Health Disparities

A health disparity is defined by Healthy People 2020 as a

"particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage"

Race, gender, and type of disability also affect

prevalence, health status and receipt of health care and screening. For example, African American women with intellectual disabilities are less likely to receive mammography than Caucasian women with intellectual disabilities.

Physiologic factors

Obesity increases the possibility of heart disease. Pregnancy places increased risk on both the mother and the developing fetus.

Questions to Ask to Ensure Quality Health Care for People with Disability: Secondary Health Conditions

•Does the patient have secondary health conditions related to their disability or its treatment? •Is the patient at risk for secondary health conditions because of environmental barriers or lack of access to health care or health promotion activities? •Are strategies in place to reduce the risk for secondary health conditions or to treat existing secondary health conditions?

People's values and beliefs about health, illness, and health care are influenced by

cultural and ethnic groups.

Genetic factors

A family history of cancer or diabetes predisposes a person to developing the disease.

Social Determinants Across the Life Stages: Adults

Access to and availability of healthier foods can help adults follow healthful diets. For example, better access to retail venues that sell healthier options may have a positive impact on a person's diet. These venues may be less available in low-income or rural neighborhoods. Longer hours, compressed work weeks, shift work, reduced job security, and part-time and temporary work are realities of the modern workplace and are increasingly affecting the health and lives of U.S. adults. Research has shown that workers experiencing these stressors are at higher risk of injuries, heart disease, and digestive disorders.

Major Areas of Risk Factors

Age Genetic factors Physiologic factors Health habits Lifestyle Environment

For example, people of ?? origin commonly sit and stand close to one another when talking, whereas people of ?? descent are more comfortable with more distance between themselves and others.

Arabic and African Asian and European

Admissions, Transfers, and Discharges

As a result of increasing costs and of health care cost reimbursement programs that are prospective rather than retrospective (meaning that costs are predetermined for specific illnesses or treatments, including severity of illness and cost of care), hospital admissions and lengths of hospital stay have decreased. More patients are having surgery, diagnostic tests, and emergency care in ambulatory care settings or on a hospital outpatient basis. Even patients who are admitted often stay for less than 24 hours, are admitted the morning of the surgery, or go home during an interim period between diagnosis and care. All this makes care coordination particularly challenging. All people who enter a health care setting take on a new role. They must add to their already established roles (e.g., spouse, parent, sibling, student) the role of patient. They also enter an environment in which strangers surround them and in which they encounter different sounds, sights, and smells. A competent, responsible, and caring nurse can make all the difference to an anxious, frightened, or confused patient and family. To meet patients' health care needs during the admission process, nurses provide holistic care and establish the basis for how patients will respond to and evaluate the remainder of their stay. Box 12-3 describes guidelines for establishing an effective nurse-patient relationship to ensure that each patient is considered as a person in any setting. During admission, the nurse acts not only as a health care provider but also as an advocate concerned about the welfare of the patient and the family. The admission period corresponds to the orientation phase of the helping relationship described in Chapter 14. In addition, regulatory guidelines direct both the continuity and the quality of care. For example, the Joint Commission standards for admission to a hospital assert that each patient's need for nursing care should be assessed by a registered nurse (RN). This assessment includes consideration of biophysical, psychosocial, environmental, self-care, educational, and discharge planning factors. In addition, nurses collaborate, as appropriate, with health care providers and members of other clinical disciplines to make decisions regarding the patient's need for nursing care.

The Health Equity Institute urges the following measures to eliminate avoidable health inequities and health disparities (Health Equity Institute):

Attention to the root causes of health inequities and health disparities—specifically, health determinants, a principal focus of Healthy People 2020. Particular attention to groups that have experienced major obstacles to health associated with socioeconomic disadvantages and historical and contemporary injustices. Promotion of equal opportunities for all people to be healthy and to seek the highest level of health possible. Distribution of socioeconomic resources needed to be healthy in a manner that progressively reduces health disparities and improves health for all. Continuous efforts to maintain a desired state of equity after avoidable health inequities and health disparities are eliminated.

Social Determinants Across the Life Stages: Older adults

Availability of community-based resources and transportation options for older adults can positively affect health status. Studies have shown that increased levels of social support are associated with a lower risk for physical disease, mental illness, and death.

For example, in some groups, illnesses are classified as either natural or unnatural. "Natural illnesses" are caused by "Unnatural illnesses" are

dangerous agents, such as cold air or impurities in the air, water, or food. punishments for failing to follow God's rules, resulting in evil forces or witchcraft causing physical or mental health problems.

Social Determinants Across the Life Stages: Adolescents

Because they are in developmental transition, adolescents and young adults are particularly sensitive to environmental influences. Environmental factors, including family, peer group, school, neighborhood, policies, and societal cues, can either support or challenge young people's health and well-being. Addressing young people's positive development facilitates their adoption of healthy behaviors and helps to ensure a healthy and productive future adult population. Adolescents who grow up in neighborhoods characterized by poverty are more likely to be victims of violence; use tobacco, alcohol, and other substances; become obese; and engage in risky sexual behavior.

Food and Nutrition

Food preferences and preparation methods often are culturally influenced. Certain food groups serve as staples of the diet based on culture and remain so even when members of that culture are living in a different country. Patients in a hospital or long-term care setting often do not have much choice of foods. This means that people with cultural food preferences may not be able to select appealing foods and thus may be at risk for inadequate nutrition. When assessing the possible causes of a patient's decreased appetite, try to determine whether the problem may be related to culture. It may be possible for family or friends to bring in foods that satisfy the patient's nutritional needs while still meeting dietary restrictions. Dietary teaching must be individualized according to cultural values about the social significance and sharing of food.

People from different cultures may also have different beliefs about the best way to treat an illness or disease.

For example, herbs are a common method of treatment in many cultures. In fact, many medications used today have a basis in herbs or other plant sources that have been used for centuries to cure illnesses. If a patient traditionally drinks an herbal tea to alleviate symptoms of an illness, there is no reason that both the herbal tea and prescribed medications cannot be used, as long as the tea is safe to drink and the ingredients do not interfere with or exaggerate the action of the medication.

Social Determinants Across the Life Stages: Children

Early and middle childhood provide the physical, cognitive, and social-emotional foundation for lifelong health, learning, and well-being. A history of exposure to adverse experiences in childhood, including exposure to violence and maltreatment, is associated with health-risk behaviors such as smoking, alcohol and drug use, and risky sexual behavior, as well as health problems such as obesity, diabetes, heart disease, sexually transmitted diseases, and attempted suicide. Features of the built environment, such as exposure to lead-based paint hazards and pests, negatively affect the health and development of young children.

