Integrating Cultural Competency, Language Access, and Health Literacy in Disparities Reduction Programs

1. How Cultural Competency, Language Access, and Health Literacy Are Integrated Into Programs and Interventions Aimed At Reducing Disparities Marshall H. Chin, MD, MPH Richard Parrillo Family Professor Director, RWJF Reducing Health Care Disparities Through Payment and Delivery System Reform University of Chicago

2. Disclosures / Funding AHRQ T32 HS00084, K12 HS023007, U18 HS023050 The Commonwealth Fund HRSA John A. Hartford Foundation Merck Foundation NIDDK K24 DK071933, R18 DK083946-01A1, P30 DK092949 Robert Wood Johnson Foundation National Quality Forum committees President, Society of General Internal Medicine CMS Innovation Center – technical assistance

3. A Roadmap and Best Practices for Organizations to Reduce Racial and Ethnic Disparities in Health Care Chin MH, et al. JGIM 2012; 27(8):992-1000www.solvingdisparities.org

4. Roadmap for Reducing Racial and Ethnic Disparities in Care 1) Recognize disparities and commit 2) Implement QI infrastructure and process 3) Make equity an integral part of quality 4) Design intervention(s) 5) Implement, evaluate, and adjust intervention(s) 6) Sustain intervention(s) Chin MH et al. JGIM 2012; 27:992-1000

5. Roadmap for Reducing Racial and Ethnic Disparities in Care #1 Recognize disparities and commit to reducing them Chin MH. Ann Intern Med 2008; 149:206-208.

6. Examine Your Performance Data Stratified by Race, Ethnicity, Language, and SES • Individual and organizational readiness to change

7. Make Sure Your Disparities Training is State of the Art SGIM Goals for Health Disparities Courses Existence of disparities, etiologies, solutions Mistrust, subconscious bias, stereotyping Communication, trust building Commitment to reduce disparitiesSmith WR et al. Ann Intern Med 2007; 147:654-665

8. Univ. of Chicago Course Self-insight exercises Field trips & Chicago history Group disparities project Reflective essays and discussion Individual patient care (e.g. interpreters) and policy (e.g. Medicare) AdvocacyVela et al. JGIM 2008; Vela et al. JGIM 2010.

9. Stratified Data and Cultural Competency Training Alone Do Not Improve Clinical Performance Measures Disparity data interventions helpful but not sufficient Knowledge/attitude interventions helpful but not sufficient - Sequist TD et al. Ann Intern Med 2010

10. Hillary Clinton and Black Lives Matter • “You can get lip service from as many white people you can pack into Yankee Stadium and a million more like it who are going to say: ‘We get it, we get it. We are going to be nicer,’ ” she says. “That’s not enough, at least in my book.” NY Times. Aug. 19, 2015 • “I don’t believe you change hearts,” Mrs. Clinton says, summarizing her basic view of social policy movements. “I believe you change laws, you change allocation of resources, you change the way systems operate.”

11. Roadmap Step 2 • Implement basic quality improvement structure and process • Quality culture • Quality improvement team • Goal setting and measuring • Local champion • Leadership support

12. Roadmap Step 3 • Make equity an integral component of quality improvement efforts

13. IOM Model of Quality

14. Roadmap Step 4 • Design intervention(s) • Determine root causes • Consider 6 levels of influence • Review literature • Learn from peers • Consider specific interventions

15. Roadmap Step 4 • Design intervention(s) • Determine root causes • Process mapping • Talk to target population, not just proxies • Minority providers may not be proxies for the target population

16. Conceptual Model Financing / Regulation / Accreditation Health Care Organization Community Provider Access Person Patient Process Outcomes Chin MH et al. Med Care Res Rev 2007 Chin MH & Goldmann D. JAMA 2011

17. 6 Levels of Influence: Cultural Competency, Language Access, Health Literacy • Policy: Clinical performance standards – reimburse. Structural measures of culturally competent organization – e.g. interpreters Clinical outcomes Equity index tools to rate organizations Mandated through legislation

18. 6 Levels of Influence • Health Care Organization: Diversity, Inclusion, and Equity initiatives Equity as a true strategic priority Senior leadership Resources and core team to facilitate and help move mountains within organizations

19. 6 Levels of Influence • Microsystem: Integration of language services and interpreters into care team; make easy to access for providers • Provider: Working with interpreters; Cultural competency training; Shared decision making training

20. 6 Levels of Influence • Patient/Family: Patient empowerment; Shared decision making training; Easy access to language services • Community: Community empowerment; community health workers; Social determinants of health

21. Roadmap Step 4 (Cont.) • Evidence-based strategies • Multifactorial attacking different levers • Culturally tailored QI • Team-based care • Families and non-health partners • Patient navigators • Interactive skills-based training

22. Roadmap Step 5 • Implement, evaluate, and adjust intervention(s)

23. Consolidated Framework for Implementation Research • Intervention (relative advantage) • Outer (external incentives) • Inner (culture) • Individuals (beliefs) • Process (plan, execute, evaluate) Damschroder et al. Implement Sci 2009; 4:50.

24. Behavior Change Theory • Beliefs and knowledge • Why innovations are good • Social norms • It’s the culture / QI collaboratives • Environmental factors • Incentives • Self-efficacy • Coaching / QI collaboratives

25. Motivation • Intrinsic • Professionalism • Do the right thing • Extrinsic • Financial • Other rewards

26. Roadmap Step 6 • Sustain intervention(s) • Institutionalization • Culture, incentives, integrate into daily operations • Societal Business Case • Direct medical costs - $229 billion 2003-2006 • Indirect costs - $1 trillion 2003-2006 • Healthy national workforce – US Census Bureau • 2050 – Hispanic 30%, Black 13%, Asian 8% Laveist TA 2009; US Census Bureau 2008.

27. Where’s the Business Case?

28. Roadmap Step 6 • Sustain intervention(s) • Values – Right thing to do • Business Case – Align policy incentives • Global payments – Accountable care organizations (ACOs), bundled payments • Population health • Pay-for-performance • Link community & health care system - CDC, HHS • Community needs assessment for non-profit hospitals

29. RWJF Reducing Health Care Disparities Through Payment and Delivery System Reform • Program Office at University of Chicago • Delivery system intervention • Payment reform • Pay for performance • Global payment • Shared savings

30. Leadership Matters “Leadership matters. It is our professional responsibility as clinicians, administrators, and policymakers to improve the way we deliver care to diverse patients. We can do better.” Chin MH. NEJM 2014; 317:2331-2.