Health Equity and Disparities

Transcription

1 Health Equity and Disparities

2 Equity versus Equality Equity giving people what they need to enjoy full, health lives. Equality giving everyone the same things in order to enjoy full, healthy lives.

3 Further distinction: Consider runners racing around an oval track At first glance, this seems fair all the runners are treated the same and starting at the same place But, the runners on the inside have an advantage since the distance to the starting line is shorter so equality doesn t result in fairness If we want to be equitable, we stagger the starting positions to offset the advantage the runners in the inside lanes have over the outer lanes. Source: SGBA

4 Why focus on equity? Eliminating health disparities for minorities would reduce medical care expenditures by $230 billion* From almost 1/3 of direct medical costs were associated with health disparities.* * Joint Center for Economic and Political Studies

5 Why Does it Matter White Asian or PI Hispanic Black AIAN Obesity % Smokers % Asthma % Diabetes % Infant Mortality (rate per 1k) HIV Dx (Rate per 100k) Heart Disease (Rate per 100k)

6 Communities in Action: Pathways to Health Equity. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; National Academies Press (US); 2017 Jan.

7 But my hospital population is Thinking beyond race and ethnicity: Language Spiritual beliefs & practices Education level Country of origin Cultural practices Geographic location Disability status Incarceration Mental illness/substance use disorder Certain conditions (i.e., chronic pain) Health insurance Veteran status Gender SOGI And?

8 Disability Status

9 Disparities impacting LGBT populations LGBT youth are 2 to 3 times more likely to attempt suicide. LGBT youth are more likely to be homeless. Lesbians are less likely to get preventive services for cancer. Gay men are at higher risk of HIV and other STDs, especially among communities of color. Lesbians and bisexual females are more likely to be overweight or obese. Transgender individuals have a high prevalence of HIV/STDs, victimization, mental health issues, and suicide and are less likely to have health insurance than heterosexual or LGB individuals. Elderly LGBT individuals face additional barriers to health because of isolation and a lack of social services and culturally competent providers. LGBT populations have the highest rates of tobacco, alcohol, and other drug use.

10 Source: September 2016 Comparison of Health and Health Risk Factors Between Lesbian, Gay, and Bisexual Adults and Heterosexual Adults in the United States Results From the National Health Interview Survey Gilbert Gonzales, PhD, MHA 1 ; Julia Przedworski, BS 2 ; Carrie Henning-Smith, PhD, MPH, MSW 2 JAMA Intern Med. 2016;176(9): doi: /jamainternmed

11 AHA Pledge A public commitment to being intentional about working towards reducing disparities. Select ONE or more of the goals: Increasing the collection and use of race, ethnicity, language preference and other socio-demographic data. Increasing cultural competency training Increasing diversity in leadership and governance Improve and strengthen community partnerships

12 Message to CEO s and Trustee s 1) Gather data (REaL data collection) 2) Make the data useful 3) Educate providers and staff 4) Develop culturally competent interventions 5) Navigate to prevention and wellness

13 The Importance of Organizational Change Management for Health Equity Health Affairs, 2017 Know who to involve Establish a powerful guiding coalition, top to bottom Shape Organizational Culture Anchor to current culture, equity as part of quality Create urgency, vision, make rational and emotional case Include data, stories, community, marketing Engage your organization and your audience Continuously with short term wins Develop strategic leadership skills Anticipate changing environment and promote a culture of learning Harness the Power of a Collaborative Network Peer learning, sharing essential

14 Committing to Equity in Washington Washington Pledged Organizations Washington State Hospital Association Cascade Medical Center Catholic Health Initiatives Harrison Medical Center Highline Medical Center St. Anthony Hospital St. Clare Hospital St. Elizabeth Hospital St. Francis Hospital St. Joseph Medical Center Columbia Basin Hospital Columbia County Public Hospital District #1 Confluence Health/Central Washington Hospital Confluence Health/Wenatchee Valley Hospital & Clinics Coulee Medical Center

15 Eastern State Hospital EvergreenHealth EvergreenHealth Monroe Fairfax Behavioral Health Island Hospital Jefferson Healthcare Kadlec Regional Medical Center Kaiser Permanente of WA Kindred Hospital Seattle - Northgate Kittitas Valley Healthcare Klickitat Valley Health Lake Chelan Community Hospital & Clinics Legacy Health Legacy Salmon Creek Medical Center Lincoln Hospital Mason General Hospital & Family of Clinics MultiCare MultiCare Allenmore Hospital MultiCare Auburn Medical Center

16 MultiCare Deaconess Hospital MultiCare Good Samaritan Hospital MultiCare Mary Bridge Children's Hospital and Health Network MultiCare Tacoma General Hospital MultiCare Valley Hospital Navos Newport Hospital & Health Services Ocean Beach Hospital Odessa Memorial Healthcare Center Olympic Medical Center Othello Community Hospital Overlake Medical Center PeaceHealth PeaceHealth Peace Island Medical Center PeaceHealth Southwest Medical Center PeaceHealth St. John Medical Center PeaceHealth St. Joseph Medical Center PeaceHealth United General Medical Center

