A Unique Health Equity Collaboration Model for State Policy Implementation

Carlessia A. Hussein, RN, DrPH, Director

Office of Minority Health and Health Disparities

Maryland Department of Health and Mental Hygiene

March 12, 2013

DiversityRxEighth National Conference on Quality Health

Care for Culturally Diverse PopulationsOakland, California

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Maryland Population, 2010 U.S. Census by Race and Ethnicity (45.3%) Minority

All Ethnicity Non-Hispanic Hispanic

White 3,359,284 58.2% 3,157,958 54.7% 201,326 3.5%

Non-White 2,414,268 41.8% 2,144,962 37.2% 269,306 4.7%

Black 1,700,298 29.4% 1,674,229 26,069

Asian Asian 318,853 5.5% 316,694 2,159

3,157 0.1% 2,412 745

American Indian 20,420 0.4% 13,815 6,605

206,832 3.6% 11,972 194,860

164,708 2.9% 125,840 38,868

MD Total 5,773,552 100.0% 5,302,920 91.8% 470,632 8.2%

Race Alone

Hawaiian/ Pac Isle

Two or More Races

Some Other Race

Source: 2010 Census Demographic Profiles, Department of Planning, Projections and Data Analysis/State Data Center, May 2011

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Progress in DisparityElimination in Maryland

Between 2001 and 2010 the gaps between the Black and White age-adjusted death rates (Black rate minus White rate) were reduced as follows:

– For All-cause Mortality, the gap was reduced by 43%

– For Cancer Mortality, the gap was reduced by 65%

– For Heart Disease Mortality, the gap was reduced by 29%

– For Stroke Mortality, the gap was reduced by 6%

– For Diabetes Mortality, the gap was reduced by 30%

– For HIV/AIDS Mortality, the gap was reduced by 57%

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Cost of Disparities

• Hospital Admission Rates by Race and Age, Maryland 2011

MHHD – Office of Minority Health and Health Disparities, DHMHHSCRC – Health Services Cost Review Commission

Source: MHHD analysis of HSCRC 2011 hospital discharge data

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Cost of Disparities (Continued)

Hospital Cost of Excess Black or African American Hospital Admissions, Maryland 2011

Source: MHHD analysis of HSCRC 2011 hospital discharge data [11]

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Maryland Office of Minority Healthand Health Disparities (MHHD)

Historical Development

Background• The Maryland General Assembly passed House Bill 86/Senate Bill 177 in

April of 2004 that mandated the Department of Health and Mental

Hygiene (DHMH) to establish an Office of Minority Health and Health

Disparities (MHHD) in the Office of the Secretary.

Mission• In fulfillment of the Department’s mission to promote the health of all

Maryland citizens, the Health Disparities Initiative shall focus the

Department’s resources on eliminating health disparities, partner with

statewide organizations in developing policies and implementing

programs and monitor and report the progress to elected officials and the

public. The target ethnic/racial groups shall include African Americans,

Hispanic/Latino Americans, Asian Americans and Native Americans.

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Maryland Plan To Eliminate Minority Health Disparities 2010-2014

• The Second Health Disparities Plan published by MHHD [First Plan published in 2006]

• Published in March 2010 – available at www.dhmh.maryland.gov/mhhd

• Developed through the consultation and work of the Collaborative and wide public input (engaged over 2,500 stakeholders in development process)

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Maryland Health Disparities Collaborative

• The Collaborative is charged with assisting the Office of Minority Health and Health Disparities (MHHD) and the Secretary of DHMH in establishing priorities for programs, services and resources for minority health.

• Established in 2008 in compliance with Maryland Health-General Article, Section 20-1006, that calls for an advisory commission to assist the Minority Health and Health Disparities (MHHD) Office in carrying out its duties

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Maryland Health Disparities Collaborative

Collaborative Leadership• Collaborative is co-chaired by the current DHMH

Secretary, Joshua Sharfstein, MD and Donna Jacobs, Esq, Senior Vice President of Governmental and Regulatory Affairs, University of Maryland Medical System

Collaborative Members• Has over 210 active members

• Members representing State and Local health leadership, healthcare administrators, community health advocates, faith-based representatives, academic leadership, and includes representatives from diverse geographic locations

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Maryland Health Disparities Collaborative

Collaborative Implementation Plan• Intended to move the State of Maryland to take concrete actions

that will achieve measurable progress toward the reduction of major health disparities in the State

