Achieving Health Equity in Primary Care Settings Alexandra García , PhD, RN, FAAN

1. Achieving Health Equity in Primary Care Settings Alexandra García, PhD, RN, FAAN alex.garcia@austin.utexas.edu April 19, 2018 Texas Association of Charitable Clinics

2. Health Equity ”…Everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care" (RWJF).

4. Structural Inequities • “the systemic disadvantage of one social group compared to other groups with whom they coexist” (National Academy of Medicine, 2016)

5. Structural Inequities include •  Policy, law, governance, culture, sex, gender identity, class, sexual orientation, and other domains • That are expressed as racism, sexism, gender identity discrimination, classism, able-ism, xenophobia, homophobia (National Academy of Medicine, 2017)

6. Structural inequities produce systematic disadvantages, which lead to inequitable experiences of the social determinants of health and ultimately shape health outcomes.

7. Intersectionality  “multiple social identities such as race, gender, sexual orientation, socioeconomic status, and disability intersect at the micro level of individual experience to reflect interlocking systems of privilege and oppression.”

8. Because…Structural Inequities •  Produce large and preventable differences (disparities) in health, such as life expectancy • For example, one’s zip code is more important to health than one’s genetic code (RWJF, 2009)

9. Structural Inequity Examples •  Affect hiring policies when both implicit and explicit biases create different opportunities along racial, gender, and physical ability divisions. • Lending policies continue to create differences in home ownership, small business development, and other asset development (Pager and Shepherd, 2008). How is health affected?

10. Equity in Primary Care means • Equity of treatment • Equal opportunities for health • Equity of outcomes • Have to address social determinants of health – factors outside the clinical setting Institute for Healthcare Improvement

11. Health is mostly determined by factors other than clinical care. County Health Rankings & Roadmaps program is a collaboration between the Robert Wood Johnson Foundation and the Population Health Institute at the University of Wisconsin’s School of Medicine and Public Health

12. Social Determinants of Health • “The conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." • Education; employment; health systems and services; housing; income and wealth; the physical environment; public safety; the social environment; transportation; immigration status; accommodations (National Academies of Medicine, 2016)

13. What Can Health Care Organizations Do? Health care organizations cannot improve all the determinants of health for everyone but they do have the power to address disparities directly at the point of care, and to impact many of the determinants that create disparities

14. Equitable Primary Care Quality does not vary because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (Derek Feeley at the Institute for Healthcare Improvement)

15. Clinical Access is Important! • Normative need: defined by an expert, e.g., a PC provider or evidence-based guidelines for the treatment of a particular group of people • Felt need: determined by asking people what they feel they need • Expressed need: services used • Comparative need: do differing populations receive differing levels of a service

16. IHI Framework for Achieving Health Equity (2016)

17. 1. Make Health Equity a Strategic Priority • Leadership commitment to achieving equity at all levels of the organization • Examine performance data by race, ethnicity, and language (REAL) • Track outcomes that matter to patients, such as quality of life and the ability to function • Use incentives at all levels to achieve equity goals

18. Making Improvements base on REAL data Example from HealthPartners in Minnesota

19. 1. Make Health Equity a Strategic Priority • Secure sustainable funding through new payment models • Fee-for-service systems reward volume and procedures but not reward prevention and does not address the social, economic, or cultural factors that drive disparities. • Should risk-adjust clinical performance scores for the socioeconomic status of patients to create a level playing field in pay-for-performance programs. • Reward high levels of quality and reductions in disparities.

20. 2. Develop structure and processes to support health equity work • Establish a leader and governance committee to oversee and manage equity work across the organization • Dedicate resources in the budget to support equity work

21. Quality improvement culture, structure, and process • Create a culture of equity • Recognize equity as a cross-cutting dimension of quality • Designate a QI team with all levels of staff • Establish a QI process with goals and metrics • Select a local champion • Obtain leadership support Six Steps for Reducing Racial and Ethnic Disparities in Care (Chin et al., 2009)

22. 3. Deploy specific strategies to address multiple determinants of health • Health care services • Socioeconomic status • Physical environment • Healthy behaviors • Begin with the needs and issues experiences by patient populations experiencing the worse health outcomes

23. What Health Care Staff Can Do • Commit to helping low-income and non-English-speaking patients get care they need • Guard against the potential for bias to influence medical care • Understand the effects of adverse childhood experiences and use trauma-informed care. • Adopt new vital signs to screen for the nonmedical factors influencing health. RWJF https://www.rwjf.org/en/library/features/achieving-health-equity.html

