Manage Chronic Disease with the EFST Model for Cultural Competence
How can clinicians help ease the stress of chronic disease? Recent healthcare news stories published in The New York Times draw attention to the incredible burden of serious illness and chronic disease on critically sick patients. Not only are they physically uncomfortable and often fighting for their lives—they are also baffled by a confusing healthcare system and swamped by medical bills. Now imagine adding a language barrier to the mix! The challenges of serious illness are compounded when there are cross-cultural issues at play. Quality Interactions' EFST Model is designed to help clinicians uncover and address these issues and provide culturally-sensitive care to all patients with chronic disease.
Chronic illness creates financial hardship
One New York Times article describes the overwhelming financial implications of long term medical treatment—even for patients with full health coverage—and how the stress creates "financial toxicity" that must be addressed by the clinician.
Khurram Nasir, an associate professor of medicine at Yale, has adopted a phrase from cancer research, “financial toxicity,” as he realized many of his cardiac patients were struggling to pay for care and making tough choices like skipping pills or cutting back on food.
“When I started realizing this, I took it upon myself as a responsibility to talk to my patients about these issues,” he said. “It was very hard for patients to bring this topic to our attention.”
Between medical bills and missed work or disability, financial hardship is an issue for most seriously ill patients. But it's of critical importance to patients already burdened by social determinants of health (SODH), such as low income or low literacy. Increasingly, healthcare providers are taking action on SODH in a clinical setting.
The healthcare system is difficult to navigate
A second article offers advice from chronically ill "power users" on how to navigate the obscure and fearsome healthcare system.
Doctor’s visits are often over before you know it, and it can be hard to follow up afterward.
“The doctor is just going to come in poke you and go, and you can’t let them go until you feel comfortable with everything,” said Tristan Berger, 47, of Tucson, who has had numerous orthopedic operations for complications from spina bifida.
It's common knowledge that doctors are pressed for time, and patient interactions are often too brief. That's why training in patient-centered, culturally competent communication is so critical.
Both these news stories describe the suffering and frustration that come with chronic illness—on top of the heartache and vexation of fighting the disease. These problems are exacerbated when patients are grappling with cultural differences in behavior and expectations around healthcare.
Cross-cultural management of chronic disease
At Quality Interactions, we teach healthcare professionals research-based strategies for managing illness with a cross-cultural approach. Our co-founders developed the ESFT (Explanatory, Social Risk, Fears, Therapeutic Contracting) Model to help clinicians provide culturally-sensitive care by:
- Uncovering barriers to adherence, such as motivations, fears about medications, or economic struggles
- Exploring health beliefs and expectations
- Creating rapport and building trust
The ESFT Model for cross-cultural communication
The ESFT Model consists of a series of questions to ask your patients. The questions are designed to increase value and improve patient adherence.
Goal: Reveal the patient's understanding and own experience of their medical condition.
Questions to ask:
- What do you call your problem?
- What do you think is causing it?
- How does it affect your life?
- How does your family feel about it?
- What kind of treatment do you think will work?
Goal: Examine social and financial barriers to adherence.
Questions to ask:
- Does your insurance cover your medications?
- Do you have access to a pharmacy?
- Is it difficult to afford your medications or copayments?
- How are your medications organized at home?
- Do you have a pill box?
Fear and concerns
Goal: Determine how the patient feels about taking medications, including concerns about side effects and dosage.
Questions to ask:
- How do you feel about taking the medication?
- What have you heard about this medication?
- What worries do you have about side effects?
- Do you think the medication will interfere with your life?
Goal: Check the patient's understanding of the treatment plan, and elicit a contract.
Questions to ask:
- How do you plan to take the medications?
- How do you feel about your treatment plan?
- Can you repeat the (treatment) instructions back to me in your own words?
Agree upon a mutually acceptable plan and ask the individual to commit and repeat back what they understood.
Notes relevant to chronic disease management:
- Language barriers may lead to significant misunderstanding, especially given the complexities involved in chronic disease management.
- It is important when interacting that information is correct and, when necessary, is delivered using a trained interpreter.
- Health literacy and general literacy both limit the individual’s ability to understand complex health information pertinent to chronic disease management.
- Preventive health management measures may not be part of an individual’s previous health management experience, which may be more focused on treatment of symptoms.
The EFST Model helps clinicians treat chronic disease in a person-centered and integrated way. It works well with all patients, and is especially important for patients with cultural barriers to care, including limited English proficiency, perceived discrimination, and low health literacy. A culturally-sensitive approach to chronic disease management can help alleviate the stress of living with chronic illness, boost patient adherence, and improve health outcomes.
Learn about our full range of cultural competency training resources.