Approaches to Organizing and Delivering Care to Reduce Disparities

1. Approaches to Organizing and Delivering Care to Reduce Disparities Marshall H. Chin, MD, MPH Associate Professor of Medicine Co-Director, Hartford Center of Excellence in Geriatrics University of Chicago Director, RWJF Finding Answers: Disparities Research for Change

2. Goals • Present conceptual model for reducing disparities • Systematically review evidence for reducing health care disparities • Raise ongoing research questions from review • Provide example of Health Disparities Collaboratives (HDC) – clinical, financial, organizational change • Brainstorm applications to aging

4. Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care • Clinical Appropriateness • and Need • Patient Preferences Non-Minority The Operation of Healthcare Systems and the Legal and Regulatory Climate Difference Quality of Health Care Minority Disparity Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Populations with Equal Access to Health Care

5. Institute of Medicine:6 Domains of Quality • Safety • Timeliness • Effectiveness • Efficiency • Equity • Patient-centeredness

6. Equity as the Poor Stepchild of Quality: Example of SQUIRE Guidelines

7. Our Philosophy • “QI should be an integral part of the plan to reduce disparities in care.” • “danger is that they create the impression that reducing racial disparities is a marginalized activity distinct from the mainstream QI efforts of an organization.”Chin MH, Chien AT. Qual Saf Health Care 2006; 15:78-79.

8. Recommendations to SQUIRE • What is the effect of the QI intervention on racial and ethnic disparities? • What is the plan for addressing racial and ethnic disparities in health care with the QI intervention? • Are there important unintended positive or negative consequences from the QI intervention that affect disparities?

9. A national program supported by RWJF with direction and technical assistance provided by the University of Chicago. Finding Answers: Disparities Research for Change

10. www.SolvingDisparities.org

11. Goals of Finding Answers • Grant funds to evaluate practical solutions to reduce racial and ethnic health care disparities. • Conduct systematic reviews of racial and ethnic health care disparities interventions. • Disseminate results to encourage health care systems to address racial and ethnic gaps in care.

12. Financing / Regulation / Accreditation Health Care Organization Community Provider Access Person Patient Process Outcomes Conceptual Model

13. RWJF Finding Answers:Systematic Review of Interventions to Reduce Racial and Ethnic Disparities • Medical Care Research and Review 10/07 supplem • Intro, Cardiovascular, Depression, Diabetes, Breast cancer, Culture, Pay-for-Performance • www.SolvingDisparities.org Articles and Searchable database of 200 interv.

14. RWJF Finding Answers:Disparities Research for ChangeLessons from Systematic Reviews • Multifactorial interventions that target multiple levers of change • Culturally tailored quality improvement • Nurse-led interventions in context of wider systems change

15. Factors Determining Depression Disparities • System • Lack of access to mental health providers • Community • Preference to seek treatment within ethnic community • Provider • Diagnostic uncertainty / Cultural barriers • Person • Cultural bias against mental health treatments

16. Key Findings: Chronic Care Model • Not Effective • Interventions addressing barriers at only one level • Access to mental health services alone does not reduce disparities • Single component interventions targeting providers did not reduce disparities • Effective • Multi-component primary care interventions using the Chronic Care Model • Addressed factors at system, community, provider and person level • Improved ethnic minority care processes and outcomes

17. Case Study: IMPACT Study • Elderly in primary care with depressive disorder • Chronic care model • Screening in primary care • Consultation liaison psychiatry available for decision support • Case-management assist patients • Navigate fragmented healthcare system • Enhance trust and knowledge • Reduce stigma and negative attitudes • Disparities eliminated Arean PA et al. Med Care. 2005;43:381-390

18. Key Findings: Socio-culturally Tailored Behavioral Interventions • Socio-culturally tailored interventions may reduce disparities compared to standard approaches • Focus on unique problems of ethnic minorities • Build on successful coping strategies within patient’s culture • Incorporate cultural frameworks of target population

19. Case Study: Mamás y Bebés • Socio-culturally adapted depression prevention intervention targeting post-partum depression • Focused on problems encountered by low-income new mother in Hispanic community • Built on cultural strengths (family solidarity) • Incorporated Hispanic family culture/structure • Pilot study • Reduced risk of major depression Munoz RF et al. Prevention of Postpartum Depression in Low Income Women: Development of the Mamas y Bebes/Mothers and Babies Course. Cognitive and Behavioral Practice. in press.

20. Key Findings—Heart Failure • Care Management—can ↓hospitalization rates in advanced heart failure • Useful elements—specialty nurse case management, education, frequent telephone follow-up with medication adjustment, oversight by a specialist

21. Key Findings—Diabetes • No single optimal target • Culturally-tailored interventions may be > standard QI programs • Human capital interventions > technological interventions • Better utilization of non-physician staff can  improvements in diabetes care

22. REACH 2010:Charleston and Georgetown Diabetes Coalition • South Carolina – 28 coalition partner organizations • Health system change • Chart audits, feedback to organization, diabetes registry • Patient empowerment – Gold Card, ABCs of diabetes • Community development, empowerment, and education • Interdisciplinary team • Five community health workers • Eliminated disparities in processes and outcomes

23. FindingAnswersInterventionResearchFAIR Database • 206 Articles • Designed to provide a customized list of interventions that match a user’s interest • health topic • racial/ethnic population • organizational setting • intervention strategy • http://www.SolvingDisparities.org/fair_database

24. Priority Research Questions from Review • What parts of a multi-component intervention provide the most value? • How can interventions developed in the research setting be successfully implemented in other organizations and patient populations?

