J. Nwando Olayiwola, MD, MPH, FAAFP – @DrNwando Family Medicine Board Review

December, 2016

Reducing Health Disparities & Achieving Health Equity: From Patterns to Practice

Objectives • Understand the terms

health disparity, health care disparities and health equity

• Understand various axes of inequity and discrimination

• Understand patient, practice and leadership strategies to move towards health equity in primary care

Thinking Styles

Perspectives

Job Level

Gender Physical Abilities

Age Skills

Religion Ethnicity

Language

Experiences Nationality

Race Culture

Sexual Orientation

Setting the stage

Thinking Styles

Perspectives

Job Level

Gender Physical Abilities

Age Skills

Religion Ethnicity

Language

Experiences Nationality

Race Culture

Sexual Orientation

What are health and healthcare disparities?

Socioeconomic status

Age

Location

Gender

Disability status

Sexual orientation

What are health and healthcare disparities?

Differences in health and health care between population groups

And more . . .

Race/ethnicity

Health and Health Care Disparities Differences that cannot be explained by variations in health care

needs, patient preferences, or treatment recommendations

Differences between groups in health insurance coverage, access to and use of care, and quality of care.

A higher burden of illness, injury, disability, or mortality experienced by one population group relative to another.

HEALTH DISPARITIES HEALTH CARE DISPARITIES

WHY DOES THIS MATTER? • Affect the groups facing disparities • Limit overall improvements in quality of care and

health for the broader population • Result in unnecessary costs • Increasingly diverse population

Racial and Ethnic Health Disparity Circles of Influence

Individual Racial/Ethnic

Health Disparity

HEALTH EQUITY • Health Equity: The opportunity for attainment of

the highest level of health for all people (HP 2020)

• Health Inequity: Barriers that prevent individuals and communities from accessing these conditions and reaching their full potential

Axes of inequity & discrimination “Race”

Gender

Ethnicity

Labor roles and social class markers

Nationality, language, and legal status

Sexual orientation

Disability status

Geography

Religion

Equality Doesn’t Mean Equity

Equality Doesn’t Mean Equity

Social Inequities Root Causes of Health Inequities

Health Inequities

Segregation Income & Employment Education

Housing Transportation Air Quality Food Access & Liquor Stores

Physical Activity & Neighborhood Conditions Criminal Justice

Access to Healthcare Social Relationships & Community Capacity

Social Inequities

When the External Becomes Internal How Health Inequities Get Inside the Body

Transportation

Housing

Segregation

Increased commute

times

Lack of access to

stores, jobs,

services

Crime

Stress

Stress

Stress Stress

Stress

Stress

Poor air quality

Stress Stress Poor quality

Education

Physical and Mental Health Impacts

ARE THERE HEALTH DISPARITIES IN YOUR PRACTICE?

HOW DO YOU KNOW?

What can be done?

Chin, Marshall H., Amy E. Walters, Scott C. Cook, and Elbert S. Huang. "Interventions to reduce racial and ethnic disparities in health care." Medical Care Research and Review 64, no. 5 suppl (2007): 7S-28S.

STRATEGIES TO REDUCE HEALTH DISPARITIES IN PRIMARY CARE

Patient Practice Leadership

STRATEGIES TO REDUCE HEALTH DISPARITIES IN PRACTICE

Patient

PATIENT LEVEL STRATEGIES TO REDUCE DISPARITIES

Patient feedback, activation and engagement

Culturally competent and linguistically congruent care and programs

Language-congruent health education and promotion

Provide patient navigation resources

Self management goal setting

Collection of REaL and SOGI data systematically

REaL Data Collection

Figure 6-1. Recommended variables for standardized collection of race, ethnicity, and language need. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/iomracereport/reldatafig6-1.html

SOGI Data Collection

SOGI Data Collection

Data for What?

Data Uses

Inform program development, planning,

and priority setting

Target quality improvement efforts

Understand differences in performance within a

setting

Understand the health needs of specific

populations and develop appropriate

interventions

Identify the need for and deploy resources for the

provision of culturally and linguistically

appropriate services

Evaluate and monitor the effectiveness of

interventions

STRATEGIES TO REDUCE HEALTH DISPARITIES IN PRIMARY CARE

Patient Practice Leadership

STRATEGIES TO REDUCE HEALTH DISPARITIES IN PRACTICE

Practice

Multidisciplinary Team-based care (including CHWs, navigators, behavioral health, etc.)

Targeted quality improvement efforts with equity focus

Targeted disparities interventions

Cultural competency training AND assessment

Disparities-based report cards

PRACTICE LEVEL STRATEGIES TO REDUCE DISPARITIES

A WORD ON CULTURAL COMPETENCE

Source: http://nccc.georgetown.edu/resources/assessments.html

• Self assessments • Practitioner

assessments • Policy

assessments • Personnel

assessments

BE SURE TO ASSESS!

Source: SAMSHA

Source: Cross cultural health program

STRATEGIES TO REDUCE HEALTH DISPARITIES IN PRIMARY CARE

Patient Practice Leadership

STRATEGIES TO REDUCE HEALTH DISPARITIES THROUGH

LEADERSHIP

Leadership

Create and train diverse leadership and workforce

Formalize cultural competency training and ongoing assessment

Implement technology and operations solutions for equity, access, screening, language and literacy

Optimize clinical workflow and advance QI systems

Community engagement, partnerships and resources

LEADERSHIP LEVEL STRATEGIES TO REDUCE DISPARITIES

J. Nwando Olayiwola, MD, MPH, FAAFP Director, Center for Excellence in Primary Care Associate Professor Department of Family and Community Medicine Zuckerberg San Francisco General Hospital Faculty Lead, School of Medicine Differences Matter Initiative University of California, San Francisco @DrNwando @UCSFCEPC

Resources and References • Robert Wood Johnson Foundation • Kaiser Family Foundation - Disparities in Health and Health Care: Five Key Questions and Answers –August 2016 • Kaiser Family Foundation - Key Facts on Health and Health Care by Race and Ethnicity – July 2016 • Chin, Marshall H., Amy E. Walters, Scott C. Cook, and Elbert S. Huang. "Interventions to reduce racial and ethnic

disparities in health care." Medical Care Research and Review 64, no. 5 suppl (2007): 7S-28S. • Brach, Cindy, and Irene Fraserirector. "Can cultural competency reduce racial and ethnic health disparities? A review and

conceptual model."Medical Care Research and Review 57, no. 4 suppl (2000): 181-217. • Freund, Karen M. "Patient navigation: The promise to reduce health disparities." Journal of general internal medicine 26,

no. 2 (2011): 110-112. • Bierman, Arlene S., Nicole Lurie, Karen Scott Collins, and John M. Eisenberg. "Addressing racial and ethnic barriers to

effective health care: the need for better data." Health Affairs 21, no. 3 (2002): 91-102. • Pinto, Andrew D., Gabriela Glattstein-Young, Anthony Mohamed, Gary Bloch, Fok-Han Leung, and Richard H. Glazier.

"Building a Foundation to Reduce Health Inequities: Routine Collection of Sociodemographic Data in Primary Care." The Journal of the American Board of Family Medicine 29, no. 3 (2016): 348-355.

• Mensah, George A. "Eliminating disparities in cardiovascular health six strategic imperatives and a framework for action." Circulation 111, no. 10 (2005): 1332-1336.

• Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/iomracereport/index.html

• Chin, Marshall H., Amanda R. Clarke, Robert S. Nocon, Alicia A. Casey, Anna P. Goddu, Nicole M. Keesecker, and Scott C. Cook. "A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care." Journal of general internal medicine 27, no. 8 (2012): 992-1000.