Vulnerable Populations in Clinical Care Study Guide PDF

E1: Vulnerable Populations in Clinical Care 1) Define and provide examples for the following terms: social determinants of health, health related social needs, health disparities and healthcare disparities. Social Determinants of Health (SDoH): the conditions in which people are born, grow, live,...

E1: Vulnerable Populations in Clinical Care 1) Define and provide examples for the following terms: social determinants of health, health related social needs, health disparities and healthcare disparities. Social Determinants of Health (SDoH): the conditions in which people are born, grow, live, work, and age (shaped by the distribution of money, power, and resources at global, national, and local levels) -​ Economic stability (employment, income, housing stability) -​ Education (literacy, early childhood education) -​ Healthcare access (insurance coverage, provider availability) -​ Neighborhood and environment (air quality, crime rates) Health-related social needs: individual-level, immediate social and economic barriers that affect health and require intervention -​ Food insecurity -​ Unstable housing or homelessness -​ Transportation issues that limit healthcare access Health disparities: differences in health outcomes between groups, often influenced by social, economic, or environmental disadvantages -​ Higher infant mortality rates among Black Americans -​ Increased prevalence of diabetes in low-income communities Healthcare disparities: differences in access to and quality of healthcare services among different populations -​ Lack of health insurance among racial/ethnic minorities -​ Lower rates of preventative screenings in rural areas 2) Describe at least 3 examples when the presence of a health-related social need may result in worse overall health. Food insecurity → poor nutrition and chronic diseases -​ Individuals with limited access to healthy food are more likely to develop obesity, diabetes, and heart disease -​ In 2016 -​ ⅛ US Citizens experienced food insecurity -​ ⅙ children had experienced food insecurity -​ 2X risk of having diabetes if food insecure -​ Food desert: a census tract with a substantial share of residents who live in a low-income area that have low levels of access to a grocery store or a healthy, affordable food retail outlet Housing instability → increased risk of illness and mental health issues  -​ Unstable or substandard housing is linked to higher rates of asthma, stress, and infectious diseases Lack of transportation → delayed medical care -​ Patients without reliable transportation may miss medical appointments, leading to worsening chronic conditions like hypertension or diabetes 3) Define socioeconomic status, including at least 3 factors that contribute to its definition. Socioeconomic status (SES): a measure of an individual’s or group’s social and economic position in society, impacting access to healthcare and overall well-being -​ Income (access to healthcare, housing, and nutritious food) -​ Education (higher levels of education are linked to better job opportunities and health literacy) -​ Occupation (type of employment influences exposure to workplace hazards, job stability, and access to employer-sponsored health benefits) 4) Analyze and provide at least three arguments as to why efforts to increase screening for health-related social needs in primary care may not achieve improved health outcomes. Increase burden on overworked providers -​ PCPs already experience burnout and time constraints, so adding SDoH screenings could reduce the time for direct medical care Lack of resources and expertise -​ Many primary care settings lack the necessary social services and expertise and funding to address identified social needs Uncertain impact on health outcomes -​ While addressing social determinants is important, evidence on whether primary care-based interventions significantly improve long-term health outcomes remains limited E2: Journal Club 1. Identify unbalanced confounding variables when authors provide common sample statistics: a) Sample size, sample mean, and sample standard deviation (or sample variance) b) Counts or alternatively sample size and sample proportions Unbalanced confounding variables: create alternative explanations for observed differences between study groups -​ They are independent variables that influence the outcome variable -​ They are unevenly distributed across levels of exposure in the outcome variable Independent t-test: compare the sample means of two groups (baseline vs most extreme group) -​ If p sensation of feeling overwhelmed or physically affected by trauma -​ Thinking too much → Excessive rumination leading to distress -​ Sleep paralysis and weak heart -​ May seek spiritual healing rather than psychiatric care Diagnostic criteria (DSM-5): -​ Intrusion symptoms: flashbacks, intrusive memories, nightmares -​ Avoidance symptoms: avoiding trauma-related thoughts, places, or people -​ Negative mood/ cognition: emotional numbness, guilt, detachment -​ Arousal/ reactivity symptoms: hypervigilance, irritability, sleep disturbances -​ Dissociative subtype: depersonalization (feeling detached from one’s body), derealization (world feels unreal) Treatment options: -​ First-line therapy: trauma-focused cognitive behavioral therapy (CBT) -​ Pharmacological management: -​ SSRIs -​ Prazosin for PTSD-related nightmares -​ Community