25. Research Questions 2 • Given heterogeneity within each type of intervention, what conclusions can be made about the effectiveness of classes of interventions? • What interventions reduce disparities in understudied populations such as American Indians and Asian American subgroups, and pediatric and geriatric ethnic subgroups?

26. Research Questions 3 • How can we comprehensively integrate the strengths of the community and health care system? • What effect do policies linking quality to payment and other performance incentives have on disparities?

27. RWJF Aligning Forces for Quality / Regional Quality Strategy • Improve quality of care and reduce disparities in 14-20 regions of country • Principles • QI • Public reporting of performance data • Consumer engagement • Nursing, community involvement

28. RWJF Commission to Build a Healthier America • Mark McClellan, Alice Rivlin – Co-Chairs • 2 year effort – recommend short and longterm strategies • Look beyond health care system • Education, environment, income, housing, personal health choices

29. Observations for ABIM:Cultural Competency Useful But Not Enough • CC improves knowledge, attitudes, skills • Lacks comprehensive skill set • Social, political, economic • Fail to demonstrate improved health outcomes

30. Observations for ABIM:3 Levels of Systems • Health care organizations – QI • Health care organization – community linkage • E.g. – community health workers, patient navigators • Macro health policy systems

31. Health Disparities Collaboratives:A Quality Improvement Collaborative • National effort in about 1000 health centers beginning in 19983 Components • CQI: Rapid Plan-Do-Study-Act cycles • Chronic Care Model • Learning sessions

32. Plan-Do-Study-Act Cycles (PDSA) Associates in Learning / Institute for Healthcare Improvement

33. MacColl Institute Chronic Care Model Community Health System Resources and Policies Health Care Organization Self-Management Support DeliverySystem Design ClinicalInformationSystems Decision Support Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes

34. Breakthrough Series • Commitment of CEO • HDC QI team in each of health center • 4 regional learning sessions • Cluster coordinator support • Monthly telephone conference calls • Monthly written progress reports • Computer listserver

35. Organizational Schema of Intervention CollaborativeTeamCenter 15-20 HCs / Trainers HDC QI Team Providers & Patients at HC

36. Methods • Systematic review of literature • Focus on key studies in this presentation

37. Results: Participants’ Perceptions of Outcomes • HDC is a success and worth effort > 80% • Improved patient outcomes 88% • Improved processes of care 83% • Improved patient satisfaction 71% • Qualitative interviews Similar Chin et al.; Chin et al. Diabetes Care 2004; 27:2-8.

38. Short-Term Clinical (1-2 years):Diabetes • Random chart review • Pre-post improvement in 7 diabetes processes of care • No improvement in intermediary outcomesChin et al. Diabetes Care. 2004.

39. Short-term Clinical:Asthma, Diabetes, Hypertension • Pre-post controlled (1 yr pre and 1 yr post) • Improvements in processes of care for asthma and diabetes • Asthma – Rx anti-inflam med 14% • Diabetes – HbA1c measurement 16% • No improvement in intermediary outcomes Landon et al. NEJM 2007; 356:921-934.

40. Long-term Clinical (2-4 years):Processes of Care (%) Chin et al. Medical Care 2007.

41. Long-term Clinical:Outcomes Chin et al. Medical Care 2007.

42. Societal Cost-Effectiveness Analysis: Diabetes • Incorporate clinical results into a NIH simulation model of diabetes complications • Simulation model needed to translate changes in processes and risk factor levels into complicationsHuang et al. HSR 2007.

43. Base Case Results ICER = $33,386/QALY

44. Business Case: Case Study of 5 Health Centers with Diabetes Huang ES, et al. The cost consequences of improving diabetes care: the community health center experience. Joint Commission Journal on Quality and Patient Safety 2008; 34:138-146. Brown SES, et al. Estimating the costs of quality improvement for outpatient health care organizations: a practical methodology. Quality and Safety in Health Care. 2007; 16 (4): 248-251.

45. Conceptual Model of the Short-Term Financial Impact of Quality Improvement for Outpatient Facilities External Environment Accreditation Bodies Local Economy Patient Demographics and numbers Direct • Costs • Daily QI activities • Personnel • Equipment • Revenues • Grants • Donations Administrative Balance Admini- strative - = + + + Internal Environ-ment Patient care revenues - Patient care costs = Clinical Clinical Care Balance = = = Direct Overall Balance - = Overall Overall center revenues Overall Center Costs Indirect Balance Indirect • Benefits • Improved clinical care • Morale • Costs • Focus of leadership on other priorities - = Insurance reimbursement and incentives Payor Mix

46. Business Case Study Results • Additional admin cost = $6-$22 per patient (Year 1) • No regular source of revenue for these costs • Balance of diabetes clinical costs/revenues did not clearly improve • Diabetes Collaborative 2-8% of health center budget • QI programs represent a new cost

47. Organizational Change and Implementation • Common barriers • Lack of resources • Lack of time • Staff burnoutChin et al.

48. Wish List fromBureau of Primary Health Care

49. Additional Support • Help patients with self-management 73% • Information systems 77% • Get providers to follow guidelines 64%

50. Predictors of Staff Morale and Burnout • Low cost • Personal recognition • Career promotion • Skills development • Fair distribution of work • More expensive – Funding, personnelGraber et al. HSR 2008.