Questions to Ask to Ensure Quality Health Care for People with Disability: Patient Education

•Are accommodations and alternative formats of instructional materials (large print, Braille, visual materials, audiotapes) provided for patients with disabilities? •Does patient instruction address the modifications (e.g., use of assistive devices) needed by patients with disabilities to enable them to adhere to recommendations? •Are modifications made in educational strategies to address learning needs, cognitive changes, and communication impairment?

People with disabilities often encounter barriers in their daily lives and in their efforts to obtain health care, health promotion, and preventive health screening.

For example, structural barriers such as stairs, lack of ramps, and narrow doorways may prevent people who are wheelchair users from entering facilities. Other structural barriers include restroom facilities that lack grab bars or sufficiently large restroom stalls, elevated toilet seats, and accessible sinks Structural barriers to accessibility are most easily identified and eliminated. Other less visible barriers include negative and stereotypic attitudes (e.g., believing that all people with disabilities have a poor quality of life and are dependent and nonproductive) on the part of the public. Health care providers with similar negative attitudes make it difficult for people with disabilities to obtain health care equal in quality to that of people without disabilities. The Rehabilitation Act and the ADA were passed more than 46 and 30 years ago, respectively, to ensure equal access to people with disabilities; however, people with disabilities continue to encounter and report multiple barriers to health care facilities and providers. This legislation, the U.S. Surgeon General's call to action (HHS, 2005) and the ADA Amendments Act of 2008 are examples of efforts to eliminate barriers encountered by people with disabilities.

Sociocultural dimension

Health practices and beliefs are strongly influenced by a person's economic level, lifestyle, family, and culture. In general, low-income groups, racial and ethnic minorities, and other underserved populations are less likely to seek medical care to prevent illness and have fewer treatment options, while high-income groups are more prone to stress-related habits and illness. The family and the culture to which a person belongs influence the person's patterns of living and values about health and illness; such patterns are often unalterable. All of these factors are involved in personal care, patterns of eating, lifestyle habits, and emotional stability. Examples of other sociocultural situations that influence health and illness are an adolescent who sees nothing wrong with smoking or drinking because her parents smoke and drink; parents of a sick infant who do not seek medical care because they have no health insurance; a single parent (abused as a child) who in turn physically abuses her own small son; and a person of Asian descent who uses herbal remedies and acupuncture to treat an illness.

Family Support

In many cultural and ethnic groups, people have large, extended families and consider the needs of any family member to be equal to or greater than their own. They may be unwilling to share private information about family members with those outside the family (including health care providers). Other cultural groups have great respect for the elders in the family and would never consider institutional care for them. Including the family in planning care for any patient is a major component in nursing care to meet individualized needs, especially if those needs can be met only through consideration of all members of the family.

Questions to Ask to Ensure Quality Health Care for People with Disability: Usual Health Considerations

•Does the health history address the same issues that would be included when obtaining a history from a person without disabilities, including recent preventive health screening, sexuality, sexual function, and reproductive health issues?

Health Disparities in the Gay, Lesbian, Bisexual, and Transgender (LGBT) Population

Healthy People 2020 (2018b) identified significant LGBT health disparities and seeks much-needed collaboration from health care professionals and policy makers to address them. Among its findings are the following: LGBT youth are two to three times more likely to attempt suicide. LGBT youth are more likely to be homeless. Lesbians are less likely to get preventive services for cancer. Gay men are at higher risk of HIV and other sexually transmitted infections, especially among communities of color. Lesbians and bisexual females are more likely to be overweight or obese. Transgender people have a high prevalence of HIV and sexually transmitted infections, victimization, mental health issues, and suicide: They are less likely to have health insurance than heterosexual, lesbian, gay, or bisexual people. Older LGBT people, referred to as elders by the LGBT community and trans elders in the transgender community, face additional barriers to health due to isolation and a lack of social services and culturally competent providers.a LGBT populations have the highest rates of tobacco, alcohol, and other drug use. These health issues are partly thought to be the effects of chronic stress resulting from stigmatization.b

Environmental dimension

Housing, sanitation, climate, and pollution of air, food, and water are elements in the environmental dimension. Examples of environmental causes of illness include deaths in older adults from inadequate heating and cooling, an increased incidence of asthma and respiratory problems in large cities with smog, and an increased incidence of skin cancer in people who live in hot, sunny areas of the world.

Emotional dimension

How the mind affects body functions and responds to body conditions also influences health. Long-term stress affects body systems, and anxiety affects health habits; conversely, calm acceptance and relaxation can actually change the body's responses to illness. As examples of the negative effects of emotions, a student may always have diarrhea before examinations and an adolescent with poor self-esteem may begin to experiment with drugs. The positive effects of emotions include reducing surgical pain with relaxation techniques and reducing blood pressure with biofeedback skills.

Who are the uninsured?

In 2015, nearly three quarters of the uninsured (74%) had at least one full-time worker in their family, and an additional 11% had a part-time worker in their family. People below poverty are at the highest risk of being uninsured (the poverty level for a family of 3 was $19,078 in 2015). In total, over 8 in 10 of the uninsured are in low- or moderate-income families, meaning they have incomes below 400% of poverty. Although a plurality (45%) of the uninsured are non-Hispanic Whites, people of color are at higher risk of being uninsured than Whites. People of color make up 41% of the nonelderly U.S. population but account for over half of the total nonelderly uninsured population. The disparity in insurance coverage is especially high for Hispanics, who account for 20% of the nonelderly population but nearly a third (32%) of the nonelderly uninsured population. Hispanics and Blacks have significantly higher uninsured rates (17.2% and 12.2%, respectively) than Whites (8.1%). Most of the uninsured (79%) are U.S. citizens, and 21% are noncitizens. Uninsured noncitizens include both lawfully present and undocumented immigrants. Undocumented immigrants are ineligible for federally funded health coverage, but legal immigrants can qualify for subsidies in the Marketplaces and those who have been in the country for more than five years are eligible for Medicaid (Henry J. Kaiser Family Foundation, 2017b).

Lifestyle

Multiple sexual relationships increase the risk for sexually transmitted infections (e.g., gonorrhea or AIDS). Events that increase stress (e.g., divorce, retirement, work-related pressure) may precipitate accidents or illness.

Physical dimension

Includes genetic inheritance, age, developmental level, race, and biological sex. These components strongly influence the person's health status and health practices. For example, inherited genetic disorders include Down syndrome, hemophilia, cystic fibrosis, and color blindness. Toddlers are at greater risk for drowning, and adolescents and young adult males are at greater risk for automobile crashes from excessive speed. There are specific racial traits for disease, including sickle cell anemia, hypertension, and stroke. A young woman whose mother and grandmother had breast cancer is more likely to have an annual clinical breast examination and mammogram.