24. Adopt new vital signs to screen for the nonmedical factors influencing health • Do you have trouble making ends meet? • Do you have trouble feeding your family • Do you have trouble paying for medications? • Do you receive the child tax benefit? • Do you have legal or immigration challenges? • Do you have a safe and clean place to live? RWJF https://www.rwjf.org/en/library/features/achieving-health-equity.html

25. Provide Patient-Centered Care • Build Trust • Listen to patients and meet their individual needs • Tailor care to individual patients and their cultures • Teams with patient navigators and community health workers who assess patients' strengths and challenges, monitor patients, and involve families and community partners in solutions

26. Interventions to Move Towards Equity • Founded in understandings of root causes of disparities in a specific context • Influence patient, provider, microsystem, organization, community, policy • Use evidence-based strategies: e.g., CLAS • Best practices from RWJF (www.solvingdisparities.org), AHRQ (www.innovations.ahrq.gov), and others: VA, Guide to Community Preventive Services • Test, evaluate, adjust the interventions • Sustain the interventions

28. 4. Decrease institutional racism within the organization • Reduce implicit bias within organizational policies, structures, norms, and patient care • Training in root causes of health disparities, cultural competency • Recruit, retain, develop diverse staff • Job description shared with community partners • Interview questions that probe perspectives

29. Promote equity with organizational policies • Physical space: • Use builders that have a diverse workforce • Create accessible and inviting clinic space • Improve the surrounding physical environment with walking trails and gardens • Offer community meeting space • Choose investments and insurance plans that promote equity • Encourage procurement practices from suppliers that use a diverse workforce • Consider a living wage

30. Reduce Implicit Bias • Counter-stereotypic imaging: Recognize that a response is based on stereotype and consciously adjust the response; imagine the individual as the opposite of the stereotype • Individuation: See the person as an individual rather than a stereotype; learn about their personal history and the context that brought them to the clinic • Perspective taking: “Put yourself in the other person’s shoes”

31. Reduce Implicit Bias • Increasing opportunities for contact with individuals from different groups: Attend events where people of other racial and ethnic groups, gender identities, sexual orientation, and other groups may be present • Partnership building: Reframe the interaction with the patient as one between collaborating equals, rather than between a high-status person and a low-status person •  Do a “Teach Back” to confirm patient understanding of health care

32. 5. Develop partnerships with community organizations • Leverage community assets to work together on community issues related to improving health and equity

33. Opportunities to Partner with CBOs • Create community spaces • Fund parks, walking trails • Make investments in the community • Create health ambassadors • Develop partnerships for healthy activities

34. Clinic-Community Collaborations Improve Outcomes • Referrals to CBOs focused on food, exercise, smoking, alcohol • Electronic Linkage Systems increased referrals to 10% from typical rate of 2-5% • Community Health Workers/Promotores to promote primary care and follow up care • Rates of blood pressure control increased from 18% to 34%

35. What Americans Think about Health as a Shared Value • National survey of 10,574 adults of American values and beliefs – most segments can be mobilized (Bye et al., 2016)

36. What Everyone Can Do to Promote Equity • Know your rights https://www.hhs.gov/civil-rights/for-individuals/index.html • Start a conversation about equity and disparities • Mobilize your community County Health Rankings Action Center http://www.countyhealthrankings.org/take-action-improve-health/action-center and Community Toolbox https://ctb.ku.edu/en

37. Some References and Resources • Chin, M. H., et al. (2012). A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. Journal of General Internal Medicine, 27, 992-1000. • National Academy of Medicine. (2018). Communities in action: Pathways to health equity.https://www.nap.edu/read/24624/chapter/1 • Office of Minority Health. (April 2013). A Blueprint for Advancing and Sustaining CLAS Policy and Practice. Department of Health and Human Services. https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedCLASStandardsBlueprint.pdf • Robert Wood Johnson Foundation. (no date). Achieving health equity. https://www.rwjf.org/en/library/features/achieving-health-equity.html • Wyatt, R., Laderman, M., Botwinick, L., Mate, K., & Whittington. J. (2016). Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement http://www.ihi.org

38. Please share… • What are the most significant health inequities you see? • What are you/your clinic doing to promote equity? • What are the biggest challenges? • What strategies might you incorporate in your clinic?