17 Providence Health Services Providence Centralia Hospital Providence Holy Family Hospital Providence Mount Carmel Hospital Providence Regional Medical Center Everett Providence Sacred Heart Medical Center & Children's Hospital Providence St. Joseph's Hospital Providence St. Mary Medical Center Providence St. Peter Hospital St. Luke's Rehabilitation Institute Quincy Valley Medical Center Samaritan Healthcare Seattle Children's Skagit Valley Hospital Skyline Hospital Snoqualmie Valley Hospital Summit Pacific Medical Center

18 Swedish Swedish Ballard Swedish Cherry Hill Swedish Edmonds Swedish First Hill Swedish Issaquah Three Rivers Hospital Tri-State Memorial Hospital UW Medicine Harborview Medical Center Northwest Hospital & Medical Center University of Washington Medical Center Valley Medical Center Virginia Mason Health System Virginia Mason Medical Center Virginia Mason Memorial WhidbeyHealth Whitman Hospital and Medical Center Last updated: 4/25/18

19 Committing to Equity in Alaska Alaska Pledged Organizations: Alaska State Hospital and Nursing Home Association HCA Alaska Regional Hospital Providence St. Joseph Health Providence Alaska Medical Center Providence Kodiak Island Medical Center Providence Seward Medical and Care Center Providence Valdez Medical Center As of 02/14/2018

20 Committing to Equity in Oregon Oregon Pledged Organizations Oregon Association of Hospitals and Health Systems Catholic Health Initiatives CHI St. Anthony Hospital Mercy Medical Center Kaiser Foundation Hospital Westside Medical Center Kaiser Permanente Sunnyside Medical Center Legacy Health Legacy Emanuel Hospital and Health Center Legacy Good Samaritan Hospital and Medical Center Legacy Meridian Park Medical Center Legacy Mount Hood Medical Center PeaceHealth PeaceHealth Cottage Grove Community Hospital PeaceHealth Peace Harbor Medical Center PeaceHealth Sacred Heart Medical Center RiverBend

21 Pioneer Memorial Hospital Portland Adventist Medical Center Providence St. Joseph Health Providence Hood River Memorial Hospital Providence Medford Medical Center Providence Milwaukie Medical Center Providence Newberg Medical Center Providence Portland Medical Center Providence Seaside Hospital Providence St. Vincent Medical Center Providence Willamette Falls Medical Center Salem Health Salem Hospital Salem West Valley Hospital St. Charles Health System, Inc. St. Charles Bend St. Charles Madras St. Charles Prineville St. Charles Redmond

22 Tillamook Regional Medical Center Tuality Healthcare Tuality Health Saint Alphonsus Medical Center Baker City Saint Alphonsus Medical Center Ontario Last updated: 10/06/17

23 AHA Pledge Process with WSHA Request a pledge from by contacting Lisa Segerstrom at LisaS@wsha.org Indicate which of the four goals you are pledging your organization to take action on (select at least one). Return to WSHA via (LisaS@wsha.org) or by faxing to (WSHA will forward your pledge form to the AHA Equity of Care program so your hospital can be recognized for its commitment to Health Equity.) Progress Updates WSHA will collect goals and progress updates from your organization and send it to the AHA Equity of Care program on your behalf. WSHA will send a survey to collect this information in March and September each year to the organizational contact you have identified.