Socioeconomic Factors

Low income is a major problem in the United States and is often described as having created a culture of poverty. A report from the U.S. Census Bureau (2014) noted that an estimated 15% of the U.S. population had an income below the poverty threshold. Of that population, the lowest income was found in African Americans, Native Americans, and Alaska Natives. In 2014, 21% of all children (15.5 million) lived in poverty—that's about 1 in every 5 children. On a single night in January 2016: An estimated 194,716 people in families, or 61,265 family households were identified as homeless. More than 19,000 were living on the street, in a car, or in another place not meant for human habitation. 120,819 were children under the age of 6 (National Alliance to End Homelessness, n.d.). There has been much debate about how to define poverty. In terms of economics, a person or family whose income falls below an established poverty line is considered poor. The U.S. Census Bureau defines poverty according to money or income guidelines that vary by family size and composition. If the family's total income is less than a set threshold, all members of the family are considered poor. Others have stated that poverty is a relative term that reflects a judgment based on community standards. Such standards vary at different times and in different places; what is judged to be poverty in one community might be regarded as wealth in another (Spector, 2013). No matter how poverty is defined, it is an increasingly devastating epidemic, fueled by real estate foreclosures and credit debt that has evolved into a culture of its own. At highest risk are children, older people, families headed by single mothers, and the future generations of those now living in poverty. Access to financial resources affects how individuals and families meet their basic needs and maintain their health. Poverty often leads to problems such as lack of health insurance, inadequate care of infants and children, lack of access to basic health care services, and homelessness. All these are of concern to nursing. The feminization of poverty threatens to increase the number of people who are living at poverty level. The number of female-headed households is increasing as a result of divorce, abandonment, unmarried motherhood, and changes in abortion laws. Because it is now common that two incomes are required in a household for economic survival, a single woman supporting a household is at a financial disadvantage. The number of single-parent families headed by women is associated closely with the increasing number of children living in poverty and the number of homeless families with children. The increasing population of older people has also raised problems associated with poverty. Many older people live on fixed incomes that often do not keep up with inflation, and many (particularly widows) are on the borderline of poverty or have already slipped below the poverty level. Socioeconomic status often differs by the cultural group of the older adult. For example, Pacific/Asian, African-American, Native American, and Hispanic elders generally have lower incomes than elders in the majority population. The work history of the cultural group, especially those who have labored all their lives as agricultural workers, often means that a person has no Social Security or Medicare benefits. In some cases, the culture of poverty is passed from generation to generation. This appears to be especially true in such groups as migrant farm workers, families living on public assistance, and people who live in isolated areas such as Appalachia. Poverty cultures often have the following characteristics: Feelings of despair, resignation, and fatalism "Day-to-day" attitude toward life, with no hope for the future Unemployment and need for financial or government aid Unstable family structure, possibly characterized by abusiveness and abandonment Decline in self-respect and retreat from community involvement Poverty has long been a barrier to adequate health care. It prevents many people from consistently meeting their basic human needs. The lack of affordable or adequate housing is a problem experienced frequently by poor people. When low-income housing is available, it sometimes lacks such necessities as running water, heat, and electricity. To stretch their available money and to pool resources, many poor people live in crowded conditions, with several families living together in one household. Research has demonstrated that crowded living conditions foster depersonalization, correlate with higher crime rates, and lead to psychological problems such as schizophrenia, alienation, and feelings of worthlessness (Spector, 2013). Such conditions also contribute to an increased incidence and severity of disease and illness because of the closer proximity of people, the sharing of utensils and belongings, poor sanitation, and poor health habits. Accessing health care facilities frequently requires transportation, which often is neither affordable nor available to poor people. Their access to health insurance also is frequently limited, and they often must choose between purchasing food and obtaining health care. Those in upper-income groups tend to live longer and to experience less disability than those in lower-income groups. Other barriers to health care include isolation, language or communication difficulties, seasonal occupations, migration patterns, depersonalization, and institutional prejudice

Tertiary examples

Medication Medical therapy Surgical treatment Rehabilitation Physical therapy Occupational therapy Job training

Effects of Illness on the Family

Most nursing care is given to patients with some form of support system, usually family members. When an illness occurs, daily life changes for both the patient and the family. For example, a chronic illness creates stress for the patient and family because of possible lifelong alterations in roles or lifestyle, frequent hospitalizations, economic problems, and decreased social interactions among family members. The responses of family members to an illness are also individualized. Some family members want to be with the patient all the time, while others might avoid visiting. Parents of a sick child often react with blame, overprotection, and severe anxiety, and family members of patients requiring intensive care often feel alone and frightened. In both cases, they might also feel guilty and imagine the worst possible outcome.

READ ABOUT ASSESSING COMMUNITY

READ ABOUT ASSESSING COMMUNITY PG. 878

Establishing an Effective Nurse-Patient Relationship During Hospital Admission

Recognize and take steps to reduce the patient's anxiety. Anxiety is a natural reaction to the unknown, but it can be reduced by therapeutic communication, teaching, and acceptance. Some common concerns that cause anxiety are: Will I have pain? Who will take care of my family if I die? Will strangers be looking at my body? How much will this cost? What if I can't keep my job? Encourage the patient and family to participate in and make decisions about all aspects of care. Remember that the medical or surgical condition for which the patient is being treated is only one part of the patient's life. Other concerns include family needs, financial status, and the future. Communicate with patients as individuals so that they can maintain their own identity. Ask patients how you should address them; some people prefer Mr., Mrs., Miss, or Ms. (last name), whereas others would rather be called by their first name. Do not call all older adults "Grandma" or "Grandpa." Do not refer to Mr. Jones, admitted to room 2218 for treatment of a ruptured appendix, as "the appendix in 2218." Take time to learn who the patient being admitted is, including that patient's cultural and religious background. Respect the patient's values and beliefs even though they may differ from yours.

age

School-aged children are at high risk for communicable diseases. After menopause, women are more likely to develop cardiovascular disease.

Secondary examples

Screenings (blood pressure, cholesterol, glaucoma, HIV, skin cancer) Pap smears Mammograms Testicular examinations Family counseling

Health habits

Smoking increases the probability of lung cancer. Poor nutrition can lead to a variety of health problems.

For example, in some ??s, being late is considered a sign of respect.

South asian

Spiritual dimension

Spiritual beliefs and values are important components of a person's health and illness behaviors (see Chapter 46). It is important that nurses respect these values and understand their importance for the individual patient. Examples of the influences of the spiritual dimension on health care include the Roman Catholic requirement of baptism for both live births and stillborn babies; kosher dietary laws, prohibiting the intake of pork and shellfish, practiced by Orthodox and Conservative Jews; and opposition to blood transfusion, common to Jehovah's Witnesses.

