05. Care of Specific Patient Populations

Definition

Specific patient populations are at risk for disparate health outcomes as a result of policies affecting social determinants of health.

Persons without Permanent Housing

  • Homelessness is a public health crisis in many places in the United States as a result of increasing housing prices, displacement, and lack of safety net policies.
  • Increased prevalence of mental illness, both acute and chronic medical illness, communicable diseases (TB, HIV, HBV/HCV), substance use disorders, and violence exposure.
  • Application: 
    • Obtain history of current and prior housing status at every visit. Consider screening for medical conditions as above (e.g. yearly PPD).
    • Screen for history of physical or sexual abuse, substance abuse, mental illness, and refer to appropriate services; address foot care; refer to dental services.
    • Utilize principles of trauma informed care and harm reduction during patient interactions.
    • Coordinate care with other members of the health care team (case managers, social workers, vocational trainers, visiting nurses).
    • Consider referral to appropriate housing: shelters, respite, board and care or other housing options that are available in your community.

Persons who Immigrated to the United States

  • Depending on the specific country of origin, they may be at risk for communicable diseases (TB, parasitic illnesses, rheumatic heart disease, malaria, hepatitis, HIV), violence and trauma exposure (particularly among refugees).
  • May hesitate to seek care due to public charge policy and may present with untreated chronic health conditions due to lack of access.
  • Application: 
    • Be explicit that you will not disclose immigration status and that their status will not influence the care you provide.
    • Acknowledge they may have low trust in healthcare system and incorporate principles of trauma informed care during interactions.
    • Consider screening for medical conditions listed above if applicable.
    • Review vaccination history.
    • Connect patient with social work to help identify local community resources.

Persons who have Limited English Proficiency (LEP)

  • All hospitals are federally required to provide language services through CMS regulations.
  • Patients with LEP receive lower quality of care than those who speak English fluently; using interpreters has been shown to narrow this gap (both in-person and telephonic interpreters).
  • Application: use trained interpreters, either in person or by video monitor (preferred over telephone interpreters). 
    • If your patient is hearing impaired, request an in-person interpreter.
    • Trained interpreters translate words, but also provide cultural interpretation and are preferable to ad hoc (or untrained) interpreters.
    • Ad hoc (untrained) interpreters (e.g., non-trained staff, family, friends):
      • Except in emergencies, children should never be used as interpreters.
      • Remind ad hoc interpreters: “thank you for your help. Please try to translate our conversation word for word, and even when you know the answer to the questions I ask, please tell me what she says. If you have something to say, we can talk separately.” 
    • Bilingual physicians: many hospitals require a certification process for bilingual physicians. If you have doubts about your language ability, it is probably best to call for an interpreter. Physicians often overestimate their own language skills.
    • If another care team member (e.g. medical student, nurse, etc.) is language concordant with the patient, always ask if they feel comfortable serving as an interpreter in a patient interaction.

Persons with Limited Health Literacy

  • Many adults in the United States have limited functional health literacy (FHL).
  • These patients can have higher rates of hospitalization, employ fewer preventive services, and have an increased risk of poorly controlled chronic disease.
  • Application: 
    • Assess patient understanding of and beliefs about their illnesses.
    • Be specific and avoid medical jargon.
    • Use “closing the loop” or the “teach-back” method: for instance, confirm comprehension by asking in a non-judgmental way, “I want to make sure that I’m being clear here. Can you tell me how you’re going to take the medicines?”
    • When preparing discharge documents, pictures/graphics may be better than written text. 

Persons with a History of Incarceration

  • Increased prevalence of communicable diseases (HIV, STDs, HBV/HCV, TB, Staphylococcus infection), mental illness, substance use disorders, and violence exposure.
  • Application:
    • Screen for history of physical or sexual abuse, substance use, mental illness, gang involvement and refer to appropriate services.
    • Screen for medical diseases above.
    • Obtain an incarceration history in a non-judgmental way and utilize principles of trauma informed care and harm reduction during patient interactions.
    • Refer to social work for assistance with housing, insurance, vocational training, reunification with children and social support.

Geriatric Population

  • Worldwide, the population is aging. Common diseases often present atypically in older individuals. They also have decreased physical abilities, financial resources, and are often socially isolated.
  • Application:  
    • The elderly are at greater risk for delirium, falls, functional decline, malnutrition and pressure ulcers.
    • Check mental status: at a minimum, obtain a three-word 5-minute recall.
    • Ask about functionality: ADLs, IADLs, activity, gait and balance.
    • Discuss their environment: sources of support, living situation.
    • Improve outcomes: place in special geriatrics units (Acute Care for Elderly – ACE unit), early mobilization, review medication list and reference Beers Criteria to minimize risk of side effects, avoid benzodiazepines, make renal dose adjustments based on creatinine clearance.
    • Please see Geriatrics for more information.

Adults with Childhood Onset of Chronic Illness

  • Advances in medicine have allowed children with chronic and serious illnesses to live longer and grow into adulthood. However, many adult physicians are not familiar with these illnesses. Examples include cystic fibrosis or cerebral palsy.
  • Application:  
    • Weight based dosing for patients <40 kg.
    • When uncertain about genetic disorders/inborn errors of metabolism use D10 IVF.
    • Consider Adolescent/Pediatric consult for assistance.
    • Involve social work and case management early for safe transitions of care.
    • Communicate with outpatient providers.
    • For patients with intellectual or cognitive disability:
      • Inpatient checklist: surrogate, PCP, baseline function, communication method.
      • Perform HEADDSSS assessment: home, education, activity, diet, development, sex, substances, suicide risk.

 

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