National association of health services executives 28 th Annual Education conference

1. National association of health services executives28th Annual Education conference Affordable Care Act: Delivering Culturally and Linguistically Equitable and Quality Care Public Policy and Advocacy Forum Friday, October 18, 2013 Miami, FL 9:45am – 11:00am

2. Introduction of Panelists Moderator Andrew M. Wiesenthal, MD, SM • Director, Deloitte Consulting, LLP Panelist 1 Joseph R. Betancourt, MD, MPH • Director, The Disparities Solutions Center Senior Scientist, The Mongan Institute for Health Policy Director of Multicultural Education, Multicultural Affairs Office, Massachusetts General Hospital • Associate Professor of Medicine, Harvard Medical School Panelist 2 Maria R. Cooper, MA • Health Policy Analyst, Texas Health Institute Panelist 3 Louis R. Preston, JR., M.Div, CDM • Diversity Officer, Florida Hospital • Director, Interpreter Services, Florida Hospital

3. Affordable Care Act (ACA) : Culturally and linguistically, equitable & Quality care • Moderator • Andrew M. Wiesenthal, MD, SM • Director, Deloitte Consulting, LLP

4. BACKGROUND on Health Disparities in the U.S. “At the most basic level, health is freedom. It’s the freedom to go about our daily lives without experiencing pain. It’s the freedom to live long enough to achieve our goals and get to know our grand-children. It’s the freedom from constant worries about a chronic condition or accumulating health care bills.” • Secretary Kathleen Sebelius, Department of Health and Human Services "Of all the forms of inequality, injustice in health care is the most shocking and inhumane." • Dr. Martin Luther King, Jr.

5. Cancer (5-year survival rates) Hypertension Rates Obesity Rates • Breast Cancer • Black women: 55.9% • White women: 68.8% • Colon Cancer • Black men and women: 55% • White men and women: 66% • 2005-2008 • Black adults: 42% • Mexican-American adults: 25.5% • White adults: 28.8% • Prevalence amongst women (older than 20) in 2008 • Black women: 51% • Mexican-American women: 43% • White women: 33% A national health concern • By 2050, racial and ethnic minorities are estimated to comprise 54% of the population¹ • Nearly 9 out of 10 adults have difficulty using the everyday health information² • Rapid growth in the racial, ethnic, and linguistic composition leads to:³ • Miscommunication of critical health care information • Lack of compliance with prescribed treatment and medication • 1 US Census Bureau • 2U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC: Author. • 3 CMS MLN Matters dated October 1, 2012 • 4 JAMA (July 2013), American Cancer Society, CDC

6. ACA Background • In March 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (ACA), into law. • ACA Section 2719(a)(1)(B) states that group health plan and health insurance issuer shall provide notices to enrollees, in a culturally and linguistically appropriate manner How the Health Care Law Benefits You • Because of the Affordable Care Act, the 85 percent of Americans who have insurance have more choices and stronger coverage than ever before. • Includes provisions to standardize the collection of data on health care quality • Efforts to reduce disparities • Federal surveys and programs collect and report data on race, ethnicity, sex, primary language, and disability status • Aim to understand disparities

7. Culturally & Linguistically appropriate Care • Health care delivery by interacting with patients/consumers from many different cultural and linguistic backgrounds • Cultural competence as an "ongoing commitment or institutionalization of appropriate practice and policies for diverse populations”.¹ • Cultural competence is a reflection of the health system's ability to deliver care that meets patients' cultural, social, and communication needs according to Dr. Bentacourt.¹ ¹Dreachslin, J., & Myers, V. (2007). A systems approach to culturally and linguistically competent care. Journal Of Healthcare Management, 52(4), 220-226.

8. A Time of Healthcare Transformation and Value • Panelist 1 • Joseph R. Betancourt, MD, MPH • Director, The Disparities Solutions Center Senior Scientist, The Mongan Institute for Health Policy Director of Multicultural Education, Multicultural Affairs Office, Massachusetts General Hospital • Associate Professor of Medicine, Harvard Medical School

9. A Time of Healthcare Transformation and Value Value-based purchasing and health care reform will alter the way health care is delivered and financed • Increasing access and assuring appropriate utilization • Decreasing ED use, linkage to primary care • Emergence of ACO’s and Patient Centered Medical Homes • Importance of Wellness, Population Management, Preventing ACS • Focus on transitions of care, safety and patient experience • Importance of preventing readmissions, avoiding medical errors, and improving patient satisfaction