• The Health Disparities Plan lays out 5 objectives each with action steps, key stakeholders and measures• The objectives align with the National Partnership for Action (NPA) and links

to the State Health Improvement Process (SHIP)

• In August 2011, the Collaborative formed 5 Workgroups that addressed each of the 5 objectives in the Plan• These Workgroups developed specific Guidelines and Principles to assist

DHMH with the implementation of the Maryland Health Improvement and Disparities Reduction Act of 2012

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Maryland Health Disparities Collaborative

Five Collaborative Workgroups • Awareness – Increase awareness of the significance of health disparities, their

impact on the state and local communities, and the actions necessary to improve health outcomes for Maryland’s racial and ethnic minority populations.

• Leadership and Capacity Building – Strengthen and broaden leadership for addressing health disparities at all levels.

• Health and Health System Experience – Improve health and health care outcomes for racial and ethnic minorities and underserved populations and communities.

• Cultural and Linguistic Competency – Improve cultural and linguistic competency.

• Research and Evaluation (Data) – Improve coordination and use of research and evaluation outcomes.

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Maryland’s Groundbreaking Health Disparities Legislation

The Maryland Health Improvement and Disparities Reduction Act of 2012 (SB 234) • History

• Before passage of the ACA in Congress, Maryland had formed a Health Quality and Cost Council with a charge to take immediate steps to raise the health of all of its citizens. Upon passage of the ACA, the State stepped up its pace to implement Health Reform. One of several recommended actions was to reduce health disparities. The Council formed a Disparities Workgroup to draft actions for the State to enact. The Maryland Office of Minority Health and Health Disparities provided staff support to this diverse group of disparities experts. The subsequent report was submitted to the Administration. The recommendations in the Report became legislation that was passed unanimously in April 2012.

• Purpose• The goals of the legislation are to reduce health disparities, to improve

health outcomes, and reduce health costs and hospital admissions and readmissions.

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The Maryland Health Improvement and Disparities Reduction Act of 2012

Provisions1. Establish Health Enterprise Zones (HEZ) in small geographic areas having very poor health statistics,

health disparities and high poverty. The HEZ is eligible for loan repayment assistance, tax credits, capital equipment credits, electronic medical records assistance and participation in the Patient Centered Medical Home program, and funding for four years.

2. Establish and incorporate a standard set of measures regarding racial and ethnic variations in the State Quality Outcomes reports generated by the Maryland Health Care Commission. Include information on the actions taken by carriers to track and reduce health disparities, including whether the health benefit plan provides culturally appropriate educational materials for its members.

3. Require each non-profit hospital in the State to include in their Annual Community Benefits Reports, a description of the hospital's efforts to track and reduce health disparities.

4. Require institutions that offer programs necessary for the licensing of health care professionals in the State to report on their actions taken to reduce health disparities.

5. Two state commissions that work with hospital and health insurer data, shall recommend standards for evaluating the impact of the Maryland Patient Centered Medical Homes on eliminating health disparities.

6. Form a workgroup to develop standards and criteria for cultural competency in medical and behavioral health treatment settings.

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Collaborative Implementation Guidelines & Principles

Provision #1 Health Enterprise Zones (HEZs) • Outreach to community-based organizations around the state

• Identify current and develop comprehensive lists of Community Based Organizations and existing networks with community based outreach

• Create and pretest outreach messages that are created through community input, focus groups, and in-person discussions with community leaders

• Create a standard outreach message template and toolkit of resources on the subject matter

• Use multi-channel marketing strategies

• Provide Hospitals, larger institutions, and Local Health Departments information on how to effectively partner with CBO’s

• Identify and collaborate with effective initiatives or programs currently being implemented in high health need areas for community outreach

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Collaborative Implementation Guidelines & Principles

Provision #1 Health Enterprise Zones (HEZs) (continued)• Establish a virtual network of community health equity leaders

• Include community health leaders and their contacts

• Identify who will be responsible for creating messages, managing the network, and disseminate messages

• Identify and employ tools and software to disseminate information to large groups

• Use effective non-IT forms of communication for outreach

• Provide technical assistance for organizations to apply and achieve both promising practices and evidence-based practices

• Locate resources for funds for the applications that are not selected

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Collaborative Implementation Guidelines & Principles

