# Presentation: 739294

## Clinical Issues in Delivering Rehabilitation Services To Asian Chinese in NYC Chinatown

**Presented By:**
_**Victoria Zhang M.D.**_** **
**Medical Director, Rusk Institute of Rehabilitation Medicine at New York Downtown Hospital**
**Clinical Assistant Professor, NYU Rusk Institute of Rehabilitation Med.**
_**Mathew Lee M.D.**_** **
**Professor Chairman, Rusk Institute of Rehabilitation Medicine at New York University Hospital **

## Introduction

_**3 Disability Issues in Chinese American Women:**_
**1) Osteoporosis**
**2) Osteoarthritis **
**3) Back pain**
**Due to language barriers as well as cultural factors, Chinese American women do not know how to seek healthcare, preventions, and treatments leading to such consequences. **

## Statistics of the Asian population 

**Over half (51%) of the Asian population in the US either live in New York or California. **
**Statistics show that there are 872,777 Asians in New York City, with144,538 residing in Manhattan.**
**There are 4,407,444 Asians living in Los Angeles.****  **

## Chinatown in New York City

**Chinatown in New York City is one of the favored destination points for new immigrants, and it is estimated that between 70,000 and 120,000 inhabitants reside there. The total elderly population increased by 15 percent in Chinatown between 1990 and 2000. **
**Between 1990 and 2030 older Chinese Americans are projected to be one of the fastest growing segments of the U.S. population. Those aged 65 and older are projected to increase by 643% in comparison to the 91% projected for the white non- Hispanic population. **

## Senior Citizens in Chinatown

**About 35% Chinatown senior citizens lived below the poverty line, compared with 19% of senior citizens citywide. These individuals have poorer health status, lack of insurance, and do not have access to health care. **
**Among elderly adults, 62% in Chinatown spoke little or no English, compared with 49 percent city-wide. Being deeply ingrained in the traditional Chinese culture, many elderly Chinese are more likely to resort to self- care. Because of language barriers, activities are often restricted within Chinatown.  **

## New York Downtown Hospital

**New York Downtown Hospital (NYDH) located adjacent to Chinatown has many Chinese language services. Over 60% of the Hospital’s inpatients and 83% of its outpatients are from New York City’s Immigrant Chinese community. **
**NYDH seeks to serve the total health care needs of the Chinese community. Three off-site primary care center located within three different boroughs: Manhattan, Brooklyn, and Queens offers health education, preventive care, and early detection services for New Yorkers. Downtown Family Care Center, located in Chinatown, offers a free Bone Mineral Density (BMD) screen study for early detection of osteoporosis. **
**They found....**

## Osteoporosis in Chinese American Women

**14% of 55- 60 year old women already have fractures.**
**20% of Asian women age 50 or older are estimated to have ****	****osteoporosis.**
**Foreign born Chinese have lower BMD at every age than US born ****	****Chinese and US white women.**
**Elderly Chinese women and recent immigrant living in inner city ****	****Chinatown are at high risk for osteoporosis due to **
**1) poor nutrition during childhood; the diet lacks of calcium and due to ****	****aging, the body will have a decrease in calcium absorption**
**2) small and thin body frame**
**3) lack of exercise**
**4) lack of acknowledgment of causes, preventions and ****	****treatments**
**5) difficulty accessing medical care or distrust of the medical ****	****system **

## Figure 1. Example of Kyphosis in Chinese Women

## Case Study

**A 74 year old Chinese female with severe Kyphosis, lower back pain, and leg pain. She was unable to lie down in bed at night. The patient was treated with Fosamax and Oscal 500 with D for 1.5 years, but the pain persisted. The patient fell down and suffered a left hip fracture. **
**The patient had ORIF and went to the Rehabilitation Center for 3 months. She is now able to ambulate with a walker at home. **
_**SH:**_** She came from China 50 years ago. She lived in Chinatown most of her life. **
_**FH:**_** Her mother and sister also had severe Kyphosis. Her mother died in a nursing home one year after a left hip fracture. **
_**Lab:**_** DEXA T- score: -3.5 at the spine; -3.0 at the     femoral neck 2 years ago**
**Repeat T- score: -3.6 at spine; -3.2 at femoral neck now.     **

## Rusk Institute of Rehabilitation

**The Rusk Institute of Rehabilitation at NYDH has an interdisciplinary community rehabilitation team composed of Chinese speaking bilingual Rehabilitation physicians, Physical and Occupational therapists, clinical coordinators and social workers. Application of the principles of Rehabilitation medicine to the community is an area of great importance to the care of the elderly and disabled individuals. **

## Chinese Elderly Immigrants

**The elderly are most vulnerable to pressures from immigrating to a new land. In addition, the prevalence of functional disability in the elderly is significant. Nevertheless, the functional, educational, and psychosocial needs of the Chinese elderly immigrants in the United States have not been explored to date. Application of principles or rehabilitation medicine to community health is an area of great importance to the care of the elderly. In 1969, one of us created theoretical framework of rehabilitation as a “third dimension of medicine” or, more narrowly, tertiary prevention. Looking at disability from the epidemiological and public health perspective, the concept of preventive rehabilitation was developed.  **

