On this episode, Megan Georges, David Wiley, and Dr. Elizabeth Pino continue their discussion on rehabilitation access disparities and share some steps that clinicians can take to help close those gaps.

Ms. Georges: We decided to look at stigmatizing language in medical records because pieces of patients’ medical charts are sent to facilities during the rehab screening process. We used deductive qualitative content analysis. We looked at predefined categories across the injury types, including expressions of disapproval, discrediting, stereotyping, portraying patient as difficult, and unilateral decision making. We collaborated with an emergency department physician, as well as a mixed methods expert, to determine our process, select these categories, and ensure that they were all-encompassing and applicable to the rehab referral process.

We found that language that demonstrated injury-specific stereotyping against violence survivors and increased use of unilateral decisions were very highly included in violence survivors’ charts as opposed to those of motor vehicle crash patients.

What we already know about violence survivors, especially individuals impacted by violence in Massachusetts, is that there are huge racial and ethnic disparities as it relates to who is harmed by community violence. In the population that we studied, 84% of patients with violent penetrating injuries identified as a member of a racial or ethnic minority group, compared with 38% of patients with motor vehicle crash injuries.

However, in our multiple logistic aggression model, we controlled for race and ethnicity and found it to be insignificant. Injury type (as a violent penetrating injury) was one of the only factors that we studied that was associated with increased denials to rehab.

Dr. Pino: We’ve already had some discussions with the Civil Rights Division of the Massachusetts Attorney General’s office exploring whether there are HIPAA violations as it relates to facilities communicating directly with law enforcement, and how that impacts post-hospital discharge planning.

We have also been in talks with another physician researcher at Boston Medical Center who has looked at this issue among patients with opioid use disorder who require inpatient rehabilitation. Patients with opioid use disorder are also receiving more denials from rehabilitation centers compared to other patients who are discharged. This group of patients is actually protected under the Americans with Disabilities Act, but even with those kinds of protections, there are still bias and stigma against patients.

We’re actively looking into what kind of protections and anti-discrimination laws could impact patients with violent injuries.

Ms. Georges: I think another thing that would help in practice would be increased transparency about policies that private institutions like rehabilitation facilities have, as well as improved documentation of the communications across institutions. This would allow for increased oversight, for us to be able to understand the conversations and what’s driving these decisions, as well as having documentation to support accountability measures that may need to be put in place to improve violence survivors’ access to inpatient rehab.

Another thing that we are hoping to explore on a state level is whether HIPAA is involved in this situation as it relates to communicating with law enforcement and giving them any influence on the placement of individuals or just the perception of these individuals prior to placement. This, in turn, could enlighten us on whether conversations involving somebody’s protected health information are permitted to be had with outside individuals such as law enforcement.

Dr. Pino: Also, an important addition to physician and nurse clinician training overall would be standardized trauma-informed care curriculum with oversight and accountability at our institution and other institutions.

Mr. Wiley: To follow up on what Megan and Liz said, I think trauma-informed care training is very important so that we’re not retraumatizing the individuals that are coming to the hospital for services. I think that’s a step in the right direction: having people on the same page when it comes to documentation and the language that they’re using, and letting people know the effects that chart documentation can have on an individual’s health outcomes.

Ms. Georges: Yeah, exactly. The American College of Surgeons has been working with partners like us to develop a trauma-informed care curriculum that is intended to be used for providers at institutions—including our hospital, but also these rehab centers—to help standardize training as it relates to not only the care clinicians are providing, but also how they’re documenting the behaviors, presentation, experiences, and interactions with patients throughout their care.

Dr. Pino: Also, there have been publications on how to reduce stigma and bias in clinical communications. They document some strategies that clinicians can use to promote non-judgmental health record keeping, including:

• using person-first language,
• eliminating pejorative terms,
• avoiding labels,
• not weaponizing quotes,
• avoiding blaming patients, and
• not leading with social identifiers.

Ms. Georges: I would like to add that we likely have an undercount in this study for the true impact of rehab denials or disparate access to follow-up care for survivors of violence. That’s because in our study, we just looked at individuals who ultimately discharged to one of these facilities. Throughout our process, we did note many individuals that fell out of care as they continued through this lengthy referral process due to repeated denials, or individuals that abandoned this next step of care that was recommended clinically because of their experiences with the process, the time it took, and the amount of administrative work and barriers they faced.

Dr. Pino: Further supporting that idea, our trauma surgery colleagues here at Boston Medical Center published a related study and found that compared to other types of traumatic injuries, violence survivors were less likely to be discharged to inpatient rehab, less likely to be discharged home with healthcare services, more likely to have a downgrade in their discharge recommendation while they were inpatient, and more likely to have another emergency department visit within 30 days.

Our study and theirs both support this conclusion that violence survivors are receiving lower quality of care due to discrimination.

Thanks for listening. Stay tuned for next week’s episode. To hear more, follow PeerPOV: The Pulse on Medicine on Apple Podcasts, Spotify, or Amazon Music.

This transcript has been edited for readability.