Provision #1 Health Enterprise Zones (HEZs) (continued)• Evidence-based options for communities and local health institutions

and health plans to consider in establishing effective community health programs• Interactive webpage of chronic disease evidence-based, promising and best

practices

• Implement a diabetes prevention “Small Steps” campaign to create materials for people at risk for diabetes, using multipronged community outreach

• Launch a tobacco cessation campaign with advertising campaigns and historical, cultural, and socioeconomic influences targeted to specific groups

• Promote healthy eating through faith-based programs and peer counseling

• Recruit barbershops to aid in improving hypertension detection and control, helping black men beat high blood pressure, and controlling cardiovascular disease

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Collaborative Implementation Guidelines & Principles

Provision #1 Health Enterprise Zones (HEZs) (continued)• Evidence-based options for communities and local health institutions and

health plans to consider in establishing effective community health programs (continued)• Assist people released from prison find primary care and navigate the health care

system

• Better use hospital emergency departments to test for HIV, HCV, and other infectious diseases and conditions, and then provide assistance and referrals

• Promote the Community Health Worker (CHW) movement

• Manage heart failure more effectively

• Employ proven effective drug treatment for addiction and combine with a broad community program in housing, medical care, social rehabilitation, job training, and social support

• Tackle obesity by addressing the social determinants of health

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Collaborative Implementation Guidelines & Principles

Provision #1 Health Enterprise Zones (HEZs) (continued)• Successful models of care that address disparities

• Bright Beginnings of Maryland (http://brightbeginningsmd.org)

• The REsidents Access to a Coalition of Health (REACH) (http://www.aahealth.org/physicianslink/access_reach_overview.asp)

• S.M.I.L.E. Program (part of the African American Health Program in Montgomery County) (http://www.onehealthylife.org/our-programs/infant-mortality.html) (http://www.onehealthylife.org/sites/default/files/AAHP_SMILE_BROCHURE051710_F.pdf)

• Diabetes Dining Club (part of the African American Health Program in Montgomery County) (http://www.onehealthylife.org/our-programs/diabetes.html)

• Community Health Partnership (CHP)’s Baltimore Community Health Action Team (B-CHAT) (http://www.nmqf.org/presentations/10MullinsDJCP1.pdf)

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Collaborative Implementation Guidelines & Principles

Provision #1 Health Enterprise Zones (HEZs) (continued)• Use criteria as a guide for assessing the level of cultural and

linguistic competence of Health Enterprise Zone applications• Include criteria as an appendix to the request for proposals with

suggested scoring rubric

• Areas of suggested criteria include:• Community Engagement• Patient-Provider Communication and Language Services• Workforce Diversity and Training• Managerial and Operational Supports• Care Delivery• Data Collection

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Collaborative Implementation Guidelines & Principles

Provision #2 Standard set of measures regarding racial and ethnic variations in the State Quality Outcomes reports & whether health benefit plan provides culturally appropriate educational materials for its members

• Adopt the approach of OMB Directive 15 as the overarching shell for Race, Ethnic and Language data collection. • Collect Hispanic ethnicity (yes or no response) and Race in categories of White, Black or

African American, American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander (pick all that apply)

• Collect data on English proficiency and preferred language for healthcare • Use the questions in the HHS new data collection guidelines

• Add to the OMB approach collection of relevant subcategories of the primary racial and Hispanic ethnic groups. • Appropriate lists of subcategories for Maryland should be determined by consultation with

appropriate minority populations and by reference to subgroup population sizes from the 2010 census

• Develop a process for obtaining input from the various minority populations and their advocacy groups

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Collaborative Implementation Guidelines & Principles

Provision #2 Standard set of measures regarding racial and ethnic variations in the State Quality Outcomes reports & whether health benefit plan provides culturally appropriate educational materials for its members (continued)• Incorporate elements of cultural, linguistic, and health literacy appropriate

communication into the health plan evaluation tools and certification processes currently being developed by the Maryland Health Benefit Exchange and the Maryland Health Care Commission

• Require Maryland health plans to incorporate into their current consumer surveys a standardized subset of supplemental items on cultural competence and health literacy

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Collaborative Implementation Guidelines & Principles

Provision #3 Description of hospital's efforts to track and reduce health disparities in Annual Community Benefits Reports

