Thank you so much for waiting and your patience. Welcome, everybody. The topic that we're going to be discussing today is Bridging Cultures in Healthcare, Latinx Physicians' Journey in Treating Hispanic Patients with Brain Injury. My name is Hemagerd Alvarez, and I'm going to be your moderator today. Next slide, sorry. So we're going to, the way that we're going to do this is going to be, we're going to be here for about 75 minutes. So we, I found that the best way was not me talking all the time. So it's going to be a panelist and starting with me to a certain degree next. Just a little bit of intro. I think, I feel like I don't look like the person on the picture today. I actually embrace my Afro-Latina heritage with my curly hair. I'm the Medical Director of the NeuroRehab here at Christine Eidling Rehab in Miami with the University of Miami and Jackson Memorial Hospital. I serve as the Brain Injury Fellowship Program Director, and my role in residency is as the Chairwoman for the Programs Evaluations Committee. I am delighted to be here, and I'm very thankful to the next person that I'm going to present that is on the next slide is Dr. Abreu Sosa. Next, I'm sorry. Dr. Abreu, I'm very proud to be here in this panel. She's not only a colleague, but also a friend. She is the Medical Director at Roche Acute Inpatient Rehabilitation Unit, and she's been in this role since 2019. She's a board-certified physical medicine and rehabilitation, and more important for this event, she's the chair of the Latinx community members. Next, we have Dr. Miranda. Dr. Miranda is originally from Puerto Rico. I forgot to mention that all the panelists are from Puerto Rico. That's part of the Latino community as well. She has her medical degree from Ponce Health Science, and she completed her residency at the University of Miami. I'm proud to say that she's pursued her fellowship in brain injury medicine at Shepard Center and Emory University, and is now an attending stethoscietist at Miami Neuroscience Institute. And last but not least, also a fellow of Puerto Rico, Dr. Vivaldi. Dr. Vivaldi, I have to say thank you, because I know that you were just giving your orals and maneuver to be here as a panelist, so I'm very grateful of you for being here. She is raised in San Juan, Puerto Rico, and completed her residency at PMNR at NYU and Ross Institute of Rehabilitation. She also is a brain injury specialist, and did her fellowship at Kessler Institute of Rehabilitation. And currently, she is the program director at West Gables Rehabilitation Hospital. Next. So, good news, we have nothing to disclose about this topic. We can go to the next slide. So, what are the objectives? My goal in this process is to kind of define culture. We want to have an understanding of what cultural competence is in care and why this is so important. I want to be able for everybody who is watching also to identify what are the key challenges that presents when we have our cultural belief, what are our language barriers, and also promoting importance of the interdisciplinary collaboration. And I think this key as a psychiatrist, I think we are the creators when it comes to the team concept, and I do believe that other specialties are embracing our model. Next. So, what is culture? When we think about culture, we think about social forms, material traits, racial, religious, the social group. It's basically what are those characteristics that we share in everyday existence from a particular place or time. Another time that you listen to the term culture, it's when we think about institutions or organizations. For those of us that work in different hospitals, the term culture, it's used, now times we're doing Lucy, that's the culture of the system or the culture of the organization. All right, next. So, I want to give you some facts, because it's important to have some context regarding what changes have been made and what culture and cultural competence is important for different institutions. So, the Joint Commission in 2008 developed an accreditation standard aimed to foster the cultural competence patient-centered care in the hospital. These standards were informed in a report called The One Size Does Not Fit All, meeting the healthcare needs for diverse populations. This went through a process and got approval in 2009, but it was formally enacted in 2011, and what is more important that now, since 2012, which is when I actually started being and attending, this has been influencing accreditation. Next. So, let's talk a little bit about what is cultural competence, right?, because that is one of the elements that we have to think, because in today's diverse healthcare landscape, it's imperative that the caregivers and the people that we serve are not necessarily based on what we think or our beliefs, but also to adapt and understand where they're coming from, and it's the ability of an individual and organization to effectively deliver service that meets social, cultural, and linguistic needs of their clients. In healthcare and other service-oriented fields, cultural competence involves responding appropriately to those cultural differences that can influence how services are delivered and also how those services are received. Next, more importantly, it's important about thinking about what is the perception, what is the cultural lens. A patient's health and healthcare are shaped through what we see, how do we feel, and how do we also behave. Healthcare professionals must develop cultural competence to be able to provide quality care and effective outcomes for all patients. Next, so now the term Latino, Latina, Hispanic, Latinx, so when Dr. Abreu sent me the whole thing about the community and the Latinx was there, you know, it was interesting for me, because I didn't know, to be fair, about what the Latinx part component, so I did my Google search and I always expressed myself as Latino or Hispanic or, moreover, I say I'm Puerto Rican, but the Latinx was a term that was created in 2004, and the idea of this is just to create a more inclusive and a more gender-neutral alternative to the Latino and Latino community. I say that for the people that some people know, but I thought that it was kind of a fun fact. Now I'm going to give you some facts that I believe are important for you guys to know. So, did you know that 63.7 million of Hispanic, it's the Hispanic population in the United States as of July of 2022, making us the nation's largest racial ethnic minority? And I think this is important because you will also find out that the projection for the U.S. Census is that by 2060, we'll be potentially at 38 percent. Another fact that is important to note, 13 are the states that have one million or more Hispanic residents in 2022, and those states are Arizona, California, Colorado, Florida, which