Human Dimensions

The factors influencing a person's health-illness status, health beliefs, and health practices relate to the person's human dimensions (see Fig. 3-1). Each dimension interrelates with each of the others and influences the person's behaviors in both health and illness. Nursing assessments of strengths and weaknesses in each dimension are used to develop a care plan that is individualized and holistic. The nursing process, used to plan, implement, and evaluate plans of care, is discussed in Unit III. Physical, Emotional, Intellectual, Environmental, Sociocultural, Spiritual

People with disabilities have also reported lack of access to information, transportation difficulties, inability to pay because of limited income, difficulty finding a health care provider knowledgeable about their particular disability, previous negative health care encounters, reliance on caregivers, and the demands of coping with the disability itself (HHS, 2005).

These issues affect both men and women with severe disabilities; however, women are at higher risk for receiving a lower level of health care than men. Women with disabilities are significantly less likely to receive pelvic examinations than women without disabilities; the more severe the disability, the less frequent the examination. In particular, minority women and older women with disabilities are less likely to have regular pelvic examinations and Papanicolaou (Pap) tests. Reasons given by women for not having regular pelvic examinations are difficulty transferring on to the examination table, belief that they do not need pelvic examinations because of their disability, difficulty in accessing the office or the clinic, and difficulty finding transportation (HHS, 2005). Health care providers often underestimate the effect of disabilities on women's ability to access health care, including health screening and health promotion, and they focus on women's disabilities while ignoring women's general health issues and concerns. Furthermore, women with disabilities have reported lack of knowledge about disability and insensitivity on the part of health care providers.

Nurse navigator

This term describes a clinically trained nurse responsible for the identification and removal of barriers to timely and appropriate cancer treatment. The nurse navigator guides the patient through the cancer care continuum from diagnosis through survivorship. More specifically, the nurse navigator acts as a central point of contact for a patient and coordinates all components involved in cancer care, including surgical, medical, and radiation oncologists; social workers; patient education; community support; and financial and insurance assistance. The nurse navigator has the clinical background to perform this role and is a critical member of the multidisciplinary cancer team.

Patient navigator

This term describes all types of navigators; the patient navigator may be a nurse, a social worker, or a lay person. The primary distinction is that the patient navigator (1) does not necessarily have a clinical background and (2) focuses on the support aspects of care. Thus, a lay person or a social worker can be a patient navigator. Depending on the patient navigator's background and training, his or her function can vary. In general, the patient navigator provides assistance with scheduling, financial assistance, psychosocial support, and community support.

Populations With Special Care Coordination Needs

Vulnerable populations are groups that are not well integrated into the health care system because of ethnic, cultural, economic, geographic, or health characteristics. Their isolation can result in these groups not obtaining necessary health care. Nurses are often on the front lines of advocating for these groups, but advocacy requires special knowledge, attitudes, and skills. We all have to ask ourselves, first, if we may have biases that interfere with our willingness to create respectful patient-centered partnerships with vulnerable people. Do we believe that chronic drug abusers, the homeless, "crazy old people," or people who do not speak English deserve the same respectful, compassionate, person-centered care that we would want for those we love most? Are we moved by the plight of those most in need? In 2013, a Washington Post columnist wrote about a "scary, abandoned hospital" in Washington, DC (the city had a $417 million budget surplus at the time) that was serving as a makeshift family homeless shelter; no one seemed to care about 600 kids crammed inside. "Stop and think about that. Six hundred kids with chubby cheeks and Spider-Man sneakers and Dora hats are beginning their journey in life on an army cot in a cafeteria or an old hospital bed in a city shelter. And that's an improvement from the time they spent sleeping in cars, bus shelters, Metro stations, apartment-house lobbies or on a different couch every night" (Dvorak, 2013). Nurses have a proud tradition of seeking to meet the needs of the most vulnerable; will the next generation of nurses continue this? Nurses also need specialized knowledge and skills to serve these people. It takes a special effort to "walk in the shoes" of a teenage single mother with three children under the age of four, or a homeless man with a history of chronic drug and alcohol abuse, to learn about who they are, what they need, and how best to help them. Think about a vulnerable population where you live, and try to interview some of its members. See if your class can devise a strategy to learn about them and then begin to meet their needs. Think about how community-based care coordination efforts can improve the health and well-being of the most vulnerable in your region.

Primary examples

Weight loss Diet Exercise Smoking cessation Reduced alcohol consumption Avoidance of illicit drugs Farm safety Seat belts and child safety seats Immunizations Water treatment Safer sex practices Effective parenting

Environment

Working and living environments (such as hazardous materials and poor sanitation) may contribute to disease.

Costs of care continue to be a factor in

delaying or forgoing health care despite changes brought about by legislation, including the ADA and the Patient Protection and Affordable Care Act (ACA) (see later discussion in this chapter). Working individuals with disability are two to four times more likely to delay necessary health care than those without disabilities. Lack of transportation and being refused care are also associated with failure to obtain needed health care among those with disabilities. Further, individuals with multiple limitations and more severe disabilities are less likely to obtain or receive health care than those without disabilities and those without multiple limitations or less severe disabilit

Questions to Ask to Ensure Quality Health Care for People with Disability: Insurance Coverage

•Does the patient have access to the health insurance coverage and other services for which they qualify? •Is the patient aware of various insurance and other available programs? •Would the patient benefit from talking to a social worker about eligibility for Medicaid, Medicare, disability insurance, and other services?

Medicare

is a federal health insurance program that is available to most people 65 years of age and older, people with permanent kidney injury, and qualified people with disabilities.

Tertiary Health Promotion and Illness Prevention

begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning. Nursing activities on a tertiary level include teaching a patient with diabetes how to recognize and prevent complications, using physical therapy to prevent contractures in a patient who has had a stroke or spinal cord injury, and referring a woman to a support group after removal of a breast because of cancer. Nurses play an important role in monitoring the responses of the patient to the prescribed therapy and in providing services to facilitate the patient's recovery or improve quality of life while living with the effects of an illness or injury.

Primary Health Promotion and Illness Prevention

directed toward promoting health and preventing the development of disease processes or injury. Nursing activities at the primary level may focus on people or groups. Examples of primary-level activities are immunization clinics, family planning services, providing poison-control information, and accident-prevention education. Other nursing interventions include teaching about a healthy diet, the importance of regular exercise, safety in industry and farms, using seat belts, and safer sex practices. Health-risk assessments are an important part of primary health promotion and preventive care. A health-risk assessment is an assessment of the total person. The resulting "picture" of the person indicates areas of risk for disease or injury as well as areas that support health. A variety of formats are used to perform this assessment, but all take a broad approach to health, focusing on lifestyle and behaviors. Box 3-3 contains an example of a health-style self-test the patient completes. As you work with patients in both hospital and community settings to provide care, use this self-test to help your patients assess their state of health and health risks, and learn a new health style through recommended lifestyle practices that support health.