24 A3 TITLE: Disparities in Healthcare Owner: Lisa Segerstrom Sponsor/Manager: Cat Mazzawy Version #: 2 DATE: 03/16/2018 Problem Statement (Describe the Problem) There is significant variation in all 16 defined communities in Washington State related to 30-day readmission rates by race. It is also unknown how many hospitals have active plans in place to address disparities. Historical Trend/Background (Current State of the Situation) Readmission rates in all defined communities vary significantly by race: Native American Medicare beneficiaries were the most likely to be readmitted to a hospital in 9 of the 16 defined communities. In those communities, Native Americans were readmitted at a rate anywhere from 107% to 700% higher than the least-readmitted race. In 11 of the 16 defined communities, the difference between the races/ethnicities with the lowest and highest re-hospitalization rates was greater than the state s overall rate of 31.3 readmissions per 1,000 Medicare beneficiaries. While Blacks comprise 2.9% of Washington s Medicare population as a whole, they account for 5.1% of those readmitted within 30 days. (Qualis, Q Q2 2016) It is presumed Inaccurate collection of REAL data in part due to lack of hospital staff comfort in asking patients. Root Cause Analysis While it is widely known that disparities exist, it remains unclear why. Disparities are not a recognized and/or prioritized problem for health system leaders. There are misperceptions related to standardized care and treating all patients equally versus providing quality care that is individualized to patient needs. Target/Goal(s) By 03/31/18, 100% of hospitals will have signed the 123 for Equity Pledge By 03/31/18, 100% of hospitals who have signed the 123 for Equity Pledge will have identified actions to reduce disparities in their organizations and reported these to WSHA. By 12/31/2018, 100% of pledged hospitals will be including disparities (race, ethnicity, language, gender, age, etc.) in at least one quality improvement area (such as readmissions, sepsis mortality, etc.). Implementation Plan/Countermeasures/Outcome WHAT will be done By WHOM By WHEN What was the Leverage board members and community partners to encourage action for hospitals who have not committed to the 123 for Equity Pledge. Form health equity collaborative for HIIN wide sharing and learning. Consider starting a dedicated Listserv for identified contacts. Provide training symposium on implementation of pledge goals. Complete needs assessment of what resources, tools and assistance hospitals require to make progress towards meeting #123 for Equity goals. Identify patients who can serve as patient/family advisors for health equity taskforce and be involved in collaborative. Survey pledged hospitals on current progress to date towards pledged goal and forward to AHA. Provide outreach and coaching to hospitals who are not stratifying data in at least one quality improvement areas. Engage hospital leadership to encourage hospitals to make health equity a priority as demonstrated by being part of each hospitals strategic plan. Summary/Wrap-Up/Next Steps Lisa and 04/15/2018 WSHA Executive team Lisa 04/30/2018 Lisa 05/02/2018 Lisa 05/30/2018 Lisa 06/01/2018 Lisa 06/15/2018 Lisa 06/30/2018 Lisa 06/30/2018 OUTCOME 30 Day: Continue to work to meet goal of 100% participation in the #123 for Equity pledge. 60 Day: Form and convene health equity learning collaborative. 90 Day: Respond to learnings identified during pledge progress update and continue one-on-one coaching to promote including disparities in at least one quality improvement area.

25 Joseph R. Betancourt, MD, MPH Aswita Tan-McGrory, MBA, MSPH

26 Welcome and Thank you! Goals of Meeting: Orient participants to key aspects of #123forEquity Pledge Provide training and tools to meet the #123forEquity Pledge Assist teams to develop a blueprint for action We Provide Real world perspectives, actionable, practical, timely strategies and approaches We find the answers together Help you develop a customized plan for action

27 Making the Case for Equity and Diversity Joseph R. Betancourt, M.D., M.P.H. Director, The Disparities Solutions Center Senior Scientist, Mongan Institute for Health Policy Director for Multicultural Education, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School

28 Outline The New Era of Health Equity The Hard Realities Equity and Action

29 Racial and Ethnic Disparities in Health Care A High-Value Target Racial/Ethnic disparities found across a wide range of health care settings, disease areas, and clinical services, even when various confounders (SES, insurance) controlled for. Many sources contribute to disparities no one suspect, no one solution Navigation Communication Stereotyping Mistrust Variations in care and quality, inefficiencies, costly care and poor outcomes are the epitome of low-value

30 IOM s Unequal Treatment Recommendations Promising strategies, Barriers to eliminating disparities Increase awareness of existence of disparities Address systems of care Support race/ethnicity data collection, quality improvement, evidencebased guidelines, multidisciplinary teams, community outreach Improve workforce diversity Facilitate interpretation services Provider education Health Disparities, Cultural Competence, Clinical Decisionmaking Patient education (navigation, activation) Research

31 The New Era of Health Equity Moving to Access and Accountability Value is real MACRA is here Attention turns to social determinants and Population Health 2.0 Mapping, duals, super-utilizers now a priority to address cost HIT and disruptors changing game Energy on diversity/inclusion, implicit bias, stereotyping Risk Adjustment??? AHA #123, CMS Equity Strategy

32 The Hard Realities for Hospitals The financing doesn t change overnight Flying plane as you reengineer equals pain Discomfort adapting from one patient to a population Extending beyond the four walls of the healthcare system Technology and Data are a blessing and a curse Move to meaningful use and the EHR is EPIC Pricing, Transparency and Accountability A new world is here, and everyone is watching The incentives have changed Beware of unintended consequences

33 The Hard Realities for Disparities Unintended Consequences Readmissions, now MACRA? Risk Adjustment One quality target or two? Leaving groups behind Native Americans, Disabled Fostering the Digital Divide Limited HIT investments for vulnerable populations Precision Medicine For all, not just some

34 MGH Equity and Disparities Disparities Committee 2003 Underlying Principle While data specific to disparities at MGH important, not necessary to begin to take action given IOM Report documented issue nationally Charge Identify and address disparities in health and health care wherever they may exist at MGH Subcommittees: Quality, Patient Experience, Education/Awareness Present plan and results to Board, Executive Council and hospital leadership Build on Strong Foundation Diversity/Recruitment/Retention/Promotion at all levels, including Governance, Leadership, Physicians, Nursing, HR, GME Fortify efforts in racial/ethnic data collection, add new elements Association of American Medical Colleges Learning Challenge Award, 2013 American Hospital Association Equity of Care Award, 2014