10. The Role of Communication Communication Patient Satisfaction Adherence Health Outcomes

11. Communication and Healthcare Transformation • ACO’s, Population Health and the Patient Centered Medical Home • Communication is key to adherence, chronic disease management and preventing avoidable hospitalizations • Transitions of Care and Readmissions • Communication is key to discharge planning and preventing readmissions • Patient Experience • Communication is key to satisfaction and experience

12. The Newly Insured Population Approximately 50% Minority 12

13. Why Cultural Competence? Disparities in Health Care 2002 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 Findings: Many sources contribute to disparities—no one suspect, no one solution Rec: Cultural Competence training for all health care professionals

14. How about the impact on quality? The Role of Communication, Cultural Competence, and Care • Safety • Minorities have more medical errors with greater clinical consequences • Effective • Minorities received less evidence-based care (asthma) • Patient-centeredness • Minorities less likely to provide truly informed consent • Timeliness • Minorities more likely to wait for same procedure (transplant) • Efficiency • More test ordering in ED for minorities due to poor communication • Equity

15. …and Payment Reform and Health Care Reform? • ACO’s, PCMH’s and Population Health • Minorities more likely to have ACS admissions; communication about use of services key • Transitions of Care and Readmissions • Minorities more likely to be readmitted with CHF in 30d; communication about what to do, where to go key • Patient Experience • We see variations in HCAHPS by race and ethnicity; communication and service is key

16. Accreditation, Quality Measures, and HC Reform • Joint Commission: Disparities/Cultural competence Standards • National Quality Forum: Disparities and Cultural Competence Quality Measures, developing disparities measures, incorporating into MAP • AHA Call to Action: REaL Data, Governance, Cultural Competency Training • Health Care Reform has multiple provisions addressing disparities

17. IOM’s Unequal Treatmentwww.nap.edu Recommendations • Increase awareness of existence of disparities • Address systems of care • Support race/ethnicity data collection, quality improvement, evidence-based guidelines, multidisciplinary teams, community outreach • Improve workforce diversity • Facilitate interpretation services • Provider education • Health Disparities, Cultural Competence, Clinical Decision making • Patient education (navigation, activation) • Research • Promising strategies, Barriers to eliminating disparities

18. Disparities Leadership Program Our Experience With the 2013-14 class, the Disparities Leadership Program will have trained: 211 participants 98 organizations 47 hospitals 21 health plans 20 community health centers 1 hospital trade organization 1 federal government agency 1 city government agency 7 professional organizations

19. 1. Gather the DataREaL Data Collection • Collect REaL and Education data of all patients • Piloted different versions • Gets key info • Doesn’t confuse patients • Can be done in a timely fashion • Registrar Training • Preamble • FAQ’s • PR Poster Campaign • QA and Registrar Feedback • “Secret Santa” • Presentation on impact • Net-Net: It can be done, is being done, no need to reinvent the wheel

20. 2. Make the Data UsefulMGH Disparities Dashboard Executive Summary • Green Light:Areas where care is equitable • National Hospital Quality Measures • HEDIS Outpatient Measures (Main Campus) • Pain Mgmt in the ED • Yellow Light: National disparities, areas to be explored • Mental Health, Renal Transplantation • All cause and ACS Admissions (so far no disparities) • CHF Readmissions (so far no disparities) • Patient Experience (H-CAHPS shows subgroup variation) • Red Light: Disparities found, action being taken • Diabetes at community health centers • Chelsea (Latino), Revere (Cambodian) Diabetes Project • Colonoscopy screening rates • Chelsea CRC Navigator Program (Latinos)

22. 3. Educate Providers and StaffLink to Transitions, Safety, Patient Experience • Quality Interactions Cross-Cultural Training offered as option as part of MGPO QI Incentive; case-based, evidence-based, interactive e-learning program which allows learners to develop a skill set to provide quality to patients of diverse cultural backgrounds; has been used to train 125,000 health care professionals nationwide • 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: http://www.qualityinteractions.org/prod_overview/clinical_program_features.html.

23. 4. Engage, Empower and Activate Patients Patient Activation Poster Campaign In 2011, MGH launched a poster campaign modeled after the national Speak Up campaign developed by the Joint Commission and Centers for Medicare and Medicaid Services in 2002. The Speak Up campaign urges patients to take a role in improving quality and preventing medical errors by becoming active, involved, and informed participants of the health care team.