• The Health Services Cost Review Commission (HSCRC) is required under 19-303 of the Health General Article, Maryland Annotated Code to collect information and prepare a Community Health Benefit Report that describes the types and scopes of community benefit activities conducted by nonprofit hospitals• Amendments to this legislation in the 2012 Legislative Session now

requires HSCRC to add to these report requirements, a description of the Hospital’s efforts to track and reduce health disparities in the community that the hospital serves

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Collaborative Implementation Guidelines & Principles

Provision #4 Report on actions to reduce health disparities by higher education institutions with health care professional licensing programs

• Consolidate the institution of higher education reporting requirements found in both the Maryland Health Improvement and Disparities Reduction Act of 2012 and HB 679 so that the information for the two reports are submitted by each health profession training program as a single document• Consider a reporting format (example provided in final report)

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Collaborative Implementation Guidelines & Principles

Provision #5 Two State commissions that work with hospital and health insurer data, shall recommend standards for evaluating the impact of the Maryland Patient Centered Medical Homes on eliminating health disparities

• The Maryland Health Care Commission has formed an advisory panel that is examining requirements relating to the Medical Home Program

• The Health Services Cost Review Commission has convened a Hospital Race and Ethnicity Disparities Workgroup that is looking at the requirements for hospital incentive programs

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Collaborative Implementation Guidelines & Principles

Provision #6 Workgroup to develop standards and criteria for cultural competency in medical and behavioral health treatment settings (MHQCC Cultural Competency Workgroup)

• Consider specifications to support the implementation of continuing education in cultural, linguistic, and health literacy competency

• Consider how process measures related to cultural, linguistic, and health literacy competency might be incorporated into the performance evaluation

• Consider assurance that eligible participation in a tiered reimbursement or other incentive program is structured in a manner that only rewards quality improvement efforts that simultaneously address health disparities

• Consider developing a provider quality recognition program that could be implemented at different provider levels

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Lessons Learned

• Recruit broad representation of stakeholders to ensure diversity of thoughts, views, and expertise • State-wide diverse outreach and representation

• Offer technical assistance in areas of expertise and need• Provides technical assistance and presentations on the Community

Health Worker model and health disparities data

• Establish and serve as a point of contact available for research and presentations• Serves as a resource to Lt. Governor, Chief of Staff

• Identify community based organizations and groups who express interest in policy and legislation• Provide technical assistance and expertise

• Distribute draft material widely for input• Reaches broader groups

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Today, Tomorrow, and Beyond

Collaborative Workgroups• Provide assistance to the MHQCC Cultural Competency

Workgroup• Review of draft materials• Providing content specific expertise

• Provide technical assistance and training to HEZ Awardees

• Continue to inform policy development and implementation

• Continue to provide technical assistance to other entities working to implement provisions in the Act

• Participate in ongoing evaluation and program re-articulation

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Resources and References

• Maryland Office of Minority Health and Health Disparities

http://dhmh.maryland.gov/mhhd/ • Maryland Health Disparities Collaborative

http://dhmh.maryland.gov/mhhd/SitePages/Health%20Disparities%20Collaborative.aspx • Maryland Office of Minority Health and Health Disparities 2012 ANNUAL REPORT

http://dhmh.maryland.gov/mhhd/Documents/2012%20MHHD%20Annual%20Report%20FINAL%20020513.pdf• Maryland Plan to Eliminate Health Disparities Plan of Action 2010-2014

http://dhmh.maryland.gov/mhhd/Documents/Maryland_Health_Disparities_Plan_of_Action_6.10.10.pdf• Maryland Chartbook of Minority Health and Minority Health Disparities Data 2012

http://dhmh.maryland.gov/mhhd/Documents/2012%20Maryland%20Health%20Disparities%20Data%20Chartbook.pdf• Health Enterprise Zone in Maryland

http://dhmh.maryland.gov/healthenterprisezones/SitePages/Home.aspx• Maryland Health Improvement and Disparities Reduction Act of 2012 (SB 234)

http://mgaleg.maryland.gov/webmga/frmMain.aspx?tab=subject3&ys=2012rs/billfile/sb0234.htm

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MHHD Contact

Office of Minority Health and Health DisparitiesMaryland Department of Health and Mental Hygiene

201 West Preston Street, Room 500 Baltimore, Maryland 21201

Website: www.dhmh.maryland.gov/mhhdFacebook: www.facebook.com/MarylandMHHD

Phone: 410-767-7117Fax: 410-333-5100

Email: dhmh.healthdisparities@maryland.gov