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36 Equity and Action Challenges and Possibilities Getting Disparities/Diversity on Leadership Agenda Leaders are swamped, anxious, full of uncertainty, and may be swimming in the red Need to connect the dots for leaders on link between disparities, equity, quality, and value Constant focus on connection to pressure points Data Collection and Monitoring Few collect data and monitor equity Monitoring performance, and targeting services accordingly will be the essential foundation for population health, safety, patient/member experience Identifying disparities can lead to high-value targets

37 Equity and Action Challenges and Possibilities Developing Interventions--Equity Chronic, complex, costly conditions will be managed through interprofessional, well-trained care teams focused on population health (the 20/80 rule) IT, Care coordination and training necessary Emergence of coaches, navigators, and reemergence of community health workers Utilizations, Wellness, Care Management, Transitions One size won t fit all; need focus to impact utilization, patient experience and patient safety Cross-cultural communication and Interpretation Health literacy Patient engagement and Shared decisionmaking Need to make case that will lead to better care for all patients

38 Diversity: What it is and what it isn t It Isn t Lowering standards Achieving quotas It is Broadening pool of perspectives Improving service processes Expanding skills for leadership

39 Not just clinical decisionmaking Stereotyping and Hiring Less than 15% of American men are over six foot tall, yet almost 60% of corporate CEOs are over six foot tall Less than 4% of American men are over six foot, two inches tall, yet more than 36% of corporate CEOs are over six foot, two inches tall Why does this happen? Clearly corporate boards of directors do not, when conducting a CEO search, send out a message to get us a tall guy, and yet the numbers speak for themselves. When corrected for age and gender, an inch of height is worth approximately $78,900 per year in salary Similar patterns are true for Generals and Admirals in the Military, and even for Presidents of the United States

40 What have we learned from other industries? Good plans and intentions are not good enough Executive leadership needed Structure, process and outcomes with real targets Accountability for performance Key metric for compensation and promotion Must be deliberate/purposeful, can t leave to chance

41 It s not just about recruitment Recruitment is just the start Strategies are needed for: Retention Promotion Success Need leadership buy-in and a strategic approach for all of these areas to create a positive cycle

42 The Importance of Organizational Change Management for Health Equity Know who to involve Establish a powerful guiding coalition Involve both leadership and middle management Develop cross collaborations Shape Organizational Culture Disparities efforts anchored to current culture, or equity as part of quality

43 The Importance of Organizational Change Management for Health Equity Create Urgency, Vision, and Make the Rational and Emotional Case Leadership buy-in & Benchmarking with external orgs creates urgency Rocket pitch Combining data with a personal story Community strategy, branding & marketing

44 The Importance of Organizational Change Management for Health Equity Engage Your Organization and Your Audience Align with key stakeholders and share vision early and often Continuous engagement through creation of short term wins such as awards, dissemination, benchmarking work or publications Senior leadership models new behavior- e.g. Chiefs request data by R/E

45 The Importance of Organizational Change Management for Health Equity Harness the Power of a Collaborative Network Develop strategic leadership skills Anticipate changing environment Promote a culture of learning Challenge assumptions and encourage divergent points of view.

46 Summary It is important to be intimately familiar with the current health care context so as to link equity to quality, safety and value Securing buy-in is critical, and having a framework for organizational change management can help There are specific change management strategies that are tied to disparities and equity efforts

47 Thank You Questions and Discussion

48 Break

49 Collecting Race, Ethnicity, and Other Social Determinants of Health and Developing a Performance Report Aswita Tan-McGrory, MBA, MSPH Deputy Director, The Disparities Solutions Center Massachusetts General Hospital

50 Outline Importance of self reported data Key considerations when implementing data collection of race, ethnicity and language Pediatrics Next Steps: Disparities Dashboard

51 A Growing Multi-Racial Population

52 Office of Management & Budget (OMB) Categories Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Ethnicity: Hispanic or Latino Not Hispanic or Latino *OMB is seeking public comments and changes to this 1997 Federal standard

53 9.2% 32% 6.7% 15%

54 Growth of Interracial Marriage

55 Source: Frey, William. Diversity Explosion, Brookings Institute: 2014

56 By 2020, the child population is projected to be a majority-minority population 1 Source: Colby SO, JM. Projections of the Size and Compositions of the US Population: 2014 to 2060, Current Population Reports. Washington, DC: US Census Bureau; P

57 The Newly Insured Population: ~50% Minority

58 Patient Safety & Patients with Limited English Proficiency Adverse events affect patients with limited English Proficiency (LEP) more frequently and severely than English speaking patients Patients with LEP are more likely to experience medical errors due to communication problems Patients with LEP are more likely to suffer physical harm when errors occur (49.1% vs. 29.5%)* *Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. Apr 2007;19(2):60-67.

