Towards Equity: Community Benefit and Community Need An evaluation of community benefit spending for a health system based in Colorado.

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1 Organization Division of Adolescent/Young Adult Medicine, Boston Children s Hospital Mongan Institute Health Policy Center Project Abstract Reproductive Health Outcomes of Sexual Minority Women Bisexual and lesbian women have been reported to be less likely to obtain reproductive health services despite their high risks of being diagnosed with sexually transmitted infections (STIs). Many assume they are at lower risk for pregnancy and STIs. Many also report feeling uncomfortable discussing their sexuality with their health care providers. As a result, they are less likely to get Pap tests to screen for human papillomavirus (HPV) and cervical cancer or receive family planning services (e.g. contraception). Additionally, clinical guidelines specific to the health care needs of sexual minorities are lacking, thus providing health care professionals with limited support and resources about how to identify and address the needs of this population compared to heterosexual women. We conducted a systematic review of the reproductive health outcomes of sexual minority women to determine gaps in health care provided to sexual minorities. Based on the results, we proposed policy recommendations to improve medical education in order to cultivate LGBTQ competent health care providers to meet the needs among of sexual minorities. MGH Diversity Culture Survey 2016 It is MGH s mission to provide culturally competent and patient centered care. In 2004 and 2012, MGH executed large scale Diversity and Patient experience surveys. The combined effect of these two surveys along with a 2014 Diversity Metrics Report for the Center for Diversity and Inclusion led to the creation of a survey on workforce diversity. The 2016 MGH Diversity Culture Survey was conducted in the fall of 2016 based on previously conducted internal reviews with two primary measures collected: Quantitative Measures: Employee perceptions of culture by diversity components Qualitative Measures: Employee stories of disrespectful treatment In order to assess the culture of diversity and inclusion amongst hospital employees, the research team at MIHPC created the 2016 MGH Diversity Culture Survey with the following primary goals: (1)Provide the MGH Diversity Committee, MGH Leadership, and the broader MGH community with quantitative and qualitative data on the experiences of the MGH Workforce, (2)Identify key diversity characteristics amongst the MGH workforce that are associated with certain experiences and perceptions, and (3) Disseminate key findings and preliminary reports through in person meetings and committee sessions. Centura Health Network MAHERY Towards Equity: Community Benefit and Community Need An evaluation of community benefit spending for a health system based in Colorado. Evaluation of Healthcare in Antongil Bay, Madagascar Introduction: Madagascar is tenth poorest country in the world. Almost 88% of its population of 24.2 million people lives below the international poverty line of $1.25 per day. A lack of data represents a key obstacle to more effective health systems planning and resource allocation. Objective: A limited exploratory mixedmethods study using free-listing exercises, surveys, and facility assessments was conducted to gain a more

2 robust understanding of human and material resources available in rural communities could inform policy decisions, advance health systems development, and facilitate improved access to healthcare. Methods: Rural villages, along the coast of Antongil Bay, in northeast Madagascar as well as towns associated with their access to care were evaluated. Data Collection was conducted from August to December A Malagasy research assistant fluent in English, French, and Malagasy, conducted the majority of interviews given his fluency in the local language and familiarity with the culture. Free listing exercises were conducted querying community members on the main illnesses seen in the village, including among children, adolescents, adult women, adult men, and the elderly. A convenience sample was identified at the CSB level to provide more in-depth information regarding reproductive health care via surveys. Facility assessments were conducted at all identified health facilities in 8 villages, defined as any location where villagers with illnesses seek care. Results: Decision to access allopathic healthcare facilities depended on a combination of a) geographic and financial access to healthcare facilities, b) perceived severity of illness, and c) availability and confidence in traditional plant-based medications. Self-induced abortions using traditional plant-based medicines were commonly reported. Health facilities included CSB I and II (6), local drug/grocery stores selling medications called epiceries (7), traveling salespeople selling medications (5), and local pharmacies (3). Staff at all epiceries, pharmacies, and traveling salesperson lacked formal training. Conclusion: Study was designed to serve as the basis for research and evidence-based programming to identify health issues and health systems strengths and needs in rural Madagascar. Results will be incorporated into future research that will identify barriers to care, explore differences in healthcare seeking behavior, and compare resource availability to health indicators. Cambridge Health Alliance Massachusetts State House First 1,000 Days Program ESOC: Supporting Families and Improving Youth Outcomes Worked to set up a grant-funded research project within Cambridge Health Alliance to evaluate the benefits of providing team based mental health services to high risk children within primary care. Advancing Policy Reform for Justice-Involved Women in Massachusetts Women are often fastest growing population in the United States criminal justice system. Development of Clinical Policies to Address Symptoms of Depression during Prenatal Care in Community Health Center Settings The main aim of this practicum project is to develop a systems-level clinical policy for interdisciplinary management of women who screen positive for depressive symptoms on prenatal and postpartum screening at health centers where the First 1,000 Days Program is being established. Specific aims: 1. To use historical data to examine changes in scores on the Edinburgh Postnatal Depression Scale (EPDS) for individual women between the initiation of prenatal care and the 6 week postpartum visit and review the score change in relation to health services utilized over the course of pregnancy. 2. To perform a retrospective review of the medical records of women who screen positive for symptoms of depression on the Edinburgh Postnatal Depression Scale (EPDS) to assess referral records, resources provided and follow-through.