Intellectual dimension

encompasses cognitive abilities, educational background, and past experiences. Whether or not someone can understand the causes of disease and the importance of healthy lifestyle behaviors can have a huge impact on health and wellness. These influence the person's responses to teaching about health and reactions to nursing care during illness. They also play a major role in health behaviors. Examples involving this dimension include a young college student with diabetes who follows a diabetic diet but drinks beer and eats pizza with friends several times a week, and a middle-aged man who quits taking his high blood pressure medication after developing unpleasant side effects.

Because of the persistence of these and other barriers, it is essential that nurses and other health care providers take steps to

ensure that clinics, offices, hospitals, and other health care facilities are accessible to people with disabilities. This includes removal of structural barriers by the addition of ramps, designation of accessible parking spaces, and modification of restrooms to make them usable by people with disabilities. Alternative communication methods (e.g., sign language interpreters, teletypewriter devices, assistive listening devices) and types of patient education (e.g., audiotapes, large print, Braille) are essential to provision of appropriate health-related information to people with disabilities. Such accommodations are mandated by the ADA, which requires their provision without cost to the patient.

Individuals with disabilities living in rural settings also face barriers associated with having

fewer resources and less access to care than those living in larger communities or urban settings. Therefore, establishing and maintaining involvement in their community can help ensure that they remain active and connected to others living around them, as described by Thurman, Harrison, and Walker (2019) (see the Nursing Research Profile in Chart 7-5). Additionally, those living in rural areas are less likely to have many types of recommended screenings

Secondary Health Promotion and Illness Prevention

focus on screening for early detection of disease with prompt diagnosis and treatment of any found. The goals of secondary preventive care are to identify an illness, reverse or reduce its severity or provide a cure, and thereby return the person to maximum health as quickly as possible. The Patient Protection and Affordable Care Act (ACA) of 2010, which broadens the scope of preventive care, also helps reduce health disparities so that underserved groups can reach their full health potential. Examples of nursing activities at this level are assessing children for normal growth and development and encouraging regular medical, dental, and vision examinations. Proposals to repeal the ACA are placing these preventive care options in jeopardy. Other activities include screenings (e.g., blood pressure, cholesterol, skin cancer), recommending gynecologic examinations and mammograms for women at appropriate ages, and teaching testicular self-examination to men. Direct nursing care interventions at the secondary level include administering medications and caring for wounds.

Health disparities are influenced by many different factors,

including race and ethnicity, poverty, biological sex, age, mental health, educational level, disabilities, sexual orientation, health insurance, and access to health care.

Transitional care

is ideal for patients with severe disabilities being discharged home. Patients hospitalized for an acute or secondary health condition may be more vulnerable to deterioration in health status or developing other health conditions because of their narrow margin of health or deconditioning that occurs with hospitalization. Important roles of the transitional care nurse are to ensure that required services are available in the home at the time of the patient's discharge, to assess and monitor the patient through home visits, and to provide support and assistance to the patient and the family in the aftermath of hospitalization and discharge

Chronic disease refers to

noncommunicable diseases (conditions not caused by an acute infection or injury), chronic conditions, or chronic disorders.

People with intellectual and developmental disabilities often need assistance in

obtaining health care, including preventive health screening. They often lack knowledge about cancer screening, including breast cancer screening. Educational materials and interventions modified to accommodate patients with intellectual and developmental disabilities are needed to enable them to make informed decisions about screening. Major barriers to breast cancer screening by this population of women include fear, anxiety, and embarrassment, primarily due to lack of understanding about cancer and the importance of its early detection.

Chronic diseases are long-term health conditions that affect

one's well-being and function in an episodic, continuous, or progressive way over many years of life. Although each chronic disease or condition has its own specific physiologic characteristics, many chronic conditions share common features. For example, common symptoms typically include pain, fatigue, sleep disturbances, and difficulty adjusting to the onset and uncertainty of a chronic condition (Larsen, 2019). Many people with chronic health conditions and disability function independently with little or no inconvenience to their everyday lives; others, however, require frequent and close monitoring or placement in long-term care facilities. Certain conditions require advanced technology for survival, as in the late stages of chronic obstructive lung disease or end-stage renal disease, or intensive care or mechanical ventilation for periods of weeks, months, or years. People with disorders such as these have been described as being chronically critically ill, although there is no consensus on a definition of chronic critical illness

Title II of the Social Security Disability Insurance program

pays benefits to those people who meet medical criteria for disability, who have worked long enough (40 quarters of covered employment) to qualify, and who have paid Social Security taxes. Title II also provides benefits to people disabled since childhood (younger than 22 years), who are dependents of a deceased insured parent or a parent entitled to disability or retirement benefits, and disabled widows or widowers, 50 to 60 years of age, if their deceased spouse was insured under Social Security.

examples of vulnerable populations

people with disabilities or multiple chronic conditions. (Think of Jeff Hart, the 9-year-old boy with severe intellectual disability, and review the case study of the Saxas presented in Box 12-2.) people with mental illnesses or substance abuse. cultural, racial, and ethnic minorities. the rural and urban poor, including the homeless. undocumented immigrants.

Many people and almost all institutions in the United States value

promptness and punctuality. When arriving for an appointment, doing a job, or carrying out an activity, being on time and getting the job done promptly are viewed as important. This is not true in some other cultures. For example, in some South Asian cultures, being late is considered a sign of respect. In addition, while some cultures are future oriented (including activities that promote future good health), other cultures are more concerned with the present or the past. Understanding the patient's orientation to time is important as you communicate, for example, the need to be on time for appointments for health care procedures and when taking medications.

Title XVI of the Social Security Disability Insurance program

provides supplemental security income payments to people who are disabled and have limited income and resources.

Disparities in health outcomes are especially common in

racial and ethnic minorities, in whom higher rates of obesity, cancer, diabetes mellitus, and AIDS are seen.

Health disparities

refers to health differences between groups of people; they can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death. Many different populations are affected by disparities, including racial and ethnic minorities; residents of rural areas; women, children, and the older adult; and persons with disabilities.

ADA in 1990

significant health status and health care disparities persist for people with disabilities. Furthermore, progress has been slow in ensuring that health care professionals receive adequate education about providing quality health care to them.