59 Race and Ethnicity Race group or groups with whom a patient identifies A category of humankind that shares certain distinctive physical traits * Examples: Asian, Black, White, etc Ethnicity background, heritage, culture, ancestry. May also include country where the patient was born Being a member of a specified ethnic group * Examples: Haitian, Vietnamese, Brazilian, etc. *Source: Merriam Webster Dictionary

60 Kaiser Family Foundation Survey of Americans on Race 35% of Blacks and 26% of Hispanics reported personally experiencing discrimination because of their racial or ethnic background - either being denied a job for which they were qualified, being denied housing they could afford, or being prevented from voting or having their ballot challenged. 11% of Whites reported such experiences. 53% of Blacks and 36% of Hispanics said that, in the previous month, they ve experienced unfair treatment because of their race, either in a store where they were shopping; at work; in a restaurant, theater or other entertainment establishment; in dealings with the police; or in getting health care. Among Blacks ages 18-34, 67% report such recent experiences of unfair treatment. 45% of Blacks said they have at some point been afraid their life was in danger because of their racial or ethnic background, compared to 27% of Whites and 20% Hispanics.

61 Race and Class Disparities in Therapist Accessibility Middle-class help seekers were offered appointments at a rate almost three times higher than their working-class counterparts Black middle class help-seekers were considerably less likely than whites to be offered an appointment. No significant racial disparities were found for appointment offers for working class help seekers. Heather Kugelmass. Sorry, I m Not Accepting New Patients : An Audit Study of Access to Mental Health Care. Journal of Health and Social Behavior, June 2016.

62 Patients Reaction Baker and colleagues (2005, 2007) found that, while most patients agreed that healthcare providers should collect race/ethnicity, minority patients may feel less comfortable providing this information. Over 40% of patients were concerned that the information could lead to discrimination. Compared with white patients, black and Hispanic patients felt less strongly that HCPs should collect race/ethnicity data from patients and black patients were less comfortable reporting their R/E than white patients. Telling patients that their R/E information would be used for monitoring quality of care improved patient comfort *Sources: Baker DW, Cameron KA, Feinglass J, et al. Patients' attitudes toward health care providers collecting information about their race and ethnicity. Journal of general internal medicine. Oct 2005;20(10): ; Baker DW, Hasnain-Wynia R, Kandula NR, Thompson JA, Brown ER. Attitudes toward health care providers, collecting information about patients' race, ethnicity, and language. Medical care. Nov 2007;45(11):

63 How to Address Patient Concerns A patient asks, Why do you want this information? Identify health differences Data will be reported by groups A patient asks, Who will see this information? HIPAA Will not be shared with immigration or government agency Registration personnel, providers, quality improvement personnel A patient asks, What do you mean by race and/or ethnicity? Provide definition Patient can have more than one answer, use free text A patient says, I think that the answers are obvious. Explain regardless of how obvious, you are required to ask the questions and record responses. What other questions have you heard in your practice?

64 Key Strategies for Success Train your registrars, front-line staff Job aids, scripts, videos, role-playing, provide time to address concerns Inform your patient of the why, who and what Why are you collecting the data Who will see the data What will you do with the data Do periodic quality checks on your data collection Secret shopper Follow up w/patients to confirm race/ethnicity/language Observation Monitor and report on your data Disparities Dashboard Develop interventions Report back to front line staff, registrars, etc about results. Keeping them informed and up to date is key.

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66 What about pediatrics?

67 Pediatric Health Equity Collaborative The Pediatric Health Equity Collaborative (PHEC) is comprised of 11 organizations working together with the goals of establishing best practices, lessons learned, and recommendations for the field with regard to race, ethnicity, language, and other demographic data collection in pediatric care settings.

68 Cultural Characteristics Race/ Ethnicity Disability PHEC Data Domains Caregiver Language Sexual Orientation and Gender Identity

69 Caregiver Language Domain Patient Caregiver 1 Caregiver 2 Preferred Spoken Language Preferred Written Language English English Spanish English Spanish Spanish

70 Recommendations for Collecting Race and Ethnicity in Pediatric Setting Include multiracial and multiethnic as options, include specific races or ethnicities Collect race/ethnicity of the care givers May be limited by your electronic health record Collect the patient s race from the patient. Sense of race may change over time

71 Study Objectives To investigate providers, registrars, and patients perspectives on collecting SO/GI data to: 1. Understand beliefs and concerns of multiple stakeholder groups (both SGM and non-sgm) on the issues and nuances of collecting SO/GI data 2. Elucidate preferred processes for asking about SO/GI 3. Understand perceived implications of SO/GI data collection

72 Preliminary Findings Registrars and patients must be well informed on the purpose of collecting SO/GI data and how the data will be used. Staff need training on how to collect SO/GI data from patients, how to manage challenging situations, and overcoming biases and/or fears related to collecting SO/GI data. Most providers and LGBTQ patients believe it is important to ask about SO/GI data. Reasons cited include (but are not limited to): Relevance to clinical care Monitoring for disparities and ensuring equitable care Providing patient-centered Enhancing patients engagement in their care Demonstrating respect, inclusivity, and sensitivity to the unique needs of LGBTQ patients. Creating a welcoming environment Heterosexism and cissexism are prevalent and may surface among hospital staff who collect or have access to SO/GI data. Policies and procedures for preventing and addressing discrimination specifically related to sexual orientation and gender identity are essential.

