Emergency department patient-centred care perspectives from deaf and hard-of-hearing patients.

BACKGROUND: Deaf and hard-of-hearing (DHH) patients are a priority population for emergency medicine health services research. DHH patients are at higher risk than non-DHH patients of using the emergency department (ED), have longer lengths of stay in the ED and report poor patient-provider communication. This qualitative study aimed to describe ED care-seeking and patient-centred care perspectives among DHH patients. METHODS: This qualitative study is the second phase of a mixed-methods study. The goal of this study was to further explain quantitative findings related to ED outcomes among DHH and non-DHH patients. We conducted semistructured interviews with 4 DHH American Sign Language (ASL)-users and 6 DHH English speakers from North Central Florida. Interviews were transcribed and analysed using a descriptive qualitative approach. RESULTS: Two themes were developed: (1) DHH patients engage in a complex decision-making process to determine ED utilization and (2) patient-centred ED care differs between DHH ASL-users and DHH English speakers. The first theme describes the social-behavioural processes through which DHH patients assess their need to use the ED. The second theme focuses on the social environment within the ED: patients feeling stereotyped, involvement in the care process, pain communication, receipt of accommodations and discharge processes. CONCLUSIONS: This study underscores the importance of better understanding, and intervening in, DHH patient ED care-seeking and care delivery to improve patient outcomes. Like other studies, this study also finds that DHH patients are not a monolithic group and language status is an equity-relevant indicator. We also discuss recommendations for emergency medicine. PATIENT OR PUBLIC CONTRIBUTION: This study convened a community advisory group made up of four DHH people to assist in developing research questions, data collection tools and validation of the analysis and interpretation of data. Community advisory group members who were interested in co-authorship are listed in the byline, with others in the acknowledgements. In addition, several academic-based co-authors are also deaf or hard of hearing.

Communication Access In Mental Health And Substance Use Treatment Facilities For Deaf American Sign Language Users.

Deaf and hard of hearing (DHH) American Sign Language users experience significant mental health-related disparities compared with non-DHH English speakers. Yet there is little empirical evidence documenting this priority population's communication access in mental health and substance use treatment facilities. This study measured mental health and substance use treatment facilities' noncompliance to Section 1557 of the Affordable Care Act (ACA), which requires health care facilities receiving government funds to provide effective communication access, such as a sign language interpreter, to DHH patients. Using nationally representative data from the Substance Abuse and Mental Health Services Administration, we found that 41 percent of mental health facilities and 59 percent of substance use treatment facilities receiving public funds reported not providing services in sign language in 2019 and were thus noncompliant with the ACA's mandate to provide accessible communication to DHH patients. We mapped these data to display state-level noncompliance, and we make detailed recommendations at the policy, facility, and provider levels. These include monitoring noncompliance among government-funded facilities, expanding state-by-state mental health licensure reciprocity and telehealth policies to improve access to American Sign Language-fluent mental health professionals and addiction counselors, establishing systematic processes to collect information on disability-related accommodation needs, and increasing the workforce of DHH American Sign Language-fluent providers.

Emergency department condition acuity, length of stay, and revisits among deaf and hard-of-hearing patients: A retrospective chart review.

OBJECTIVE: Deaf and hard-of-hearing (DHH) patients are understudied in emergency medicine health services research. Theory and limited evidence suggest that DHH patients are at higher risk of emergency department (ED) utilization and poorer quality of care. This study assessed ED condition acuity, length of stay (LOS), and acute ED revisits among DHH patients. We hypothesized that DHH patients would experience poorer ED care outcomes. METHODS: We conducted a retrospective chart review of a single health care system using data from a large academic medical center in the southeast United States. Data were received from the medical center's data office, and we sampled patients and encounters from between June 2011 and April 2020. We compared DHH American Sign Language (ASL) users (n = 108), DHH English speakers (n = 358), and non-DHH English speakers (n = 302). We used multilevel modeling to assess the differences among patient segments in outcomes related to ED use and care. RESULTS: As hypothesized, DHH ASL users had longer ED LOS than non-DHH English speakers, on average 30 min longer. Differences in ED condition acuity, measured through Emergency Severity Index and triage pain scale, were not statistically significant. DHH English speakers represented a majority (61%) of acute ED revisit encounters. CONCLUSIONS: Our study identified that DHH ASL users have longer ED LOS than non-DHH English speakers. Additional research is needed to further explain the association between DHH status and ED care outcomes (including ED LOS and acute revisit), which may be used to identify intervention targets to improve health equity.

Emergency department utilization among deaf and hard-of-hearing patients: A retrospective chart review.

