Patient engagement and empowerment: Strategies to improve ... · Patient engagement and empowerment: Strategies to improve the chronic disease control among Ethnical Minority Patients

Patient engagement and empowerment: Strategies to improve the chronic disease control among Ethnical Minority Patients

in the primary care

Dr. Catherine Chen Dept. of FM and GOPC, KCC

Background

• Hong Kong is “Asia’s World City” with multi-culture and diversity.

• Ethnic minorities constitute an important component of the HK population. According to census in 2011, about 95% of the local inhabitants are ethnic Chinese; the remainder are mainly from South Asia (India, Philippines, Nepal, Pakistan, and Indonesia).

• Yau Ma Tei Jockey Club GOPC locates at Central Kowloon, where most of the South Asian minorities including Indians, Nepalese, and Pakistanis reside. The attendance from the Ethnical Minority Groups (EMGs) accounts for about 10-15% of overall yearly attendance at YMTJC GOPC.

Source: Hong Kong 2011 Population Census Thematic Report : Ethnic Minorities. Census and Statistics Department. Hong Kong Special Administrative Region. http://www.census2011.gov.hk/pdf/EM.pdf

Culture disparity and its clinical impact • Previous studies have shown that chronic disease, i.e. DM and

HT affect certain EMGs differently. • South Asians are at higher risk for T2DM by up to 4 to 6 fold

compared with other ethnic groups, probably due to a combination of genetic and environmental factors.

• In addition, South Asians have a much higher prevalence of T2DM with cardiovascular disease that occurs at an earlier age and is associated with higher morbidity and mortality.

• Differences in health care systems, limited access to health services, and social deprivation can further compound the risk of developing diabetes and its complications.

Reference: Abate N, Chandalia M. The impact of ethnicity on type 2 diabetes. J Diabetes Complications 2003;17:39-58. Gholap N, Davies M, Patel K, Sattar N, Khunti K. Type 2 diabetes and cardiovascular disease in South Asians. Prim Care Diabetes 2011;5:45-56.

4

Our mission

• To provide comprehensive programs that facilitate access for all, including EMGs, to the public health care system.

• To promote that all individuals enjoy equality of health and guard against discrimination.

• Study subjects: EMG patients with chronic disease (DM or HT) and had been regularly FU in YMTJC GOPC of KCC for chronic disease control.

• The first cycle was carried out from 01/01/2013 to 31/12/2013 with deficiencies of chronic disease control identified.

• Implementation of change: 01/01/2014 to 31/12/2014

• The second cycle was carried out from 01/01/2015 to 31/12/2015.

• Patients’ demographics, blood pressure (BP) and biochemical parameters were retrieved from the Clinical Management System (CMS) and the clinical outcome between the first and second cycle were compared.

• Student’s t-test was used for analyzing continuous variables and Chi-square test for categorical data. All statistical tests were two-sided, and a p-value of < 0.05 was considered significant.

Clinical audit on chronic disease control among EMG patients: methodology

• Compared with Chinese diabetes and hypertension patients, those patients from the EMGs were much younger and more obese.

• Deficiencies existed in the comprehensive management of chronic diseases, particularly with respect to glycemic control and blood pressure control.

• During the first cycle, it was found that compared with Chinese hypertensive patients, EMG hypertensive patients have higher systolic and diastolic BP (both P < 0.001), and had a much lower proportion with BP adequately controlled (68% versus 80%, P < 0.001).

• Within lipid profile, high density lipoprotein (HDL) level was lower while triglyceride level higher in EMGs (P < 0.001).

• Similarly, the glycemic control was poorer in EMG diabetes patients than their Chinese counterparts (HbA1c 7.8 ± 1.7% vs 7.5 ± 1.4%; P=0.006), with a much lower proportion being adequately controlled metabolically (Hba1c <7%, 48% versus 60%, P<0.001).