is the state that I am, Georgia, Illinois, I believe that Dr. Abreu is in Illinois, New Jersey, New Mexico, New York, North Carolina, Pennsylvania, Texas, and Washington, and that means a lot because one million people can make a difference when it comes to the element of representation and what are the things that we can potentially make an impact in this country. Next. This is the part that I was pretty taken about and surprised because despite that we are probably the biggest ethnic and racial minority group, only nine percent of the national health care practitioners and technicians are Hispanic, and moreover, out of representation when it comes to physicians, only seven percent physicians and surgeons, and seven percent is the registered nurse and Hispanic. This data is from the Pew Research Center analysis. So, I think that this is key because representation matters, and in my research of looking about how Hispanics feel, they sometimes want to be treated by somebody that also looks like them or speaks like them. Let's go now. What are the five facts that I want you to know about Hispanic Americans in health care? So, number one, Hispanic adults are less likely than other Americans to have seen a health care provider recently and to have primary care provider. I personally can discuss about that. A lot of my patients feel that I am their primary care physician, and although in a way I feel as I treat brain injury patients, a lot of these patients have never seen a doctor. Hispanic Americans are also less likely than people of other racial and ethnic backgrounds to have health insurance. The element of insurance is huge, right, because they will have less access and less opportunity to have that access to be faster. Many Hispanic Americans say worse health outcomes for Hispanics are tied to occupation and structural factors. For me, that work in the element of traumatic brain injury, we see a lot of, I see a lot of also like workers' compensation. As we know, one of the number one reasons for traumatic brain injury is fall, so the occupation and structural factors play a key role, so I kind of agree on this. And number four, about a third of Hispanic Americans, including five percent of Hispanic immigrants, say they prefer to see a Spanish-speaking health care provider. And, you know, I don't think that's their surprise of that. I think that any other ethnic group that cannot communicate, that represents a big challenge. And the other thing that I learned is Black Hispanic adults are more likely to report negative health care experience than other Hispanic adults. And when we think about Hispanic and we think about the Latinx community, we come in different colors and we're also a rainbow, so this is important to know. Next. So now I just want to talk a little bit about the component of traumatic brain injury when we think about brain injury. So, next, how big is the problem? So, when we think about how big is the problem, we think about 190 Americans died from a TBI-related injury since, into 2021, and 223,000, there were TBI-related hospitalizations in 2019, and 50 percent, 15 percent in 2019 of all U.S. high school students still reported one or more sports recreation-related concussions within the preceding 12 months. And we know, for us who practice brain injury medicine, some of these numbers potentially can be underreported. But I think what is important to know is that TBI is a major cause of death and disability. Next. The other element that I want to briefly discuss is outcome, and the reason that it's important about the outcome element is that when you think about your outcomes on persons with TBI, we see that 26 percent of those individuals will improve, but 30 percent of them can become worse, and the reason that this is important is because we know that traumatic brain injury is not just an acute event. It's something that has chronicity, to the point that currently the Brain Injury Association of America is trying to claim to the CDC that this condition should present more of a chronic condition and not necessarily just an acute event. Next. So, when we speak of epidemiology, we think about what are the groups that are going to be affected, and we are part of that group, so what we know is that when it comes to brain injury, there is health care disparities, right? So, racial and ethnic minorities are going to be affected, service members and veterans, people who experience homelessness, and people who are in correctional and detention facilities, and survivors of intimate partner violence, and people living in rural areas. Next. So, now let's talk a little bit about what is racial and ethnic minorities. I don't know if people know it, but to my surprise, the American Indian and Native Children and Adults have higher rates of TBI-related hospitalizations than other racial ethnic groups, and the factors that contribute to this disparity include higher rates of motor vehicle crashes, substance use, suicide, as well as difficulty in accessing profit health care. In addition, and this is the part that affects us, difference in race and TBI racial and ethnic minority groups, when you compare non-Hispanic Black and Hispanic patients, are less likely to have follow-ups. This is something that I can personally attest to that and experience, and this is also related to the difficulty having insurance and how do you communicate the importance of these steps. Next. Okay. The other element that we have to think about is income, right? People with lower incomes and those without health insurance have less access to TBI care. This part, reading about it, I kind of, how my teenagers would say, cringe about the element, just because people who have a TBI and have lower incomes and potentially don't have insurance are least likely to obtain a procedure, and I'm talking about craniectomy and craniotomy. We know as a physician and as we practice that that potentially can save a life, but not only about big surgeries. We'll be talking about a central line placement and an anterior line, and when it comes to what it pertains to us, patients after having traumatic brain injury, if they are poor, basically, and don't have health insurance, they will not receive inpatient rehabilitation and have those services, what we know that may change significant outcomes, and sadly, being poor and not having health insurance is very likely considered to die in the hospital. Next. All right. I know that I try to share about positive stuff and not so positive, but I want to, now this is an opportunity for my team of strong doctors here to navigate the brain injury treatment, so we're going to go now to go over cases, and based on those cases, I will have my colleagues discussing what would they do in this case and what would