Practical Implementations for ACGME Health Care Disparity Requirements

2. Practical Implementations for ACGME Health Care Disparity Requirements Katherine M. Aguirre Ph.D. Department of Surgery

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4. Learning Objectives Be able to define and provide examples of health care disparities Understand national findings of the CLER report regarding health care disparities awareness and processes in GME Learn and apply best practices from the literature on how to better address health care disparities in GME

5. What are health care disparities? A “health care disparity” typically refers to differences between groups in health coverage, access to care, and quality of care. While access to care—limited by financial constraints, workforce shortages, and geographic challenges—is an important contributing factor to health care disparities, it is not the only factor Residents and fellows should be aware of these disparities and participate in efforts to eliminate them

6. What are the differences between health and health care disparities? “Health” and “health care” are related but not synonymous Health disparities are differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States Health care disparities typically refer to differences between groups in health insurance coverage, access, and there are many socio-cultural and economic barriers that affect patient care ACGME Institutional Requirements call on sponsoring institutions to ensure that residents and fellows have access to data to reduce health care disparities

7. Clinical Learning Environment Review (CLER) Aims for Clinical Learning Environments (CLEs) CLER is a mechanism by which the ACGME assesses a sponsoring institution to evaluate its commitment to developing a culture of quality, patient safety, and performance improvement for both resident education and patient care. Specifically for health disparities: Understand both health disparities and health care disparities, as well as their potential causes Demonstrates awareness of the CLE’s community health needs assessment findings and how the CLE is attempting to address health disparities in the community Demonstrates ability to identify groups of patients who, by their social/economic/cultural or physical limitations, may be at risk for receiving inequitable care within the CLE

8. CLER Report 2018 Findings Few CLEs appeared to have a formal strategy to address health care disparities or a systematic approach to identifying variability in the care provided to or clinical outcomes of their patient populations at risk for health care disparities In addition, a limited number of CLEs were engaged in comprehensive efforts to identify and eliminate health care disparities in a systematic manner Across most CLEs, education and training on health care disparities and cultural competency was largely generic and often did not address specific populations served by the institution When the CLEs involved residents and fellows in health care disparities, it was most often at the level of providing direct service to select patients

9. CLER Report Goals Enhance the safety and quality of clinical care and remove health disparities, both today in the teaching environment, as well as tomorrow in the future practice of our graduates Provide opportunities for sponsoring institutions to demonstrate leadership in patient safety, quality improvement and reduction in health care disparities Resident/fellow and faculty member education on reducing health care disparities Resident/fellow engagement in clinical site initiatives to address health care disparities

10. Example of Program Deficiencies “Tampa General Hospital does not appear to have a systematic approach to identifying variability in the care provided to or clinical outcomes of their known vulnerable patient populations.” 65% of the trainees, 48% of the faculty members and 75% of the program directors reported they knew the hospital’s priorities with regard to addressing health care disparities as: Supporting clinics to care for patients without insurance Having an inpatient elder care unit, serving as safety net hospital, providing social work support to assist patients in obtaining insurance, and translation services Nineteen percent of residency programs provided no education on caring for patients with limited English proficiency

11. Recommendations CLEs should begin to equip new clinicians with the skills needed to engage in quality improvement behaviors soon after these clinicians begin clinical practice in the CLE Eliminating health care disparities requires periodic review of performance measures to identify disparities in patient care or outcomes, targeted quality improvement efforts to address these disparities, and ongoing analyses to assess these efforts Recommendations for addressing disparities include: Collecting and reporting data on patient race and ethnicity Supporting language interpretation services Increasing awareness of health care disparities through education Requiring cultural competency training for all health care professionals Increasing diversity among those delivering health care

12. Why is awareness of health care disparities important for GME? As front-line caregivers, residents and fellows are a valuable resource for formulating strategies on these matters They can assist CLEs in addressing not only low income populations, but also those that experience differences in access or outcome based on gender, race, ethnicity, sexual orientation, health literacy, primary language, disability, geography, and other factors The diverse, often vulnerable, patient populations served by CLEs also provide an important opportunity for teaching residents and fellows to be respectful of patient cultural differences and beliefs, and the social determinants of health Ensure a generation of physicians who are firmly grounded in the principles of practicing culturally competent care and committed to the reduction of health care disparities

13. References The Accreditation Council for Graduate Medical Education (ACGME). CLER Pathways to Excellence: expectations for an optimal clinical learning environment to achieve safe and high quality patient care. ACGME website. https://www.acgme.org/acgmeweb/Portals/0/PDFs/CLER/CLER_Brochure.pdf. Accessed July 15, 2016. ACGME CLER Visit USF and TGH. PowerPoint presentation. American Diabetes Association. (2017). 1. Promoting health and reducing disparities in populations. Diabetes Care, 40(Supplement 1), S6-S10. Cardinal, L. J., Maldonado, M., & Fried, E. D. (2016). A national survey to evaluate graduate medical education in disparities and limited English proficiency: a report from the AAIM Diversity and Inclusion Committee. The American journal of medicine, 129(1), 117-125. Maldonado, M. E., Fried, E. D., DuBose, T. D., Nelson, C., & Breida, M. (2014). The role that graduate medical education must play in ensuring health equity and eliminating health care disparities. Annals of the American Thoracic Society, 11(4), 603-607. Nasca TJ. Introduction to the CLER National Report of Findings 2016. J Grad Med Educ. 2016;8 (2 suppl 1):7-9. Picture of GME from the First Round of CLER Visits and Opportunities Ahead. PowerPoint presentation.

14. Questions?