Goldman Chin

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    Integrated Framework forIntegrated Framework for

    Reducing Racial andReducing Racial andEthnic Disparities in theEthnic Disparities in the

    Quality of Health CareQuality of Health Care

    Marshall H. Chin, MD, MPH, and Don Goldmann, MDMarshall H. Chin, MD, MPH, and Don Goldmann, MD

    University of Chicago, Institute for HealthcareUniversity of Chicago, Institute for Healthcare

    ImprovementImprovement

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    RoadmapRoadmap

    Context and problems in current efforts toContext and problems in current efforts to

    reduce disparities in health care qualityreduce disparities in health care quality

    Conceptual models for reducing disparitiesConceptual models for reducing disparitiesEvidence on disparity interventionsEvidence on disparity interventions

    6 key components for reducing disparities6 key components for reducing disparities

    Implications for fundersImplications for fundersExercise: Advice to AHRQExercise: Advice to AHRQ

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    Promising TimePromising Time

    Increased public awareness of disparitiesIncreased public awareness of disparities

    Health reform legislation will increaseHealth reform legislation will increase

    collection of race, ethnicity, and languagecollection of race, ethnicity, and languagedatadata

    Increased motivation for providers andIncreased motivation for providers and

    health care organizations to addresshealth care organizations to address

    disparitiesdisparities

    An opportunity to move from descriptionAn opportunity to move from description

    and complaint to actionand complaint to action

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    Problems and GapsProblems and Gaps

    Lots of research on the magnitude ofLots of research on the magnitude of

    disparities, but relatively little work ondisparities, but relatively little work on

    interventionsinterventions to reduce disparitiesto reduce disparities

    Many providers, organizations, and policyMany providers, organizations, and policy

    makers do not know where to start tomakers do not know where to start to

    reduce disparitiesreduce disparities

    Despite language encouraging proposalsDespite language encouraging proposals

    on vulnerable populations, many publicon vulnerable populations, many public

    and private funders receive fewand private funders receive few

    applicationsapplications

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    Models, Models, ModelsModels, Models, Models

    Models can inform approaches toModels can inform approaches to

    disparities, but.disparities, but.

    Models must be customized to addressModels must be customized to address

    the unique underlying causes of disparitiesthe unique underlying causes of disparitiesdirectly, but.directly, but.

    Customized solutions are sparse,Customized solutions are sparse,

    therefore.therefore.The nations research agenda must beThe nations research agenda must be

    directed at testing interventions thatdirected at testing interventions that

    address disparities specificallyaddress disparities specifically

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    Level of Engagement Model

    Patient/Person

    Provider

    Microsystem - small unit of care delivery

    Organizations that house or supportmicrosystems

    Communities and regions that span care

    delivery, prevention, and health promotion forpopulations

    Environment of policy, payment, regulation,

    accreditationBased on Berwick, Health Affairs 2002;21:n. 3

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    Informed,

    ActivatedPatient

    Productive

    Interactions

    Prepared,

    ProactivePractice Team

    Functional and Clinical Outcomes

    Delivery

    System

    Design

    Decision

    Support

    Clinical

    Information

    Systems

    Self-

    Management

    Support

    Health SystemResources and Policies

    CommunityOrganization of Health Care

    Wagner

    Planned Care Conceptual ModelPlanned Care Conceptual Model

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    Finding Answers: Disparities Research for Change

    www.SolvingDisparities.org

    New IOM FrameworkCro

    sscutting

    Dimen

    sions

    EQ

    U

    ITY

    VAL

    UE

    Components of

    Quality Care

    Type of Care

    Chronic conditionmanagement

    Acute

    Treatment

    Preventive

    Care

    Effectiveness

    Safety

    Timeliness

    Patient/family-centeredness

    Care Coordination

    Health Systems Infrastructure Capabilities

    Access

    Efficiency

    Crossc

    utting

    Dimen

    sions

    EQ

    U

    ITY

    VAL

    UE

    Components of

    Quality Care

    Type of Care

    Chronic conditionmanagement

    Acute

    Treatment

    Preventive

    Care

    Effectiveness

    Safety

    Timeliness

    Patient/family-centeredness

    Care Coordination

    Health Systems Infrastructure Capabilities

    Access

    Efficiency

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    RWJF Finding AnswersRWJF Finding Answers

    Conceptual ModelConceptual ModelChin et al. Med Care Res Rev 2007; 64:7SChin et al. Med Care Res Rev 2007; 64:7S--28S28S

    Provider

    Patient

    Policy / Payment / Regulation / Accreditation

    Health Care

    Organization

    Person

    Community

    Process

    Outcomes

    Access

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    Systematic ReviewsSystematic Reviews

    Reviewed 200+ articlesReviewed 200+ articles

    ConditionCondition--specificspecific

    Cardiovascular diseaseCardiovascular disease

    DiabetesDiabetes

    DepressionDepression

    Breast cancerBreast cancer

    CrossCross--cuttingcuttingCultural leverageCultural leverage

    PayPay--forfor--performance incentivesperformance incentives

    FAIR DatabaseFAIR Database

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    Common Successful InterventionsCommon Successful Interventions

    from SystematicR

    eviewsfrom SystematicR

    eviewsMultifactorialMultifactorial interventions that addressinterventions that addressmultiple leverage points along a patientsmultiple leverage points along a patientspathway of carepathway of care

    Culturally tailored QI more than generic QICulturally tailored QI more than generic QI

    NurseNurse--led interventions withled interventions with

    multidisciplinary teams and close trackingmultidisciplinary teams and close trackingand monitoring of patientsand monitoring of patients

    Chin MH, etal. MedCare Res Rev 2007; 64:7S-28S.