they try to make, what are the challenges and what do they do to help these patients. All right, next. Next. Okay. Sophia. Sophia is a 42-year-old right-handed Hispanic woman who recently suffered a traumatic brain injury or motor vehicle collision. She's a Spanish-speaking immigrant with limited English proficiency and lives in a predominantly English-speaking community. Upon admission to the hospital, Sophia struggled to communicate her symptoms and medical history due to use of lack of bilingual staff, and she felt she's in a daze and confused. Patient and family is trying to help Sophia and help her in making decisions. I just want to say to the team, what do you guys think are the potential challenges? Well, I can go first. She is Spanish-speaking immigrant. She says that she doesn't have English proficiency and lives in an English-speaking community, lack of bilingual staff, so there is really no opportunity for her to communicate her needs. She's feeling dazed and confused, so I think that being dazed and confused is part of the traumatic brain injury and not necessarily that she is lost in translation, but very well it could be, so if you have someone that can communicate but you have your family members trying to figure stuff out, all that is just a big challenge there. Okay, so the language barrier is a big component here. Yeah, absolutely, and then you mentioned also the element of lack of personnel who speaks the language, right? That can also be a big issue in the case of Sophia. Correct. Something that I've seen here in Illinois, because I'm in Chicago, there's a lot of immigrants that we treat in our hospital as well, and I think there's fear, you know, fear of many things. One is even though they want to express themselves, hopefully in Spanish, right, they believe that if they say something, somebody's going to come after them, so I have to convince them at times. Yeah, correct. I need to introduce myself, right? I'm bilingual. I ask them what they prefer. I switch to Spanish immediately. In my hospital, I'm a qualified bilingual staff. That means that I don't need a translator to be able to communicate with my patients or family members. In case the Joint Commission is around, right, I'm certified by the highest hospital standards, but I'm able to communicate in the patient's language, so when I do that and I start noticing perhaps, you know, more detailed history, maybe a little bit of puddles, right, on what they're trying to tell me, maybe I'm starting to pick up on certain things, right, that go with that brain injury, so it is highly important, you know, regardless of where you're at. Like you, Dr. Alvarez, presented earlier, there is a law that states that the patient should have access, right, in their first access to, what do you call it? Translation, translators. Correct, translators, yeah, in the hospital. Yeah, I will comment. I believe that Glenda Lizbos just raised her hand. Yeah, I think something that people maybe don't talk about as much also is that when the, like that language component can affect access, but it also can affect how other people evaluate the patients. Correct. Especially in a patient that has a brain injury, the patient could actually be worsening in their clinical status, but they're talking in their native language, and so there may be delayed treatment because people may just be minimizing and they think that they're just, oh, they're just talking in their language, and they're not picking up that this person is clinically compensating. The other thing that can happen is that these patients also can be exposed to more antipsychotic and sedative medications, which we know impact outcomes in brain injury, just because the other piece of it is that they might think that they're restless and agitated when they're all, when they're just trying to communicate and they're unable to do so. So I've seen patients that have been sedated because people just assume that they're agitated when it's just, again, like a language barrier. Yes. Thank you so much for providing that feedback there, and so like Dr. Bosquez mentioned, I think, you know, it seems some of the symptoms can get overlooked, and moreover, one of the biggest problems that can happen in this is you are delaying the care that this lady may need. Next, anything that Dr. Miranda want to say before I change to the next slide? Yeah, no. So, regarding this at the potential challenges, like, okay, so if the, if the, you know, that the patient can communicate well in that language, then, you know, the hospital should have that, you know, equipment to be able to use a translator, like there's translator lines. And I feel like a lot of times, the staff could get like a little bit lazy, because they don't want to do the whole process of getting the iPad if they have it at the hospital that helps with the translation or call the translator line. And that also then can lead to the delayed of care and everything else. I agree. I agree. So, can you go to the next slide? So, very important that I want to kind of highlight here is know your rights and duty, right? So, there are actually three laws that it's called one, the title six from the Civil Rights Act of 1964 that prohibits discrimination based on national origin including language. So, hospital receiving federal funds must provide language access services to patients with limited English proficiency to ensure meaningful access to healthcare services. You have to also think about the ADA, right, that mandates that hospitals offer us auxiliary aids and services such as qualified interpreters, patients with disabilities, including those who are deaf or hard of hearing to ensure effective communication. And the section 1557 from the Affordable Care Act that extends non-discrimination to health programs or activities receiving federal financial assistance reinforcing the requirement to provide language assistance services. And, you know, the reason that I put these three laws here is because, one, I think as physicians it's important that we know our legal terms, what things protect our patients. As physiatrists we need to, we work with disability disabled individuals. So, one of the biggest things that I feel like as a physician that I can provide to my community is to educate them, right, educate them. I'm so sorry, I got a little, okay, my lights went away. Okay, I'm back. The importance of what are their rights and also it's important to know what is our duty as doctors. So, if we know that they're to empower, the idea is to empower our patients. Next slide. So, after a stabilizing Sophia condition, the hospital prepared to discharge her to our rehabilitation facility. However, Sophia lives in a community with limited resources for Spanish-speaking patients. The nearest facility with