and spiritual support: engagement with Buddhist monks, meditation, and culturally specific healing practices 2. What is the relationship between cultural barriers to Western medicine and adherence to treatment, and how can culturally competent care improve medication adherence and health outcomes? Barriers to Western Medicine: -​ Historical trauma and trust issues: Khmer Rouge survivors may distrust government-related institutions, including healthcare -​ Language barriers: low English proficiency leads to misunderstandings in medical instructions -​ Beliefs about health and medicine -​ Western medicine is seen as complementary to traditional methods -​ Preference for herbal remedies, coining therapy, or spiritual healing over prescribed treatments -​ Mental illness is viewed as a result of spiritual imbalance or bad karma -​ Medications perceived as short-term symptom relief rather than long-term management -​ Sharing medications among family members is common -​ Healthcare access issues: -​ Limited finances, transportation difficulties, and social isolation hinder healthcare access  -​ Fear of discrimination or stigma leads to avoidance of medical professionals Strategies for improving medication adherence and health outcomes: -​ Culturally competent care -​ Incorporate traditional healing practices into treatment plans -​ Train healthcare providers on Cambodian cultural perspectives -​ Use bilingual providers or interpreters -​ Education and communication -​ Provide translated educational materials -​ Use visual aids and oral instructions for those with low literacy -​ Involve family and community leaders in discussions about care -​ Building trust -​ Acknowledge cultural beliefs without dismissing them -​ Encourage discussion about traditional practices and integrate them safely with Western medicine -​ Adapting treatment plans: -​ Combining traditional Cambodian methods with Western therapy (mindfulness meditation and CBT) -​ Flexible scheduling and home-based care options for those with transportation challenges 3. What is the significance of latent tuberculosis (TB), including the impact of BCG vaccination on diagnostic testing and risk factors for reactivation? Pathophysiology: TB bacteria remains dormant in the body kept in check by the immune system -​ Reactivation risk increases with immunosuppression (HIV, diabetes, immunosuppressive drugs) BCG Vaccine: Given in many countries (including Cambodia) to prevent severe TB in children -​ Does NOT cause false positives of QuantiFERON-TB GOLD (QFT) or T-SPOT TB tests -​ Can cause false positives on Tuberculin Skin Test (TST) reactions but not in adults decades after vaccination Risk Factors for reactivation of latent TB: -​ HIV/AIDS, diabetes, immunosuppressive therapy (TNF-alpha inhibitors, steroids) -​ Chronic kidney disease, malnutrition, cancer -​ Increased risk in aging populations and those with a history of incarceration or substance abuse Precautionary Measures for Travel to Cambodia: -​ Vaccinations before travel: -​ Routine vaccines: MMR, TDaP, Polio, Influenza, Hep A and B, Typhoid  -​ Consider Japanese encephalitis, meningococcal, and rabies (if rural travel is expected) -​ Preventing other infectious diseases: -​ Malaria prophylaxis -​ Dengue prevention (avoid mosquito bites – use insect repellents) -​ Traveler’s diarrhea prevention (safe food/ water, may need antibiotics) -​ Post-travel screening: -​ TB testing, liver function tests (if on anti-TB meds), stool exam for parasites E4: Refugee and Immigrant Health 1. Distinguish refugees, asylees and migrants and describe the demographics of each group as part of larger US population. Refugees: apply for asylum before leaving their home country -​ Feeling persecution based on race, religion, nationality, political opinion, or membership in a social group Asylees: already in the US or port of entry when they apply for asylum -​ Must prove they cannot return home due to a well-founded fear of persecution Migrants: leave their country for reasons not related to persecution -​ such as economic opportunities, environmental disasters, or better living conditions Demographics: -​ Immigrants (including refugees and asylees) make up 13% of US residents -​ Refugees and asylees primarily come from conflict-affected regions such as Central America, Africa, and the Middle East 2. Describe the resettlement process as described by the UNHCR (the United Nations High Commission on Refugees) as well as patterns of global migration among refugees, asylees and internally displaced persons. Overseas medical exam: required under US immigration law (Title IV) -​ Identifies class A (active TB, untreated STDs, substance abuse) and class B conditions (disabilities requiring follow-up) Domestic medical exam: includes a physical, mental health screening (PTSD), infectious disease testing (TB, Hep B/C, HIV, STDs) and vaccinations Legal and social support: refugees receive assistance from resettlement agencies -​ Housing, employment, and healthcare enrollment Global migration patterns:  -​ Internally displaced persons: move within their home country due to conflict, disasters, or persecution -​ Refugees and asylees: common regions of origin include Syria, Afghanistan, Ukraine, Venezuela, and parts of sub-Saharan Africa -​ Economic migrants: From Latin America, South Asia, and Africa, often seeking better economic opportunities in the U.S. or Europe. 