Health Disparities: Beyond the Epidemiological Evidence

1. Health Disparities: Beyond the Epidemiological Evidence Presenter: John Fontanesi Co-authors: Linda Hill, Jill Rybar, David Kopald, CDC University of California, San Diego

2. Differences are Significant

3. …AND GROWING

4. …And Cost not an explanation

5. Patient Factors Lack of trust in Health Care System Fear of “Research” Doubts about vaccine efficacy Health Literacy Cultural barriers Clinic Factors Availability of Providers Cultural competency Lack of audit and feedback information Dysfunctional System Poor or non-existent automation Proposed Reasons

6. Examining the Health Center • Cultural competency • Access to care, • Hours of operation • Types of services/specialists available • Staff turnover • Congruence • Patient-Provider language • Patient-Provider conversation • Economic

7. Financial Stress Matters:Missed Opportunity Rates Insolvent Facilities

8. … And staff turnover matters CASA rates < 70% % Annual Staff turnover

9. … But “structure” is too simple an explanation CASA rates < 70% CASA rates >85%% % Annual Staff turnover

10. Recommended strategies to improve coverage rates • Provider prompts • Provider audit and feedback • Organizational change • STANDING ORDERS • PATIENT REMINDER/RECALL • IMMUNIZATION CHAMPION • SPECIAL CLINICS

11. Organizational Behavior • There is (and should be) an interaction between “client” and organization • Being “customer-centric” means adapting delivery strategies to client preferences • The implementation of generic strategies in specific settings should reflect the interaction between the specific organization and client

12. Patient-oriented and community-based approaches are used to reach target populations

13. Brief Examples:What 4 San Diego clinics have in common • Medical Director aggressive about vaccinations • Active QI Program • Multi-arm delivery strategy • Targeted case management • Reminder/recall (automated) • Combination of mass clinics and individual appointments • Standing Orders • Self administered + contractual Audit/feedback

14. Clinic A Multi-site, for profit Upper middle class mixed ethnicity Arrive by Car Primary Payor: Managed Care HEDIS audit How they are different • Clinic B • Rural Indian Health Center • Rural poverty • Some clients travel 60+ miles • Primary Payor: IHS • GPRA audit • Clinic C • FQHC • Urban-impoverished • Hispanic Immigrants • Walk to clinic • Primary payor: Multiple/HRSA • Clinic D • FQHC • Suburban-lower SES • Hispanic-American • Drive or take Bus to clinic • Primary payor: Multiple/HRSA

15. Emphasize client convenience Vaccinate at Mass clinics Vaccinate at local business, churches and schools Active case management for Diabetes Purchased and administered influenza 8500 dosages 4300 at “alternative" sites No or low cost No documentation HEDIS Client satisfaction rating over 98% HEDIS ALL “high risk young adult” coverage rate=42% HEDIS Diabetic Coverage rate = 87% HEDIS “senior” rate = 47% Clinical Encounter coverage rate= 42% Clinic A: Implementing Patient and Community Based Approaches

16. Emphasize respect for community elders Prioritized vaccination strategy Elders on reservation Diabetics on reservations Reservation members attending clinic Rural Indians attending clinic Urban Indians attending clinic Purchased and administered influenza 600 dosages Patient chart travels to reservation GPRA “senior” coverage rates = 95% GPRA Diabetics coverage rates = 78% Clinical encounter coverage rates = 48% Clinic B: Implementing Patient and Community Based Approaches

17. Emphasize Family Vaccinate adults accompanying children “Walk-in” Vaccination clinic Low cost “Saturday” clinics Active Case Management for Asthmatics Purchased and administered influenza 1300 dosages HEDIS “Senior” coverage rates = 84%(Grandma’s better then Grandpa's) Asthmatic coverage rates = 86% Clinical encounter coverage rates = 56% Clinic C: Implementing Patient and Community Based Approaches

18. Emphasize “working poor” Mass weekend Clinics $2 “donation” Vaccinate at all eligible scheduled appointments Active Case Management for several “high risk” populations “Senior” coverage rates = 84% “At risk” coverage rates = 86%% Clinical encounter coverage rates = 74% Clinic D: Implementing Patient and Community Based Approaches

19. Organizational Behavior • There is (and should be) an interaction between “client” and organization • Being “customer-centric” means adapting delivery strategies to client preferences • The implementation of generic strategies in specific settings should reflect the interaction between the specific organization and client • The decisions will impact relevant performance outcomes

20. Conclusions • Population-based and Clinic-based coverage rates are related but not the same • Patient and Provider characteristics may not be as important as infrastructure • Global strategies take on local context • Measurement may not always be aligned with local context

21. Conclusions • Some combination of working from the outside in (Rochester model) and the inside out (San Diego model) can mitigate disparities in health care settings • Work on understanding what works rather then concentrate on understanding failures