BACKGROUND: Deaf and hard-of-hearing (DHH) patients are an underserved priority population. Existing, although contextually limited, findings indicate that DHH patients are more likely to use the emergency department (ED) than non-DHH patients. However, little attention has been given to the differences in ED utilization by patients' language modalities. OBJECTIVE: We hypothesized that DHH ASL-users and DHH English speakers would have higher rates of ED utilization in the past 36 months than non-DHH English speakers. METHODS: We used a retrospective chart review design using data from a large academic medical center in the southeastern United States. In total, 277 DHH ASL-users, 1000 DHH English speakers, and 1000 non-DHH English speakers were included. We used logistic regression and zero-inflated modeling to assess relations between patient segment and ED utilization in the past 12- and 36-months. We describe primary ED visit diagnosis codes using AHRQ Clinical Classifications Software. RESULTS: DHH ASL users and DHH English speakers had higher adjusted odds ratios of using the ED in the past 36-months than non-DHH English speakers (aORs = 1.790 and 1.644, respectively). Both DHH ASL users and DHH English speakers had a higher frequency of ED visits among patients who used the ED in the past 36-months (61.0% and 70.1%, respectively). The most common principal diagnosis code was for abdominal pain, with DHH English speakers making up over half of all abdominal pain encounters. CONCLUSIONS: DHH ASL users and DHH English speakers are at higher risk of using the ED compared to non-DHH English speakers. We call for additional attention on DHH patients in health services and ED utilization research.

Community-Engaged Needs Assessment of Deaf American Sign Language Users in Florida, 2018.

OBJECTIVES: Deaf American Sign Language (ASL) users comprise a linguistic and cultural minority group that is understudied and underserved in health education and health care research. We examined differences in health risk behaviors, concerns, and access to health care among Deaf ASL users and hearing English speakers living in Florida. METHODS: We applied community-engaged research methods to develop and administer the first linguistically accessible and contextually tailored community health needs assessment to Deaf ASL users living in Florida. Deaf ASL users (n = 92) were recruited during a 3-month period in summer 2018 and compared with a subset of data on hearing English speakers from the 2018 Florida Behavioral Risk Factor Surveillance System (n = 12 589). We explored prevalence and adjusted odds of health behavior, including substance use and health care use. RESULTS: Mental health was the top health concern among Deaf participants; 15.5% of participants screened as likely having a depressive disorder. Deaf people were 1.8 times more likely than hearing people to engage in binge drinking during the past month. In addition, 37.2% of participants reported being denied an interpreter in a medical facility in the past 12 months. CONCLUSION: This study highlights the need to work with Deaf ASL users to develop context-specific health education and health promotion activities tailored to their linguistic and cultural needs and ensure that they receive accessible health care and health education.

Conceptual Model of Emergency Department Utilization among Deaf and Hard-of-Hearing Patients: A Critical Review.

Deaf and hard-of-hearing (DHH) populations are understudied in health services research and underserved in healthcare systems. Existing data indicate that adult DHH patients are more likely to use the emergency department (ED) for less emergent conditions than non-DHH patients. However, the lack of research focused on this population's ED utilization impedes the development of health promotion and quality improvement interventions to improve patient health and quality outcomes. The purpose of this study was to develop a conceptual model describing patient and non-patient (e.g., community, health system, provider) factors influencing ED utilization and ED care processes among DHH people. We conducted a critical review and used Andersen's Behavioral Model of Health Services Use and the PRECEDE-PROCEED Model to classify factors based on their theoretical and/or empirically described role. The resulting Conceptual Model of Emergency Department Utilization Among Deaf and Hard-of-Hearing Patients provides predisposing, enabling, and reinforcing factors influencing DHH patient ED care seeking and ED care processes. The model highlights the abundance of DHH patient and non-DHH patient enabling factors. This model may be used in quality improvement interventions, health services research, or in organizational planning and policymaking to improve health outcomes for DHH patients.

Promoting health equity for deaf patients through the electronic health record.

Language status can be conceptualized as an equity-relevant variable, particularly for non-English-speaking populations. Deaf and hard-of-hearing (DHH) individuals who use American Sign Language (ASL) to communicate comprise one such group and are understudied in health services research. DHH individuals are at high-risk of receiving lower-quality care due to ineffective patient-provider communication. This perspective outlines barriers to health equity research serving DHH ASL-users due to systems developed by large-scale informatics networks (eg, the Patient-Centered Clinical Outcomes Research Network), and institutional policies on self-serve cohort discovery tools. We list potential to help adequate capture of language status of DHH ASL-users to promote health equity for this population.

Health insurance literacy and health service utilization among college students.

Objective: Health literacy and health insurance literacy affect healthcare utilization. The purpose of this study was to determine the relation between health insurance knowledge, self-efficacy, and student healthcare utilization in the past year. Participants: A random sample of 1,450 respondents, over the age of 18, attending a public university in the southeastern United States completed a survey in March 2017. Methods: A model was constructed to test the effect of health insurance self-efficacy on the relation between knowledge and healthcare utilization in the past year. Results: Health insurance knowledge (M = 5.8, range 0-10) and self-efficacy (M = 2.48, range 1-4) were low. Self-efficacy was a significant moderator when explaining healthcare utilization in the past year. Conclusions: College students have low knowledge and self-efficacy regarding health insurance. These findings can be used for developing policies and self-efficacy-based health education programs that may increase student healthcare utilization.