Basic human needs

something essential that must be met for emotional and physiologic health and survival. A person whose needs are met may be considered to be healthy, and a person who has one or more unmet needs is at an increased risk for illness.

Risk factor

something that increases a person's chances for illness or injury. Like other components of health and illness, risk factors are often interrelated. Risk factors may be further defined as modifiable (things a person can change, such as quitting smoking) or nonmodifiable (things that cannot be changed, such as a family history of cancer). As a person's number of risk factors increases, so does the possibility of illness. For example, an overweight executive under pressure to increase sales may smoke and drink alcohol in excess. These factors, combined with a family history of heart disease, place this person at higher risk for illness.

A key element of the health care law that took effect in 2014 provided a new way to get health insurance: ?????. The Marketplace was designed to help people more easily find health insurance that fits their budget. Every health insurance plan in the new Marketplace must offer comprehensive coverage, from doctors to medications to hospital visits. People can compare all their insurance options in terms of price, benefits, quality, and other features that may be important to them, in plain language that makes sense. As of the end of 2015, the number of uninsured nonelderly Americans stood at 28.5 million, a significant reduction. Even under the ACA, many uninsured people site the high cost of insurance as the main reason they lack coverage

the Health Insurance Marketplace

Personal space

the area around a person regarded as part of the person. This area, individualized to each person and to different cultures and ethnic groups, is the area into which others should not intrude during personal interactions. If others do not consider a person's personal space, that person may become uncomfortable or even angry. When providing nursing care that involves physical contact, you should know the patient's cultural personal space preferences.

Healthy People 2020 defines health equity

the attainment of the highest level of health for all people. Although health care is increasingly focused on the promotion of health and the prevention of illness, there continue to be disparities that lead to different health outcomes among different populations of people

Health promotion

the behavior of a person who is motivated by a personal desire to increase well-being and health potential. In contrast, illness/disease prevention, also called health protection, is behavior motivated by a desire to avoid or detect disease or to maintain functioning within the constraints of an illness or disability (Pender, Murdaugh, & Parsons, 2014). Health promotion and illness prevention activities are traditionally described as occurring on primary, secondary, and tertiary levels

care coordinator

the care provider (nurse case manager, social worker, community health worker, or lay person) who is responsible for identifying a patient's health goals and coordinating services and providers to meet those goals. To be effective, care coordinators must have expertise in self-management and patient advocacy, and must be adept at navigating complex systems and communicating with a range of people, from family members to PCPs and specialists. It is the responsibility of the care coordinator to identify life and health goals with the patient and to coordinate services and community supports to work with the patient and family toward better health outcomes. The care coordinator must also understand the strengths and gifts that the individual and family bring (their "assets"). This begins with conversations between the care coordinator and the patient about life goals and health goals, and how they interact. These conversations must be nonjudgmental, with the care coordinator taking an open, learning stance to understand the person's life context, challenges, struggles, and gifts. The care coordinator has ultimate responsibility for ensuring that the care plan is delivered as described, and for incorporating new knowledge to keep the care plan fresh and relevant. As the care coordinator and patient learn more about what promotes and what gets in the way of improved health, they are able to modify the care plan to meet the person's emerging strengths and needs.

Healthy People 2020 defines social determinants of health as

the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks

chronic illness refers to

the human experience of living with a chronic disease or condition.

Chronic illness includes

the person's perception of the experience of having a chronic disease or condition and the person's and others' responses to it, including health care professionals (Larsen, 2019). Persons' and their families' values and previous experiences determine their perceptions and beliefs about the condition, which in turn affect their illness and wellness behaviors. Their values are influenced by a number of demographic, socioeconomic, technologic, cultural, and environmental variables. Only the person and the family really know what it is like to live with chronic illness

In some cultures,

the power to heal is thought to be a gift from God bestowed on certain people. People in these cultures believe that these folk or traditional healers know what is wrong with them through divine intervention and experience. A patient accustomed to traditional healers may think that health care providers are incompetent because they have to ask many questions before they can treat an illness. Traditional healers speak the patient's language, often are more accessible, and are usually more understanding of the patient's cultural and personal needs.

Other traditional therapies include

the use of cutaneous stimulation, therapeutic touch, acupuncture, and acupressure. Cutaneous stimulation by massage, vibration, heat, cold, or nerve stimulation reduces the intensity of the sensation of pain. Therapeutic touch is an intentional act that involves an energy transfer from the healer to the patient to stimulate the patient's own healing potential. Acupuncture, long used in China, is a method of preventing, diagnosing, and treating pain and disease by inserting special needles into the body at specified locations. Acupressure involves a deep-pressure massage of appropriate points of the body.

National trends in efforts to prevent health disparities focus on

vulnerable populations, such as racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs.

Patient Protection and Affordable Care Act (PPACA),

which provides Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty, beginning in 2014.

Summary of Facts About People with Disability

•Approximately 61 million people in the United States have a disability, or one in every four people. •The prevalence of disabilities in adults is approximately 10% of people 18-64 years of age and 38% of adults 65 years of age and older. •The prevalence of disabilities varies by state and by gender, with higher prevalence in the South and among females. •More than 11 million people with disabilities require personal assistance with everyday activities (e.g., getting around inside the home, bathing or showering, preparing meals, and performing light housework). •Approximately 3.3 million people use a wheelchair; another 10 million use a walking aid such as cane, crutches, or walker. •More than 1.8 million people report being unable to see printed words because of vision impairment, 1 million are unable to hear conversations because of hearing impairment, and 2.5 million have difficulty with their speech being understood. •More than 16 million people have limitations in cognitive function or have a mental or emotional illness that interferes with daily activities, including those with Alzheimer's disease and intellectual disabilities. •Self-reported health status among adults with disabilities differs from that of people without disabilities, with fewer people with disabilities describing their health as excellent or good. •The percentage of people with disabilities who are employed ranges from 17.8% to 23.4%; of those without disabilities, the percent ranges from 63.5% to 66.2%. •Among all age groups, people with a disability are much less likely to be employed than those without a disability. People with a disability who work are more likely than those without disability to work part time. People with a disability who were not in the labor force (neither employed nor unemployed) are about 8 in 10, compared with about 3 in 10 of those without a disability. •Many people with disabilities would like to work but are hampered in doing so by limited access, lack of accommodations in the workplace, lack of transportation, and reluctance of employers to hire them. •The percentage of people with disabilities below the poverty level is more than twice that of people without disabilities.

