets of explanations have been investigated to explain SES differences in health care use: (1) financial access or affordability differences (e.g. the poor use fewer services because they have fewer financial means); (2) knowledge, attitudinal and cultural differences in seeking care (e.g. the poor use fewer services because they value and/or understand the benefits of health care less than other people); and (3) health care system factors (e.g. the poor use fewer services because of ways in which the health care system is organized). The empirical evidence from a number of countries suggests that health care system variables, especially non-financial components of access, offer the greatest explanatory power regarding SES differences in utilization. The policy implications of such findings are important, for they suggests that providing universal coverage or offering free health services to the poor is not a panacea for reducing social inequalities in health care utilization. Research across countries also suggests that, although SES differences in the use of health care services may contribute to some portion of observed SES disparities in health status, the contribution here is likely to be small. Social inequalities in health status are driven by myriad factors other than access to and use of personal health services.