73 What is the next step?

74 MGH Leading the Nation on Equity in Health Care Quality Since 2006 MGH has released the Annual Report on Equity in Health Care Quality (formerly the Disparities Dashboard) In 2013, MGH received the AAMC Learning Health System Challenge Award for our efforts to reduce disparities through data collection & quality improvement In 2014, MGH received AHA s inaugural Equity of Care Award. The AHA Equity of Care Award was created to recognize outstanding efforts among hospitals and care systems to advance equity of care to all patients, and to spread lessons learned and progress toward achieving health equity.

75 MGH Annual Report on Equity in Health Care Quality Disparities Solutions Center Joseph R. Betancourt, MD, MPS Aswita Tan-McGrory, MBA, MSPH Karey S. Kenst, MPH Edward P. Lawrence Center for Quality & Safety Elizabeth Mort, MD, MPH Syrene Reilly, MBA Andrea T. Tull, PhD Taekyu Kim, MBA Robert J. Malin, MHA

76 Acknowledgements The AREHQ is made possible by the contributions of several staff from the following departments and centers at MGH and the MGPO: Center for Quality & Safety The Disparities Solutions Center The Mongan Institute Health Policy Center Admitting & Registration Services MGH Interpreter Services Department of Medicine Department of Obstetrics and Gynecology MassGeneral Hospital for Children Center for Community Health Improvement Information Systems

77 Annual Report on Equity in Health Care Quality MGH Commitment to Diversity & Inclusion Demographic profile of MGH patients New area of exploration: Readmissions Caring for patients with limited English proficiency Department-specific quality measures Obstetrics Pediatrics Standard reporting measures Inpatient clinical quality indicators Outpatient clinical quality indicators Patient Experiences of care

78 Where Do I Start?

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80 What Are Disparities Specific Measures? Care with high degree of discretion (pain management) Communication sensitive services (discharge instructions) Social determinant-dependent measures (SES, education, environment as barriers to selfmanagement of CHF or Diabetes) Outcome and communication-sensitive process measures (flu shot)

81 MGH Patient Population: Race & Ethnicity MGH sees a small proportion of patients from racial/ethnic minority groups We see more minority patients in our ED, health centers, Peds, OB/GYN, and primary care services than inpatient services and outpatient specialty care. % of MGH Patients by Race & Ethnicity Compared with Catchment Area (CY 2016) Inpatient Outpatient

82 MGH Patient Population: Language The proportion of patients with limited English proficiency seen as MGH is not representative of the catchment area population. % of MGH Patients by Language Compared with Catchment Area (CY 2016)

83 National Hospital Quality Measures Data showed no disparities by race or primary language in the NHQMs (inpatient measures) included in the report Measure Timeframe for Analysis Status Stroke Retired Venous Thromboembolism Endoscopy/ Polyp Surveillance Inpatient Influenza Vaccination Retired April 2014-Dec New Ongoing

84 Linking Patients to Primary Care MD or Practice Why is it important to link patients to a usual source of care? Better health outcomes, fewer disparities Less likely to postpone care Higher rates of receiving preventative services Sources: 2020 Topics & Objectives: Access to Health Services. US Department of Health and Human Services Accessed 19 December, Shi L, Nie X, Wang TF. Type of usual source of care and access to care. The Journal of Ambulatory Care Management. Jul-Sep 2013;36(3):

85 HEDIS Measures: Ambulatory Screening Rates HEDIS measures for patients seen between include: o o o Breast, cervical, colorectal, and prostate cancer screening rates Diabetes care measures Coronary artery disease measures No disparities were found in diabetes care or coronary artery disease. Disparities were found in breast, cervical, and colorectal cancer screenings for Asian patients compared to white patients.

86 Key Findings: Patient Experience MGH collects patient experience data through the inpatient HCAHPS survey and the ambulatory C/G-CAHPS surveys. Results reflect responses from Jan 2014-Dec Asian/Pacific Islander patients reported significantly less positive experiences than non-hispanic whites for 5 out of 11 HCAHPS measures and for both C/G- CAHPS measures: HCAHPS Overall hospital rating Recommend the hospital Nurse communication Room cleanliness Care transitions C/G-CAHPS Overall provider rating Willingness to recommend provider

87 Key Findings: Care Transitions New care transitions measures added in 2014: 1. Patient and family preferences taken into account at discharge 2. Patient had good understanding of responsibilities for managing health at discharge 3. Patient understood purpose for taking each medication at discharge Hispanic, Asian/Pacific Islander and patients of Other race reported significantly more negative experiences with care transitions than non- Hispanic whites. Spanish-speaking respondents reported significantly more negative experiences with care transitions than English-speaking respondents.

