Improve Client Patient Relationships Understanding of Hidden Rules

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Improve Client/ Patient Relationships
Understanding of Hidden Rules

• Fran Klene, RT, RDMF, MS
• Clarian Health Partners Education Coordinator
• Robin Costley, CRT, AE-C
• Marion County Health Department /Asthma Alliance

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Consider Hidden Rules
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Research Continuum

• Behaviors of the Individual
• (Pathology of the Poor)
• Absence of Human and Social Capital Within the
  Community
• Human Exploitation
• Political/Economic Structures

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Key Points

• Focus is on economic diversity
• Poverty is relative
• BOP work is based on patterns and all patterns
  have exceptions
• An individual brings with him/her the hidden
  rules of the class in which he/she was raised
• In order to move from poverty to middle class or
  from middle class to wealth, an individual must
  give up relationships (at least for a time) for
  achievement

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Key Points Hidden Rules
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Asthma Referral Service

• To provide an extension of resources and free
  services to residents in Marion County with a
  diagnosis of asthma or allergies
• Integration of health care services
• Improve coordinate care
• Initiated in 2001
• To instill healthy habits for life

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Benefits

• A face to face can be very effective allow more
  information to be learned
• Use visit to assess the indoor environment where
  a person spends most of their day

• Evaluate firsthand sources of triggers
  potential pathways that may lead to asthma flare-
  ups
• PCPs can use the results to understand the
  context of exposure tailor treatment accordingly

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Medical Benefits

• May experience overall improvements in their
  quality of life as well as decreased symptoms,
  fewer severe episodes requiring emergency care.
  Also improving preventive care self monitoring.

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Economical Benefits

• Increased productivity from fewer missed work and
  school days
• Save on costs when rates of hospitalization ED
  care decrease

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Components of a Asthma Home Visit

• Asthma self management
• Common symptoms early detection
• Review medication plans
• Peak flow monitoring, if applicable
• Home, work, and school environment
• Identify mitigate the effects of exposure to
  environmental triggers
• Socio economic/ psychosocial concerns
• Resources
• Safety issues

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Where Do Referrals Come From?

• Hospitals
• MCHD Programs
• Schools
• Self referrals

• Head Start Centers
• Other daycares
• HCP offices
• Neighborhood clinics
• Health Centers

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Reporting Information

• Parent or Guardian
• Primary Care Physician
• Allergy/ Asthma Specialist
• Source of referral
• Health Insurance Portability Accountability Act
  of 1996 (HIPAA)
• Acknowledgement of receipt of notice of privacy
  practice
• Authorization for release of information

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Barriers Challenges

• Transient clients
• Family not ready to initiate education and
  management
• Other STUFF is priority
• Not an early intervention
• Too many caretakers
• New asthma guidelines
• Addictions
• Language barriers
• Cultural behaviors

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Environmental Assessment

• Assessment tool in survey form or checklist
• Assess common triggers such as dust mites, pests,
  pets, mold, second hand smoke.
• Give special attention to sleeping area
• Housing defects that contribute to the presence
  of triggers
• Impact of outdoor air pollution on asthma.

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Environmental Assessment

• Begin assessment by focusing on exposures that
  are relevant to known sensitivities.
• If trigger is found explain how the trigger
  affects the persons condition provide advice
  on how to reduce exposure.

• Important to remember that recommendations should
  be viable for the patients means and conditions.
• Make referrals to appropriate resources

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Offer Education Tools

• Provide hands-on assistance in educating about
  mitigation techniques
• Follow up to assess compliance with
  recommendations, track overall progress,
  support continued self-management

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Special Considerations in Low-Income Population

• Should carefully consider the effort that will be
  required to make their home visit recommendations
  successful.
• It is essential to
• Make social service referrals when applicable
• Providing products at no cost
• Providing hands-on assistance on instruction with
  product usage other mitigation techniques

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Special Considerations

• Cultural language issues
• Need to establish trust before conducting an
  assessment
• Flexible program that provides enough home visits
  to achieve the desired health outcomes

• Lack of progress
• Worsening symptoms
• Continued demonstration of limited knowledge of
  the disease.
• Those with most severe asthma have the greatest
  potential to benefit from home visits.
• Have a mechanism to identify them

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DESPERATE CAREGIVER

• Self Referral- Grandmother, Great Grandmother, 2
  small Grandchildren, and 1 teenage Daughter
• Problems identified
• Deplorable living conditions
• Standing water in all of the bedrooms, closets,
  with visible mold throughout the house.
• 2. Windows not placed properly. Heat at 95
  degrees in winter to overcome cold temperatures
  in the home. Bugs in home, fly paper placed in
  all rooms.
• 3. Toilet not seated properly with human waste
  coming up on the floor with each use.