24. 5. Develop Culturally Competent Interventions Diabetes Disease Management Program A quality improvement / disparities reduction program with 3 primary components: • Telephone outreach to increase rate of HbA1c testing • Individual coaching to address patients’ needs and concerns regarding diabetes self-management to improve HbA1c • Group education meeting ADA requirements *Also focus on link between mental health, chronic disease management, and prevention

25. * * Chelsea Diabetes Management Program began in first quarter of 2007; in 2008 received Diabetes Coalition of MA Programs of Excellence Award

26. Preparing for the Future • Addressing variations in quality—such as racial/ethnic disparities in health care—will be essential going forward if we are to achieve equity and high-value • This is not just about equity for equity’s sake—ethics and cost are key—as equity connects to all areas of quality: • Population Management • Transitions of Care and Readmissions • Appropriate Utilization and Avoidable Hospitalizations • Patient Safety • Patient Experience • Hospitals ignore this at their own peril…action will separate winners from losers…

27. Health insurance Exchanges • Panelist 2 • Maria R. Cooper, MA • Health Policy Analyst, Texas Health Institute

28. Health insurance Exchanges • The ACA has potential to enfranchise as many as 19 million racially & ethnically diverse individuals starting in 2014 • Insurance Provisions: • State Exchanges • Navigator Program & C/L Information • C/L Summary of Benefits • C/L Claims Appeals Process • Use of Plain Language in Health Plans • Non-discrimination in Federal Programs • Remove cost-sharing for AI/AN • Market incentives for Reducing Disparities

29. State Exchange Decisions Source: Kaiser Family Foundation, State Health Facts, June 20, 2013

30. Health Insurance MarketplacesProjected Enrollees by Race & Ethnicity 42% or over 12 million Non-Whites 25% will speak a language other than English at home

31. How Do the Marketplaces Plan to Address Disparities? Source: Andrulis DP, Jahnke LR, Siddiqui NJ, and Cooper MR. Implementing Cultural and Linguistic Requirements in Health Insurance Exchanges, 2013. Texas Health Institute: Austin, TX. Available at: http://www.texashealthinstitute.org/health-care-reform.html

32. Actionable Items and Next Steps What challenges do marketplaces face in addressing disparities? • How to elevate disparities to a priority level when focus is on exchange startup, IT, benefit design, etc. • How to effectively reach a range of diverse individuals: • Culturally or linguistically isolated • Not familiar with concept of insurance • Low literacy and low health literacy • Mixed-citizenship • Distrust of government, federal programs, new law • Training navigators & outreach workers Measurable outcomes for evaluation: • Are equity objectives present in mission and planning? • Do health plans use active purchasing? • Partnerships with trusted advocates and representatives? • Language access services and C/L appropriate communication?

33. ACA: A Hospital’s perspective • ACA : Triple Aim • Triple Aim • Quality • Cost • Population health • $155 B in hospital Medicare cuts • Expanded coverage, but there will be uninsured • Individual penalty is $95 in 2014 • Hardship exemptions • No Medicaid expansion in Florida July 2013 Panelist 3Louis R. Preston, JR., M.Div, CDM

34. Language Access at Florida Hospital • In-person • FH Staff for Spanish interpretations • Agency interpreters in ASL and Other Languages • Over-the-phone • Video Remote Interpretation (VRI) • Translation of Documents • Vital documents, Patient medical records, other documents relaying medically relevant information

35. Potential benefits for utilizing qualified medical interpreters(QMI) • Cost Reductions under the Affordable Care Act • Increased patient satisfaction with care provider communication and overall patient experience – evident in increase in HCAHPS scores • Enhanced provider/hospital Federal compliance – by increasing compliance with Federal Laws

36. CREATION Health Whereas: the ACA promotes access to health care services and preventive care, and Whereas: the Seventh-day Adventist (SDA) church has espoused whole-person preventive healthcare from its inception, Therefore: Adventist Health System and others will benefit from ACA incentives for health promotion – not merely the treatment of disease. God’s Guide to Health and Harmony

37. Diversity in leadership “Are we ever going to produce a diverse workforce and leadership that look different than what we are now, or do we study ourselves to death and look the same way we’ve always looked?” Don Jernigan, Leu Gardens, August 6, 2004. Executive Accountability Over the five year period commencing in 2008 and ending in 2013 it is the goal of each AHS facility to have its employee workforce, beginning with administration, reflect it’s own community’sdiversity… Don Jernigan, PhD Adventist Health System President and CEO

38. Open discussion Andrew M. Wiesenthal, MD, SM awiesenthal@deloitte.com Joseph R. Betancourt, MD, MPH jbetancourt@partners.org • www.mghdisparitiessolutions.org • www.qualityinteractions.org Maria R. Cooper, MA mcooper@texashealthinstitute.org Louis R. Preston, JR., M.Div, CDM louis.preston@flhosp.org