88 Pediatrics: Outpatient Patient Experience Asian patients provided lower overall provider rating and willingness to recommend provider than non-hispanic white patients.

89 New Area of Exploration: Readmissions

90 A Brief Word About Interventions Consider your resources and capacity when developing your dashboard Data will drive interventions and inform leadership The low-hanging fruit versus the ideal intervention Ownership is key - ideally these would be deployed by your Quality and Safety department, or by a specific department (OB, peds)

91 Lessons Learned Assume disparities exist, the dashboard will monitor and allow for action Engage key stakeholders early on and continue during the process Clinicians are key in interpreting data and determining if you are looking at the right source/denominator Don t underestimate the role of your EHR

92 Lessons Learned It s complicated - Examining disparities-specific measures at the department level is a more complex process than stratifying existing, off the shelf measures (HEDIS, NHQM, H-CAHPS) It s an iterative process to develop the measure and to define the population Transparency is key leverage reporting back to C-suite, department chairs, or specific departments involved in getting the data (admitting) and include a brief overview of disparities for your audience

93 Resources NQF Healthcare Disparities Measurement %20Commissioned%20Paper.pdf AHRQ s National Healthcare Disparities and Quality Report 3nhdr.pdf

94 Resources CMS/Agency- Information/OMH/Downloads/Data- Collection-Resources.pdf

95 Thank You Aswita Tan-McGrory, MBA, MSPH Deputy Director, The Disparities Solutions Center Massachusetts General Hospital Follow us on Like us on Facebook: ww.facebook.com/disparitiessolutionscenter

96 Lunch

97 Cross-Cultural Training for Practicing Health Professionals Joseph R. Betancourt, M.D., M.P.H. Director, The Disparities Solutions Center Senior Scientist, Institute for Health Policy Director for Multicultural Education, Massachusetts General Hospital Associate Professor of Medicine, Harvard Medical School

98 Outline Current Healthcare Context What we know about practicing health professionals A Model, Case Study and Lessons Learned

99 A Timely focus on Value The Talking Cure for Health Care Wall Street Journal Lack of communication can impact quality, cost, safety and value. Communication closely linked to: Transitions and Readmissions Patient Experience and Safety Test Ordering Adherence Key health care stakeholders are "extremely interested" in improving communication.

100 What is the goal of Cultural Competence? To improve the ability of health care providers and the health care system to effectively communicate and care for patients from diverse social and cultural backgrounds Drivers include increasing diversity, research on communication, disparities, as well as accreditation/regulation and push towards value

101 The Premise 1. We strive to deliver quality care to all 2. Communication matters 3. It is harder to communicate with some than others, especially across cultures 4. Now more than ever before, we need to be skilled at communicating and conveying lots of information in a short amount of time, and often in critical situations 5. When we are ineffective, we get frustrated, and patients receive lower quality care 6. If we are to deliver quality care, we must be skilled at communicating and caring for all patents 7. This requires a skill set, or check-list, to assure we are prepared and able

102 Major Misconceptions Addressing culture is art, not skill Culture is important, but we don t have time We need key cultural do s and don ts Culture is about the other

103 Key Principles and Reframing Culture is broadly defined (not just race/ethnicity) We all have culture There is great variation within cultural groups A skill set can help bridge gaps

104 Resident and Physician Surveys Key Highlights 2000 Residents (JAMA 2005) and 4000 MD (Quantia 2011) Culture is important in clinical care Being inattentive to culture has clinical consequences Longer LOS, non-adherence, unnecessary visits, tests, hospitalizations and delays obtaining informed consent Although majority feel prepared, they lack basic skills Those who received training feel better prepared Training matters Time is the biggest barrier to cross-cultural care

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106 Model for Cross-Cultural Communication Assess Core cross-cultural issues Explore the meaning of the illness/treatment Determine the social context Engage in negotiation

107 Key Triggers Discipline Specific Non-Adherence to Medications Lost to Follow-Up Patient Refusal of a Dx or Tx Procedure Informed Consent Patient not at Target Specific Clinical Situations: End of Life

108 Model for Cross-Cultural Care: A Patient-Based Approach Awareness of Cultural and Social Factors Elicit Factors Negotiate Models Implement Management Strategies Avoid stereotyping and build trust Tools and skills necessary to provide quality care to any patient we see, regardless of race, ethnicity, culture, class or language proficiency.