3 3. To interview community stakeholders and healthcare providers at the health centers where the First 1,000 Days Program is being implemented to evaluate processes at the health centers for addressing positive EPDS screening results during pregnancy. The study will identify key aspects in the clinical pathways that are currently working or not working well in order to develop the most effective systems for optimizing patient outcomes. MGH Revere Health Care Center The Greater Boston Food Bank National Health Systems Resource Centre (NHSRC), Delhi NeuroValue Lab at Massachusetts General Hospital Enhancing Clinical-Community Partnerships to Address Healthy Diet, Food Access and Food Insecurity at MGH Revere The project included two major components: 1) Needs Assessment completion of IRB approved interview surveys with overweight/obese adult patients in the Med-Peds practice at MGH Revere measuring food insecurity (USDA 6-item screener), health literacy, and qualitatively assessing motivation for change, strengths and barriers to change, and recommendations for how to improve the approach to interventions to promote lifestyle changes at MGH Revere. Additionally includes a staff/provider survey regarding perceptions on role and ability of clinic to address food insecurity. 2) Enhancement of Clinical-Community Partnerships to Address Food Insecurity the primary focus will be on designing, enacting, and evaluating a pilot project with Project Bread to facilitate bi-directional referrals to assist families and individuals who screen positive on the Hunger Vital Sign or self-identify as needing additional support with food resources. Overarching these two specific initiatives, a primary goal will be to develop a team of champions and policies to help direct and focus this work ongoing. Improving Access to Healthy Foods via the use of Community Health Needs Assessments My primary work with the GBFB will involve reviewing the Community Health Needs Assessments (CHNAs) and Community Health Improvement Plans (CHIPs) that have been completed by community health centers in the GBFB s service area. My work will address the following research questions: How often food insecurity is identified as a problem in the CHNAs? What metrics were used to understand food issues? If food issues were identified as a problem, how were they addressed and how often in CHIPs? To what degree do the CHIPS reinforce/align with national guidelines, i.e. Healthy People 2020 and 2015 ADA Scaling up complex innovative interventions in developing countries: A retrospective review of the Home Based Newborn Care program in Delhi, India The present study reviewed the scale-up process of Home Based Newborn Care program in India using an objective assessment tool, the Scaling-Up Management Framework developed by MSI to acquire insights that may guide scaling-up of similar interventions in resource-restricted settings. Patient-reported outcome measures in epilepsy care My practicum project concentrates on health care delivery, especially the patient-reported outcomes assessment that is being established at MGH's Department of Neurology. With the demographic changes taking place in the United States, Europe and East Asia, more and more people get affected by neurologic