3. Describe health screening requirements, health disparities and determinants of health unique to immigrant populations. Key conditions to screen for: -​ Mental health (PTSD, depression, trauma) -​ Latent TB -​ Malnutrition, anemia, vitamin deficiencies -​ Hepatitis B/C -​ STDs (syphilis, gonorrhea, chlamydia) -​ Parasitic infections (Strongyloides, Schistosoma) -​ Vaccine-preventable diseases (measles, polio) Barriers to care: -​ Fear of deportation -​ Language barriers -​ Financial concerns (lack of insurance) -​ Cultural differences (distrust of Western medicine, gender-based healthcare preferences) Health disparities and social determinants: -​ Higher rates of chronic diseases (DM, HTN, CVD) due to stress, poor access to care, and dietary changes -​ Limited preventative care due to lack of insurance and healthcare literacy -​ Gender-based violence concerns in women 4. Describe how immigration status affects access to health care. Medicaid eligibility: -​ Refugees and asylees qualify for Medicaid upon arrival -​ Undocumented immigrants do not qualify but may receive emergency medical care Public charge rule: -​ Immigrants applying for a green card may be denied (viewed as a strain on the system) if they use public assistance for 12 out of 36 months, discouraging healthcare use Fear and misinformation:  -​ Many avoid hospitals due to fear of ICE -​ PCPs can ask about immigration status but should do so sensitively and only when medically relevant 5. Practice techniques for exploring cultural sensitivity. LEARN Model: -​ Listen to the patient’s perspective -​ Explore their beliefs and concerns -​ Acknowledge differences -​ Recognize cultural influences -​ Negotiate a treatment plan that respects their values Explanatory model: -​ What is your understanding of this condition → how is this treated in your home country Cultural competency techniques -​ Use culturally appropriate dietary recommendations and inquire about herbal remedies​. -​ Recognize that family decision-making may differ (e.g., husband making medical choices for wife). PBL #4: Mr and Mrs. NR 1. What is the nature of ALS (Amyotrophic Lateral Sclerosis), including its pathophysiology, progression, prognosis, and treatment options? Pathophysiology: a neurodegenerative disorder that affects upper and lower motor neurons -​ UMN findings: weakness with slow movements, hyperreflexia, and spasticity -​ LMN findings: weakness, atrophy, and fasciculations Two genes associated with it: -​ SOD-1 gene (Cu/Zn dismutase): mutations in this gene can cause ALS by leading to the accumulation of misfolded proteins in neurons and glia, eventually causing cell death -​ A gene coding for a protein involved in RNA processing: expansions of this gene can also lead to inherited forms of ALS Progression: leads to progressive muscle weakness, atrophy, and eventually paralysis -​ Lose ability to walk, use hands/ arms, speak, swallow, and eventually breath Prognosis: no cure for ALS and no treatment to stop the neuronal loss -​ Average survival time after diagnosis is 2-5 years (varies widely) Treatments: help manage symptoms and improve quality of life -​ Riluzole: decreases glutamate levels (toxic to motor neurons)  -​ Edaravone: free radical scavenger and antioxidant (helps protect motor neurons from damage) -​ Supportive care: physical therapy, occupational therapy, speech therapy, and nutritional support -​ Later stages may involve ventilators to help with breathing 2. What is the significance of “disability” as used in the ADA (Americans with Disabilities Act) versus in the Social Security Administration as it relates to employer responsibilities, accommodations, and/or benefits for individuals with ALS or other disabilities? ADA definition: someone who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is regarded as having such an impairment -​ Requires employers to provide reasonable accommodations to qualified employees with disabilities, unless doing so would impose an undue hardship on the employer -​ Reasonable accommodations: changes in the workplace that enable people with disabilities to perform the essential functions of their jobs -​ Making facilities accessible, restructuring jobs, providing part-time or modified work schedules, assigning employees to vacant positions, providing interpreters or readers, providing assistive devices -​ Broader definition, focuses on preventing discrimination and ensuring equal opportunities SSA definition: inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months -​ Provides social security disability insurance and supplemental security income -​ SSDI is for workers who have paid social security taxes and are now unable to work due to a disability -​ SSI is for low-income individuals with disabilities who have imited work history -​ Focuses on providing financial assistance to those who are unable to work Individuals with ALS may be eligible for both ADA protection and SSA benefits (depending on the stage of disease) 3. What are the nature of legal and ethical considerations, including advanced directives, and how do they influence care planning and guardianship decisions in terminal illness? Advanced directives: allow individuals to express their wishes regarding their future care, including end-of-life decisions -​ Living will: states whether a person wishes to have life-sustaining treatment if they have a terminal condition or are permanently unconscious  -​ Healthcare