109 Live training Deployment Strategies Costly, can be disruptive, achieving scale a challenge, need skilled trainers; benefit is interaction, discussion E-Learning Cost-effective, can train large group, standardized dose, short time; downside is no real-time discussion* Blended Learning Ideal, as achieve benefits of both above with limited downside, except for logistics, scale

110 MGH Case Study Link to Transitions, Safety, Patient Experience Quality Interactions Cross-Cultural Training as part of MGPO QI Incentive; casebased, evidence-based, interactive e-learning which allows learners to develop a skill set to provide quality to diverse populations 987 doctors completed at MGH; more than 88% said program increased awareness of issues, would improve care they provide to patients, and would recommend to colleagues; average pretest score 51%, posttest score 83% Trained 1500 frontline staff with Healthcare Professional Version 1. Available at:

111 Quality Interactions elearning and Training Foundational & Specialized Over 25 clinical and non-clinical courses used to train over 140,000 practicing caregivers nationwide: Teaches patient-based approach to improve cross-cultural interactions Based on real scenarios Engage learners through interactive exercises and case vignettes Adult learning theory, teachable moments Offers responsive feedback Include pre- and post-test reporting 2016 Quality Interactions, Inc.

112 AHA Inaugural Equity of Care Award Winner Recognizing leaders in the field of equitable care that demonstrate success in reducing healthcare disparities and promoting diversity within their organizations. Quality Interactions Supports Success at MGH Training for all clinicians: QI Foundational elearning QI Test Your Skills elearning Training for most non-clinicians: QI Foundational elearning Key for #123 Pledge for Equity

113 Providing Safe & Effective Care for Patients with LEP Module focused on working effectively with interpreters in clinical settings was rolled out to providers at Massachusetts General Hospital as part of mandatory training requirements in FY16 and FY17. 6,046 MGH employees have been trained to date. LEP E-Learning Completions by Role (FY16 & FY17) N = 6,064 23% MDs, PhDs, Residents, Fellows 77% Ambulatory Nurses, Advanced Practitioners (NPs & PAs)

114 Key Lessons from the Field Messaging is key to secure buy-in Demonstrate value add, saving time, addressing frustration Reframe and adjust misconceptions Engage your learners early and often Case Based, Adult Learning Theory with Teachable Moments Make education personalized and sticky Link to literature, evidence-based guidelines Development of a practical, actionable framework Focus on common scenarios Using 20/80 rule and respectful of discipline and job function Learning pathway is key One program does not behavior change make; need pathway of learning with booster cases, cues From general to specific skills Foundations/Applications/Specific topics

115 Summary Sociocultural factors impact communication There are multiple approaches that can be taken to successfully deploy a cross-cultural education strategy Effective cross-cultural communication improves the quality of encounters, and the effectiveness of health care

116 Thank You Joseph R. Betancourt, MD, MPH

117 Organizational Assessment and Developing a Blue Print for Action Aswita Tan-McGrory, MBA, MSPH Deputy Director, The Disparities Solutions Center Massachusetts General Hospital

118 SWOT Analysis Internal External Strengths characteristics of the organization or project that give it an advantage over others Opportunities elements that the project could use to its advantage Weaknesses are characteristics that place the organization/project at a disadvantage relative to others Threats elements in the environment that could cause trouble for the organization or project Positive Negative

119 Threats Opportunities Strengths What can we take advantage of? SWOT Analysis What threats can we withstand? Weaknesses What are we missing out on? Where are we vulnerable? Positive Negative

120 SWOT Analysis Example-Dashboard Internal External Strengths CEO buy-in & support Collect R/E/L data Opportunities Meaningful Use Readmissions penalties Weaknesses Lack of resources/staff time Data warehouse infrastructure Threats Public perception if disparities identified Positive Negative

121 Team Exercise Divide into your teams Each team, for your project/org assess: SWOT Strengths, Weaknesses, Opportunities, Threats 10 minutes then group discussion

122 Threats Opportunities Strengths What can we take advantage of? SWOT Analysis What threats can we withstand? Weaknesses What are we missing out on? Where are we vulnerable? Positive Negative

123 Group Exercise What was your key take away when you did the SWOT analysis?

124 Organizational Change Management For Health Equity: Perspectives From The Disparities Leadership Program JR Betancourt, A Tan-McGrory, KS Kenst, TH Phan and L Lopez. Organizational Change Management For Health Equity: Perspectives From The Disparities Leadership Program. Health Affairs 36, no. 6 (2017):

125 The Importance of Organizational Change Management for Health Equity Know who to involve Establish a powerful guiding coalition Involve both leadership and middle management Develop cross collaborations Shape Organizational Culture Disparities efforts anchored to current culture, or equity as part of quality

126 Team Exercise Divide into your teams Come up with three descriptions of your organization s culture 5 minutes then group discussion

127 Questions?

128 Thank You Aswita Tan-McGrory, MBA, MSPH Deputy Director, The Disparities Solutions Center Massachusetts General Hospital Follow us on Like us on Facebook: ww.facebook.com/disparitiessolutionscenter "The analyses upon which this publication is based were performed under Contract Number HHSM C entitled, "Hospital Improvement Innovation Network," sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services."