4 conditions. Especially epilepsy is becoming increasingly common, as many advances have been made in the past decades in regards to epilepsy drugs, increasing life expectancy for epilepsy patients. Furthermore, patients suffering from Alzheimer's disease have a risk of developing epileptic seizures that is five times as high compared to the general population. The physical condition of epilepsy patients can vary greatly, meaning that risk-adjustment measures are of special importance in assessing the amount of medical care these patients will require. The currently used risk-adjustment measures, however, are outdated and often do not adequately reflect the patient's level of impairment. For my project, I assessed how the patientreported outcomes are collected in the MGH epilepsy clinic. With these observations, I developed interventions that have the potential to increase the collection and completion rates as well as improve workflow and patient satisfaction at the reception desk and in the waiting room while filling out the PROMs questionnaire. In addition, I examined what role, patient-reported outcome measures could play in risk adjustment. Self-reported outcomes tend to give a fairly accurate picture of the patient's state. I compared the some of the already existing analyses of these measures with the risk-adjustments schemes; examine where they overlap and where in the risk adjustment model they could factor in. Furthermore, I am examining the data from those patients who already filled out PROMs surveys. Boston Children's Hospital Massachusetts Department of Public Health ACLU National Prison Project Grass Roots Diabetes Patient Characteristics and Spending Patterns in a Pediatric Accountable Care Contract Boston Children's Hospital recently signed an accountable-care contract (similar to an ACO) with Neighborhood Health Plan, a Medicaid managed-care organization. In preparation for this contract, BCH was hoping to understand the patient population they were taking risk for, as well as defining some of the utilization patterns at play. Creating a Predictive Model of Homelessness in Massachusetts We attempted to create a model by which to predict homelessness in Massachusetts through analyzing large datasets from various state agencies and determining risk factors for homelessness in these populations. We sought to create a predictive model by which a service provider could enter in various characteristics and receive a probability of future or current homelessness for an individual. ACLU National Prison Project I researched, wrote, and edited a notice of substantial non-compliance in a case in which defendant prisons had agreed to provide greater out-of-cell time for seriously mentally ill, maximum security inmates. Introducing a Community Level Diabetes Education Program in Singapore My main project will be to assess the current state of community diabetes care and care access in Singapore and work with the Grassroots team to produce a culturally sensitive version of the On the Road program for piloting in Singapore. I will also be involved in other aspects of work such as literature reviews, development of diabetes training tools, and be exposed to community level applications of evidence-based diabetes care. I will utilize my prior experience in curriculum development and evaluation to improve the diabetes education programs.

5 I will also assist Grassroots Diabetes to establish appropriate networks and linkages within the healthcare system in Singapore. Thereafter, conduct a review of the existing Singapore healthcare system focusing on chronic disease management, and assessment of current care delivery systems and healthcare insurance programs. Finally, I would work with Grassroots Diabetes to develop pilot and assess pilot programs. Community Catalyst Sana, Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology Ensuring Hospital Financial Assistance Policies Work for Consumers I conducted research on promising practices in financial assistance policy and areas of concern in financial assistance policy. I used what I found to contribute to a model financial assistance policy and rationale document that can be used by Community Catalyst Advocates to: -Improve transparency of hospitals billing and collections practices -Increase awareness among consumers about hospital financial assistance programs -Encourage hospitals to offer financial support to patients whose financial or personal circumstances make it challenging to pay their medical bills -Ensure hospitals are thinking about how medical debt influences the financial and physical health of their communities Hackathons to Spur Innovation in Healthcare Healthcare Hackathons (HCHs) are being increasingly used to generate innovation in healthcare delivery using technology and data, and as a model for cross-disciplinary education opportunities. However, few studies have measured their effectiveness with either objective. This practicum encompassed an immersive field experience of a HCH in Khon Kaen, Thailand, and formal research to characterize the educational benefits of HCHs, and their impact on healthcare delivery and outcomes. Massachusetts Department of Public Health Atrius Health Oral health disparities between foreign-born and native-born pregnant women in MA I mapped maternal health disparities between foreign-born and native-born women in the state. Oral health emerged as a major disparity, with foreign-born women being at a disadvantage. I analyzed the unique barriers faced by foreign-born women, oral health initiatives in MA and in other states, and proposed additional interventions to implement. Behavioral Health Prescriber Care Models & Health Policy The Atrius Health Behavioral Health Prescriber Care Model project is a lean process redesign focused on developing and spreading operational efficiencies and clinical standards across the organization. Main goals of the project included 1) reviewing best practice mental health prescribing standards currently maintained in the field, summarizing these, and promoting a system-wide decision to adopt one or more as the Atrius Health standard and 2) Developing protocols and standard work to spread these protocols throughout the Departments of Behavioral Health and Internal Medicine at Atrius Health.