representative: allows patients to appoint a trusted individual to make healthcare decisions on their behalf -​ Voluntary designation of conservator: enables individuals, while competent, to designate a conservator who will be appointed by the probate court to manage their medical or personal decisions if they become incapable Guardianship: ensures minors are cared for and their assets are managed -​ Guardianship of the person: This involves responsibility for the care of a minor. -​ Guardianship of the estate: This involves managing the assets of a minor. -​ Temporary Guardianship: This is a temporary guardianship that is done through probate court and needs to be renewed every 12 months. -​ Post-death Guardianship: This is a permanent guardianship that is assigned after the death of a parent. E6: The Role of Conservatorships in Health Care 1. Identify and discuss the four elements necessary in a capacity evaluation; Communicating a choice: must clearly express a preferred tx option or decision -​ Frequent reversals of choice may indicate impaired capacity Understanding information: must grasp the fundamental aspects of their medical condition, tx options, and risks/ benefits -​ Ask pt to paraphrase the information given Appreciating the situation and consequences: must acknowledge their medical condition and understand the likely outcomes of their decision -​ Risks of refusing tx Reasoning about tx options: must be able to compare options logically and provide rationale for their decision 2. Describe the types and limits of conservatorship in the state of Connecticut and the protections built into the law; Conservator of person: manages personal affairs such as food, shelter, safety, and medical care Conservator of estate: manages finances, property, and financial decisions Special limited conservators: appointed for short-term purposes, such as consenting to psychiatric medication for a person in a psychiatric hospital Temporary conservators: appointed in emergencies to prevent immediate and irreparable harm Voluntary conservators: appointed as an individual request without a finding of incapacity, can be terminated with 30 days' notice Legal protections: -​ Cannot override civil rights unless explicitly granted by the court -​ Courts require strict evidence before appointing a conservator to protect the individual's independence -​ A conservator cannot force psychiatric medication without a special court hearing and order -​ A conservatory cannot move a person to a nursing home or sell their property without court approval 3. Distinguish cases of abuse of the conservatorship process; Common issues of exploitation: -​ Financial exploitation: misuse of assets under court supervision -​ Failure to audit conservatorship finances systematically -​ Conservators removed for cause: removal due to misconduct -​ Judicial oversight issues: local courts lack proper tracking systems, allowing exploitation to go undetected 4. Discuss the relevant competing ethical principles in conservatorship Autonomy: individuals should maintain as much control over their own decisions as possible -​ CT law prioritizes the least restrictive measures Beneficence: if an individual is unable to make safe decisions, a conservator may be necessary to act in their best interest Nonmaleficence: courts and healthcare providers must ensure that conservators do not harm or exploit the individuals under their care Justice: courts must ensure equitable treatment and protect individuals from undue influence or abuse by conservators **The challenge lies in protecting individuals who lack capacity while preserving the rights of those who may still make their own decisions E10: Wearable Health Technology 1. Define wearable health technology, describe the most popular products, the data they collect, and how they collect data. Wearable health technology: technology that can be worn on the body and perform some function for a wearer and/ or caregiver -​ In healthcare: have specialized sensor(s) that sense, measure, collect and present different health and fitness metrics -​ Fitness tracking, sleep tracking, heart rate Examples: -​ Apple Watch: blood oxygen, ECG, fitness, heart rate, sleep tracking -​ Fitbit: fitness/ sleep tracking, stress management -​ Oura ring: activity tracking, body temp, HRV, sleep tracking -​ Garmin: advanced fitness metrics, GPS, HR, sleep, VO2 max -​ WHOOP: HRV, recovery metrics, sleep, strain -​ Dexcom: glucose monitoring with real-time data How they collect data: specialized sensors to track physiological and environmental parameters -​ Heart rate monitor: photoplethysmography (PPG) to measure changes in light absorption -​ ECG: cardiac rhythm/ activity using electrodes to detect electrical impulses in the heart -​ Pulse oximeter: measures oxygen saturation using PPG -​ Temperature sensor: measures skin temp using thermistors/ infrared sensors to detect heat changes -​ Accelerometer: tracks movement and orientation by detecting changes in acceleration along 3 axes -​ Gyroscope: detects rotational/ tiling movements by measuring angular velocity -​ Galvanic skin response (GSR): measures skin conductivity changes caused by moisture from stress/ emotions Sensing → signal processing → algorithms → data communication → cloud storage/ local storage 2. Evaluate the benefits and potential risks of using wearable technology in evidence-based clinical decision-making a. Describe the most