appropriate services is far from her home, posing a significant logistical and financial challenge for her family. This is just adding to the picture. What do you guys are thinking? What are the challenges here? Dr. Vivaldi? Hello, good evening. Happy to be here. This panel is fabulous for weekends. So, obviously, there's big challenges in transportation and patients having access to outpatient clinics or that has specialists in brain injury and then the language again. It's a challenge and I feel like it's also a challenge for them to ask questions if they feel that no one will understand them. Any ideas of how you guys would assist and resolve this element? I mean, definitely, we have to get case management involved in the case because they can provide different resources to the family, like from money-wise to the rehab that may be close to where they live. And also, just like planning, what is the plan? What type of rehab are you looking for, like rehabilitation facility? And seeing, does the patient need that level of care? And then also explaining to the family, okay, maybe I understand it's far away right now, but that would be more beneficial than going home. So, it's just giving them all the options and really educating the family as to the option, but definitely getting social work so they can look for other stuff that we don't know about to help the family with financial services and all that. Yeah. One of the biggest things, we are here located in Miami and I work at the biggest county hospital that we have in the States. So, there is a program for patients who are in the community that despite not having insurance, potentially they get a short stay, which has been an incredible benefit here in Miami. However, I think what I think is important how to help and assist, I believe with Dr. Miranda, that is including that team of those social workers and the case manager, having that information. And again, comes to the education, I think it's very important to know what services you will have in your area. I don't know if you guys also see utilizing the technology, right? Utilizing technology, I know if you are in a group on Facebook or women's physiatry that has seen that you have questions and you can share it with colleagues to how to help, and I think that's important to have that collegial element as well. Have you encountered a similar experience with a patient like this? I have. I mean, I have many patients that feel that or they can't afford the transportation or they can't afford the copay when it comes time to leave the inpatient facility. So, I know that there's a hotline too for patients to call, and they can just leave a voicemail. It's through the American Brain Injury Association, and they can leave a voicemail, and then someone will answer in their preferred language. So, that's a good resource to have. Yeah. So, again, learning and knowing your resources, I think it's paramount to advocate for our community and help them as much as possible. Next. I'm sorry. Go ahead. It's okay. Here in Chicago, we do have in the hospital that I work at charity care services, not only for inpatient rehabilitation in the rehabilitation unit, but also for home health, and there's some cases that can also bring or come over to the outpatient clinic. I know for a fact that the charity care services at home, they're not frequent, right, but they can come. They go to the houses for therapy twice a week. They have nursing care, and they also have a voucher for 30 days of medications, right? There is a big push in the west side of Chicago, which is where the hospital is located, where they have different outreach programs in the vicinity of the hospital for that same reason, not only to provide the care for those patients that need it, but to make sure they don't get lost in the system, right?, because sometimes that can be a challenge, too. You do something for that patient while you're taking care of them in the hospital. Maybe you see them for the next two weeks, and then all of a sudden, because everything falls through, there's no continuation of care. They don't get to see their primary care. Nobody's following up on their medical conditions, so it is a big push and a big mission of this hospital, so I think we're very fortunate to be part of that, and I know that this is not the standard of care everywhere else. Yeah, but then again, I mean, everything, there is some organizations that ideally, when, you know, I think either when you're seeing a patient like this from, it could be from the consult perspective, it could be from the clinic perspective, but I think that it's important for us as physicians, and we owe to the community to have that knowledge to provide at least what are the steps that they should be able to follow. Next. So, Sophia experienced significant post-injury depression and anxiety. However, mental health services that cater specifically to the cultural and linguistic needs of Hispanic patients are scarce in the area, delaying her psychological recovery and impacting her overall rehabilitation progress. What do you guys think that we can do for her? I mean, especially now, there's a lot of telehealth options, so I think that would be a good idea, and just making sure that all this stuff is set up prior to her leaving the hospital, because if we know that the patient already has difficulty with the transportation with where she lives, you don't want her to get lost in the system, so making sure that she has those appropriate appointments prior to, with telehealth services, looking for physicians that, you know, speak Spanish, and on the websites usually now, especially like when you Google a doctor, usually it says like even like the languages that they speak and that they're able to provide, so I think that would be one of the things that could be done for her. Any other? One of the things that I think in her case, right, that you had, she has depression and anxiety, might have limited, is that component also of support groups, right? What are the support groups in the area? What are other resources on mental health or a clinic that potentially can provide these services free of charge? I agree with Dr. Miranda on the telehealth component. It could be an excellent resource that using technology can do. So, next, so that comes up to, honestly, outcome, right, so due to the compound disparities, Sophia's recovery is lower, right? She has, her integration into daily life is more challenging than might have been in a culturally competent, linguistically inappropriate, and accessible health care service, so, you know, what I wanted to depict in this case is like how we could help, but also what are the challenges that the Hispanic community can have when it comes to care? All right, next. So, what are the