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    Review of Pediatric LiteratureReview of Pediatric Literature

    (Asthma, Immunizations)(Asthma, Immunizations)

    Measure and improve structural aspectsMeasure and improve structural aspects

    of care experience that impact outcomesof care experience that impact outcomesIncorporate families into interventionsIncorporate families into interventions

    Integrate nonIntegrate non--health care partners intohealth care partners into

    QI interventionsQI interventions

    Chin MH, etal. Pediatrics 2009;124 (Suppl3):S224-S236.

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    Lessons fromLessons from

    RWJF Finding Answers: DisparitiesRWJF Finding Answers: Disparities

    Research for Change GranteesResearch for Change Grantees

    Knowledge/attitude interventions helpful but notKnowledge/attitude interventions helpful but not

    sufficientsufficient

    Providing disparity data helpful but not sufficientProviding disparity data helpful but not sufficient

    Context and tailoring are criticalContext and tailoring are critical

    MultifactorialMultifactorial,, multitargetmultitarget interventionsinterventions

    Intervention & the process of implementationIntervention & the process of implementation

    BuyBuy--in, incentives, sustainability, systemin, incentives, sustainability, system

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    Integral Components of Systems Approach

    to Reducing Disparities

    1) Examine your performance data stratified byinsurance status, race/ethnicity, language, andsocioeconomic status.

    2) Get training for your staff to work effectivelywith diverse populations.

    3) Make reduction of inequities in care for

    vulnerable populations an integral componentof quality improvement efforts.

    Chin MH. Ann Intern Med 2008; 149:206-208.

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    Systems Approach - 2

    4) Provide models of care and infrastructuralsupport to enable organizations to improvethe quality of care for vulnerable patients.

    5) Align incentives to reward providers andhealth care organizations for providing highquality care to vulnerable populations.

    6) Allocate more resources for the uninsuredwith chronic diseases.

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    Implications for FundersImplications for Funders

    Move beyond asking applicants simply to showMove beyond asking applicants simply to showthat they have included priority populations inthat they have included priority populations in

    their research plantheir research plan

    Ask all quality of care applicants to addressAsk all quality of care applicants to address

    specifically how they will reduce known disparitiesspecifically how they will reduce known disparities

    or gaps discovered in the course of the workor gaps discovered in the course of the work

    Include a measurement plan that stratifies dataInclude a measurement plan that stratifies data

    appropriatelyappropriately

    Design an overall portfolio of grants and granteesDesign an overall portfolio of grants and grantees

    that addresses improving outcomes and reducingthat addresses improving outcomes and reducing

    gaps in diverse populations and settingsgaps in diverse populations and settings

    Reward applicants who address equity issuesReward applicants who address equity issues

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    Spheres of Influence forSpheres of Influence for

    Disparity InterventionsDisparity InterventionsPatient/personPatient/person

    ProviderProvider

    MicrosystemMicrosystemHealth care delivery organizationHealth care delivery organization

    Community and regionCommunity and region

    Policy, payment, regulation, accreditationPolicy, payment, regulation, accreditationWhich spheres are you addressing or plan

    to address in your comprehensive,

    multifactorial approach to reducing an equity gap ?

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    ExampleExample -- Care CoordinationCare Coordination

    for Chronically Ill Patientsfor Chronically Ill Patients

    Patient: engagement, empowerment, mobilizationPatient: engagement, empowerment, mobilization

    Provider: engagement, training in health literacyProvider: engagement, training in health literacy

    and cultural competencyand cultural competencyMicrosystemMicrosystem: teamwork, communication,QI,: teamwork, communication,QI,

    practice redesign, stratified data and real timepractice redesign, stratified data and real time

    feedbackfeedback

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    Care CoordinationCare Coordination

    for Chronically Ill Patientsfor Chronically Ill Patients -- 22

    Health care delivery organization:Health care delivery organization:

    communication, coordination, support forcommunication, coordination, support for

    patients and families across the continuum,patients and families across the continuum, teletele--

    health and monitoring, focus on value andhealth and monitoring, focus on value andlonger term fiscal horizonlonger term fiscal horizon

    Community: activation, mobilization of nonCommunity: activation, mobilization of non--

    medical resources and supports, attention tomedical resources and supports, attention to

    social capital and environmentsocial capital and environment

    PolicyPolicy alignment of incentives and payment toalignment of incentives and payment to

    promote the above actionspromote the above actions

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    Exercise:

    Advice to AHRQ

    Request For Applications

    Think of your research area

    Pick one of the 6 spheres of influence

    Write a research question youd like to be a priorityarea for the RFA for your research area in that sphere

    of influence

    If time, write questions for other spheres

    To reduce disparities in health care quality, whatelse might AHRQ do, in addition to directing and

    supporting research on specific topics?

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    Spheres of Influence forSpheres of Influence for

    Disparity InterventionsDisparity InterventionsPatient/personPatient/person

    ProviderProvider

    MicrosystemMicrosystemHealth care delivery organizationHealth care delivery organization

    Community and regionCommunity and region

    Policy, payment, regulation, accreditationPolicy, payment, regulation, accreditation