Behavioral Health Institute (BHI)Training, Workforce and Policy

Innovation Center

BEHAVIORAL HEALTH TELEHEALTH RESOURCE

Telehealth Provider Forum Series

Fridays 11AM – 12PM

Visit us online:

https://bhi-telehealthresource.uwmedicine.org/

Email us:

melmckee@uw.edu

Behavioral Health Institute (BHI)Training, Workforce and Policy Innovation Center

The Behavioral Health Institute (BHI) Is a Center of Excellence where

innovation, research and clinical practice come together to improve

mental health and addiction treatment. The BHI established initial

priority programs which include:

• Improving care for youth and young adults with early psychosis

• Behavioral Health Urgent Care Walk in Clinic

• Expanded Digital and Telehealth Services

• Behavioral Health Training, Workforce and Policy Innovation

Center

Thorp, 2012

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> Will be shared in the chat box near the end & also emailed out

> Helps the presenters plan future sessions

▪ There will NOT be certificates or CEUs for this series.

▪ Slides & resources WILL be posted after the session

After today’s sessionPlease complete the evaluation

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Today’s Panelists Brad Felker, MD

VA Puget Sound Health Care System Professor, University of Washington Dept of Psychiatry & Behavioral Sciences

Marc Avery, MD Principal Consultant, Health Management Associates Clinical Professor of Psychiatry, University of Washington

Cara Towle MSN RN MA Associate Director, Telepsychiatry University of Washington

Derek P. Murphy, M-RAS, SUDP, CSCDirector of Clinical ServicesOlalla Recovery Centers

Melody McKee, MS, SUDP Program Director, Behavioral Health Training, Workforce and Policy Innovation Center, Behavioral Health Institute

Thorp, 2012

Behavioral Health Institute (BHI)Training, Workforce and Policy

Innovation Center

BEHAVIORAL HEALTH TELEHEALTH RESOURCE

Telehealth Provider Forum Series

Fridays 11AM – 12PM

Visit us online:

https://bhi-telehealthresource.uwmedicine.org/

Email us:

melmckee@uw.edu

Telehealth: How can We Improve Health Equity and

Cultural Competency in the Era of Covid-19?

June 19, 2020

Karen L. Hill, PhD, ANP-C

Health Management Associates

Senior Consultant

HAPPY JUNETEENTH-Freedom Day, Jubilee Day and Cel-Liberation Day

The oldest nationally celebrated commemoration of the ending of slavery in the United States.

Juneteenth commemorates when General

Granger read federal orders in Galveston, Tx,

freeing all previously enslaved people in Tx in the

State. Although the Emancipation Proclamation

had formally freed them in Jan 1, 1863 nearly two

and a half years earlier.

Texas was the most remote of the slave states,

with a low presence of Union troops, so

enforcement of the proclamation had been slow

and inconsistent.

At the conclusion of today’s presentation

participants will be able to:

1. Define health equity, culture and implicit bias 2. Describe how health disparities increases secondary

effects of the COVID-19 pandemic risk and poor patient health outcomes

3. Explore how telehealth can assist in bridging the health equity gap

4. List at least three PCP and staff telehealth opportunities to promote health equity and cultural competency

Population: 7.3M

Median age: 38 yrs.

Poverty rate: 11%

Median household income: 67K

Citizens: 95%

WASHINGTON STATE DEMOGRAPHICS

76.3

12.48.3

5.7 3.7 1.3 .66 4.3

LET’S HEAR FROMEACH OTHER

CHATTER FALL

Type an answer into chat

but do not hit enter yet…..

1. What does Cultural

Competency mean to

you?

66 yr. old male, divorced with 2 young adult children (17 and 22). He is retired from Fairchild Air Force Base and works as a part-time bus driver. He was injured in Afghanistan but the military won’t cover his injury and he has chronic pain. He reports that the quarantine and the civic unrest has him feeling ‘down’, angry and he started smoking again and is having trouble sleeping. Mr. Jones has asthma, depression previous phq-9 was 6, hypertension (BP is 165/90). His oldest son was killed by the police.

He lives in a small house in Bothell and has reported an increase in unpleasant encounters with his new neighbors. The kids are currently living with him and have had several verbal run-in’s with the neighbors. He has internet and a computer but his kids use the most.

Since the COVID-19 restrictions and the George Floyd murder he reports feeling anxious and has concerns about his kids leaving the house.

Mr. Smith is from Arkansas and is often very hard to engage and has history of issues with alcohol misuse. You are going conduct his 1st telehealth visit.

CASE OF THE DAY

Mr. Smith

Healthy People 2020 defines a health disparity as “a

particular type of health difference that is closely linked

with social, economic, and/or environmental

disadvantage…and adversely affect groups of people

who have systematically experienced greater

obstacles to health based on their:

racial or ethnic group;

religion; socioeconomic status; gender; age;

mental health;

cognitive, sensory, or physical disability;

sexual orientation or gender identity;

geographic location;

or other characteristics historically linked to

discrimination or exclusion

Environmental

Conditions

PHYSICAL and MENTAL HEALTH DISPARIES DEFINED

So, what is the

relationship between

Disparity and Inequity?