## Convalescence Care for Seniors

**So our interdisciplinary community rehabilitation team participates in the community outreach, education, and rehabilitation program. The mission of “Convalescence Care: A Comprehensive Approach for seniors in the Chinese Community.” This program is funded by a grant from the Langeloth Foundation to ensure that Chinatown’s most vulnerable elderly will receive the necessary care to return to the highest possible level of functional ability. In addition, the goals are to provide assistance in living resulting with less isolation, more independence, and more meaningful lives. **

## Interdisciplinary approach- “Teamwork”

**The program aims to provide high quality, efficient, and effective health care services and promotes wellness, dignity, mobility, and independence for elderly persons with functional or psychosocial needs. One of the key characteristics of the program is its interdisciplinary approach. “Teamwork” was the original and unique approach that rehabilitation brought to medical care. Teamwork characterized the relationship and interaction of medical and paramedical professionals in their effort to restore the disabled.  **

## Found Chinese Elderly Needs

**First, we found baseline needs through our outreach programs. Figure 1 shows the summary of 70 participants, who underwent initial screening (average age: 70 years old.)**
**It is clear that cultural, communication, and transportation issues have a greater influence on the quality of life in this population than that of medical, vocational, and financial barriers.**

## Figure 1. Barriers of life participation for Chinese elderly in the convalescence care program

## Break Language Barriers

**Addressing these factors, our program focuses on education to improve cultural understanding of health care and common diseases. The programs are available in the participants own native language to better improve communication and understanding. Language barriers are prevented by the availability of interpreters 24/7 and having a >50% bilingual staff in every department. Assistance with transportation can be provided by Shuttle Buses offered by the hospital. Physical barriers are prevented by having Chinese signs in hospitals, Chinese menus in dining facilities, and Chinese registration forms.  There are many advertisements relative to health care in Chinese newspapers and in addition, the radio broadcasts many information regarding healthcare daily. **

##  Educational Workshops- “Coping with Arthritis”

**During the 15 month program, we organized 17 workshops in community sites including clinics, 8 senior centers, and assisted living housing facilities to  present 2 topics of interest for 1000 elderly participants.**
**The First series of workshop was titled, “Coping with Arthritis without Medication or Surgery.” (Figures 2. and 3.)**

## Figure 3. Osteoarthritis of the Hand

##    “Back pain in the Chinese Elderly”

**The second workshop was about “Back pain in the elderly.” (Figure 4.)**
**The topic focuses on common causes, diagnosis, treatments, and rehabilitations of lower back pain and osteoarthritis. Moreover, the workshop focuses on how the elderly can benefit from our Rehabilitation services for education treatment to prevent disability. **

## 	Cultural Understanding

**Research supports our choice of topics as Chinese patients showed an increased risk due to hard labor in farms, factory works, and long hours of working in restaurants. Many of these occupations lead to the abuse and overuse of the joints. They have a false belief that work is equivalent to exercise, therefore, this leads to the risk of getting osteoarthritis and back pain. Even though limitations in daily activities are associated with osteoarthritis, they do not seek for treatment because of the belief that it is a natural occurrence. Furthermore, they have no acknowledgment of treatments and preventions.  That is why we have to approach them in our outreach programs, workshops, and health fairs for them to gain more knowledge of preventions and treatments. (Fig. 5)**

## Figure 5. How much did workshop 	add to participant’s knowledge?

##     Work in the Community

**We participated in 8 community health fairs, 3 based at NYDH and 5 street fairs in Chinatown. (Figure 6.) It was another good way to reach out to the community elderly and we were able to present out our programs and rehabilitation services to over 250 people each time. Most of the patients were recruited through the educational workshops or the health fairs.** **(Figure 7)**

##       Figure 6. Referral Source

##  	Figure 7. Street Fairs

**Cholesterol, glucose, blood pressure, Body Mass Index, height, weight, osteoporosis rehabilitation consultation were offered free of charge.**

##         Prevention Program

**The patients recruited through the workshops, health fairs, or through physician referrals are scheduled for initial screening by the geriatric outreach social worker. The physiatrist and the social worker see the patients at the Rusk Institute at NYU Downtown Hospital. The hospital setting is favorable because of its location (within walking distance from Chinatown), directories in Chinese, the Chinese health care staff, and the familiarity of the place, as well as the close relationship to physical and occupational therapy services. Referrals to medical specialty services are arranged within the hospital to encourage the elderly to join local senior centers, community dances, Tai- chi, and other physical and recreational activities. (Figure 8.) **

## Figure 8. Exercise for Prevention

**Community members enjoyed an aerobics performance by The Salvation Army Senior Center, a tai chi demonstration by the New York Downtown Tai Chi Club and traditional Chinese music by the Chinese American Arts Council’s orchestra.**

##               Conclusion

**The “Convalescence Care for Seniors of the Chinese Community” is able to reach out successfully to an underserved Chinese population in Chinatown. The location of NYU Downtown Hospital is very beneficial because of vicinity to Chinatown, familiarity among Chinese people, Chinese- speaking health care staff, and directories in their language. The interdisciplinary team is important for an excellent outcome of the program and consists of an physiatrist, geriatric outreach social worker, program/ research coordinator, and rehabilitation staff (physical and occupational therapists). Through educational workshops, health fairs, and physician referrals, the Chinese patients were able to get services and benefits from the functional approach of rehabilitation.  **

## Existing Problems
Future Studies
Questions and Answers?

**Future Studies**
**Questions and Answers?**

## Thank you