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CHILD WITH AUTISM MOTHER DISABLED

• Self Referral
• Problems identified
• Single Mother desperate for help. Has CP with a
  severe speech impediment.
• Two sons a 6 y.o. with asthma newly diagnosed
  autism, a 10 y.o.
• No medical home- numerous medications that she
  didnt know what to do with
• Collaborated with school nurse to develop a more
  effective management plan for the school
  environment.

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AUTISM Case continued

• Services utilized
• About Special Kids (ASK)
• Inadequate equipment- DME donated portable neb.
• Provided neb machine for before school care.
• Staff education at school and before care.
• Allergy testing finally completed with new MD.

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MULTIPLE FAMILY MEMBERS LIVING AT RESIDENCE

• Referral from Health Clinic
• Problems identified
• Non compliant with medications. Son 7 y.o. ,3
  y.o. 2 y.o. daughters with severe asthma.
• Very transient
• Home not kept clean. Many people in out of
  home.
• Equipment in bad condition, dirty.
• Concerns over child development. Son is
  restricted to an air conditioned room all summer.
  Referred to programs for parents children /
  Childrens Bureau
• Loosing materials that were provided. Not
  filling prescriptions
• When do you call it quits?!

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LIFE WITHOUT SLEEP

• Referral from Sickle Cell Program
• Problems identified
• Single Mom states that 2 y.o. Son has symptoms
  daily. Mostly at night. Not sure of triggers.
• Son only sleeps 2 hours/ night. Not sure if it
  is the medications he is on or irritation from
  his severe eczema.
• Roaches present in home. ( Dbl. Occupancy)
• Educated on dust mite reduction. Removed large
  stuffed animal from room. Dust mite pillow
  protector provided.
• Mom stressed from his care. No one will help her
  care for him because of his of his lack of sleep
  and he gets into things in the home when Mom
  falls asleep.

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NEED FOR INTERVENTION

• Self referral
• Problems identified
• 10 y.o. Son with severe asthma, Mother lost job
  2nd to repeated calls from work to pick Son up at
  school with asthma symptoms
• No food in home. Ran out of food stamp support,
  no transportation
• Referred to appropriate DHO for basic needs
  resources. Social Worker intervened
• 4. Presently goes to school daily to give Son
  his asthma treatment

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Continued

• Needed direction in job search. Inquired about
  a job at her sons school/ may be aide position
  available in the near future. Continues to seek
  employment/ has submitted several applications.
• Son had sleep study, cab was involved in accident
  on the way home. Needed direction to report
  incident.
• Wal-Mart card given for household goods ,
  toiletries, and eye drops for her son. Bus
  vouchers also provided for transportation.
  Encouraged to go to Trustees office to obtain
  assistance with her utility bill and school
  clothes for her Son.

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Continued

• Paid all but 7 of her electric bill obtaining
  by doing odd jobs. Needed direction in
  contacting the power company so that her
  electricity wasnt turned off in 2 days. Need
  for utility assistance.
• Son doing much better. No further
  hospitalizations since initial asthma referral.
• Continued visits to support ongoing needs of
  family

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Situation at School

• 11 y.o. with what appears to be little support at
  home
• School making every effort to assist in his
  asthma
• How do we make a difference without crossing the
  line of the parent/ guardian?
• OR, how can we engage them?

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Rewards

• Improvement of symptoms is often directly related
  to the degree clients follow environmental
  recommendations
• Greatly affected by the partnership with the
  educator.

• Building partnerships with clients their
  families ensuring that support , consistent
  messages coordinated care are provided.

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Questions

• What percentage of the people you serve are
  living in poverty?
• How do your outcomes with people in poverty
  compare with people in middle class?

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Hidden Rules ResourcesPlus

• Bridges Out of Poverty, Strategies for
  Professionals and Communities by Phil DeVol, Ruby
  Payne and Terrie Dreussi
• Framework for Understanding Poverty by Ruby Payne
• Changing Childrens Minds by Reuven Feuerstein

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Thank you for letting us shareWe welcome your

• Questions?
• Comments?
• Open discussion