Disparity leads to Inequity.

Disparities in physical, mental health and the factors that shape health, that are systemic and avoidable and are, consequently considered unjust or unfair.

PHYSICAL and MENTAL HEALTH DISPARIES DEFINED

Factors that contribute to health disparities include:

No shared or common definition of health disparity

Lack of knowledge and understanding of health equity

No shared social analysis of discrimination and historical

racism and the impact these factors have on the access to

health care services, delivery of health care services and

health related data collection

Systemic reluctance across the health care sector to

acknowledge that health care disparities are real

Lack of coordination between the social support systems and

the health care system

Lack of consideration of the importance of culture

Lack of acknowledgement of implicit bias

MANY FACTORS CONTRIBUTE TO HEALTH DISPARITIES

Disparities Video The Unequal

Opportunity Race

LET’S HEAR FROMEACH OTHER

Polling Question

1. Is there a difference between

cultural competency and

cultural humility?

a) yes b) no c) I don’t know

2. Can we achieve health

equity without racial equity?

a) Yes b) no c) maybe

“Health equity” means all people have full and equal access to opportunities that enable them to lead healthy lives”.

“Racial equity is defined as just and fair inclusion into a society in which all people, immaterial of their race or ethnicity, can participate, prosper, and reach their full potential”.

WHAT IS RACIAL and HEALTH EQUITY?

OHE VISION, MISSION & CENTRAL CHALLENGE

Vision

Everyone in

California has equal

opportunities for

optimal health,

mental health and

well-being.

Mission

Promote equitable social,

economic, and

environmental conditions to

achieve optimal health,

mental health, and well-

being for all.

Central Challenge

Mobilize understanding and sustained

commitment to eliminate health inequity and

improve the health, mental health, and well-

being for all.

WHAT IS CULTURE and Cultural Humility?

https://youtu.be/16dSeyLSOKw

“Culture is the characteristics and

knowledge of a particular group of

people, encompassing language,

religion, cuisine, social habits, music and

arts. ...

The word "culture" derives from a French term, which in turn derives from the Latin

"colere," which means to tend to the

earth and grow, or cultivation and

nurture”.

LET’S HEAR FROMEACH OTHER

CHATTER FALL

Type an answer into chat

1. How has your approach to culturally responsive care mean changed since the COVID-19 pandemic?

1. What NEW issues must you consider as we connect via telephonic or virtual conferencing and less F2F visits?

2. What NEW issues must you consider in your daily work due to COVID-19?

3. What NEW issues must you consider with racism now considered a public health crisis?

4. What NEW issues must you consider with civil unrest?

LET’S HEAR FROMEACH OTHER

CHATTER FALL

Type an answer into chat

but do not hit enter yet…..

1. What does Cultural

Competency mean to

you?

CULTURALLY RESPONSIVE HEALTH CARE

Source: Beach et. al, Commonwealth Fund Report, 2006

CULTURALLY and LINGUISTICALLY APPROPRIATE SERVICES

(CLAS) PRINCIPAL STANDARD APPROPRIATE SERVICES (CLAS) PRINCIPAL STANDARD

“Provide effective, understandable, and respectful

quality care and services that are responsive to

diverse cultural health beliefs and practice, preferred

languages, health literacy and other communication

needs”.

Office of Minority Health ,2000

BIAS AND STEREOTYPES

(WE ALL HAVE THEM…IT’S

HUMAN)

LET’S HEAR FROMEACH OTHER

CHATTER FALL

Type an answer into chat

but do not hit enter yet…..

1. What is Implicit Bias?

Bias is a pre-judgment in favor of or against one thing,

person, or group compared with another usually in a

way that’s considered to be unfair.

Biases may be held by an individual, group, or

institution and can have negative or positive

consequences.

There are two types of biases:

Conscious bias (also know as explicit bias)

Unconscious bias (also know as implicit bias)

Video Resource

Cognitive Biases Explained - How to

Think Better and More Logically Removing Bias

https://youtu.be/wEwGBIr_RIw

WHAT IS BIAS?

INTERVENTIONS TO TACKLE IMPLICIT BIAS

1. Acknowledge and accept the existence of

implicit bias, its manifestations, and its impact.

2. Assume individual responsibility to address

implicit bias

3. Engage in self-reflection and assessment

4. Make good use of the neuroscience to combat

“hard wiring”

5. Collect and use data effectively and perform

self-monitoring

6. Incorporate cultural and linguistic humility and

competence in your practice

Video Resources

https://implicit.harvard.edu/implicit/takeatest.html

How might we provide Mr. Smith with culturally responsive telehealth services?

Remember Mr. Smith?

