An Integrated Framework for Reducing Health Disparities AMGA September 21 st , 2011

1. An Integrated Framework forReducing Health DisparitiesAMGASeptember 21st, 2011 Beth Averbeck, MD Associate Medical Director, Primary Care HealthPartners Medical Group & Clinics

2. HealthPartners • Not-for-profit, consumer-governed • Integrated care and financing system • 12,000 employees • Health plan • 1.36 million members in Minnesota and surrounding states • HealthPartners Medical Group • 500,000 patients • 800 physicians • 35 medical and surgical specialties • 23 locations • Multi-payer • Dental Clinics • Four hospitals • Regions: 454-bed level 1 trauma and tertiary center • Lakeview: 97-bed acute care hospital, national leader in orthopedic care • Hudson: 25-bed critical access hospital, award-winning healing arts program • Westfields: 25-bed critical access hospital, regional cancer care location

3. WHO WE ARE Health is what we do. Partnership is how we do it. MISSION: WHY WE’RE HERE. Improve the health of our members, our patients and the community. VISION: WHERE WE’RE HEADED. Through our innovative solutions that improve health and offer a consistently exceptional experience at an affordable cost, we will transform health care. We will be the best and most trusted partner in health care, health promotion and health plan services in the country. • VALUES: HOW WE ACT. • Passion  Teamwork  Integrity  Respect • STRATEGIES: WHAT WE DO. • People  Health  Experience  Stewardship • Implementation of Organizational & Divisional Work Plans • RESULTS: HOW WE WILL KNOW WE DID IT. • People  Health  Experience  Stewardship • Balanced Scorecard Including Health Goals 2010 Nested Divisional & Departmental Measures

4. Today’s Minnesota Growing Aging Increased Poverty More Immigrants

5. ….more diverse Communities of color will grow faster than white population between 1995 and 2025 Source: State Demographic Center at Minnesota Planning

6. 2010 HealthPartners Active Patients *Active patients: a count of unique patients seen in the system from 7/1/2009 through 12/31/2010 7-County Metropolitan Area (2010 Census Data)

7. The Disparities Challenge… “The real challenge lies not in debating whether disparities exist, the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them.” Alan Nelson, MD Chairman, IOM Committee Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2003

8. Session Objectives Leadership: Set Goals, Aim High Collecting Data Standardization Customization Integration, Accountability Reducing Disparities Workforce Strategies Community Partnerships

9. #1: Leadership: Set Goals, Aim High • A priority since the beginning of the decade: • 2001: Cross Cultural Care Taskforce Established • 2003: Organization Assessment • 2004: Cultural Competencies, Data Collection, Improvement Strategies • 2010 and 2014: Health Goals: specific aims to reduce racial and financial class disparities in health • Part of our organization’s culture: "Cross cultural care is not just about 'other' cultures. It's about recognizing the effect of cultural values - which we all have - on health." -- Mary Brainerd, CEO

10. #2: Patient-CenteredData Collection • Mission driven • Changing demographics • Understanding disparities • Measurement and transparency • MN Community Measurement, statewide transparency • Patient experience • Workforce needs • Our workforce should reflect the communities we serve • Partner with the community for messaging and process

11. Asking the QuestionCommunity Feedback We want to ask you about your race and country of origin. If you answer, you will help us provide the best care to all of our patients. We will use this information to help our doctors and nurses give you better care. We will keep your information private and confidential.

12. Demographic Data Collection 99% - Language Collection goal 90% - Race/ethnicity Collection goal

13. Minnesota’s Publically Reported Results on Socioeconomic Disparities (2010) = Medical Group had confidence intervals fully above the medical group average for patients enrolled in MHCP Blank = Measure reported by rate was average or below average www.mnhealthscores.org

14. Improving Results • We’re doing well, but need to do better • Used national data to decided where to start: • Optimal Diabetes Care • Breast Cancer Screening • Colorectal Cancer Screening

15. DiabetesNational Data Indicate Disparities • Studies suggest that African Americans are 1.4 to 2.2 times more likely to develop diabetes than whites • The prevalence of diabetes amongst American Indians is 2.8 times greater than the population average • Compared to the white population, Hispanics or Latinos are more than 1.5 times more likely to develop diabetes Sources: ahrq.gov, cdc.gov