Questions to Ask to Ensure Quality Health Care for People with Disability: Accessibility of the Health Care Facility

•Are clinics, hospital rooms, offices, restrooms, laboratories, and imaging facilities accessible to people with disabilities, as legally required by the Americans With Disabilities Act and Rehabilitation Act? •Has accessibility been verified by a person with a disability? •Is a sign language interpreter other than a family member available to assist in obtaining a patient's health history and in conducting a physical assessment? •Does the facility include appropriate equipment to permit people with disabilities to obtain health care (including mammography, gynecologic examination and care, dental care) in a dignified and safe manner?

Questions to Ask to Ensure Quality Health Care for People with Disability:Health Promotion and Disease Prevention

•Are health promotion strategies discussed with people with disabilities along with their potential benefits: improving quality of life and preventing secondary health conditions (health problems that result because of preexisting disability)? •Are patients aware of accessible community-based facilities (e.g., health care facilities, imaging centers, public exercise settings, transportation) to enable them to participate in health promotion?

Questions to Ask to Ensure Quality Health Care for People with Disability: Modifications in Nursing Care

•Are modifications made during hospital stays, acute illness or injury, and other health care encounters to enable a patient with disability to be as independent as they prefer? •Is "people-first language" used in referring to a patient with disability, and do nurses and other staff talk directly to the patient rather than to those who accompanied the patient? •Are all staff informed about the activities of daily living for which the patient will require assistance? •Are accommodations made to enable the patient to use his or her assistive devices (hearing/visual aids, prostheses, limb support devices, ventilators, service animals)? •If a patient with disability is immobilized because of surgery, illness, injury, or treatments, are risks of immobility addressed and strategies implemented to minimize those risks? •Is the patient with a disability assessed for other illnesses and health issues (e.g., other acute or chronic illness, depression, psychiatric-mental health, cognitive disorders) not related to the primary disability?

Hearing Loss (Hard of Hearing, Deaf, Deaf-Blind)

•Ask the person how they prefer to communicate. •If you are speaking through a sign language interpreter, remember that the interpreter may lag a few words behind—especially if there are names or technical terms to be finger spelled—so pause occasionally to allow the interpreter time to translate completely and accurately. •Talk directly to the person who has hearing loss, not to the interpreter. However, although it may seem awkward to you, the person who has hearing loss will look at the interpreter and may not make eye contact with you during the conversation. •Before you start to speak, make sure that you have the attention of the person you are addressing. A wave, a light touch on the arm or the shoulder, or other visual or tactile signals are appropriate ways of getting the person's attention. •Speak in a clear, expressive manner. Do not over enunciate or exaggerate words. Unless you are specifically requested to do so, do not raise your voice. Speak in a normal tone; do not shout. •To facilitate lip reading, face the person and keep your hands and other objects away from your mouth. Maintain eye contact. Do not turn your back or walk around while talking. If you look away, the person might assume that the conversation is over. •Avoid talking while you are writing a message for someone with hearing loss, because the person cannot read your note and your lips at the same time. •Try to eliminate background noise. •Encourage feedback to assess clear understanding. •If you do not understand something that is said, ask the person to repeat it or to write it down. The goal is communication; do not pretend to understand if you do not. •If you know any sign language, try using it. It may help you communicate, and it will at least demonstrate your interest in communicating and your willingness to try.

General Considerations OF Interacting and Communicating with People Who Have Disabilities

•Do not be afraid to make a mistake when interacting and communicating with someone with a disability or chronic medical condition. Keep in mind that a person with a disability is a person first and is entitled to the dignity, consideration, respect, and rights you expect for yourself. •Treat adults as adults. Address people with disabilities by their first names only if extending the same familiarity to all others present. Never patronize people by patting them on the head or the shoulder. •Relax. If you do not know what to do, allow the person who has a disability to identify how you may be of assistance and to put you at ease. •If you offer assistance and the person declines, do not insist. If your offer is accepted, ask how you can best help, and follow directions. Do not take over. •If someone with a disability is accompanied by another person, address the person with a disability directly rather than speaking through the accompanying companion. •Be considerate of the extra time it might take for a person with a disability to get things done or said. Let the person set the pace. •Do not be embarrassed to use common expressions, such as "See you later" or "Got to be running," that seem to relate to the person's disability. •Use people-first language: Refer to "a person with a disability" rather than "a disabled person" and avoid referring to people by the disability or disorder they have (e.g., "the diabetic").

Mobility Limitations

•Do not make assumptions about what a person can and cannot do. •Do not push a person's wheelchair or grab the arm of someone walking with difficulty without first asking whether you can be of assistance and how you can assist. Personal space includes a person's wheelchair, scooter, crutches, walker, cane, or other mobility aid. •Never move someone's wheelchair, scooter, crutches, walker, cane, or other mobility aid without permission. •When speaking for more than a few minutes to a person who is seated in a wheelchair, try to find a seat for yourself so that the two of you are at eye level (see Fig. 7-2A,B). •When giving directions to people with mobility limitations, consider distance, weather conditions, and physical obstacles such as stairs, curbs, and steep hills. •Shake hands when introduced to a person with a disability. People who have limited hand use or who wear an artificial limb do shake hands.

Questions to Ask to Ensure Quality Health Care for People with Disability: Disability-Related Considerations

•Does the health history address the patient's specific disability and the effect of disability on the patient's ability to obtain health care, manage self-care activities, and obtain preventive health screening and follow-up care? •What physical modifications and positioning are needed to ensure a thorough physical examination, including pelvic or testicular and rectal examination?

Questions to Ask to Ensure Quality Health Care for People with Disability: Communication Strategies

•Does the patient with a disability require or prefer accommodations (e.g., a sign language interpreter) to ensure full participation in conversations about their health care? •Are appropriate accommodations made to communicate with the patient? •Are efforts made to direct all conversations to the patient rather than to others who have accompanied the patient to the health care facility? •Is appropriate language (people-first language) used in referring to the patient?

Vision Loss (Low Vision and Blindness)

•Identify yourself when you approach a person who has low vision or blindness. If a new person approaches, introduce them. •Touch the person's arm lightly when you speak so that they know to whom you are speaking before you begin. •Face the person and speak directly to them. Use a normal tone of voice. •Do not leave without saying that you are leaving. •If you are offering directions, be as specific as possible and point out obstacles in the path of travel. Use specifics such as "Left about 20 feet" or "Right 2 yards." Use clock cues, such as "The door is at 10 o'clock." •When you offer to assist someone with vision loss, allow the person to take your arm. This will help you guide rather than propel or lead the person. When offering seating, place the person's hand on the back or the arm of the seat. •Alert people with low vision or blindness to posted information. •Never pet or otherwise distract a canine companion or service animal unless the owner has given you permission.