solutions, right, because we talk about her problem, so we, I think it's important to encourage the use of language services and also to facilitate those language services to the staff. I think it's key as there's a lot of fatigue when it comes to health care. If you provide technology and accessibility to the providers and the health care, it's easier to use the language services and educate the importance of this. Cultural training, I think training is important, and in my hospital, we do receive like a lecture that we have to take, and I think that that makes a difference. Know where your rehabilitation services are. I think we're located in providing this education and empower the community can help. Understanding what community-based support you have and to reach, and always the most important element is interdisciplinary approach. This is not something that only we do as physicians, but as the team members know, I have had a significant amount of therapists that are very versed on what other services are in the community and provide that education for the patients, so those are the ones that I think are solutions to this particular case. Next. All right, we're going to do the navigating the brain injury treatment again, but we're going to go to a different case, all right? Case number two. Okay, so we're going to talk about Ricardo. Ricardo is a fifty-nine-year-old Hispanic male who suffered a stroke that resolved cognitive impairment. Ricardo lives in a rural area where access to specialized neurological care is limited. The closest hospital with a neurology specialist and a rehabilitation care is over fifty miles away from Ricardo's home. Ricardo's family does not have reliable transportation, which complicates traveling to appointments. Communication between Ricardo, who's predominantly Spanish-speaking, and healthcare providers is strained. What are the challenges here? So, similar challenges to the first case with the transportation, with the limited access to care, and then the communication. So, this is not a one-size-fits-all. This is a person that has language communication and has cognitive issues, so you can imagine how difficult it is to navigate the system. So, I don't know if, you know, I wish help all the people that are here are part of the panelists, but navigating the system, even for somebody who has the education and being on the phone, is very difficult. It's press one, press two, press three, you know, so you can imagine the challenges that that presents. So, in this case, you know, he has limited specialized care near his home. So, I think, Dr. Miranda, you mentioned something for the other case that I think will apply on this one. So, because what will you offer, right, in a case that you have, that somebody's done so far? Yeah, as I, yeah, as I mentioned earlier about the telehealth visits, you know, because if the nearest is 50 miles away for any, like, type of rehab care, but maybe if they could start something with telehealth visit and seeing exactly what type of, you know, rehabilitation needs they can, helping him get resources for therapy also, like, via telehealth, or at least starting the process, like, if they have one visit telehealth, and then he can continue stuff, then at home, but providing those resources. Also, verifying with their insurance, like, are, can the insurance provide transportation to those places if they're far away, because since they don't have those in their area. So, also, that, and just, like, if he has family support, because right now, if we're just talking about, about him, about the patient, Ricardo, and then we're saying that he has cognitive impairments, is he, does he have people around him that can help him with the impairments that he, that he has right now? Yeah, no, that's, that's important. Another service that now I see that is provided is telehealth with speech therapy. So, speech therapy could be a good source for this patient to work on cognitive retraining with speech pathologists that can offer that. So, the transportation issues here in, I don't know, in your area, but here in Miami, we do have a transportation service that only charges patients $3. It's just an application process. Obviously, it's not ideal, because sometimes relying on the transportation, they get late, and so I don't know for, for the physicians that are in the call that, I mean, some of the patients coming late, and I'm trying to be a little bit more understanding, because just, I, I see that the transportation element could be a significant challenge. Piggybacking on what Dr. Miranda said also about involving the family, I think that there's a lot you can do, especially in the Hispanic community with their family and their, like, extended family in the community by training them on how to do some exercises, and it could be very helpful. I agree. I agree. And also, I guess, regarding the transportation, depending, you know, financially, how they are and all that stuff, you know, now there's so many, like, Ubers and Lyft. There's actually, like, I know here in Miami, they have, and I think even in the Keys also, they have, like, this transport that it's free for, like, some specific areas, so it's just also, like, knowing those types of resources, if they're available in that area. All right. Let's go to the next slide. So, I, you know, like, what are the solutions? So, I think we mentioned some of them. We're thinking about telehealth services, transportation services, and communication tools. There, you know, I do think that we have to use a lot of the whole machine learning. People now are on their phones regardless, right, so how, if you're going to have that device and you're going to have it at all times, so you might as well help your patients to use it, you know, and somebody who has cognitive deficits using different type of apps, people that have communication, even communication or language issues, you know, that there's Google Translate. There's different things that they can potentially use to help to make their life easier, so I think it's important to have that, again, education and empowerment to help these patients, and I think as a part of the community, we have the chance, even if it's one time that you get to access that patient, to be able to provide those tools. All right, we're going to go now to our last case. Can you go to case number three? Thank you. All right, so we have Roberto. Roberto is a 50-year-old Hispanic man who suffers a severe brain injury from a motor vehicle collision. He's deeply embedded in his community and values the close-knit nature of his extended family, who are an integral to his lifestyle and decision-making. In the initial stages of his hospitalization, Roberto's family finds it difficult to be involved in his care due to hospital