Reducing health disparities among end-stage dementia patients

Health Disparities: End-Stage Dementia Patients

Health Disparities

Reducing Health Disparities among End-Stage Dementia Patients

Reducing Health Disparities among End-Stage Dementia Patients

According to the U.S. federal government the health of the nation depends on the health of the communities and the health of communities depends on individual health (U.S. Centers for Disease Control and Prevention, 2011). The natural extension of this logic is that health disparities reduce the overall health of a nation; therefore, it is incumbent upon health policymakers, healthcare organizations, and medical professionals to minimize differential access to quality health care across racial, ethnic, or socioeconomic boundaries. Prior to implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, minorities disproportionately suffered from a lack of healthcare coverage and an inability to pay out of pocket for medical expenses (U.S. Centers for Disease Control and Prevention, 2011). This disparity contributed to a higher prevalence of health problems among minorities and low-income individuals, including obesity, diabetes, lung cancer, and heart disease.

A priori, there would be no reason to expect the prevalence of health disparities to be absent among the elderly. The most vulnerable among this already protected patient group are those suffering from end-stage dementia because of the sometimes severe cognitive deficits. To better understand the health disparities suffered by end-stage dementia patients a review of the research literature will be conducted. In addition, the recommended strategies for implementing a culturally-competent Chronic Care Model health promotion plan for home-based palliative care will be discussed.

Defining Health Disparity

A health disparity occurs when one demographic group suffers disproportionately from a health-related condition or disease. Health disparities are also defined by the fact that they are unnecessary, avoidable, and unjust (Braverman et al., 2011). Within the United States, health disparities tend to be defined by race, ethnicity, and socioeconomic status, although sexual-orientation, gender, and age can also be a factor (U.S. Centers for Disease Control and Prevention, 2011). For example, the prevalence of obesity among Americans of Asian or Pacific Islander descent was 6.7-10.3%, but among American Indians it was between 45.5-46.2%. One of the main contributors to health disparities has been differential access to care, however, studies have also revealed that even for minorities with equal access the quality of the care provided differed along racial and ethnic lines (Fink, 2009). These findings suggest that even if all Americans receive adequate healthcare coverage under the ACA, the quality of the care provided will still be a significant contributor to health disparities.

The U.S. healthcare system is therefore a significant contributor to health disparities. From my own personal experience, African-American residents in a nursing home where I once to work seemed predisposed to pressure ulcers when compared to other residents. This possibility was never formally investigated, even after I reported my observation to an administrator. This may have changed after the Centers for Medicare and Medicaid Services (CMS) implemented Clinical Quality Indicators (CQI) for reimbursement purposes (CMS, 2014). The possible implication of my observation is that the quality of care afforded to African-American nursing home residents is not equivalent to the care provided to other residents, thereby resulting in a health disparity.

Why are Health Disparities an Important Issue for Providers?

Health professionals should care about health disparities for the same reasons that they care about preventing iatrogenic events. For example, the estimated prevalence of central-line associated blood stream infections declined by 58% between 2001 and 2009 in the U.S. (Srinivasan et al., 2011). With mortality rates associated with this type of nosocomial infection reaching 25%, the estimated number of lives and excess direct healthcare costs that were saved was 6,000 and $414 million, respectively. This success story can probably be attributed in part to mandated changes in how CMS reimburses for iatrogenic events. After these rules were implemented in 2008, nosocomial infection rates declined significantly in California hospitals (Stone et al., 2011). Given the morbidity, mortality, and cost savings associated with reducing nosocomial infections, similar savings would be realized by reducing health disparities.

Health disparities also violate the civil and human rights principles of equality, equal value to society, and nondiscrimination (Braveman et al., 2011). To elaborate, a person's economic stability and mobility is dependent on their physical and mental health. In the U.S., the long history of discrimination has resulted multigenerational barriers to economic success, but unequal treatment by the healthcare system would tend to strengthen these barriers because person's health is intimately linked with their ability to thrive in society.

DNP-prepared nurses will have had cultural competency training in preparation for practicing in racially, ethnically, and socioeconomically-diverse communities. In practice, however, the main elements that can increase patient satisfaction, compliance, and continuity of care are improved provider-patient communication and exchange of information (Castro & Ruiz, 2009). Importantly, the race and ethnicity of the provider is not necessarily a barrier to achieving above average levels of patient satisfaction, although language barriers could prove to be significant for providers fluent in English only.

Culturally Appropriate Health Promotion Plan

The core elements of the Chronic Care Model (CCM) should help reduce health disparities in a home-based palliative care setting (Brodaty & Donkin, 2009). The emphasis on patient-centered care, systematic attention to behavioral needs, and explicit protocols would be expected to reduce some of the disparities that have been discovered among minority dementia patients. As discussed above, provider-patient communications would be an important focus of CCM implementation for home-based palliative care in terms of cultural competency. For example, over 70% of low-income African-Americans fail to apply for Medicaid benefits despite eligibility (Kingsberry & Mindler, 2012). Not surprisingly, the family caregivers of African-American elders tend to rely on family resources to meet care needs. This practice is probably a major contributor to health disparities among this demographic. In other words, the already substantial discriminatory practices contributing to socioeconomic inequality along racial lines would be exacerbated by a failure to receive financial support through Medicaid. A care manager could assist minority, low-income dementia caregivers with filling out the necessary forms and submitting the applications to the appropriate state agencies.

The recommended strategy for providing a culturally-competent health promotion plan is to first develop community partnerships with community leaders, academic organizations, and health departments (Lettlow, 2008). Once the health promotion plan has been developed, coalitions should be fostered with local advocates and leaders to help disseminate the information. For example, primary care providers, church leaders, social groups could be approached to help get the word out and provide constructive critique in terms of cultural sensitivity. These efforts should be tracked by an evaluation strategy, not only for the health outcomes among end-stage dementia patients and their caregivers, but for the community as a whole.

Conclusions

Developing a culturally-sensitive CCM health promotion plan for end-stage dementia patients in home-based palliative care is both necessary and straightforward. The primary contributors to health disparities along racial, ethnic, and socioeconomic boundaries are access to care, unequal care quality, and probably patient low expectations due to a history of discrimination. Aside from engaging in additional research, partnerships and coalitions should be developed and fostered to help implement the health promotion plan community-wide. Among the most important aspects to the health promotion plan will be the benefits associated with a care manager, who can ensure that all six core elements of CCM are implemented fully. If this is accomplished, there should be a significant reduction in health disparities for patient and caregiver outcomes across generations.