66 yr. old male, divorced with 2 young adult children (17 and 22). He is retired from Fairchild Air Force Base and works as a part-time bus driver. He was injured in Afghanistan but the military won’t cover his injury. He reports that the quarantine and the civic unrest has him feeling ‘down’, angry and he started smoking again and is having trouble sleeping. Mr. Jones has asthma, depression previous phq-9 was 6, hypertension (BP is 165/90). His oldest son was killed by the police.

He lives in a small house in Bothell and has reported and increase in unpleasant encounters with his new neighbors. The kids are currently living and have had several run-in’s with neighbors. He has internet and a computer but his kids use the most.

Since COVID-19 restrictions and George Floyd murder he reports feeling anxious and has concerns about his kids leaving the house.

Mr. Smith is from Arkansas and is often very hard to engage and has history of issues with alcohol misuse. You are going conduct his 1st telehealth visit.

Empathic and Culturally Responsive

Telehealth (video visit)Dress in accordance with your organization’s dress code. Present with the normal dress for the clinic setting (at least from the waist

up!).

Test the camera to see how the background looks and adjust accordinglyto convey a professional image. Consider lighting, a plain and tidy

Background. Consider using a virtual background and plugging in a photo

of your actual office or other therapeutically neutral image.

Use a headset and close doors to preserve confidentiality and minimize

interruptions during the session.

Find a comfortable place to sit and work to avoid poor posture or straining

to see the camera. Ergonomics are important for sustainably being able to

work from home.

Empathic and Culturally Responsive

Telehealth (video visit)Set the foundation:

-check in about tech

-check tech competency and get a plan B if there is a problem

Personal connection:

-use empathy

-ask about support systems

-ask about COVID-19 concerns

-without politics: ask about how current events are making the client feel

-it is our responsibility to broach topics that can cause discomfort

Normalize:

- Initiate a conversation about the experience and process of

phone communication.

Just saying ‘I know it is a bit different, for us to have a visit this way. It can feel

pretty odd. What are your thoughts, questions or concerns?’

We can also check in at the end, to ask about the experience.

Empathic and Culturally Responsive

Telehealth (phone visit)

Set the foundation:

This is the most important sentence in this document:

We are unable to listen and communicate skillfully when we

are doing something else.

Demonstrate attentiveness to other’s comfort:

On the phone, it is important to begin by asking if this is still a

good time to talk, and if they are comfortable. Asking whether they feel they

have sufficient privacy is important too.

Normalize:

Empathic and Culturally Responsive

Telehealth (phone visit)

Reflecting listening: motivational interviewing

is one of the empathic communication skills that takes the most practice and

skill to use effectively.

If you’ve shied away from it before, telephone conversations

are the time to dive in and practice; ideally, we are reflecting through

summarizing, exact words.

Just as a reminder,

reflective listening is repeating back to another, what our understanding is of

what they’ve said.

It can start with stems like:

o It sounds like what you are saying is

o What I hear you saying is….

Culturally Responsive Telehealth

(telephonic)

Jump in quickly, to check in. When we hear the other person trail off,move around; when they are answering open ended questions with oneword answers, or there are long silences, we likely were unable to see theearlier cues and clues about how they are responding to the conversation.By the time we actually ‘hear’ this, it is time to say something. For example: ‘Iwonder how you are feeling right now in this moment?

Narrate your pauses and process. In person, others can see us look downthoughtfully, nod, look to the sky in consideration…on the phone, it is justsilence, which might be misinterpreted. Comments like ‘I’m just thinking about what you just shared…’ or ‘I want to sit with that, for just a minute. It sounds so important, what you just said’ help convey we are still with the other person, as gives the other a visual picture of us in thought.

Culturally Responsive Telehealth

(telephonic)

Narrate your smile. We convey an enormous amount of goodwill,physically, by smiling, close proximity and eye contact. When we smile, forexample, at the beginning of the conversation, or in response to whatsomeone is saying, we can verbalize this . Comments like: ‘I’m happy to be talking to youtoday; and ‘I have a big smile on my face right now, hearing you say that’.

Affirm strengths more often. Others are more vulnerable when they can’tsee us.Comments like: “I can hear how much effort you aremaking to keep your family safe during this time’ frequently can assure”

TELEHEALTH CULTURALLY RESPONSIVE PEARLS

• Be present, authentic, open, humble• Client or patient is most knowledgeable about experience • Respectful of how people connect and identify• Reflect and address your feelings and experience• Allow for some discomfort and awkwardness• Use your resources• Check in with patients-clients-colleagues • Participate in self-care strategies• Try to have a bit of fun and learn

LET’S HEAR FROMEACH OTHER

CHATTER FALL

Type an answer into chat

but do not hit enter yet…..

1. What will you do

improve your practice

from cultural

competency and

health equity lens ?

QUESTIONS AND THANK YOU!”

This Photo by Unknown Author is licensed under CC BY-NC