policies that limit visitations and decision-making to immediate family members only. This restriction is contrary to Roberto's cultural values, where extended families often involve in patient care decisions. What are the challenges here? I can speak. He's Hispanic. We have a big close-knit community, you know, everybody under the sun that loves you and that knows of you wants to help out, and so this is a cultural thing, you know, but it could be manageable, especially after, I guess, identifying one key player. That is what I do here. I need to identify one or two key players, and then I communicate to those key players, who will then extend other information to other family members, because otherwise, they get too overwhelmed. Everybody is, you know, in your case, you're getting a lot of conflicting information. The patient is getting overwhelmed, so in this case, on contrary to the other two, he has a lot of support from his family, you know. They want to be integrated. They want to be involved. They just don't know how, and they need direction. Yeah, that is key. I mean, I recently can share a case that, I mean, everybody was in the room and talking about, and from my perspective, I could understand that, but I also can understand how other physicians say, like, there's too many people, but for the patient, it was helpful, so I know that we, I think that we have encountered this situation more than once. Any other suggestions? I think maybe, you know, not with maybe all the family, but some, as Dr. Abreu was mentioning, some, like, key family members doing the, like, team family, like a family conference, just to be able to really explain, go through the case especially if they have any questions and you can tell them like hey bring a list of questions of of all your other family members um and that way like to keep it like closer with those like like tighter people and then they can also like let the other person in their in their family know. Yeah so I think it's important to have identifying key key members without making um making the feel part of the decision making of the process. I think that's as Latinos uh we learned that whenever there is an issue uh you will ask your tia, tío, primo, everybody uh will be be part of the whole um process as well. So I think this is uh um kind of make us kind of unique in that element um uh when when we when we compare ourselves to other other cultures as well. And when COVID was going on that clearly wasn't uh an issue but now that's now there's like I saw a consult yesterday I went into the room and there was 10 people in 10 people in the room you know so it's and it can get crazy definitely. Yeah but I think you know that the I think ultimately this is when you want to apply um cultural competence and although we as Latino may understand that concept uh sharing and um you know educating also our colleagues regarding this type of difference can also be helpful as well. All right so uh I think that this is we cover uh well on on this case. Can we go to the next? Okay decision making so I I think that we we touch on this this is um when it comes to decision making and we're talking about the Latino cultures although there's great diversity among Latino cultures I want to kind of to touch on that because you know when we think about Latinos know when we think about Latinos there's so many of us and all we have uh different kind of words that we might say different and some foods that might be uh different one but what we definitely share is that uh we uh we have a collective approach to things rather than a uh individualistic uh decision making. So the family not the individual is the most often they're gonna make that decision. So I think that it's important to to know that although they might be a lot of opinions as long as that cultural belief is not harmful uh to the patient um caregivers should not should support them right and and no matter how strange uh or unreasonable they they may seem from the caregiver's cultural perspective. So you know like I think uh it's important from the cultural competence uh element uh you know no judgment and try to understand um why they want to make decisions like that. I do want to add like something that I think um it's also important when especially when there's a lot of people a lot of family sometimes they are more opinionated that the patient themselves and then maybe not necessarily that's what the patient wants. So I think it's very important to kind of if you're kind of noticing that's what's going on like really hey can you step aside I need to talk to the patient just specifically so then we know what he wants or the patient wants and not necessarily what what the family wants especially if they're cognitively there and everything. Absolutely, absolutely. I think there are actually a question on training like how to when you have the room full of people and you're about to discuss that the proper way to do is to remove everybody from the room discuss things with the patient and then bring them over and you know to see how the the patient so it's it's important to exercise despite the whole element of our culture the um the autonomy element right it's important to just taking into account that family is going to be there and it's okay. All right, next. So we discussed a bunch of things from the language element to low socioeconomic elements as far as health insurance so what we can summarize are the challenges is access to care particularly for immigrants present significant challenges compared to non-Hispanic white Hispanics with TBI report longer wait times to see an emergency room physician they're also more likely to be discharged home which is something that we have discussed here today that you know it could be lack of access lack of insurance so they're less likely to receive rehabilitation service following an acute hospitalization and have worse functional outcomes at one year post-injury you know I read this and you know I feel terrible that this this happens and how do we can potentially change this. Ethnic disparities in outcomes following TBI may be partially explained by the insurance status a lot of people like I said I think I mentioned the number probably like 58 percent are not insured and uninsured Hispanics with TBI are greater risk for mortality compared to African Americans and uninsured non-Hispanic whites with TBI. Whether privately insured publicly insured or uninsured Hispanics have a lower rate of receiving post-acute care following hospitalization. Primary language is a potential contributor to these disparities and over 70 percent of Hispanics in the United States speak Spanish at home so you know the issue of language although I mentioned it in several of the slides it's a it's a it's a big big element. Next