common sources of inaccuracies for various classes of wearable technology b. What evidence exists that wearable technology changes health outcomes -​ Answer is unclear as of now -​ Most study designs may be limited to truly detect effects over time -​ Need for more studies (one piece of a multifaceted intervention) Attributes of wearable tech: -​ Constant -​ Unrestrictive  -​ Not monopolizing -​ Observable -​ Controllable and responsive -​ Attentive/ environmentally aware -​ Communicative -​ Personal Concerns: -​ False negatives and positives -​ User error -​ Device inaccuracies (Fitbit devices were shown to overestimate sleep efficiency and underestimate wake counts compared with actigraphy) -​ Patient interpretation of the data -​ Physicians express concern that noisy data would lead to misdiagnosis and unnecessary concern 3. Describe how wearables affect barriers to care in different patient populations a. Describe the epidemiology of wearable technology -​ India has the highest rate of ownership (the US in 7th) -​ 28–41% of the US population uses wearable technology -​ US demographics; -​ Young to middle-aged -​ High SES -​ High education level -​ Urban residence -​ Female -​ Private insurance -​ Good health b. Describe new barriers created by wearable technology and ways to address those barriers -​ Technical (need better FDA regulation of data quality and increased diversity of study recruitment) -​ Device and data reliability -​ Ethnic underrepresentation -​ Healthcare overutilization -​ Data and integration (need to establish data standards, education on meaning of metrics, protection against sale/ misutilizaiton of health data) -​ Interoperability limitations (apple devices with Apple devices) -​ Monitoring benefits companies more than individuals -​ Data exacerbates health gaps -​ Economic and accessibility (healthcare team 1 on 1 education, insurance coverage for wearables) -​ Technological literacy -​ Adherence  -​ Predatory pricing -​ Sustainability (electronic recycling programs, extended software support or upgradability) -​ E-waste c. Describe the barriers wearable technology helps overcome -​ Bridging disability gaps -​ Braille smartwatch -​ AI vision assistance -​ Wearables for workplace safety -​ Warehouse smart vests -​ Airpods Pro 2 alternative to hearing aids -​ Cheaper, basic audiogram testing, protect against loud noise exposure -​ CGM use in T1DM and T2DM pts -​ Real-time (blood sugar values actively) ** better -​ Intermittent scan (store a record of 2 weeks, and only provide data when scanned) **no better than finger pricking 4. Evaluate the ethical and legal considerations of utilizing health data collected through wearable technology for both patients and healthcare providers Patients: -​ Privacy (can re-identify data) -​ The consent process contrasts with informed consent in healthcare settings -​ Data ownership remains unclear Providers: -​ Accuracy and reliability challenges -​ How much data should healthcare providers have access too? -​ Should they be held liable for breaches in data collected by wearables? Healthcare system: -​ Justice and equity (unequal access) -​ Data privacy and security -​ Corporate and system responsibility (ensure secure and ethical data use) -​ Cost perspective (divert funding from other public health needs) 5. Determine whether health data collected, stored, transmitted, and utilized from wearable technology is considered PHI and what appropriate regulations exist (if any) to ensure ethical and responsible use of the data a. Understand the value of informed consent and data anonymization as it pertains to wearable technology Protected health information: any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment -​ Pt names, elements of dates directly related to pt, device identifiers and serial numbers, IP address, biometric identifiers (finger and voice prints), photographic images Health Insurance Portability and Accountability Act of 1996 (HIPPAA): protect sensitive health information from disclosure without the patient’s consent -​ Those required to comply with HIPAA regulations are called “covered entities: -​ Health plans -​ Healthcare providers -​ Health care clearinghouses -​ Non-covered entities: -​ Life insurers -​ Employers -​ Law enforcement agencies -​ Municipal offices -​ Privacy rule: 2000 → Safeguards PHI -​ Health plans, health clearinghouses, and healthcare providers who conduct transactions electronically -​ Security rule: 2003 → protects a subset of info protected by the privacy rule (pt’s electronic health information, EPHI) -​ Protect confidentiality, integrity, and availability of electronic PHI -​ Unclear if monitoring a patient’s personal wearable device creates a physician-patient relationship requiring a duty of care -​ Enforcement rule -​ Standards for enforcement of all administrative simplification rules Gap where entities handling PHI are not covered by HIPAA -​ Have to partner with a HIPAA covered entity to be covered by HIPAA 6. Describe potential future applications for wearable technology in healthcare a. Describe potential future direction for innovations and evidence-based research in the application of health wearables to improving health outcomes HIPAA compliance? Increased accuracy Further accessibility of medical equipment to consumers Chronic and prevetnative disease management → providing real-time and cumulative information for physicians to analyze