Clinical audit on chronic disease control among EMG patients: 1st cycle Results

Clinical audit on chronic disease control among EMG patients: 1st cycle Results

% of HT patient with satisfactory BP control

% of DM patient with satisfactory HbA1c control

P<0.001 P<0.001

• Culture competence: defined as the level of knowledge-based skills required to provide effective clinical care to patients from a particular ethnic or racial group.

• We strive to enhance the culture competence among patients from EMGs and to reduce the ethnic health disparities.

• Major improvement strategies: – Internet resources for health information in multi-languages – Interpreter services – Training, coordinating with traditional healers – Use of community health workers – Culturally competent health promotion, including

family/community members

Clinical audit on chronic disease control among EMG patients: improvement strategies

Resources for Multi-language Service at government website

1. http://www21.ha.org.hk/smartpatient/tc/empowerment_activities.html

3. http://www.chp.gov.hk/en/view_content/22550.html 2. http://www.gov.hk/en/theme/multilanguage/mlp/

Interpreter Service in HA

Workflow for Calling Interpreter Service in KCC GOPC

Chronic Patients with next follow up appointment

Attend Nurse Station

Episodic cases

Approach the counter desk in Shroff Office Clerical staff identify patient’s language Direct to nurse station for further arrangement

Nurse identify the language that the patient is needed Nurse confirm patient’s needs and ask clerical staff to book the appointment as

required Fill the Service Request Form and fax to HKTS, #24286708 Call the Hotline Centre at 24235100 to confirm the delivery of the facsimile The Hotline Centre reply for the Service Reference Number and Interpreter Code

Number Nurse keep the booking record till patient’s next appointment day for further follow

up action

Convenient and coordinated medical care to minority patients (1): Doctor’s assessment

Convenient and coordinated medical care to minority patients (2): Nursing Care

Convenient and coordinated medical care to minority patients (3): Allied Health

Physiotherapy & Occupational Therapy

Convenient and coordinated medical care to minority patients (4): Ethnical diet education by dietitian

Diet sheets for ethnic minorities: Hindi, Nepali, Urdu, Indonesian, Thai

Sharing of studies on EMGs at various platforms

KCC convention 2015 HA convention 2014

Reference: Chen XR, Chan KH. Type 2 diabetes management in Hong Kong ethnic minorities: what primary care physicians need to know? HK Med J 2014 Jun; 20(3): 222–8

Sharing of studies on EMGs at various platforms

Community School Outreach Program: To schools with predominately minority students (2015)

• After two yrs of implementations of the above improvement strategies, the KPI of chronic disease control including BP control rate among HT cases, HbA1c capture rate and control rate among diabetes cases were all significantly improved among EMG patients.

Clinical audit on chronic disease control among EMG patients: 2nd cycle result

HT patients with satisfactory BP control among EMGs

DM patients with satisfactory metabolic control among EMGs

P<0.001 P=0.006

Working and recognitions from NGOs

Awards from Indian Association, Hong Kong

Video clip sharing

Mr. Mohammad from Pakistan. He has known history of DM, HT, hyperlipidemia, obesity and has been FU in our clinic since 2012. Latest DMCS reports have shown that his BP, glycemic and lipid control were satisfactory. He will share with us his experience about treatment in HA……

Conclusion • Deficiencies existed in the comprehensive management

of chronic diseases, particularly diabetes and hypertension, among EMG patients.

• Through a team approach including a closer collaboration with different NGOs and further enhanced culturally competent health promotion and culturally tailored health care interventions, their chronic disease control has been significantly improved.

24

To closely collaborate with different NGOs and further enhance culturally competent health promotion, including family/community members

To intensify culturally tailored health care interventions, i.e. to widen the service scope and frequency in delivery Ethnical diet education;

To set up special clinic for poorly controlled chronic disease patients from Ethnical Minority Groups.

Way forward

Acknowledgements I would like to extend my gratitude to Dr. King Chan for his continuous inspirations and support during this study. I would also like to thank all medical and nursing staff of Dept. of FM & GOPC,KCC and the clinical effectiveness subcom. members for their great effort and support in providing quality primary care to the EMGs.

Bring better health to the community!