I want to show you guys something of are looking and I'm doing my research on this on this topic I run into this article called Soy Diferente and it's a qualitative study on the perception of recovery following traumatic brain injury among Spanish-speaking U.S. immigrants and I was I have to say very happy to find this article because a lot of the things that I found were things that you know wake up in me the element of advocacy and some of the data is also negative but what I'm most proud of is like they did this study right that so the purpose was to explore the impact of traumatic brain injury on the quality of life and the self-concept of the Spanish-speaking U.S. Hispanic immigrants so basically it was a prospective study qualitative study and it was conducted in a level one trauma center in a community and they did a semi-structured interviews and they conducted this with 24 so it's a small a small sample of speaking so the results and the conclusions on this case is that Spanish-speaking and Hispanic immigrants held a strong faith and a positive outlook after TBI and in spite of significant barriers to recovery I needed so I think that speaks highly about our positive mentality and how our community see things in a different perspective despite the difficulty that they can encounter this could be related to the fact that family is very important to us so perhaps those 10 people sometimes are in their room might help you to make the process a little bit better there is no doubt that there's need to support and and the recovery of the Spanish-speaking population so I wanted to have you get you can look this article out it's pretty good so I was happy to be able to share this with you next so I mean we're later going to potentially have questions but I what I want you to take home it's the importance of addressing barriers right Spanish-speaking Hispanic immigrants often encounter significant obstacles following a TBI social success and suitable rehabilitation service which we had mentioned and re-mentioned in this presentation the importance of obtaining that follow-up care recognizing and addressing this virus is essential for effective recovery like I mentioned in the in the previous article you know the role of faith and social support this is important for the Hispanic community rehabilitation professionals should acknowledge the vital role of faith and the benefit of positive thinking in the recovery process encouraging active social support from the family friends and community and can significantly aid in coping with TBI related challenges and I think this is important because I think recovery is not only on one person I think it's important to implement the social support and the support groups more and more data kind of talks about the phenotype and genotype of the traumatic brain injury and express how the social interactions are key for recovery the importance of enhancing communication right the provision of Spanish-speaking rehabilitation professionals translator in Spanish language educational material is crucial so where all of the people that are on this call get you know fired by this and we need we need more Latino doctors we need more Latino health care professionals so I think that we have we have a duty to perhaps do more things like this to motivate others to serve other community particularly where we're the the highest growing community in the United States and we need to make an impact the other thing is community partnership rehabilitation facilities must forge partnerships with community-based organizations and to serve the uninsured these collaborations are critical for improving access and necessary so the concept of team the concept of talking to each other is important to improve the environment next my future vision and I hope and I don't know I want to so you know when I after getting all this information I'm thinking what what would be an ideal place so you know we need to have multilingual education materials and this is something that already exists my next slide I believe that is on all resources and it's important to to know that the TBI translation service offers both information for traumatic brain injury in English and Spanish of the potential I'm sorry bye all right I apologize for that the I was talking about the TBI translation service the TBI translation service is all both from the from the model system from both spinal cord injury and traumatic brain injury and they have significant resources in both languages so I think that's a tool that you have to have to think about in the importance of integrating care coordination so implement our care coordination program that includes follow-up calls it won't be ideal if somebody can call those patients say how how things are doing in particular in Spanish in their in their own language and clarify the treatment plans and answer any questions post-discharge this has been my dream I always want a discharge navigator somebody who calls the patient 72 hours hey did you receive everything that you needed is there anything else that we can do for you because I I often feel that when my I see my patients four to six weeks and some of them unfortunately because of insurance because of all the hurdles that they have may come late there are things that were missed and and the patient I find that is decompensated and and I have to kind of work straight for again having cultural and community resources network create networks for our community resources that can provide support service for the Hispanic community a cultural liaison or an advocate you know like somebody who is ideally in the hospital and try to navigate patients of difficulty and understanding what where they're going through and in dealing with medical and rehabilitation needs so I believe that by implementing this solution healthcare provides can better address the specific needs for the Hispanic patients all right next the resources so for everybody who's listening think about the brain injury association of america that it's a have great resources and great uh tools the model system knowledge translation center um and uh 60 oh thank you to dr michelle uh that is there um there's 60 model system in the nation so uh you know there's this work on the research that is being done um find out your organizations that can help on your state I think it's important and I think after all everything that is on this session I want you to think about advocacy you know I I think like by reading this about where we are in the in the right now in the United States why is our position as our our Hispanics and Latinos we do have a duty to our patients and to our fellow um you know uh to to do advocacy for us to help us to so we have better care and uh you know people don't die just because of