6 Community Catalyst Adverse Childhood Experiences: Tipping the Scale Toward Resilience The CDC in conjunction with Kaiser Permanente conducted a study to investigate the effects of Adverse Childhood Experiences (ACE) on later health in life. The Study findings repeatedly revealed a relationship between ACEs and negative health and well-being outcomes across the life course. I plan to work on a campaign focused on advocating for pediatric/ provider community to adopt an ACEs screening tool for all children. This will entail reviewing successful ACE s legislation and programs across the country to date; interviewing practitioners who are leading best practices on the ground. I would also like to create a tangible deliverable in the form an issue brief for consumer health advocates and the pediatric physician community to help them understand what efforts are underway and what policy vehicles are available to advance ACEs work. American Hospital Association Harvard University School of Public Health U.S. House of Representatives Ways and Means Health Subcommittee Minority Staff Office Southern Jamaica Plain Health Center's Health Promotion Center Data, Diversity, and Dollars: Creating a Framework for Building the Business Case for Health Equity In 2011, a National Call to Action to Eliminate Health Care Disparities was created by the American Hospital Association, American College of Healthcare Executives, Association of American Medical Colleges, America s Essential Hospitals, and Catholic Health Association of the United States. Three goals were created to reduce health disparities and improve health equity: 1) Improve the collection of race, ethnicity and language preference data (REaL), 2) Improve cultural competency training for clinicians and support staff, and 3) Improve diversity in governance and management. In 2015, AHA launched its #123forEquity pledge campaign in an effort to build on these goals. Hospitals and health systems across the U.S. pledge to take action in these goal areas to improve health equity. Understanding how these health equity initiatives intersect with the Triple Aim (improve the individual experience of care, improve the health of populations, and reduce the per capita costs of care for populations), helps to create a framework for the economic case for achieving health equity. Lancet Oncology Commission on Sustainable Pediatric Cancer Evaluating frameworks of service-delivery for pediatric cancer care at Centers of Excellence in low-andmiddle income countries Combatting the ACA Repeal I worked on a number of smaller projects all related to fighting the repeal of the ACA. I worked on both policy and political projects including creating fact sheets, pulling up quotes from past amendments and political statements to be used in hearings, gathering stories from people who benefitted from the ACA, and other assignments. Health Promotions Fellow As part of the Southern Jamaica Plain Health Center's Health Promotion Center s racial justice and health

7 equity work, I focused on quality improvement of their pediatric obesity intervention ( JP Fit ) and researching barriers to physical activity and nutritious food and their policy implications. I finalized, implemented, and evaluated their rounding system screening pediatric patients for obesity and social determinants of health needs. I designed, implemented, and analyzed a survey identifying barriers to food access and physical activity, including mapping the resource needs on a map of Boston. I am currently designing a strategy to distribute the results of our work to stakeholders and community partners working on policy related to social determinants of health in Boston, including reviewing literature on health centers who invest in social determinants of health activism for pediatric obesity Hydralyte Lancet Oncology Commission on Sustainable Pediatric Cancer Care/Harvard School of Public Health South Texas Veterans Health Care System (STVHCS) Eliminating Sports Drinks from the Standard of Care For the practicum project, I investigated why the oral rehydration market is saturated with inferior products such as sports drinks. I assessed the current state of care and guidelines for treating dehydration in the U.S., researching the conditions treated in the inpatient and outpatient setting. For the inpatient setting, I focused on dehydration in pediatrics, oncology, and gastroenterology. I also evaluate gaps in the healthcare guidelines that are leading healthcare professionals to recommend less effective solutions. I distributed a short pilot survey to health care professionals, and used these results along with the literature review to provide a recommendation on best practices to remove sports drinks from the standard of care, and how better position a cost-effective, clinically viable ORS product. Understanding Models of Excellence in Pediatric Cancer Care in Limited-Resource Settings: Guatemala and El Salvador I performed an analysis of health models of excellence in pediatric cancer care in Guatemala and El Salvador. The project was primarily qualitative in nature where I helped in preparing a standarized interview guide that I then conducted through semi-structured interviews with key stakeholders. A stratified purposive sample of stakeholders were interviewed representing governmental, health care, and advocacy roles instrumental to policy processes and program development. Qualitative interviews were be audiotaped, transcribed verbatim, and translated into English where relevant. The focus of the interviews was on three dimensions at the interface between institutional, programmatic and health system structures: (1) governance, (2) integration, and (3) diffusion. These dimensions will be placed upon a political framework to generate insights in key determinants of success in these programs, sources of innovation, and interface with the greater health care system. Safe Surgery Initiative: Implementation of LiveData PeriOp Manager system In 2013, the Miami VA Medical Center (MVAHS) implemented a technology-enabled solution to help improve patient safety, quality of care and operative workflow efficiency known as LiveData PeriOp Management and its OR-Dashboard with Active Time Out. The STVHCS received approval to implement this system which to assist in its efforts to ensure safe, high quality surgical care. My project will be to engage immediately as part of the team established to prepare for and implement this system; my experience as an active surgeon who is deeply committed to ensuring safe surgical care of the highest quality lends itself to this project. This automated checklist prompts confirmation of the patient s identity and will display two