16. #3: Standardization • Care Model Process: Care redesigned to establish standardized workflows • Right person, doing the right thing, at the right time, with the right patient experience • Every encounter is an opportunity to ensure patient receives evidence-based care and service • Use of professional interpreters and translated health information

17. Created Standard Work Flowsfor the Visit Cycle • Clinical Topics Team Members • Depression Physician Led • Diabetes Registered Nurse • Preventive Services Rooming Staff • Tobacco CessationClerical Staff • Pediatric Immunizations Ad hoc: dieticians, pharmacists, • Child and Teen Check-up diabetes educators, • Pediatric Asthma interpreters

18. Standardization Improves Care: Optimal Diabetes Measure: % of HPMG patients with diabetes who have had an A1c in the last 12 months with a value <8.0, LDL screen in last 12 months with a value <100, last recorded blood pressure <140 and <90, documented non-tobacco user and documented regular aspirin user.

19. Optimal Diabetes Process Measures July 2011 *Patients of color: includes patients whose self-identified race is either American Indian or Alaska Native, Asian, Black or African-American, Hispanic or Latino, Some other race, and patients with more than one race documented (Multiple race)

20. Diabetes Outcomes by RaceJuly 2011 LDL goal: <100 A1c goal: <8.0 BP goal: <140/90 70.2% 2010 HEDIS national 90th percentile 55.0% 2010 HEDIS national 90th percentile *Patients of color: includes patients whose self-identified race is either American Indian or Alaska Native, Asian, Black or African-American, Hispanic or Latino, Some other race, and patients with more than one race documented (Multiple race)

21. Preventive Services Focus Areas: National Data Indicates Variation Breast Cancer Screening • Breast Cancer Surveillance Consortium • Receipt of Mammography: • African American 65% • Whites 72% Colorectal Cancer Screening • Medicare Data (Cooper/2003) • African Americans less likely to undergo screening tests

22. Standardize, then Customize:Preventive Services by Race 2006 *Patients of color: includes patients whose self-identified race is either American Indian or Alaska Native, Asian, Black or African-American, Hispanic or Latino, Some other race, and patients with more than one race documented (Multiple race)

23. #4: Customize to Individual PatientPreferences and Values • Formed multi-disciplinary team in 2007 • Utilize small tests of change then spread • Embed in Care Model Process • Clinical Focus Areas: Breast Cancer Screening, Colorectal Cancer Screening • Input from community leaders and our patients

24. Breast Cancer Screening:Interventions that have worked • Messaging and education specific to race Breast cancer is the most common cancer among African American women. Because African American women have fewer mammograms than other groups, they are more likely to learn they have breast cancer after it has spread. As a result, they are more likely to die from it. But, when African American women have regular mammograms, they have the same chances of surviving breast cancer as other women. As your provider, I strongly recommend that you have a mammogram soon. Do it for yourself and for your family. We can help you schedule it before you leave today, or you can call 952-967-*** to schedule the test. • Offer same day mammogram • Outreach calls

25. HealthPartners Clinics Breast Cancer Screening by Race Mammography Screening: % of women age 50-75 who have been screened by Mammography in the 18 months prior to and including their most recent primary care visit. GAP is 3.8% points GAP is 12.4% points 80.1% 2010 HEDIS national 90th percentile (commercial)

26. Breast Cancer Screening:One Clinic’s Story Leadership Commitment Staff Passion Systems Approach The ‘Pink Ticket’ Program at Brooklyn Center

27. CustomizedColorectal Cancer Screening • Institute for Clinical Systems Improvement (ICSI) Guidelines • African American and American Indians: screening begins at 45 • Other races: screening begins at age 50

28. Colon Cancer Screening:Interventions that have worked • Implement Decision Support in EHR • Specific messaging and education • FIT testing • Specialty and Primary Collaboration • GI receives orders and positive FIT tests and outreaches to patients • Outreach to patients that are due for testing

29. Colorectal Cancer Screening Measure: The % of all Black or African-American (and Native American, starting 1Q11) patients ages 45-80 having an eligible primary care or OB-GYN office visit during the most recent quarter who are up-to-date with colorectal cancer screening, which includes the following: colonoscopy within 10 years OR flexible sigmoidoscopy within 5 years OR Fecal Occult Blood Test (FOBT) or Fecal Colorectal Test (FIT) within 12 months OR Double contrast barium enema within 5 years 54.3%% 2010 HEDIS national 50th percentile (commercial) Expanded eligible population to include American Indians beginning at age 45 (previously age 50)