their Hispanic just because they didn't receive uh the the actual care all right I think that's it thank you I wanna all right I wanna you know say thank you Dr. Alvarez Jorgema for uh putting this talk together and getting us all together and for Dr. Vivaldi Dr. Miranda for being available and uh able to support our our colleague and friends Dr. Dr. Alvarez I I wanted to mention something uh very quickly that I've seen here um you know of course I I'm a hospitalist I'm Puerto Rican just like everybody else here I'm I'm Latina I did practice in in Puerto Rico for about six years before coming back to the mainland to Chicago and and working in in Chicago and um I guess I was so used to speaking my native language and um you know used to the cultural norms right that are defined Hispanic here um yes there was a little bit of fear there was a little bit of struggle and confusion and I learned that when I was a resident training here but I think there is a lot of immigrants here that rely on their children you know children are the ones that are becoming the um advocates for them you know they translate for them they pay attention to um you know their medical conditions medications that their parents or grandparents are going through and at times they also can get into translation so it's really important to pay attention to that particular group of children right or or uh people right they they also need support and um and also those patients that are bilingual and then because of a catastrophic event from a stroke or TBI they sort of lose one of the languages right they either lose the ability to speak Spanish or vice versa they can't speak English and everything now again it's in Spanish and then you have to rely on the parents now you know how to communicate in the parents native language so that we can close that gap you know from um health care um and I happened this was so vivid two weeks ago I sent a patient home was bilingual after a stroke um from a cabbage and um he lost all the ability to speak in Spanish um his parents are immigrants they only speak English and they're uh sorry Spanish and uh they have poor poor health literacy so there are a lot of words that they don't understand so you have to really break it down to a very simple level so navigating what it will be to go home you know where is the nearest pharmacy that you need to go to get medications the equipment that you will need when do I need to think all of that you know was was a lot of work not because I had to do it but also I needed to bring in my supportive team like you're saying my therapist my community my case managers to truly speak to that family members in their language so so that that could be a successful discharge home a successful you know continuation of life and I think that is an important element that we should think about you know not because we're immigrants working in this country we're Hispanics and we have a catastrophic event it's not it's not the end the end of all you know um they have us like everybody that is in this call is the perfect representation of why we're here why we went into medicine and uh what it means to be Hispanic at the end of the day so I I truly appreciate everybody's time uh I'm just going to open the floor to anybody just if anybody has any questions or comments um I wanted I wanted to add something I think the whole um I I appreciate Dr. uh Dr. Buskus that said don't be fearful about asking the system to change even if this feels like small change I think it's important we need to be our own voices we need to you know again advocacy it's it comes in different ways so I think it's important to to to represent you know represent the Latino and and work and and you know utilizing uh encourage your other colleagues to utilize language services encourage you know for me residents even when they're presenting I'm like do you use the language line because sometimes they say that they speak the language but they don't speak that much and then when I go in it's like a a lot of other stories so it's important to use our resources yeah and I think it's just also like education to to a staff like um I had one day in clinic that the MA came to me and she was like oh yeah um yeah he's taking all the meds but he was trying to tell me something and I wasn't really understanding it oh okay um so the the she's okay um so the the she's like oh they speak Spanish I'm like oh don't we have you know the the iPad that you can call and she's like oh yeah but that takes too long so you know it's also like okay but you know we really want to make sure like that we're not missing stuff just because it's a little bit more work um so I think that's also like something important just you know we have to take that time to make sure that the patient feels comfortable and that we're understanding what they're trying to say to us yes hi um I just wanted to make a comment uh my name is Lucila I'm a fourth year medical student about to be a PGY1 in July um I just wanted to uh make a comment and say that I really enjoyed kind of the end of the presentation as well with like the future vision and the resources I think that's really helpful um for a lot of us that are just starting off um our careers and I think it's uh just helpful to know kind of the things that we can use and um think about as we start thank you thank you I really appreciate those comments I think uh where we you know I think it's important to define where are we the goal masters uh as physiatrists you know like what are our goals I think it's it's important to know you know what do we want to do for our community okay I think we uh Dr. Abreu I think we have a little bit uh shorter I try to speak slow me too I did try my best well you got it and it was beautiful so I really thank you I really really appreciate everybody that kind of jumping in in the in the view this it's I do believe it's recorded so um you can speed me or slow me uh in the process but I I just want to say thank you so much to my colleagues that participate in this and I hope that the information that was provided encourage you to make a a difference uh for our community yeah well said thank you very much so I wish everybody a good evening and uh hope to see everybody in November right where are we going San Diego San Diego oh my god and I want to throw a shout out to I mean I'm I'm uh tech uh technically challenged and so thank you so much um for the APME art uh people that were like supporting and moving my slides I really appreciate you not a problem not a problem thank you have a good evening bye

Dr. Hernandez Alvarez

Latinx physicians

Hispanic patients

brain injury

cultural competence

language barriers

interdisciplinary collaboration

telehealth services

care coordination

community partnerships