8 approved identifiers. Similarly, the checklist will prompt confirmation of the surgical procedure confirmation and displays the surgical procedure as listed on the consent. Most importantly, the interactive process fosters surgical team engagement during the timeout process supporting the national surgical initiative to improve patient safety and quality of care. My project will focus on all aspects of implementing this system within the STVHCS. Massachusetts Department of Public Health Massachusetts General Hospital Commonwealth Care Alliance Planned Parenthood League of Massachusetts Home Health Agency Licensure From Scratch DPH is exploring statutory language to license and oversee home health agencies in Massachusetts. This project involved research of other state licensure and operations and development of legal and/or programmatic recommendations for state oversight. This project documented the landscape of home health agency licensure in different states (review of statutory and regulatory approaches, successes, and challenges) with a focus on successes and best practices, included potential funding approaches, as well as ideas and recommendations for funding mechanisms, and included a review of CMS certification to mirror and augment as appropriate. Commercializing Science: Innovation in Trauma and Emergency Medicine I helped to commercialize a number of products in the trauma and emergency medicine spaces. Optimizing Care Transitions for People with Disabilities Commonwealth Care Alliance (CCA) is a not-for-profit, consumer-governed, pre-paid care delivery system for Medicare and Medicaid beneficiaries with complex medical needs. CCA provides enhanced primary care and care coordination through multi-disciplinary clinical teams, including physicians, nurses, and behavioral health and geriatric specialists. CCA is one of the original programs in created in Massachusetts to serve people covered by Medicaid and those who are dual eligible for both Medicaid and Medicare and has been nationally recognized for highly individualized, compassionate health care programs since CCA provides coverage from early intervention to urgent care to long-term services and support and generates savings through innovative care redesign that create savings from reduced hospitalizations and institutional care. My practicum project will involve operational workflow and performance measurement analysis and program development for the implementation of an initiative to improve care transitions between hospitals, skilled nursing facilities, home care entities, and outpatient providers at CCA that is scheduled for roll-out in early Describing the Impact of Parental Involvement Laws for Minors Seeking Abortion Care: the Case of Massachusetts Massachusetts has a parental consent law for teenagers seeking abortion services. However, the law s impact on teenagers and their access to care is not understood. Planned Parenthood League of Massachusetts is embarking on a research endeavor to elucidate the reasons teenagers provide for seeking judicial bypass of the parental consent law, demographic information of teenagers who are affected, and health (care) impacts of the bypass procedure. My practicum will be to review legal referral forms of teenagers who sought a judicial bypass to parental consent in order to identify recurrent themes and health

9 impacts. Mass Dept. of Public Health City Councilor at Large Ayanna Pressley Institute for Healthcare Improvement (IHI) DPH Homelessness Project Predicting homelessness in MA Zoning for Healthy Communities Policy Initiative Councilor Ayanna Pressley aims to advance her vision for developing a Zoning for Healthy Communities model in the City of Boston in light of the Imagine Boston 2030 initiative. Our practicum team was charged with engaging community organizations through interviews and focus groups. Our goal is to bridge the recommendations from these conversations to the Boston Zoning Code rewrite and to advocate to the Mayor's team the importance of using a health equity lens in drafting zoning policies. To promote the framework of health in all policies, we are convening a working group comprised of our practicum team, Councilor Pressley's Chief of Staff, community leaders, and members of the Boston Public Health Commission and the Boston Planning and Development Agency to work together on this policy initiative. The role of quality of health care services in achieving effective Universal Health Coverage in Latin America I worked with the Head of Europe and Latin America of IHI doing a qualitative assessment of the perspective of key stakeholders on the role of quality of primary health care services in government-run clinics in achieving effective Universal Health Coverage in Latin America. The stakeholders included officials from Ministries of Health of different countries in Latin America, as well as primary care providers and quality improvement managers. I conducted semi-structured interviews and 2 focus groups to examine their understanding of the quality level of primary care services being provided and their perspective of the role of that quality plays in achieving effective Universal Health Coverage in Latin America.