Questions to Ask to Ensure Quality Health Care for People with Disability: Independence versus Dependence

•Is independence, rather than dependence, of the patient with a disability the focus of nursing care and interaction? •Are care and interaction with the patient focused on empowerment rather than promoting dependence of the patient? •Is the patient aware of available resources and supports and do they know how to access them?

Questions to Ask to Ensure Quality Health Care for People with Disability: Cognitive Status

•Is it assumed that the patient is able to participate in discussion and conversation rather than assuming that they are unable to do so because of a disability? •Are appropriate modifications made in written and verbal communication strategies?

Questions to Ask to Ensure Quality Health Care for People with Disability: Abuse

•Is the increased risk for abuse (physical, emotional, financial, and sexual) by various people (family, paid care providers, strangers) addressed in the assessment? •If abuse is detected, are men and women with disability who are survivors of abuse directed to appropriate resources, including accessible shelters and hotlines?

Questions to Ask to Ensure Quality Health Care for People with Disability: Depression

•Is the patient experiencing depression? If so, is treatment offered just as it would be to a patient without a disability, without assuming that depression is normal and a result of having a disability?

Psychiatric-Mental Health Disabilities

•Speak directly to the person. Use clear, simple communication. •Offer to shake hands when introduced. Use the same good manners in interacting with a person who has a psychiatric-mental health disability that you would with anyone else. •Make eye contact and be aware of your own body language. Like others, people with psychiatric-mental health disabilities will sense your discomfort. •Listen attentively, and wait for the person to finish speaking. If needed, clarify what the person has said. Never pretend to understand. •Treat adults as adults. Do not patronize, condescend, or threaten. Do not make decisions for the person or assume that you know the person's preferences. •Do not give unsolicited advice or assistance. Do not panic or summon an ambulance or the police if a person appears to be experiencing a mental health crisis. Calmly ask the person how you can help. •Do not blame the person. A person with a psychiatric disability has a complex, biomedical condition that is sometimes difficult to control. The person cannot just "shape up." It is rude, insensitive, and ineffective to tell or expect a person to do so. •Question the accuracy of media stereotypes of psychiatric-mental health disabilities: Movies and media often sensationalize psychiatric-mental health disabilities. Most people never experience symptoms that include violent behavior. •Relax. Be yourself. Do not be embarrassed if you happen to use common expressions that seem to relate to a psychiatric-mental health disability. •Recognize that beneath the symptoms and behaviors of psychiatric disabilities is a person who has many of the same wants, needs, dreams, and desires as anyone else. If you are afraid, learn more about psychiatric-mental health disabilities.

Managing Disability and Chronic Illness at Home - At the completion of education, the patient and/or caregiver will be able to:

•State the impact of disability or chronic illness on physiologic functioning, ADLs, IADLs, roles, relationships, and spirituality. •State changes in lifestyle (e.g., diet, activity) necessary to maintain health. •State the name, dose, side effects, frequency, and schedule for all medications. •State how to carry out prescribed regimens (e.g., skin care, bladder/bowel care, daily weights). •State how to obtain medical supplies after discharge. •Identify durable medical equipment needs, proper usage, and maintenance necessary for safe utilization. •Demonstrate safe usage of adaptive equipment for ADLs. •Identify community resources for peer and caregiver/family support: •Identify sources of support (e.g., friends, relatives, faith community) •Identify phone numbers of support groups for people with chronic illness/disabilities and their caregivers/families •State meeting locations and times •Demonstrate safe mobility skills and/or how to access transportation. •Identify community resources for recreation: •State local recreation centers that offer programs for people with disabilities •Identify leisure activities that can be pursued in the community •State how to reach health care provider with questions or complications. •State time and date of follow-up appointments. •Identify the need for health promotion, disease prevention, and preventive screening activities.

Speech Disabilities or Speech Difficulties

•Talk to people with speech disabilities as you would talk to anyone else. •Be friendly; start up a conversation. •Be patient; it may take the person a while to answer. Allow extra time for communication. Do not speak for the person. •Give the person your undivided attention. •Ask the person for help in communicating with them. If the person uses a communication device such as a manual or electronic communication board, ask the person the best way to use it. •Speak in your regular tone of voice. •Tell the person if you do not understand what they are trying to say. Ask the person to repeat the message, spell it, tell you in a different way, or write it down. Use hand gestures and notes. •Repeat what you understand. The person's reactions will clue you in and guide you to understanding. •To obtain information quickly, ask short questions that require brief answers or a head nod. Avoid insulting the person's intelligence with oversimplification. •Keep your manner encouraging rather than correcting.

Intellectual/Cognitive Disabilities

•Treat adults with intellectual/cognitive disabilities as adults. •Be alert to the person's responses so that you can adjust your method of communication as necessary. For example, some people may benefit from simple, direct sentences or from supplementary visual forms of communication, such as gestures, diagrams, or demonstrations. •Use concrete rather than abstract language. Be specific, without being too simplistic. When possible, use words that relate to things you both can see. Avoid using directional terms such as right, left, east, or west. •Be prepared to give the person the same information more than once in different ways. •When asking questions, phrase them to elicit accurate information. People with intellectual/cognitive disabilities may be eager to please and may tell you what they think you want to hear. Verify responses by repeating the question in a different way. •Give exact instructions. For example, "Be back for lab work at 4:30," not "Be back in 15 min." •Avoid giving too many directions at one time, which may be confusing. •Keep in mind that the person may prefer information provided in written or verbal form. Ask the person how you can best relay the information. •Using humor is fine, but do not interpret a lack of response as rudeness. Some people may not grasp subtleties of language. •Know that people with brain injuries may have short-term memory deficits and may repeat themselves or require information to be repeated. •Recognize that people with auditory perceptual problems may need to have directions repeated and may take notes to help them remember directions or the sequence of tasks. They may benefit from watching a task demonstrated. •Understand that people with perceptual or "sensory overload" problems may become disoriented or confused if there is too much to absorb at once. Provide information gradually and clearly. Reduce background noise if possible. •Repeat information using different wording or a different communication approach if necessary. Allow time for the information to be fully understood. •Do not pretend to understand if you do not. Ask the person to repeat what was said. Be patient, flexible, and supportive. •Be aware that some people who have an intellectual disability are easily distracted. Try not to interpret distraction as rudeness. •Do not expect all people to be able to read well. Some people may not read at all.

Questions to Ask to Ensure Quality Health Care for People with Disability: Accommodations in the Home

•What accommodations does the patient have at home to encourage or permit self-care? •What additional accommodations does the patient need at home to encourage or permit self-care?

Questions to Ask to Ensure Quality Health Care for People with Disability: Aging

•What concerns does the patient have about aging with a preexisting disability? •What effect has aging had on the patient's disability, and what effect has the disability had on the patient's aging?