30. #5: Integration of Disparities Reduction Goals in Accountability Mechanisms • Data available by Clinic • 90 day work plans to cascade awareness, goals, and accountability • Part of management incentive program • Added to 2011 physician compensation incentive program

31. Disparities Results Reviewed Monthly by Site Leaders • Point of review: • Preview results at care meetings • Institute interventions • Remind providers of goals • Share Best Practice

32. #6: Workplace Strategies • Increase diversity of our workforce • Cultural competencies: • Leadership Symposium focused on diversity • Site Visits – “Every encounter is a cultural encounter” • Health in Any Language Training (to coincide with introduction of interpreters) • Intranet site with resources • Equitable Care Fellows

33. Overall HealthPartners Minority Workforce Trends DB: 12/26/06, 12/31/07, 1/2/09, 12/31/09,12/31/10

34. Physician Diversity • 19% of our physician group has listed a country of origin other than the USA • 55 languages spoken • 47 countries of origin

35. Equitable Care Fellows • Be a role model • Actively participate in raising the overall cultural awareness of our workforce • Share Culture Roots articles with co-workers (huddles, group discussions, etc)

36. Cultural Roots

37. #7: Intentional Community Involvement • Community supported improvement collaborative • Community and patients continue to be the most important voice in our strategy development • Citizen Health Project • Promise Neighborhood • Lets Talk about Race • Patient Council • EBAN

38. An Equitable Health Collaborative

39. Community Engagement • Invitation to join the EBAN Experience™ teams • Placement on teams desiring specific cultural understanding • Prepare community advisors to partner with teams • Provide resources, training and support • Assess integration and involvement • Share stories and experiences • Involve in the planning and implementation of QI projects • Develop public awareness

40. Teams

41. Expected Outcomes uEach team completes QI project uPresent data and results to collaborative at year-end uSponsors leverage recommended changes into large scale improvements u Participants gain an increased awareness and understanding of the communities they serve u Community advisors will affirm that their voices were heard and acted upon uImprove health disparities, patient care and community health

42. Cultural Awareness Example: Diabetes • East Africans do not follow a calendar for their daily events. Therefore, having a scheduled clinic appointment is hit or miss. • Whatever religion they follow, they still have the same health care belief model, similar to passive acceptance of a condition. • Negative words are viewed as a curse. • Using the approach that tomorrow can be a better day works well. • The key to reaching people of this culture is to develop a personal relationship within professional boundaries through the use of stories.

43. EBAN Team Findings: General • The clinics learned that they do not have visuals (signage, pictures, periodicals) that welcome non-English speakers. • Having same sex interpreters may be preferable.  • Somali patients may view the provided robes as unwashed and may be unwilling to wear them. Purification of the body and clothes is called Taharah and is an essential part of Islamic culture. Due to the importance of cleanliness to their faith, Somali people will not put on clothing unless they are certain that it is clean and untainted.

44. EBAN Team Findings: Cancer Screening • Somalis tend to believe cancer is an American disease, so resistance to screening. • Hmong tend to fear being ostracized with cancer diagnosis. • Hmong patients may object to removal of tissue since it’s a cultural belief that a body should be buried whole. • Word of mouth is powerful. • Communities need fact-based info on cancer to get past myths.

45. Looking to the Future: 2014 Goals • 2014 ‘Partners for Better Health Goals 2014’: reduce socioeconomic, physical, environmental barriers to better health • 4 drivers: • Health care: 20% • Health behaviors: 30% • Physical Environment: 10% • Social and Economic factors: 40% • HP Partners with the community to reduce the socioeconomic barriers to better health

47. 2011: yum Power

48. Where to Start: Community Outreach Workflow Framework Determine Specific Communities of Focus Identify and Understand the Issue Identify passionate care team members and community leaders Develop Strategies Continue & Share Best Practice Implement and Evaluate Outreach Strategies Project Management and Data Support

49. Keys to Success/Checklist • Strong support from leaders • Community and patient involvement • Electronic Health Records • Systematic data collection and reporting • Consistent work flows and work processes • Customization • Accountability

50. Questions?